Wurtland Nursing And Rehabilitation

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 recognize and notify a physician of a resident’s significant weight gain and associated symptoms, as required by facility policy and the resident’s care plan. The facility’s Weight Monitoring policy required staff to notify the physician of a weight gain or loss of three pounds within one week. The resident was admitted with diagnoses including pneumonia, nontraumatic subdural hemorrhage, primary hypertension, atrial fibrillation, and hypertension, and had a care plan intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes, documenting abnormal findings and notifying the physician. The physician’s orders included weekly weights. From admission, the resident’s weight increased from 252.8 pounds to 259 pounds within four days, a gain of 6.2 pounds, and then to 267 pounds within nine days, a total gain of 14.2 pounds from admission. These weights were entered by the DON and an LPN, respectively. There was no documentation that the provider was notified of either the 6.2‑pound gain in four days or the 14.2‑pound gain in nine days, despite the facility policy requiring notification for a three‑pound gain in one week. Nursing documentation also showed that the resident had shortness of breath and/or labored breathing with exercise and while lying flat, but there was no documentation that the physician was notified of these abnormal findings, contrary to the resident’s care plan interventions. The resident’s weight continued to increase, reaching 270 pounds 13 days after admission, a total gain of 17.2 pounds. On that date, an LPN documented +3 to +4 pitting edema in all four extremities and shortness of breath, and notified the APRN, obtaining orders for a chest x‑ray, labs, and intramuscular furosemide. The resident was sent to the hospital for evaluation at the request of a family member. Interviews with the family member indicated he observed increasing swelling of the resident’s legs, feet, and scrotum throughout the stay and reported these concerns daily to staff, who told him the edema was not a problem. Interviews with the APRN, Medical Director, DON, and Administrator confirmed that staff were expected to notify a provider of significant weight changes and changes in condition, and that there was no evidence staff had identified the resident’s weight gain as a significant change in condition or notified the APRN or physician of the repeated weight gains prior to the date when the APRN was finally contacted.

Removal Plan

• All current residents were re-weighed and reassessed for change of condition by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager; weights for the last 6 months were reviewed.
• For any significant weight changes identified, nursing assessments were completed by the Director of Nursing Services, Assistant Director of Nursing Services, or Unit Manager with physician or nurse practitioner notification for orders as needed.
• All residents were reassessed and reweighed.
• All residents were reassessed by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager with any changes of condition reported to the Nurse Practitioner and orders obtained.
• Director of Nursing Services was educated by the Regional Nurse Consultant to review weight reports timely related to the weekly Nutritional At Risk meeting.
• All nurses were educated by the Infection Preventionist/Staff Development, Director of Nursing Services, or Assistant Director of Nursing Services regarding the policy on notifying the physician or nurse practitioner of all changes of condition including weight changes; education completion tracked.
• A post-test was administered to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
• Director of Nursing Services, Assistant Director of Nursing Services, Infection Preventionist/Staff Development, or Unit Manager will provide education until all nurses complete it.
• Education on notification of changes in condition including weight changes will be added to new-hire nurse orientation.
• An ad hoc QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, and education regarding notification of changes.
• The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all changes in condition including weight changes resulted in physician or nurse practitioner notification.
• Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.

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 develop and implement a comprehensive, resident-specific care plan that addressed all identified needs, including monitoring and response to significant weight changes and potential complications from continuous IV fluids. The resident was admitted with diagnoses including pneumonia, nontraumatic subdural hemorrhage, atrial fibrillation, coronary artery disease, and hypertension, and had an IV access for antibiotics. The care plan included an intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes, and was later updated to identify risk for cardiac dysfunction with instructions to observe for signs such as shortness of breath, cough, abnormal lung sounds, change in mental status, activity intolerance, decreased urine output, edema, dizziness, and weakness, document abnormal findings, and notify the physician. However, the care plan did not include resident-specific interventions related to potential complications from continuously infusing IV fluids. The facility’s own Weight Monitoring policy required staff to notify the physician of a weight gain or loss of three pounds within one week, and the physician’s orders for the resident included weekly weights. The weight records showed that the resident’s weight increased from the admission weight to 259 pounds within four days (a gain of 6.2 pounds), then to 267 pounds within nine days (a gain of 14.2 pounds), and then to 270 pounds within 13 days (a total gain of 17.2 pounds). Despite these significant weight gains, there was no documented evidence that staff implemented the care plan interventions by notifying the physician of the changes between the admission date and the date of the last recorded weight. Interviews with nursing staff indicated that they did not recall notifying the physician about the weight gain, and one LPN acknowledged she did not always directly assess residents for edema, despite the care plan requiring observation for edema as a sign of cardiac dysfunction. A family member reported observing progressive swelling of the resident’s legs, feet, and scrotum during daily visits and stated he felt staff ignored his concerns about the edema. He indicated that he requested the resident be sent to the hospital due to his concerns about the swelling, and that the transfer occurred only after his request. The APRN stated that staff did not notify him of changes in assessment findings, including the resident’s weight gain, until the date the resident was ultimately sent to the hospital. The facility’s leadership, including the DON and Administrator, stated they expected staff to follow care plans, including interventions to notify the physician of significant weight changes and edema, but could not explain why staff failed to implement the care-planned interventions for this resident. The combination of incomplete care planning for continuous IV fluids and failure to implement existing care plan interventions and notification requirements led to the cited deficiency under F656 for not ensuring a comprehensive, resident-centered care plan was developed and implemented. Hospital documentation showed that the resident arrived on the inpatient unit in the evening and was later found unresponsive with pulseless electrical activity and agonal breathing, with a Code Blue initiated and the resident subsequently pronounced expired. The hospital admission diagnoses included fluid overload and myocardial infarction. The surveyors concluded that the facility’s failure to implement the care plan interventions and notify the physician beginning several days prior resulted in a delay in intervention and treatment for the resident, and Immediate Jeopardy was identified related to the deficient practice in comprehensive care planning and implementation.

Removal Plan

• All residents were reassessed and reweighed.
• All residents were reassessed by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager, with any changes of condition reported to the Nurse Practitioner and orders obtained.
• All care plans for residents with congestive heart failure, use of diuretics, and orders for daily or weekly weights were reviewed by the Regional Resident Assessment Specialist to ensure accuracy.
• All nurses were re-educated regarding the care plan policy, including implementation and physician notification with changes of condition, with no nurse working before receiving the education.
• A post-test was given to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
• DNS/ADNS/IPSO/Unit Manager will provide education until all nurses complete the education.
• Care plan and notification education will be added to new nurse hire orientation.
• An ADHOC QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, plan, and education regarding notification of changes.
• The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all weight changes resulted in physician or nurse practitioner notification per the care plan.
• Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.

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 recognize and respond to a significant change in condition for one resident, including substantial weight gain and edema, in accordance with its own policies and the resident’s care plan. The resident was admitted for short-term rehabilitation following a serious illness with sepsis and a spinal abscess, with hospital diagnoses including atrial fibrillation, coronary artery disease, pneumonia, and stable shortness of breath at discharge. On admission, the facility documented diagnoses of pneumonia, nontraumatic subdural hemorrhage, and primary hypertension, and the MDS reflected atrial fibrillation, hypertension, moderate cognitive impairment (BIMS score of 8/15), IV access, and shortness of breath when lying flat. The care plan directed staff to weigh the resident as ordered, notify the physician of significant weight changes, and, after an update, to observe and document signs and symptoms of cardiac dysfunction such as shortness of breath, abnormal lung sounds, decreased urine output, edema, and changes in mental status, and to notify the physician of abnormal findings. The facility’s policies on Change in Condition and Weight Monitoring required staff to notify the physician or nurse practitioner for abnormal weights and significant changes, to re-weigh residents for weight changes of 3 pounds or more in one day or 5 pounds in one week, and to notify the physician, resident, and representative of such changes. Despite these policies, the resident’s weight increased from an admission weight of 252.8 pounds to 259 pounds within four days, then to 267 pounds within nine days, and to 270 pounds within 13 days, for a total gain of 17.2 pounds. The DON entered the 259‑pound weight and acknowledged later that this represented a clinically significant gain per policy but did not assess the resident or notify the APRN. LPN1 entered the 267‑pound weight but did not document any re‑weigh, assessment, or provider notification related to this gain and could not recall taking any such actions, stating that if she had notified a provider she would have charted it. During this period of rapid weight gain, clinical signs consistent with fluid accumulation were present but not consistently recognized or acted upon as a change in condition. A Health Status Note documented that a family member reported the resident’s right hand swelling, increased confusion from baseline, and complaints of shortness of breath; LPN5 documented these findings and notified the APRN, who ordered continued monitoring only, without further specified parameters. Skilled nursing assessments on two dates documented shortness of breath or labored breathing with exertion and when lying flat, need for supplemental O2 and head-of-bed elevation, and edema in both lower extremities, yet the corresponding progress notes from admission through the date of transfer contained no documentation of edema or shortness of breath and no evidence that staff recognized the weight gain as a significant change in status or notified the physician as required. On the thirteenth day, LPN4 documented +3 to +4 pitting edema in all four extremities, marked scrotal swelling, and shortness of breath after the family member again raised concerns, and EMS later assessed the resident as in acute respiratory distress with crackles/wheezing and pitting edema in all extremities. The APRN and Medical Director both stated they relied on nursing staff to notify them of rapid weight gain and changes in assessment findings, and the DON confirmed she could find no evidence that staff identified the resident’s weight gain as a potential change in condition or notified the APRN after the initial report of arm swelling, leading surveyors to cite the facility under F684 for failing to provide care in accordance with policies, care plan, and professional standards.

Removal Plan

• Resident #117 was discharged.
• All current residents were re-weighed and reassessed for change of condition by the Director of Nursing Services, Assistant Director of Nursing Services, and Unit Manager, with weights reviewed for the last 6 months.
• For any significant weight changes identified, a nursing assessment was completed by the Director of Nursing Services, Assistant Director of Nursing Services, or Unit Manager with notification of the physician or nurse practitioner for orders as needed.
• All residents were reassessed and reweighed, and any changes of condition were reported to the Nurse Practitioner with orders given.
• All nurses were re-educated by the Infection Preventionist/Staff Development, Director of Nursing Services, or Assistant Director of Nursing Services regarding the policy to notify the physician or nurse practitioner of all significant weight changes and the policy on changes in condition; no nurse worked before receiving the education.
• A post-test was administered to all nurses with an expected 100% pass rate; if 100% was not achieved, re-education was provided.
• The Director of Nursing, Assistant Director of Nursing, Infection Preventionist/Staff Development, or Unit Manager will provide education until all nurses complete it.
• Education on notification of significant weight changes and changes in condition will be added to new-hire orientation for nurses and certified medication technicians.
• An ad hoc QAPI meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and Medical Director to review the alleged deficiency, audit tools, plan, and education regarding notification of changes.
• The Director of Nursing Services, Assistant Director of Nursing, or Unit Manager will audit to ensure all weight changes and head-to-toe resident assessments resulted in physician or nurse practitioner notification when warranted.
• Audit results will be forwarded to the QAPI Committee for review and presented by the Director of Nursing.

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 the ordered diet for a resident with dysphagia and a puree diet order. The resident, who was admitted with diagnoses including anorexia nervosa, anxiety disorder, and dysphagia, had a puree diet ordered on the day of admission and was documented in the hospital discharge paperwork as being on a puree diet. The resident’s care plan initially directed staff to follow the diet as ordered. On the evening of the choking incident, the resident was served a regular tray instead of a puree tray. The incident report stated the tray ticket was correct, but a regular texture tray was served. While eating, the resident attempted to take a bite of chicken, became unable to speak, held her throat, and turned cyanotic. A nurse responded and performed the Heimlich maneuver, which cleared the airway after two quick thrusts. The resident was not taken to the hospital. The resident’s record also showed she had a Modified Barium Swallow prior to admission, and speech therapy documented that a puree diet was clinically indicated. The resident later stated she remembered choking and was now eating smoothed out food. The deficiency was based on the facility’s failure to ensure the resident received the correct diet texture that had been ordered and clinically indicated.

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 an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two sampled residents. Facility policy and CDC guidance required reusable resident care equipment to be cleaned or disinfected between residents, and required aseptic technique during medication preparation and administration. During observation, KMA1 used a blood pressure cuff on R13 and then returned the cuff to the vitals cart without disinfecting it. Shortly afterward, the same cuff was removed from the cart and used on R84 without being cleaned first, and it was again returned to the cart without disinfection. Staff interviews confirmed that shared equipment such as blood pressure cuffs was expected to be disinfected between resident uses, and KMA1 acknowledged she should have disinfected the cuff before it was used on either resident. During medication administration, KMA1 dropped a pill into a medicine cup that already contained another medication, then reached into the cup with an ungloved hand, removed the dropped pill, and administered the remaining medication. KMA1 stated she should have worn gloves and discarded and repulled both medications to prevent cross contamination. Other staff, including an LPN, the IP/SDC, the DON, and the Administrator, stated medications should not be handled with an ungloved hand and that shared equipment and medication administration practices should follow facility IPCP policies to prevent contamination.

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 results of its surveys, certifications, complaints, and any related plans of correction from the three preceding years were available for any individual to review upon request. Review of the facility’s Resident Rights policy showed residents had the right to examine the results of the most recent survey and any plan of correction in effect. However, review of the facility-provided binder showed it did not contain the required survey results and related plans of correction for the preceding three years, including a recertification and abbreviated survey, two revisit surveys, and a Life Safety Code survey with its revisit survey. During Resident Council, a resident stated she had looked for the survey book location but did not ask about it because she found the information online. During interview, the Administrator stated he knew the survey book was incomplete and lacked the most current documents. He stated he understood the requirement to have the binder current and up to date so the survey results were available to anyone who wanted to view the binder.

Penalty

No penalty information released

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

Summary

The facility failed to provide the required written transfer notice and bed-hold form to resident representatives for 2 residents who were sent to the hospital. The facility’s policy titled Transfer and Discharge stated residents and their representatives were to receive written notice of the specific reason for transfer, including emergency transfers to an acute care hospital. For one resident, the record showed admission with diagnoses including unspecified intellectual disabilities, type 2 diabetes, and epilepsy, and a quarterly MDS with a BIMS score of 0, indicating severe cognitive impairment. An APRN documented that the resident was to be transferred to the hospital because of a concern identified on a CT scan, but the Notice of Transfer or Discharge/Notice of Bed Hold form had the date mailed to the responsible party left blank. The resident’s family member stated she had never received paperwork from the facility related to the hospital transfer and sometimes learned the resident was in the hospital from the hospital rather than the facility. For the second resident, the record showed admission with diagnoses including pneumonia, nontraumatic subdural hemorrhage, and primary hypertension, and an admission MDS with a BIMS score of 8, indicating moderate cognitive impairment. A health status note documented that the resident was sent to the hospital for evaluation at the request of the family member, but the Notice of Transfer or Discharge/Notice of Bed Hold form again had the date mailed to the responsible party left blank. The resident’s representative stated he never received any paperwork from the facility about the transfer. The Medical Records Nurse stated the transfer forms were scanned into the medical record and then given to the SSD to be mailed, while the SSD stated she had only recently taken over mailing the forms and did not know who mailed them before; the Administrator stated he expected either the Medical Records Nurse or the SSD to mail the form, especially if the resident was cognitively impaired.

Penalty

Inspection fine: $69,90829 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 comprehensive person-centered care plans for several residents, leading to unmet medical and personal care needs. For Resident 80, the care plan included the use of a medicated shampoo for plaque psoriasis, but specific instructions for its application were not provided to the staff. As a result, the shampoo was not left on the scalp for the required duration, leading to continued itching and scalp issues. Additionally, the care plan for skin breakdown risk was not updated with specific interventions for the scalp condition until after the surveyor's intervention. Resident 27's care plan identified the need for regular repositioning and incontinence care to prevent pressure ulcers. However, staff failed to assist with repositioning and did not provide timely incontinence care, as observed during the survey. The facility's staffing issues were highlighted as a contributing factor, with staff unable to follow care plans due to insufficient support. The Assistant Director of Nursing Services acknowledged the lack of audits to verify compliance with care plan interventions. For Resident 52, the care plan required frequent toileting assistance and oral care, but these interventions were not consistently implemented. The resident was found with soaked briefs and reddened skin, indicating inadequate incontinence care. Oral care was also neglected, as staff failed to assist or remind the resident to perform it. The Director of Nursing Services admitted to not verifying the implementation of these care plan interventions. Similar issues were noted for Resident 36, whose care plan lacked specific instructions for cleaning an artificial eye, leading to improper care and infection. Resident 124's care plan included dressing changes for a midline, but these were not performed as ordered, resulting in the dressing remaining unchanged for an extended period.

Penalty

Inspection fine: $69,90829 days payment denial

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

Summary

The facility failed to provide necessary services to maintain good personal and oral hygiene for six residents, leading to deficiencies in activities of daily living care. Residents expressed feelings of embarrassment and humiliation due to the facility's failure to provide timely incontinence care. Interviews with residents and their family members revealed that residents often waited long periods, sometimes up to four hours, before staff could change them, resulting in residents urinating in their beds and lying in urine for extended periods. Additionally, the facility failed to provide daily oral care for two residents, who had plaque build-up as noted by the dentist. One resident, admitted with diagnoses including a fracture and heart failure, required substantial assistance for toileting hygiene and lower body dressing. The resident reported waiting over four hours to be changed, resulting in soiling of a leg brace. Another resident, with mild cognitive impairment and a pressure ulcer, reported waiting long periods for incontinence care, leading to skin breakdown and embarrassment. Observations confirmed that residents were left in soiled conditions for extended periods, and staff interviews indicated that short staffing contributed to the delays in care. The facility's failure to provide adequate oral care was also noted, with one resident having a bridge of calculus on their teeth and another resident with partial dentition requiring assistance with daily tooth brushing. Observations and interviews revealed that oral care was often neglected due to staff being busy with other tasks. The facility's policies on activities of daily living and oral care were not followed, resulting in inadequate care for the residents.

Penalty

Inspection fine: $69,90829 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 appropriate treatment and care according to professional standards and resident preferences for three residents. For one resident with a scalp condition, the facility did not ensure that the medicated shampoo was applied correctly. The shampoo was not left on the scalp for the required three to five minutes, as specified by the manufacturer's instructions. The resident continued to experience itching and discomfort, and there was no documentation of the condition's evaluation or the treatment's effectiveness. The resident had not been seen by a healthcare provider for over a month, and the staff responsible for applying the shampoo were not adequately informed about the correct procedure. Another resident with a prosthetic eye experienced ongoing issues with eye drainage and infection. The facility did not have specific care instructions for the prosthetic eye, and staff were unaware that the eye needed to be removed for proper cleaning. The resident's eye was observed to have green, pus-filled drainage, and staff interviews revealed that this was a persistent problem. Despite the presence of an artificial eye, there were no physician orders for eye care until after the survey began, and the care plan did not include necessary interventions for the prosthetic eye. A third resident with a midline IV access for antibiotic therapy did not receive the required dressing changes as ordered. The dressing was not changed weekly as specified, and observations confirmed that the dressing had not been updated since the resident's admission. Staff interviews indicated a lack of awareness regarding the outdated dressing, and the facility's procedures for ensuring timely dressing changes were not followed. The failure to change the dressing as ordered was not addressed until after the surveyor's intervention.

Penalty

Inspection fine: $69,90829 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 pressure ulcer care and prevention for two residents, leading to the development of facility-acquired pressure ulcers. Resident 27, who was admitted with mild cognitive impairment, osteoarthritis, and depression, was identified as at risk for skin breakdown. Despite being assessed as cognitively intact and requiring assistance with mobility and incontinence care, Resident 27 developed a Stage III pressure ulcer on the right buttock and a deep tissue injury on the left buttock. The facility's records indicated a lack of timely incontinence care and repositioning, contributing to the worsening of the resident's skin condition. Interviews with staff revealed systemic issues, including understaffing and inadequate implementation of care plans. Staff members reported that residents often waited long periods for incontinence care, leading to prolonged exposure to moisture and increased risk of skin breakdown. The facility's interdisciplinary team failed to identify a root cause for the pressure ulcers and did not ensure that necessary interventions, such as timely repositioning and incontinence care, were consistently provided. Resident 10, with a history of multiple sclerosis, vascular dementia, and diabetes, also developed a facility-acquired pressure ulcer. Despite being identified as at risk for pressure ulcers, the resident's care plan was not effectively implemented, resulting in a deep tissue injury on the right hip. Staff interviews highlighted challenges in providing timely care due to high resident-to-staff ratios, with reports of residents being left soiled for extended periods. The facility's recent termination of a wound care service contract further strained the ability of nurses to manage wound care effectively.

Penalty

Inspection fine: $69,90829 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 adequate staffing levels, resulting in insufficient care for residents. Observations and interviews revealed that residents did not receive necessary assistance with activities of daily living, such as incontinence and dental care. Additionally, staff failed to provide proper care for residents with specific medical needs, including incorrect application of medicated treatments and failure to change dressings as ordered. The lack of sufficient, competent staff led to the development of facility-acquired pressure ulcers in some residents and inadequate care for those with catheters, resulting in urinary tract infections. The facility's staffing documentation and Payroll Based Journal (PBJ) reports indicated a chronic shortage of State Registered Nurse Aides (SRNAs) and licensed nurses, particularly on weekends and night shifts. This shortage resulted in each SRNA being responsible for an excessive number of residents, often leading to delays in care and unmet needs. Interviews with staff and family members highlighted the impact of these staffing issues, with reports of call lights going unanswered for extended periods and residents being left in soiled clothing or without necessary hygiene care. The facility's internal assessments and policies acknowledged the need for sufficient staffing to meet resident needs, yet the actual staffing levels fell short of these requirements. Staff interviews revealed a high turnover rate and dissatisfaction with the workload, contributing to the ongoing staffing challenges. Despite the facility's stated goals for staffing levels, the actual number of staff on duty frequently did not meet these targets, compromising the quality of care provided to residents.

Penalty

Inspection fine: $69,90829 days payment denial

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

Summary

The facility failed to inform and provide written information to all adult residents concerning their right to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for eight of the thirteen sampled residents reviewed for advance directives. The facility's policy required the Social Services Director (SSD) or Designee to provide this information prior to or upon admission, and to document any existing advance directives in the resident's medical record. However, the review revealed that this process was not consistently followed. For several residents, including those with cognitive impairments and those who were cognitively intact, there was no documented evidence that the opportunity to formulate or decline an advance directive was explained in a manner they understood. In some cases, residents were not asked about advance directives at admission, and existing directives were not requested or documented in the electronic medical record. The admission agreements often contained incomplete Living Will Packets, with only the resident's name and birthdate filled in, and no further documentation of discussions or decisions regarding advance directives. Interviews with facility staff, including the SSD, Director of Nursing Services (DNS), and Executive Director (ED), revealed a lack of awareness and understanding of the requirement to document these discussions and decisions. The SSD stated that verbal discussions were held with residents, but this was not reflected in the records. The ED believed that a signed acknowledgment of receipt of documents was sufficient, despite the absence of completed forms or evidence of informed discussions. This lack of documentation and adherence to policy led to the deficiency identified by the surveyors.

Penalty

Inspection fine: $69,90829 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 store medications at the correct temperature, specifically insulin, in two of four medication refrigerators. Observations revealed that Refrigerator 1 in the Front Hall Medication Room registered a temperature of 26 degrees Fahrenheit, which is below the recommended range of 36 to 46 degrees Fahrenheit. This refrigerator contained various insulin pens, including Lantus, Insulin Glargine, Insulin Degludec, Basaglar, and Novolog. The presence of thick frost in the small freezer section of Refrigerator 1 was also noted. Similarly, Refrigerator 3 in the Back Medication Room registered a temperature of 30 degrees Fahrenheit and contained Admelog, Fiasp, Tresiba, Basaglar, and Lantus insulin pens. Interviews with the Assistant Director of Nursing (ADON) confirmed that medications stored at 26 degrees Fahrenheit would freeze and become ineffective. The ADON indicated that the Maintenance Director needed to adjust or repair the refrigerators and defrost Refrigerator 1, and that the medications needed to be returned to the pharmacy. The Executive Director stated that nurses were responsible for monitoring the medication refrigerator temperatures on both shifts and taking corrective action if temperatures were out of range. Despite requests, a Medication Storage policy was not provided prior to the exit.

Penalty

Inspection fine: $69,90829 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 its infection prevention and control program as required, resulting in multiple deficiencies related to the prevention of communicable diseases and infections. Surveyors observed that a room designated for droplet precautions did not have a personal protective equipment (PPE) cart available outside the room, contrary to facility policy and CDC guidelines. Staff interviews confirmed that PPE carts should be present and accessible, but staff were unaware of the missing cart until it was pointed out. Additionally, the door to a droplet precaution room was found open, despite signage and CDC guidance requiring it to remain closed. Staff and leadership interviews revealed a lack of awareness regarding the open door, and a malfunctioning door latch was later identified as the cause. Further observations revealed that staff did not consistently follow proper cleaning and disinfection protocols for shared medical equipment. An LPN was seen cleaning a glucometer with a disinfectant wipe for less than the required dwell time and without performing hand hygiene after glove removal. Another LPN transported contaminated bandage scissors through the hall without using a container, failed to perform hand hygiene before cleaning, and did not allow the disinfectant to remain on the scissors for the required time. Staff interviews indicated knowledge of the correct procedures, but these were not followed in practice. Additional deficiencies were noted in the handling of food items used during medication administration. Opened containers of pudding and applesauce on medication carts were not dated or stored on ice as required. Staff interviews confirmed that food items should be dated when opened, kept on ice during use, and discarded after administration, but these practices were not consistently observed. The facility's infection prevention and control policies, as well as CDC and manufacturer guidelines, were not adhered to in these instances, contributing to the overall deficiency.

Penalty

Inspection fine: $69,90829 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 reasonable accommodation for the needs of three residents by not ensuring their call lights were within reach, which is crucial for their safety and ability to request assistance. Resident 21, who was severely cognitively impaired and dependent on staff for all activities of daily living, had an adaptive call light placed out of reach on a nightstand. Despite staff being informed, no action was taken to rectify the situation. Resident 27, who was cognitively intact but required assistance with mobility, was found attempting to get out of bed without access to her call light, which was tangled in the bed frame. She called out for help, but no staff were present to hear her. Resident 91, who had dementia and mild intellectual disabilities, was also found calling for help with his call light out of reach on a nightstand by the window. Interviews with staff, including the Director of Nursing Services and the Executive Director, confirmed that staff were trained to keep call lights within reach, and it was expected for resident safety. However, the observations indicated a failure to adhere to this practice, compromising the residents' ability to communicate their needs effectively.

Penalty

Inspection fine: $69,90829 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 a baseline care plan within 48 hours of admission for a resident, identified as R93, who was admitted with pressure ulcers. The baseline care plan did not address the identification or treatment of these pressure ulcers, which is a requirement according to the facility's policy. The policy mandates that a baseline care plan should include minimum healthcare information necessary for proper care, including interventions for health and safety concerns such as pressure injuries. Despite the presence of pressure ulcers at the time of admission, as confirmed by interviews with the resident and staff, this critical information was omitted from the baseline care plan. Interviews with various staff members, including a State Registered Nurse Aide, a Licensed Practical Nurse, the Assistant Director of Nursing, the MDS Nurse, and the Director of Nursing Services, revealed that the omission was not in line with the facility's procedures. The MDS Nurse and the Director of Nursing Services emphasized the importance of including pressure ulcers in the baseline care plan to ensure accurate and effective care. The failure to include this information in the baseline care plan indicates a lapse in adhering to the facility's policy and professional standards of quality care.

Penalty

Inspection fine: $69,90829 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 appropriate care and treatment to prevent and/or treat urinary tract infections (UTIs) for two residents with indwelling urinary catheters. For one resident, the catheter collection bag was observed lying on the floor, and the tubing was not anchored, which is against the facility's policy and CDC guidelines. The resident reported experiencing pain consistent with a UTI and had informed the staff, but no immediate action was taken to assess or address her concerns. The resident's electronic medical record lacked documentation of her complaints, and it was only after the surveyor's intervention that a nurse assessed the resident and initiated appropriate testing and treatment. Another resident with a suprapubic catheter also had their collection bag lying on the floor, unsecured to the wheelchair. This observation was made despite the facility's policy and training that emphasized the importance of securing catheter bags to prevent infections. Interviews with staff revealed that they were aware of the proper catheter care procedures, yet the deficiency occurred, indicating a lapse in adherence to these protocols. The facility's failure to secure catheter bags and promptly address residents' symptoms of UTIs demonstrates a lack of compliance with established care standards. The staff's inaction and inadequate documentation contributed to the delay in recognizing and treating the residents' conditions, potentially increasing the risk of infection and discomfort for the residents involved.

Penalty

Inspection fine: $69,90829 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, identified as R62, received appropriate treatment and services to prevent complications from enteral feeding. R62, who was admitted with diagnoses including epilepsy, dysphagia, and intellectual disabilities, was dependent on a gastrostomy tube for nutrition and hydration. Despite physician orders for specific amounts of enteral feed and water flushes, R62 did not receive the prescribed amounts, leading to severe dehydration and hypernatremia, which required hospitalization. The facility's documentation and communication practices were inadequate, contributing to the deficiency. Nursing staff failed to document changes in R62's condition, such as nausea, vomiting, and diarrhea, which led to the interruption of tube feedings. There was also a lack of communication with the nurse practitioner regarding these interruptions and the resident's declining condition. The Director of Nursing Services acknowledged that documentation should have been made when the tube feeding was stopped, and the nurse practitioner should have been notified to ensure proper nutrition. Interviews with facility staff, including the LPN, MDS Nurse, and NP, revealed a lack of consistent documentation and communication regarding R62's condition and care. The Executive Director expected staff to follow the resident's care plan, but the failure to administer treatments as ordered and the lack of documentation and communication led to R62's hospitalization for dehydration, hypernatremia, and a urinary tract infection.

Penalty

Inspection fine: $69,90829 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 timely and appropriate pain management for a resident, identified as R119, who was admitted with a principal diagnosis of right acetabulum fracture with delayed healing, among other conditions. The resident was on a scheduled pain medication regimen, specifically oxycodone, which was not administered as ordered due to a failure in reordering the medication in a timely manner. On multiple occasions, the resident's pain medication was not available, leading to missed doses and unmanaged pain. On April 16, 2024, the resident missed several doses of oxycodone because the medication was not reordered in time, and the facility did not utilize the Emergency Kit to provide the necessary medication. The resident's pain was documented as 7/10 on the pain scale, yet there was no evidence of non-pharmacological interventions being attempted during the time the medication was unavailable. Additionally, the facility staff failed to notify the provider about the unavailability of the medication or request authorization for retrieval from the Emergency Kit. Interviews with staff revealed a lack of consistent practice in monitoring medication stock and reordering procedures. Staff members indicated that they should notify the nurse when medication stock was low, but this process was not effectively followed, resulting in the resident experiencing unmanaged pain. The Director of Nursing Services acknowledged that staff should be aware of declining stock and order medications in time, but this expectation was not met, leading to the deficiency in pain management for the resident.