Heartwood Lodge Trinity Health

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 male resident with dementia was observed sitting at a dining table during breakfast and requested that a Certified Nurse Aide (CNA) warm up his eggs, stating they were ice cold. The CNA responded by telling the resident that the microwave was broken and then left the area without assisting further. As a result, the resident did not finish his breakfast. Subsequent interviews revealed that there was, in fact, a working microwave in the kitchen, and the resident recalled that the CNA sometimes did not help him. The facility administrator acknowledged that the CNA's interaction was not acceptable and did not meet expectations for resident treatment. This incident demonstrates a failure to treat the resident with dignity and respect, as the staff member did not address the resident's request appropriately and did not facilitate his ability to enjoy his meal.

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 resident with multiple complex diagnoses, including cerebral palsy, epilepsy, abnormal posture, torticollis, and scoliosis, was admitted to the facility and assessed as a moderate fall risk. The resident's care plan specified the need for two staff members for repositioning and turning in bed, while only one staff member was required for brief changes and use of the bed pan. Despite these documented care needs, the resident reported that typically only one staff member provided care, including bed baths. During an incident in February, a CNA was providing a bed bath to the resident after a bowel movement. The CNA rolled the resident onto her right side to clean her and then turned away to get more washcloths. While unattended, the resident rolled off the bed and fell to the floor. The CNA acknowledged checking the kardex for toileting and transfer assistance but did not recall checking the bed mobility assistance requirement. The resident sustained multiple rib fractures, a hip fracture, and additional complications, requiring hospitalization. Documentation and interviews confirmed that only one staff member was present during the bed bath, contrary to the care plan's requirement for two staff during bed mobility. The CNA received a final written warning for failure to follow policies, procedures, or regulations, though the specific infraction was not detailed in the personnel file. The incident resulted in significant injury to the resident, as confirmed by hospital records and staff interviews.

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's QAPI committee failed to identify, address, and implement appropriate plans of action for several critical areas, including call light response times, grievance handling, timely and accurate MDS submissions, antibiotic stewardship, infection control, maintenance of complete and accurate medical records, annual review and updating of policies and procedures, and monitoring nursing staff compliance with standards of practice. Interviews and record reviews revealed that concerns raised by residents and documented in council minutes regarding call light response were not followed up with ad hoc meetings or effective action. Grievances from resident council meetings were not consistently documented or brought to the interdisciplinary team, and the process for addressing and tracking grievances was incomplete. The facility also failed to address late and incorrect MDS submissions, and the NHA acknowledged ongoing issues with documentation and coding accuracy. Antibiotic stewardship and infection control practices were not aligned with facility policy, and the Infection Control Preventionist had not compared the Infection Control Pathway to policy. Medical records were found to be incomplete and disorganized, with ongoing issues in documentation by CNAs and delays in uploading information to the EMR. Several key policies and procedures were outdated, missing, or not reviewed annually, including those for admissions, infection control, skin/wound management, and water management. The QAPI plan provided during the survey was blank, and the NHA was unable to provide adequate answers regarding the lack of updated policies and procedures.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the required attendance of a Medical Director or designated physician was maintained at the Quality Assessment and Assurance (QAPI) meetings at least quarterly. Review of QAPI monthly sign-in sheets from June 2024 to June 2025 showed that a physician was present only at three meetings, leaving eight months without physician representation. During an interview, the Nursing Home Administrator confirmed that monthly QAPI meetings are held but could not explain the absence of the Medical Director or a designated physician at least quarterly. This deficiency affected all 74 residents residing in the facility, as there was a lack of required medical oversight during the QAPI process.

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 annual review of its Infection Control policy and procedures to verify adherence to current national standards of care. During the survey, documentation was requested to show that the Infection Prevention policy and program had been reviewed annually, but neither the Infection Preventionist nor the Director of Nursing could provide evidence of such a review. The policy provided did not indicate when it had been implemented or last reviewed, and no verification of an annual review was available by the time of survey exit. Additionally, the facility did not have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. The Environmental Services Director was unable to confirm when the last review of the Water Management Plan had occurred or identify the current members of the interdisciplinary water management team. The Water Management Policy on file was developed by previous owners and had not been updated to reflect the current ownership or reviewed for ongoing effectiveness.

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 establish and implement an effective antibiotic stewardship program, as evidenced by the lack of written protocols for antibiotic use, insufficient documentation, and the absence of a monitoring system to provide feedback to prescribing practitioners. The Infection Control policy referenced antibiotic stewardship but did not include specific protocols for antibiotic use, procedures for residents admitted on antibiotics, or a system for feedback and documentation. During interviews, the Infection Preventionist described a general process for identifying infections and initiating antibiotics but did not reference any formalized, written procedures or monitoring systems. A review of the electronic medical record for a resident admitted with a urinary catheter revealed multiple deficiencies in antibiotic management and documentation. The resident exhibited symptoms of a urinary tract infection (UTI), and laboratory tests were conducted. Despite positive urinalysis results, antibiotics were initiated without documented justification or evidence that the physician had been notified. There were conflicting entries for two different antibiotics, with no documentation regarding consideration of renal function or culture results. The medical provider did not document in the facility's EMR, and there was no care plan for the UTI or antibiotic therapy. The facility was unable to provide additional documentation to demonstrate that antibiotic therapy was consistent with an antibiotic stewardship program.

Penalty

No penalty information released

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

Summary

The facility failed to answer call lights in a timely manner for multiple residents, as documented in Resident Council meeting minutes and individual resident interviews. Residents, particularly those on the 2nd and 3rd shifts, reported that call lights were often left unanswered for extended periods, with staff sometimes entering the room, stating they would return, but not meeting the resident's needs. Meeting minutes from two separate Resident Council meetings indicated that the issue was ongoing and unresolved, with several residents expressing dissatisfaction. The Activities Director also communicated these concerns to the previous DON, noting that the problem persisted across different units. One resident, who required substantial to maximal assistance for toilet transfers and was always continent, reported waiting up to an hour for call light response, resulting in incontinence. Call light logs for this resident showed multiple instances of wait times ranging from over 20 minutes to more than 45 minutes. Staff interviews confirmed awareness of the issue, and the DON acknowledged that reasonable response times should be 5-10 minutes, but audits had not identified problems. The NHA was aware of the concerns but had not initiated an ad hoc review, and grievances from Resident Council meetings were not individually addressed unless resolved.

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 transmit Minimum Data Set (MDS) assessments in a timely manner for four residents. For one resident, the annual assessment with an assessment reference date (ARD) in March was not completed until June, resulting in a significant delay. Another resident's annual assessment, due in early May, was not completed until June as well. The MDS Coordinator/Registered Nurse confirmed that these assessments were over 120 days old and acknowledged that one assessment was missed entirely, while another was not flagged as due or late in the electronic medical record (EMR) system. Additionally, two other residents experienced delays in the completion and submission of their MDS assessments. One resident's 5-day assessment and admission assessment were flagged as overdue in the EMR, with the entry not signed off until several days after the ARD. Another resident's 5-day admission assessment was also submitted late, as confirmed by the MDS Coordinator. The Nursing Home Administrator was made aware of these late assessments by the MDS 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 provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with chronic heart failure, sepsis, pressure ulcer, and Alzheimer's disease, there was a lack of assessment, monitoring, and action upon abnormal findings. The resident experienced a significant change in condition, including slurred speech, inability to assist with transfers, and coffee ground emesis, but there was no documentation of transfer to the hospital or death in the facility. Physician orders for vital sign monitoring were not followed, with vital signs often not recorded as ordered, and abnormal findings such as low blood pressure and low oxygen saturation were not addressed or communicated to the physician. Additionally, there was a delay in administering ordered IV antibiotics due to medication unavailability, and the physician was not notified of this delay. Skin assessments and care planning for pressure injuries were not completed timely or accurately, with missing documentation and delayed initiation of care plans and wound assessments. Another resident admitted with a history of lumbar spine fusion, UTI, and pelvic fracture did not receive antibiotics for a UTI in a timely manner, as the medication was not available upon admission and was started three days later. The care plan inaccurately reflected the presence of an indwelling catheter, which the resident did not have, and there was no documentation of orders to discontinue a catheter. Additionally, x-ray results ordered for this resident were not documented or followed up in the electronic medical record, and staff were unaware of the results until prompted. There was also a lack of communication and documentation regarding the resident's transfer needs and the use of appropriate transfer techniques. A third resident admitted with a surgical wound requiring a wound vac and a stage II pressure ulcer experienced delays in receiving the necessary wound vac supplies, resulting in alternative wound care and subsequent infection. Documentation of wound assessments was inconsistent, with discrepancies in wound measurements and lack of clear identification of wound sites. There was no evidence that the physician was notified of abnormal wound findings, such as foul odor and changes in wound condition, in a timely manner. Additionally, skin assessments were not completed as required, and documentation of dressing changes did not match observations, with dressings not in place as ordered. The facility lacked formal policies for admissions, transfers, discharges, and documentation of medical records, relying instead on standards of practice without clear protocols.

Penalty

No penalty information released

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

Summary

A resident admitted with a history of lumbar spine fusion, UTI, and pelvic fracture was documented as always continent of bowel and bladder and required substantial to maximal assistance for toilet transfers. Despite this, the resident experienced significant delays in receiving toileting assistance, as evidenced by call light logs showing multiple instances of wait times exceeding 20 to 45 minutes. The resident reported having to wait up to an hour for assistance, resulting in episodes of incontinence, and stated that some staff advised her to urinate in her brief if she could not wait. Documentation showed that on several days, the resident was only toileted once, and there were gaps of many hours between toileting events. Staff interviews confirmed awareness of the resident's concerns regarding long call light response times and inappropriate toileting practices, such as being given a bedpan instead of being assisted to the bathroom. The DON acknowledged that the facility's expectation is for call lights to be answered within 5-10 minutes and that it is not standard practice to advise continent residents to urinate in their briefs. The care plan indicated the resident was at risk for infection related to an indwelling catheter, but the resident did not have a catheter at the time of the deficiency. No concern forms were found for the resident, and documentation revealed multiple incontinence episodes and insufficient toileting assistance.

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 monthly pharmacy medication regimen review (MRR) irregularities and pharmacist recommendations were received and addressed by the physician for two residents. For one resident with multiple complex diagnoses, including cerebral palsy, epilepsy, and scoliosis, the pharmacist made several recommendations over a period of months, such as changes to Vitamin D dosing, lab monitoring for seizure medication, and administration timing for warfarin. Documentation of these recommendations and their review or implementation by the physician was missing or incomplete in the resident's medical record. In one instance, although the physician accepted a pharmacist's recommendation to change Vitamin D dosing, the change was not implemented for over ten months. Additionally, there was no evidence that the physician was notified in a timely manner of a critical recommendation regarding warfarin administration, and documentation of physician review for other recommendations was not found. For another resident with a diagnosis of GERD, the pharmacist recommended tapering and discontinuing omeprazole and ordering a basic metabolic panel (BMP) during routine MRRs. Although the physician accepted the recommendation to taper and discontinue omeprazole, the medication continued to be administered as before, and the change was not implemented. For the BMP recommendation, the physician accepted the recommendation, but there was no documentation in the electronic medical record (EMR) that the lab was completed as directed or that the physician reviewed a previous lab result to determine if it was sufficient. Interviews with facility staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), confirmed the lack of documentation and failure to implement or address the pharmacist's recommendations. In some cases, signed consultation reports were found outside of the residents' medical records, and in other cases, the facility was unable to provide any evidence that the recommendations were reviewed or acted upon by the physician. The deficiencies were identified through record review and staff interviews, and as of the survey exit, the facility had not provided additional information to demonstrate compliance.

Penalty

No penalty information released

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

Summary

Surveyors observed that the facility failed to ensure proper labeling of medications in both a medication cart and a medication room, potentially affecting 25 residents. During inspection of a medication cart, a box of Ketotifen fumarate ophthalmic solution was found labeled with a resident's name and room number, but the solution bottle inside the box was not labeled with any identifying information. Other single-user bottles and vials in the cart were properly labeled. The LPN present was unsure if it was necessary to label the bottles themselves or if labeling the box was sufficient. In the medication room, a box of Tuberculin Purified Protein Derivative (TB PPD) solution was labeled with an open date, but the vial inside was not. The Clinical Care Coordinator stated she did not label TB vials with the open date, only the box, and expressed uncertainty about what to do if vials became separated from their boxes. Upon further inquiry, she acknowledged learning that vials should be labeled with the open date. A registered nurse later confirmed that vials and bottles in boxes should be labeled with resident names and that TB vials should be labeled with the open date to ensure proper identification if separated from their boxes.

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 assess a resident for self-administration of medication and did not track or record the resident's medication use as required. The resident, who was admitted with diagnoses including Acute Respiratory Failure, COPD, and Emphysema, was observed with a nebulizer, CPAP machine, and an Albuterol inhaler at bedside. The resident reported using the inhaler multiple times a day, but staff had not inquired about its use or provided any education regarding the medication. Review of the resident's electronic medical record and medication administration record revealed a lack of documentation regarding assessment, education, or monitoring for the safe and proper use of the inhaler, with only one instance of self-administration recorded despite the resident's reported frequent use. Facility policy requires that residents be assessed by the interdisciplinary care team for the safety and appropriateness of self-administering medications, be educated on side effects, and be regularly observed and monitored, with all actions documented in the care plan and medication administration record. However, there was no evidence that these procedures were followed for this resident. The Director of Nursing confirmed that if the documentation was not present in the record, the required assessments and monitoring likely did not occur.

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 always continent of bowel and bladder and required substantial to maximal assistance for toilet transfers reported experiencing long wait times for call light responses when needing toileting assistance. The resident stated that on one occasion, she waited about an hour for help, resulting in soiling her pants. Additionally, some night staff reportedly told her to use her brief if she could not wait, which made her feel bad even though staff were kind and cleaned her up. The DON acknowledged ongoing monitoring of call light response times, stating that audits had not shown problems and that a reasonable response time was 5-10 minutes. The NHA was aware of call light concerns but had not yet conducted an ad hoc review.

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 the physician or provider in a timely manner following a resident's fall with injury. A cognitively intact resident with a history of traumatic subdural hemorrhage experienced an unwitnessed fall in the bathroom, resulting in a skin tear to the left elbow, swelling to the back of the head, and complaints of headache. Documentation showed that the incident occurred in the early morning, but the physician or provider was not notified until two days later. The Nursing/Physician Communication form and progress notes did not indicate any earlier notification, and the swelling to the back of the head was not included in the initial communication form. Interviews with facility staff confirmed that the physician should have been notified at the time of the fall, and that documentation of such notification was lacking. The Nursing Home Administrator and Clinical Care Coordinator both acknowledged that if the notification was not documented, it likely did not occur. The resident was subsequently admitted to the hospital with an elevated white count and a small intracranial bleed, but there was no evidence that the physician was informed of the fall and injuries in a timely manner.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of neglect to the state survey agency after a resident experienced a significant fall resulting in serious injuries. The resident, who had multiple diagnoses including cerebral palsy, epilepsy, abnormal posture, torticollis, and scoliosis, was assessed as being at moderate risk for falls and required two staff members for repositioning and turning in bed, according to her care plan. However, during a bed bath, only one CNA was present and rolled the resident onto her side. The CNA briefly turned away to get more washcloths, during which time the resident rolled off the bed and fell to the floor. Following the fall, the resident experienced pain and difficulty breathing, and was found to have several fractured ribs, a hip fracture, a pulmonary embolism, and a small pneumothorax. The incident was documented in the nurse's notes and the resident was sent to the hospital for evaluation and treatment. The CNA involved acknowledged checking the kardex for some care needs but was unsure if she reviewed the bed mobility assistance requirement, and expressed remorse for the incident. Despite the severity of the injuries and the circumstances of the fall, the Nursing Home Administrator did not report the incident to the state survey agency. The decision not to report was based on advice from a Regional Nurse Consultant, who attributed the fall to a mattress issue rather than a reportable event. The administrator later acknowledged that the CNA's handling technique contributed to the fall, but maintained that the incident was not reported as neglect or abuse as required by facility policy.

Penalty

No penalty information released

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

Summary

The facility failed to appropriately document and notify regarding the transfer and discharge of two residents. For one resident, the Minimum Data Set (MDS) indicated a discharge to a short-term general hospital, but nursing progress notes and discharge instructions showed the resident was actually discharged to an assisted living facility with his son. The discharge documentation was incomplete, lacking the reason for discharge, destination, resident or representative signature, and home care agency information. There was also no discharge summary or recap of stay in the electronic medical record (EMR). Staff interviews confirmed discrepancies in the documentation and confusion about the resident's actual discharge location. For the second resident, the MDS indicated the resident died in the facility, but EMR review and staff interviews revealed the resident was transferred to a hospital by EMS and died there. There was no documentation in the EMR to show the resident left the facility or was accompanied by EMS, and no physician orders for discharge or transfer were present. A bed hold request was documented, but no transfer forms were found. The facility did not have formal policies for admissions, transfers, and discharges, relying instead on standards of practice and outdated training materials.

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 accurately code the Minimum Data Set (MDS) for two residents whose records were reviewed. For one resident, the MDS indicated the individual died in the facility, but review of the electronic medical record and staff interview revealed the resident was transferred to a hospital by EMS and died there, with no documentation supporting an in-facility death or transfer. For another resident, the MDS coded the discharge as a transfer to a short-term general hospital, but nursing progress notes and staff interviews confirmed the resident was actually discharged to an assisted living facility with his son, not to a hospital. The facility's MDS Completion Guideline had not been updated, reviewed, or revised since its original date.

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 complete an annual Preadmission Screening/Annual Resident Review (PASARR) Level I Screening and Level II Evaluation in a timely manner for a resident with multiple diagnoses, including dementia, depression, and narcissistic personality disorder. The resident's last PASARR Level II Evaluation was completed on 5/15/24, and there was no documentation of a subsequent PASARR Level I Screening or Level II Evaluation being completed as required before 5/15/25. The social worker responsible for tracking PASARR screenings acknowledged that the screening was overdue and had not yet been completed. Record review and staff interviews confirmed that the facility was aware of the overdue PASARR screenings and evaluations, as indicated by the social worker's tracking tool and statements from the nursing home administrator. Although the issue was identified and discussed in the facility's QAPI committee, there was no evidence that corrective actions to address the overdue screenings and evaluations were initiated until the time of the annual survey.

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 person-centered care plan that accurately reflected the needs of a resident with a history of lumbar spine fusion, UTI, and fractures. The resident was documented in the Minimum Data Set as always continent of bowel and bladder and requiring substantial to maximal assistance for toilet transfers. However, the care plan included interventions for an indwelling catheter, which the resident did not have, and focused on infection risk related to a catheter. The care plan also indicated the resident required one staff member for toilet use. During observation and interview, the resident reported experiencing long wait times for call light responses when needing toileting assistance, sometimes waiting up to an hour and soiling herself as a result. She also reported that some staff at night instructed her to use her brief if she could not wait, which made her feel bad, even though staff were kind and cleaned her up. These findings indicate the care plan was not individualized to the resident's actual needs and was not effectively implemented to address her toileting assistance requirements.

Penalty

No penalty information released

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

Summary

The facility failed to revise the care plans for two residents following documented changes in their care needs. One resident, admitted with acute respiratory failure and COPD, was observed self-administering an Albuterol inhaler multiple times daily. Despite a physician's order allowing the inhaler at bedside and specifying its use as needed, the care plan did not include any assessment or monitoring of the resident's self-administration, nor did it outline staff responsibilities for monitoring or documentation related to the inhaler. Another resident, admitted with a fracture and a history of repeated falls, had a urinary catheter inserted upon admission. The resident developed signs of a urinary tract infection (UTI), including cloudy, foul-smelling urine and an elevated white blood cell count, which led to laboratory testing and the initiation of antibiotic therapy. However, the care plan was not updated to reflect the new diagnosis of UTI or the administration of antibiotics. The facility's policy requires care plans to be revised as residents' conditions change, but this was not done in either case.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurate medical records for one resident with multiple complex diagnoses, including cerebral palsy, epilepsy, abnormal posture, torticollis, and scoliosis. The resident reported that in February, she rolled out of bed while a staff member was providing a bed bath, resulting in pain, difficulty breathing, and subsequent hospitalization for several fractured ribs and a hip fracture. Documentation in the nurse's notes inaccurately described the incident as an unwitnessed fall, rather than reflecting that the fall occurred in the presence of staff during care. Additionally, the certified nursing assistant's statement indicated she was present and momentarily turned away when the resident rolled off the bed. A review of the resident's medical record revealed missing documentation related to the fall, including the facility-to-hospital transfer form and delayed uploading of neurological checks and hospital notes, which were only added to the record several months after the incident. Despite multiple requests during the survey, the facility was unable to provide the required transfer form, and some documentation was not present in the resident's record at the time of review. The facility's process for uploading and maintaining records was inconsistent, resulting in incomplete and inaccurate medical records for the resident.

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 Emergency Preparedness plan that was reviewed and updated annually, as required. Specifically, the facility's emergency preparedness plan and hazard vulnerability assessment were not scored based on the percentage and probability of listed emergency events occurring. Additionally, the plan was not updated and was not site-specific to the facility. This deficiency was identified during a review of the facility's emergency preparedness documentation and was confirmed through interviews with the Maintenance Director and Administrator. The lack of a comprehensive, updated, and site-specific emergency preparedness plan could potentially affect all occupants and staff in the event of an area disaster.

Plan Of Correction

Element 1 - Upon identification of the finding, the Nursing Home Administrator reached out to its corporate organization to verify support in the event of a catastrophic event. This support was confirmed by the Vice President of Operations. Concurrently, the assistance of our Regional Environmental Services Coordinator was provided to assist Heartwood Lodge- Trinity Health in the construction of a comprehensive and compliant Hazard Vulnerability Assessment (HVA). Element 2 - The Emergency Preparedness Plan including the HVA will be constructed to include a scoring methodology based on the percentage and probability of each identified emergency event occurring within the facility's specific context on or before July 10th, 2025. Element 3 - The HVA will be revised to be entirely site-specific, incorporating unique aspects of the facility's layout, patient population, services provided, and surrounding environment. The Nursing Home Administrator, Environmental Services Director, and Director of Nursing will be reviewing and updating the Emergency Preparedness Plan and Hazard Vulnerability Assessment as required to maintain compliance on or before July 10th, 2025. Any identified issues will trigger retraining and/or corrective action. Element 4 - The QAPI Committee will be reviewing and updating Emergency Preparedness Plan and Hazard Vulnerability Assessment annually with a reminder recurrence online work order that occurs the first Monday of January. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.

Penalty

No penalty information released

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

Summary

Surveyors observed that aisles, passageways, and corridors were not maintained free of obstructions as required by Chapter 7 of the Life Safety Code. Specifically, isolation carts without wheels attached were found stored in the corridor outside residents' rooms 121 and 122 in the 100 hall, and outside room 213 in the 200 hall. These findings were confirmed during interviews with maintenance staff present at the time of observation. The deficiency was identified during a walkthrough on June 10, 2025, and could potentially affect 18 occupants within the smoke compartment in the event of an emergency evacuation. No information regarding the medical history or condition of the residents in the affected areas was provided in the report.

Plan Of Correction

Element 1 - Environmental service staff removed all isolation carts without wheels stored in the corridor outside resident rooms 121 and 122 located at 100 hall and isolation carts without wheels stored in the corridor outside resident room 213 located at 200 hall with isolation carts with wheels to meet Means of Egress compliance. Element 2 - The Environmental Services Director or designee inspected all remaining isolation carts to ensure compliance with Means of Egress. Element 3 - Environmental Services Director or designee will complete monthly inspections on aisles, passageways, corridors, and exit locations for isolation carts being stored without wheels for 3 months to ensure compliance with NFPA 101 Chapter 7. Element 4 - The Environmental Services Director or designee will report audit findings to the Quality Assurance / Performance Improvement (QAPI) Committee quarterly x 3 with further monitoring per QAPI recommendations. Any identified issues will trigger retraining and/or corrective action. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.

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

During an observation on June 10, 2025, at approximately 10:06 AM, surveyors found that the doors to the clean linen closet located in the 200 hall near room 216 were open and did not close to a positive latch when tested. This was confirmed through interviews with two facility maintenance staff present at the time. The doors in question are required to be self-closing and kept in the closed position unless held open by an approved release device, in accordance with regulatory standards. The failure to ensure these doors were properly self-closing and latched constituted a deficiency, as it did not comply with the requirements for doors in exit passageways, stairway enclosures, horizontal exits, smoke barriers, or hazardous area enclosures.

Plan Of Correction

Element 1 - Upon identification, environmental services staff repaired the latch to the clean linen closet located at the 200 hall near room 216. This latch now closes "per positive latch" as required. Element 2 - Environmental Services Director Designee inspected all other clean linen closet doors to assure compliance. Element 3 - The Environmental Services Director/designee will complete monthly audits for 3 months of auto latching doors to ensure compliance in accordance with NFPA 101 7.2.1.8.2. Element 4 - The Environmental Services Director/designee will report audit findings to the Quality Assurance / Performance Improvement (QAPI) Committee quarterly x 3 with further monitoring per QAPI recommendations. Any identified issues will trigger retraining and/or corrective action. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.

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 cooking facilities were protected in accordance with NFPA 96 and NFPA 17A standards. Specifically, there was an 11-month gap between service inspections of the kitchen hood fire suppression system, as evidenced by inspection reports dated 1/2/24 and 12/2/24 from two different vendors. NFPA 17A 7.3.3 requires that hood fire suppression system inspections be conducted semi-annually. This deficiency was confirmed during interviews with two maintenance staff members at the time of observation. No information regarding specific patients, their medical history, or their condition at the time of the deficiency was provided in the report.

Plan Of Correction

Element 1 - The Environmental Services Director was able to locate the inspection report from Summit Fire Protection conducted on 6/28/24 to comply with semi-annual kitchen hood fire suppression inspections. The reviewed indicated dates are 1/2/24 and 12/2/24. Element 2 - The Environmental Services Director placed the inspection report for the semi-annual kitchen hood suppression system with other inspection reports to verify compliance. Element 3 - The Environmental Services Director or designee will audit report documentation annually and follow up on inspection reports from outside vendors with a recurring work order to ensure compliance with NFPA 96. Element 4 - The Environmental Services Director or designee will report audit findings to the Quality Assurance Performance Improvement (QAPI) Committee annually, with further monitoring per QAPI recommendations. Any identified issues will trigger retraining and/or corrective action. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.

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, during an observation on June 10, 2025, an extension cord was found in use in a resident's room (room 218, 200 hall). The use of this extension cord did not comply with the requirements of NFPA 99 and NFPA 70, which specify that extension cords should not be used as a substitute for fixed wiring and must be removed immediately after temporary use. The finding was confirmed through interviews with two facility maintenance staff present at the time of observation. The report notes that this practice could potentially affect 16 occupants within the smoke compartment in the event of an electrical fire resulting from unauthorized electrical cord use.

Plan Of Correction

Element 1 - Upon identification, environmental services removed the extension cords that were in use in resident room 218 located at 200 hall at the time of observation. The residents were educated on the safety risk and acknowledged compliance. Element 2 - The Environmental Services Director inspected all resident rooms to ensure no other deficiencies concerning extension cords existed. Element 3 - The Maintenance Director/designee will complete monthly audits for 2 months for extension cords to ensure compliance with NFPA 70 400.8.1. Element 4 - Any trends will be reported to the Administrator monthly by the Environmental Services Director/designee. The Environmental Services Director or designee will report audit findings to the Quality Assurance Performance Improvement (QAPI) Committee quarterly for monitoring per QAPI recommendations. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.

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 document arrangements with other LTC facilities and providers to receive patients in the event of limitations or cessation of operations, as required for maintaining continuity of services. During a review of the emergency preparedness plan, surveyors found no evidence of such arrangements. This deficiency was confirmed through interviews with the Maintenance Director and Administrator during the survey observation period. No specific patient medical histories or conditions were mentioned in the report, and the deficiency was identified through record review and staff interviews rather than through direct patient impact.

Plan Of Correction

Element 3 - The Environmental Services Director and the Nursing Home Administrator will be educated on the requirement to develop arrangements with other Long Term Care (LTC) facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients on or before June 10th, 2025. Element 4 - The QAPI Committee will be tasked with reviewing the updated risk assessments and emergency preparedness plan quarterly x3 to ensure ongoing relevance and effectiveness until substantial compliance has been determined by the QAPI Committee. Any identified issues will trigger retraining and/or corrective action. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.

Penalty

19 days payment denial

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

Summary

The facility failed to maintain appropriate infection control practices for one resident and one unit, potentially affecting multiple residents. One resident, who had a history of left knee prosthesis infection and a peripherally inserted central catheter (PICC) line, was sent to the hospital after it was discovered that their PICC line had been left uncapped overnight. The resident reported that the night nurse left the line uncapped for approximately ten hours, which was confirmed by the hospital's emergency department report. The facility's documentation did not include the reason for the resident's transfer, and the only available explanation was found in the hospital's records, which were not part of the resident's medical record at the facility. Additionally, on the Blue Neighborhood unit, staff failed to adhere to required mask protocols during a period when a resident with COVID-19 was present. Observations showed a certified nursing assistant repeatedly wearing a surgical mask below the nose and a housekeeper not wearing any mask, despite posted signage and facility policy requiring surgical masks for all staff on the unit. The Director of Nursing confirmed that all staff were expected to wear masks on the unit due to the presence of a COVID-positive resident. These deficiencies were observed through interviews, record reviews, and direct observation, and were corroborated by reference to CDC guidelines and facility policies regarding infection prevention and control, including the proper use of personal protective equipment and the care of central lines.

Penalty

19 days payment denial

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

Summary

The facility failed to maintain complete and accurate medical records for one resident who was admitted with multiple diagnoses, including an infection of a left knee prosthesis. The resident, who was cognitively intact, reported being sent to the hospital via ambulance after a nurse left their PICC line uncapped overnight, resulting in the need for a new PICC line and a four-day hospital stay for antibiotics. Review of the resident's medical record revealed inconsistencies and missing documentation regarding the reason for the hospital transfer, the mode of transportation, and whether transfer paperwork was completed or sent with the resident. Nurse's notes contained conflicting information, suggesting both that the resident was transported by their partner and that they were transferred out to the hospital, but did not specify the reason for transfer. The facility administrator confirmed that the medical record lacked documentation explaining why the resident was sent to the hospital, how they were transported, and whether appropriate transfer paperwork was completed. The only available information about the reason for transfer was found in the hospital's emergency department report, which was not included in the resident's medical record at 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 accurately assess, monitor, and treat wounds for three residents, leading to deficiencies in wound care management. Resident 1, a male with a history of orthopedic aftercare and an infected amputation stump, experienced inadequate wound care following his return from the hospital. Despite orders for a wound vacuum to be applied and changed regularly, the facility did not implement these orders in a timely manner. There was a lack of documentation and assessment of the surgical wound, and the facility did not investigate the issues surrounding the wound care as ordered by the surgeon. Resident 2, a female with multiple sclerosis and a history of osteomyelitis, had a coccyx wound that was not properly documented or measured. The facility failed to adhere to the resident's preferred treatment times, leading to refusals of care. The facility did not have a system in place to measure and monitor surgical wounds, and there was no documentation of wound assessments since the resident's return from the hospital. Resident 3, a female with Alzheimer's disease, had wounds on her right elbow and knees that were not properly assessed or documented. The facility did not have any wound dressing orders in place, and there was no description of the wounds in the medical record. The Unit Manager confirmed that no standing orders or treatments were implemented for the resident's wounds, and there was a lack of awareness regarding the assessment process for recording wound size and description.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of abuse in a timely manner for a resident diagnosed with dementia and anxiety. The resident reported to the facility's Nurse Practitioner that he had been assaulted by staff the previous day. This report was made at approximately 11:30 AM, but the Nursing Home Administrator (NHA) was not notified until the afternoon. The incident was not reported to the State of Michigan until almost 10:00 PM, which was outside the required 2-hour timeframe for reporting such allegations. The delay in reporting was attributed to the NHA and the Director of Nursing (DON) being away from the facility on the day of the incident. The Former NHA cited extenuating personal circumstances as the reason for the delay in reporting the abuse allegation. The facility's policy requires that all alleged violations involving abuse be reported immediately, but not later than 2 hours after the allegation is made. This policy was not adhered to in this instance, resulting in a deficiency citation.

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 sanitary conditions in the kitchen, which could potentially spread foodborne illnesses to residents consuming food from the kitchen. During an initial tour of the walk-in cooler, a half-empty box of nutritional shakes was found without a date, and the Certified Dietary Manager (CDM) was unable to provide one. The shakes are typically dated for 14 days after thawing, but there was no indication of when they were placed in the cooler. Similar issues were found in the Blue and Yellow Pantries, where nutritional drinks and an open container of vanilla Med Pass 2.0 were found without discard dates, contrary to the manufacturer's instructions. Further observations revealed unsanitary conditions in various parts of the kitchen. The top of the convection oven was covered with dust and crumbs, and clean utensils stored in bins by the ice machine had accumulated debris and crumbs. The juice machines in the Blue and [NAME] Pantries had sticky residue on the underside corners of the spouts. Additionally, pans were improperly stacked and stored wet, with water trapped between them, violating air-drying requirements. The dish machine was also found to be malfunctioning, with the rinse pressure gauge only reaching eight psi, below the required 20 +/- 5 psi as per the machine's data plate. The facility's dish machine log did not include checks for rinse pressure, and a loose screw in the top spray arm was impeding proper spray. These findings indicate a failure to adhere to the FDA Food Code requirements for equipment and utensil cleanliness, air-drying, and mechanical warewashing equipment operation.

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 administer controlled medications according to physician orders and professional standards of practice, resulting in medication errors for four residents. Resident #1, a female with spastic quadriplegic cerebral palsy, did not receive her prescribed 8:00 PM dose of Norco on one occasion, and on another day, she received an additional dose not ordered by the physician. The Medication Administration Record inaccurately documented the administration of these doses, indicating discrepancies between the Controlled Substance Record and the actual administration. Resident #14, a male with diabetes mellitus, was administered Insulin Lispro despite his blood sugar levels being below the physician-ordered parameter of 120 on multiple occasions. This indicates a failure to adhere to the prescribed parameters for insulin administration, potentially compromising the resident's safety. Similarly, Resident #32, a male with hypertension, was administered both amlodipine and carvedilol despite his systolic blood pressure being below the ordered parameters, and there were multiple undocumented administrations of Norco as needed. Resident #57, a male with hypertension, was administered Lisinopril without documented verification that his blood pressure and pulse were within the ordered parameters. The facility's previous Director of Nursing acknowledged that physician-ordered parameters should be reviewed before medication administration, yet this practice was not consistently followed. The current Director of Nursing confirmed the medication errors and indicated that education for nurses would begin immediately, highlighting a systemic issue in medication administration practices at 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 adhere to its protocol for providing clean oxygen delivery equipment and monitoring oxygen levels for a resident. A resident, a [AGE] year-old female, was observed using oxygen with tubing and a humidifying water bottle dated 06/05/24, which was not replaced weekly as per the facility's protocol. The water bottle was found empty on multiple occasions, and the oxygen tubing was not changed until 06/27/24. Additionally, the resident's oxygen saturation levels had not been monitored or documented since 03/07/24, and there was no physician order for oxygen delivery, including the rate and method of delivery.

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 operationalize policies and procedures for controlled substances, leading to potential drug diversion and misappropriation of property. During an observation, a night shift RN and an oncoming LPN were seen discarding 23 tablets of Norco, a Schedule II narcotic, without signing any documentation to indicate the count and destruction of the medication. The nurses reported that there was no form available for documenting the destruction of the narcotic. The Individual Resident's Controlled Substance Record for the resident involved was incomplete, lacking the medication name and dosage, and showed discrepancies in the count of tablets. Further review of the records revealed that the facility did not accurately document the receipt, administration, and disposal of controlled substances. The records showed inconsistencies in the number of tablets on hand, with unexplained changes in the count and missing documentation for the destruction of tablets. The Director of Nursing (DON) confirmed the inaccuracies and acknowledged the need for education on proper documentation and procedures. Additionally, the facility had recently switched pharmacy providers, which may have contributed to the confusion and lack of proper documentation. Another resident's controlled substance record also showed issues, with handwritten information and white-out used on the document, which is against facility policy. The DON confirmed that white-out should not be used on controlled substance records and indicated that further investigation was needed. The facility's policies on medication administration and disposal were not followed, as evidenced by the lack of proper documentation and the failure to have two nurses witness and sign off on the destruction of controlled substances.

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 Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices, as required by the Centers for Medicare & Medicaid Services (CMS) guidance effective April 1, 2024. During the survey, it was observed that residents with these conditions were not placed under EBP, as there was no signage on doors or personal protective equipment (PPE) carts available near the rooms. The Director of Nursing (DON) and Registered Nurse/Consultant (RNC) confirmed that EBP had not been implemented, despite the CMS guidance mandating its use for residents with chronic wounds or indwelling medical devices. Additionally, the facility failed to conduct a thorough outbreak investigation during an Influenza A outbreak in March 2024. Nine residents tested positive for Influenza A, but there was no documentation of contact tracing, notification of the medical director, health department, staff, residents, or families. Furthermore, there was no record of interventions implemented to prevent the spread of the virus, such as transmission-based precautions, increased cleaning, or staff and resident education. The facility's Infection Prevention and Control Program lacked documentation of daily active surveillance of all residents and staff for illness. The facility's Infection Prevention and Control Program was reviewed, and it was found that there was no outbreak investigation documentation related to the March 2024 Influenza A outbreak. The DON and RNC acknowledged that a complete and thorough outbreak investigation should have been initiated at the time the outbreak was identified. The lack of documentation and implementation of necessary precautions and investigations contributed to the deficiency in infection prevention and control within 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 provide timely care for two residents who were dependent on staff for their activities of daily living. Resident #1, a cognitively intact female with quadriplegic cerebral palsy, was observed with her call light activated for over an hour without receiving assistance. She reported being wet and not having been changed or repositioned during the night. Her care plan required prompt response to call lights, anticipation of needs, and maintenance of skin cleanliness and dryness, as she was at high risk for skin breakdown. Resident #53, who had recently undergone surgery for an infected total knee replacement, also experienced a delay in care. Her call light was activated for over an hour before staff responded. She was found soaked in urine, indicating she had not been changed during the night. The aide who eventually assisted her placed a blanket over the urine-soaked spot on her bed, failing to address the issue adequately. Both incidents highlight the facility's failure to meet the residents' needs promptly, as required by their care plans.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development of a pressure injury and a delay in treatment. The resident, a severely cognitively impaired female, was identified as being at high risk for pressure injuries, with a Braden Scale score of 12. Despite this, her care plans did not include a repositioning schedule or pressure offloading devices, and she was observed multiple times in a Broda chair without any offloading devices in place. The resident's skin assessments initially showed intact skin, but a small open area on her left buttocks was identified on a subsequent assessment. There was no documentation of notification to the resident's physician or family about the pressure injury, and no treatment order was initiated immediately. The pressure injury worsened, increasing in size, and the family was only notified days later. The care plan was not updated to reflect necessary interventions such as repositioning every two hours. The facility's policy required skin observation every shift and repositioning for residents with a Braden score of 14 or less. However, these protocols were not followed, as evidenced by the lack of repositioning and the absence of pressure offloading devices. The wound care nurse was not informed of the pressure injury in a timely manner, delaying appropriate assessment and intervention.

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 equipment for a resident with limited mobility, leading to a deficiency in care. The resident, a severely cognitively impaired elderly female, was dependent on staff for daily activities and required specific equipment for mobility as recommended by the therapy department. The therapy department had prescribed a high back wheelchair with specific supports and cushions to aid in the resident's mobility and comfort. However, observations revealed that the resident was consistently placed in a Broda chair without the necessary equipment, contrary to the therapy recommendations. The resident's care plan did not reflect the prescribed equipment, and there was no documentation of a change in the resident's equipment needs. Despite the presence of a picture in the resident's room detailing the required equipment, staff interviews indicated a lack of awareness or understanding of the resident's equipment needs. The CNA reported that the resident had not used the high back wheelchair for months and believed a recent therapy evaluation had changed the equipment to a Broda chair, which was not the case. Further interviews with the therapy manager and other staff confirmed that no recent therapy evaluation had been conducted to justify the change in equipment. The therapy manager reiterated that the resident should be using the high back wheelchair with the prescribed supports. The lack of communication and documentation regarding the resident's equipment needs resulted in the resident not receiving the appropriate care to maintain or improve her range of motion and mobility.

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 discard expired medications on one of the three medication carts reviewed, out of a total of six medication carts. This resulted in residents potentially receiving medications that were expired and/or had reduced efficacy. During an observation and interview, it was found that the 200 hall medication cart contained a bottle of eye drops, a bottle of nasal spray, and two Lantus multi-dose vials, all of which had been opened beyond their recommended usage period. The LPN responsible for the cart was unsure of the expiration dates for these medications once opened, although she believed it to be around 28 days. A review of the facility's Insulin Storage Parameters document confirmed that Lantus should be discarded 28 days after opening, and eye medications should follow the manufacturer's instructions or facility policy.