Lakeshore Manor Nursing & Rehab

Penalty

No penalty information released

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

Summary

Failure to provide pressure ulcer care and prevent new ulcers from developing occurred for Resident #3, who was admitted with diagnoses of cerebral infarction and mild-protein calorie malnutrition. His Braden score on 04/23/2026 was 10, and the record noted that a score of 12 or less represented high risk for skin breakdown. His active physician’s orders included bilateral heel protectors at all times, with a revision date of 05/07/2025. On 05/12/2026, the resident was observed multiple times without bilateral heel protectors while sitting in a geri-chair and while lying in bed, with his bilateral lower extremities directly on the mattress. A CNA assigned to the resident confirmed he did not have heel protectors as a pressure ulcer intervention and stated he was not wearing them during her shift. Another CNA stated the resident never wore heel protectors on any of the shifts he was assigned to him. The DON confirmed that if heel protectors were ordered, they should have been placed on the resident.

Penalty

Inspection fine: $30,565

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 its written abuse, neglect, exploitation, and misappropriation prevention policy by not ensuring employment screening and verification for an individual who presented as agency staff. On the morning in question, an individual identified as S12 entered the locked building after being allowed in by a CNA and initially inquired about job openings. She was directed to the back nurses’ station to speak with LPNs. After briefly leaving to change footwear at the request of an LPN, she re-entered the facility and then represented herself to multiple LPNs as an agency CNA arriving to cover an open shift. Facility staff did not verify her identity, employment with the staffing agency, or credentials before assigning her to resident care. S12 was handwritten onto the daily assignment sheet and assigned to provide direct care to ten residents, all of whom had significant medical conditions, including hemiplegia and hemiparesis following cerebrovascular events, COPD with acute exacerbation, gastrostomy malfunction, atrial fibrillation, non-traumatic subarachnoid hemorrhage, hypertensive urgency, acute infarction of the spinal cord, and encephalopathy. S12 reported that she rounded on residents, answered call lights, and obtained snacks from the kitchen for some residents. She specifically described answering a call light for one resident on barrier precautions, donning a gown and gloves, entering the room, rolling the resident to remove his brief, and becoming soiled with feces on her gloved hand and gown sleeve. She then requested assistance from two CNAs, removed her PPE, left the room, and did not return to complete care. Interviews with the two CNAs confirmed that S12 had been present in the resident’s room, had begun incontinence care, and then left after removing her gloves and gown, without returning, leaving them to complete the care. Both CNAs stated they did not know whether she was facility or agency staff. The resident involved confirmed that a female aide, who did not identify herself, answered his call light, called two male CNAs to assist with changing his brief, donned a gown and gloves, became soiled, and then left the room without removing his brief or returning. Review of the visitor log and personnel list showed S12 was not listed as a visitor and was not a current employee. The benefits coordinator, DON, and administrator all confirmed that S12 was not employed by the facility or the staffing agency, that no registry or background checks or credential verification had been completed for her, and that there was no existing process to screen, orient, or complete competency evaluations for agency staff upon entry before they began resident care. This failure to verify and screen S12 before assigning her to direct resident care led to an Immediate Jeopardy situation for the residents under her care. Additional interviews with nursing staff further demonstrated that the facility lacked an operational process to ensure agency staff were verified and oriented before working. One LPN stated that S12 was asked if she was agency staff and, upon her affirmative response, no further verification of agency employment or credentials was performed before she was placed on the assignment sheet. Another LPN acknowledged assigning S12 to care for the ten residents without confirming her agency status, screening, orientation, or competency. The DON confirmed that neither she nor other administrative staff had verified S12’s credentials or screening before S12 was allowed to provide care for approximately two hours. Staff also reported that agency personnel were generally expected to report to any hall, clock in through their agency on their phones, and check the daily assignment sheet, and that agency staff did not receive facility orientation, abuse/neglect training, or competency evaluations prior to being assigned resident care. These actions and inactions collectively demonstrate the facility’s failure to follow its own abuse prevention policy requiring screening of employees and contracted staff, resulting in an Immediate Jeopardy situation.

Removal Plan

• Conduct an immediate search of the facility to locate the unidentified individual and confirm she is no longer present in the building.
• Verify with the staffing agency that the individual is not employed by the agency and confirm through the facility staffing system that she is neither an active nor former employee.
• Instruct receptionist and front desk staff not to allow the individual entry should she return.
• Search the parking lot to ensure the individual has left the premises.
• Contact the Police Department to document the incident and obtain identifying information.
• Print and display a photograph of the individual throughout the facility with instructions to contact law enforcement if she returns.
• Establish a door monitor to ensure all individuals entering the facility are identified, verified, and logged prior to entering the building.
• Evaluate residents who could have potentially been affected by the unidentified individual.
• Interview residents residing in the area where the individual's name had been placed on the assignment sheet to determine whether the individual provided care or engaged in any abusive behavior.
• Interview all residents with a BIMS score of 8 or greater regarding any concerns related to abuse, neglect, or mistreatment.
• For residents with a BIMS score of less than 8, complete a head-to-toe assessment by a licensed nurse to evaluate any signs or symptoms of abuse.
• Implement a system for verification of employee and agency staff credentialing prior to working, including completing required pre-employment screening for facility employees consistent with the facility abuse policy.
• Verify active license/certification prior to the staff member's first shift and maintain documentation.
• Require final clearance by designated facility leadership before marking any employee as cleared for scheduling.
• For agency/contract staff, verify with the staffing agency that the individual has been screened to the same or substantially similar standards and maintain documentation prior to scheduling.
• Prohibit placement of any employee or agency staff member on the daily work schedule until required credentialing and screening verification is completed and documented.
• Conduct a daily schedule review prior to each shift to confirm all scheduled staff have been cleared to work and that any replacements/changes are verified prior to working.
• Validate facility entry at the start of each shift by reviewing identification, confirming the person matches the daily schedule/approved list, and requiring sign-in on the daily staff log.
• Prevent any unverified individual from providing resident care and require immediate follow-up by designated leadership to re-check records, contact the agency, validate licensure/certification, determine eligibility, and remove/replace if verification cannot be confirmed.
• Maintain an ongoing system to monitor employee and agency credentials for expirations/status changes and remove staff from assignment if credentials are expired or unverifiable until resolved.
• Maintain documentation of credentialing verification activities with Administrator and DON oversight and corrective action for failures.
• Have regional staff routinely audit the verification process and trend/correct variances through QAPI.
• Require all people, including staff, entering the facility to sign in and out at the front desk.
• Ensure the front desk is not left unattended by arranging staff coverage for continuous monitoring.
• Change keypad door codes throughout the facility, delete previously stored codes, and input new codes to prevent unauthorized access.
• Provide education for all staff in all departments on abuse/neglect/exploitation prevention, responsibility to identify and report unknown individuals, verification of agency staff prior to resident care, facility entry procedures, and sign-in requirements.
• Verify abuse training requirements for agency staff by obtaining a copy of the training from the agency and providing facility abuse training at the beginning of the agency staff member's first scheduled shift.
• Validate staff competency following abuse prevention education via verbal return demonstration and staff interviews and provide re-education before returning to resident care duties if needed.
• Conduct random staff interviews during supervisory rounds to confirm ongoing staff knowledge of abuse reporting requirements and monitor results through QAPI.
• Monitor the entry log and door monitoring process to ensure all individuals entering the facility are properly verified.
• Conduct random audits of the sign-in log and staffing assignments to ensure only verified staff are providing resident care.
• Complete verification of agency staff credentials and employment status prior to any agency staff member providing resident care, with assigned responsibility.
• Ensure the Manager on Duty and Nurse Supervisor complete abuse training with agency staff secured for nights or weekends.

Penalty

Inspection fine: $30,565

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 administer an effective screening and onboarding system for non-employee staff, which allowed an unknown individual (S12) to be assigned to provide direct resident care without verification of employment, credentials, or required training. On the morning of 03/12/2026, S12 entered the locked building after inquiring about job openings and was allowed entry by a CNA (S14). She was directed to the nurses’ station to speak with LPNs identified as S10 and S13. After briefly leaving to change her footwear at the request of S10, she re-entered the building and was allowed back in by staff member S9R. Upon her return, S12 told S10, S11, and S13 that she was agency staff reporting for an open shift. Without verifying her identity, employment with the staffing agency, or CNA credentials, S11 provided S12 with a temporary ID badge and assigned her to a group of residents (R1 through R10) on the daily assignment sheet, where her name was handwritten. These residents had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction or other cerebrovascular disease, chronic obstructive pulmonary disease with acute exacerbation, gastrostomy malfunction, unspecified atrial fibrillation, non-traumatic subarachnoid hemorrhage, hypertensive urgency, acute infarction of the spinal cord, and encephalopathy. S12 reported that she rounded on residents, answered call lights, and obtained snacks from the kitchen for some residents. She specifically described answering a call light for one resident on barrier precautions, donning gown and gloves, entering the room, rolling the resident to remove a brief, and becoming soiled with feces before calling other CNAs for assistance and then leaving the room. Interviews with administrative nursing staff confirmed that there was no process in place at the time to verify the identity of non-employees upon entry, to confirm agency assignment and credentials, or to provide facility orientation, abuse/neglect training, or competency evaluation before assigning resident care. S13, identified as part of the administrative staff, acknowledged that when S12 presented herself as agency staff, neither she nor S10 verified S12’s agency status or credentials before S11 placed S12 on the assignment sheet for residents R1–R10. S11 confirmed she did not verify that S12 was agency staff and still issued a temporary ID and resident assignment. S10 and the DON (S2) both confirmed that the facility frequently used agency staff but had no existing process to pre-screen non-employees, verify credentials, or ensure completion of orientation and abuse/neglect training prior to allowing them to provide direct care. The administrator (S1) further confirmed that there was no process to verify the identity of non-employees upon entry and that S12 was not employed by the facility or its staffing agency, yet was allowed to provide care to residents for approximately two hours before the issue was discovered. The surveyors determined that this failure to verify and approve agency personnel prior to assignment of resident care created an Immediate Jeopardy situation beginning at 8:00 a.m. on 03/12/2026, when S12 first presented herself as agency staff and was subsequently assigned to provide direct care to residents R1 through R10. The facility’s ineffective administrative system for screening and onboarding agency personnel resulted in residents being placed at a likelihood of serious harm, injury, impairment, or death, as stated in the report. The visitor log for that day did not list S12, further evidencing the lack of a functioning entry and verification process for non-employees.

Removal Plan

• Removed the individual (S12) from the facility and ensured only verified nursing staff were permitted to provide resident care.
• Conducted an immediate search of the facility to locate S12 and confirmed she was no longer present in the building.
• Verified with the staffing agency that S12 was not employed by the agency and confirmed through the facility staffing system that she was not an active employee.
• Ensured S12 was not permitted to provide resident care and confirmed she was no longer present in the building.
• Contacted the Police Department to document the incident and obtain identifying information related to S12.
• Implemented monitoring of the front entrance to ensure all individuals entering are identified, verified, and logged in before entering.
• Interviewed residents assigned to the unit where S12 was listed on the assignment sheet to determine whether she provided care or performed CNA duties.
• Interviewed all residents with a BIMS score of 8 or greater regarding concerns related to care provided by unknown staff.
• Completed head-to-toe assessments for residents with a BIMS score less than 8 to evaluate for signs of injury, neglect, abuse, or improper care.
• Implemented a trained facility staff member as a front desk monitor to verify all individuals entering the facility.
• Required all staff and visitors entering the building to sign in and out at the front desk.
• Continuously monitored the front desk to ensure the entry process is followed and unknown individuals are not allowed entry.
• Changed keypad door codes throughout the facility, deleted previously stored codes, and input new codes to prevent unauthorized access.
• Educated all staff in all departments on verification of agency staff to be completed by the scheduler and/or Payroll Benefits Coordinator and maintained on file prior to placement on the daily schedule; on weekends/holidays verification to be performed by the DON.
• Verified abuse training requirements for agency staff by obtaining documentation from the agency and providing facility abuse training at the beginning of the agency staff member’s first scheduled shift.
• Educated staff on the responsibility to report unknown individuals attempting to provide resident care immediately to the DON or Administrator after ensuring resident safety.
• Educated staff on facility entry procedures and sign-in requirements.
• Educated staff on abuse prevention and resident safety.
• Completed education for staff not present during initial sessions prior to their next scheduled shift.
• Provided education/training for leadership/administrative staff by the Chief Nursing Officer with the Regional Director of Clinical.
• Implemented regional/corporate onsite monitoring of administrative staff compliance with agency staff verification and abuse training, and compliance with sign-in/out and continuous front desk monitoring.
• Restricted resident care assignments to only nursing staff whose employment status, credentials, and agency authorization have been verified by facility leadership prior to assignment.
• Administrator and DON to review the entry sign-in log daily and ongoing to ensure all staff entering are verified.
• Administrator, DON, ADON, and SDC to conduct random audits of staffing assignments and ongoing to confirm only verified employees/agency staff provide resident care.
• Required verification of agency staff credentials and agency confirmation to be completed prior to assigning any agency staff to provide resident care by the Scheduler/Payroll Benefits Coordinator.

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 effective system was in place to identify residents assessed as unsafe smokers and to provide supervision and interventions during smoking for one resident reviewed for smoking. The facility policy stated that residents deemed unsafe to smoke independently would be supervised by staff members while smoking, and smoking blankets or aprons would be furnished for residents assessed to require them. Resident #50 had diagnoses including cerebral infarction due to embolism of the left middle cerebral artery, aphasia following cerebral infarction, dysphagia following cerebral infarction, and hemiplegia and hemiparesis affecting the right dominant side. His quarterly MDS showed a BIMS of 6, indicating severe cognitive impairment, and he self-propelled independently in a wheelchair. A practitioner note documented that he burned his clothing with a cigarette, though his skin was not burned. His care plan identified that he required a smoking apron while smoking and supervision while smoking. The smoking screens completed for the resident identified multiple smoking safety concerns, including cognitive loss, a history of hiding smoking materials or activities from staff, noncompliance with the facility smoking policy, smoking in non-designated areas, inability to use a fire extinguisher, and inability to retrieve a dropped cigarette. Despite these findings, on observation the resident was seen in the designated smoking area without a smoking apron and without staff supervision. He was leaning forward in his wheelchair, held a partially smoked cigarette, propelled himself toward another resident who lit his cigarette, and then loosely held the lit cigarette. Interviews with nursing and CNA staff showed they did not know the resident was an unsafe smoker, did not know where to find smoking supervision status or interventions, and stated there was no list on Hall A identifying safe or unsafe smokers. The ADON confirmed the resident was not being supervised and was not wearing a smoking apron, and the DON stated there was no designated staff member assigned to supervise unsafe smokers and no designated smoking times.

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 store food under sanitary conditions by not ensuring items in the walk-in refrigerator and freezer were properly dated, labeled, and sealed. During an initial kitchen tour, surveyors observed a metal pan of mustard greens covered with plastic wrap with no date or label, three pork loins with no date or label, a metal pan of green beans with no date or label, and a clear bag of hamburger patties that was not sealed and was open to air with no open date. The facility policy titled Food Safety stated that refrigerated foods, including leftovers, will be labeled and dated in the refrigerator. Staff confirmed the observations and acknowledged that the items should have been labeled, dated, and sealed. The director also confirmed that 72 residents ate from the kitchen.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean environment for Resident #74 by not ensuring the resident’s toilet was kept clean and usable. Resident #74 was admitted to the facility and was assessed on the MDS with a BIMS of 15, indicating he was cognitively intact. During interview, he stated his toilet had been clogged with feces and toilet paper for at least 3 days, that he could not use the toilet in his room, and that he had to use a restroom at the end of the hall. He also stated he reported the clogged toilet to a CNA 2 days earlier and nothing had been done. Observations confirmed the condition of the bathroom. The toilet in Resident #74’s restroom was seen with multiple layers of feces and toilet paper, and the feces was dry with very little water in the bowl. Later the same day, the toilet remained clogged with multiple piles of feces and toilet paper. Staff interviews indicated housekeeping staff were responsible for cleaning each room daily, including each resident’s bathroom once a day and as needed, and that daily rounds were completed at 7:00 a.m. in each resident room, including the restroom. The S6HKS stated the issue should have been discovered during daily rounds or housekeeping cleaning, but it was not. The S1ADM stated he would expect housekeeping staff to identify a clogged toilet on their daily rounds, report it to maintenance, and they did not.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident with an identified mental health diagnosis was referred for a PASARR Level II evaluation as required. Resident #12 was admitted with diagnoses including hemiplegia and hemiparesis, and the clinical record also showed a diagnosis of Unspecified Psychosis with an onset date of 09/30/2019. Review of the resident’s PASARR Level I dated 09/27/2019 showed that no mental health diagnoses were selected, and there was no evidence that a Level II evaluation and determination had been submitted for the resident despite the psychosis diagnosis. During interview, the S9SS confirmed the resident had a diagnosis of Unspecified Psychosis upon admission and was not accurately screened, and confirmed that a new resident review should have been conducted but was not. The S2DON also reviewed the PASARR documents and confirmed the resident had a diagnosis of Unspecified Psychosis upon 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 smoking interventions identified on the care plan were implemented for a resident who was assessed as severely cognitively impaired with a BIMS of 6 and had diagnoses including cerebral infarction due to embolism of the left middle cerebral artery, aphasia following cerebral infarction, dysphagia following cerebral infarction, and hemiplegia and hemiparesis affecting the right dominant side. The resident's care plan identified that he required a smoking apron while smoking and required supervision while smoking, and the facility policy stated that smoking blankets or aprons would be furnished for residents assessed to require them and that residents deemed unsafe to smoke independently would be supervised by staff while smoking. During observation, the resident was seen smoking in the designated smoking area without supervision and without a smoking apron. The ADON confirmed the resident was in the smoking area without staff supervision and not wearing a smoking apron. An LPN stated she was unaware the resident was outside smoking and had not yet reviewed the resident's care plan that shift, and did not recall whether the resident needed supervision or a smoking apron. A CNA also stated she was unaware the resident was outside smoking and did not know where to find the resident's smoking interventions. The DON reviewed the care plan and confirmed the resident required both a smoking apron and staff supervision while smoking, and that these interventions were not implemented.

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 and sanitary environment to help prevent the development and transmission of infection for 1 of 3 residents observed for perineal care. The deficiency involved Resident #2, who was admitted with diagnoses including a personal history of urinary tract infections with gram-negative sepsis and irritable bowel syndrome, and whose infection log showed treatment for a urinary tract infection with sepsis on 10/06/2025. During an observation on 12/09/2025 at 12:00 p.m., S8CNA was observed providing peri care to Resident #2, who was soiled with urine and feces. S8CNA removed and disposed of the soiled adult brief, but did not perform hand hygiene before donning clean gloves, did not remove the soiled gloves or perform hand hygiene during the dirty-to-clean transition, and continued care by applying a clean adult brief and adjusting the resident's bed linen. S8CNA also handed the resident the call light and television remote before removing the soiled gloves and exited the room without performing hand hygiene. In interview, S8CNA stated she was unaware she should change gloves and perform hand hygiene during the dirty-to-clean peri care process and confirmed she did not do so. S7ICN and S2DON both confirmed that hand hygiene should be performed before direct resident contact and between dirty and clean peri care, with clean gloves donned after handwashing.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a resident, who was dependent on staff for activities of daily living due to a history of a motorcycle accident, neuralgia, and the need for a geri-chair, did not receive necessary assistance with personal hygiene, specifically nail care. The resident had moderate cognitive impairment and required staff support for grooming and hygiene. Observations revealed the resident's fingernails were long, yellow, and had dirt and grime embedded underneath. The resident reported having requested nail trimming for over a month without receiving assistance, and staff interviews confirmed the resident's dependence on staff for nail care. Staff members, including a CNA, the infection prevention nurse, and the DON, all observed and acknowledged the resident's unclean and overgrown fingernails but did not provide the required care or report the need for intervention. The facility's policy required staff to provide necessary care and services to maintain residents' grooming and personal hygiene, but this was not followed for the resident in question, resulting in a failure to meet the resident's needs for nail 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 provide appropriate treatment and services for a newly readmitted resident who required physician orders for immediate care following surgery and the implantation of a cardiac loop recorder. The staff did not accurately transcribe and clarify the hospital discharge recommendations, including wound care and dressing orders, cardiology follow-up for surgical incision care, and monitoring equipment instructions. This oversight resulted in the resident not receiving necessary care and treatment for the surgical incision site or assistance with ensuring the monitoring equipment was functioning for 26 days. The resident was readmitted to the facility after a surgical implantation of a loop recorder, but the facility staff did not ensure that the discharge orders were accurately transcribed and clarified. The resident's hospital records indicated the need for specific wound care instructions and follow-up appointments, which were not addressed by the facility. The staff, including the Admission Nurse, Charge Nurses, Wound Care Nurses, LPNs, and RNs, failed to assess, monitor, document, and treat the resident's surgical incision site and loop recorder monitoring equipment. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's surgical incision and monitoring equipment. The staff did not conduct a full body and skin assessment upon the resident's readmission, and there was no evidence of the surgical incision site being addressed in the resident's clinical records. The facility's failure to provide appropriate care and services created a likelihood of post-surgical complications and delayed treatment of potential arrhythmias identified by the loop recorder.

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 and accurately document resident records in accordance with accepted professional standards for one of the sampled residents. Specifically, the facility did not complete a readmission assessment for a resident who was readmitted from the hospital with diagnoses including Acute Arterial Ischemic Stroke and Hypertension. The Licensed Practical Nurse (LPN) responsible for the readmission confirmed that a complete and accurate physical and skin assessment should have been documented in the Electronic Health Record (EHR) but was not. The Director of Nursing (DON) also confirmed the absence of the required documentation in the resident's records. Additionally, the facility did not document blood pressure readings in conjunction with the administration of Lisinopril, a medication prescribed for hypertension, from the start date of the order until a specified date. The LPNs involved confirmed that blood pressure readings were not documented in the EHR, and one LPN admitted to recording them on personal nursing flowsheets, which were subsequently discarded. The DON verified the lack of documented blood pressure readings in the EHR during this period. Furthermore, the facility failed to accurately document weekly skin assessments for the resident. Despite the presence of a new surgical incision from an implanted loop recorder, the weekly skin observation assessments did not reflect this finding. The LPN acknowledged observing a new dressing but did not document the new wound or incision. The DON confirmed that the nursing staff was expected to document such findings accurately, and the omission was verified upon review of the resident's records.

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 the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding the presence of a surgical wound. The resident, who was admitted with a diagnosis including Cerebral Infarction, had a surgical procedure involving a loop recorder placement, which resulted in a left chest wall dressing with scant bloody drainage. This condition was documented in the Nurse Practitioner (NP) progress notes but was not accurately coded in the resident's Quarterly MDS under Section M: Skin Conditions. The oversight occurred when an LPN, responsible for completing the resident's Quarterly MDS, reviewed the NP's progress notes but overlooked the section indicating the presence of a surgical wound. This error was confirmed during an interview with the LPN, who acknowledged that the MDS did not accurately reflect the resident's status. The Director of Nursing (DON) also reviewed the MDS and confirmed the inaccuracy, acknowledging that the resident should have been coded for a surgical wound.

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 a comprehensive care plan for a resident who had undergone a surgical procedure for a loop recorder placement. The care plan did not include the resident's medical and nursing needs related to the surgical incision and loop recorder monitoring equipment, nor did it have measurable objectives and timeframes. This oversight was identified during a review of the resident's clinical records and after-visit summary discharge instructions from a local hospital, which included specific care instructions for the loop recorder incision. The deficiency was further confirmed through interviews and observations. The resident, who had been readmitted to the facility following a hospital stay for an acute arterial ischemic stroke, had a dressing on his left chest wall with dried drainage, indicating the need for specific care that was not documented in the care plan. The Care Plan nurse admitted to overlooking the discharge instructions and the nurse practitioner's progress notes, which should have prompted an update to the resident's care plan. The Director of Nursing also confirmed the omission in the care plan, acknowledging that it should have included the resident's medical and nursing needs for the surgical wound and loop recorder monitoring.

Penalty

Inspection fine: $224,27555 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 protect a resident's right to be free from sexual and psychosocial abuse, resulting in an Immediate Jeopardy situation. A cognitively impaired and legally blind resident was subjected to inappropriate behavior by a staff member, identified as S5MAIN. The staff member was observed by another CNA sitting on the resident's bed, rubbing her shoulder, and kissing her on the cheek. Despite witnessing this behavior, the CNA did not report the incident, allowing the staff member to continue working in the facility. Further investigation revealed that another resident, who was the roommate of the victim, reported witnessing the staff member making inappropriate comments and physical contact with the resident. The roommate reported that the staff member had previously seen the resident naked in the hallway and made sexually suggestive comments about it. The roommate was initially scared to report the incident but eventually informed a trusted CNA, who then reported it to the LPN and RN on duty. The facility's administration was notified of the situation, and it was discovered that the staff member had a history of inappropriate behavior, including an incident where he pulled down the pants of an LPN without consent. Despite this, the staff member was not immediately removed from duty, and the facility failed to report the incident to the police. The resident involved in the incident was unable to recall the events due to cognitive impairment, but it was determined that a reasonable person would have experienced severe psychosocial harm from such abuse.

Penalty

Inspection fine: $224,27555 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 allegations of sexual abuse were reported immediately to the administrator and law enforcement authorities. This deficiency involved a cognitively impaired blind resident who was subjected to inappropriate behavior by a staff member. The incident occurred during the Christmas/New Year holiday season when a CNA witnessed a maintenance staff member sitting on the resident's bed, rubbing her shoulder, and kissing her on the cheek. Despite feeling uncomfortable and recognizing the behavior as inappropriate, the CNA did not report the incident to the administration. The situation escalated when another resident reported to a CNA that the same staff member had again engaged in inappropriate behavior with the resident, including kissing her and making inappropriate comments. This report was made several days after the initial incident, and the administration was only made aware of the situation on January 5, 2025. Despite being informed, the administrator failed to report the allegations to local law enforcement, which resulted in an Immediate Jeopardy situation for the resident. Interviews with staff revealed that multiple employees were aware of the inappropriate behavior but failed to report it to their supervisors or the administrator. The facility's policy on abuse, which requires immediate reporting of such incidents, was not followed. The failure to report the abuse in a timely manner left the resident vulnerable to further harm and demonstrated a significant lapse in the facility's responsibility to protect its residents.

Penalty

Inspection fine: $224,27555 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 adhere to professional standards for food service safety by not properly storing food items. During an inspection, it was observed that several food items in Refrigerator A and Refrigerator B were not labeled, dated, or sealed as required. Specifically, in Refrigerator A, there were multiple gallons of milk with expired dates, and small containers of fruit and a large container of jelly that were unlabeled and undated. In Refrigerator B, there were loaves of bread, grated parmesan cheese, feta cheese, and a block of margarine that were either unlabeled, undated, or unsealed, exposing them to air. Interviews with staff members, including S17DM and S1ADMIN, confirmed these findings. Both acknowledged that stored foods should be properly labeled, dated, and sealed once opened, and that expired items should be removed and not available for consumption. The failure to follow these guidelines resulted in the presence of expired and improperly stored food items, which were available for consumption, indicating a lapse in maintaining food safety standards.

Penalty

Inspection fine: $224,27555 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 received services with reasonable accommodation of needs, as evidenced by the failure to have a call pad within reach for a resident with cerebral infarction and right-sided hemiplegia. The resident, who was moderately cognitively intact and required total dependence for transfers and activities of daily living, was observed multiple times with the call pad out of reach. Despite being able to use the call pad when it was within reach, the resident was unable to access it due to its improper placement. Observations revealed the call pad was often placed at the upper left shoulder area, hanging off the bed, or behind the resident's head, making it inaccessible. Interviews with staff confirmed that the call pad should have been placed at the mid-chest area for the resident to reach it with her left hand. The Director of Nursing acknowledged the deficiency, confirming that the call pad was not within reach and should have been accessible to the resident at all times.

Penalty

Inspection fine: $224,27555 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 resident assessments accurately reflected the resident's status, specifically for one resident among those reviewed for the Minimum Data Set (MDS). The resident in question was admitted with multiple diagnoses, including dementia, difficulty walking, dysarthria following a cerebrovascular accident, lack of coordination, depression, and failure to thrive. The quarterly MDS for this resident indicated that a chair preventing rising was used less than daily. However, interviews with staff, including a physical therapy assistant and the MDS coordinator, revealed that the resident used a Geri chair for support and safety due to poor trunk control, not as a restraint. The MDS was incorrectly coded, as confirmed by the Director of Nursing, who stated that the Geri chair was not used as a restraint.

Penalty

Inspection fine: $224,27555 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 revise the care plan for a resident to include the use of a geri chair. The resident, who was admitted with diagnoses including Dementia, Difficulty Walking, Dysarthria following a CVA, Other lack of Coordination, Depression, and Failure to Thrive, was observed to use a geri chair for support and safety due to poor trunk control. Despite this, the resident's most recent care plan did not document the use of a geri chair. Interviews with multiple CNAs confirmed that the resident consistently used a geri chair when out of bed. The MDS coordinator, responsible for assessments and care plans, acknowledged the omission upon review. The Director of Nursing was unaware that the use of a geri chair needed to be included in the care plan but agreed to update it.

Penalty

Inspection fine: $224,27555 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 and maintain an effective infection prevention and control program, as evidenced by improper use of Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) by staff. During an observation, an LPN was seen assisting two residents, one with a PEG tube and the other with a left leg wound, both of whom were on EBP. The LPN did not change her gown between assisting the two residents, which involved repositioning one resident and administering medication to the other. This was confirmed by the LPN and the Director of Nursing (DON), who acknowledged that the gown should have been changed between these activities. Additionally, the facility's infection control and prevention policy was not reviewed annually as required. The policy had a published date of 2017 and a revision date of 2022, but there was no evidence of an annual review. The facility administrator was unable to provide documentation of any recent review, indicating a lapse in maintaining up-to-date infection control policies, which could potentially affect all 92 residents in the facility.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a sanitary and comfortable environment for residents in Hall A, as evidenced by multiple brown and black stains on the floor around the nurse's station and throughout the hallway. This deficiency was identified during an initial walkthrough of the facility. The facility's policy, titled 'Resident Rights: Safe, Clean and Comfortable Environment,' mandates that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. Interviews with staff revealed that the hallway floors were expected to be mopped daily. However, S7HSK, who was responsible for mopping the hallways, confirmed that he was unable to mop both halls daily and did not mop Hall A on the day the stains were observed. S6HSUP, who was interviewed during an environmental tour, confirmed the presence of the stains and acknowledged that they should have been cleaned the previous day. S8RD, when informed of the observations, stated that the floors were cleaned the day before and needed time to be mopped for the day, despite the stains being present from the previous morning.

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 ongoing communication and collaboration with the dialysis facility for two residents requiring dialysis services. According to the facility's policy on dialysis care, there should be continuous communication between the nursing home and dialysis staff, including the completion of Pre Dialysis Assessment & Communication forms. However, for two residents, these forms were found to be incomplete or missing for several dates. Specifically, Resident #1 had incomplete communication forms on certain dates and missing forms on others, while Resident #2 had incomplete communication for the entire month of August, with no documentation of post-dialysis weights or code status. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the nurses were expected to fill out these forms completely before the residents left for dialysis treatment. The DON acknowledged the missing and incomplete documentation for both residents and confirmed that continuous documentation between the dialysis center and the facility was not maintained as required. This lack of documentation and communication represents a failure to adhere to the facility's policy and professional standards of practice for dialysis 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 maintain accurate records in accordance with accepted professional standards and practices for one of the sampled residents reviewed for baths. The facility's policy on Activities for Daily Living requires that any decision to refuse care and treatment be documented in the medical record. However, a review of the clinical record for a resident admitted to the facility revealed a lack of documentation for baths or showers from August 1, 2024, through August 14, 2024. During an interview, a CNA responsible for resident baths admitted to giving the resident bed baths and noted that the resident refused the bed bath two or three times upon admission. The CNA acknowledged that she should have documented all baths given or refused on the bath/shower log. The Director of Nursing confirmed the absence of documentation for the specified period.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's laboratory tests were completed as ordered by the physician. Resident #3 was admitted to the facility and had a physician's order for a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) to be conducted on a specified date. However, upon review of the resident's clinical record, there was no documented evidence that these laboratory tests were completed as ordered. Interviews with staff confirmed that the tests were not conducted as scheduled, indicating a lapse in following the physician's orders for the resident's 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 notify a resident's representative of significant changes in the resident's health status, specifically the development of new wounds. The facility's policy, dated March 2023, mandates that the resident's representative be informed of significant changes in health status, such as the deterioration of physical health. However, the facility did not adhere to this policy for a resident who was readmitted with a sacral wound and later developed three new wounds on the right upper thigh, lower abdomen, and right inner thigh. The resident's clinical records and nurse's notes from June 19, 2024, to June 25, 2024, showed no documentation of notification to the resident's representative about these new wounds. Interviews with the resident's representative and the wound care nurse confirmed that the representative was not informed of the new wounds until the resident was admitted to the hospital on June 25, 2024. The wound care nurse acknowledged that the notification should have been documented and confirmed that the representative was not notified as required by the facility's policy.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate medical records in accordance with accepted professional standards for a resident with a wound on the right upper thigh. The resident was readmitted to the facility with a physician's order to cleanse the wound, apply triad paste, and cover it with a clean dry dressing once daily. However, the Treatment Administration Record (TAR) for the resident showed multiple instances where the documentation of wound care treatment was missing. Specifically, there were blank entries on the TAR from June 18 to June 21 and June 23 to June 25, indicating a lack of documentation for the wound care treatment. Interviews with the wound care nurse and two LPNs revealed that they provided the wound care treatment on the specified dates but failed to document the completion of the treatment in the TAR. The wound care nurse confirmed that the boxes on the TAR for June 18, 20, 21, and 24 were blank, and the LPNs confirmed similar omissions on June 19, 22, and 23. This lack of documentation suggests that the facility did not adhere to its policy on pressure ulcer documentation, which requires recording dressing and treatments, thereby failing to maintain accurate records for the resident's wound 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 ensure accurate MDS assessments for two residents, leading to deficiencies in the documentation of their statuses. Resident #52, who was admitted with a serious mental illness as indicated by the OBH-Level II Evaluation Summary, was incorrectly coded in the MDS assessment. The assessment, dated 06/04/2024, did not reflect the resident's status as having a serious mental illness, as Section A1500 was marked as 'No' and Section A1510 was left blank. This discrepancy was confirmed during an interview with the MDS coordinator, who acknowledged the error in coding. Similarly, Resident #80's discharge status was inaccurately documented. Although the resident was discharged home with orders for home health and follow-up care, the Discharge MDS incorrectly indicated a discharge to a short-term general hospital. This error was also confirmed by the MDS coordinator after reviewing the nurse's notes and physician orders, which clearly stated the resident's discharge to home. The Director of Nursing reviewed these findings and confirmed that the MDS assessments should have been coded correctly.

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 pharmaceutical services that ensured the proper dispensing and administration of insulin, as evidenced by the lack of priming of insulin pen needles before administration. This deficiency was observed in two residents who were receiving insulin injections. The facility's policy on medication administration, which aligns with the manufacturer's guidelines, requires that insulin pen needles be primed to remove air and ensure accurate dosing. However, during observations, it was noted that the Licensed Practical Nurses (LPNs) did not prime the insulin pen needles before administering insulin to the residents. Resident #17 was prescribed insulin lispro to be administered subcutaneously before meals. During an observation, the LPN prepared and administered the insulin without priming the pen needle, contrary to the manufacturer's instructions. Similarly, Resident #42, who had orders for insulin aspart, received insulin without the pen needle being primed. Interviews with the LPNs revealed a misunderstanding of the requirement to prime the insulin pen needles, which was later confirmed by the Director of Nursing (DON) upon reviewing the manufacturer's instructions.

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 labeling and storage of drugs and biologicals in accordance with accepted professional principles. Insulin pens containing multiple doses were found unlabeled and without open dates on Med Cart C and in the medication room's refrigerator. This lack of labeling could lead to the incorrect administration of insulin to residents. Interviews with staff confirmed that insulin pens should be labeled with the resident's name and dated when opened, but this was not consistently done. Additionally, multi-dose vials of insulin were not discarded within the required 28 days after opening on Med Carts B and C. Observations revealed that vials of Lispro and Lantus insulin were past their expiration dates but had not been removed. Furthermore, Med Cart B was found to contain loose pills, which is against the facility's policy for maintaining clean and organized medication storage. Staff interviews confirmed these deficiencies, acknowledging that the vials should have been discarded and the cart should have been free of loose medications.

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 accommodate a resident's food preferences, leading to a deficiency in providing personalized dietary care. Resident #26, who was cognitively intact with a BIMS score of 15, had expressed a preference for chef salads every Monday, Wednesday, and Friday for supper. Despite this request being communicated to the dietary staff, the resident did not receive the preferred meals. On July 1, 2024, an observation confirmed that the resident was served chicken tenders and French fries instead of the requested chef salad. The meal ticket for that day incorrectly indicated 'No preferences,' highlighting a failure in the communication and documentation process. Interviews with the facility's staff, including the dietary manager and the administrator, revealed that the resident's food preferences were not properly entered into the system, which should have ensured the kitchen staff accommodated the request. The dietary manager confirmed the oversight, acknowledging that the resident should have received a chef salad as per his preference. The administrator also confirmed that the dietary manager is responsible for updating the system with residents' food preferences to ensure accurate meal preparation. This deficiency indicates a lapse in the facility's process for managing and honoring residents' dietary preferences.

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 person-centered care plan for a resident diagnosed with multiple malignant neoplasms, including those of the colon, liver, intrahepatic bile duct, and lung. The resident's physician orders required weekly and monthly laboratory tests, with results to be faxed to the oncologist's office. However, the facility did not ensure these results were consistently faxed as ordered, which was confirmed through interviews with the charge nurse at the oncologist's office and facility staff. Interviews with various staff members, including an LPN, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and a Nurse Practitioner (NP), revealed a lack of clarity and accountability regarding who was responsible for faxing the lab results. The ADON admitted to only faxing results upon request from the oncologist's office, rather than proactively following the physician's orders. This lack of a designated person to ensure the lab results were sent led to the deficiency in the resident's care plan implementation.

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 received treatment and care in accordance with professional standards of practice by not facilitating a follow-up appointment with a cardiothoracic surgeon. The resident, who was cognitively intact and had been admitted with a diagnosis of Non-ST Elevation Myocardial Infarction, was discharged from the hospital with orders to attend a post-operative appointment. The appointment was initially scheduled for 05/21/2024 but was rescheduled to 05/28/2024 due to a hospitalization. However, the resident did not attend the rescheduled appointment, and no further follow-up was arranged. Interviews revealed that the staff member responsible for scheduling appointments was unaware of a physician's order placed on 06/11/2024 to make a follow-up appointment with the cardiothoracic surgeon. The Director of Nursing confirmed that the follow-up appointment should have been made when the resident returned from the hospital and when the order was placed. The oversight resulted in the resident not receiving the necessary post-operative care as per the discharge instructions and physician's orders.

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 correct food portions and snacks as ordered by a physician. Resident #73, who was admitted with diagnoses including malignant neoplasm of the colon and secondary malignant neoplasms of the liver, intrahepatic bile duct, and unspecified lung, had a physician's order for a regular/NAS diet with double portions and snacks twice a day (BID) between meals for weight stability. However, observations and interviews revealed that the resident did not receive double portions or the prescribed snacks. The dietary slip for the resident indicated regular portions instead of the required double portions. Interviews with various staff members, including an LPN, CNA, RD, RDM, DON, ADON, NP, and ADM, highlighted a breakdown in communication and protocol adherence. The RD had made dietary recommendations, which were supposed to be reviewed by the MD/NP and then entered into the computer system by the ADON, who was also responsible for communicating these changes to the dietary department. However, these steps were not followed, resulting in the resident not receiving the prescribed diet. Staff members confirmed that they were unaware of the specific dietary orders, and the kitchen staff did not provide the required snacks, indicating a failure in the facility's process for implementing dietary orders.

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 appropriate plans of action to correct identified quality deficiencies in medication storage. Specifically, the facility did not conduct an audit on the scheduled date, which resulted in expired and unlabeled insulin being available for resident use in medication carts and the medication storage room. Observations revealed that Med Cart C contained two Novolog Flex Pens and one Lantus insulin pen that were opened, unlabeled, and undated. Similarly, Med Cart B had a vial of Lantus insulin with an open date that indicated it should have been discarded. Additionally, the medication storage room contained an opened, unlabeled, and undated Novolog Flex Pen. Interviews with staff confirmed the deficiencies. An LPN acknowledged that multi-dose insulin pens and vials expire 28 days after opening and should have been discarded. The Assistant Director of Nursing (ADON) confirmed that insulin pens should be labeled and dated, and the Director of Nursing (DON) admitted that the missed audit led to expired and unlabeled insulin being available for use. The Administrator also confirmed the missed audit and the presence of expired and unlabeled insulin, indicating that the facility's Quality Assurance/Performance Improvement (QA/QAPI) system was ineffective.

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 nurse staffing data was posted daily in a prominent location accessible to residents and visitors, as required by their policy. The policy, dated March 2023, mandates that at the beginning of each shift, the facility must post the facility name, current date, total number and actual hours worked, and resident census. However, during an observation on July 1, 2024, at 10:00 a.m., no staffing data sheets were observed. Interviews conducted shortly after with S16HR and S1ADM revealed that the last daily staffing data sheet was completed on June 27, 2024. This lapse in posting staffing information had the potential to affect any of the 80 residents residing in the facility.