Montcare At Wheaton
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheaton, Maryland.
- Location
- 11901 Georgia Avenue, Wheaton, Maryland 20902
- CMS Provider Number
- 215048
- Inspections on file
- 14
- Latest survey
- July 29, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Montcare At Wheaton during CMS and state inspections, most recent first.
The facility failed to store food according to professional standards, with several items in the walk-in refrigerator and unit snack/refreshment refrigerators found improperly labeled or past their use-by dates. Staff acknowledged these issues, indicating a lack of adherence to proper food storage protocols.
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect. In one case, a resident's family reported rough handling, but the investigation lacked specific details and interviews with all involved staff. Another resident reported being slapped, but the investigation misidentified the staff member and lacked proper documentation. Additionally, a neglect allegation was not substantiated due to missing staff interviews, and another abuse allegation lacked identification of the involved staff.
A resident was not provided with a copy of their baseline care plan and medication summary upon admission and readmission. Although the care plan was reviewed with the resident, there was no documentation indicating that a physical copy was given. The DON was informed but did not comment further.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. One resident's care plan for functional mobility lacked specificity and evidence of improvement, while another resident's care plan did not adequately address depression and medication use. Interviews revealed confusion over responsibility for updating care plans, resulting in non-individualized plans. The DON and NHA acknowledged these issues.
The facility failed to conduct timely interdisciplinary care plan meetings and incorporate therapy recommendations into care plans. Several residents did not have care plan meetings scheduled within the required timeframe, and therapy recommendations were not documented or communicated effectively, leading to deficiencies in care planning.
A physician failed to properly document progress notes and review care plans for residents, leading to deficiencies in care. One resident's progress notes were delayed, while another's diabetes management was inadequately monitored, with no blood glucose checks before administering Metformin. These issues were acknowledged by facility leadership without further comment.
A pharmacist failed to identify medication irregularities for two residents, leading to deficiencies in the medication regimen review process. One resident's pain medication orders lacked a necessary pain scale, and another resident received Metformin without required blood glucose monitoring. The facility's policies also lacked a specified timeframe for physician response to identified irregularities.
The facility failed to administer medications according to physician orders, leading to deficiencies. A resident did not receive Ciprofloxacin for the prescribed duration, and another's blood glucose was not monitored before Metformin administration. Additionally, antihypertensive medications were given to residents outside of prescribed parameters, with inadequate documentation. These issues indicate non-compliance with medication protocols.
The facility failed to maintain accurate documentation in resident medical records, with errors including incorrect care plan meeting dates, contradictory MOLST forms, and inaccurate medication administration records. These discrepancies were acknowledged by staff, highlighting significant lapses in documentation practices.
The facility failed to accurately code MDS assessments for several residents, leading to deficiencies in care planning. A resident's limited range of motion was not documented, another's vision and dental status were misrepresented, and a discharge destination was incorrectly recorded. Additionally, significant contractures and pressure wounds were not accurately captured in the assessments.
A facility failed to notify a resident and their representative of their rights upon admission by not executing an admission contract. This was discovered during a complaint and recertification survey after the resident's sudden death. The complaint alleged that the facility did not return the resident's belongings, and the complainant was unaware of the facility's rules and grievance procedures. The facility administrator confirmed that a signed admission contract could not be located, indicating a failure to inform the resident and their representative of their rights and responsibilities.
The facility failed to notify providers about a resident's allergy, leading to non-administration of medication. Another resident's personal representative was not informed of a fall, and a third resident's blood pressure medication was withheld without notifying the provider. These deficiencies highlight communication lapses in the facility.
The facility failed to provide written transfer notifications to two residents and/or their representatives, as required. One resident, who was cognitively intact, did not receive written notice of their hospital transfer, and staff interviews revealed a lack of awareness and procedure for issuing such notifications. Another resident's record also lacked documentation of written notification for a hospital transfer, highlighting a systemic issue in the facility's notification process.
A facility failed to notify a resident's representative in writing of the bed hold policy during a transfer to an acute care facility. The resident was admitted in July 2023 and transferred to the ER in August 2023 due to a change in condition. Although the representative was present, they were not given the bed hold policy in writing. The administrator stated that the policy was only mailed starting March 2024.
A resident with a right hip fracture requiring extensive assistance was scheduled for twice-weekly showers but received only one shower and five bed baths during their stay. The facility's records showed incomplete documentation, and interviews confirmed the discrepancy between scheduled and actual care.
The facility failed to provide appropriate care and develop comprehensive care plans for two residents with gastrostomy tubes (g-tubes). One resident, admitted with dysphagia following a stroke, lacked documentation of physician orders for g-tube care, including daily site examination and positioning during feedings. The care plan addressed nutritional needs but not g-tube maintenance. Another resident with dementia and a history of stroke also lacked a care plan for g-tube site care, with no evidence of daily site examination and cleaning. Staff interviews indicated expectations for g-tube management were not met.
A resident admitted with a right hip fracture post-surgery experienced severe pain but had to wait over four hours for pain management due to a failure in executing the facility's process for obtaining opioid medication. Despite having a prescription for Oxycodone, the resident did not receive it upon admission, and Tylenol was ineffective. The care plan for pain management was initiated, but there was no follow-up pain level assessment, leading to inadequate pain management.
A facility failed to provide a diabetic resident with bedtime snacks as recommended by the dietician and outlined in the care plan. Despite the resident's nutritional risk and need for additional calories, documentation showed that snacks were inconsistently offered, with the resident receiving them on only a few occasions. The Nursing Home Administrator acknowledged the deficiency.
The facility failed to maintain resident dignity by having staff stand over residents during meal assistance and not using privacy bags for urine drainage bags. Despite available chairs, staff stood while assisting residents with meals, contrary to facility best practices. Additionally, a resident's Foley catheter bag was left exposed without a privacy bag, despite orders to ensure its use. The DON and Unit Manager acknowledged these concerns.
A facility failed to provide a deaf resident with communication in their preferred language, ASL, over a year-long stay. Staff used a whiteboard and gestures instead of an ASL interpreter, despite the resident's care plan indicating the use of sign language. The deficiency was confirmed through staff interviews and an interview with the resident, who expressed a preference for signing over other communication methods.
The facility failed to inform two residents of their right to formulate an advanced directive. One resident's record incorrectly labeled a MOLST form as an advanced directive, with no evidence of discussion during admission. Another resident's records lacked documentation of advanced directive discussions, and there were discrepancies in code status documentation. The Social Services Director acknowledged these issues.
The facility failed to report and repair maintenance issues in two resident rooms. A resident's room had wallpaper separating and stapled together, and their wheelchair armrest was damaged, with no maintenance reports filed. Another room had cracked floor tiles, which were not addressed, and similar issues were found in an adjacent room, attributed to structural problems.
The facility failed to complete Significant Change in Status MDS assessments within 14 days for two residents admitted to hospice care. One resident's assessment was completed 22 days after hospice admission, while another's was completed 24 days after. Staff interviews confirmed the delays.
A facility failed to act on a hospice consult order for a resident, resulting in no documentation of the referral being addressed with the resident or family, nor contact with a hospice provider. The resident passed away without the consult being addressed, despite the process involving the interdisciplinary team and social services.
The facility staff failed to securely store an oxygen cylinder in one of the nursing units. During a survey, an unsecured oxygen cylinder was observed leaning against a counter in the nurse's station. The ADON confirmed the unsecured state of the oxygen cylinder, which poses a risk if the valve were to break off.
Two residents experienced significant weight loss due to the facility's failure to monitor and address their nutritional needs. One resident lost 16% of body weight over 47 days, with a delayed re-weigh, while another lost 5.62% in 22 days without follow-up. The dieticians involved were unaware of the weight loss notifications, leading to deficiencies in care.
A facility failed to ensure a resident received Physician or NP visits at least once every 60 days. The resident expressed concerns about infrequent visits, and a review of progress notes showed no documented visits from a provider over several months. The DON confirmed the lack of documentation for the required visits.
A facility failed to document and account for Lacosamide, a controlled medication, for a resident. The medication was brought in by the family, and the facility's pharmacy had not delivered it. The control sheet lacked proper documentation, and staff were unaware it was a controlled substance. The primary care provider was not informed of the medication's unavailability before a new order was placed.
The facility failed to manage psychotropic medications properly for two residents. One resident had a PRN Lorazepam order without a 14-day limit or documented rationale for extension, despite pharmacist recommendations. Another resident on Mirtazapine was not monitored for behavior changes or side effects, and lacked a care plan for the medication. The DON acknowledged these issues.
A facility failed to maintain a medication error rate below 5%, with two errors identified. One involved a nurse not applying a prescribed lidocaine patch to a resident's back, while another involved an LPN administering a multi-vitamin with minerals instead of the ordered multi-vitamin without minerals. Both errors were confirmed through record reviews and staff interviews.
A resident with rheumatoid arthritis had a medication error involving lidocaine patches. A nurse applied patches to the knees instead of the prescribed location on the back and incorrectly documented the administration. The nurse misunderstood the order as PRN, leading to a discrepancy in the Medication Administration Record (MAR).
The facility failed to store medications securely and maintain proper documentation. Insulin was left unsecured on medication carts, and a vial of ceftriaxone was not returned to the pharmacy after use. In the medication storage room, insulin pens and an injectable lacked resident names, and a Controlled Medication Utilization Record was incomplete for a controlled substance brought in by a resident's family.
A resident at the facility did not receive dental services despite having dental insurance and requesting appointments. The facility's records showed no dental appointments for the resident, and the administrator could not provide documentation of any services prior to the survey's end.
The facility failed to serve meals according to a resident's preferences and did not properly evaluate another resident before developing a therapeutic diet. A resident did not receive milk and coffee as per standing orders, and another resident was placed on a puree diet without a proper evaluation, leading to confusion about the dietary change.
A resident with an indwelling Foley catheter and open wounds did not receive care with proper PPE, as a geriatric nurse aide failed to wear a gown during high-contact activities. Additionally, a nebulizer mask used by the resident was improperly stored uncovered, contrary to infection control protocols. These deficiencies were observed and confirmed through staff interviews.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a survey. During an initial tour of the facility's walk-in refrigerator, several food items were found improperly labeled or past their use-by dates. These included opened thickened lemon-flavored water, cranberry cocktail juice, thickened apple juice, and pomegranate-flavored water, all lacking proper open or use-by dates. Additionally, sliced American cheese, sliced ham, mayonnaise, sweet pickle relish, and fresh produce such as tomatoes and lettuce were either past their use-by dates or not labeled with open dates. Staff acknowledged these discrepancies, indicating a lack of adherence to proper food storage protocols. Further observations in the short-stay and long-term care unit snack/refreshment refrigerators revealed similar issues. Pineapple slices and a cake from a family were not labeled with open or use-by dates. Staff members, including a registered nurse and unit managers, admitted that these items should have been labeled and dated. Interviews with staff revealed a lack of consistent understanding and implementation of food labeling and storage procedures, contributing to the deficiency in maintaining food safety standards.
Incomplete Investigations into Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving residents. In the case of one resident, the facility did not include specific details such as the shift or staff member involved in the alleged rough handling incident. The investigation documentation was incomplete, lacking interviews with all staff who cared for the resident during the relevant period, and the concern form submitted by the family was missing. Another resident reported being slapped on the wrist by a staff member during morning activities of daily living. The facility's investigation concluded that the allegation could not be substantiated, but the documentation did not include staffing schedules or interviews with the correct staff member who was on duty during the alleged incident. The investigation incorrectly identified a staff member who was not working during the time of the alleged abuse. In a separate incident, a resident's family member reported neglect when it took an extended time for staff to respond to a request for assistance. The facility's investigation identified the staff involved but did not document interviews with them. Additionally, another resident reported being punched by a night shift nurse aide, but the facility's documentation failed to identify the staff member or include interviews with them or other residents. The facility concluded there was no evidence to substantiate the abuse allegation.
Failure to Provide Baseline Care Plan and Medication Summary
Penalty
Summary
The facility failed to provide a resident or their representative with a summary of their baseline care plan and medications upon admission. This deficiency was identified for one resident who was admitted towards the end of April 2024. Although the resident was able to understand and communicate, and a baseline care plan was developed, there was no documentation indicating that a copy of the care plan and medication summary was offered or provided to the resident. The nurse documented reviewing the care plan with the resident, but failed to provide a physical copy. The issue persisted when the resident was readmitted in May 2024 after a hospital transfer. Again, a baseline care plan was developed, but there was no documentation showing that the resident received a copy of the care plan. The nurse documented reviewing the care plan with the resident, but did not provide a copy. The Director of Nurses was informed of these concerns but did not offer further comments.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility staff failed to develop and implement comprehensive, resident-centered care plans for two residents, leading to deficiencies in their care. For one resident, identified as Resident #22, the care plan for functional mobility was not specific to the resident's needs and lacked evidence of improvement despite multiple revisions. Interviews with the Physical Therapist, Director of Rehab, and Social Services Director revealed a lack of clarity and responsibility regarding who should update the care plan, resulting in a template-based plan that did not reflect the resident's specific requirements. The Director of Nursing and Nursing Home Administrator acknowledged that the care plan did not convey appropriate treatment and services to maintain, restore, or improve the resident's functional mobility. For another resident, identified as Resident #64, the care plan was not comprehensive in addressing the resident's depression and the use of the psychotropic medication Mirtazapine. The care plan lacked measurable goals and interventions to monitor the resident's response to the medication and potential side effects. The Director of Nursing acknowledged the concern but did not provide comments at the time. These deficiencies highlight the facility's failure to create individualized care plans that adequately address the residents' medical and psychological needs.
Deficiencies in Care Plan Meetings and Therapy Integration
Penalty
Summary
The facility failed to ensure that interdisciplinary team care plan meetings were held to review and revise care plans following each Minimum Data Set (MDS) assessment. This deficiency was evident in several cases, including Resident #286, who was admitted in May 2024 but did not have a care plan meeting scheduled within the required timeframe. Despite being alert and oriented, Resident #286 confirmed that no care plan meeting had occurred since admission. Staff interviews revealed that care plan meetings were typically scheduled 7-14 days after admission, but this was not adhered to in Resident #286's case. Similarly, Resident #24, who was responsible for making their own decisions, had no care plan meetings conducted following two MDS assessments completed in March and May 2024. The only documentation available was from a care plan meeting held in November 2022, and staff could not confirm any meetings had occurred since then. This lack of documentation and adherence to care plan meeting schedules was a recurring issue, as seen with Resident #64, who also did not have a care plan meeting following their re-admission and subsequent MDS assessment. The facility also failed to incorporate therapy recommendations into resident care plans. For instance, Resident #67, who had been discharged from therapy with recommendations for a home exercise program, did not have these recommendations reflected in their care plan. Interviews with staff revealed that while residents were verbally informed of their exercise programs, there was no documentation or consistent communication to ensure these were included in care plans. This issue was also noted with Resident #5, who was unaware of any exercise program despite staff claims of providing multiple copies. The lack of documentation and communication regarding therapy recommendations was a significant deficiency in the facility's care planning process.
Physician Documentation and Care Review Deficiencies
Penalty
Summary
The physician failed to write, sign, and date progress notes at each visit for several residents, leading to deficiencies in the documentation of care. For Resident #64, progress notes were not created on the day of the visit, with significant delays between the effective and created dates of the notes. Similarly, for Resident #86, there were multiple instances where progress notes were not documented on the day of the visit, with delays ranging from weeks to months. These lapses in documentation were acknowledged by the Nursing Home Administrator and the Director of Nursing, but no further comments were provided. Additionally, the physician failed to review the total program of care for Resident #73, particularly concerning the management of diabetes. Despite an order for Metformin being given, there was no documentation of blood glucose monitoring before administration, as required. The attending physician's progress notes indicated that certain diabetes medications were discontinued due to hypoglycemic episodes, yet there was no evidence that the physician was aware of the ongoing administration of Metformin. This oversight was acknowledged by the Director of Nursing, but no further comments were made.
Pharmacist Fails to Identify Medication Irregularities
Penalty
Summary
The pharmacist failed to identify irregularities in the medication orders for two residents, leading to deficiencies in the medication regimen review process. For one resident, the pharmacist noted an irregularity in April regarding the administration of multiple pain medications without a specified pain scale. However, subsequent reviews in May and June failed to identify that the current pain medication orders did not include a pain scale, which was necessary for determining the appropriate medication to administer based on the resident's pain level. The resident's orders were changed after a hospital readmission, but the lack of a pain scale persisted, and the pharmacist acknowledged missing this irregularity. For another resident, the pharmacist did not identify an irregularity in the administration of Metformin, which required a fingerstick blood glucose check before administration. The medication administration record showed that the resident received Metformin twice daily without documentation of the required blood glucose monitoring. The pharmacist admitted to not noticing the fingerstick requirement in the order and assumed it might not have been intended, leading to a failure in identifying this irregularity during the medication regimen review. Additionally, the facility's policies and procedures for medication regimen reviews were found lacking, as they did not specify a timeframe for physician response to identified irregularities. This deficiency was acknowledged by the Director of Nursing, who was informed of the pharmacist's failure to identify the irregularities and the inadequacies in the facility's policies.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received medications according to physician orders, leading to several deficiencies. For Resident #64, the facility staff did not accurately transcribe the consultant physician's order for Ciprofloxacin, an antibiotic, which was supposed to be administered for 14 days. The medication administration record (MAR) showed that the order lacked a stop date, and the Director of Nurses (DON) acknowledged this oversight. Additionally, Resident #73's MAR revealed that the staff did not monitor the resident's blood glucose levels via finger stick before administering Metformin, an antidiabetic medication, as required by the physician's order. Resident #95's MAR indicated multiple instances where Diltiazem, an antihypertensive drug, was administered outside of the prescribed parameters. The medication was given even when the resident's blood pressure and heart rate were below the specified limits, and there was a lack of documentation explaining why the medication was not held. The Nursing Home Administrator (NHA) was informed of these issues, which included failing to document the resident's blood pressure or pulse in the MAR and not providing reasons for not administering the medication. Further deficiencies were noted with Resident #37, who received antihypertensive medications despite having heart rates below the parameters set by the attending provider. The DON confirmed that the medications were administered against the orders. Similar issues were found with Resident #94 and Resident #190, where the nursing staff failed to hold medications as instructed by physician orders when the residents' vital signs were outside the specified parameters. These failures highlight a pattern of non-compliance with medication administration protocols within the facility.
Inaccurate Documentation in Resident Medical Records
Penalty
Summary
The facility failed to maintain accurate documentation in resident medical records, as evidenced by several discrepancies across multiple cases. For one resident, a care plan meeting was inaccurately documented as having occurred on a different date and time than it actually did. This error was acknowledged by both the Nursing Home Administrator and the Social Service Director, who confirmed the mistake in the documentation. In another case, a resident's MOLST form, which indicated a preference for no CPR, was contradicted by a social services note and care plan that incorrectly documented the resident as full code. This discrepancy was acknowledged by the Social Service Director, who noted the need to address the inconsistency in the resident's code status documentation. Additionally, another resident's medical record contained two unvoided MOLST forms with differing orders, which had not been properly updated when a new MOLST was established. Further issues included incorrect documentation regarding the setup of home health services for a discharged resident, and a medication administration record that inaccurately indicated the removal of lidocaine patches. Additionally, a resident with a known sulfa allergy was documented as having received a sulfa-containing medication, although the medication was never actually administered. These errors highlight significant lapses in the facility's documentation practices, impacting the accuracy and reliability of resident medical records.
Inaccurate MDS Assessments Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for several residents, leading to deficiencies in care planning and service provision. For Resident #24, the MDS assessments did not capture the resident's limited range of motion in the legs, despite physical therapy documentation and the resident's own report indicating such limitations. This discrepancy was acknowledged by both the MDS coordinator and the physical therapist, highlighting a failure in accurately assessing and documenting the resident's mobility status. Resident #37's MDS assessment inaccurately recorded the resident's vision and dental status. Despite documentation of right eye blindness and edentulous status, the MDS assessment failed to reflect these conditions, which was later admitted as an error by the MDS coordinator. This misrepresentation could potentially affect the resident's care plan and the services provided to address their specific needs. For Resident #84, the discharge MDS assessment incorrectly indicated that the resident was discharged to a hospital, whereas records and family confirmation revealed the resident was transferred to another skilled nursing facility. This error was compounded by conflicting documentation regarding the discharge destination, leading to confusion about the resident's actual discharge location. Additionally, Resident #35's MDS assessments failed to document significant contractures, and Resident #67's MDS inaccurately reported pressure wounds as present upon admission, when they developed during the resident's stay at the facility.
Failure to Notify Resident of Rights and Return Belongings
Penalty
Summary
The facility staff failed to notify a resident and the resident's representative of their rights upon admission by not executing an admission contract. This deficiency was identified during a complaint and recertification survey for a resident who had passed away. The complaint alleged that the facility staff did not return the resident's belongings to the family after the resident's sudden death. A review of the facility's admission contract revealed that it included a section on the limitations of liability, stating that the facility is not responsible for loss or damage to the resident's valuables unless caused by negligence or willful action of the staff. However, there was no signed admission contract found for the resident, indicating that the resident and their representative were not informed of these terms. The resident was admitted with personal belongings, including a phone, clothing, and an iPad, which were documented by the nursing staff. After the resident's death, the complainant reported that several items were not returned, and they were not informed about the facility's rules, grievance procedures, or how to obtain medical records. The facility administrator was unaware of the phone being admitted with the resident and confirmed that a signed admission contract could not be located. The administrator did acknowledge that the facility reimbursed the complainant for the iPad, but the lack of a signed contract indicated a failure to properly inform the resident and their representative of their rights and responsibilities upon admission.
Failure to Notify Providers and Representatives
Penalty
Summary
The facility failed to notify the provider about a resident's allergy to sulfa medication, which resulted in the resident not receiving the prescribed Silver Sulfadiazine Cream. The resident had been residing at the facility since March 2024 and required assistance with activities of daily living. Despite the pharmacy alerting the facility about the allergy, there was no documentation indicating that the physician was informed before the medication order was discontinued. Interviews with staff revealed a lack of communication regarding the medication not being delivered or administered. In another instance, the facility did not notify a resident's personal representative after the resident experienced a fall. The resident's daughter was informed, but the documented personal representative, the resident's husband, was not contacted. The RN Unit Manager confirmed the oversight and failed to provide documentation of any attempt to contact the personal representative. Additionally, the facility did not notify the provider when a resident's blood pressure was below prescribed parameters, leading to the non-administration of blood pressure medication. The resident's Medication Administration Record showed multiple instances where the medication was held without proper documentation of blood pressure or pulse readings. The Nursing Home Administrator was informed of these concerns, acknowledging the lack of physician notification.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification of transfer to residents and/or their representatives, as required by regulations. This deficiency was identified for two residents who were hospitalized. Resident #22, who was cognitively intact and served as their own representative, reported not receiving any written notification regarding their transfer to the hospital. The medical record confirmed the hospitalization, and interviews with facility staff revealed a lack of awareness and proper procedure for issuing transfer notifications. The Director of Nursing was unaware of the transfer notification process, and the Nursing Home Administrator admitted that only bed hold policies were sent out, not transfer notifications. Similarly, for Resident #100, there was no documentation of written notification to the resident or their representative regarding the transfer to the hospital due to a change in condition. The Assistant Director of Nurses confirmed that the staff could not determine what documents, if any, were sent with the resident or to the family. This indicates a systemic issue within the facility regarding the failure to provide required written notifications for resident transfers.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of the bed hold policy upon transfer to an acute care facility. This deficiency was identified during a review of medical records and interviews, specifically for one resident out of eleven reviewed for neglect. The medical record review revealed that the resident was admitted to the facility in July 2023 and experienced a change in condition in August 2023, prompting a transfer to the emergency room. Although the resident's representative was present at the time of transfer, there was no documentation indicating that the facility's bed hold policy was provided to them in writing. The nursing home administrator confirmed that the practice of mailing the bed hold policy to residents' representatives began in March 2024, indicating that the resident's representative was not informed in writing at the time of the transfer in August 2023.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for a resident who required extensive help with transfers and bathing. The resident, admitted in June 2021 with a right hip fracture post-surgery, had intact cognitive status and was scheduled to receive showers twice weekly on Mondays and Thursdays. However, during the resident's stay from June 17 to July 9, 2021, the facility's records indicated that the resident received only one shower on July 6, 2021, and five bed baths on other days, contrary to the scheduled six showers. The deficiency was identified through a review of the Minimum Data Set (MDS) assessment and Geriatric Nursing Assistant ADL documentation, which showed incomplete and inconsistent records of the resident's bathing schedule. Interviews with the assistant director of nursing confirmed the discrepancy between the scheduled and actual care provided. The documentation revealed that several days were left blank, and staff had marked 'not applicable' on one occasion, indicating a lack of adherence to the resident's care plan and failure to meet the resident's ADL needs.
Deficiencies in G-Tube Care and Maintenance
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident receiving gastrostomy tube (g-tube) feedings and did not develop and implement a care plan addressing the care and maintenance of the feeding tube. Resident #73, admitted with dysphagia following a stroke, was receiving enteral feedings through a g-tube. The medical record lacked documentation of physician orders related to the care and maintenance of the g-tube, such as daily examination and cleaning of the insertion site, routine monitoring of tube placement, and assessment for gastrointestinal intolerance. Additionally, there was no documentation of the resident's positioning before and after tube feeding, despite orders for aspiration precautions and head elevation. The care plan for Resident #73, initiated by a dietician, addressed the resident's nutritional needs but did not include interventions for the care and maintenance of the feeding tube. The care plan lacked comprehensive interventions to prevent complications from tube feeding and did not address the psychosocial impact of the feeding tube on the resident. The facility's policy on feeding tubes required the resident's plan of care to address the use of feeding tubes and strategies to prevent complications, but this was not reflected in the care plan for Resident #73. Similarly, Resident #107, admitted with dementia and a history of stroke, had a g-tube for feeding but lacked a care plan addressing the care of the gastrostomy tube site. The facility's records did not show that the g-tube insertion site was examined and cleaned daily to prevent skin irritation. Interviews with facility staff revealed that nurses were expected to obtain orders for g-tube management and document care in the medication or treatment administration records, but this was not evident in the records for Resident #107.
Failure in Pain Management for Resident with Hip Fracture
Penalty
Summary
The facility staff failed to effectively manage a resident's pain, as evidenced by the case of a resident who was admitted with a right hip fracture post-surgery and required opioid medication for severe pain. Upon admission, the resident experienced critical pain but had to wait over four hours for pain management. The discharge medication list from the hospital included an opioid medication to be taken every six hours as needed for severe pain. However, the resident did not receive the prescribed Oxycodone upon admission, despite complaints of severe pain and communication of needs verbally. The attending provider's progress notes indicated that the resident was given Tylenol, which did not relieve the pain, and the nursing staff reported not finding the prescription for Oxycodone initially. The care plan for pain management was initiated, but the review failed to show that the resident received appropriate pain management for severe pain or that a follow-up pain level assessment was conducted. The facility's process for obtaining opioid medication involved faxing the prescription to the pharmacy and using the backup medication box, but this process was not effectively executed, resulting in delayed pain management for the resident.
Failure to Provide Recommended Snacks to Diabetic Resident
Penalty
Summary
The facility failed to provide a resident with snacks as recommended by the dietician and outlined in the resident's care plan. This deficiency was identified for a resident with multiple medical conditions, including Type 2 Diabetes Mellitus, who was at nutritional risk following a recent hospitalization. The dietician had recommended an evening snack to help stabilize the resident's blood sugar levels and provide additional calories. However, documentation revealed that the resident was not consistently offered or provided with the recommended bedtime snacks. The review of the resident's medical records and geriatric nursing assistant (GNA) task documentation showed that the resident received a snack on only 2 out of 14 days in May and on 2 out of 7 days in June. The GNA frequently documented 'not applicable,' indicating that the resident had not been offered or had not received the recommended snacks. The Nursing Home Administrator was informed of these concerns, acknowledging the failure to adhere to the dietician's recommendations and the resident's care plan.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of residents during meal assistance and in the handling of urinary drainage bags. Observations revealed that staff members were standing over residents while assisting them with meals, despite the availability of chairs in the room. This was noted for three residents, with staff members consistently standing over them during meal times. The Director of Nursing (DON) confirmed that the facility's best practice is for staff to be seated while assisting residents with meals, yet this practice was not followed until after the surveyor's intervention. Additionally, the facility did not ensure the use of privacy bags for urine drainage bags, compromising the dignity of a resident with a Foley catheter. The resident's medical records indicated an order for the Foley bag to be housed in a privacy bag every shift, which was marked as completed by nursing staff. However, observations on two separate occasions showed the urine drainage bag exposed without a privacy bag. The Unit Manager confirmed the oversight and acknowledged the concern regarding the dignity of the resident.
Failure to Provide ASL Communication for Deaf Resident
Penalty
Summary
The facility failed to have a process in place to communicate with a resident in their preferred language, which was American Sign Language (ASL). This deficiency was identified during a survey when it was observed that a long-term resident with a history of dementia and deafness, who communicated using ASL, was not provided with an ASL interpreter. Instead, staff members communicated with the resident using a whiteboard and gestures. Interviews with various staff members, including a GNA, RN unit manager, and the Long-Term Care Social Worker Coordinator, confirmed that an ASL interpreter had never been used to communicate with the resident, despite the resident's care plan indicating the use of sign language and a communication board. The deficiency was further highlighted during an interview with the resident, conducted with the assistance of a qualified ASL interpreter. The resident expressed that while the whiteboard was acceptable, signing was the best method of communication for her. The lack of ASL interpreter services over the resident's year-long stay at the facility was a significant concern, as it was reported that the resident experienced decreased anxiety and delusions when able to communicate in ASL. The facility's failure to provide communication in the resident's preferred language led to the deficiency noted in the survey.
Failure to Inform Residents of Advanced Directive Rights
Penalty
Summary
The facility staff failed to provide evidence that residents were informed of their right to formulate an advanced directive, as required. This deficiency was identified for two residents during a review of their medical records and staff interviews. For one resident, the medical record contained a MOLST form incorrectly labeled as an advanced directive, with no documentation indicating that an advanced directive was discussed or offered during admission. The Social Services Director (SSD) acknowledged the absence of an advanced directive discussion and noted that the resident was admitted before her tenure. After the surveyor's inquiry, a progress note was added indicating that the resident refused to formulate an advanced directive. For another resident, the review of the electronic health record and paper medical record revealed no evidence of an advanced directive or documentation that the resident was informed of their right to formulate one. The resident's admission assessment indicated moderate cognitive impairment, and there was a contradiction between the MOLST form and the social services note regarding the resident's code status. The care conference note did not indicate that advanced directives were discussed, and the care plan inaccurately reflected the resident's code status. The SSD acknowledged these concerns but did not provide further comments.
Failure to Report and Repair Maintenance Issues
Penalty
Summary
The facility failed to ensure that items in need of repair were reported to the maintenance department, affecting two resident rooms. In the first instance, a surveyor observed that the wallpaper in a resident's room was separating and had been stapled together in several areas. Additionally, the material covering the right armrest padding of the resident's wheelchair was not intact, with a section missing. Despite the availability of a computerized system for reporting maintenance issues, no reports were made for these concerns, and the maintenance director confirmed no recent work had been done on the resident's wheelchair. The maintenance director also noted that there were no current plans for wallpaper removal. In the second instance, a surveyor observed cracks in four floor tiles in another resident's room, located between the bathroom and the left wall. The maintenance director acknowledged replacing tiles in other rooms but did not address the cracks in this particular room. Upon further inspection, additional cracks were found in a similar area in the adjacent room, which the maintenance director attributed to a structural problem. These observations indicate a lapse in the facility's maintenance reporting and repair processes.
Delayed MDS Assessments for Hospice Admissions
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required 14-day period following a significant decline in the condition of two residents who were admitted to hospice care. Resident #37, who was admitted to the facility in June 2020 with a diagnosis of stroke and one-sided weakness, was admitted to hospice care on February 13, 2024. However, the Significant Change in Status MDS assessment for this resident was completed and signed on March 5, 2024, which was 22 days after the hospice admission and eight days late. Staff interviews confirmed the delay in completing the assessment. Similarly, Resident #4, who had been residing in the facility since June 2013, was admitted to hospice care on May 1, 2024. The Significant Change in Status MDS assessment for this resident was completed and signed on May 24, 2024, which was 24 days after the hospice admission and ten days late. The MDS coordinator, staff #9, indicated that the assessments were completed 14 days after learning about the residents' admission to hospice, rather than within 14 days of the actual start of hospice care, leading to the delay.
Failure to Act on Hospice Consult Order
Penalty
Summary
The facility failed to act upon an order for a hospice consult for a resident who had been residing at the facility for several years. On May 22, 2024, an order for a hospice consult and evaluation was placed in the resident's medical record. However, there was no documentation indicating that the hospice referral was addressed with the resident or their family, nor was there any evidence that a hospice provider was contacted regarding this consult order. The resident passed away on May 26, 2024, without the hospice consult being addressed. The Assistant Director of Nursing reported that hospice consults are reviewed by the interdisciplinary team and that social services are responsible for contacting hospice based on the family's choice. Despite this process, no documentation was found to show that social services addressed the hospice consult order before the resident's death.
Unsecured Oxygen Cylinder in Nursing Unit
Penalty
Summary
The facility staff failed to store oxygen cylinder tanks securely, which was observed in one of the two nursing units. Specifically, on Unit 2's nursing station, two surveyors noted an unsecured oxygen cylinder leaning against a counter in the left, back corner of the nurse's station. This observation was made during a survey on 6/24/24 at 10:00 AM. The Assistant Director of Nurses (ADON), who was present on the unit, confirmed the findings upon being shown the unsecured oxygen cylinder. Compressed oxygen cylinders, also known as oxygen tanks, store pressurized oxygen and need to be secured to prevent them from tipping over and becoming damaged.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to effectively monitor and address significant weight loss in two residents, leading to deficiencies in nutritional care. Resident #1, a long-term resident, experienced a notable weight loss of 16% over 47 days, as documented by a dietician. Despite a request for a re-weigh to verify the weight change, the re-weigh was delayed by 13 days, during which the resident lost an additional 4% of body weight. The dietician reported not receiving notifications of weight loss or re-weigh completions, relying instead on reviewing electronic health records, which contributed to the oversight. Resident #72, a newly admitted resident, also experienced significant weight loss, losing 5.62% of body weight in 22 days. A dietician noted the weight loss and requested a re-weigh, but there was no evidence that this was completed, nor were there any changes to the resident's dietary orders. The dietician responsible for follow-up was unaware of the previous dietician's note and did not include the resident in the list of those needing follow-up, resulting in a lack of timely intervention for the resident's nutritional needs.
Failure to Provide Timely Physician/Nurse Practitioner Visits
Penalty
Summary
The facility failed to provide Physician or Nurse Practitioner services to a long-term care resident at least once every 60 days, as required. This deficiency was identified during a survey when Resident #53 expressed concerns about the infrequency of physician visits. A review of the resident's progress notes from November 22, 2023, to March 8, 2023, revealed no documentation of a visit by a Physician or Nurse Practitioner. The Director of Nursing confirmed the absence of any handwritten physician visit notes for the specified period, acknowledging that there were no documented provider visits for Resident #53 during that time frame.
Failure to Document and Account for Controlled Medication
Penalty
Summary
The facility failed to ensure accurate documentation and accounting of a controlled medication, specifically Lacosamide, for a resident. The medication order was in effect since late June, but the medication was not administered on one occasion due to it being in transit from the pharmacy. The medication was brought in by the resident's family, and the facility's pharmacy had not delivered it. The Controlled Medication Utilization Record did not include the name of the medication or the resident, and doses were removed without proper documentation. The facility's policy required immediate recording of delivered medications, but this was not followed. The medication was not documented correctly on the control sheet, and the primary care provider was not informed about the unavailability of the medication before a new order was placed. The staff was unaware that Lacosamide was a controlled substance and did not realize it was brought from home. The facility's pharmacy eventually supplied the medication, but the initial supply was directly from an external pharmacy. The facility's policy on unavailable medications required staff to take immediate action when a medication was unavailable, including notifying the physician and obtaining alternative treatment orders. However, there was no documentation indicating that the primary care provider was informed of the medication's unavailability. The shift-to-shift count sheets showed that multiple staff conducted counts but did not identify the issue with the Lacosamide. The DON acknowledged the concern and provided documentation of staff education and an updated policy after the issue was identified.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the prescription and monitoring of psychotropic medications for residents. For one resident, a PRN order for Lorazepam was not limited to 14 days and lacked a discontinuation date. Despite the pharmacist's repeated recommendations to address this irregularity, the attending physician continued the order without documenting a rationale for extending it beyond the 14-day limit. This oversight was noted in the resident's medical records and discussed with the facility administrator, who acknowledged the concern. Another resident was prescribed Mirtazapine for depression, but the facility did not monitor the resident for changes in behavior or side effects associated with the medication. Additionally, there was no care plan addressing the use of the antidepressant or the behaviors it was intended to manage. The Director of Nurses acknowledged these concerns, indicating that the issue of monitoring residents on psychotropic medications had been identified but not yet addressed for this particular resident.
Medication Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by two medication errors identified during the survey. The first error involved a nurse who incorrectly administered lidocaine patches to a resident. The nurse applied two patches to the resident's knees, but failed to apply a third patch to the resident's back as per the physician's order. The nurse had documented that the patch was applied to the back, although it was not. This discrepancy was confirmed during a review of the medical record and a subsequent interview with the nurse, who mistakenly believed the back patch was an as-needed order. The second error occurred when an LPN administered a multi-vitamin with minerals to a resident, contrary to the physician's order for a multi-vitamin without minerals. The error was discovered during a review of the resident's Medication Administration Record, which showed the incorrect medication was given. The LPN acknowledged the mistake and noted that the multi-vitamins were a stocked item, indicating a potential issue with the stock medication provider.
Medication Administration Error with Lidocaine Patches
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of lidocaine patches. Resident #36, who was admitted in 2023 with a diagnosis including rheumatoid arthritis, had a physician's order for a lidocaine patch to be applied to the left lower back for pain management. However, during a surveyor's observation, a nurse (Staff #35) was seen applying two lidocaine patches to the resident's knees instead of the prescribed location on the back. The nurse incorrectly documented that the patch was applied to the back, despite not doing so, and claimed there were two separate orders for the patches. Further investigation revealed that the medical record contained two current orders for lidocaine patches, one for the knees and right thigh/groin, and another for the left lower back. The nurse mistakenly believed the back patch was a PRN (as needed) order, which was not the case. The Medication Administration Record (MAR) showed consistent documentation of the back patch being administered daily, although it was not applied on the day of the survey. The Director of Nursing (DON) acknowledged the issue, noting that the nurse was nervous when questioned about the discrepancy.
Medication Storage and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in accordance with acceptable professional standards, as observed on two nursing units. On the first-floor nursing unit, insulin vials and pens were found unsecured on top of medication carts, with a Licensed Practical Nurse (LPN) leaving them unattended while attending to other tasks. The Director of Nursing (DON) confirmed that it was against facility policy to leave medications unsecured and instructed the nurse to secure them. Additionally, a vial of ceftriaxone, an antibiotic, was found on a medication cart with a date indicating it should have been returned to the pharmacy after a one-time use for a resident. Further deficiencies were noted in the medication storage room on the skilled unit, where insulin pens and an injectable medication were found without resident names. A Controlled Medication Utilization Record was incomplete, lacking the name of the medication or resident, despite documentation of doses being removed. The medication in question, lacosamide, a schedule 5 controlled substance, was reportedly brought in by a resident's family. These observations indicate a failure to adhere to proper medication storage and documentation protocols.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to provide dental services to a long-term resident, identified as Resident #53, during their stay. The resident reported not receiving any dental services despite having purchased dental insurance offered by the facility. Interviews with the resident revealed that they had requested dental appointments but had not seen a dentist since their admission. A review of the electronic medical records confirmed the absence of any dental appointments for the resident prior to June 2024. Further investigation showed that the resident enrolled in dental insurance coverage in February 2023, and the facility's business office manager confirmed that dental services were available on-site every two months. However, the administrator was unable to provide documentation of any dental services provided to the resident before the survey's conclusion. This lack of documentation and service provision led to the determination of a deficiency in the facility's obligation to provide necessary dental care to its residents.
Failure to Serve Meals According to Preferences and Evaluate Therapeutic Diets
Penalty
Summary
The facility failed to ensure that a resident was served a meal according to a predetermined menu that incorporated the resident's preferences. An observation on 6/17/24 revealed that Resident #24's breakfast tray was missing milk and coffee, which were supposed to be included as per the standing orders on the meal ticket. The resident confirmed the absence of these items, and staff interviews indicated that the kitchen was out of milk and did not provide a cup for coffee. Despite the standing order, the corporate food service manager could not explain why the resident did not receive the specified items. Additionally, the facility failed to evaluate a resident before developing a therapeutic diet, resulting in the resident's food preference not being considered. Resident #57, who was on a puree diet, reported not understanding the reason for this dietary change, as he had no known swallowing issues. A review of the resident's physician orders and interviews with staff revealed that the diet was downgraded without a proper evaluation by a speech therapist. The dietician, who worked remotely, did not conduct a thorough evaluation, as he did not review any swallow evaluation or consult with the speech therapist. The facility did not provide a speech therapy swallowing evaluation after the diet downgrade, despite documentation indicating the need for such an assessment.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols in two instances involving Resident #286. Firstly, staff #27, a geriatric nurse aide, did not wear a gown while providing direct care to the resident, who was on enhanced barrier precautions due to having an indwelling Foley catheter and open wounds. Despite the signage on the resident's door indicating the need for gowns and gloves during high-contact care activities, staff #27 only wore gloves and admitted to forgetting to wear a gown. This oversight was noted during an observation and confirmed through interviews with the staff and the director of nursing. Secondly, the facility did not store a nebulizer mask in a sanitary manner, as observed with Resident #286, who was using oxygen therapy and had a prescription for nebulizer treatments. The nebulizer mask was found lying uncovered on top of the nebulizer machine, contrary to the expected practice of rinsing, drying, and storing it in a sealable plastic bag after use. This improper storage was acknowledged by staff #38, an LPN, who stated that the mask should have been kept in a plastic bag to prevent infection. The assistant director of nursing confirmed the expected procedure for nebulizer mask storage during a subsequent interview.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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