Richland 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 facility failed to implement PROM exercises per COTA recommendations for a resident with quadriplegia, cervical spine fusion, and neuromuscular dysfunction of the bladder. The resident’s MDS documented no cognitive deficits, and the care plan did not include any problem areas related to restorative nursing or therapy services for quadriplegia. The resident stated he was quadriplegic following a spinal cord injury in September 2025, that he hoped to transfer to a facility specializing in spinal cord injury rehabilitation, and that he was afraid he would develop contractures because he did not feel staff were completing his ROM effectively. An OT treatment encounter report documented that the therapist educated staff to perform daily PROM to prevent stiffness and contractures because the resident was unable to move his extremities on his own. The therapist also educated staff on daily bed baths, repositioning every 2 hours, and placed reminders on the resident’s wall for daily baths, repositioning, ROM, and wheelchair use. The COTA later stated she had educated CNA staff that the resident should receive AROM to the head and neck and PROM to the rest of the body at least once daily, but she was not sure whether the CNAs were doing it. She also stated the facility’s two restorative aides had been returned to floor work and would not be replaced. During observation, a CNA was seen performing PROM for the resident, but the movements did not meet the stated minimum of 10 repetitions for multiple body parts. The documented repetitions included right shoulder 2, right fingers and thumb 0, left wrist 8, left thumb and fingers 4, left elbow 6, left shoulder 5, left ankle 7, left knee 5, left hip abduction 0, right hip extension 4, and bilateral toes 0. The CNA stated the resident was to receive PROM once every 12-hour shift. The DON stated CNA staff would be in-serviced on the resident’s restorative needs and that the care plan would be updated.

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 urinary catheter care according to professional standards of practice for one resident with an indwelling catheter. The resident’s record showed diagnoses including quadriplegia, cervical spine fusion, and neuromuscular dysfunction of the bladder, and the care plan identified the resident as requiring enhanced barrier precautions related to the indwelling catheter and routine assessment of drainage every shift and as needed. The record also showed that catheter output was documented only once daily on some dates in April 2026, with no documentation of urine output on several other dates. The resident’s urinalysis and urine culture showed cloudy urine, abnormal red and white blood cells, many bacteria, and greater than 100,000 gram negative bacilli. A provider note documented that staff reported the resident had increased confusion and that the resident had a UTI, with Keflex started by the primary care physician. The resident and a family member stated the catheter bag had become very full, and the family member reported emptying 2000 cc of urine from the bag after no staff responded to the call light, with an immediate return of 400 cc of residual urine that had been backed up into the bladder. During observation of catheter care, a CNA entered the room without donning PPE, did not wear a gown despite the EBP sign on the door, and stated she did not think the resident was on EBP. The CNA cleansed the catheter tubing by going back and forth with the same washcloth rather than using one motion from proximal to distal, then drained 500 cc of urine while wearing contaminated gloves, did not perform hand hygiene before handling the drainage tube, and re-clamped the tube without sanitizing it. The DON stated catheter bags should be emptied at least every 12-hour shift and no more than 1000 cc should be allowed to collect, and the facility policies required emptying the bag at least every eight hours, documenting output, and using gown and gloves for residents with indwelling devices.

Penalty

Inspection fine: $39,780

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

Summary

The deficiency involves the facility’s failure to protect residents from resident‑to‑resident physical abuse on the behavioral unit and other units, resulting in multiple altercations. One incident involved a resident with schizoaffective disorder and moderate cognitive impairment who was asleep in bed when she awoke to another resident, also diagnosed with schizoaffective disorder and anxiety disorder, standing over her with gloved hands placed over her mouth and nose and pushing down. The sleeping resident reported that the other resident was trying to kill her and yelled for her to get out of the room. Staff, including an LPN and a CNA at the nurses’ station, heard the yelling, observed the alleged aggressor coming up the hallway wearing medical gloves, and were informed by the victim that the aggressor had tried to cut off her breathing. Multiple staff interviews documented that the alleged aggressor did not deny placing her hands over the other resident’s mouth and nose and, in some accounts, demonstrated how she did it and stated she had planned it because she believed the other resident had taken fentanyl patches. A second incident involved a resident with severe dementia, expressive aphasia, and a history of cerebral infarction, who had care plan interventions for communication deficits and pain assessment. Another resident with dementia, cognitive communication deficit, and a care plan identifying wandering, verbal aggression, physical aggression, and resisting care was observed entering the first resident’s room. A CNA reported seeing the aggressive resident block the other resident in the room with her wheelchair in a corner and, before she could intervene, saw the aggressive resident kick the other resident above the knee. Nursing documentation confirmed that the resident was kicked by another resident, with no injury or complaints of pain noted at that time. A third incident occurred a few hours later and involved the same aggressive resident and another resident with unspecified dementia with behavioral disturbance, Alzheimer’s disease, seizures, generalized anxiety disorder, major depressive disorder, atrial fibrillation, delusional disorder, and chronic heart failure, who was severely cognitively impaired and care planned as at risk of abuse/neglect related to dementia. A CNA sitting at the nurses’ station witnessed the aggressive resident self‑propel her wheelchair behind this resident, who was seated in a wheelchair, and slap her on the back. The CNA separated the residents and notified nursing and administration. Progress notes and the facility’s incident reports documented that the aggressive resident had hit another resident in the back and that these were resident‑to‑resident altercations. Across these events, the facility’s abuse prevention policy defined abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and required steps to prevent further potential abuse while investigations were in progress, but the incidents demonstrate that residents were not kept free from physical abuse by other residents.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to notify a physician of significant weight changes for a resident as required by physician orders and the care plan. The resident was admitted with diagnoses including dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease, and had a moderate cognitive deficit per the MDS. The care plan identified a problem of risk for impaired nutrition and hydration, with an intervention to monitor weight and notify the provider of significant weight changes. Physician orders directed staff to obtain daily weights before breakfast and to notify the physician for weight gain greater than 3 pounds in 1 day or 5 pounds in 1 week, and also included an order for PRN bumetanide to be given for specified weight gains. The resident’s January weight records showed multiple instances where the notification parameters were met: a 3‑pound gain in one day on three separate dates and a 5‑pound gain in one week on another date. An LPN stated she noted a 3‑pound weight gain on one of those days and administered the PRN bumetanide but did not remember notifying the physician. The Regional Clinical Director reviewed the resident’s weights and progress notes and was unable to find documentation that the physician had been notified of the weight changes as ordered. The Nurse Practitioner who routinely followed the resident stated she had not been notified of any weight gains during that month and indicated that, if notified, she would have directed staff to administer the PRN bumetanide as ordered. The facility’s policy on obtaining and following physician orders states that if orders are not followed for any reason, the physician and DON will be promptly notified, which did not occur 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

Surveyors identified a deficiency related to failure to ensure a resident was free from significant medication errors when PRN bumetanide was not administered as ordered. The resident had diagnoses including dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease, and had a Brief Interview for Mental Status score indicating moderate cognitive deficit. The physician’s order, effective since 12/08/2025, directed administration of bumetanide 1 mg by mouth daily as needed for weight gain of more than two pounds in one day or more than three pounds in five days. The resident’s care plan did not include a problem area related to medication administration. Weight records for the month showed multiple instances of weight gain that met the parameters for bumetanide administration. The vitals/weight report documented specific daily weights demonstrating that the resident met the criteria for bumetanide on several days. Based on these weights, the medication should have been administered on multiple dates, including 1/3, 1/6, 1/7, 1/9, 1/11, 1/16, and 1/22. However, review of the Medication Administration Record showed that on many days the medication entry was marked with initials in parentheses, which the Regional Clinical Director confirmed indicated the medication was not given. The Regional Clinical Director also confirmed that the medication should have been administered whenever the resident had the specified weight gain and that this did not occur on at least 1/6, 1/7, and 1/16, contrary to the physician’s order and the facility’s policy requiring physician orders to be followed or the physician and DON to be notified if not followed.

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

Facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive, despite the resident being a full code. The resident was discovered without a pulse or respirations by two CNAs, who then notified a Registered Nurse (RN). The RN did not know the resident's code status and did not initiate CPR, assuming the resident was a Do Not Resuscitate (DNR) because there was no documentation in the electronic medical record. However, the resident's progress notes and hospital discharge summary indicated that the resident was a full code. The care plan and physician order summary did not document the code status, and the POLST form was not completed during the resident's 12-day stay at the facility. Multiple staff members, including CNAs and nurses, were unaware of the resident's code status at the time of the incident. The CNAs relied on the RN for direction, and the RN failed to check or confirm the code status before pronouncing the resident deceased. The facility had a system in place to indicate code status with colored stars outside resident rooms and in the electronic medical record banner, but this information was either missing or not utilized. Staff interviews revealed confusion and lack of familiarity with the resident and the facility's protocol for determining and documenting code status. The failure to initiate CPR was contrary to facility policy, which states that in the absence of a documented code status, staff should treat the resident as a full code and begin CPR. The lack of documentation, incomplete admission paperwork, and failure to verify code status led to the resident not receiving life-sustaining measures when found unresponsive. The resident was pronounced dead at the facility without any attempt at resuscitation, and the incident was identified as Immediate Jeopardy due to the failure to provide basic life support as required.

Removal Plan

• V2 (Director of Nursing), V14 (LPN / MDS) and V20 (LPN) were educated by V10 (Regional Clinical Director) on code status policy, death of a resident and change of condition policy, and the CPR policy.
• V4 (Registered Nurse) was educated by V2 on Code status policy, death of a resident, change in condition policy, notifications, and CPR policy.
• V9 (Social Services Director) and V14 completed an audit of all residents to ensure an order for a code status was in place, POLST form was in place and care plan indicates the order appropriately.
• V3 completed an audit of all staff who are CPR certified and schedule a class for the staff who are not.
• V3 reviewed the facility policy on CPR.
• V2 initiated and completed the following in-servicing with all nursing staff on CPR initiation policy including immediate initiation of CPR for all full code residents when unresponsive, documentation of a death, code status when to initiate CPR and change in condition policy.
• V9 (Social Service Director) will be doing ongoing monthly audit to ensure all code status orders remain accurate and current.
• V2 (Director of Nursing) will monitor. Random audits of 3 resident records per week for accuracy of code status and 2 staff interviews to verify knowledge of protocol. Results will be reviewed by V1 (Administrator) and the Quality Assurance Committee monthly.

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 formulate or offer to formulate an advance directive for one resident upon admission, despite the resident having multiple significant medical diagnoses, including cerebral infarction due to embolism, acute respiratory failure with hypoxia, acute on chronic diastolic heart failure, type 2 diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, and unspecified intellectual disabilities. The resident's face sheet and physician order summary did not include a code status or advance directive, and the care plan lacked a focused area addressing the resident's choices regarding advance directives. The POLST (Physician Order for Life-Sustaining Treatment) form was not completed at the time of admission, and there was confusion among staff regarding who was responsible for ensuring its completion. Interviews with facility staff revealed a lack of clarity and communication about the process for obtaining and documenting code status and advance directives. The administrator was unaware of the facility's policy on when POLST forms should be completed, and the social services director indicated a preference for residents to arrive with a completed POLST from the hospital. The social services director also noted that the resident was difficult to assess due to behaviors and a low BIMS score, and had not reviewed all hospital paperwork or ensured the POLST was completed. The nurse practitioner confirmed that no discussion had occurred with the resident's family regarding code status, and that in the absence of a POLST, the resident was automatically considered a full code. Facility policy required that written information about advance directives be provided to residents prior to or upon admission, and that staff inquire about the existence of any written advance directives. However, these procedures were not followed for this resident, resulting in a lack of documented code status or advance directive for 12 days after admission. Multiple staff members expressed uncertainty about their roles and responsibilities in this process, contributing to the deficiency.

Penalty

Inspection fine: $45,800

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 abuse involving three out of six residents reviewed for abuse. In one incident, a resident with unspecified dementia and anxiety was bitten on the wrist by another resident with severe dementia, behavioral disturbances, and other neurological and psychiatric diagnoses. The biting incident resulted in a bruise, and in response, the first resident grabbed the other by the shirt and slapped them on the face. Staff witnessed the altercation, and documentation confirmed the physical interactions and resulting injuries. Another incident involved a resident with dementia and behavioral disturbances who was struck on the shoulder by a recently admitted resident with severe cognitive impairment and a history of traumatic brain injury, bipolar disorder, and major depressive disorder. The striking occurred as the first resident was walking by the second resident's room, leading to a loss of balance and a fall that resulted in a right hip fracture. Witnesses, including CNAs and a wound care nurse, confirmed the sequence of events and the resulting injury. The resident who initiated the physical contact stated they were trying to prevent the other from entering their room. The facility's abuse prevention policy defines abuse as the willful infliction of injury or intimidation resulting in physical harm or mental anguish. Despite this policy, the incidents described demonstrate that the facility did not effectively prevent resident-to-resident abuse, as evidenced by physical altercations resulting in injuries such as bruising and a hip fracture. The report includes direct observations and statements from staff and residents involved in the incidents.

Penalty

Inspection fine: $22,315

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 provide proper supervision during ambulation for a resident with severe cognitive impairment and a high risk for falls. The resident had multiple diagnoses, including unsteadiness on feet, dementia, and a history of fractures. The care plan and assessments indicated that the resident was dependent for mobility, required maximum assistance from two staff members, and was not safe to ambulate or stand unassisted. Despite these documented needs, the resident was left standing in the hallway while a CNA briefly left to retrieve a walker, during which time the resident fell and sustained a comminuted fracture to the right arm and elbow. Interviews with staff confirmed that the resident was unsteady, impulsive, and should not have been left alone while standing or walking. The CNA involved stated that he attempted to get the resident to sit back in the wheelchair and then moved a few feet away to get the walker, at which point the resident stumbled and fell into the handrail. Other staff, including LPNs, the DON, and the facility administrator, all acknowledged that the resident required continuous supervision and should not have been left unassisted during ambulation or while standing. The facility's fall management policy required individualized interventions and supervision for residents at high risk for falls, including the use of assistive devices and staff assistance as necessary. The failure to follow these protocols and provide adequate supervision directly resulted in the resident's fall and subsequent injury. Documentation and staff interviews consistently indicated that the resident's needs for supervision were well known but not adhered to at the time of the incident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely assistance with activities of daily living (ADLs), specifically toileting, and did not respond promptly to call lights, compromising the dignity of several residents. One resident with severe cognitive impairment and frequent incontinence was observed repeatedly requesting help to use the bathroom over a 35-minute period, both verbally and by seeking out staff, but did not receive assistance. During this time, staff members, including CNAs and a patient aid, informed the resident that they could not help due to being occupied with feeding other residents, and the resident ultimately experienced an episode of incontinence in a public area, becoming visibly upset and distressed. Other residents also reported excessive wait times for call lights to be answered, with some stating they had to attempt self-toileting to avoid accidents, despite requiring assistance. Multiple residents described call light response times as too long, sometimes up to an hour, particularly during meal times or when staffing was reduced. Staff interviews confirmed that there were not enough CNAs on duty to meet residents' needs in a timely manner, and that they were instructed not to interrupt feeding to provide toileting assistance. Facility policies reviewed by the surveyor required prompt response to residents' requests for toileting assistance and call lights, and prohibited practices that compromise resident dignity. Despite these policies, staff actions and statements indicated that care was delayed due to staffing shortages and prioritization of other tasks, resulting in residents' needs not being met in a manner that promotes dignity and respect.

Penalty

No penalty information released

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

Summary

The facility failed to provide sufficient nursing staff to monitor and deliver timely care to residents, as evidenced by multiple direct observations, interviews, and record reviews. During a lunch period on the Alzheimer's unit, a resident with severe cognitive impairment and incontinence repeatedly requested assistance to use the bathroom but was told by staff that they could not help her immediately due to being occupied with feeding other residents. The resident became visibly upset, cried out for help, and ultimately soiled herself after waiting for an extended period without assistance. Other residents were observed wandering unsupervised, attempting to exit the facility, and eating food from other residents' plates, indicating a lack of adequate supervision and timely care. Staff interviews confirmed that the unit was short-staffed due to a CNA leaving early, leaving only two CNAs and a patient aid (PA) present. Staff consistently reported that this level of staffing was insufficient to meet residents' needs in a timely manner, especially during busy periods such as mealtimes. Staff also described being unable to stop feeding residents to provide other necessary care, and noted that administrative and nursing staff were not available to assist during these times. The PA stated she was not permitted to provide direct care, further limiting the available support. The nurse manager and DON acknowledged the chaotic environment and agreed that more staff would be beneficial, particularly during meals and evenings. Additional documentation and interviews revealed similar staffing concerns on other units and shifts, including night shifts where a nurse was shared between two units and only two CNAs were present. Staff described delays in responding to alarms, providing incontinence care, and assisting residents with activities of daily living. One resident experienced a fall when staff were occupied elsewhere and alarms were not heard in time. Multiple staff members and residents reported that care was not provided in a timely manner due to inadequate staffing, and assignment sheets confirmed the low staffing levels. The facility's own policy stated that adequate staffing would be maintained to meet residents' needs, but this was not observed in practice.

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 the dining room floor in a clean and sanitary condition for all residents who dined in the Center and East Halls Dining Room. Over the course of two consecutive days, surveyors observed multiple dried liquid spots, including what appeared to be dried milk and other clear or semi-clear substances, as well as debris such as food particles, dirt, and maple tree seeds scattered throughout the dining room floor. These observations were made despite the presence of housekeeping staff, and the same spills and debris remained unaddressed from one day to the next. The administrator acknowledged that the cleanliness observed did not meet the facility's standards. Interviews with staff revealed concerns about the adequacy and consistency of cleaning practices. A housekeeper described the daily cleaning routine, which included cleaning tables, sweeping, mopping, and taking out trash, and stated that the current staffing level was sufficient. However, an LPN reported that housekeepers were not routinely sweeping and mopping as expected, leading nursing staff to sometimes clean areas themselves. Facility policy requires daily cleaning and immediate attention to spills or soiling, but these procedures were not followed, resulting in a failure to provide a clean, safe, and homelike environment for residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents who required substantial help, resulting in unmet care needs. One resident with severe cognitive impairment, frequent incontinence, and a care plan requiring substantial assistance with toileting repeatedly requested help to use the bathroom over a 33-minute period. Despite her visible distress and repeated verbal requests to multiple staff members, she was not assisted in a timely manner. Staff were observed prioritizing feeding other residents and charting over responding to her toileting needs, and the resident ultimately urinated on herself while waiting for assistance. Interviews with staff confirmed that staffing shortages and task prioritization contributed to the delay, and documentation indicated that the resident was found with soiled clothing and incontinence products after the incident. Another resident, who was dependent on staff for bathing and required two-person assistance with transfers, did not receive scheduled showers for two separate six-day periods. The resident reported not having received a shower in two to three weeks, despite a physician's order for twice-weekly showers. Documentation errors were identified, with a CNA admitting to mistakenly recording showers that did not occur. There was also no documentation to support claims that the resident received bed baths during the missed shower periods. Staff interviews revealed that showers were often scheduled late at night, which may have contributed to missed care, but the resident denied refusing showers. The facility's own bathing policy requires regular and as-needed bathing assistance, but this was not followed for the residents in question. Staff and management acknowledged that the expected frequency of showers was not met and that residents should have been offered alternative hygiene care when showers were missed. The deficiencies were substantiated through direct observation, resident and staff interviews, and review of care plans and documentation.

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 necessary person-centered care and services to residents with dementia, as evidenced by multiple direct observations and staff interviews. During a continuous observation of the Alzheimer's unit dining area, a resident with severe cognitive impairment repeatedly requested assistance to use the bathroom but was not promptly assisted by staff, resulting in visible distress and incontinence. Staff were observed prioritizing other tasks, such as feeding residents and documenting, and stated they were not allowed to interrupt these duties to assist with toileting. The resident's care plan did not include progressive, person-centered interventions specific to her dementia diagnosis. Another resident with moderate dementia and behavioral disturbances was observed wandering the hallways and eating food from other residents' plates, despite being on a mechanical soft diet. Staff redirected her only after she had already consumed food from multiple plates. The care plan for this resident also lacked individualized, progressive interventions tailored to her dementia-related needs. Staff interviews confirmed that residents frequently wander into other rooms and that there are insufficient activities and supervision to engage and monitor them effectively. A third resident with severe cognitive impairment was observed handling dirty dishes and smearing food on her hands without appropriate staff intervention until after the fact. Staff interviews and record reviews revealed that staffing levels were inadequate to meet residents' needs in a timely manner, and that activity programming was inconsistent and often disrupted. The care plans for all three residents reviewed did not reflect person-centered, progressive interventions for dementia care, and the facility's own dementia protocol was not followed as required.

Penalty

Inspection fine: $26,631

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 cognitively impaired, ambulatory resident with a diagnosis of Alzheimer's disease and a history of exit-seeking behaviors was able to leave the facility's Dementia Care Unit unsupervised and unwitnessed. The resident exited the building, walked approximately one block away, fell in the street, sustained a skin tear over the left temporal region and abrasions on both hands, wrists, and elbows, and then entered an unlocked private vehicle. The resident was found by an off-duty police officer, who noted confusion and inability to provide his address or explain his whereabouts. The resident was subsequently transported to the emergency room for evaluation and treatment of his injuries. The resident's care plan and elopement evaluation had previously identified him as being at risk for elopement, with interventions such as redirection, notification of staff, diversional activities, and 30-minute checks. Despite these interventions, staff were unable to effectively supervise the resident on the day of the incident. Staff interviews and documentation revealed that the resident had been displaying increased exit-seeking and challenging behaviors throughout the day, including attempts to open doors, requests for keys, and verbal aggression. Staff attempted various redirection techniques, but these were unsuccessful. At the time of the elopement, staff were occupied with other residents, and the resident was able to access an unlocked office, open a window, and push out the screen to exit the building without triggering door alarms. Further investigation found that the facility had several environmental and procedural lapses that contributed to the incident. The office door providing access to the window was left unlocked, and the window was unsecured. Additionally, the north exit door's alarm system was not functioning properly, allowing doors to be opened without alerting staff. Maintenance logs showed that door alarms were not being checked daily as required by facility policy, and staff were unaware of this requirement. Staffing levels were also cited as a concern, with staff reporting that increased supervision was not possible due to the number of residents and the level of care required on the unit.

Removal Plan

• R1 was placed on 30-minute checks.
• R1's Care Plan was updated to reflect elopement interventions.
• V9 ensured the office door from which R1 was believed to have accessed a window to elope was locked.
• V5 installed a self-locking doorknob, replaced the window screen and secured the window.
• All residents identified at risk for elopement care plans were updated with interventions, as well as the facility's Elopement Binder by V9.
• V5 installed a self-locking doorknob on the north hall shower room, and secured the window so as not to allow opening.
• V5 and V13, Corporate Regional Director, confirmed the north exit door did not automatically open with 15 seconds of pressure.
• V9 completed Elopement Assessments on all residents of the Dementia Care Unit.
• V14, Minimum Data Set Coordinator, completed a Care Plan audit on all residents of the Dementia Care Unit to ensure Care Plans addressed elopement risk.
• V13 reviewed the Resident Supervision Policy with no changes made.
• V2 and V15, LPN/Assistant DON, completed staff education on resident supervision with all staff.
• V13 completed education for V5 regarding window and door security.
• V5 will complete window and door audits daily for one week, twice weekly for two weeks.
• V2 will complete a Facility Activity Audit to identify exit seeking behavior of residents daily for one week, twice weekly for two weeks, and weekly for 4 weeks.
• V9 will complete an audit of the Elopement Binder to ensure it is up to date according to Elopement Assessments daily for one week, twice weekly for two weeks, and weekly for four weeks.

Penalty

Inspection fine: $26,631

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

Summary

The facility failed to provide adequate nursing staff on the Dementia Care Unit, which affected all 25 residents living on that unit. The Director of Nursing (DON) confirmed that the standard staffing pattern was one nurse and two CNAs per shift, but acknowledged that this was not always achieved due to CNA call-ins. Staff interviews revealed that the unit was often staffed with only one nurse and one or two CNAs, which was insufficient given the residents' high level of care needs, including incontinence, mechanical lift transfers, total feeding assistance, and behavioral supervision. Staff also reported that requests for increased staffing were denied by corporate administration. Family and staff interviews further documented the impact of inadequate staffing, including difficulty finding staff to assist with resident care and supervision, and instances where family members were called to help manage resident behaviors. Assignment sheets confirmed that on multiple occasions, only one CNA and a shared nurse were present on the Dementia Unit during overnight shifts. The facility's own staffing policy required adequate staffing to meet resident needs and regulatory requirements, but documented staffing levels did not consistently meet these standards.

Penalty

Inspection fine: $26,631

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 promptly notify a resident's Power of Attorney (POA) and provide a comprehensive report following an elopement incident. The resident involved had diagnoses including Alzheimer's Disease and Hypertensive Heart Disease with Heart Failure, was severely cognitively impaired, and had a documented history of wandering and exit-seeking behaviors. The care plan included interventions such as redirecting the resident, notifying staff of exit-seeking tendencies, providing diversional activities, and conducting 30-minute checks. On the date of the incident, the resident was found by an off-duty police officer approximately 0.2 miles from the facility, sitting in a vehicle with visible injuries including a laceration on the left eyebrow and abrasions on the hands, wrists, and elbows. The resident was disoriented, unable to state his address, and was subsequently transported to the emergency department for evaluation. Medical records confirmed the injuries and noted that the resident had escaped from the memory care unit, tripped, and fallen on the street before being returned to the facility. The facility did not notify the resident's POA until after the resident had returned from the emergency department, several hours after the elopement and subsequent injuries occurred. The POA reported being upset about not being informed when the facility first became aware of the elopement and not receiving full details of the event. Facility policy required prompt assessment and notification of a resident's designated medical contact in the event of a change in condition, which was not followed 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 safely transfer residents according to their Transfer Assessments and Care Plans, resulting in falls and injuries. One resident, who had severe cognitive deficits and required substantial assistance for transfers, fell during a transfer from the toilet to a wheelchair. The resident's wheelchair brakes were not properly locked, leading to a fall that resulted in a fractured rib and dislocated shoulder. The resident had a history of impulsive behavior and agitation, which contributed to the incident. Another resident, diagnosed with cerebral palsy and requiring maximal assistance for transfers, fell when a CNA attempted to transfer her without applying necessary interventions such as shoes, socks, and a leg brace. The resident's legs gave out during the transfer, and she was lowered to the floor by the CNA. The resident was not injured, but the failure to follow the care plan and use appropriate equipment was evident. A third resident, with moderate cognitive deficits and Parkinson's disease, fell during a transfer to a bedside commode. The CNA assisting the resident let go of the gait belt to adjust the resident's oxygen tubing, resulting in the resident losing balance and falling. The resident sustained minor injuries, including skin tears. The CNA was unaware that the resident required assistance from two staff members for transfers, highlighting a lack of adherence to the care plan and proper communication among staff.

Penalty

No penalty information released

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

Summary

The facility failed to provide sufficient staff to meet the needs of all 78 residents, particularly in providing care for Activities of Daily Living (ADL) and supervision during meals. This deficiency was observed through multiple instances where residents did not receive scheduled showers or bed baths due to staffing shortages. For example, one resident, who is dependent on two-person assistance for transfers, reported not receiving a shower for over a month and only occasionally receiving bed baths. Another resident, also requiring substantial assistance, similarly reported not receiving regular showers or bed baths, with staff confirming that showers were missed due to insufficient staffing. Additionally, the facility failed to provide adequate supervision during meal times, leading to incidents where a resident with cognitive impairments took food from other residents' plates. This lack of supervision resulted in residents not receiving their dietary requirements, as seen when one resident's meal was taken by another, and the replacement meal did not meet the original dietary specifications. Staff acknowledged the issue, noting that additional help would be beneficial to ensure residents receive proper assistance during meals. The facility's Director of Nursing and several Certified Nurse Assistants confirmed the staffing issues, noting that the facility technically had enough staff according to census but still struggled to meet residents' needs. The documentation discrepancies, such as incorrect charting of shower tasks, further highlighted the staffing inadequacies. The facility's policy mandates regular showers and adequate staffing to meet residents' needs, yet these were not consistently met, as evidenced by the observations and interviews conducted during the survey.

Penalty

No penalty information released

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

Summary

The facility failed to provide dignified dining services and maintain resident rights for four residents with cognitive impairments, including dementia and communication deficits. One resident, who was unable to complete a mental status interview, repeatedly took food from other residents' plates during meal times. This resident, who required supervision or assistance with eating, was observed taking ham from the plates of three other residents, all of whom also had cognitive impairments and required dietary accommodations. The incidents occurred despite the presence of staff, who were aware of the resident's behavior but did not prevent it. The facility lacked a policy for resident rights, and staff were observed attempting to address the situation only after the food was taken. In one instance, a Certified Nurse Aide offered a replacement meal to a resident whose food was taken, but the replacement did not match the original dietary order. The facility's staffing policy indicated that adequate staffing should be maintained to meet residents' needs, yet the repeated incidents suggest a failure to adequately supervise and protect residents during meals. The facility administrator confirmed the absence of a policy for resident rights, highlighting a systemic issue in addressing and preventing such deficiencies.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate assistance with activities of daily living, specifically eating and bathing, for several residents. Resident R55, who is cognitively intact but dependent on assistance for bathing, reported not receiving a shower for over a month due to staffing shortages. Despite being scheduled for showers twice a week, documentation showed multiple instances where the activity did not occur, and staff confirmed the lack of sufficient personnel to provide the necessary care. R55 expressed a willingness to receive bed baths but noted that these were also infrequent. Resident R63, with severely impaired cognition, also did not receive regular showers or bed baths as required. The care plan indicated a need for substantial assistance, yet documentation and staff interviews revealed that showers were often missed due to inadequate staffing. R63 reported not remembering the last time he received proper bathing care, and observations noted poor hygiene, including oily hair and body odor. Staff acknowledged the challenges in providing care due to the limited number of CNAs available during night shifts. Residents R71 and R52 experienced issues with meal assistance. R71, who requires supervision and assistance with eating, was left with her meal covered and unattended for an extended period, resulting in her not eating until a new tray was provided. Similarly, R52, who is dependent on assistance for eating, waited over an hour before receiving help with his meal. The facility's policy on maintaining adequate staffing was not adhered to, leading to these deficiencies in resident care.

Penalty

No penalty information released

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

Summary

The facility failed to properly identify specific medical conditions or symptoms that necessitated the use of a physical restraint for a resident, referred to as R71, who was part of a sample of 50 residents. R71, who has diagnoses including dementia, type 2 diabetes mellitus, and anxiety disorder, was observed with a seatbelt restraint while in a wheelchair. The Minimum Data Set (MDS) for R71 indicated that restraints and alarms were not used, yet the care plan documented the use of a seatbelt due to cognitive decline and safety risks. The care plan also specified that the restraint should be removed during activities of daily living, dining, and leisure activities, but observations showed that the seatbelt was not undone during meals, and R71 did not attempt to remove it herself. Observations over several days revealed that R71's seatbelt remained fastened during meal times, and she did not make any movements towards her food or the seatbelt. Interviews with staff, including a Certified Nurse Aide and the Administrator, indicated uncertainty about when the seatbelt should be undone and whether R71 could remove it on command. The facility's policy on restraint use emphasized the need for ongoing documentation and assessment, including recording the duration of restraint use and attempts to reduce its use. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and assessment for R71's restraint use.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident with a mental illness diagnosis was referred to the appropriate state-designated authority for a Level II PASARR evaluation. The resident, identified as R48, was admitted with diagnoses of visual hallucinations and bipolar disorder. The initial Level I PASARR form indicated a need for a Level II evaluation due to the mental health conditions. However, the Level II evaluation was not conducted because the facility staff believed the diagnoses were related to other medical conditions such as Parkinson's disease and Lewy body disease. The Social Service Director (SSD) was unaware of the new bipolar disorder diagnosis and did not initiate a new Level I screen or the necessary Level II evaluation. The facility's policy requires coordination with the PASARR program to ensure appropriate placement of residents with serious mental disorders. Despite this policy, the staff did not notify the SSD of the new bipolar diagnosis, leading to a failure in conducting the required Level II PASARR evaluation. This oversight resulted in non-compliance with the PASARR requirements for residents with mental health conditions, as the resident did not receive the necessary evaluation to determine the need for specialized services.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision to a resident, identified as R28, during mealtime, which led to multiple incidents of the resident taking food from other residents' plates. R28, who has diagnoses including dementia, anxiety disorder, and dysphagia oropharyngeal phase, requires a mechanically altered diet and supervision or assistance with eating. Despite these needs, R28 was observed on several occasions taking regular consistency food, specifically ham, from other residents' plates and consuming it, which is not suitable for her dietary requirements. These incidents occurred over a period of time during a single mealtime, indicating a lack of adequate supervision. Staff members, including a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN), acknowledged that R28 has a history of taking food from other residents and requires constant redirection. The facility's policy on consistency modified diets emphasizes the need for individualized diets based on residents' chewing and swallowing abilities, which was not adhered to in R28's case. Additionally, the facility's staffing policy states that adequate staffing should be maintained to meet residents' needs, which was evidently not sufficient in this instance, as R28 was able to repeatedly access inappropriate food items without proper intervention.

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 the diet as ordered for three residents, leading to deficiencies in meeting their nutritional needs. Resident 28, who has dementia and dysphagia, was observed receiving broccoli pieces that were not mechanically soft as per her dietary order. This inconsistency in food preparation could potentially impact her ability to safely consume her meals. Resident 71, who has dementia and a BMI less than 20, also received broccoli pieces that were not minced as required for her mechanical soft diet. The Dietary Manager acknowledged that the spreadsheet used for meal preparation did not differentiate between regular and mechanical soft diets, leading to the oversight. This failure to adhere to dietary orders could affect the resident's nutritional intake and overall health. Resident 66, who is at risk for impaired nutrition and hydration, did not receive finger foods as ordered. Instead, she was served mashed potatoes and gravy, which are not suitable as finger foods. The Dietary Manager admitted that the facility lacked a finger food menu, and the Registered Dietician was unaware of this issue. This lack of appropriate menu planning and execution could hinder the resident's ability to maintain adequate nutrition.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to proper infection control practices during resident care, as observed in the actions of a Licensed Practical Nurse (LPN) and other staff members. The LPN did not wash or sanitize her hands between administering medications to multiple residents, even after handling used medication and water cups by their rims. This lapse in hand hygiene was acknowledged by the LPN, who admitted to being nervous and unaware of her failure to sanitize. The Director of Nursing confirmed that hand sanitization between residents is a standard practice expected of the nursing staff. Additionally, the facility did not implement enhanced barrier precautions for a resident with an open wound and an indwelling urinary catheter, despite signage indicating the need for such precautions. Both a Wound Care Nurse and a Certified Nursing Assistant performed care without donning protective gowns, contrary to the facility's policy. Although both staff members had received training on enhanced barrier precautions, they were unable to explain the principles or demonstrate proper adherence. The Director of Nursing acknowledged the need for further training on infection control procedures and enhanced barrier precautions.

Penalty

Inspection fine: $98,98248 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 respond to residents' requests for assistance in a timely manner, impacting the dignity and quality of life for three residents. Resident R3, who is cognitively intact and requires a mechanical lift for transfers, experienced significant delays in receiving assistance, leading to discomfort and humiliation from sitting in urine and feces. R3 reported waiting up to four hours for assistance on weekends, causing pain in the coccyx area and anxiety about when help would arrive. Resident R6, with moderate cognitive impairment and requiring substantial assistance for transfers, also experienced delays in care. R6 reported waiting over an hour for call lights to be answered, which exacerbated pain due to existing wounds and the inability to reposition independently. R6 emphasized the need for more staff, particularly on weekends, to address these delays. Resident R7, who is cognitively intact and at risk for pressure ulcers, faced similar issues with delayed responses to call lights. R7 reported waiting up to an hour for assistance, which worsened pain in the coccyx area. Staff shortages were noted as a significant issue, with only two CNAs available to care for 34 residents on certain days, leading to extended wait times for residents needing assistance.

Penalty

Inspection fine: $98,98248 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 sufficient staffing levels to meet the needs of its residents, as evidenced by multiple instances of delayed response to call lights and inadequate care. Resident R3, who is cognitively intact and requires assistance with transfers, reported waiting up to an hour and a half for assistance, leading to pain and incontinence. On one occasion, R3's call light was observed to be unanswered for nearly an hour, and R3 expressed that the lack of staff was a consistent issue, particularly on weekends. Resident R6, who has moderate cognitive impairment and requires substantial assistance, also reported waiting over an hour for care, which exacerbated his discomfort due to existing wounds. Similarly, Resident R7, who is at risk for pressure ulcers, stated that the facility's staffing issues resulted in long waits for care, including the application of necessary creams to manage his condition. These delays in care were attributed to insufficient staffing, particularly on weekends, as noted by both residents and staff members. The facility's staffing records and interviews with staff members, including the Director of Nursing and Certified Nursing Assistants, confirmed the ongoing staffing challenges. The facility's policy requires adequate staffing to meet residents' needs, but the actual staffing levels often fell short, with call-ins and unfilled positions exacerbating the issue. The facility's failure to update staffing schedules accurately further complicated the situation, leading to inadequate care and unmet resident needs.

Penalty

Inspection fine: $98,98248 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 maintain the kitchen in a clean, sanitary, and pest-free condition, which has the potential to affect all 85 residents. During a kitchen tour, several issues were observed, including the absence of paper towels at the handwashing sink, jelly packets, and cereal pieces on the storeroom floor, and food particles, dust, dirt, and debris scattered throughout the kitchen. Dead bugs, including roaches, were found on a paper bait trap and behind the oven. Additionally, bones were found on the floor under a metal table, and a towel under a leaking sink was brown and speckled. The Dietary Manager, V5, stated that the morning and evening staff are responsible for cleaning the kitchen, but was unaware of the bugs, debris, and bones on the floor. The facility's pest control measures were inadequate, as V1, the Temporary Administrator, acknowledged the presence of roaches in the kitchen and stated that the pest control company had been spraying routinely. However, the Pest Control Employee, V17, noted that cleanliness was an issue and that bugs would not be attracted to bait with food particles present. The facility's cleaning schedule policy, dated February 2012, requires a comprehensive cleaning schedule to be posted and monitored, but V5 admitted to discarding the old schedule after creating a new one. Despite the expectation for the kitchen to be cleaned continuously, the facility failed to adhere to its cleaning and sanitation policies, resulting in unsanitary conditions.

Penalty

Inspection fine: $98,98248 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 maintain an effective pest control program, resulting in the presence of roaches and bed bugs, which could potentially affect all 85 residents. The issue began when a resident was admitted with bed bugs, and the problem was exacerbated when the resident's family brought in clothes infested with bed bugs. Despite initial attempts to isolate the issue by moving the resident's roommate and conducting tape tests, the facility did not follow its policy due to the inability to locate it on the server. The pest control company was eventually called to treat the affected rooms, but the treatment was delayed. In the kitchen, the facility had ongoing issues with roaches, as evidenced by food debris and dead bugs found on the floor and behind equipment. The pest control company had been conducting routine treatments, but the problem persisted due to cleanliness issues. The pest control employee noted that the presence of food particles hindered the effectiveness of the bait traps. Despite assurances from the pest control company that a new treatment plan would resolve the issue, the facility continued to struggle with maintaining a clean environment, which contributed to the pest problem. Interviews with staff revealed that the facility had a history of pest issues, with staff reporting sightings of bugs in the kitchen and dish room. The facility's pest control policy required routine inspections and monitoring, but the lack of cleanliness and delayed response to pest sightings indicated a failure to adhere to these procedures. The facility's inability to promptly address the pest issues and maintain a clean environment led to the deficiency noted in the report.

Penalty

Inspection fine: $25,662

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 physical abuse of a resident by another resident with a known history of aggression. Resident 1, who has severe cognitive impairment, was physically abused by Resident 2, who also has severe cognitive impairment and a history of aggressive behavior. Resident 2, who was admitted with diagnoses including Moderate Dementia with Agitation and Intermittent Explosive Disorder, exhibited aggressive behavior towards Resident 1 on multiple occasions. These incidents included slapping, choking, and hitting Resident 1, which were witnessed by staff and reported by Resident 1's family. Despite previous interventions, Resident 2 continued to exhibit aggressive behavior towards Resident 1, leading to two documented incidents of physical abuse. The facility's records and staff interviews confirmed that Resident 2 had physically attacked Resident 1 on at least two occasions, causing fear and insecurity for Resident 1. The facility's failure to effectively manage Resident 2's aggressive behavior and protect Resident 1 from abuse constitutes a deficiency in providing a safe environment for its residents.