Phillips County Retirement Center

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 conduct resident-centered post-fall analyses and to implement timely, appropriate fall-prevention interventions for a cognitively impaired resident with multiple falls and serious injuries. The resident had dementia, anxiety, and osteoporosis, with documented memory problems, moderately impaired cognition, behavioral symptoms, rejection of care, and wandering. MDS assessments showed the resident required assistance with transfers and walking, self-propelled in a wheelchair, and had multiple falls, including falls with major injury. Despite these risk factors, the Cognitive Loss/Dementia and Falls Care Area Assessments triggered on 10/07/25 were not completed, and the care plan, while listing numerous generic fall-risk interventions, did not consistently reflect individualized analysis of why specific falls occurred. Across numerous documented falls, the facility’s fall investigations were incomplete or missing, and root cause analyses were not performed. For a fall on 08/05/24, the post-fall evaluation noted a non-injury fall, but the investigation lacked an RCA, and only a general intervention to place grip strips in front of recliners was documented. The facility could not provide any fall investigations or interventions for falls on 10/04/24, 11/01/24, and 12/23/24. For other falls on 10/03/24, 11/02/24, 12/22/24, and 12/28/24, investigations were provided but did not identify causal factors, and interventions such as assistance with gait belt and walker, toileting after evening meal, 15-minute checks, use of a recliner in the commons area, and placement in a low bed were initiated 18–22 days after the falls. A fall report dated 01/03/25 documented a fall with minor injury, but the progress notes contained no corresponding entry, and the fall report again lacked an RCA. The resident experienced a series of significant events related to falls and injuries that were not linked to timely, resident-specific analysis. After a non-injury fall on 12/23/24, the resident later reported increased pelvic, hip, and lower back pain, leading to x-rays that revealed a right greater trochanteric fracture. The resident was initially returned from the ED with non-surgical management orders, but the next day had another unwitnessed fall with right leg shortening and rotation, and was sent back to the ED where the fracture was found to be worse, further fractured, and dislocated, ultimately requiring surgery. A later fall on 02/12/25 resulted in left leg pain and outward rotation and was classified as a fall with major injury, yet the associated investigation again lacked an RCA. Additional falls on 07/10/25, 09/23/25, 10/25/25, 12/05/25, 12/14/25, and 01/08/26 were documented in post-fall evaluations, but the report does not describe completed, detailed causal analyses for these events. Facility processes and staff practices contributed to the deficiency. Floor nurses and CNAs reported they did not have access to the electronic care plan and relied on Administrative Staff C and Administrative Nurse D to determine and communicate fall interventions, often via shift report or an intervention book. Staff stated they did not create or implement their own fall-prevention interventions, and that the care plan book was often kept in an office, limiting access. Administrative Nurse D acknowledged that fall investigations were incomplete or missing, lacked root cause analysis, and that the facility did not have a fall packet to guide staff documentation. She also stated that IDT meetings to review falls and develop interventions were not consistently held within 24–48 hours and were now held only when possible due to scheduling conflicts. Administrative Staff C, a CNA, reported she was in charge of care plan interventions for falls, could revise care plans without DON approval, and that residents could go two to four weeks between a fall and the development of a new intervention, further demonstrating the lack of timely, resident-centered analysis and intervention after falls. The facility’s own Fall Prevention Protocol stated that each resident would receive services and care to ensure the environment remained as free from accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents. However, the pattern of missing or incomplete fall investigations, absence of root cause analyses, delayed implementation of interventions, and limited staff access to and involvement in care planning for falls shows that this protocol was not followed for this resident. The repeated falls, including those resulting in major injuries and surgery, occurred in the context of these systemic failures in post-fall assessment and individualized intervention planning.

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 provide required RN coverage for at least eight continuous hours daily and to employ a full-time RN as the DON. Surveyors observed the posted daily staffing sheets on three separate days and found no RN hours documented. Review of the facility’s Payroll Based Journal (PBJ) staffing data for FY Q4 2025 showed multiple dates across July, August, and September with no recorded RN hours. The facility’s own undated Registered Nurse policy stated that an RN would be employed for at least eight consecutive hours, seven days per week, but the documented staffing patterns did not reflect this requirement. Administrative staff confirmed that the facility had not had an RN serving in the DON role since 2023 and that the individual currently functioning as DON was an LPN enrolled in an RN program, with an anticipated completion date in the future. Administrative staff also confirmed the accuracy of the PBJ report for dates with no RN coverage and declined to review those dates with the survey team. They reported that the facility did not provide skilled services, stating those were provided by a neighboring hospital, and that the facility was actively but unsuccessfully recruiting RNs. The job description for the DON provided to surveyors did not specify that the DON must hold an active, unencumbered RN license, further evidencing the lack of a full-time RN in the DON role as required.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control program for its 29 residents, 12 of whom were included in the sample. Review of the Infection Control Log for tracking and trending infections from March 2025 through February 2026 showed no documentation of organism identification, duration of prescribed antibiotics, or the specific infections being treated, and the facility was unable to provide this information when requested. The Infection Preventionist, who was also an administrative nurse, reported that she only tracked which residents were taking antibiotics in the EMR and confirmed she could not provide tracking and trending data for antibiotic use. She stated that floor nurses were expected to open the infection document for tracking but were not completing the form, leaving her with only records of antibiotics that residents had taken for infections, without the additional required details. This practice did not align with the facility’s Infection Preventionist policy, which assigned responsibility for effective direction, management, and operation of the infection prevention program, including use of evidence-based practices and compliance with CMS and state regulatory requirements. No additional resident-specific medical histories or conditions at the time of the deficiency were provided in the report.

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 designate a qualified Infection Preventionist (IP) with the required training and certification to be responsible for the Infection Prevention and Control Program for a census of 29 residents. During the entrance conference, an administrative staff member identified an administrative nurse as the facility’s IP, stating she was a licensed nurse who had been completing continuing education in infection prevention. Documentation provided by the facility showed that this nurse had completed education on Enhanced Barrier Precautions and implementation of an antibiotic stewardship surveillance plan. In a subsequent interview, the administrative nurse confirmed she had been performing IP duties and participating in continuing education but acknowledged she did not hold an Infection Preventionist certificate, and that the facility’s plan was for her to take the course and obtain the certificate. The facility also had an undated antibiotic administration policy describing appropriate use and stewardship of antibiotics, but there was no evidence that a properly qualified and certified IP had been designated to oversee the infection prevention and control program.

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 complete required Care Area Assessments (CAAs) for multiple residents whose comprehensive Minimum Data Set (MDS) assessments triggered these areas. The facility had a census of 29 residents with 12 residents sampled, and record review showed that four residents’ annual MDS assessments had triggered multiple CAAs that were not completed. One resident’s annual MDS dated 09/28/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer/injury, and psychotropic drug use, but none of these CAAs were completed. Another resident’s annual MDS dated 10/07/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, behavioral symptoms, falls, pressure ulcer/injury, psychotropic drug use, and pain, which were also not completed. A third resident’s annual MDS dated 08/25/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, nutritional status, pressure ulcer/injury, physical restraints, and pain, but these CAAs were not completed. A fourth resident’s annual MDS dated 04/16/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, mood state, falls, nutritional status, dental care, pressure ulcer/injury, psychotropic drug use, and pain, and these CAAs were likewise not completed. During an interview on 03/10/26 at 4:06 PM, an administrative nurse acknowledged that the CAAs for these residents were missed, stated that the CAAs should be filled out to more accurately trigger care plan interventions, and noted she was still learning how to complete MDS assessments. The facility’s undated MDS Accuracy Audits policy documented a commitment to ensuring the accuracy, timeliness, and completeness of all MDS assessments.

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 found that the facility failed to ensure accurate completion of MDS assessments for five residents regarding the use of bedrails as restraints. For these residents, multiple Quarterly MDS assessments documented that bedrails were used as physical restraints on a daily basis during the look-back periods. Specifically, the MDS assessments dated 01/20/25, 11/25/25, 01/16/26, 02/15/26, and 12/20/25 each indicated daily use of bedrails as physical restraints. However, during an interview on 03/10/26 at 4:06 PM, Administrative Nurse D stated she had coded bedrails as restraints on the MDS for all residents whose beds had bedrails installed, regardless of whether the residents actually used the bedrails or whether the bedrails restricted their mobility. Administrative Nurse D further confirmed that, for the identified residents, the bedrails did not restrict mobility and therefore did not meet the definition of a restraint, despite being coded as such on the MDS. She also stated that her expectation was that MDS assessments accurately reflect each resident’s status. The facility’s undated “Minimum Data Set (MDS) Accuracy Audits” policy documented that the facility was committed to ensuring the accuracy, timeliness, and completeness of all MDS assessments, which contrasted with the inaccurate coding practice described.

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 ensure medications were stored securely in locked compartments accessible only to designated staff. The facility had a census of 29 residents, with one medication room, three medication carts, and one treatment cart. During an observation, a licensed nurse approached a medication cart parked directly outside the nurse's station, prepared medications in a small cup, locked only the computer screen, and then walked away from the cart, which remained unlocked. The cart’s lock was positioned outward, indicating it was not engaged and that the contents were accessible to anyone who attempted to open it. The nurse then entered a resident’s room down the hall, leaving the unlocked cart unattended and out of staff visual range. Upon returning, she logged back into the computer, prepared medications for another resident, again locked the monitor screen, closed the medication drawer, and walked down the hall into another resident’s room, once more leaving the cart unlocked and unsupervised. During interview, the nurse acknowledged that the medication cart and computer monitor should be locked every time they are left unattended. The administrative nurse also stated she expected staff to lock the medication cart before walking away. The facility’s Medication Labeling and Storage policy required all medications to be stored in a secure, locked location accessible only to designated staff.

Penalty

No penalty information released

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

Summary

Surveyors identified multiple infection prevention and control deficiencies involving respiratory equipment, personal protective equipment (PPE) use, and laundry handling. During an initial walk-through, one resident’s CPAP mask was found lying directly on the bedside table without being stored in a sanitary container. Three other residents’ nebulizer masks were also observed either on bedside tables or hanging over a side table and lying in a magazine rack, all without sanitary containers. Facility nursing leadership later stated that respiratory equipment should be rinsed, laid to dry covered, and then placed in a marked bag labeled with the resident’s name and date when not in use, which was not done in these cases. Surveyors also observed improper handling of dirty laundry and failure to follow Enhanced Barrier Precautions (EBP) PPE requirements. A CNA was seen carrying unbagged dirty laundry close to their uniform down a hallway to a dirty laundry barrel, contrary to the administrative nurse’s expectation that staff move the laundry tub to the resident’s door and avoid carrying dirty laundry next to their clothing. Another CNA was observed holding a graduated cylinder containing dark amber urine while wearing only gloves and no additional PPE, despite the resident having a urinary catheter and signage on the door indicating required PPE for EBP. Staff interviews confirmed that all CNAs had been trained on EBP and that a gown and gloves were expected for personal care of residents with urinary catheters. The facility was unable to provide a policy for EBP when requested, despite having written policies for respiratory care and laundry protocols.

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency related to resident dignity when a dependent resident with severe cognitive impairment was observed in a common TV area wearing only a green hospital gown with a white sheet over her lap. The resident’s EMR documented diagnoses including Alzheimer’s disease, dementia, aphasia, anxiety, pain, and major depressive disorder, and her most recent MDS showed a BIMS score of 0, indicating severely impaired cognition, and dependence on staff for all ADLs. While seated in a Broda chair in the TV room, the resident moved her hands up and down, raising her sheet and gown so that her white incontinence brief became visible to two male residents seated in the same area. Staff interviews confirmed that this situation was inconsistent with facility expectations and policy. A CNA stated the resident should have been dressed or completely covered and that residents should not be exposed to other residents. A licensed nurse stated residents should not be in the TV room wearing only a gown and sheet and should remain in their rooms until the bath aide was ready for them. An administrative nurse stated facility protocol required residents to be dressed and groomed before leaving their rooms, that residents should be fully dressed when in the TV area, and that incontinence briefs should never be exposed. The facility’s Resident Rights Policy documented that all residents have the right to a dignified existence and that all staff are responsible for protecting those rights, underscoring that the observed exposure of the resident’s incontinence brief in a public area constituted a failure to ensure dignity.

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 an as-needed psychotropic medication order for a resident included a required 14-day stop date or a specified duration with physician rationale for extended use. The resident had diagnoses of hypertension and diabetes mellitus and a BIMS score of zero, indicating severely impaired cognition, and required substantial to maximal assistance with all ADLs except eating. The MDS documented that the resident received an antidepressant, hypnotic, and antianxiety medication during the observation period. The Psychotropic Use CAA noted no adverse reactions to antidepressant treatment, and the care plan included goals for the resident to be free from medication side effects and symptoms related to black box warnings, with pharmacist consultation and education for the DPOA and the resident. Despite these care plan elements, the EMR orders showed lorazepam cream 0.5 mg to be applied every eight hours and as needed for dementia without a 14-day stop date or any specified duration. The EMR also lacked a physician’s rationale for the extended as-needed use of lorazepam. Nursing staff interviews confirmed that nurses taking orders were expected to inform physicians that as-needed lorazepam required a stop date and that the DON served as a second check for all orders. Administrative staff stated the facility’s policy was to follow regulations for as-needed psychotropic medications, but the facility did not provide an unnecessary psychotropic drug policy when requested by surveyors.

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 conduct a thorough, facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. With a census of 29 residents and a sample of 12 residents, surveyors reviewed an undated Long-Term Care Self-Assessment provided by administrative staff. The assessment did not identify specific staffing levels needed for each unit, nor did it specify the number of RNs, LPNs/LVNs, CMAs, and CNAs required based on unit, resident acuity, and census. It also lacked staffing levels for each shift, including evenings and weekends. The assessment did not fully document resident condition reports or any extenuating circumstances that would make those condition reports unusual. The assessment further failed to document staff competencies and skill sets necessary to provide the level and types of care needed for the facility’s resident population. It did not fully document contractual agreements with outside providers for services such as laboratory, radiology, therapy, hospital, or transportation, and it omitted contracts for lawn care and snow removal. Administrative staff reported that the assessment was reviewed annually, most recently on a specific date, and acknowledged that the facility did not have a vision or mission statement. The administrative staff member stated he was unaware that certain sections of the assessment (orange boxes) were required to be completed, confirmed that the staffing breakdown per unit was missing, and verified that unchecked competencies (including Safety and Missing Resident for all staff) indicated those staff were not responsible for those competencies. The facility’s own Facility Assessment Policy stated that the assessment was to be the foundation for determining staffing levels, competencies, and resources, and was to address resident care needs, staff competencies, and third-party contracts during normal operations and emergencies, but the completed assessment did not meet these requirements.

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, identified as R14, remained free from neglect, which placed him in immediate jeopardy. R14, who had diagnoses of paraplegia, spinal stenosis, and muscle weakness, required extensive assistance with activities of daily living and used a wheelchair for mobility. On a particular day, a Certified Nurse Aide (CNA) assisted R14 into the courtyard and left him there without any means to contact the facility or return inside. R14 was found unresponsive outside several hours later, with a dangerously high body temperature and elevated pulse, indicating severe neglect in supervision and care. R14's care plan required staff to assist him with all activities of daily living and to provide supervision, especially when he was outside. However, the facility failed to adhere to this plan. The CNA who assisted R14 outside did not inform the oncoming staff that R14 was outside, leading to a lack of supervision for over three hours. During this time, R14 was exposed to conditions that led to his unresponsiveness and required emergency medical intervention. The facility's failure to conduct a thorough investigation into the incident further compounded the deficiency. There was no evidence of a facility investigation, witness statements, or analysis of causative factors related to the event. This lack of documentation and follow-up indicates a significant oversight in the facility's procedures for handling such incidents, as outlined in their Abuse, Neglect, and Exploitation policy.

Removal Plan

• The facility will no longer employ the nurse on duty.
• The facility will train all current staff and will train all future employees including the agency staff on outdoor safety and neglect.
• The facility provided re-training on the Abuse, Neglect, and Exploitation Policy.
• The facility created a procedure specific to the incident that all staff were trained on.
• The administration will monitor outdoor safety on an ongoing basis.
• Staff will ensure residents outside receive adequate visual checks and adequate hydration.

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 comply with regulatory requirements by not employing a full-time Registered Nurse (RN) as the Director of Nursing (DON) and not providing RN coverage for eight consecutive hours a day, seven days a week. The facility had a census of 31 residents, and the deficiency was identified through observation, record review, and interviews. A review of the nursing schedule from January to December 2023 revealed that there was no RN coverage for eight consecutive hours on more than 50 occasions. Administrative Staff A confirmed the absence of a full-time RN as DON and the lack of consistent RN coverage, citing difficulties in securing an RN except occasionally from an agency. The facility's policies required a full-time DON and RN coverage for eight consecutive hours daily, which were not met, placing the residents at risk for inadequate care.

Penalty

No penalty information released

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

Summary

The facility failed to implement a comprehensive water management program to address the risk of Legionella and other waterborne pathogens, which placed residents at risk for infectious diseases. During an observation, Maintenance Staff U confirmed the absence of routine water management checks and noted that the 300 hall was not in use, with no regular flushing of water in unoccupied rooms. Administrative Staff A acknowledged that while the city conducted monthly water checks, there were no records available, and the facility lacked a system to monitor standing water and mitigate the risk of Legionella. The facility's Legionella Surveillance policy outlined the need for Legionella risk assessments, identification of potential growth areas, and implementation of control measures. However, the facility did not adhere to these standards, as evidenced by the lack of regular inspections, microbiological monitoring, temperature checks, and flushing. The policy also required documentation of all monitoring activities and the appointment of a responsible person for the water system, which was not fulfilled. This failure to implement a water management program exposed residents to the risk of contracting Legionella pneumonia.

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 environment free from accident hazards when staff left a gallon chemical bottle in an unlocked bottom cabinet in one of three kitchenettes. This incident placed 12 cognitively impaired, independently mobile residents at risk for preventable accidents or injuries. During an observation, a plastic gallon bottle of Attack Enzyme odor digester, drain opener, and maintainer was found in an unlocked cabinet underneath the sink in a kitchenette located off the family dining room. The label on the bottle warned to keep it out of reach of children, avoid contact with eyes, and noted it may cause skin irritation. A Licensed Nurse verified the finding and acknowledged that the cabinet should be locked, subsequently moving the bottle to a locked housekeeping closet. An Administrative Nurse later stated that staff were expected to store chemicals in a locked cabinet. The facility did not provide a chemical storage policy upon request, highlighting a lapse in ensuring a safe environment for residents.

Penalty

No penalty information released

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

Summary

The facility failed to report an incident of neglect involving a resident, identified as R14, to the State Agency as required. R14, who had diagnoses including paraplegia, spinal stenosis, and muscle weakness, required extensive assistance with activities of daily living and used a wheelchair for mobility. On a particular day, R14 was found outside unresponsive in his wheelchair, with no shirt on, and showing signs of distress such as drooling and minimal responsiveness. Staff intervened by cooling him down and calling EMS, who later transported him for further care. However, the facility did not conduct an investigation into the incident, nor did they report it to the State Agency, as evidenced by the lack of documentation in R14's electronic health record. Further observations revealed that R14 was again outside on the front patio, unable to re-enter the facility on his own. Administrative Staff B had to assist him inside, and it was noted that R14 was unaware of how to use his walkie-talkie, which was meant for communication. Administrative Staff A later confirmed that a CNA had let R14 outside as she went off duty, and the oncoming staff did not check on him. The facility's policy required the Nursing Home Administrator to report such incidents, but this was not done, placing R14 at risk for ongoing neglect.

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 thoroughly investigate an incident of neglect involving a resident with paraplegia, spinal stenosis, and muscle weakness, who required extensive assistance with activities of daily living and used a wheelchair for mobility. The resident was found outside unresponsive in his wheelchair, with no means to contact the facility for assistance. The incident occurred when a CNA took the resident outside and went off shift without informing the incoming staff, leaving the resident unattended. The resident's care plan required staff to assist with all activities of daily living and to monitor for signs of immobility, skin breakdown, and fall-related injuries. However, the facility did not conduct a written investigation or gather witness statements and causative factors related to the event. The facility's policy mandates that all allegations of neglect be thoroughly investigated, including a root cause analysis and review by the Quality Assurance Performance Improvement Committee. Despite the policy, the facility was unable to provide evidence of an investigation into the incident. Administrative staff acknowledged that the resident was left outside without any means to contact the facility and that the staff was not informed of the resident's whereabouts. This lack of investigation placed the resident at risk for unidentified and ongoing neglect.

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 review and revise the care plan for a resident with stasis ulcers on her shins, which are open wounds caused by circulation problems in the leg veins. The resident's electronic medical record documented diagnoses of weakness, neuropathy, and localized edema. The resident had a Brief Interview of Mental Status score indicating moderately impaired cognition and required partial to moderate staff assistance with most activities of daily living. Despite these conditions, the care plan, last revised on 05/01/24, did not include a section on skin integrity or instructions for caring for the resident's bilateral lower legs. Observations and interviews revealed that the licensed nurse was unaware of the appearance or treatment of the resident's ulcers, as the resident received wound care at the hospital. The administrative nurse confirmed the absence of a skin integrity section in the care plan and acknowledged responsibility for updating it. The facility's policy stated that changes in a resident's condition require updates to the care plan, but this was not done for the resident's venous ulcers. This oversight placed the resident at risk for decreased quality of care due to uncommunicated care needs.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a physician acknowledged and responded to a Consultant Pharmacist's recommendation regarding a stop date for a resident's PRN antianxiety medication. The resident, identified as R19, had diagnoses of anxiety and hypertension and was receiving lorazepam, an antianxiety medication, without a specified stop date. The Consultant Pharmacist recommended a 14-day stop date for the medication, but the clinical record lacked evidence of a physician's response to this recommendation. This oversight placed the resident at risk for unintended effects related to psychotropic drug medications. Observations and interviews revealed that the resident continued to receive lorazepam PRN without a stop date, and the facility's policy required a 14-day stop date for PRN psychotropic medications. The Administrative Nurse confirmed that the pharmacist's recommendations were sent to the physician, but there was no response regarding the duration or rationale for the continued use of the medication. The facility's policy also required an assessment and documentation of the resident's response to the medication before extending its use, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a 14-day stop date or a specified duration with rationale for a resident's ongoing as-needed (PRN) antianxiety medication, lorazepam. The resident, identified as R19, had diagnoses of anxiety and hypertension and was noted to have moderately impaired cognition. The resident's care plan indicated the use of lorazepam for trouble sleeping and behavior problems, with a specific dosage at bedtime and an additional dose allowed during the night. However, the physician's order for lorazepam lacked a stop date, and there was no documented rationale for the extended use of the PRN medication. Observations and interviews confirmed that the resident received lorazepam PRN without a stop date, which was verified by the administrative nurse. The facility's policy on psychotropic drug use required a 14-day stop date for PRN psychotropic medications, with an assessment and documented rationale for continued use if necessary. The absence of a stop date or specified duration for R19's lorazepam placed the resident at risk for adverse psychotropic medication side effects.

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 appropriately store medications by not labeling a resident's insulin flex pen with the date it was opened and the discard date. During an observation of the treatment cart, it was found that the Basaglar flex pen for a resident lacked these essential labels. This oversight was confirmed by Administrative Nurse D, who acknowledged that nurses are required to date the flex pens upon opening and discard expired insulin and medications. The facility's Medication Storage and Labeling policy mandates that medications and biologicals be stored in secured, clean, and sanitary conditions, with insulin pens clearly labeled for single-resident use to prevent cross-contamination. The failure to label and date the insulin pen placed the resident at risk for receiving ineffective 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 coordinated plan of care for a resident receiving hospice services, which placed the resident at risk for inappropriate end-of-life care. The resident, who had diagnoses of Alzheimer's disease, aphasia, and dementia, was admitted to the facility and received hospice treatment. However, the resident's nursing care plan lacked information regarding hospice services and evidence of coordination between the hospice and the facility. The facility did not maintain a communication book or external document related to the resident's hospice services, and the care plan did not reflect the resident's hospice status. Observations and interviews revealed that the facility had initial hospice admit notes with limited care plan information but lacked a complete plan of care. An administrative nurse confirmed the absence of hospice information in the facility's electronic health records and acknowledged difficulties in receiving information from the hospice. The facility's hospice program policy required a coordinated comprehensive plan of care involving communication between hospice, the resident, family, and external resources, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to obtain signed consent for influenza immunizations for three residents, identified as R4, R13, and R18, during the flu season. The clinical medical records for these residents lacked evidence that the facility or the residents' representatives received or were offered the current influenza vaccine. Administrative Nurse D confirmed that while the facility sent out consent forms annually, they did not receive all forms back and did not follow up, resulting in some residents not receiving the vaccinations. Additionally, it was noted that some residents' representatives were difficult to contact and did not return the forms. The facility's Immunization Policy, revised in March 2024, stated that all residents would be offered vaccinations on admission and annually, with documentation of each resident's immunization status in their clinical record. The failure to offer or obtain informed declinations for the flu vaccination placed the residents at risk of acquiring, spreading, and experiencing complications from influenza.