Rock River Health 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 deficiency involves the facility’s failure to ensure the safety and adequate supervision of a dependent resident during a community pass. The resident was a quadriplegic, paralyzed from the neck down, dependent on staff for all care, and required a mechanical lift for transfers. Her assessments documented extensive care needs, lack of cognitive impairment, and that she was not capable of unsupervised outside pass privileges. A Community Survival Skills assessment indicated she was not sufficiently able to navigate safely in the community, and several items related to self-harmful behavior, adherence to pass policies, and following rules could not be determined. The discharge planning review identified that her physical and mental health problems increased her vulnerability and that she would likely suffer from lack of proper care and could become a victim or perpetrator of abuse/neglect in a less structured setting. Despite these documented limitations, the resident left the facility on a community pass with a male individual described by staff as her boyfriend or ex-boyfriend, who had reportedly just been released from jail or prison. Staff accounts show that earlier in the day the resident repeatedly stated she was going to leave and that her boyfriend was coming to get her. In the evening, after dinner, the man arrived, and staff assisted the resident with putting on her coat and preparing to leave. Staff questioned whether the man understood that the resident was paralyzed from the neck down and required complete care, and he reportedly stated he was aware of her care needs. Staff observed him take her out of the building and wheel her across the street to a city bus stop, and they expressed concern among themselves about who would be caring for her once she left. No medications were sent with her, and there was no physician order in place authorizing community access. The facility’s documentation and communication around the resident’s departure were incomplete and inconsistent. The sign-out sheet at the facility entrance contained an undated sign-out for the resident with an illegible signature for the party accepting responsibility, and the resident’s record contained no notes on the day she left indicating that she was going out on pass, with whom she left, or when she was expected to return. Nursing staff reported varying understandings of curfew expectations, with references to an 8 p.m. return time and an alleged agreement with the Administrator for a midnight return, but there was no clear documentation of these arrangements. When the resident did not return, staff discussed among themselves that she had called saying she would be back by midnight and that if she did not return she should be admitted to a hospital, but there was no indication in the record that law enforcement or family were promptly notified. The Administrator and charge nurse later stated that staff should have contacted the non-emergency police line and family when the resident failed to return, but this was not documented as having occurred. The resident ultimately did not return to the facility and was later admitted to an acute care hospital with a diagnosis including fluid overload.

Removal Plan

• Re-educate all staff on ensuring the safety of a dependent resident during community pass.
• Re-educate all staff on notifying law enforcement when a resident fails to return to the facility at the designated time.
• Re-educate all staff on completing an audit of residents with pass privileges for appropriateness related to resident care needs while out on pass.
• Re-educate all staff on ensuring resident contact information is available prior to going out on pass.
• Re-educate all staff on ensuring residents are aware of expectations for return to the facility.
• Educate new hires on the community pass systems prior to starting on the floor.
• Provide on-the-spot education as needed regarding community pass processes.
• Re-educate staff not present in the facility via phone prior to the beginning of their next shift and obtain signed education sheets.
• Social Services/DON to complete an audit of residents with pass privileges for appropriateness related to resident care needs while out on pass, including an audit of contact information.
• Implement a QAPI audit tool to audit weekly the community survival skills assessment for appropriateness and safety related to care needs while out on pass.
• Implement a weekly audit of residents who sign out on pass to ensure they returned at the designated time or that police were called.
• Implement a weekly audit to ensure resident contact information is available prior to going out on pass.
• Ensure residents are aware of expectations for return to the facility via a resident handout and resident council meeting.
• Implement a weekly audit to verify residents received and understand expectations for return to the facility.
• Analyze audit results and present analysis through QAPI quarterly.
• Conduct a root cause analysis to identify barriers and further education needed.
• Complete an Ad Hoc QAPI to review systems and analyze the root cause analysis.
• Have the QAPI Committee determine whether audits will continue after the initial audit period.

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 received a urology consultation as ordered following hospitalization for sepsis due to urinary tract infection (UTI). The resident had multiple sclerosis (MS), neuromuscular dysfunction of the bladder, and required an indwelling urinary catheter due to urinary retention. Hospital records from a stay ending on 12/19/25 documented that the resident was discharged back to the facility with an order for referral to a urologist. The resident’s power of attorney reported concerns about multiple UTIs and hospitalizations and stated that the resident was supposed to see a specialist but that she never received any update from the facility. A registered nurse stated that the local urology office did not accept the resident’s insurance and acknowledged that neither the physician nor the family were notified that the urology consultation ordered on 12/19/25 did not occur. The director of nursing confirmed that the resident had recurrent UTIs requiring hospitalizations and should have been referred to a urologist for bladder management and ongoing care due to these recurrent infections, but this referral and evaluation were not completed.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident’s safety during care by not providing adequate supervision and assistance during a transfer, resulting in a fall. On 11/21/25, an LPN (V3) reported that while passing morning medications, a CNA (V4) asked her to come to the resident’s (R1’s) room, where R1 was upset and angry as V4 was about to get him up for breakfast. When V3 entered the room, R1 was holding onto the side rails, turned over to his left side, and then fell over the side rails. The LPN stated she did not know why the CNA was alone attempting to get R1 up. R1’s fall incident report documented that R1 turned over too quickly and flipped himself over the side rails, and listed predisposing physiological factors including resistance to care, weakness, agitation, anxiety, involuntary movements, and decreased strength. R1’s care plan, which identified him as at risk for falls related to multiple sclerosis with contractures, tremors, impaired cognition, impulsivity, psychiatric diagnosis with behaviors, and self-care deficits, specified that he was dependent in ADLs, required total assistance with hygiene and dressing, needed two staff for turning and repositioning, and required transfers with a mechanical lift with two staff. The DON (V2) confirmed that R1 was at high risk for falls due to MS and required two staff assistance for all care for safety. The deficiency centers on the facility’s failure to follow the resident’s care plan and provide the required two-person assistance and mechanical lift during transfer activities, as evidenced by the CNA being alone with the resident at the time of the incident and the subsequent fall over the side rails.

Penalty

Inspection fine: $23,625

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 obtain accurate and timely weights, follow dietician recommendations for weekly weights, and communicate nutrition-related issues for a cognitively intact resident with a G-tube, end-stage renal disease on dialysis, oral cancer, and Type 2 diabetes. The resident initially received continuous Nephro tube feeding at 40 ml/hr while NPO, then was hospitalized and later readmitted with orders for an oral diet plus bolus tube feedings four times daily. The dietician assessed the resident and documented that tube feeding provided approximately 88% of estimated caloric needs and recommended weekly weights due to changes in diet and tube feeding orders. However, no admission/readmission weight was obtained upon return, and no weight was documented for the week of the dietician’s assessment, contrary to facility policy and the dietician’s recommendation. Weight records showed a documented weight of 135 lbs early in the month, followed by a later documented weight of 101.4 lbs and then 101 lbs, reflecting a significant weight loss over a short period. The dietician stated she was not notified of these weights when they were first recorded and only discovered the 12/5 weight herself in the electronic record the day before the survey, at which point she requested a reweigh. The dietician also reported that she was not informed of the resident’s refusals or missed bolus tube feedings, even though the progress notes and MAR showed at least one documented refusal and multiple missed feedings without documentation of refusal or notification. The resident reported sometimes not receiving tube feedings when feeling too full and specifically stated that tube feedings were not given as supposed to be over a weekend. The restorative nurse later produced a revised weight report in which previously documented weights were crossed out and replaced with weights obtained from dialysis records, acknowledging that the CNAs’ earlier weights could not be verified and that the facility had been unaware of the dialysis weights until the night before. The nurse practitioner stated she was not notified of the resident’s significant and continued weight loss until the day before her exam, despite expectations that staff notify her promptly of excessive weight changes. Based on the combined original and revised weight records, the resident experienced a significant weight loss over a two-month period. These failures to obtain accurate and timely weights, follow ordered/ recommended monitoring, and notify the dietician and nurse practitioner of refusals, missed feedings, and significant weight loss contributed to the resident sustaining significant weight loss.

Penalty

Inspection fine: $23,625

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

Summary

The facility failed to employ a qualified certified dietary manager as the food service director, as required for the food and nutrition service. CMS Form 671 dated 12/8/25 documented that 81 residents resided in the facility. During an interview on 12/8/25 at 9:31 AM, the food service director (V13) stated he was not licensed as a certified dietary manager, explaining that he had taken the relevant courses at a local community college 7 to 8 years earlier, failed the certification exam on his first attempt, and had not retaken it. V13 reported that he completes initial and quarterly assessments of residents, while a contract dietitian performs all assessments on high-risk residents. Course certificates provided by the facility showed that V13 completed coursework in food nutrition therapy, food safety sanitation and human resource management, and management of food service operations, but verification with the Association of Nutrition and Foodservice Professionals showed there were no current certified dietary managers in the nation with V13’s last name. The facility’s job description for the Food Service Supervisor required either a Bachelor of Science degree in Foods and Nutrition from an accredited college or university, or graduation from a qualifying food service supervision course with at least 90 hours of classroom instruction and on-the-job counseling by a dietitian, which V13 did not meet as a certified dietary manager.

Penalty

Inspection fine: $23,625

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 failure to follow hand hygiene requirements in the kitchen during food service operations. Surveyors observed a dietary aide (V14) working in the dishwashing and food preparation areas who handled a garbage can lid, then immediately proceeded to handle clean and sanitized food service equipment without performing hand hygiene. After placing the lid onto the garbage can, V14 did not wash or sanitize their hands before picking up a clean, sanitized food service pan, carrying it to the storage rack, and placing it with other clean pans. During this time, V14 repeatedly placed their hands into the front pocket of a hooded sweatshirt and then removed them to perform additional tasks, still without any handwashing. Surveyors further observed that V14 continued to perform multiple tasks without hand hygiene, including responding to another staff member at the kitchen entrance, opening the cooler door, retrieving an item from the cooler, and handing it to the staff member. V14 then again placed their hands back into the sweatshirt pocket, took three large plastic bags, opened them to prepare for covering tray carts during service, and again returned their hands to the sweatshirt pocket, all without washing hands. The Food Service Director (V13) stated that kitchen staff are expected to wash their hands after touching the garbage can or lid and when completing different tasks. The facility’s kitchen handwashing policy dated 9/21/23 requires employees to wash hands before starting any task, after touching hair, face, or body, after taking out the garbage, and anytime hands are soiled.

Penalty

Inspection fine: $23,625

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 pureed pork was prepared to a smooth, pudding-like consistency for four residents on pureed diets, resulting in food that was chunky and required chewing. A facility diet report dated 12/8/25 showed that four residents were ordered pureed diets. On that date at 11:45 AM, a cook (V15) removed a pot from the stove containing seven servings of pork slices cooked in chicken broth, placed all pork slices into a blender pitcher, and added additional chicken broth to puree. At 11:48 AM, V15 added thickening powder to the pureed pork, and by 11:52 AM had finished blending and transferred the product to a food service pan. The finished pureed pork appeared chunky and not smooth, despite V15 stating that pureed foods should have a pudding-like consistency and not be too thick or too runny. At 1:00 PM, a surveyor and the Food Service Director (V13) tested a pureed test tray and found the pureed pork was not smooth and required chewing; V13 acknowledged it could have been cooked longer, blended longer, or made thinner to be easier to swallow and that it was not an appropriate texture. The facility’s Pureed Food Preparation policy dated 9/26/23 states that pureed food must be the consistency of pudding or mashed potatoes, which was not met in this instance.

Penalty

Inspection fine: $23,625

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 completion of a required Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for a resident admitted with known mental illness. The resident’s Facesheet documented an admission with multiple psychiatric diagnoses, including schizoaffective disorder, dementia, major depressive disorder, post-traumatic stress disorder, and generalized anxiety disorder. A PASRR report dated 10/2/24 indicated that a Level 2 PASRR evaluation was required for this resident, but the facility was unable to provide evidence that this Level 2 evaluation was ever completed. During an interview on 12/10/25, the Restorative Nurse stated that the facility had requested a Level 2 evaluation for the resident, but the evaluation was canceled when the evaluator went to the resident’s previous facility to conduct it. Despite this cancellation, there was no documentation showing that the Level 2 PASRR evaluation was subsequently completed after the resident’s admission. This failure occurred despite the facility’s own PASRR policy stating that it would request full and complete PASRR materials, including Level 1 and Level 2, from each referral source prior to or soon after admission.

Penalty

Inspection fine: $23,625

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 resubmission of a Level 1 Preadmission Screening and Resident Review (PASRR) evaluation before the expiration of a 60‑day approval period for one resident with a mental health diagnosis. The resident’s facesheet showed admission with a diagnosis of bipolar disorder. A PASRR Level 1 screening dated 1/24/24 authorized a nursing facility stay of 60 days or less and explicitly required that a re‑screening be performed by or before the end of that 60‑day period. However, the next PASRR document available in the record was a Level 2 evaluation dated 2/26/25, which was completed well beyond the 60‑day timeframe specified in the initial Level 1 approval. During an interview, the Social Services Director stated that PASRR is completed on admission and after a temporary approval expires, that hospitals usually complete the 30‑ or 60‑day temporary assessments, and that a new PASRR 2 is requested when there is a new mental illness diagnosis, but there was no evidence that a timely re‑screening occurred within the required 60 days for this resident. This deficiency centers on the lapse between the expiration of the resident’s 60‑day PASRR Level 1 approval and the subsequent PASRR Level 2 evaluation, with no documented re‑screening by or before the required deadline.

Penalty

Inspection fine: $23,625

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 schedule a specialist appointment as ordered and indicated for a visually impaired resident with Type 2 Diabetes Mellitus and diabetic retinopathy. The resident’s care plan dated 6/27/25 documented visual impairment related to these diagnoses. On 11/24/25, an in-house optometrist examined the resident and diagnosed bilateral cataracts, documenting that facility staff were to make an appointment with a glaucoma specialist. Subsequent review of the physician order report printed 12/9/25 showed no scheduled appointment with an optometrist specializing in glaucoma, and progress notes from 11/24/25 through 12/8/25 contained no documentation that such an appointment had been scheduled. During an interview on 12/8/25, the resident reported that vision had significantly worsened over the past six months and stated that although an eye doctor had recommended seeing a specialist for cataracts or glaucoma, no appointment had been made. On 12/9/25, the Social Services Director stated she was not aware of the referral from the in-house optometrist. The Charge Nurse, who reported being responsible for making outside appointments once notified, stated she had not received a referral from the Social Services Director and was unaware of the need for a glaucoma specialist appointment. On 12/10/25, the Administrator stated the facility did not have a policy on scheduling outside appointments for residents.

Penalty

Inspection fine: $23,625

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 low air loss mattresses were correctly programmed according to residents' weights for multiple residents with pressure injuries. One resident with a Stage 4 pressure injury to the coccyx had a care plan listing a pressure-reducing low air loss mattress as an intervention, with no documentation that the resident requested a specific mattress setting. The resident’s recorded weight was 101 lbs, yet observations on two consecutive days showed the mattress programmed for a 350-lb setting. Another resident with a Stage 4 pressure injury to the medial right knee also had a care plan including a low air loss mattress, with no documentation of any resident request for a specific setting. This resident weighed 81.4 lbs, but observations on two days showed the mattress programmed for a 400-lb setting. A third resident with pressure injuries to the left ischium and coccyx had a care plan that included a low air loss mattress as a pressure-relieving intervention, again without documentation that the resident requested a specific setting. This resident weighed 205.3 lbs, but observations on two days showed the mattress programmed for a 400-lb setting. The wound care nurse stated that low air loss mattresses should be programmed to the correct resident weight so the mattress can help heal or prevent pressure injuries, and that if the weight is set too high, the mattress will not reduce pressure to wound areas and can impede wound healing. The facility’s pressure injury prevention policy required following the manufacturer’s instructions for low air loss mattress use, and the operator’s manual directed staff to determine the patient’s weight and set the control knob to that weight setting.

Penalty

Inspection fine: $23,625

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

Summary

The deficiency involves the facility’s failure to ensure medications were administered as ordered by the physician and in accordance with facility policy, resulting in a medication error rate of 40% (12 errors out of 30 opportunities) during a medication pass observation. For one resident, a registered nurse prepared and administered a chewable aspirin 81 mg tablet in the morning, despite the physician’s order specifying aspirin enteric coated delayed-release 81 mg once daily for heart health. The Director of Nursing later confirmed that chewable aspirin should not be given when the order is for enteric-coated aspirin. For another resident, an LPN prepared 11 oral morning medications and placed the medication cup on the resident’s breakfast tray while the resident was seated in a chair with breakfast at the overbed table. The LPN then administered the resident’s insulin, left the room, documented the medications as administered in the computer, and moved the medication cart to another area of the building without observing the resident take the medications. Several minutes later, the medications remained on the breakfast tray, and the resident stated she needed to eat before taking them. There was no physician order authorizing this resident to self-administer medications. The Director of Nursing stated that a complete medication pass includes preparing medications, bringing them to the resident, and watching the resident take them, and that medications should not be left at the bedside for residents to take on their own. The facility’s policy requires medications to be administered per physician orders with verification of the right medication, dose, route, time, and resident identity.

Penalty

Inspection fine: $23,625

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

Summary

The deficiency involves the facility’s failure to ensure medications were securely stored and that residents did not self-administer medications without appropriate physician orders and assessments. One resident with Type 2 Diabetes Mellitus had active orders for Novolog insulin and Ozempic, but no physician order permitting self-administration or in-room medication storage. Surveyors observed this resident seated in bed with opened and partially used Novolog and Ozempic pens on the bedside table on two consecutive days. The resident stated he kept the medications at his bedside and administered them himself because he felt his medications were sometimes given late. The DON confirmed that residents are not permitted to have medications in their rooms or self-administer unless there is a physician order and an assessment confirming it is safe, and the Administrator confirmed that no self-administration assessment had been completed for this resident. A second resident had an order for Breo Ellipta inhalation aerosol powder, to be taken once daily with instructions to rinse the mouth and spit after use, but there was no order for self-administration or in-room storage. Surveyors observed this resident sitting on the side of the bed with the Breo inhaler on the bedside table; the resident reported having just used it and was unsure if anything needed to be done after taking the medication. The medical record contained no self-administration assessments, and the resident’s care plan did not address any desire or attempts to self-administer medications. An LPN stated that residents who self-administer must be assessed and have an order. Facility policies on administering medications and self-administration specified that medications may only be self-administered upon assessment and physician order, and that bedside storage is not permitted unless the resident has been assessed and found safe to do so, which had not occurred for these residents.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a comfortable temperature in a resident's room, resulting in the room temperature remaining above 81 degrees Fahrenheit for several hours. The resident, who had a diagnosis of chronic obstructive pulmonary disease and intact mental status, reported feeling uncomfortably hot for several days. Multiple temperature checks by both the surveyor and the facility administrator confirmed that the room temperature and the air coming from the wall air conditioner were consistently above 81 degrees Fahrenheit. The room did not have a portable air conditioner, and the built-in unit was not effectively cooling the space. The administrator stated that two out of four compressors for the facility's air conditioning system were not working, causing the system to operate at only 50% capacity. The facility was awaiting parts to repair or replace the compressors and was using portable air conditioning units in some areas to help maintain comfort. However, a portable unit was not present in the affected resident's room. The outside heat index was forecasted to be 104 degrees Fahrenheit on the day of the observations. The facility's policy indicated a commitment to ensuring resident comfort during hot weather.

Penalty

No penalty information released

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

Summary

A resident with a history of post-traumatic seizures, COPD, major depressive disorder, anxiety, and traumatic brain injury experienced a significant medication error related to the administration of seizure medications. On the morning of the incident, the resident exhibited unusual behavior by requesting to return to bed after breakfast, which was not typical for him. Shortly after being transferred to bed, the resident began experiencing seizure activity, prompting staff to call emergency services. Review of the resident's medication administration records (MAR) for June and July revealed multiple missed doses and refusals of prescribed seizure medications, including Phenytoin, Divalproex, Levetiracetam, and Aptiom. The medication cards also showed discrepancies between the number of tablets dispensed and those remaining, indicating that several doses were not administered as ordered. Interviews with nursing staff confirmed that the resident could be non-compliant with medication administration depending on his mood, and that staff would attempt to re-approach him if he initially refused. However, documentation practices were inconsistent, with staff acknowledging that if a medication was not signed off in the MAR, it was not given. The facility's policy required physician notification if three consecutive doses or a pattern of frequent refusals occurred, but there was no documentation of such notifications or grievances related to the resident's medication administration. The failure to ensure consistent administration and documentation of seizure medications resulted in a significant medication error for the resident.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to identify and document new skin alterations for a resident at risk for developing pressure wounds. The resident, a cognitively impaired male with a history of traumatic brain injury, bilateral lower leg amputation, lack of coordination, and unspecified dementia, was dependent on staff for most activities of daily living. During a skin check performed by the DON, two open areas were found on the resident's lower buttocks, both over previously healed pressure wounds. These areas were not listed on the facility's current list of residents with pressure wounds, and there was no documentation in the medical record of new skin assessments, orders, or progress notes related to these open areas. The resident had recently attended an appointment with a new primary care provider, during which two open areas were also identified by the provider's office nurse. However, the facility's records, including a shower sheet from the same day, only noted discoloration on the buttocks and did not document any open areas. The resident's care plan required daily and weekly skin checks, with instructions to notify the charge nurse of any new skin issues for further assessment and treatment. Despite these protocols, the new skin alterations were not promptly identified or communicated, resulting in a failure to provide appropriate pressure ulcer care and prevention.

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 safe and appropriate respiratory care by not maintaining or replacing CPAP machines and supplies for all five residents reviewed who required respiratory treatments. Observations revealed that residents were using old or unclean CPAP masks, tubing, and water tanks, with some equipment showing visible signs of wear, discoloration, or contamination. Residents reported that they had not received new supplies since admission, and some had to clean their own equipment with tap water, while others stopped using their CPAP machines due to ill-fitting masks provided by the facility. Record reviews showed that care plans and physician orders did not include specific instructions or time frames for replacing CPAP supplies. In several cases, there were no orders for CPAP devices or supplies at all, and care plans lacked any focus on respiratory device use. Staff interviews indicated a lack of knowledge regarding the appropriate cleaning and replacement schedule for CPAP equipment, and the facility's policies did not specify time frames for exchanging supplies. The infection control policy referenced the need to prevent and control infections but did not address CPAP supply management. The third-party medical equipment company's replacement schedule recommended regular replacement of masks, tubing, and water chambers, but this guidance was not reflected in facility practice or policy. Interviews with clinical staff, including nurse practitioners and the infection control preventionist, confirmed that supplies should be exchanged according to manufacturer guidelines to reduce infection risk, but acknowledged that this was not being done. The administrator stated that supplies were only ordered when requested by residents or staff, and was unaware of recommended replacement intervals.

Penalty

No penalty information released

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

Summary

The facility failed to protect two residents from physical abuse, resulting in one resident being kicked in the genitals and another being pushed to the ground, sustaining a fracture of the left femur. Resident 1, who has no cognitive impairment, was involved in an altercation with Resident 2, who has severe cognitive impairment and exhibits hallucinations and delusions. The incident occurred after Resident 2, who is known to become verbally aggressive and agitated, allegedly kicked Resident 1, prompting Resident 1 to push Resident 2, causing him to fall and fracture his femur. Staff interviews revealed that Resident 2 often becomes confused and aggressive, particularly in the evenings, and requires intervention to prevent escalation. On the day of the incident, staff heard yelling and found Resident 2 on the floor in pain, while Resident 1 claimed he acted in reaction to being kicked. The facility's policy emphasizes the residents' right to be free from abuse, yet the staff's inability to prevent the altercation indicates a failure to adhere to this policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the accuracy of medication administration records (MAR) for three residents, leading to blank spots on their MARs for specific dates. Resident 1's MAR had blank spots for multiple medications on two consecutive days, although the resident recalled receiving the medications. Resident 2's MAR also showed blank spots for the same dates, despite documentation indicating receipt of a controlled drug and the resident's confirmation of receiving medications. Resident 3's MAR had a blank spot for one day, with the resident confirming medication receipt. All three residents had varying mental statuses, with two being intact and one moderately impaired. The deficiency was attributed to a Licensed Practical Nurse (LPN) who admitted to administering the medications but failing to document them on the MAR. A Registered Nurse (RN) emphasized the importance of documenting medication administration as proof of delivery, noting that blank spots could cause confusion. The facility administrator acknowledged that blank spots on a MAR suggest that medications were not given, highlighting the critical nature of accurate documentation in medication administration.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that staff adhered to enhanced barrier precautions when providing care to a resident with an indwelling urinary catheter. Specifically, a Certified Nursing Assistant (CNA) was observed emptying the urinary catheter drainage bag of a resident without wearing the required personal protective equipment (PPE). The CNA was only wearing gloves and did not have on a gown or a splash guard, which are mandated by the facility's Enhanced Barrier Precautions policy for high-contact activities involving indwelling medical devices. The resident in question was on enhanced barrier precautions due to the presence of an indwelling urinary catheter and had a history of receiving antibiotics for a urinary tract infection, as noted in the December 2024 infection control log. The facility's policy, revised in August 2024, clearly states that gowns and gloves are the minimum PPE required during high-contact activities, with additional PPE such as a face shield recommended when there is a risk of splashes. The Infection Control Nurse confirmed that the staff should have worn gloves, a gown, and a splash guard when emptying the catheter drainage bag.

Penalty

Inspection fine: $17,540

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 perform a pain assessment and provide appropriate pain management for a resident admitted with a left tibia and fibula fracture. Upon admission, the resident did not receive her prescribed pain medication, oxycodone, as the facility's pharmacy was located two hours away, and the medication had not arrived. The resident reported severe pain, rated 10/10, and was not provided with the prescribed medication, leading to her return to the hospital for pain management. The facility had hydrocodone/acetaminophen available, but it was not administered until after the resident's hospital visit, despite the resident's report that it was less effective than oxycodone. The resident's pain assessment was not completed upon admission, and the first recorded pain assessment showed severe pain the following day. The Nurse Practitioner was aware of the situation and had written prescriptions for both hydrocodone/acetaminophen and oxycodone, but the facility did not have the oxycodone on hand. The resident's pain was not adequately managed, resulting in her request for emergency room transport due to uncontrolled pain. The facility's delay in obtaining and administering the appropriate pain medication contributed to the resident's distress and need for additional medical intervention.

Penalty

Inspection fine: $17,540

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 comply with the requirement of having a Registered Nurse (RN) on duty for at least 8 hours per day, 7 days a week, affecting all 74 residents. The CMS-671 application confirmed the presence of 74 residents in the facility. On specific dates, including April 28, June 2, and October 6, 2024, the facility's daily assignment sheets revealed that there was either no RN present or the RN was present for less than the required 8 hours. Specifically, on April 28, 2024, an RN was only present from 7:00 AM to 11:00 AM, totaling 4 hours. On June 2 and October 6, 2024, there were no RNs working at all. The Director of Nursing (DON) confirmed these findings and acknowledged the failure to meet the staffing requirement. The facility's policy, dated January 2024, mandates the presence of an RN for at least 8 consecutive hours daily, which was not adhered to, and the facility does not have a waiver for this requirement.

Penalty

Inspection fine: $17,540

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 the prescribed menu and recipe for the noon meal, affecting all 74 residents. On October 7, 2024, the facility's menu specified cheesy chicken baked penne, Italian blend vegetables, and mandarin oranges for the noon meal. However, the cook prepared a different meal for residents on puree diets, consisting of chicken, noodles, and broth, along with pureed carrots, instead of the specified menu items. For residents on regular diets, the cook served penne pasta in a red sauce with chicken, onion, and some cheese, but omitted green peppers due to unavailability and did not bake the dish as required by the recipe. The facility's standardized recipes, dated October 2, 2023, mandate that all recipes be followed as written to ensure consistent quality, portion size, and cost control. The dietary manager acknowledged that the menus and recipes should have been followed for all meals. The discrepancy between the prepared meals and the standardized recipes indicates a failure to comply with the facility's policy, resulting in a deficiency in meeting the nutritional needs of the residents as outlined in the menu.

Penalty

Inspection fine: $17,540

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 controlled substances were double locked, as required by their medication storage policy. During an observation on October 7, 2024, at 10:09 AM, it was noted that the medication refrigerator in the second-floor medication room was unlocked, with the lock placed on top of the refrigerator. This refrigerator contained liquid lorazepam, a Schedule IV controlled substance, prescribed to four residents. The Director of Nursing acknowledged that the refrigerator should have been locked. The facility's policy mandates that Schedule II-V medications must be stored in separately locked, permanently affixed compartments, which was not adhered to in this instance.

Penalty

Inspection fine: $17,540

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 residents with meals that were appetizing, appealing, and served at the preferred temperature. Multiple residents reported dissatisfaction with the food, noting that hot items were served cold and cold items were warm. There was a lack of menu options and alternatives, with some residents expressing frustration over the inability to request substitutions or receive meals that accommodated their dietary preferences or restrictions. For instance, a resident allergic to pork was only offered peanut butter and jelly as an alternative, while another resident who preferred vegetables over meat found the vegetables too poorly cooked to consume. Additionally, the facility's food service practices contributed to the deficiency. Residents reported receiving repetitive meals with little variety, and the portions were often insufficient, leaving them hungry. The absence of steam tables, which were previously used to keep food warm, resulted in meals being served cold, as confirmed by an LPN. The lack of communication about meal options and the inability to provide requested items further exacerbated the residents' dissatisfaction with the dining experience.

Penalty

Inspection fine: $17,540

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 requested drinks to six residents during their noon meal, despite having sufficient milk available. On the specified date, six residents requested milk, but the facility only provided milk to five residents, citing a kitchen policy that milk was not for lunch, only dinner. The LPN confirmed that the kitchen staff limited the milk supply to five, despite the dietary manager stating there was plenty of milk available and no restrictions on providing it. The residents' diet orders allowed for thin liquids with no dairy restrictions, yet they did not receive the milk they requested.

Penalty

Inspection fine: $17,540

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 dress a resident, identified as R2, in a dignified manner, which is a violation of the resident's rights to dignity and self-determination. On October 7, 2024, R2 was observed sitting in a wheelchair near the nursing station wearing pants with a 4-5 inch rip on the left inner thigh and a 2-inch rip on the right inner thigh. R2 expressed embarrassment about the condition of his pants. A Certified Nursing Assistant (CNA), identified as V7, confirmed that R2 was dressed by facility staff in the ripped pants after receiving a shower that morning. V7 stated that R2 is unable to dress himself and requires moderate to maximum assistance with dressing and grooming tasks, as noted in his current care plan. The Director of Nursing (DON), identified as V2, stated that residents' clothing should be clean, well-kept, comfortable, and free of holes, in accordance with the facility's dignity policy dated January 2023.

Penalty

Inspection fine: $17,540

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

Summary

The facility failed to maintain a clean and clutter-free environment in the shower room on the second floor, as observed on October 7, 2024. A resident reported the shower room was dirty and cluttered, which was confirmed by observations that included a towel and a pink basin on the floor, a razor face down in the corner, a rolled-up blue gown on the floor, cracked or peeling caulk, and a missing drain cover. The Director of Nursing acknowledged that the shower room should be organized, clutter-free, and clean, with no towels on the floor or old clothing present. Additionally, another resident's room was found to be dirty and in need of repairs. The baseboard was pulling away from the wall, and there was a black substance lining the corners of the room and baseboard. The wall appeared heavily stained with spilled liquids. The resident mentioned that cleaning was infrequent, and the room had been in this condition for a long time. The Administrator and Maintenance Director stated that they wait for rooms to become empty before conducting repairs. The facility's policy on maintaining a safe, clean, and comfortable homelike environment was not dated but emphasized regular cleaning, preventative maintenance, and timely repairs.

Penalty

Inspection fine: $17,540

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 wound care for a resident with a stage 4 pressure ulcer on the weekend shift. The resident, who had a wound on the left upper buttocks, reported that the wound nurse attended to the dressing five days a week, but if the dressing fell off over the weekend, it was not changed by the floor nurse. The Director of Nursing confirmed that wound care was documented in the Medication Administration Record (MAR) and that the floor nurse was responsible for dressing changes on weekends. However, the MAR for September 2024 showed empty boxes indicating that wound care was not performed on several weekends, specifically on Saturday 09/07/24, Sunday 09/08/24, Sunday 09/15/24, Saturday 09/21/24, and Sunday 09/22/24.

Penalty

Inspection fine: $17,540

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 adequately supervise residents to prevent a resident on a specialized diet from consuming inappropriate food. A resident, identified as R38, who was on a pureed diet due to swallowing difficulties, was observed eating snack cakes with a doughnut-like consistency. This occurred while an LPN was present but did not intervene or express concern. The resident reported that another male resident had given her the snack cakes. R38's medical records indicated she was placed on a pureed diet due to issues with swallowing and phlegm in her throat, which had previously necessitated an emergency room visit. Interviews with facility staff, including an LPN, a dietitian, and a speech therapist, confirmed that R38 was on a pureed diet due to her medical condition, which included spinal stenosis and difficulty swallowing. The dietitian and speech therapist both acknowledged that the snack cakes were not suitable for R38's diet. The facility's documentation on pureed diets indicated that cake consistency desserts should be soaked in milk, which was not done in this case, further highlighting the lack of supervision and adherence to dietary restrictions.

Penalty

Inspection fine: $17,540

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 monitor a resident while taking medications and did not document the administration of medications for another resident. In the first instance, a Licensed Practical Nurse (LPN) was observed administering morning medications to a resident by placing them in a cup and leaving them on the resident's meal tray without ensuring the medications were taken. The LPN left the room without monitoring the resident, who did not have an order to self-administer medications. The Director of Nursing confirmed that residents should be observed while taking medications unless they have a physician's order to self-administer, which this resident did not have. In the second instance, a resident reported not receiving their evening medications on specific dates. The Medication Administration Record (MAR) confirmed that several medications, including those for hypertension, edema, and diabetic polyneuropathy, were not documented as administered on multiple occasions. The Director of Nursing stated that nurses are required to sign the MAR when medications are provided, indicating a failure in documentation and potentially in medication administration for this resident.

Penalty

Inspection fine: $17,540

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

Summary

The facility failed to maintain a resident's room free of pests, specifically bugs, as observed in the case of one resident. On multiple occasions, black and red bugs were observed on the interior portion of the resident's room window. The resident reported the presence of wasps to an LPN, but the issue was not addressed promptly. The Director of Nursing acknowledged that resident rooms should not have bugs. However, the maintenance staff was not informed of the pest issue in the resident's room, and the pest control company present on-site did not address this specific room. The facility's pest control policy requires employees to report pest observations to their department heads, which was not followed in this instance.

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 received their scheduled pain medication and did not document the administration of medications on the Medication Administration Record (MAR) for two of the three residents reviewed. One resident, identified as R3, did not receive a scheduled dose of hydrocodone-acetaminophen because the medication was reportedly unavailable. The Licensed Practical Nurse (LPN) responsible for R3's care on the night in question stated that the medication was not included in the pharmacy delivery and was later found in the narcotic overflow storage area. Additionally, R3's MAR was blank for two days, although the resident confirmed receiving all medications, and the Controlled Drug Receipt indicated the medications were administered. Another resident, R1, had blank entries on their MAR for two separate days, despite the resident confirming receipt of all medications. The Registered Nurse (RN) responsible for R1's care admitted to administering the medications but failing to document them on the MAR. The facility's policy requires that medications be checked off on the MAR as given or indicate why they were not given, which was not adhered to in these instances.

Penalty

No penalty information released

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

Summary

The facility failed to ensure medications were reconciled for four residents, leading to missed doses of critical medications. On 5/21/24, a surveyor observed 20 individual packages of various medications in the second-floor medication room that were supposed to be administered on 5/12/24. The medications included seizure prevention drugs, antidepressants, and other essential medications. Licensed Practical Nurse (LPN) V6 confirmed that these medications should have been given at bedtime on 5/12/24 but were not. Resident R2 reported not receiving his seizure medications on multiple occasions, while R3, R4, and R5 also had medications that were not signed off as given on the same date. R5 had already been discharged and was unavailable for an interview. None of the residents' care plans indicated any refusals of medications, suggesting that the medications were simply not administered as required. The Director of Nursing (DON), V2, verified that LPN V5 was responsible for administering the evening and bedtime medications on 5/12/24. V2 acknowledged receiving a report from RN V4 on 5/13/24 about the medications still in the cart. V2 contacted V5, who admitted to possibly missing a few medications but claimed to have passed most of them. V2 also noted that V5 was new to the facility and had issues understanding her medication pass responsibilities. V4, who followed V5 on 5/13/24, confirmed finding numerous medications still in the cart from the previous evening and reported the incident to V2. V4 also mentioned that duplicate medications were not a factor in this case, as the pharmacy had not sent any duplicates for these 20 residents. The facility's policies and procedures require that medications be signed off in the Medication Administration Record (MAR) immediately after administration. However, V2 admitted that there were ongoing issues with nurses not signing off medications in the MAR, particularly with V5. The facility's pharmacy director, V11, confirmed that no duplicate medications were sent for the 20 residents in question. Despite the facility's policy and the pharmacy's procedures, the failure to administer and sign off medications as required led to significant lapses in care for the affected residents.