Mission Point Nursing & Physical Rehabilitation Ce

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 fire alarm system was installed, tested, and maintained in accordance with Life Safety Code (LSC) Section 19.3.4.1, 9.6, and NFPA 72. During a review of facility records, it was found that documentation for the testing of fire alarm devices did not include individual device testing by location with a minimum pass or fail result, as required by NFPA 14.6.2.4(7). Additionally, there was no current documentation for the required bi-annual smoke detector sensitivity testing, with the last record dated 12/30/2022, which does not meet the requirements of NFPA 72 14.4.5.3. These findings were confirmed during an interview with a maintenance staff member at the time of the records review.

Plan Of Correction

Element #1: Fire alarm devices have been recorded and tested by location to at a minimum of pass or fail by 07/09/2025 by Boynton Fire Safety Service. Bi-annual smoke detector sensitivity testing has been completed on 07/09/2025 by Boynton Fire Safety Service. Element #2: This deficient practice could potentially affect all occupants in the event of failure to the fire alarm system. Ensure fire alarm system is tested and maintenance in accordance with LSC Section 19.3.4.1, 9.6 and NFPA 72. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Services Director on Fire Alarm System policy by the completion date. Element #4: Environmental Services Director/designee will complete audits to ensure that Fire alarm devices have been recorded and tested by location to at a minimum of pass or fail and the smoke detector sensitivity testing gets completed as required. Audits will be completed weekly for four weeks and then monthly thereafter until substantial compliance has been sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved.

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 the A Hall Resident Care Supply room door was observed not to self-close to a positive latch as required by Life Safety Code (LSC) 8.7.1.3. This observation was made during a facility inspection and confirmed in an interview with a maintenance staff member. The lack of a self-closing, positively latching door in this hazardous area means the area was not properly protected as required for spaces containing combustible or hazardous materials, as outlined in LSC 19.3.2.1. The deficiency was specifically noted in relation to the protection of hazardous areas, which is necessary to prevent the spread of fire and smoke within the facility.

Plan Of Correction

Element #1: A Hall Resident Care Supply room door self-closer has been adjusted. The A Hall Resident Care Supply room door was checked to ensure the door self-closed to a positive latch. Element #2: This deficient practice has the potential to affect 15 occupants of the facility in the event of a fire not being contained to the hazardous area. Hazardous area doors in the facility have been checked and verified that they self-close to a positive latch. Doors that did not self-close to a positive latch were fixed at the time of the audit. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Service Director on the Fire and Smoke Doors policy by the completion date. Element #4: Environmental Services Director/designee will complete audits on hazardous area doors to ensure they self-close to a positive latch. Audits will be completed weekly for four weeks and then monthly thereafter until substantial compliance is sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Nursing Home Administrator is responsible for attaining and 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 inspection, it was observed that the corridor room door at resident room #20 did not close to a positive latch as required by Life Safety Code (LSC) 19.3.6.3.5. The door failed to meet the standard for resisting the passage of smoke, which is necessary for corridor doors in areas other than required enclosures of vertical openings, exits, or hazardous areas. The deficiency was identified through direct observation and confirmed in an interview with a maintenance staff member at the time of the inspection. The report specifies that the door in question did not provide the required positive latching hardware, which is essential for ensuring the door remains closed and can resist smoke passage. This failure was noted as a violation of the applicable regulations and could potentially affect 15 occupants in the event of a fire not being contained to the smoke compartment. No additional details about the medical history or condition of the residents in the affected room were provided in the report.

Plan Of Correction

The Nursing Home Administrator is responsible for attaining and maintaining compliance. Element #1: The corridor room door at resident room #20 has been repaired. Resident room #20 door has been checked to ensure the door closed to a positive latch. Element #2: This deficient practice could potentially affect 15 occupants of the facility in the event of a fire not being contained to the smoke compartment. Resident room doors in the facility have been checked and verified that they close to a positive latch. Any doors that did not close to a positive latch were fixed at the time of the audit. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Services Director on the Fire and Smoke Doors policy to a positive latch by the completion date. Element #4: Environmental Services Director/designee will audit to ensure resident room doors close to a positive latch. Audits will be completed for 10 random resident rooms weekly for four weeks and then monthly thereafter until substantial compliance has been sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Nursing Home Administrator is responsible for attaining and 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 prevent the misappropriation of resident medications by a licensed nurse, RN M, who diverted controlled medications for personal use. This incident involved two residents, Resident #109 and Resident #110, whose medications were found in RN M's home. The local police discovered narcotic medications, including Lorazepam, Oxycodone, and Tramadol, prescribed to these residents, during an investigation at RN M's residence. The facility's records indicated discrepancies in the destruction of these medications, with RN M and other staff members signing off on the destruction without proper witnessing or verification. Interviews with staff members revealed a pattern of non-compliance with the facility's policy on medication destruction. LPN K and RN H admitted to signing off on the destruction of narcotic medications without witnessing the process, trusting RN M's word that the medications had been destroyed. This breach of protocol was not reported to management, despite the staff's awareness that it was against professional standards and facility policy. The Controlled Substance Proof-Of-Use Records showed inconsistencies, with medications marked as destroyed but later found in RN M's possession. The facility's failure to adhere to its medication destruction policy and the lack of oversight allowed RN M to misappropriate medications over an extended period. The incident highlights the vulnerability of the facility's medication management system, as the lack of proper witnessing and verification procedures enabled the diversion of controlled substances. The facility's response included suspending involved staff members and initiating re-education, but the deficiency itself stemmed from inadequate adherence to established protocols and insufficient monitoring of medication handling processes.

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 professional standards of nursing care, as evidenced by the misappropriation of controlled medications involving two residents. Licensed nurses falsely documented the destruction of narcotic medications, which were later found in the possession of a registered nurse (RN M) at their home. The incident was discovered when the local police informed the Director of Nursing (DON B) about the medications found at RN M's residence, leading to a full narcotic count and pain assessments for all residents in the facility. The investigation revealed discrepancies in the Controlled Substance Proof-Of-Use Records for the affected residents. For Resident #109, records showed that Lorazepam and Tramadol tablets were falsely documented as destroyed by RN M, with LPN K witnessing the destruction without actually seeing the medications. Similarly, for Resident #110, Oxycodone tablets were falsely documented as destroyed by RN M, with RN H witnessing the destruction without verifying the medications. Both LPN K and RN H admitted to signing off on medication destruction without witnessing it, trusting RN M's word instead of following facility policy. Further observations during the survey indicated ongoing issues with the controlled substance count process. The Controlled Substance Shift Inventory record was not properly signed by both outgoing and oncoming nurses, as required. LPN L admitted to not signing the record at the start of her shift, and UM C and DON B confirmed that the process was not being followed correctly, indicating a lack of adherence to the facility's policies for controlled substance management.

Penalty

Fine: $48,86738 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 prevent the elopement of a cognitively impaired resident, identified as Resident #305, who was mistakenly allowed to exit the facility by staff. On the evening of 6/13/2024, Resident #305, who had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was let out of the facility by an LPN who mistook him for a visitor. The resident then traveled on foot along a busy road, posing a significant risk to his safety. This incident resulted in an Immediate Jeopardy situation, as the resident was found by community members and returned to the facility by staff who were searching for him. The facility's failure to properly assess and monitor Resident #305's risk for elopement contributed to the incident. The resident's admission assessment did not identify him as at risk for elopement, despite his cognitive impairment and history of wandering behaviors. Additionally, the facility's elopement and wandering residents policy, which requires systematic monitoring and management of residents at risk for elopement, was not effectively implemented. Staff interviews revealed a lack of awareness and communication regarding the resident's status, leading to the mistaken assumption that he was a visitor. Further investigation revealed that the facility did not have adequate procedures in place to ensure the safety of residents at risk for elopement. The facility's admission process failed to capture critical information about the resident's elopement behaviors from the hospital, and there was a lack of coordination among staff to address potential risks. The facility's oversight in conducting daily door alarm checks also contributed to the deficiency, as several days were missed, compromising the security measures intended to prevent such incidents.

Removal Plan

• R305 was placed on a 1:1 supervision upon return to the facility.
• Employee placed on administrative leave. Upon return from administrative leave, this staff member was provided 1:1 education on the elopements and wandering residents policy.
• All newly admitted residents that have a guardian or activated DPOA were identified as being at risk for this deficient practice.
• All resident's elopement risk assessments reviewed and any identified elopement risks residents that were currently residing in the facility were reviewed to ensure appropriate interventions were in place.
• External door checks were completed by the Administrator.
• All-staff re-education was initiated.
• Education was completed to all-staff on elopement and wandering residents policy was initiated; any facility staff member and agency staff member who did not receive education will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. All facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their next shift.
• Administrator/designee audited daily door alarms checks to ensure proper functioning of the egress and wander guard system. The audits have been conducted weekly for four weeks and then monthly for two months.
• Elopement drill has been completed.
• Director of Nursing/designee audited new admission elopement risk assessments to ensure proper interventions have been placed if a resident triggers as an elopement risk and to verify a wander guard is in place for the first 7-days if the resident has a legal decision maker. The audit has been conducted weekly for four weeks and then monthly for two months.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to ensure that residents were free from significant medication errors, resulting in an Immediate Jeopardy situation. On the morning of May 23, 2024, a resident, identified as R404, was mistakenly administered medications intended for another resident, R7. This error occurred when LPN WW prepped the medications and handed them to LPN XX, who then administered them to R404 instead of R7. The medications included potent drugs such as Dilaudid and Gabapentin, which led to R404 becoming unresponsive and requiring hospitalization in the ICU. The incident was compounded by a lack of proper orientation and training for the nursing staff involved. LPN WW, who had been working at the facility for just over a month, was still in her orientation phase and was paired with LPN XX, an agency nurse on his first day at the facility. Both nurses were unfamiliar with the residents and the facility's procedures, leading to the critical error. LPN WW admitted to pulling medications and having LPN XX administer them, a practice that deviated from standard medication administration protocols. The facility's failure to adhere to its own medication administration guidelines, which emphasize the Five Rights of medication administration, contributed to the error. Additionally, there was a lack of proper identification measures, such as wristbands or room identifiers, which could have prevented the mix-up. The incident highlighted significant lapses in the facility's training and orientation processes, as well as in the execution of medication administration protocols.

Removal Plan

• Newly hired nurses to only be assigned to follow facility nurses.
• Medication Administration Guidelines policy was reviewed by the administrator and Director of Nursing and deemed appropriate.
• Medication Administration - General Guideline to be followed at each medication pass.
• Daily schedules were reviewed by the DON and scheduler to ensure appropriate nurse orientation practice is occurring.
• Education was completed to nurses on medication administration-general guidelines; any facility staff member and agency staff member who did not receive education will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. All facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their first shift.
• Medication administration audits began and were completed weekly x 2 weeks then monthly x 2 months to ensure the Medication Administration Guidelines were being completed.
• DON completed daily schedule audits when there was a nurse on orientation to ensure that they are scheduled with a facility nurse - ongoing.
• NHA/designee began to complete resident identifiers audits to ensure there was a picture uploaded to PCC (electronic medical records) and room is identified with the resident name once weekly x 2 weeks then monthly x 2 months.
• Results of audits have been reviewed with the QAA committee to ensure compliance and any further recommendations.
• Additional education provided on the Medication Administration - General Guidelines policy to 8 out of 21 licensed nurses, including licensed agency nurses. All licensed nurses including agency nurses will have education on the Medication Administration - General Guidelines policy completed prior to the beginning of their next shift.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to adhere to professional standards of practice for medication administration, resulting in a significant medication error involving two residents. One resident, identified as R404, was mistakenly given another resident's medications, including opioids, which led to respiratory failure and required hospitalization for life-sustaining treatment. The error occurred when LPN WW prepared medications for R7 but handed them to LPN XX, who administered them to R404 without verifying the resident's identity. The incident unfolded as LPN WW and LPN XX worked together, with LPN WW preparing medications and LPN XX administering them. LPN XX was given the medications intended for R7 and was told the resident's first name, which was the same as R404's. Without confirming the last name or checking identification, LPN XX administered the medications to R404, who had already received his own medications earlier. R404, who was cognitively intact, expressed confusion but ultimately took the medications after LPN XX insisted they were his. The facility's policy on medication administration was not followed, as the medications were not verified against the resident's identification, and the person who prepared the medications did not administer them. This breach of protocol led to R404 experiencing an overdose, requiring multiple doses of Narcan and hospitalization. The facility's failure to ensure the right resident received the right medication directly contributed to the adverse event experienced by R404.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to provide appropriate care for two residents, resulting in significant deficiencies. Resident #27, a male with a history of dementia, stroke, and other medical conditions, experienced a fall from his wheelchair, leading to a laceration on his left eyebrow. Despite the fall, the resident did not receive a thorough assessment for potential injuries, particularly to his right hip, which was later found to have an intertrochanteric fracture of unknown origin. The resident had been complaining of increased pain in his right leg, but the facility's staff did not adequately address these complaints, leading to a delay in diagnosing the fracture. Interviews with staff revealed that the resident's pain was not properly managed, and his behaviors were misinterpreted, resulting in inadequate care. Resident #406, a female with spinal stenosis and a history of spinal surgery, did not attend follow-up appointments with her spinal surgeon as required. The Health Information Coordinator (HIC) failed to schedule these appointments, despite discharge instructions indicating the need for follow-up care. The resident had been back in the facility for approximately two weeks without seeing the spinal surgeon, and the Therapy Director confirmed that spinal precautions should remain in place until reviewed by the surgeon. The Director of Nursing confirmed that it was the HIC's responsibility to schedule these appointments, highlighting a lapse in the facility's coordination of care. These deficiencies demonstrate a failure in the facility's processes to ensure residents receive care in accordance with their needs and medical conditions. The lack of timely assessments and follow-up care for both residents resulted in prolonged pain and potential complications. The facility's staff did not adequately communicate or act upon the residents' needs, leading to significant oversights in their care.

Penalty

Fine: $48,86738 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 employ a qualified Activity Director, which resulted in a deficiency related to the activities program. The deficiency was identified through observations, interviews, and record reviews. A Certified Nursing Assistant (CNA) on light duty was temporarily filling in as an activities aide, despite lacking prior experience in activities. The CNA reported not having attendance sheets and documented activities in the electronic medical record. The facility had been without an Activities Director since mid-May 2024, and the administrator confirmed that a light duty CNA was being used to conduct activities for the residents.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to ensure that five reviewed certified nurse assistants (CNAs) completed the required 12 hours of in-service education, which is essential for maintaining performance standards and ensuring resident safety. The Education Spreadsheet for 2024, provided by the Director of Nursing (DON), showed significant gaps in training completion across various critical categories, including abuse, compliance, infection control, quality assurance and performance improvement (QAPI), resident rights, and communication. None of the five CNAs reviewed (CNA H, CNA I, CNA O, CNA P, and CNA ZZ) completed all the assigned training, with some not completing any training at all. Interviews with facility staff, including the DON and the Nursing Home Administrator (NHA), revealed systemic issues in the training process. The facility relied on computer-based training assigned during new hire orientation and annually thereafter. However, the second day of orientation, which was supposed to include these trainings, was not being completed as expected. Additionally, there was no staff member dedicated to tracking the completion of the 12-hour in-service requirement, leading to a lack of oversight. Despite notifications being sent to employees about their training assignments, the CNAs did not complete the required courses, as confirmed by interviews with CNAs X and ZZ.

Penalty

Fine: $48,86738 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 sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial tour, several food items in the reach-in and walk-in refrigerators were found without proper labeling and dating, including salami sandwiches, lettuce and tomato slices, a pitcher of juice, macaroni noodles, BBQ pork, sour cream, and waffle fries. The Dietary Manager acknowledged that staff are supposed to label and date leftover foods but admitted to having to constantly remind them to do so. Additionally, expired yogurts and improperly stored food items were found in the A and B side pantries, with the Regional Dietitian stating that staff should check these units daily and follow expiration guidelines. Further observations revealed physical facility issues, including gray chipping paint inside a metal drawer for clean utensil scoops, leaking condensate from the overhead ventilation system, cracks and open pits on the floor near the three-compartment sink, and a broken temperature gauge on the dish machine. The Regional Dietitian confirmed the presence of debris accumulation and the use of a thermometer to check the dish machine's temperature. These findings indicate a lack of adherence to the 2017 FDA Food Code and the facility's own food storage policy, which requires proper labeling, dating, and maintenance of physical facilities.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to adhere to infection prevention standards, as evidenced by multiple observations and interviews. One resident, identified as R7, had a wound dressing on his right elbow that was not labeled or dated, which is against the facility's protocol for infection control. The dressing was observed on multiple occasions without proper labeling, and staff acknowledged the oversight. Additionally, a soiled elbow pad with blood was found on the floor of R7's room, which was not addressed by the staff, posing a risk of infection. Another issue was the improper handling of resident-shared equipment. An LPN was observed using a vital sign machine on a resident without cleaning it afterward, despite the facility's policy requiring disinfection after each use. The LPN did not have disinfectant wipes readily available, and there was confusion about where to store them, indicating a lapse in infection control practices. The facility also failed to implement enhanced barrier precautions for residents with wounds or indwelling medical devices. For instance, Resident #23, who required such precautions, was assisted by staff who did not don the necessary personal protective equipment (PPE) during high-contact care activities. This non-compliance with enhanced barrier precautions was confirmed through interviews with staff and observations of care practices. Additionally, the facility lacked an active plan for managing Legionella and other pathogens in the water supply, as there was no regular sampling or team meetings to review the water management plan.

Penalty

Fine: $48,86738 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 an effective training program for its nursing department employees, which included essential trainings in areas such as resident rights, abuse, neglect, exploitation, quality assurance, infection control, compliance and ethics, and communication. The Education Spreadsheet 2024 revealed significant gaps in training completion, with numerous employees lacking recorded completion dates across various training categories. Specifically, 10 employees had not completed abuse training, 15 had not completed compliance training, 12 had not completed infection control training, 23 had not completed QAPI training, 18 had not completed resident rights training, and 13 had not completed communication training. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that there was no staff member assigned to track the completion of required trainings, and the expected in-person facility training during new hire orientation was not being completed as planned. Additionally, several Certified Nurse Assistants (CNAs) had not completed their assigned required trainings, with some not completing any trainings at all. Despite being notified by email about the trainings, the staff did not complete them, indicating a lack of oversight and accountability in the training process.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to develop person-centered care plans for three residents, leading to inadequate monitoring of anticoagulant medication side effects and a known skin condition. Resident #34, diagnosed with dementia, atrial fibrillation, and cerebral infarction, was prescribed Xarelto for atrial fibrillation but lacked a care plan to monitor for bleeding or bruising, which are potential side effects of the medication. Similarly, Resident #49, with a history of atrial fibrillation and deep vein thrombosis, was prescribed Apixaban but also did not have a care plan addressing the monitoring of anticoagulant side effects, despite the physician's order to do so. Resident #6, who had a chronic lesion on her nose due to untreated skin cancer, did not have a care plan addressing the lesion, which sometimes bleeds. The lesion was noted during an observation, and interviews with staff revealed a lack of awareness and documentation regarding the condition. The resident's guardian had declined further treatment, and the lesion was managed with antibiotic ointment when it bled. The Director of Nursing acknowledged the need for a care plan and orders to monitor the wound, but these were not in place at the time of the survey.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to provide consistent, meaningful, and person-centered activities for six residents, leading to potential negative impacts on their well-being. The report highlights that the facility did not have an Activities Director since mid-May 2024, and activities were being managed by a CNA on light duty, who lacked experience in activities. This resulted in a lack of scheduled activities after 4:00 PM, on weekends, and no outings for the months of May, June, and July 2024. Additionally, there were no individualized activities observed during the survey period, and scheduled activities were often canceled without replacements. Resident #11, a male with diagnoses including dementia and major depressive disorder, reported staying in his room most of the time due to a lack of activities that interested him, such as woodworking or building model cars. He also mentioned that the facility did not provide him with books or magazines, and he expressed a desire for outdoor activities like fishing. Resident #12, a female with cognitive communication deficit and other health issues, reported that a scheduled Bingo game was not conducted by staff, and another resident had to run it. She expressed interest in activities like coloring and playing games, but these were not consistently provided. Resident #17, a male with multiple health issues, reported that there were no activities staff after 4:00 PM or on weekends, and the facility had not replaced the activities aides who were let go due to budget cuts. Resident #40, a female with Alzheimer's disease, also reported that activities were not being conducted as scheduled. Resident #406 had no care plan for activities, and no Recreation Assessment was completed. Resident #34, with dementia and major depressive disorder, expressed dissatisfaction with the lack of engagement in activities and reported missing scheduled activities due to lack of reminders. The facility's policy on activities was not being followed, as it stated that activities should support residents' physical, mental, and psychosocial well-being, which was not observed during the survey.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to provide sufficient staffing to meet the needs of several residents, resulting in prolonged wait times for assistance and unmet care needs. Resident #2, who has significant physical disabilities, reported waiting over an hour for staff to respond to call lights and missing scheduled showers due to staffing shortages. Similarly, Resident #15, who is dependent on a wheelchair and has severe obesity, experienced extended wait times for incontinence care, leading to discomfort and frustration. These issues were corroborated by observations and interviews with staff, who confirmed that staffing levels were inadequate to meet the residents' needs. Resident #17 and other members of the resident council also reported excessive wait times for call lights to be answered, particularly during night shifts. The resident council minutes from several months highlighted ongoing concerns about staffing levels and call light response times, with specific mentions of inadequate staffing on certain shifts. Interviews with CNAs and the Director of Nursing revealed that staffing levels were often below the required numbers, with CNAs being overburdened with high resident-to-staff ratios, leading to delays in care provision. Additional issues were noted with Resident #304 and Resident #406, who both reported being left in soiled conditions for extended periods due to insufficient staff availability. Resident #406, who requires significant assistance due to spinal issues, had not received a proper shower or bath for weeks. Interviews with staff indicated that the facility did not use agency staff for CNAs, further exacerbating the staffing shortages. The facility's assessment revealed a high number of residents requiring assistance with daily activities, yet the staffing did not reflect the acuity and needs of the residents, contributing to the deficiencies observed.

Penalty

Fine: $48,86738 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 was found to have significant lapses in monitoring and maintaining the proper temperatures of personal refrigerators in residents' rooms. During observations, it was noted that there were no visible temperature logs in the rooms, and the staff did not consistently monitor the refrigerators. In one instance, a refrigerator was found with a thermometer reading 46 degrees, indicating a failure to maintain the required temperature. The staff, including a Dietary Aide, admitted to not consistently checking the refrigerators, and there were significant gaps in the documentation of temperature checks. The facility's policy requires daily checks and recording of temperatures, but these were not consistently followed, as evidenced by missing logs and unrecorded temperatures. The facility's records showed repeated failures to maintain the required temperatures, with multiple instances of refrigerators being recorded at temperatures above the safe threshold of 41 degrees. The logs from May, June, and July 2024 showed significant lapses in monitoring, with many instances of missed checks and recorded temperatures that were too high. The staff's failure to maintain proper records and the lack of consistent checks on the refrigerators posed a risk of food safety issues, as the facility's policy was not adhered to. The facility's staff, including the Dietary Manager, acknowledged the lapses in maintaining the refrigerators and the lack of consistent checks, which could potentially lead to food safety issues.

Penalty

Fine: $48,86738 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 the dignity of a resident, identified as Resident #15, who was cognitively intact and had diagnoses including muscle weakness, dependence on a wheelchair, and morbid obesity. The deficiency was identified through observations, interviews, and record reviews. Resident #15 reported multiple instances of having to wait for extended periods, sometimes over an hour, for her call light to be answered when she required incontinence care. This delay in response led to the resident sitting in a wet and soiled brief, causing feelings of frustration and anger. The resident documented specific dates when these delays occurred, highlighting the ongoing nature of the issue. Interviews with Certified Nurse Assistants (CNAs) revealed that staffing levels were insufficient to meet the needs of the residents, with one CNA reporting an assignment of about 14 residents per shift. Observations confirmed that Resident #15's call light was not promptly answered, with one instance where the call light was on for about 10 minutes before being addressed. The resident's care plan indicated her preference to use bariatric disposable briefs and notify staff when she needed to be changed, yet the facility's failure to respond promptly to her needs compromised her dignity and well-being.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to provide an environment free from psychosocial abuse for two residents, resulting in feelings of frustration, mental anguish, and a loss of autonomy. Resident #2, who is cognitively intact and has a history of substance abuse, was restricted from leaving the facility independently due to safety concerns. Despite having a physician's order allowing therapeutic leave of absence and independent smoking, the facility placed a wander guard on his wheelchair and revoked his leave privileges. This decision was influenced by the resident's family and provider's concerns about his safety and substance abuse history. The resident expressed feelings of being on 'house arrest' and reported that he was being punished by not being allowed to leave the facility. Resident #2's situation was further complicated by the facility's communication with his family, who were pursuing guardianship. The facility's interdisciplinary team decided to revoke his leave privileges due to safety concerns and alleged illicit drug use. Despite being his own medical decision-maker, Resident #2 was informed that leaving the facility would be considered against medical advice (AMA), and he would not be allowed to return. The facility also began the process of involuntary discharge, which added to the resident's distress and feelings of being trapped. Resident #36, who has dementia and other medical conditions, was also restricted from smoking independently despite having a safe smoking assessment that allowed it. The facility changed the rules, requiring him to be accompanied by a responsible person, even though he had been smoking independently for 18 months. The resident's guardian had given permission for him to sign himself out to smoke, but the facility imposed additional restrictions, citing safety concerns. This change in policy led to the resident feeling blocked from going outside, contributing to his frustration and loss of autonomy.

Penalty

Fine: $48,86738 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 prevent the misappropriation of medications for Resident #36, who was diagnosed with type 2 diabetes and was cognitively intact. The resident's diabetes medication, Ozempic, was not administered as prescribed, resulting in missed doses on multiple occasions. The medication was supposed to be delivered and administered weekly, but records indicated missed doses on 4/23/24, 4/30/24, 5/2/24, and 5/9/24. This failure led to a delay in the treatment of the resident's diabetes. The issue began when the pharmacy delivered a tote of medications on 5/1/24, which included Resident #36's Ozempic. LPN R verified the delivery but mistakenly left the medication in the tote when transferring it to another hall. RN MM, who was informed of the delivery, did not have time to put away all the medications and later denied seeing the Ozempic. During an investigation, UM W found the empty box of Ozempic in the B hall medication room, indicating that the syringes were missing. Further interviews revealed that the B hall medication room door was propped open for several hours on the day of the delivery, and there were issues with missing keys. Despite the delivery being verified by LPN R, the medication was not properly secured, leading to its misappropriation. Resident #36 confirmed missing several doses of the medication and stated that no authorization was given for its use by others.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to revise the care plan for a resident, resulting in the potential for inaccurate care interventions. The resident, who had diagnoses including acquired absence of both legs above the knee and paraplegia, was cognitively intact with a BIMS score of 13/15. Despite having physician orders allowing therapeutic leave of absence and independent smoking, the resident reported being unable to leave the property and having a tracker on their power wheelchair. The care plan included conflicting information, such as the resident's ability to smoke independently and the use of a nicotine patch for smoking cessation, as well as the presence of a wander guard related to behavioral symptoms. The facility's records showed inconsistencies in the resident's elopement risk assessment and inclusion in the elopement book, which was not updated to reflect the resident's current status. Interviews with staff revealed confusion about the resident's elopement risk and smoking status, with some staff indicating the resident should be in the elopement book while others stated the resident was not an elopement risk. The unit manager acknowledged that the care plan contained conflicting information and needed updating, highlighting the facility's failure to maintain accurate and current care plans for the resident.

Penalty

Fine: $48,86738 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 consistently provide showers and bathing assistance to two residents, resulting in unmet personal hygiene needs. Resident #27, a male with multiple diagnoses including dementia and stroke, was observed on two occasions appearing disheveled, with uncombed hair and an untrimmed beard. His care plan indicated a preference for morning showers twice a week, but observations suggested these were not being consistently provided. Resident #406, a female with spinal stenosis and other mobility impairments, reported not having received a shower or full bed bath since her admission. Despite being cognitively intact, she expressed that it was very important for her to choose her bathing method. Observations and interviews revealed her hair was unkempt and had not been washed for 4-6 weeks. She was dependent on staff for bathing assistance, yet reported only minimal washing had been done. Interviews with staff, including CNAs and hospice aides, highlighted issues with staffing levels and documentation practices. CNA N reported being responsible for 15 residents and often working alone, which impacted her ability to complete all tasks, including showers. The facility's policy required documentation of bathing and refusals in the medical record, but inconsistencies in practice were noted, contributing to the deficiency in care.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to provide adequate incontinence care for Resident #304, who was admitted with diagnoses of anxiety, depression, and dementia. The resident was cognitively intact and expressed concerns about being left in urine for about an hour, which she feared could lead to skin breakdown. Upon admission, the resident had moisture-associated skin damage (MASD) to her buttocks and groin area, and subsequent weekly skin sweeps revealed an open area and rash/excoriation. Despite these findings, the resident's care plan did not include a urinary toileting program or bladder training to address her frequent incontinence. Interviews with staff revealed a lack of awareness and communication regarding the resident's skin condition and necessary treatments. The Unit Manager was unaware of the open area noted in a skin sweep, and the LPN who conducted the sweep could not recall if a treatment was initiated. The resident's care plan failed to address incontinence care adequately, and no treatment was ordered for the MASD upon admission. Additionally, the Therapy Director confirmed that therapy did not assist with the resident's bladder incontinence or staff training. The facility's incontinence policy mandates appropriate treatment and services based on comprehensive assessments, which were not provided in this case.

Penalty

Fine: $48,86738 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 proper infection control practices for a resident using a BiPAP machine, leading to a potential risk of cross-contamination and transmission of disease. The resident, who had diagnoses including heart failure, pulmonary hypertension, insomnia, obstructive sleep apnea, and asthma, reported that staff did not clean her CPAP/BiPAP mask after use and did not replace the mask as required. Observations confirmed that the mask was left on the nightstand without a barrier or bag, contrary to the facility's protocol. The resident also reported having to ask staff to fill the distilled water tank and that her sister assisted her in changing the tubing, indicating a lack of adherence to the care plan and orders. Interviews with the Unit Manager revealed that the responsibility for cleaning the CPAP/BiPAP mask and filling the water reservoir lay with the nursing staff, who were expected to perform these tasks daily. However, the resident's reports and observations indicated that these tasks were not consistently performed. The facility's policy required daily cleaning of the mask with an approved disinfecting solution and proper storage in a mesh bag or approved container, which was not followed. This lack of compliance with established procedures for respiratory equipment maintenance resulted in a deficiency in infection control practices.

Penalty

Fine: $48,86738 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 identify and address post-traumatic stress disorder (PTSD) triggers for a resident, leading to a deficiency in trauma-informed care. The resident, who had a history of trauma and pertinent medical diagnoses including spinal stenosis and lumbar vertebra fractures, was sent to a psychiatric hospital in another state. During her stay, she experienced significant fear due to the behavior of a male resident in the adjacent room, which exacerbated her anxiety and fear of harm. This situation was not adequately addressed by the facility, as they did not conduct a trauma assessment or develop a care plan to mitigate these triggers. Interviews with facility staff revealed a lack of appropriate actions to support the resident's mental health needs. The Social Service Director admitted to not completing a trauma assessment before or after the resident's psychiatric hospitalization. The Director of Nursing acknowledged that the facility did not explore alternative, less restrictive services before sending the resident to a psychiatric hospital for declining care. The resident's ex-husband and roommate provided insights into her history of trauma and behaviors, which were not sufficiently considered in her care plan. The resident's fear and resistance to care were further compounded by her physical condition, including numbness and weakness in her extremities, which made her reluctant to participate in therapy and care activities. Despite being cognitively intact, the resident's needs were not met, leading to a decline in her physical condition, including the reopening of a surgical wound and the development of an open area on her bottom. The facility's failure to provide trauma-informed care and address the resident's PTSD triggers resulted in a deficiency that could potentially lead to re-traumatization.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to ensure that nursing staff were evaluated for appropriate competencies and skill sets, which could potentially impact the residents' ability to maintain their highest practicable physical, mental, and psychosocial well-being. The Director of Nursing (DON) reported that a competency fair was held for nursing employees, but attendance was not mandatory, resulting in poor participation. Additionally, the facility lacked a dedicated staff development role, leaving the responsibility to the DON. A review of an untitled spreadsheet revealed that out of 50 nursing department employees, only 12 had completed their annual competency evaluations for 2024, while the remaining 38 were either overdue or incomplete. The Nursing Home Administrator (NHA) confirmed that annual competencies and performance reviews were expected to be completed, but many were found to be overdue, missing, or incomplete. Furthermore, new hire competency evaluations, which were supposed to be completed on the second day of orientation, were not being conducted as expected. This lack of adherence to competency evaluation protocols highlights a significant deficiency in ensuring that nursing staff possess the necessary skills to provide optimal care for residents.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to provide appropriate mental health treatment and services for a resident, resulting in the resident being sent to a psychiatric hospital, which caused psychosocial distress and fear. The resident, who had a history of spinal stenosis, lumbar vertebra fractures, and recent spinal surgery, was admitted for subacute rehabilitation. Despite having no documented mental health diagnoses, the resident was sent to a psychiatric hospital due to perceived self-neglect and risk to herself and others, as determined by the facility's interdisciplinary team (IDT). The resident experienced significant pain and fear of falling, which affected her participation in therapy and care. She was resistant to therapy due to numbness in her extremities and fear of falling, which was documented by therapy staff. The resident's surgical wound began to open, and she developed an infection due to declining incontinence care and basic hygiene. Despite these issues, the facility did not conduct a trauma assessment or refer the resident to mental health services before deciding on psychiatric hospitalization. Interviews with facility staff revealed that the resident was not approached for mental health support, and the social service director did not contact the contracted mental health provider for evaluation. The decision to send the resident to a psychiatric hospital was based on the IDT's assessment of self-harm through self-neglect, without exploring less restrictive alternatives. The resident reported feeling fearful and distressed during her stay at the psychiatric hospital, highlighting the facility's failure to provide necessary behavioral health care services in a person-centered manner.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to ensure follow-up on pharmacy recommendations for a resident, leading to a deficiency in medication management. The resident, who was cognitively intact and had a history of type 2 diabetes, bipolar disorder, anxiety, and depression, was admitted with PRN orders for Meclizine and Dicyclomine. These medications were flagged by the pharmacist for discontinuation due to their high anticholinergic load and potential inappropriateness for older adults, as per the Beer's List. The physician agreed with the pharmacist's recommendation to discontinue these medications. Despite the agreement to discontinue, a review of the resident's current physician orders revealed that the medications were still active several months later. This oversight was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged that the discontinuation of the medications was missed and only addressed on the day of the interview. The facility's Medication Regimen Review Policy mandates that staff act upon all recommendations, highlighting a lapse in adherence to established procedures.

Penalty

Fine: $48,86738 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 properly label, date, and store medications in one of two medication rooms and both medication carts, which could potentially decrease the efficacy of medications and lead to their compromise or misappropriation. During an observation, it was found that the refrigerator in the B hall medication room, which contained multiple resident medications and vaccinations, had missing temperature records for daytime monitoring and almost no monitoring at night. The Unit Manager reported that the night shift nurse was responsible for monitoring the refrigerator temperatures, but the logs were not being checked regularly, prompting the relocation of the binder with the logs to the nurses' station. Additionally, during a medication storage observation, several issues were identified, including stock OTC medications with worn-off expiration dates, an Anoro Ellipta inhaler without an open date, and another inhaler without a resident name, drug name, label, or open date. A loose pill was also found in the A hall medication cart, with the LPN unable to identify it or its intended recipient. Furthermore, the B hall medication room door was found propped open for several hours due to a missing key, which coincided with a report of missing medication for a resident. The Environmental Service Manager confirmed that extra keys had to be made because the previous unit manager had not returned her keys.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to ensure timely vaccination for two residents, leading to a deficiency in their immunization program. Resident #6, who had consented to all vaccines on December 2, 2022, was not offered additional pneumococcal vaccines despite being eligible. The Director of Nursing (DON) B acknowledged this oversight and had only recently audited residents' records for pneumococcal vaccination status, indicating a lapse in the vaccination tracking process. Resident #27's records showed inconsistencies, as the resident had consented to receive influenza and pneumonia vaccines on December 7, 2023, but the records inaccurately indicated a refusal without documentation of declination. Furthermore, the pneumococcal vaccine was delayed until June 25, 2024, despite the earlier consent. The DON was unable to explain these discrepancies, highlighting a failure in the facility's vaccination administration and documentation procedures.

Penalty

Fine: $48,86738 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 consistently educate, offer, and administer COVID-19 vaccines to residents and staff, as well as maintain valid declination documentation in the medical records. Specifically, for one resident, there was a discrepancy between the immunization record, which indicated a refusal of the COVID-19 vaccine without a recorded date, and a vaccine consent form that showed the resident's desire to receive the vaccine. The Director of Nursing (DON) was unable to explain this inconsistency or provide documentation of declination. Additionally, the facility did not ensure that staff were educated about or offered the COVID-19 vaccination, nor did it track the vaccination status of its staff. Interviews with the DON and the Infection Preventionist (IP) revealed a lack of familiarity with the process for tracking staff vaccinations and a cessation of offering the COVID-19 vaccine to staff. The facility's policy stated that COVID-19 vaccinations should be offered to healthcare personnel per CDC guidelines, and any declined vaccinations should be documented in the human resources file, which was not being followed.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to ensure that a working call system was available and within reach for a resident, identified as Resident #5, who was under hospice care and severely cognitively impaired. During an observation, the resident was found lying in bed with emesis on her arm, bed, floor, and fall mat, and her call light was not functioning. The unit manager was unaware of the resident's condition and the malfunctioning call light until it was brought to her attention by the surveyor. The call light was subsequently replaced with a working one. Further observations revealed that the resident's call light was not consistently within reach, as it was found under the bed and at the foot of the bed on separate occasions. Interviews with the Environmental Services Manager and the Unit Manager indicated that monthly inspections of call lights were conducted, but there was a lack of immediate reporting and resolution of call light issues. The facility's policy required staff to ensure call lights were within reach during each interaction and to report any problems immediately, which was not adhered to in this case.

Penalty

Fine: $48,86738 days payment denial

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

Summary

The facility failed to provide adequate care to prevent the development of pressure ulcers in a resident, resulting in the development of pressure ulcers on both heels. The resident, who was admitted with diagnoses including weakness, difficulty walking, and prediabetes, was identified as being at risk for pressure ulcers. Despite this, the resident's care plan included only general pressure interventions and was not updated to reflect the resident's individual status. The resident's practitioner noted heel pain and the presence of a blood blister on the left heel, indicating pressure-induced deep tissue damage. The resident's physical therapy notes also indicated a decline in participation due to bilateral foot pain. The facility's documentation and treatment administration records revealed several missed opportunities to document and implement prescribed treatments, such as floating the resident's heels off surfaces. Additionally, the use of unna boots, which are not indicated for pressure wounds on the heels, was ordered, further indicating a lack of appropriate care. Interviews with facility staff revealed that the resident frequently complained of being wet and soiled, and the Director of Nursing confirmed that the resident did not have any wounds upon admission. However, the resident's care plan and treatment records did not adequately address the identified pressure wounds, contributing to the development of pressure ulcers.