Medilodge Of Capital Area

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that a physician documented the necessity of a resident’s transfer/discharge based on safety concerns. The resident was admitted with multiple diagnoses including a left leg fracture, epilepsy, anxiety disorder, depression, schizophrenia, and PTSD, and was documented as cognitively intact on the MDS BIMS assessment. On one day, social services and the nursing home administrator attempted to issue immediate involuntary discharge paperwork citing repeated threats toward staff and other residents, and the resident requested appeal paperwork but refused to physically accept the documents. Nursing notes indicated that police came to the facility after the resident called 911, and the DON gave the police the involuntary discharge letter. The resident was documented as being aware he needed to leave the next day, based on what the police told him. The following day, nursing documentation showed the resident was unexpectedly discharged via police car to the ED under a court-appointed petition. Multiple staff interviews confirmed that the facility was in the process of an involuntary discharge and had not yet received State Agency approval. The NHA, DON, ADON, SSD, and an RN all reported that when the hospital called seeking to return the resident, facility staff stated the resident would not be readmitted and instead could go to a local motel, and the hospital ultimately discharged him to the community when he refused the motel. The involuntary discharge forms and notice cited endangerment to the safety and health of others due to the resident’s clinical/behavioral status, but review of the medical record revealed there was no physician documentation that the transfer/discharge was necessary for these safety reasons.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect a resident from verbal abuse by an outside x‑ray technician. The resident had a history of major depressive disorder and traumatic brain injury and was cognitively intact per a recent MDS assessment. The resident had an order for an x‑ray, and the contracted x‑ray technician entered the resident’s room to perform the procedure. During the encounter, the technician and the resident engaged in a heated verbal exchange that escalated beyond a simple disagreement. According to the facility’s own incident investigation and multiple staff interviews, the technician used profanity toward the resident, stood over the resident, and engaged in an aggressive, confrontational manner. The resident reported that the technician got in his face, threatened him with a closed fist, and used profanity. Nursing staff documented hearing the resident yell for help and, upon entering the room, observed a verbal altercation in progress. Staff reported that the technician told the resident he did not care who the resident told, that he was going to finish his “f*cking job,” and that he antagonized the resident by challenging him to get out of bed and try to hit him, while continuing to yell and curse. Additional staff corroborated that the technician spoke aggressively and disrespectfully, made statements such as “this is why you’re in here” and “I wish you could get up and hit me,” and that the resident asked staff to remove the technician from his room because he felt threatened and disrespected. The technician himself acknowledged that the interaction became extremely heated, that cursing went back and forth, and that he warned the resident to watch his mouth or he would leave, while continuing to perform the x‑ray. The facility’s investigation substantiated that the incident occurred and that there was yelling and words exchanged between the resident and the technician, but the facility concluded it could not substantiate that verbal abuse occurred, despite the consistent staff accounts of aggressive, profane, and threatening behavior toward the resident by the vendor.

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 allegations of abuse, neglect, or misappropriation of property to the State Agency for four residents, as required by regulation and facility policy. In one case, a resident with a history of alcohol dependence and anxiety disorder was alleged by a family member to have had her debit card taken and used by a staff member. The resident initially confirmed the allegation to the Nursing Home Administrator (NHA) and Director of Nursing (DON), resulting in the suspension of the accused staff member. However, after the family member left, the resident retracted her statement, claiming she felt pressured to make the accusation. Despite the retraction, both the DON and NHA acknowledged that the initial allegation constituted a reportable event, but it was not reported to the State Agency. Additional incidents involved residents with severe cognitive impairment. Two separate altercations occurred between residents, resulting in physical contact and complaints of pain. Incident reports documented these events, including one where a resident's arm was grabbed and another where residents swung at each other, making contact. The NHA, who was responsible for abuse investigations, was not initially notified of these incidents. Upon later review of the incident reports, the NHA agreed that these events met the criteria for abuse allegations and should have been reported and investigated, but no such actions were taken at the time. Facility policy clearly defined abuse to include staff-to-resident and resident-to-resident altercations, and required immediate investigation and reporting of all allegations to the appropriate authorities. Despite this, the NHA signed off on incident reports without ensuring that the required notifications and investigations were completed. The failure to report these incidents as required resulted in a deficiency related to the timely reporting and investigation of suspected abuse, neglect, or misappropriation.

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 investigate allegations of abuse involving three residents with severe cognitive impairment. Incident reports documented physical altercations between residents, including one event where a resident removed another's hat, leading to both residents swinging at each other and one making contact with the other's back. Another incident involved a resident becoming agitated, grabbing another resident's arm, and a physical struggle ensued, resulting in pain and minor injury to both residents and a CNA who intervened. Despite these documented events, there was no evidence that the facility initiated investigations or reported the incidents to the appropriate state agency as required by policy. Interviews with the Nursing Home Administrator (NHA), who also served as the facility abuse coordinator, revealed that she was not notified of the incidents at the time they occurred. Upon review of the incident reports during the survey, the NHA acknowledged that the events constituted allegations of abuse and should have been investigated and reported. The NHA also confirmed that she had signed the incident reports after the fact but had not initiated any investigation or reporting process prior to the surveyor's inquiry. Facility policy required immediate investigation and reporting of any suspicion or report of abuse, including resident-to-resident altercations. The policy defined physical abuse to include actions such as hitting, slapping, and grabbing. Despite this, the facility did not follow its own procedures, as the incidents were neither investigated nor reported in accordance with state and federal regulations. The failure to act was confirmed through record review, staff interviews, and the absence of investigation documentation.

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 its own written policies and procedures for abuse and neglect for multiple residents. Specifically, the facility did not initiate investigations or report incidents of resident-to-resident altercations as required by its policy. For example, one incident involved a resident with severe cognitive impairment who was involved in a physical altercation with another resident over a personal item, resulting in physical contact. The incident report documented the altercation, but the Nursing Home Administrator (NHA), who is also the facility abuse coordinator, was not notified and did not investigate or report the event to the appropriate state agency. Another incident involved a resident with severe cognitive impairment and multiple comorbidities who was physically grabbed by another resident, leading to pain and minor injury. The incident report documented the event, including the resident's complaints of pain and the involvement of a certified nursing aide (CNA) who intervened. Despite the documentation and the facility's policy requiring immediate investigation and reporting of suspected abuse, the NHA was not aware of the details and did not initiate an investigation or report the incident to the state agency. Record review confirmed that the NHA signed the incident reports days after the events occurred, but there was no evidence of timely investigation or reporting as required by the facility's abuse, neglect, and exploitation policy. Interviews with the NHA revealed a lack of awareness of the incidents and a failure to follow the facility's procedures for investigating and reporting allegations of abuse, particularly in cases involving resident-to-resident altercations resulting in physical contact and injury.

Penalty

No penalty information released

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

Summary

The facility failed to obtain a physician order to implement an advanced directive/Do Not Resuscitate (DNR) for one resident. The resident, who had moderate cognitive impairment and a full legal guardian authorized to make health and medical care decisions, had an advanced directive form signed by the guardian and witnessed, with a physician signature present on the form. However, upon review of the clinical record, it was found that there was no corresponding physician order in place to enact the DNR status. Interviews with facility staff revealed that the process for updating orders relies on notification from the social worker, but the Assistant Director of Nursing was not notified that the advanced directive had been signed, and the responsible social worker was unavailable for interview during the 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 complete accurate and timely Minimum Data Set (MDS) assessments for two residents with pressure ulcers. For one resident, the MDS inaccurately indicated the presence of a tracheostomy and the need for tracheostomy care, despite direct observation, resident interview, and staff confirmation that the resident did not have a tracheostomy or require related care. The error was acknowledged by the MDS nurse, who confirmed the assessment was incorrect. For another resident, staff interviews and record review revealed that a new pressure ulcer developed on the resident's left heel, but a required change in condition MDS assessment was not completed within the mandated timeframe. The MDS nurse confirmed that the development of a new pressure ulcer should have triggered a change in condition assessment, but this was not done. The failure to complete accurate and timely assessments was confirmed through interviews with nursing and MDS staff, as well as review of the residents' medical records.

Penalty

No penalty information released

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

Summary

The facility failed to update and revise the individualized, person-centered care plan for one resident following a significant change in the resident's care environment. The resident, who had severe cognitive impairment with a BIMs score of 1 out of 15 and diagnoses including dementia, anxiety, and depression, was observed resting in bed on the 300-unit hall with a perimeter mattress and bilateral fall mats. Despite being moved from the secure dementia unit (100-unit hall) to the 300-unit hall on July 17th, the resident's care plan continued to state that the resident resided on the secure care unit for a therapeutic environment related to dementia. This discrepancy was identified during a survey through observation, interview, and record review. The LPN managing the 300-hall unit confirmed that the care plan had not been updated to reflect the resident's new location and care needs, despite the facility's policy requiring comprehensive, person-centered care plans to be developed, implemented, and revised as needed. The failure to update the care plan resulted in the potential for unmet care needs 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 ensure that a resident who required assistance with activities of daily living (ADLs) received appropriate care to maintain personal hygiene and grooming. The resident, who was cognitively intact and required one-person assistance for hygiene according to the care plan, was repeatedly observed over several days with greasy, uncombed hair, an excessively long mustache that extended into his mouth, and wearing the same soiled clothing with food and debris. There was no documentation indicating that the resident refused or was resistant to care. Interviews with staff confirmed that the resident was cooperative with care and had not refused showers, clothing changes, or grooming. Staff also reported that the resident had been requesting a haircut, but the facility had been without a beautician for approximately six months. The Assistant Director of Nursing was unaware of the resident's unkempt appearance and soiled clothing, and acknowledged that, despite the family's wishes for the resident to be independent, it was ultimately the facility's responsibility to ensure care needs were met.

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 care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.

Penalty

No penalty information released

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

Summary

The facility failed to serve food at the preferred temperature for two residents, resulting in dissatisfaction during meals. One resident, who was cognitively intact and had multiple medical diagnoses including kidney failure and heart disease, reported never receiving a hot meal since admission, with meals described as only warm at best. This resident also noted that hot tea was rarely hot, iced tea was rarely cold, and meats were inconsistently cooked, sometimes overcooked or undercooked. Another resident, with severe cognitive impairment and a history of stroke, diabetes, and dysphagia, frequently received meals in his room and stated that the food was never really warm. Direct temperature checks of this resident's food trays revealed that hot items such as quiche, peas, and coffee were served well below the expected temperature of 165°F, and ice cream was above the recommended cold temperature. On another occasion, breakfast items like hash browns, biscuits, and coffee were also served below appropriate temperatures, and the resident expressed dissatisfaction with the temperature of the food. Staff did not offer to provide warmer food when concerns were raised.

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 food in accordance with a resident's documented preferences, resulting in repeated instances where the resident did not receive requested or preferred food items. The resident, who was cognitively intact and had multiple medical diagnoses including kidney failure, heart disease, and mood disorders, reported ongoing issues with meal accuracy. Specific examples included not receiving items such as tossed salad, hot tea, yogurt, cold cereal, 2% milk, potato chips, ketchup, and homestyle turkey and gravy, and instead receiving items on his dislike list, such as coffee and beef products. The resident had documented these issues through multiple Quality Assistance Forms, noting frequent discrepancies between meal tickets and actual meals received. Despite the resident's ongoing communication with the dietary manager and submission of concerns, the problems persisted over several weeks, as evidenced by saved meal tickets and repeated complaints. Interviews with facility staff, including the Nursing Home Administrator and Dietary Account Manager, confirmed that the resident's food preferences were not consistently honored and that staff could not explain the repeated errors. The facility's own review of the situation acknowledged noncompliance with meeting the resident's food preferences as documented.

Penalty

No penalty information released

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

Summary

The facility failed to follow physician's orders for medications for a resident who was admitted with diagnoses including type two diabetes and cirrhosis of the liver. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Physician orders included Lactulose, Glimepiride, and Isosorbide Dinitrate, which were not consistently administered on specific dates. A family member raised concerns about the unavailability of these medications, which were confirmed by a review of the medication administration record. The Director of Nursing discovered the issue when the family filled out a Quality Assurance form. Despite attempts to contact the staff responsible for the medication administration, no responses were received by the time of the survey exit. The facility's failure to ensure the timely delivery and administration of the prescribed medications led to the deficiency, as the medications were not available from the pharmacy and were not pulled from the backup supply as expected.

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 professional guidelines by using PDI Sani-Cloth Germicidal Disposable Wipes for incontinent bowel care on a resident. The resident, who had a history of traumatic brain injury, schizoaffective disorder, dementia, and other medical conditions, was admitted to the facility in 2020. During an incident in early 2025, a Certified Nurse Aide (CNA) reported that a Staff Development Coordinator (SDC) used bleach wipes to clean the resident after a bowel movement, despite knowing it was inappropriate for skin contact. The incident was observed and reported by the CNA, who witnessed the SDC using the wipes on the resident's buttocks, groin, legs, and penis. The resident later confirmed that bleach wipes were used on him, although he could not recall specific details about the incident. The SDC admitted to using the wipes, initially intended for cleaning the mattress, on the resident's skin, acknowledging it was a mistake. The facility's incident report corroborated the CNA's account, detailing the use of disinfectant wipes during the resident's care. The SDC's witness statement explained the decision to use the wipes due to the resident's condition and the difficulty in cleaning him. The Safety Data Sheet for the wipes clearly stated they were not intended for skin use, highlighting the deviation from proper care protocols.

Penalty

Inspection fine: $22,710

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

Summary

The facility failed to protect a resident, R505, from sexual abuse by another resident, R501, resulting in a sexual assault. R505, who was cognitively impaired, was ushered into R501's room, where she remained for over an hour. The incident was captured on surveillance video, but the facility did not save the footage. Staff later found R505 with soiled underwear, leading to her being sent to the emergency room for examination. The Director of Nursing confirmed the incident after reviewing the video, which showed R501 barricading his room to prevent entry. R505 was diagnosed with Alzheimer's disease and dementia, with a BIMS score indicating severe cognitive impairment. She was unable to make decisions for herself and had a legal guardian. The facility's staff did not report her missing for over an hour, and the missing resident policy was not activated. R501, who had a history of sexual offenses, was not under any special monitoring or supervision, and his care plan did not reflect any precautions related to his past behavior. The facility's failure to implement adequate monitoring and supervision for R501, despite his known history, and the lack of timely reporting and intervention by staff, contributed to the incident. The facility's policies on abuse prevention and missing residents were not effectively followed, leading to the sexual assault of R505 and the subsequent investigation by law enforcement.

Removal Plan

• Resident was transferred to hospital and was provided a SANE examination.
• Resident was placed on 1:1 supervision until discharged from the facility.
• Female residents with a BIMS 10 or less had skin assessments completed with no concerns identified.
• Female residents with a BIMS 10 or higher were interviewed regarding any concerns with other residents in the facility and if they feel safe.
• Social Services Director completed an audit of sex offender registry for residents in facility.
• Three additional residents identified as sex offenders were placed on one to one supervision and assessed regarding risk factors.
• Resident's interventions/supervision updated as deemed appropriate based on risk factors.
• Care plans updated for residents identified as sex offenders.
• Facility staff were re-educated on the facility Abuse, Neglect and Exploitation Policy to include Criminal Sexual Abuse.
• Administrator, Director of Nursing and Social Services Director educated on ensuring that active sex offenders within the facility have appropriate supervision and interventions initiated and have ongoing monitoring.
• Facility staff were educated on signs of potential sexual abuse and actions to take if sexual abuse is suspected or has occurred.
• Facility staff were educated on following the kardex / care plan regarding interventions placed for residents who are active registered sex offenders.
• Sexual Abuse education will be completed during ongoing facility orientation.
• Residents who are on the sex offender list will be care planned with discussion and agreement, to allow entry when staff has a need to verify the whereabouts of another resident.
• Should a suspected or confirmed sexual abuse occur, the facility staff will immediately intervene and stop contact between residents.
• Perpetrator will be placed on one to one supervision in the interim.
• Notify the Administrator and Police as appropriate.
• Nurse will complete a physical assessment.
• Ad hoc QAPI initiated.
• Current residents in facility with a sex offender history will be reviewed by the Social Services Director or designee and IDT weekly for any new behaviors and to ensure current interventions remain in place and are appropriate.
• The Medical Director/designee was notified of the event.

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 its plumbing and refrigeration equipment, which could potentially increase the risk of foodborne illness for all residents consuming food from the kitchen. During an observation, a leak was noted from the in-line water filter for the coffee maker, resulting in water accumulation on the floor. This is a violation of the 2017 FDA Food Code Section 5-205.15, which requires plumbing systems to be repaired according to law and maintained in good repair. Additionally, the Arctic Air reach-in cooler was observed to be holding a temperature of around 52 degrees Fahrenheit, which is above the safe temperature threshold for cold holding as per the 2017 FDA Food Code Section 3-501.16. This section mandates that time/temperature control for safety food should be maintained at 41 degrees Fahrenheit or less. The Certified Dietary Manager (CDM) acknowledged the issue and discarded the food from the cooler as the temperature was not decreasing. Furthermore, the atmospheric vacuum breaker for the mop sink was under constant pressure, which is against the 2017 FDA Food Code Section 5-202.14, requiring backflow prevention devices to meet specific standards.

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 control pests in the kitchen, resulting in a swarm of gnats affecting the entire facility with a census of 99 residents. Observations on multiple occasions revealed gnats in various areas of the kitchen, including the dry storage room, the grease trap by the three-compartment sink, the dish machine area, and the dining room. The presence of gnats was particularly noted around food storage and preparation areas, such as the bread rack next to a drainage pipe and breakfast trays in the dining room, which were attracting gnats. The Certified Dietary Manager (CDM) acknowledged the issue, stating that the pest control operator had provided floor and drain cleaner to address the gnats. However, the pest control service reports from previous months did not mention any treatment for gnats, drain flies, or fruit flies. The facility's failure to eliminate harborage conditions and effectively control pests is in violation of the 2017 FDA Food Code, which mandates that premises be maintained free of insects and other pests through routine inspections and appropriate pest control methods.

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 Activities Director on the memory care unit was qualified to perform the duties effectively. Observations over several days revealed that residents were often left unengaged, with many observed sleeping or passively watching television. Scheduled activities, such as 'Coffee and Cocoa' and 'Dance to Dine,' were either not conducted as planned or were inadequately executed. For instance, during a scheduled activity, the Activities Director engaged residents in a brief two-minute balloon toss before leaving them with an aide who did not attempt further engagement. The Activities Director admitted to not being a recreational or occupational therapist and was still in the process of completing the MEPAP class to become certified in Activities. She had no prior experience as an Activity Director, having only three months of experience as an Activity Aide at a sister facility. The director's lack of qualifications and experience contributed to the deficiency, as she was unable to provide meaningful and individualized activities for the residents, many of whom were observed to be disengaged and inactive.

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 serve food at the preferred temperature and provide necessary condiments and utensils, leading to dissatisfaction among residents. One resident, identified as R57, consistently received cold meals and was informed by staff that reheating was not allowed. Instead, a new tray had to be requested from the kitchen, which took additional time. On one occasion, R57's breakfast tray was replaced, but it lacked hash browns and included a plastic spoon instead of metal silverware, further delaying her meal consumption by 27 minutes. A confidential group of six residents reported ongoing issues with food service, including cold food, soggy bread, and inaccuracies in meal trays. They noted that their preferences were often not followed, such as missing condiments or utensils. During a test tray observation, a resident's lunch was found to be served at inadequate temperatures, with meatloaf at 113 degrees F, mashed potatoes at 133 degrees F, and corn at 125 degrees F. The Dietary Manager acknowledged awareness of these issues and mentioned ongoing audits to address them.

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 immediately report an injury of unknown origin for one resident, resulting in the potential for further injuries of unknown origin to not be reported and facility corrective action to not be taken. The resident, who had been at the facility since November 2023 with a recent readmission in January 2024, was noted to have a small bruise on her forehead. The incident report indicated that the resident often leaned her head on the wall while being changed in the bathroom, but the report lacked details on the color or stage of healing of the bruise. Interviews with staff provided conflicting accounts of the resident's behavior and the timeline of the bruise's appearance. Some staff members reported that the resident would rest her head on the wall, while others stated they had not observed this behavior. The bruise was described by different staff members as being yellow, purple, or blue at various times, indicating inconsistencies in observations and documentation. The facility's Administrator and DON were notified of the bruise, but the report was not made to the state agency as it was determined internally that the bruise was caused by the resident's behavior. However, the investigation and reporting process was unclear, with discrepancies in who reported the incident and when. The lack of immediate reporting and thorough investigation of the injury of unknown origin highlights a deficiency in the facility's handling of such incidents.

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 conduct a thorough investigation into an alleged abuse incident involving a resident, identified as R25, who was found with a bruise on her forehead. The incident report dated 6/20/2024 noted a small bruise on R25's forehead, but lacked details such as the color or stage of healing. Statements from staff, including a CNA and an LPN, suggested that R25 had a habit of leaning her head against the bathroom wall, which was believed to be the cause of the bruise. However, there was inconsistency in the staff's accounts regarding the timing and nature of the bruise, with some staff reporting it as a newer bruise and others as an older one. The facility's Director of Nursing (DON) and Administrator were notified of the bruise, but the investigation was incomplete. The Administrator could not recall who reported the incident to her, and there was no documentation of further investigation or assessment of other residents for similar injuries. Interviews with various staff members revealed discrepancies in their observations and recollections about R25's behavior and the bruise's appearance. Some staff members reported that R25 did not tap her head on the wall, while others stated she did. The lack of a comprehensive investigation and documentation raises concerns about the facility's ability to protect residents from potential abuse. The incident report was the only document available regarding the bruise, and it contained only two staff witness statements. There was no follow-up documentation or assessment of the bruise after 6/20/2024, indicating a failure to ensure resident safety and compliance with reporting requirements for injuries of unknown origin.

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 complete a comprehensive assessment for a resident, resulting in the potential for unmet care needs. The resident was admitted with multiple diagnoses, including Parkinson's Disease, type 2 diabetes, COPD, epilepsy, schizoaffective disorder, atrial fibrillation, anxiety, insomnia, dementia, hypertension, depression, anemia, orthostatic hypotension, and stroke. Upon admission, a Skin & Wound Evaluation identified a stage 3 pressure ulcer on the resident's right ischial tuberosity. However, the Minimum Data Set (MDS) assessment, completed shortly after admission, did not document this pressure ulcer. During interviews, both the MDS Coordinator and the MDS Nurse confirmed the presence of the pressure ulcer in the resident's medical record but could not explain why it was omitted from the MDS assessment. The omission of the pressure ulcer from the MDS assessment indicates a failure in accurately completing the comprehensive assessment, which is crucial for addressing the resident's care needs effectively.

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 adequate care plans for two residents, leading to potential health risks. Resident #34, who had severe cognitive impairment and was dependent on assistance for activities of daily living, was observed with a Stage 3 pressure ulcer. The care plan for this resident included specific interventions such as using a mechanical lift with a shower sling, orthotic boots, and a pillow between the knees. However, observations revealed that these interventions were not consistently implemented. The resident was transferred using an incorrect sling size, and staff failed to use the required shower sling, leading to a bruise on the resident's forehead. Additionally, there was no documented assessment of the correct sling size, and staff competency in using the mechanical lift was not validated. Resident #36, who had moderate cognitive impairment, complained of mouth sores and was supposed to see a dentist. However, there was no care plan addressing dental issues or oral care. The resident's dental visit notes indicated a need for a referral to an oral surgeon for the removal of nodules, but this referral was delayed. The Unit Manager confirmed that the referral was sent to the scheduler, but the appointment was not scheduled in a timely manner. The care plan developed after the surveyor's interview did not include the nodules noted by the dentist, and the resident's goal to receive dentures was not addressed. These deficiencies highlight the facility's failure to ensure that care plans were comprehensive and effectively implemented, resulting in potential harm to the residents. The lack of proper documentation, assessment, and follow-up on care plans contributed to the inadequate care provided to these residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide a meaningful, diverse, and engaging activity program for a resident with severe cognitive impairment residing in the secured memory care unit. The resident, who enjoys music, talk radio, walking, and pet visits, was observed wandering alone in the hallways on multiple occasions without staff intervention to engage them in scheduled activities. Despite having an activity care plan that included encouraging participation in group activities and providing sensory materials, the resident was not encouraged to join activities such as 'Coffee and [NAME]' or music sessions on the patio. The activity director, who has been with the facility for 10 months, acknowledged the resident's interest in sensory activities and pet visits, yet the activity participation record for June 2024 did not reflect any pet visits in the last 30 days. Additionally, the resident's activity care plan and the most recent activity assessment did not include pet therapy, indicating a disconnect between the resident's interests and the activities provided. This lack of engagement and failure to adhere to the resident's care plan contributed to the deficiency identified by the surveyors.

Penalty

No penalty information released

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

Summary

The facility failed to safely transfer a resident using a mechanical lift, resulting in a hematoma and bruises. During an observation, a resident was lifted from her bed with a transfer sling that did not support her head or lower trunk adequately. The staff involved, including a Resident Aide and a Certified Nurse Aide, were not properly trained or assessed for competency in using the mechanical lift. The Staff Development Registered Nurse expressed concerns about the incorrect donning of the sling and the lack of proper assessments for sling size. The resident's care plan required a shower sling for transfers, but no specific size was recommended, and the sling used was inappropriate for the resident's weight. The resident, who had severe cognitive impairment and was dependent on assistance for activities of daily living, had a history of non-traumatic brain dysfunction, dementia, anxiety, depression, arthritis, and a hip fracture. An incident report noted a bump on the resident's forehead and bruising on her ear, which were not previously observed. The Nursing Home Administrator and Director of Nursing acknowledged that the injury could have been caused by a staff member not following the mechanical lift transfer policy, as the transfer was performed without the required two-person assistance. The staff member involved was suspended, but there was no confirmation that the resident's transfer was evaluated after the injuries were noted and before the surveyor's observation.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed for one resident, resulting in an error rate of 11.11%. The errors were identified during the administration of medications to a resident with thoracic spine injuries and hypertension. The Licensed Practical Nurse (LPN) administered a full tablet of Metoprolol 25 mg instead of the prescribed half tablet (12.5 mg), two Senna Plus capsules without a corresponding physician's order, and an incorrect dosage of ClearLax, which was not measured using the appropriate measuring cap. The LPN admitted to administering a full tablet of Metoprolol due to the pharmacy providing full tablets and confirmed the resident's preference for Senna Plus, despite the lack of an order. Additionally, the LPN used a plastic pill cup to measure ClearLax instead of the bottle's measuring cap, which is marked for the correct dosage. The Director of Nursing (DON) acknowledged the errors related to Metoprolol and Senna Plus and was unaware of the improper measurement method for ClearLax.

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 promptly schedule a dental referral for a resident, resulting in continued pain and a delay in meeting the resident's goals. The resident, who had a moderate cognitive impairment, was observed complaining of mouth sores and pain. Despite a dental visit on 3/28/24 recommending a referral to an oral surgeon for the removal of nodules on the maxillary anterior frenum, the referral was not scheduled in a timely manner. The unit manager confirmed that the referral was sent to the scheduler on 5/28/24, but the appointment had not been scheduled by 6/26/24. The resident's care plans did not initially address the dental issues or oral care, and even after the dental visit, the care plan was not updated to include the nodules or the goal of receiving dentures. The resident's goal to have reduced complications related to dental issues and to receive upper and lower dentures was not incorporated into the care plan. This oversight contributed to the delay in addressing the resident's dental needs and alleviating their pain.

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 adaptive equipment for a resident, identified as R30, who required built-up eating utensils due to multiple health conditions, including osteomyelitis, type 2 diabetes, arthritis, and a history of stroke. R30 was admitted to the facility with a care plan that included the provision of built-up handles for utensils at meals. Despite this, observations on two separate occasions revealed that while R30 was provided with a built-up spoon and fork, a built-up knife was consistently missing from his meal tray. This omission required R30 to use inappropriate utensils to prepare his food, such as buttering toast and applying jam. Interviews with the Dietary Manager (DM) G confirmed that the facility had adaptive knives available and that the meal ticket for R30 indicated the need for built-up utensils. However, DM G was unable to explain why the built-up knife was not provided, despite acknowledging that it was expected to be included with every meal. This oversight in providing the necessary adaptive equipment as per the resident's care plan highlights a deficiency in the facility's adherence to ensuring residents' needs are met for meal preparation and eating.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of coordination of comprehensive care. The resident, who was admitted with multiple diagnoses including dementia and Alzheimer's Disease, was receiving hospice care as indicated in their medical record. However, the Durable Power of Attorney (DPOA) for the resident was not informed about the specific hospice services being provided or the schedule of these services. Despite a physician's order for hospice services to begin, there was no evidence that the DPOA was notified about the hospice disciplines involved or the frequency of visits. Interviews with facility staff revealed that there was no documentation of a hospice admission meeting with the DPOA, and the hospice visit calendar was not consistently updated in the resident's medical record. The hospice calendar for certain weeks was not scanned into the medical record until after the visits had occurred, and there was no calendar for some weeks. The facility's policy required coordination of a care plan with the hospice provider, but this was not effectively implemented, as evidenced by the lack of communication with the resident's representative.

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 pneumococcal immunizations in accordance with CDC recommendations for a resident, resulting in a potential risk for severe illness and complications from pneumococcal disease. The resident, identified as R25, was admitted to the facility with multiple diagnoses including dementia, chronic kidney disease, and severe protein-calorie malnutrition. The resident's medical record indicated that she had received the PCV13 vaccine in 2017 and the PCV23 vaccine in 2018, but there was no documentation of the PCV20 vaccine being administered, which is recommended by the CDC for individuals over the age of 65 at least five years after their last pneumococcal vaccination. During an interview, the Infection Preventionist (IP) confirmed that the resident had not been offered or received the PCV20 vaccine as per CDC guidelines. The IP admitted to being unaware of the specific CDC recommendation that the resident should receive the PCV20 vaccine. The facility's policy on pneumococcal vaccines, last revised in October 2023, stated that the type of vaccine offered should depend on the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines. However, this policy was not followed in the case of the resident, leading to the deficiency.

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 honor a resident's rights, resulting in increased anxiety, PTSD symptoms, decreased self-worth, and psychosocial wellbeing. The resident, who has a history of chronic obstructive pulmonary disease, acute kidney failure, pressure ulcers, malignant neoplasm, major depression, anxiety, PTSD, and other conditions, was cognitively intact and required assistance for personal care. Despite the resident's care plan emphasizing the need to offer choices and promote self-worth, the facility imposed a two-person assist for all care, including answering call lights, against the resident's wishes. The resident reported that the facility did not always staff two female caregivers on her hall, leading to delays in care. The resident also stated that the facility's decision to require two caregivers was a response to her allegation that an occupational therapist had left bruises on her arm. The facility investigated the allegation and found no wrongdoing, but continued to enforce the two-person assist policy, which the resident felt violated her rights and privacy. The resident expressed her concerns to the ombudsman, who confirmed that the resident's rights were not being honored. The facility's staff, including the Social Services Director, Unit Manager, and Nursing Home Administrator, maintained that the two-person assist was necessary for the resident's safety and to protect staff. However, the resident repeatedly expressed that this policy exacerbated her anxiety and PTSD, and she felt her autonomy and privacy were being compromised. The resident's refusal of care and verbal aggression were documented multiple times, highlighting her distress and the ongoing conflict between her wishes and the facility's policies.