Munster Med-inn

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 implement measures to prevent resident-to-resident verbal and physical abuse involving a cognitively impaired, dependent resident and his roommate, who had a documented history of behavioral disturbances. Resident B had multiple diagnoses including vascular dementia with behaviors, delusional disorder, psychotic disorder with delusions, intellectual disabilities, anxiety, chronic kidney disease, and a prior traumatic subdural hemorrhage. Behavior documentation over several months showed repeated episodes of verbal aggression, physical aggression toward staff, spitting on staff, yelling aggressive words in common areas, and making outbursts about killing. The Annual MDS documented that his behaviors significantly interfered with care and activities and posed a significant risk of physical injury and disruption of the living environment, and that his behaviors had worsened since the prior assessment. Despite this history, the care plan only identified verbal behavioral symptoms not directed toward others and included an approach to separate the resident from others as needed, without updating or expanding interventions in response to escalating behaviors. Behavior notes and medication administration records showed that Resident B repeatedly yelled at his roommate on multiple occasions, with PRN lorazepam administered for agitation and anxiety, but there was no documentation of additional non-pharmacological interventions or environmental changes. On one occasion, staff documented that Resident B was standing up, hovering over his roommate while yelling; staff assisted him back to bed and gave PRN lorazepam, but did not implement further interventions, did not move him to another room, and did not report this incident up the chain of command. The Memory Care Director, DON, and Nurse Consultant later indicated they were unaware of this event, even though facility policy required staff to report new or worsening behaviors and to document and address disruptive behaviors. Subsequently, Resident B and his cognitively impaired roommate, Resident C, who had dementia, anxiety, and Alzheimer’s disease and required substantial to maximal assistance with ADLs, were involved in an unwitnessed physical altercation in their shared memory care room. Staff discovered the incident when a CNA doing rounds found Resident B with blood on his clothing and Resident C with blood around his nose and redness and discoloration to the side of his face. Facility documentation and a police report indicated that Resident C was found in bed with a bloody face, multiple bruises, and swelling to the face and mouth area, and that he was initially unable to articulate what had happened. Hospital imaging later confirmed a depressed fracture of the anterior wall of the left maxilla with associated hemorrhage. Interviews revealed that the CNA assigned to the residents had heard yelling from Resident B earlier but did not check on him, believing nurses in the hallway would respond, and that the LPN on duty heard Resident B yell but did not assess him. Key leadership staff, including the DON and Memory Care Director, confirmed they had not been informed of the earlier hovering/yelling incident, despite existing behavior and abuse policies requiring reporting and intervention when behaviors were disruptive or potentially abusive. The facility’s own policies on behavior management and abuse prevention required staff who witnessed behaviors to report them to the resident’s care staff, document them, and, when disruptive to others, temporarily separate the resident from others. Policies also required that any incident or allegation involving abuse or neglect be investigated and reported to the Administrator within specified time frames. In this case, after the documented incident of Resident B hovering over and yelling at his roommate, there was no evidence that staff escalated the concern, updated the care plan, implemented separation or other protective measures, or ensured that leadership responsible for behavior oversight was informed. This lack of action and failure to follow policy allowed a resident with known, worsening aggressive behaviors to remain in the same room with a cognitively impaired, dependent roommate, culminating in a physical altercation in which Resident C sustained facial bruising, a bloody nose, swelling, and a fractured facial bone.

Removal Plan

• Implemented a plan of correction and held a quality assurance meeting with department heads
• Inserviced all staff on the different types of abuse and reporting abuse
• Inserviced staff on the behavior management program for residents with new or worsening behaviors, including when and who to report those behaviors to
• Separated the residents and moved Resident B to a private room on a different floor

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 report resident-to-resident verbal abuse and escalating behaviors by a resident with known behavioral issues (Resident B) toward his roommate (Resident C) to administration or appropriate supervisory staff. Resident B had multiple diagnoses including vascular dementia with behaviors, delusional and psychotic disorders, anxiety, and intellectual disabilities, and his most recent Annual MDS showed physical, verbal, and other behaviors that significantly interfered with care and activities and posed significant risk of physical injury and disruption to others. His care plan called for monitoring and documenting target behaviors such as violence or aggression toward others and separating him from others as needed when behaviors were disruptive. In early December, medication administration notes documented that Resident B was yelling at his roommate on at least two occasions and was given PRN lorazepam for agitation and anxiety. On 12/11/25, a behavior note documented that staff heard Resident B yelling, found him standing and hovering over Resident C while yelling, and assisted him back to bed, again administering PRN lorazepam. Despite this, there were no new interventions implemented, no change in room assignment, and no documented notifications to the DON, Administrator, charge nurse, Memory Care Director, or other responsible leadership regarding these behaviors. Staff later reported that Resident B “yelled all the time” and that the nurse on duty did not report the incident of hovering over the roommate to anyone, and key staff including the Memory Care Director, Nurse Consultant, and primary day-shift RN were unaware of the 12/11/25 incident. Both residents remained in the same room, and on 12/28/25 an incident note documented that Resident B and Resident C were involved in a physical altercation. The residents were separated and assessed; Resident B had no injuries, but Resident C was sent to the hospital and diagnosed with a depressed fracture of the anterior wall of the left maxilla with associated maxillary hemorrhage. The facility’s behavior management policy in effect at the time required staff who witnessed behaviors to report them to the resident’s care staff and document accordingly, and to temporarily separate residents if behaviors were disruptive to others. The failure to report and act on the earlier verbal and threatening behaviors, including the hovering and yelling over the roommate, led to a lack of interventions to prevent the later physical altercation that caused injury.

Removal Plan

• Implemented a plan of correction and held a quality assurance meeting with department heads
• Inserviced all staff on the different types of abuse and reporting abuse
• Inserviced staff on the behavior management program for residents with new or worsening behaviors, including when and who to report those behaviors

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 who was assessed as having no limited range of motion at therapy discharge received the recommended restorative services. Resident M, who had diagnoses including stroke, monoplegia of the right upper limb, and dementia, was repeatedly observed in bed with the right hand closed in a fist and unable to be opened or moved. No anticontracture device was observed in the hand during these observations. The resident’s record showed that the 12/2/25 MDS indicated cognitive intactness for daily decision making and functional limited ROM to one upper extremity, and the care plan identified risk for complications related to stroke. An OT evaluation and plan of treatment for 4/3/25 through 6/26/25 documented impaired ROM and strength in the right shoulder, elbow, and wrist, but no contracture at that time. The OT discharge summary recommended 24-hour care with a restorative program, including active ROM exercises for the left upper extremity and passive ROM to the right upper extremity. The restorative nurse stated she was unaware of the recommendation and said she would only evaluate residents when she received a restorative referral, sometimes picking them up and sometimes not. OT 1 stated the resident did not have a contracture in June 2025, was referred to restorative nursing, and was later evaluated and picked up for a right hand contracture.

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 mandatory Payroll Based Journal (PBJ) staffing information, based on payroll and other verifiable and auditable data, was electronically submitted to iQIES. Record review showed the CMS PBJ Staffing Data report for FY Quarter 4 2025 indicated the facility failed to submit the data. The deficiency was identified during survey review of nurse staffing information, and the issue involved the facility’s submission of staffing data for the quarter due on 11/14/25. During interview, the VP of Operations stated he could access the PBJ submission log for the 4th quarter and that iQIES showed a connection error with files failing to send. He reported that Nurse Consultant 2, the HR Director Consultant, and he reviewed schedules quarterly before submitting to iQIES. Nurse Consultant 2 stated she called iQIES on 12/17/25 and was told it was the facility’s responsibility to ensure the PBJ was transmitted and submitted. She also stated that she, the HR Director, and the VP of Operations met on 11/11/25 to finalize the 4th quarter PBJ, but she did not check to ensure the submission had gone through.

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 multiple failures to provide treatment and care according to physician orders and facility policy for several residents. For one resident with dementia, stroke history, and ADL self-care deficits, physician orders required the use of geri-sleeves on arms and legs to prevent skin tears and, after an incident in which the resident struck her arm on a bed rail and sustained two skin tears and an abrasion, daily wound care with normal saline, Xeroform, dry gauze, and kerlix until healed. Although incident and wound care notes documented the new skin condition and that wound care was to complete the treatment, the treatment administration record showed the ordered arm treatment coded as “9 (see nurse’s notes)” on two days, indicating it was not completed by the nurse, and there was no wound assessment documented in the wound round section as required by facility policy. Another deficiency occurred when a resident with diabetes and congestive heart failure experienced hypoglycemia. An alert note documented that the resident was found clammy and not his normal self, oxygen was applied, and a blood sugar of 47 mg/dl was obtained, after which 911 was called and the resident was transferred to the hospital with a diagnosis of hypoglycemia. The record did not show that the physician was notified or that any hypoglycemia interventions, such as providing carbohydrates or administering glucagon, were attempted prior to transfer, despite the facility’s hypoglycemia protocol directing staff to give glucose if the resident is conscious and to contact the physician when blood sugar is below 60 unless specific call parameters exist. Additional deficiencies involved medication administration and holding medications without physician parameters. During a medication pass, an LPN withheld ordered metoprolol and amlodipine for a resident with chronic respiratory failure, diabetes, breast cancer, blindness, and congestive heart failure because the diastolic blood pressure was below 60, even though there were no physician-ordered blood pressure parameters to hold these medications. For another resident with hemiplegia after stroke, diabetes, and ischemic cardiomyopathy, the medication administration record showed multiple blank entries for scheduled Lantus insulin and Humalog sliding scale doses with no notes or orders explaining the omissions, and repeated held doses of Entresto and metoprolol without any physician orders or parameters authorizing these holds, despite care plans directing that insulin and cardiac medications be administered as ordered.

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 residents were assessed for self-administration of medications and had physician orders permitting self-administration for 5 of 5 residents reviewed. Resident P, who was cognitively intact and had diagnoses including type 2 diabetes, anxiety, and a sacral pressure ulcer, was observed with a bottle of Rolaids on her overbed table. The resident stated she needed the Rolaids for stomach problems, but the record showed no self-administration assessment, no care plan related to self-administering medications, and no physician order for self-administration. The order in the chart was for calcium carbonate as needed for indigestion, but not for the resident to self-administer it. Resident 161 was observed with a plastic medication cup containing five pills left on a windowsill after the nurse had handed him the cup and left the room. He stated the nurse had initially brought his pills during breakfast, returned later, and left the medication with him after he told her to come back when he was finished eating; he then took only five pills and left the rest for later. His record showed diagnoses including type 2 diabetes, stroke, high blood pressure, heart disease, and dementia with moderate anxiety, but there was no self-administration assessment or physician order for self-administration. Resident 155 was observed with a cup containing eight pills on the nightstand while she was in the bathroom, and the cup was later taken to the nurse’s station and returned to the room for administration. Her record showed diagnoses including heart disease, anorexia, major depressive disorder, high blood pressure, and anxiety, and although a prior self-administration assessment said she could self-administer medications, it did not specify which medications and there was no order for self-administration before the observation. Resident Q stated that nurses often left his pills in a cup on the table and left the room, so he did not know what he was taking. His record showed diagnoses including Parkinson’s disease, emphysema, dementia, dysphagia, heart disease, high blood pressure, and anxiety disorder, and there was no order or assessment for self-administration. Resident X was observed self-administering an inhaler after an LPN placed it on the bedside table and left the room; the LPN later returned, removed the inhaler, and took it back to the medication cart. The resident’s record showed chronic respiratory failure and blindness, and there was no self-administration assessment or physician order for self-administration. The DON stated that a resident needed to be assessed as safe to self-administer medications before being allowed to do so, and the facility policy stated that the interdisciplinary team must determine that self-administration is clinically appropriate and identify which medications may be self-administered.

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 dependent residents received assistance with ADLs, including bathing, hair washing, facial hair removal, nail care, incontinence care, and feeding assistance. Surveyors observed multiple residents with unkempt or dirty hair, long or dirty fingernails, facial hair that had not been addressed, and meals left untouched for residents who required staff feeding. Record review showed that several residents were assessed as dependent or needing substantial assistance with bathing, personal hygiene, and eating, yet the documentation did not consistently reflect the care that was actually required or provided. Resident P stated she had not had a shower since admission and had only received bed baths, and her hair was matted in the back. Her record showed she was dependent on staff for showering and bathing, but the bathing documentation reflected only one shower in January and otherwise partial or complete bed baths, with no documentation of when her hair was last washed. Resident O was observed over several days with heavy facial hair on her chin and long fingernails with chipped nail polish, and she stated staff only washed and dressed her without asking about nail trimming or removal of facial hair. Her record showed dependence for showering, bathing, and personal hygiene, while the task documentation reflected repeated bed baths and nail care entries without corresponding evidence that the facial hair concern was addressed. Resident H was repeatedly observed with matted hair, and the record showed only two showers documented over several months, with no documentation that her hair was washed or that she refused care. Resident G reported her hair had not been washed in a long time and that incontinence care was not being provided frequently enough; during observation, she had dried urine in her brief, and the CNA acknowledged awareness that she should be checked and/or changed every two hours. Resident M was observed with matted hair, dry skin flakes, dirty long fingernails, and dirty ears, and during breakfast he was seen trying to eat with standard silverware despite being unable to use one arm and needing adaptive equipment. Resident K’s breakfast tray remained untouched while staff confirmed she needed to be fed, and Resident Q and Residents L and N were observed with long facial hair and dirty or greasy grooming conditions, with records lacking documentation of refusals or preferences that would explain the lack of care. Resident R was observed unshaven and stated he had not received a shower since admission, while bathing documentation for January showed no showers or baths recorded since admission.

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 proper medication storage when a syringe of normal saline was left at Resident P’s bedside stand even though the resident did not have a care plan for self-administration of medications and did not have a Self-Administration of Medication Assessment completed. Resident P’s record showed diagnoses including type 2 diabetes, need for assistance with personal care, anxiety, and a pressure ulcer of the sacral region, and the resident was cognitively intact on the Quarterly MDS dated 1/6/26. During interview, the Third Floor Unit Manager stated the resident was receiving IV antibiotics and the syringe of normal saline should not have been left in the room. The facility also failed to keep medication carts free of loose pills and residue on multiple units. During observations, loose pills were found in the medication cart drawers on the 5th floor Odd Hall, 2nd floor Odd Hall, 3rd floor Odd Hall, and 4th floor Even Hall medication carts, with dark, sticky spillage noted in the bottom drawers of the 3rd and 4th floor carts. Staff members observed with the carts stated it was the nurse’s responsibility to keep the carts clean, and one LPN indicated the cart drawers needed to be cleaned out. During an IV medication administration for Resident 145, an LPN left a prefilled saline syringe in the resident’s room after the medication was complete, stating she thought it was acceptable because there was no needle on it; the DON later stated the syringes should not be left in the resident’s room.

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 keep the kitchen clean and in good repair in the Main Kitchen and on the First, Second, Third, Fourth, and Fifth Floors. During a kitchen sanitation tour, surveyors observed dried spillage on the front door of the reach-in freezer that housed frozen health shakes, two sanitation buckets that registered zero parts per million of quaternary solution, lime buildup on the outside of the dishwasher, dirt and debris on the floor underneath the dishwasher, and food debris on the shelves of the cabinet next to the dishwasher. The Food Service Manager stated that the areas needed cleaning and that the sanitation buckets should have registered chemical solution. Surveyors also observed multiple food items in unit pantries that were not labeled and dated as required. In the Third Floor Pantry, there was dried red juice spillage on the bottom shelf of the refrigerator, a box of Kentucky Fried Chicken with no name and date, a ziplock bag of stale bread with a room number but no date, and two plastic containers of food with no name or date. In the Second Floor Pantry, a plastic container of food had a resident's name but no date. In the Fourth Floor Pantry, a covered brown plastic bowl with a yellow substance had no name or date, and a take-out container had a resident's name but no date. In the Fifth Floor Pantry, a bag of chicken wings was not labeled or dated. In the First Floor Pantry, a take-out container of soup had no name or date, and Refrigerator 2 had dried juice spillage. The Assistant Administrator stated that the food in the pantries was to be labeled and dated, and the facility policy required all resident foods and beverages brought from outside to be labeled with the resident's name and dated.

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 infection control practices were followed during resident care and staff movement in the building. During a random observation, a housekeeper was seen wearing the same pair of gloves while in the hallway, after exiting the soiled utility room, while pushing a cart, and while walking to and from the nurse's station. In interview, the Nurse Consultant stated the housekeeper should not have been wearing gloves in the hallway. During a partial bed bath for Resident 128, who had a PEG tube and was on Enhanced Barrier Precautions, a CNA donned gloves but did not wear an isolation gown. The CNA used the same gloved hands and the same wash water to provide face, underarm, abdominal, incontinence, oral, hair, and lotion care after finding a large amount of fresh bowel movement in the brief. Later, an LPN entered the room, donned gloves but not a gown, touched the PEG tube, flushed it, and started enteral feeding. In a separate observation on the 3rd floor, an LPN checked one resident's blood pressure, pulse oximetry, and temperature, then used the same equipment on five other residents without cleaning it between uses. The Infection Preventionist stated reusable equipment should be cleaned after each resident use, and the facility policy required gloves to be changed and hand hygiene performed before moving from a contaminated body site to a clean body site during 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 deficiency involves failure to follow ordered pressure ulcer treatment for one resident and failure to implement ordered heel offloading interventions for another resident. For one resident with diagnoses including a left humerus fracture and cellulitis of the left lower extremity, surveyors observed wound care to a small sacral pressure ulcer measuring approximately 0.5 cm. The physician’s order directed staff to cleanse the sacrum with normal saline and/or wound cleanser, apply skin prep to the surrounding skin, and cover with a hydrocolloid dressing. During the observed dressing change, the wound nurse cleansed the area with normal saline, patted it dry, and applied a hydrocolloid dressing, but did not apply the ordered skin prep. In a subsequent interview, the wound nurse confirmed that she had not applied the skin prep as ordered. The deficiency also includes failure to ensure heel offloading for another resident with a sacral/buttocks pressure ulcer and diagnoses including multiple sclerosis, cerebral infarction, and peripheral vascular disease. This resident was observed in bed on two occasions with a standard mattress and padded overlay, but without any pillow or padded boots in place to offload the heels; the resident’s feet were resting directly on the mattress. The resident’s MDS indicated cognitive intactness, bilateral range of motion impairment, and dependence for toileting and transfers. A physician’s order directed that the resident’s heels be suspended or offloaded while in bed. During an interview, the Unit 2 Manager acknowledged that the resident’s heels were not offloaded, stating that the resident did not like to wear the boots but that there should have been a pillow in place for offloading.

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 scheduled opioid pain medication was available and administered as ordered for a resident with significant pain-related conditions. The resident, who was cognitively intact, had diagnoses including diabetes mellitus, repeated falls, unspecified protein calorie malnutrition, and a stage 3 pressure ulcer, and had a pain care plan indicating use of pain medication for cancer of the left breast, chronic pain syndrome, and arthritis, with interventions to administer analgesics as ordered. A physician’s order directed that a fentanyl 50 mcg/hr transdermal patch be applied every 72 hours for pain, but the Medication Administration Records for November and December showed that the fentanyl patch was not administered on multiple scheduled dates, with Order Administration notes documenting that the medication was unavailable, a prescription refill was needed, or there was no script, despite indications that a new prescription had been obtained but not received by the pharmacy. During interview, the DON stated that the Nurse Practitioner should have been notified and a prescription obtained, and acknowledged that although a new prescription was received, the pharmacy did not receive it, resulting in missed doses of the ordered fentanyl patch.

Penalty

No penalty information released

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

Summary

The facility failed to honor a resident’s right to make choices regarding bathing preferences. The resident was cognitively intact, had diagnoses including multiple sclerosis, cerebral infarction, and peripheral vascular disease, and had range of motion impairment to both sides with dependence for toileting and transfers. The resident stated he preferred showers but was being given bed baths since having a stroke. The resident’s quarterly preferences indicated it was very important for him to choose between a tub bath, bed bath, shower, or sponge bath. Bathing records for November and December 2025 and January 2026 showed that he received only one shower and otherwise was given partial or complete bed baths, with one refusal documented. Staff stated the resident could no longer use the regular shower chair after his stroke because he needed a reclining shower chair that did not fit in the Unit 2 shower, although another staff member noted the Unit 1 shower was larger and could accommodate the reclining chair.

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 PRN anti-anxiety medications were not prescribed longer than 14 days and failed to ensure non-pharmacological interventions were attempted before administering PRN anti-anxiety medications for 2 of 6 residents reviewed. The deficiency involved Resident P and Resident B, both of whom had diagnoses that included anxiety and other significant medical and behavioral conditions. Surveyors reviewed records, medication orders, MARs, care plans, MDS assessments, and interviewed nursing staff and the DON. For Resident P, the record showed a diagnosis of anxiety and a care plan addressing use of anti-anxiety medication for anxiety disorder. The resident received Xanax 0.25 mg PRN for agitation or anxiety under successive physician orders that extended beyond 14 days, including orders dated 10/1/25, 11/26/25, and 12/27/25. The resident received the medication multiple times during each order period. During interview, the DON stated the PRN Xanax initially should have been ordered for 14 days at a time and that clarification would be obtained to determine whether it could be administered routinely. For Resident B, diagnoses included vascular dementia with behaviors, delusional disorder, intellectual disabilities, psychotic disorder with delusions, and anxiety. The care plan identified verbal behavioral symptoms and PRN anti-anxiety use for agitation and aggressive behaviors. The resident received Lorazepam under orders dated 10/9/25, 11/4/25, and 12/2/25, and the MAR documented multiple administrations with no non-pharmacological interventions attempted beforehand. During interview, the Nurse Consultant stated PRN anti-anxiety medications should only be ordered for 14 days, and an LPN stated she was aware staff were to try redirection or distraction before giving the PRN medication.

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 cognitively intact resident was involved in and informed of new medication orders entered by the physician as part of care planning. Resident 17, whose diagnoses included heart failure, dementia, high blood pressure, hypothyroidism, anemia, and osteoarthritis, stated during interview that she was given an iron pill but was never told who ordered it, and that after some labs were done the iron pill appeared with her daily medications. The record showed a physician order for Ferrous Sulfate 325 mg daily for low iron and a later order for Levothyroxine Sodium 150 mcg in the morning, but there was no documentation that the resident was notified of these medication additions or changes. The annual MDS dated 12/1/25 indicated the resident was cognitively intact for daily decision making.

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 professional standards of quality when a CNA removed the dressing from a resident’s sacral pressure ulcer during incontinence care. During observation, the Wound Nurse was preparing to provide wound care for Resident P, who was positioned on her left side and had no dressing on the sacrum when the nurse entered the room. CNA 5 stated she had just provided incontinence care and removed the dressing because it was soiled. The Wound Nurse then proceeded to treat the sacral area. Resident P had diagnoses including type 2 diabetes, need for assistance with personal care, anxiety, and a stage 4 pressure ulcer of the sacral region that was present on admission. The resident’s MDS indicated she was cognitively intact and had one stage 4 pressure ulcer. Her care plan included wounds to multiple areas, including the sacrum, and the physician’s order directed the sacral wound to be cleansed, treated with Anasept-soaked gauze, and covered with a dry dressing every day shift and as needed. The DON stated the CNA should not have removed the dressing to the resident’s sacrum.

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 an ongoing activity program was implemented for two cognitively impaired and dependent residents. One resident had diagnoses including bone and prostate cancer, vascular dementia with mood disturbance, stroke, and major depressive disorder. The annual and quarterly MDS assessments indicated moderate cognitive impairment, little interest or pleasure in doing things, and dependence on staff for bed-to-chair transfers. Although the care plan identified a variety of activity interests and included interventions to encourage participation, the resident was repeatedly observed in bed in his room with the television on, and the activity record showed only intermittent one-to-one contacts such as conversation and a ball activity over several months. The activity aide stated the resident had declined and was on hospice, and the Activity Director stated the resident no longer got out of bed and that one-to-one activities would be revised to reflect his current status. The second resident had diagnoses including Alzheimer's disease, type 2 diabetes, major depressive disorder, dementia, and protein calorie malnutrition. The significant change MDS indicated she was not cognitively intact, received hospice services, and it was very important for her to listen to music. Her care plan called for activities on a one-to-one basis and in small groups, with television or radio turned on when she was in the room for increased stimulation as tolerated. However, she was observed sitting in a broda chair staring forward with no TV or radio on, later in bed with no TV or radio on, and at other times in bed with a cartoon on the television or up in a broda chair in front of the nurses' station with no activity happening. The one-to-one documentation consisted of brief pop-in visits such as talking, watching TV, bringing magazines, or offering activities, and there was no resident response documented. The Activity Director stated she was unaware the care plan was not up to date, that the resident was now on hospice and not active in activities, and that staff needed education on the one-to-one visits.

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 for a resident with swallowing precautions. Resident M had diagnoses including stroke, dysphagia, COPD, chronic respiratory failure, dementia, and heart failure, and the record showed he required set-up assistance with eating, received a mechanically altered diet, and had coughing or choking during meals or when swallowing medications. During observations, he was seen eating breakfast in bed without staff present, despite meal ticket directions for supervision with meals, no straws, and to check his mouth after solids. A straw was observed in his water cup, and on another observation he fed himself without supervision, taking large bites of toast, eggs, and oatmeal and drinking thickened liquids without staff in the room. CNA 5 stated she was unsure whether he needed assistance and supervision, and the Unit Manager stated that self-feed with supervision meant someone had to be watching the resident eat. The facility also failed to keep a sharp object out of a resident's room on the memory care unit. A disposable razor was observed in a cup on the resident's over-bed table during multiple observations, and the resident stated he shaved himself. The resident had diagnoses including psychotic disorder, anxiety, dementia, and alcohol abuse, and the MDS showed moderate cognitive impairment and a need for moderate assistance with ADLs and transfers. The care plan identified that the resident became easily agitated with physical aggression and included interventions to remove objects that may be thrown to maintain safety. Another care plan noted the resident was at risk for complications related to antiplatelet therapy use and indicated use of an electric razor. The DON stated the resident should not have had a disposable razor in his room.

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

Provide enough food and fluids to maintain a resident's health was not met when Resident 16 did not receive the correct diet as ordered. On 1/20/26, the resident was observed in bed in his room when a staff member brought his lunch tray, which included meatloaf, mashed potatoes with gravy, and vegetables. The tray ticket indicated a Heart Healthy diet with double portions, and when the tray was observed by an LPN, it was noted that it was not a double portion. Record review showed Resident 16 had diagnoses including diabetes mellitus and dependence on renal dialysis, was cognitively intact, and needed set-up assistance for eating. A physician's order dated 11/10/25 indicated a CKD renal diet with regular texture, and there was no order for double portions. During interview, the Dietary Manager stated she had received an order that morning for CKD diet and had just changed the order, and that the previous order had been Heart Healthy diet; she also stated there was no order for double portions.

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 oxygen was set at the physician-ordered flow rate for 2 residents reviewed for oxygen therapy. Resident M, who had diagnoses including stroke, right-sided monoplegia, dysphagia, COPD, chronic respiratory failure, major depressive disorder, dementia, and heart failure, was observed wearing oxygen via nasal cannula at 0.5 liters per minute on 1/20/26 and at 1 liter per minute on 1/21/26, although the physician’s order dated 1/15/25 specified oxygen via nasal cannula at 2 liters per minute. The 12/2/25 MDS indicated the resident was cognitively intact for daily decision making and received oxygen while a resident, and the care plan revised on 12/12/25 identified oxygen therapy for respiratory failure with oxygen to be provided as ordered by the physician. Resident X, who had diagnoses including chronic respiratory failure, diabetes, blindness, and asthma, was observed wearing oxygen via nasal cannula set at 4 liters per minute on 1/20/26 and at 3.5 liters per minute on 1/21/26, despite a physician’s order dated 12/19/25 for oxygen via nasal cannula at 3 liters per minute continuously. The 12/19/25 MDS indicated the resident was cognitively intact for daily decision making, required substantial assistance with ADLs and moderate assistance with transfers, and had severely impaired vision. During interview, an LPN stated the resident’s oxygen should be set at 3 liters per minute, and the DON was informed of the finding and offered no additional information.

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 routine dental services for 1 resident reviewed for Dental Services. The resident stated during interview that he had only seen the dentist once since admission to the facility and later reported that his bottom lower teeth were breaking off and that he wanted to see a dentist. Observation showed the resident's lower teeth were broken and dark in color. The resident's record showed diagnoses including hemiplegia following a stroke, diabetes, adult failure to thrive, and need for assistance with personal care, and the 12/10/25 MDS indicated he was cognitively intact for daily decision making and dependent in ADLs and transfers. A physician's order dated 12/3/25 allowed services of an eye care physician, audiologist, dentist, and podiatrist, but the record lacked documentation that the resident had received or refused dental services since 2022.

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 clinical records that were complete and accurately documented when medication administration was incorrectly recorded for one resident. During a medication pass, the resident asked an LPN for Maalox and Miralax, stating both medications were listed on the MAR and were needed for different problems. The LPN prepared and administered Lactulose but told the resident it was Miralax, and when the resident questioned why it was not mixed with water, the LPN stated what was given did the same thing. The resident’s record showed diagnoses including chronic respiratory failure, diabetes, breast cancer, blindness, and congestive heart failure. The quarterly MDS indicated the resident was cognitively intact for daily decision making, required substantial assistance with ADLs, and had severely impaired vision. Physician orders listed Miralax 1 packet by mouth every 24 hours as needed for constipation, Maalox 5 ml by mouth every morning and at bedtime for constipation, and Lactulose 15 ml by mouth every 24 hours as needed for constipation. The January MAR documented that Maalox was administered, not Lactulose. The LPN later stated she gave Lactulose because Miralax was not on the MAR and said she signed out Maalox in error.

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 professional standards of quality in the care of residents with pressure ulcers. Certified Nursing Assistants (CNAs) were observed removing dressings from pressure ulcers, a task outside their scope of practice, as confirmed by both the Director of Nursing and the Indiana Nurse Aide Curriculum. In one instance, a CNA removed a soiled dressing from a resident's sacral wound prior to wound care being performed by the Wound Nurse, despite facility policy and state guidelines prohibiting CNAs from performing such actions. Additionally, Qualified Medication Aides (QMAs) were documented as having signed out and, according to interviews and records, performed wound care treatments for residents with stage 3 and stage 4 pressure ulcers. Physician orders specified detailed wound care regimens for multiple residents, but the Treatment Administration Records (TARs) showed that QMAs completed and documented these treatments on several occasions. The DON confirmed that QMAs are not permitted to perform pressure ulcer treatments, and facility policy only allows QMAs to perform minor skin treatments, such as those for stage 1 pressure ulcers. The residents involved had significant medical histories, including diagnoses such as osteomyelitis, vascular dementia, major depressive disorder, bone cancer, and diabetes, and were dependent on staff for care. The deficiencies were identified through observation, record review, and interviews, including a family member's report of witnessing QMAs performing pressure ulcer treatments. These findings demonstrate that unqualified staff performed wound care tasks, contrary to professional standards and facility 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

Surveyors identified that a resident with heart failure and hypertension received blood pressure medications, Coreg and Hydralazine, despite physician orders specifying these medications should be held if the resident's pulse was below 60. The Medication Administration Record showed that the medications were administered on multiple occasions when the resident's pulse was under the specified threshold. The Director of Nursing confirmed that the medications should have been withheld according to the orders. In another instance, a resident with multiple diagnoses, including bone cancer and diabetes, was observed with undated and soiled bandages on his feet and hip, with visible dried and fresh drainage. The resident's skin was noted to be very dry and scaly, and the Wound Nurse was unaware of any cream ordered for the dry skin, despite a physician's order for Aquaphor ointment. Review of the Treatment Administration Record revealed that a prescribed wound treatment for the left hip was not documented as completed for one evening shift, although the Aquaphor application was signed out as completed. Additionally, a third resident with vascular dementia and multiple pressure ulcers was found with outdated and incorrect wound dressings on the left knee and hand. The Wound Nurse discovered that the foam dressing in place was not the oil emulsion bandage ordered by the physician, and the bandages were not dated. The Treatment Administration Record indicated that treatments were signed out as completed, but the actual dressings in place did not match the physician's orders. The Director of Nursing acknowledged that wound and skin treatments should be performed as ordered.

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 pressure ulcer treatments were completed as ordered for three residents with pressure ulcers. For one resident with a history of osteomyelitis and stage 4 sacral pressure ulcer, the wound nurse was observed using Dakin's solution instead of the physician-ordered Anasept for wound care, and the treatment administration record (TAR) showed missed documentation of treatments on several days. The wound nurse also did not follow the correct treatment protocol for the resident's right ankle, and the director of nursing confirmed that the treatments should have been completed as ordered. Another resident, who was dependent on staff for bed mobility and had multiple comorbidities including bone cancer and diabetes, was observed with undated and soiled bandages on his left hip and both feet. The left heel bandage, which should have been changed according to updated physician orders, was found to be old, with dried blood and necrotic tissue present. The wound nurse could not verify if the bandage had been changed since the order update, and indicated that wound care was not consistently performed on weekends. The director of nursing acknowledged that wound and skin treatments should be done as ordered. A third resident with vascular dementia and multiple pressure ulcers was observed with outdated bandages and received incorrect wound care. The wound nurse was unaware of a recent change in the treatment order for the right medial distal foot and did not apply the newly ordered Mupirocin ointment. The TAR indicated that treatments were signed out as completed on days when the correct treatment was not provided. The director of nursing confirmed that treatments should be administered as ordered by the physician.

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 and follow infection prevention and control guidelines during wound care for three residents. Observations revealed that the Wound Nurse did not consistently perform hand hygiene before and after glove removal, as required by facility policy. For example, during wound care for one resident, the nurse donned gloves without sanitizing or washing her hands, changed gloves multiple times without hand hygiene, and at times failed to wear a gown when enhanced barrier precautions were indicated. Supplies were also retrieved from outside the room without appropriate hand hygiene upon re-entry. In another instance, the Wound Nurse washed her hands and donned PPE at the start of wound care for a different resident but repeatedly changed gloves without performing hand hygiene between glove changes. The nurse was observed to be unaware of the requirement to perform hand hygiene every time gloves were removed, as confirmed during an interview. The Director of Nursing confirmed that hand hygiene should be performed before and after glove removal, in accordance with facility policy. A third resident's wound care was also observed with similar lapses. The Wound Nurse performed hand hygiene at the start and at certain points but failed to do so consistently between glove changes throughout the treatment of multiple wounds. The facility's hand hygiene policy, provided by the Director of Nursing, clearly stated that hand hygiene is required before and after glove removal, but this was not followed during the observed wound care procedures.

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 and assistance to a dependent resident, resulting in a fall and a left femur fracture. Resident B, who required total assistance for bed mobility, was being repositioned by only one staff member when the incident occurred. The resident had a history of falls and was at high risk, as indicated by a Fall Risk Evaluation and a Care Plan that noted the need for staff to anticipate and meet the resident's needs. During the incident, two staff members, a CNA and a QMA, were initially present to provide care. However, the QMA left the room to get more towels, leaving the CNA alone with the resident. The resident, who was on an air mattress, began to slide off the bed. The CNA, who was not familiar with the resident, attempted to assist but was on the opposite side of the bed and had to run around to help ease the resident to the floor. The resident was found sitting on the floor with complaints of knee pain and was later diagnosed with an acute fracture of the left femur. Interviews with staff revealed that the CNA was a float CNA and not familiar with the resident's care needs, which required care in pairs. The Director of Nursing confirmed that the CNA should have moved to the resident's side of the bed when the QMA left the room. The facility did not provide a policy related to the incident prior to the exit of the surveyors.

Penalty

27 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 the safety of mechanical lift straps before transferring a dependent resident, resulting in a significant accident. During a transfer, the sling straps of a mechanical lift broke, causing a resident to fall and sustain a left femur fracture. The resident, who was cognitively impaired and dependent on staff for mobility, had a care plan indicating a risk for falls. However, there was no documentation that the mechanical lift sling straps were checked for damage prior to the transfer, and the facility's investigation revealed that the straps were not inspected before use. Additionally, the facility did not maintain safe hot water temperatures on two of its floors. Observations revealed that the water temperature in several rooms exceeded 120 degrees Fahrenheit, reaching as high as 137 degrees. The Maintenance Supervisor acknowledged that the water was hotter on the upper floors due to the boiler's location and admitted to checking the water temperatures daily. However, the thermostats were set incorrectly, leading to dangerously high water temperatures. The facility's policies and procedures were insufficient in ensuring the safety of residents, as evidenced by the lack of specific guidelines for inspecting mechanical lift slings and maintaining appropriate water temperatures. The failure to properly inspect equipment and regulate environmental conditions contributed to the incidents, highlighting deficiencies in the facility's safety protocols.

Penalty

27 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 cleanliness and proper sanitation in the main kitchen, which had the potential to affect 154 of 155 residents. During a kitchen sanitation tour, surveyors observed several issues, including dirty convection ovens with grease and burned food spillage, a scoop left inside a sugar bin, and dirty sides of food preparation and steam tables. Additionally, transportation carts were found with dried food spillage, and the freezer had significant ice buildup. Reach-in coolers were also dirty, with dusty vents. The Food Service Manager acknowledged the need for cleaning, and the Maintenance Director suggested the ice buildup might be due to improper door closure. Further observations revealed improper food handling practices. A dietary staff member used the same pair of gloves to handle various items, including bread and milk cartons, without changing them, which was observed by the Food Service Manager. Another dietary aide was seen stacking clean but wet plates and dome lids, which was against the facility's policy. The Administrator was aware of the kitchen's condition and acknowledged that the Food Service Manager should have intervened during the improper glove usage. The facility's infection control policy emphasized proper handwashing and avoiding contamination, which was not adhered to in these instances.

Penalty

27 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 invite and hold care planning conferences for residents and/or their family members, and did not update care plans to reflect residents' preferences, such as wearing a hospital gown. For instance, Resident 1 was observed wearing a hospital gown during multiple observations, but the care plan was outdated and did not reflect the current preference. Interviews revealed that the care plan had not been updated in the new computer system due to time constraints. Resident 9's son reported receiving few invitations to care conferences, and the facility did not attempt to reschedule when he was unavailable. The resident's record showed no documentation of a care planning conference in the past year. Staff interviews indicated a misunderstanding that care plan meetings were not necessary if the family did not attend, even for cognitively impaired residents. Other residents, such as Residents 129, 141, 72, and 31, also lacked documentation of care planning conferences. Some residents had not had a care plan meeting since admission, and there was no evidence of invitations being extended. Staff interviews highlighted a lack of awareness and follow-up regarding the necessity of holding care plan meetings, regardless of family attendance or resident cognitive status.

Penalty

27 days payment denial

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

Summary

The facility failed to provide adequate ADL care for four residents, resulting in long and dirty fingernails and untrimmed facial hair. Resident 1, who was severely impaired for daily decision-making and dependent on staff for personal hygiene, was observed multiple times with long fingernails despite documentation indicating nail care was provided. Interviews revealed that the CNA responsible had not cut the resident's fingernails, and the Unit Manager was unaware of the issue. Resident 6, who was cognitively intact but required substantial assistance with personal hygiene, reported having long and dirty fingernails and facial hair. Despite documentation of nail care being completed, observations confirmed the resident's complaints. The CNA was unaware of the resident's condition, and the Unit Manager clarified that the activity department was not responsible for nail care. Resident 129, who was cognitively intact but needed maximal assistance for personal hygiene, was observed with long and dirty fingernails and facial hair. Although nail care was documented, there was no record of shaving. The Unit Manager confirmed that nails and facial hair should be groomed as needed. Similarly, Resident 116, who was severely impaired and dependent on staff for all ADLs, was observed with long, dirty fingernails and facial hair. Despite documentation of nail care, the DON acknowledged that grooming should have been performed.

Penalty

27 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 properly prepare pureed diets for residents, which could potentially affect all 10 residents who required such diets. During an observation, a dietary staff member was seen preparing pureed bread without a recipe, using 27 slices of bread and 32 ounces of milk, which deviated from the recipe provided by the Food Service Manager. The recipe specified 10 slices of bread, 3 cups of milk, and 1/2 cup of melted margarine for 10 servings. The Food Service Manager was present but did not intervene during the preparation. In another instance, the same dietary staff member prepared pureed baked chicken without a recipe, using 4 cups of chicken broth for 4 cups of diced chicken, contrary to the recipe which called for 2.5 pounds of chicken and 1 cup of broth for 10 servings. The Food Service Manager again did not intervene. The facility's Administrator acknowledged that the dietary cook was new and that the dietary manager should have instructed her to follow the recipe.

Penalty

27 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 a clean and well-repaired environment for residents, staff, and the public, as evidenced by multiple observations and interviews. Dirty floors, toilets, walls, tube feeding poles, ceiling vents, overflowing garbage cans, and debris in light fixtures were noted across various rooms on the 2nd, 3rd, 4th, and 5th floors. Specific instances included an overflowing garbage can with personal protective equipment in a resident's room, dried bowel movement on a toilet seat, and dirty tube feeding poles. Family members reported persistent urine odors and unclean floors, with some resorting to cleaning the rooms themselves. The Environmental Tour further revealed issues such as gouged door frames, debris in light fixtures, and stained, sticky floors. The kitchen was also found to be in poor condition, with dirty floors, walls, and piping under the dish machine. Observations during the Kitchen Sanitation Tour highlighted adhered dirt, dried food substances, and black scuff marks on the kitchen floor, as well as dried food spillage on walls and ceilings. The Food Service Manager acknowledged the need for cleaning. These deficiencies were documented in relation to Complaint IN00445179, indicating a systemic issue with cleanliness and maintenance throughout the facility.

Penalty

27 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 dignity of three residents by allowing them to be exposed from their doorways and wearing inappropriate clothing during the day. Resident 91 was observed multiple times seated in his wheelchair wearing only a shirt and an incontinence brief, visible from the hallway with the door open. Despite being moderately impaired for daily decision-making and requiring assistance for dressing, there was no care plan addressing his preference for not wearing pants. The Assistant Director of Nursing acknowledged the absence of a care plan for this resident. Resident 120 was repeatedly observed in bed wearing a t-shirt and an incontinence brief, with his legs uncovered and visible from the hallway due to the privacy curtain not being pulled. Although his care plan indicated a preference for minimal clothing, it lacked specific interventions to ensure his dignity. The Assistant Director of Nursing noted the need to update the care plan if the resident preferred the privacy curtain to be pulled. Resident 92 was found wearing a hospital gown during the day without a care plan indicating this preference, despite being dependent on staff for dressing. Interviews revealed that the Social Service was responsible for updating care plans, but no such plan existed for this resident.

Penalty

27 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 develop and implement a comprehensive care plan for a resident receiving anti-anxiety medications. Resident 139, who has diagnoses including type 2 diabetes mellitus, hypertension, and depression, was noted to be mildly cognitively impaired and was receiving anti-anxiety and antipsychotic medications as per the Quarterly Minimum Data Set (MDS) assessment. A Physician's Order indicated the resident was to receive ABH gel, a hospice medication for agitation, applied topically twice a day for agitation and aggressive behavior. The Medication Administration Record confirmed the administration of this medication. However, there was no current care plan addressing the use of anti-anxiety medication for agitation or aggressive behaviors. During an interview, the Director of Nursing acknowledged the absence of a specific care plan for the anti-anxiety medication, despite the existence of an antipsychotic medication use care plan and an asthma care plan that mentioned anxiety medication as needed.

Penalty

27 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 properly assess and monitor non-pressure skin injuries for three residents, leading to deficiencies in care. Resident 56 was observed with a reddish/purple discoloration on his left hand, but there was no care plan addressing this bruising. The Weekly Skin Observation form did not document the bruising, and it was only after an observation by the Assistant Director of Nursing that a physician's order was obtained to monitor the bruise every shift. Resident 79 had a large open area on his left upper jaw, which was not covered during multiple observations. Despite having a care plan for a scabbed area due to a history of cancer, there was no care plan addressing the resident's behavior of removing the dressing. The resident was noted to pick at the area, increasing the risk of infection, and refused to keep the dressing on, which was not addressed in a care plan until 10/16/24. Resident 6 was observed with a bruised area on her left upper arm, but there was no documentation of this in the nursing progress notes. The resident, who was on anticoagulant therapy, had a care plan to observe and report bruising, but the CNA task section showed no areas checked for over two weeks. The bruise was only assessed after it was brought to the attention of the RN and the Second Floor Unit Manager, who noted the bruise matched the height of the wheelchair armrest.

Penalty

27 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 implement preventative measures to avoid the development of pressure ulcers in a resident, specifically behind the ears and on the left side of the nose, due to the improper use of oxygen tubing. During an observation, the resident was seen without shoes and not wearing his oxygen, and upon further inspection, dried blood was found behind both ears. The resident reported pain in these areas, which had been present for some time. The oxygen tubing was noted to be tight, causing indentations on the resident's face, and there were no padded protectors on the tubing to prevent skin breakdown. The resident's medical history includes chronic obstructive pulmonary disease, chronic respiratory failure, heart failure, heart disease, anxiety, palliative care, dependence on oxygen, and chronic pain. Despite having a care plan indicating the potential for pressure ulcers, the facility did not have an order for protective padding for the oxygen tubing. The last skin assessment did not mention any pressure ulcers, and the facility's policy required daily observation for skin breakdown, which was not effectively carried out. The wound nurse and unit manager were unaware of the pressure ulcers until they were pointed out, indicating a lapse in communication and monitoring.

Penalty

27 days payment denial

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

Summary

The facility failed to ensure that enteral tube feedings were administered at the correct times for a resident who relied on a PEG tube for nutrition. On the morning of the observation, the resident's tube feeding was running at 70 ml/hr with a bottle dated from the previous day, indicating it should have been stopped at 6:00 a.m. A new bottle, dated for the current day, was present but not in use until later that morning. The Qualified Medication Aide (QMA) confirmed that she had started the new tube feeding and changed the tubing during the medication pass. The resident in question had multiple diagnoses, including hemiplegia, stroke, depression, dementia, anxiety, dysphagia, and diabetes, and was severely impaired in daily decision-making. The care plan indicated the resident was at risk for malnutrition and required tube feeding for all nutrition and hydration. Physician's orders specified the tube feeding schedule, which was not adhered to, as evidenced by the discrepancy in the feeding times. The Director of Nursing acknowledged the concern but did not provide additional information.

Penalty

27 days payment denial

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

Summary

The facility failed to ensure that a resident's oxygen was maintained at the correct flow rate as per the physician's order. Resident 120, who has diagnoses including dementia with behavior disturbance, psychotic disorder with delusions, chronic obstructive pulmonary disease (COPD), and is oxygen dependent, was observed multiple times with the oxygen concentrator set below the prescribed 4 liters per minute. Observations on different days showed the oxygen concentrator set at 3 liters, 3 1/2 liters, and below 4 liters, which did not comply with the physician's order for continuous oxygen at 4 liters per minute. The resident's care plan, which was reviewed and dated earlier in the year, indicated the need for oxygen therapy due to conditions such as congestive heart failure (CHF), COPD, and a recent history of pneumonia. Despite this, the Assistant Director of Nursing, during an interview, mentioned that he had been checking the resident's oxygen daily and found it set at 4 liters, suggesting the possibility that the resident might have been adjusting the flow rate themselves. This inconsistency in maintaining the prescribed oxygen flow rate led to the deficiency noted in the report.

Penalty

27 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 complete and accurate documentation of clinical records for two residents. For Resident 139, the medication order for ABH gel, a hospice medication for agitation, lacked documentation of the strength, dosage, or amount to be administered. Despite this, the Medication Administration Record (MAR) indicated that the medication was administered twice daily. The Director of Nursing confirmed that the medication label contained the necessary information, but the Physician's Order in the computer system was not updated to reflect this. For Resident 113, the facility did not update medication orders to reflect the resident's NPO (nothing by mouth) status. The resident, who was severely impaired and reliant on tube feeding, had orders for oral medications, including Xanax and Norco, which were documented as administered despite the NPO status. The Director of Nursing acknowledged the discrepancy and indicated that the orders would be changed to align with the resident's dietary restrictions.

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 the necessary treatment and services to promote healing for pressure ulcers. Resident D, who had diagnoses including heart failure, chronic obstructive pulmonary disease, and peripheral vascular disease, was discharged to the hospital with two stage 3 and two stage 4 pressure ulcers. The care plan for Resident D, dated March 26, 2024, included interventions such as administering treatments as ordered and monitoring for effectiveness. However, a physician's order dated April 11, 2024, for treating a stage 4 pressure ulcer on the right heel was not updated or implemented as required. A wound physician note from April 18, 2024, indicated the need for an additional treatment order for a daily oil emulsion, but there was no documentation of this updated order being implemented. During an interview, the Director of Nursing confirmed the absence of documentation for the updated treatment order. The facility's policy on treatment and services to prevent and heal pressure ulcers emphasized the need for necessary treatment and services consistent with professional standards to promote healing and prevent new ulcers. This deficiency was related to a specific complaint, IN00436912.

Penalty

No penalty information released

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

Summary

The facility failed to follow dietary recommendations for a resident with a gastrostomy tube, identified as Resident H. The resident had a history of dysphagia, presence of a gastrostomy, and aphasia, and was severely impaired in daily decision-making. The care plan required quarterly evaluations by a Registered Dietician (RD) and adjustments to the tube feeding as needed. A physician's order initially prescribed Glucerna 1.2 at 55 ml/hr for 20 hours, which was later discontinued. On 6/13/24, the RD recommended increasing the feeding rate to 65 ml/hr due to the resident's weight loss and recent above-the-knee amputation. However, there was no documentation indicating that this recommendation was addressed. Further review revealed that by 6/27/24, the RD again noted the potential benefit of increasing the feeding rate to meet the resident's nutritional needs. Despite this, the feeding rate remained unchanged until a new physician's order on 6/29/24, which implemented the RD's earlier recommendation. The Director of Nursing stated that new treatment orders or RD recommendations should be implemented within 72 hours, but the facility's policy allowed for implementation within five working days. This discrepancy in following the RD's recommendations contributed to the deficiency cited in the complaint.