Regency At Fremont

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 call lights were within reach for 7 of 25 residents reviewed for accommodation of needs. During observations on 05/04/26, residents in beds 100-1, 100-2, 104-1, 105-1, 106-1, and 310-1 were found resting in bed with their eyes closed while their call lights were out of sight and out of reach, including hanging over the headboard, curled on top of a blanket at the foot of the bed, or sitting on the floor beside the bed. One resident in bed 208-2 was observed sitting in a wheelchair near the foot of the bed, slumped to the right with the privacy curtain pulled, and the call light was wrapped around the head of the bed and not reachable by the resident. During interview on 05/04/26 at 9:20 AM, a CNA stated that staff were expected to make sure call lights were within reach each time they entered a room. The facility policy titled Call Lights, last reviewed on 03/12/25, stated that when a resident is in bed or confined to a chair, the call light should be within easy reach 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 one resident’s drug regimen was free from unnecessary drugs by not adequately monitoring medication side effects, not prescribing medications with an adequate or correct indication, and not frequently monitoring or re-assessing medication effectiveness. The resident had a history of dementia, alcohol abuse with alcohol-induced mood disorder, and alcohol use with alcohol-induced persisting dementia. Family reported that she had been diagnosed with early onset Alzheimer’s disease based on APOE-e4 genetic testing and had progressively worsened before admission, including wandering, forgetfulness, and behavioral changes. After transfer from the hospital, the resident was ordered Memantine and Donepezil, and the hospital also started Seroquel and Ativan for behavioral symptoms. On arrival to the facility, she was combative, verbally abusive, physically lashing out, and placed on 1:1 supervision. She received Haldol for psychosis. The prescriber later increased Ativan to compensate for alcohol withdrawal, although the record did not show when her last alcohol use occurred, how much she had been drinking, or that she was in acute withdrawal. The Ativan order was increased without a stop date, and later Depakote was started and Donepezil was discontinued without the prescriber seeing or assessing the resident that day. Seroquel was also increased later without the prescriber seeing or assessing the resident, and the resident’s chart contained nursing gaps with no notes for multiple days. The resident’s record also showed inconsistent and incomplete monitoring. Orders required staff to document side effects twice daily for Seroquel, Ativan, and Depakote, but side effect documentation was not completed as ordered and was marked with check marks instead of the required entries. Behavior monitoring entries were also inconsistent, with many days showing no behaviors or only partial documentation. The resident experienced unwitnessed falls during the stay, and later notes documented fatigue, low energy, bladder incontinence, falls, weakness, confusion, tachycardia, and weight loss. A psychiatric specialist was requested but did not see the resident until days later. By the end of the stay, the resident became acutely ill with diarrhea, fever, weakness, abnormal lung sounds, shortness of breath, and severe hypoxia, and was sent to the hospital. The medication profile also reflected concurrent use of multiple CNS drugs and psychotropics, including Ativan, Depakote, Haldol, Risperdal Consta, and Seroquel.

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 promptly identify and act upon a resident’s change in condition following an alleged fall, resulting in delayed medical treatment for significant pelvic and sacral fractures. The resident was an older female admitted with existing sacral and pelvic fractures from a prior fall and Parkinson’s disease, and was cognitively intact with a BIMS score of 13. Her Kardex indicated she required one-person assist with a gait belt and walker for stand-pivot transfers and that staff were to report changes in normal behavior and decline in ADLs and continence. On the date of the alleged incident, a family member later reported that the resident told him she fell in the shower and that the aide told her not to tell anyone. The family member identified the aide as a specific CNA, who denied involvement or knowledge of a fall. There was no documentation in the EMR that this CNA notified licensed staff or management of a fall allegation on that date. Over the next several days, multiple changes in the resident’s condition occurred without appropriate assessment, documentation, or escalation. The family member observed that the resident had increased pain over the weekend and later increased confusion. A CNA reported finding a large bruise on the resident’s hip and stated she immediately notified an RN, but there was no documentation of a physical assessment, investigation, or notification of the provider or family regarding this new injury. Nursing notes documented confusion with hallucinations, pain to both lower extremities that improved with repositioning, and elevated blood pressure, leading to an ED visit where hospital documentation referenced a possible fall, but the facility did not obtain or scan the full hospital record into the EMR. Upon the resident’s return, there was no documented comprehensive assessment, no fall investigation, and no documented notification of the provider or management about a possible fall. Further changes in function and symptoms were documented but not acted upon as a change in condition. The resident’s functional status declined from one-person assist to needing two-person assist with a sit-to-stand device due to new onset sciatic pain, and a provider note documented right-sided sciatica that was not improving, leading to an order for gabapentin. Despite this, there was no documentation of a comprehensive assessment related to the new pain, the need for mechanical lift assistance, or the large bruise later identified. On a subsequent day, a nurse and the family member observed a large bruise and hematoma on the resident’s lower back and right thigh, and the resident reported that she had fallen in the bathroom several days earlier. An incident report was then completed, and management and the physician were notified, but this occurred several days after the alleged fall. During this period, documentation showed a marked increase in urinary and new bowel incontinence, a decline in ADL independence, and a downward trend in hemoglobin levels, yet there was no documented recognition or reporting of these as significant changes in condition. When the resident was ultimately transferred to the hospital, imaging revealed multiple new and worsened fractures, including comminuted bilateral sacral fractures with anterior subluxation of S1 on S2, pelvic fractures, and a large right buttock hematoma. Hospital consultants documented that she had cauda equina on presentation with no rectal tone and overflow incontinence, and that the fractures appeared new and worse compared to prior imaging, while facility records lacked timely assessments, investigations, and notifications consistent with the facility’s fall management policy and nursing standards cited in the report. The facility’s own fall management policy required licensed nurses to complete incident/accident reports, document in the medical record and 24-hour report, notify the attending physician and responsible party of falls, and communicate falls to the interdisciplinary team. Fundamentals of Nursing references cited in the report emphasized the need for comprehensive assessments, timely reporting of significant changes in condition, and accurate, complete documentation. In this case, the record showed no timely incident report or investigation on the date of the alleged fall, no documented assessments of the large bruise when first identified, no documented follow-up on the ED note referencing a possible fall, and no documented recognition or reporting of the resident’s new or worsening pain, functional decline, continence changes, and hemoglobin drop as changes in condition. The NHA confirmed that staff did not report the injury following facility policy, that management was not notified of the alleged fall and injury until several days later, and that staff should have identified and reported the injury during daily care based on its size and extent.

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 professional standards of nursing practice for medication and treatment administration for multiple residents. For one resident with an order for lorazepam twice daily, the controlled drug record showed only one dose dispensed on several days, while the medication administration record documented two doses as given, indicating a discrepancy in controlled medication handling and documentation. Another resident with an order for metoprolol, which included specific blood pressure and pulse parameters, received the medication even when the required assessments were not performed or when the parameters were not met, such as administering the drug when the systolic blood pressure was below 120 or the pulse was below 60, contrary to the physician's order. A third resident with congestive heart failure had a physician's order for daily weights and notification if weight increased by more than 2.5 pounds in 24 hours or 5 pounds in a week. Documentation showed missing daily weights, repeated use of a previous day's weight, and a failure to notify the provider when the resident's weight increased by more than 2.5 pounds in 24 hours. For another resident with a fentanyl patch order, the patch was not changed as scheduled, and the resident was observed with a medication cup containing multiple pills and two capsules left on the overbed table, with no assessment completed to determine if the resident could safely self-administer medications. Additionally, on the Oak and Maple Units, several resident treatments were not documented as completed during specific shifts. The facility's documentation practices did not align with professional standards, as required pre-assessment data and timely documentation of medication and treatment administration were not consistently performed. These findings were confirmed through observation, record review, and interviews with facility leadership.

Penalty

No penalty information released

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

Summary

Surveyors observed multiple failures in food storage, preparation, and sanitation practices within the facility's kitchen and kitchenettes. During the initial kitchen tour, a bag of sliced turkey was found in the refrigerator with unclear dating, and several expired yogurts were discovered in the Masterside Kitchenette refrigeration unit. In the J Wing Kitchenette, nutritional juice drinks and shakes lacked discard dates, and additional expired yogurts were present. The Certified Dietary Manager (CDM) was unable to confirm when certain items were thawed or when the ice machine was last deep cleaned by a vendor. Further inspection revealed unsanitary conditions and improper utensil storage. The inside mechanism of the ice machine had visible black accumulation, and clean utensil drawers contained scoops with dried food debris. The microwave had dried food debris on its interior top, and a disposable Styrofoam cup was found stored in a container of powdered milk. Five spatulas hanging over the preparation table were chipped and torn, yet still in use according to the CDM. Additional deficiencies included improper ice storage and maintenance. Ice chest coolers near the Masterside and J Wing Kitchenettes had visible water accumulation with no means for self-drainage, allowing water to mix with the ice. These findings demonstrate a lack of adherence to professional standards and FDA Food Code requirements for food safety, sanitation, and equipment maintenance, potentially affecting all residents consuming food from the kitchen.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that call lights were within reach for four residents with significant physical and cognitive impairments. Observations revealed that the call light devices for these residents were consistently placed out of sight and out of reach, such as on the floor near the foot of the bed, on a chair at the foot of the bed, or clipped to an over-bed light. Each of these residents had care plans specifying that call lights should be kept within reach to promote safety and allow them to request assistance as needed. The facility's own policy also required that call lights be accessible to residents in bed or confined to a chair, but this was not followed during multiple observations. Additionally, the facility failed to accommodate the durable medical equipment (DME) needs of a resident with complex physical disabilities, including hemiplegia, contractures, and chronic pain. Despite repeated requests and grievances from the resident, his guardian, and the Ombudsman, the facility did not ensure a proper DME assessment or timely submission of paperwork for an appropriate, comfortable, and safe wheelchair. The resident experienced ongoing discomfort and pain due to an ill-fitting wheelchair lacking necessary features such as a headrest and adequate pressure relief. Multiple communications documented the family's and Ombudsman's efforts to guide the facility through the insurance process, but the facility failed to follow through, resulting in prolonged unmet needs. Interviews with staff, including the Occupational Therapist, Social Worker, and Director of Nursing, confirmed awareness of the resident's discomfort and the family's dissatisfaction. Staff acknowledged the lack of a headrest and the resident's pain, and documentation showed that grievances were filed and marked as unresolved by the guardian. Despite these ongoing concerns, there was no evidence that the facility completed the necessary assessments or submitted required documentation to obtain a properly fitted wheelchair, nor was there documented follow-up from the Nursing Home Administrator on the grievances.

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 respond to grievances raised by the Resident Council, resulting in an ineffective forum for residents to present concerns and recommendations. The Resident Council President and other members consistently reported two main issues: delayed call light response and untimely meal service. Residents described situations where staff would turn off call lights and leave without meeting their needs, often not returning as promised. Additionally, residents reported long waits for meals, with some waiting over an hour in the dining room before being served. These concerns were repeatedly brought up at Resident Council meetings, but residents stated that the facility did not provide follow-up or feedback on actions taken to address the issues. Documentation reviewed from Resident Council meetings over a six-month period did not reflect any mention of the ongoing concerns about call light response or meal service delays, despite residents' claims that these were recurring topics. Only one individual concern about room cleanliness was documented and followed up. The Activities Director, who facilitated the meetings, stated that concerns were documented and addressed, but the records did not support this. The Nursing Home Administrator was unaware of the Resident Council's concerns, and residents reported that their issues were not revisited or resolved in subsequent meetings. Observations of the dining service confirmed significant delays in meal delivery, supporting the residents' complaints.

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 document the administration of controlled medications and did not ensure that controlled medications were administered according to provider orders for four residents. For one resident, temazepam was not documented as dispensed on the Controlled Substances Proof of Use form, despite being recorded as administered on the Medication Administration Record. Additionally, lorazepam was dispensed and documented prior to the start date of the order and after the order had expired, with no corresponding documentation of administration or a physician's one-time order in the medical record. Another resident had lorazepam dispensed on multiple occasions without an active order, and there was no documentation of administration or a physician's order for those instances. For two other residents, hydrocodone-acetaminophen and lorazepam were dispensed as indicated on the Controlled Substances Proof of Use forms, but there was no documentation on the Medication Administration Record that these medications were administered. The lack of documentation for as-needed medication administration impedes the ability to assess ongoing need and symptom control. The DON and NHA confirmed these medication administration and documentation errors during interviews, and facility policy requires medications to be administered per physician orders and documented accordingly.

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

Facility staff failed to safely transport six residents in wheelchairs by not ensuring the use of footrests during movement throughout the facility. Multiple observations documented staff, including CNAs and an activities aide, pushing residents in wheelchairs without footrests attached or without the residents' feet placed on the footrests. In several instances, residents' feet were observed dragging on the floor while being transported, and in one case, a resident was wearing grip socks while her foot dragged. These actions occurred in various locations, such as from dining rooms to nurses' stations, down hallways, and to resident rooms. The residents involved had significant medical histories, including Alzheimer's disease, unsteadiness on their feet, muscle weakness, history of falls, dementia, epilepsy, and left-sided weakness following a stroke. All residents reviewed for this deficiency were noted to be severely cognitively impaired, as indicated by low BIMS scores. Staff interviews confirmed that facility policy requires residents' feet to be securely on footrests when being pushed in wheelchairs, but this was not followed during the observed 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 provide dignified care and timely assistance to two residents who required help with toileting and mobility. One resident, who was non-weight bearing on both lower extremities and required assistance for toileting, reported that staff did not respond promptly to call lights, sometimes turning them off without providing the needed help. This resident experienced episodes of incontinence and humiliation after being told by staff to defecate in bed due to the unavailability of a bed pan, despite being continent and able to make his own medical decisions. The resident began wearing briefs out of concern that staff would not respond in time to his needs. Another resident, also cognitively intact and able to make her own medical decisions, reported similar issues with delayed call light response and staff turning off the call light without returning to assist. As a result, this resident experienced incontinence and emotional distress. Both residents' experiences were corroborated by their own accounts and observations during the survey, and the facility's policy required call lights to be answered promptly and not turned off until the resident's needs were met. Additionally, the facility failed to ensure effective communication and self-determination for a Spanish-speaking resident who was dependent on staff for all transfers and toileting hygiene. The medical record indicated that this resident was her own decision maker, but there was no communication care plan in place to guide staff in engaging her in her care. Documentation showed that staff and medical providers did not consistently use translation services, resulting in the resident being unable to communicate her needs or participate in care decisions, including pain management and reporting incidents such as falls.

Penalty

No penalty information released

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

Summary

A male resident with severe cognitive impairment, who was fully dependent on staff for all daily needs, was observed sitting in a broda chair at the dining room table with visibly wet pants from urine. This condition persisted for over an hour, as multiple observations noted the resident remained in the same state, both in the dining room and later when moved to the nurses station. The resident's sweat pants continued to be visibly wet in the crotch area until staff eventually took him to his room to change his clothing and provide peri-care. These observations indicate that the facility failed to maintain the resident's dignity by not promptly addressing his incontinence and ensuring he was clean and dry.

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 the Minimum Data Set (MDS) assessments for one resident who was receiving hemodialysis. According to the Resident Assessment Instrument manual, Section O is intended to document any special treatments, procedures, or programs, including dialysis, that a resident receives during the specified look-back period. Review of the facility's records and interviews confirmed that the resident regularly left the facility three times a week to receive dialysis treatment. Despite this, multiple MDS assessments for the resident, including admission and subsequent assessments, did not indicate that the resident was receiving dialysis. The MDS Coordinator/Registered Nurse verified that the dialysis treatment was not marked on the MDS, even though the resident was actively receiving it. This omission resulted in the resident's MDS assessments being inaccurate regarding their special treatments.

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 Spanish-speaking resident with bilateral leg amputations was admitted to the facility and was her own responsible party. Despite her language needs being documented in the medical record, there was no comprehensive communication care plan in place to guide staff on how to effectively communicate with her. The electronic medical record did not contain a care plan addressing her communication needs, and staff documentation indicated that the resident was unable to describe incidents, such as a fall, due to the language barrier. There was no evidence that translation services or Spanish-speaking staff were consistently utilized to facilitate communication with the resident. Medical provider documentation acknowledged the resident's exclusive use of Spanish and noted challenges in assessing her pain and obtaining her input during evaluations. The provider was not Spanish-speaking, and there was no indication that translation services were used during medical assessments. Interviews with facility leadership confirmed that, prior to a specific date, no communication care plan existed for the resident, and it was unclear if available Spanish-speaking staff had direct contact with her.

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 comprehensive nursing assessments were completed and did not identify or notify the provider of a change in condition for one resident with significant chronic respiratory conditions. The resident, a male with progressive multifocal leukoencephalopathy and a history of multiple hospitalizations for sepsis, aspiration pneumonia, and acute respiratory distress, required frequent monitoring and interventions, including suctioning and temperature management. The resident's care plan specifically instructed staff to observe for and report signs and symptoms of acute respiratory insufficiency and infection, and to document and communicate abnormal findings to the physician. Despite these instructions, after the resident's return from a recent hospitalization, there was no documentation of a provider assessment or a comprehensive respiratory assessment by licensed nurses. The last full set of vital signs was recorded on one date, with only sporadic temperature checks thereafter, even though the resident experienced a fever and was administered Tylenol. The provider was notified of the fever and instructed staff to manage it in-house, with the expectation of continued monitoring, but there was no evidence of ongoing temperature monitoring or further sepsis screening evaluations until the resident was found unresponsive and subsequently pronounced deceased. Interviews confirmed that the facility's nursing home administrator expected nurses to assess temperatures when administering Tylenol for fever and to complete respiratory assessments for residents returning from hospitalization due to respiratory illness. However, these assessments were not completed, and there was no provider assessment following the resident's readmission, despite the resident's complex medical history and recent acute changes in condition.

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 development of a facility-acquired pressure ulcer and did not follow its own policies and procedures regarding pressure ulcer care for one resident. Upon admission, the resident had no pressure ulcers and was assessed as low risk for developing them. However, a new stage II pressure ulcer developed on the resident's left heel during their stay. Documentation regarding the wound was inconsistent, with conflicting assessments about the stage and origin of the ulcer. The care plan was not updated with new interventions after the onset of the pressure ulcer, despite evidence of deterioration and changes in the wound's condition. Observations revealed that the resident's heels were resting on the footboard while sitting up in bed, which was not addressed in the care plan. The facility's policy required that preventative measures and care plan updates be implemented and documented for residents at risk or with pressure injuries, but these steps were not followed. Additionally, staff interviews indicated confusion about the resident's wound status and history, further highlighting lapses in assessment and care planning.

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 occurred when the facility failed to act upon a pharmacy recommendation regarding the administration of a psychoactive medication for one resident. The resident, who was admitted with non-traumatic brain dysfunction and had moderate cognitive impairment as indicated by a BIMS score of 10 out of 15, was prescribed Lorazepam as needed without a stop date. The pharmacy conducted a drug regimen review and recommended that as-needed non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documented the specific condition being treated, the rationale for the extended use, and the duration of the order. The physician accepted this recommendation in writing. Despite the physician's acceptance, the order for Lorazepam remained active beyond the recommended 14-day period without a documented stop date, specific condition, or rationale for continued use. Review of the electronic medical record confirmed that the pharmacy's recommendation was not implemented, and the resident continued to receive Lorazepam past the recommended stop date. The deficiency was acknowledged by the Director of Nursing after being informed of the oversight.

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 proper infection control practices during wound care, peri-care, and blood glucose monitoring for three residents. In one instance, an LPN performed surgical wound care on a resident with necrotizing fasciitis and diabetes, changing gloves without performing hand hygiene and allowing the tail end of the wound packing gauze to touch the resident's clean brief and leg. After completing the dressing change, the LPN removed her gown and gloves, fixed her hair without hand hygiene, and left the room to find hand sanitizer. The facility's policy required hand hygiene between glove changes and after glove removal, as well as preventing clean dressing materials from contacting unclean surfaces. In another case, a CNA provided peri-care to a male resident with severe cognitive impairment and total dependence, cleaning the perineal area in an incorrect sequence that could introduce microorganisms into the urethra. After care, the CNA did not sanitize the broda chair that had been in contact with the resident's urine-soaked clothing. Additionally, an LPN was observed performing a blood glucose test on a resident in a communal dining area, without providing privacy, contrary to facility policy and best practices. The DON confirmed that this practice was not acceptable and did not align with facility procedures.

Penalty

No penalty information released

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

Summary

The facility failed to conduct fire drills at unexpected times and under varying conditions as required by regulations 19.7.1.4 through 19.7.1.7. Record review on April 9, 2025, showed that first shift fire drills in the first quarter were held at similar times in the morning, specifically at 10:00 am and 10:30 am, while third shift drills in the first and second quarters were both conducted around 3:30 am and 3:40 am. This pattern indicates a lack of variation in the timing and conditions of the fire drills. The deficiency was confirmed through an interview with the facility Maintenance Director during the observation period.

Plan Of Correction

K712 Fire Drills Element 1: There have been no negative effects concerning residents related to the fire drills not being conducted at unexpected times, under varying conditions. Element 2: Residents that reside in the facility have the potential to be affected by this deficient practice. Element 3: The Maintenance Department was educated by the Nursing Home Administrator on conducting fire drills on all shifts at unexpected times, under varying conditions. Element 4: Facility fire drills will be audited monthly for 4 months to ensure completion at unexpected times, under varying conditions. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained 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 document a required battery test during the monthly inspection of its generators. Specifically, the monthly test did not include either the specific gravity fluids or the cold crank amperage for maintenance-free batteries, as required to ensure the operational condition of the generator cells. This omission was identified during a record review conducted on April 9, 2025, and was confirmed through an interview with the facility Maintenance Director at the time of observation. The deficiency pertains to non-compliance with NFPA 110, which mandates that such battery tests be part of the monthly generator inspection. The lack of documentation and testing could potentially affect all occupants and staff in the event of a failed generator battery during a main utility power loss, as the operational readiness of the emergency power source could not be verified.

Plan Of Correction

K918 Electrical Systems Element 1: Facility purchased tester for generator battery. Battery tested and is in operational condition. Element 2: Residents that reside in the facility have the potential to be affected by this deficient practice. Element 3: The Maintenance Department was educated by the Nursing Home Administrator on monthly generator inspections to include a documented battery test. Element 4: Facility generator checks will be audited monthly for 4 months to ensure monthly generator inspections include a documented battery test. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained compliance.

Penalty

No penalty information released

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

Summary

During an observation of the facility's main kitchen, it was found that the kitchen hood filter system located above the commercial stove and appliances had a filter that was partially out of position. The filter was observed resting on top of another filter, which resulted in the system not maintaining a tight seal as designed. This improper positioning of the filter compromised the system's ability to prevent grease-laden vapors from entering the plenum space above. The finding was confirmed through an interview with the facility Maintenance Director at the time of observation. No information regarding specific patients, their medical history, or their condition at the time of the deficiency was provided in the report.

Plan Of Correction

K0324 Cooking Facilities Element 1 The filter in the main kitchen hood system was serviced and adjusted to maintain a tight system for the prevention of grease-laden vapors to enter above into the plenum space. Element 2 Kitchen hood system was checked to ensure that all filters are placed and fitted appropriately to maintain a tight system. No other concerns were identified. Element 3 The Maintenance Department was educated by the Nursing Home Administrator on checking the hood system for proper filter placement, ensuring a tight system is in place. Element 4 Kitchen hood system will be checked for proper filter placement weekly for 4 weeks, then monthly for 3 months to ensure a tight system for the prevention of grease-laden vapors to enter above into the plenum space. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained compliance.

Penalty

No penalty information released

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

Summary

A deficiency was identified when, during an observation in the physical therapy area at the staff desk, a power strip was found plugged into a second power strip, with several items drawing power from this setup. This arrangement does not comply with NFPA 99 and NFPA 70 requirements regarding the use of power strips and extension cords in patient care areas. The improper use of power strips was confirmed through an interview with the facility Maintenance director at the time of observation. The report specifically notes that the power strips were not being used in accordance with the required safety standards, as outlined in the referenced NFPA codes, and that this practice could potentially affect 12 occupants and staff.

Plan Of Correction

K920 Power Cords and Extension Cords Element 1: Power strips in the Therapy Room were removed from service. Element 2: Residents that reside in the facility have the potential to be affected by this deficient practice. Element 3: The Maintenance Department was educated by the Nursing Home Administrator on completing checks within the facility to ensure that power strips and extension cords are not in use outside of temporary work being completed. Element 4: Facility rounds will be audited weekly for 4 weeks, then monthly for 3 months to ensure monthly power strips and extension cords are not inappropriately in use. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained 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 review and revise its facility-wide assessment to accurately reflect the current resident census and acuity. During an entrance conference, the Nursing Home Administrator (NHA) reported a current census of 93 residents, while the facility assessment was based on an outdated Resident Population Profile with an average daily census of 73 residents. Additionally, the Core Staffing and Personnel Audit attached to the assessment had not been reviewed since August 6, 2024. The assessment also failed to update the roles of the NHA and the Director of Nursing (DON), which had changed since July 10, 2024. The NHA, who had been in the position for 90 days, was unaware of the need to update the Facility Assessment.

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 protect a resident's right to be free from sexual abuse by another resident. Resident #1, who was admitted with diagnoses including dementia and a mood disorder, exhibited severe cognitive impairment and inappropriate sexual behaviors. These behaviors were documented in a mental health consult note, which included incidents of public masturbation and attempts to expose himself. Despite being on a care plan that required direct supervision when out of bed and 15-minute checks, Resident #1 was not adequately monitored. On the night of the incident, Resident #1 was found in Resident #2's room, engaging in non-consensual sexual contact. Resident #2, who was also severely cognitively impaired with a BIMS score of 00/15, was found naked and unresponsive to the situation. The staff member who discovered the incident, CNA B, reported that Resident #1 was pulling Resident #2's head towards his body. Despite the care plan interventions, Resident #1 was not under direct supervision at the time, and staff were unaware of his whereabouts. Interviews with staff revealed a lack of clarity regarding who was responsible for supervising Resident #1. Multiple staff members, including CNAs and an LPN, acknowledged that Resident #1 required direct supervision and 15-minute checks but were unable to account for his location or actions leading up to the incident. The facility's abuse prohibition policy, which mandates monitoring to ensure residents are free from abuse, was not effectively implemented, resulting in the failure to prevent the abuse incident.

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 monitor blood pressures and follow physician-ordered parameters before administering blood pressure medications to a resident, identified as R3, who was reviewed for medication parameter monitoring. R3, a resident with a history of hypertension and Torsades de Pointes, had specific physician orders to withhold medications such as amlodipine, lisinopril, and metoprolol if the systolic blood pressure was below 110 mmHg. Despite these orders, the medications were administered on multiple occasions when R3's blood pressure was below the specified threshold or when no blood pressure reading was obtained prior to administration. The Medication Administration Records (MARs) for R3 from November 1, 2024, to January 21, 2025, revealed numerous instances where blood pressure medications were given without adhering to the required monitoring. On several dates, the medications were administered even when the recorded blood pressure was below the threshold, such as readings of 92/56 mmHg and 106/58 mmHg. Additionally, there were multiple days when blood pressure readings were either not obtained at all or were taken several hours after the medications had been administered, contrary to the physician's orders. During an interview, the Nursing Home Administrator acknowledged the discrepancies in the MARs and the absence of blood pressure monitoring on certain days. The administrator noted that the pharmacy had removed the blood pressure documentation boxes from the MARs starting in December 2024, which may have contributed to the oversight. The failure to monitor and document blood pressure readings as per the physician's orders resulted in a deficiency, highlighting a lapse in the facility's medication administration process.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with severe intellectual disabilities, major depressive disorder, anxiety disorders, dysphagia, dementia, and late-onset Alzheimer's Disease. The resident, who was cognitively intact with a BIMS score of 14/15, was subjected to verbal and physical abuse by a CNA while receiving care. The abuse was witnessed by a Certified Nursing Aide in Training (CNAT), who reported the incident to Human Resources. The incident occurred when the CNAT requested assistance from the CNA to provide care to the resident. During the care, the resident was yelling, and the CNA responded by yelling back, using derogatory language, and placing her hand over the resident's mouth. The CNAT reported that the CNA used offensive language and covered the resident's mouth, which was corroborated by the CNAT's interview with Human Resources and the Assistant Director of Nursing. The CNA admitted to raising her voice and placing her finger over the resident's mouth but denied using offensive language. The facility's Abuse Prohibition Policy, which was last revised in September 2022, clearly states that residents should be free from all forms of abuse, including verbal and physical abuse. Despite this policy, the CNA's actions violated the resident's rights and the facility's standards of care. The incident was reported to the State Licensing Board as required by law, and the CNA was subsequently separated from employment due to the violation of the facility's work rules.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper labeling and dating of foods and documentation of food temperatures, affecting 70 residents receiving meals from the kitchen. During an initial tour of the kitchen, surveyors observed 12 cups of strawberry shortcake ice cream in Styrofoam cups, a peanut butter and jelly sandwich in a plastic bag, and approximately 20-8 oz cups of juice, all without labels and dates. The Dietary Manager confirmed that these items should have been labeled and dated. Additionally, a review of the time/temperature food preparation log revealed missing temperature recordings for coleslaw on one date and for the entire dinner meal on another date. The Dietary Manager was unsure why these temperatures were not recorded, acknowledging that they should have been completed. The 2017 FDA Food Code and the facility's own policies require that all perishable food items in refrigerators be properly dated, labeled, and stored in appropriate containers. The policies also mandate that food temperatures be taken and recorded for all Time/Temperature Control for Safety (TCS) foods at all meals. The failure to adhere to these standards increased the risk of contaminated foods and foodborne illness among the residents. The facility's Food Purchasing and Storage Policy and Food Temperatures Policy were not followed, leading to this 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 effectively maintain the outdoor dumpsters, affecting 70 residents. On 4/17/2024 at 10:20 AM, it was observed that the lids of two dumpsters, one for trash and one for cardboard boxes, were not closed. Later, at 1:32 PM, the Maintenance Assistant (MA) confirmed that the trash dumpster lid was stuck and could not be closed, while the cardboard boxes dumpster lid was closed. The Maintenance Director (MD) was unaware of the issue until informed by the MA and mentioned that the frame of the trash dumpster was bent, necessitating a call to the dumpster company for repairs. By 3:15 PM, the MD stated that the trash dumpster lid was fixed. During an interview on 4/18/2024, the Nursing Home Administrator (NHA) admitted that there was no policy regarding the outdoor dumpsters.

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 sufficient levels of nursing staff to meet the needs of residents, resulting in several incidents involving three residents. Resident #13, a male with Alzheimer's and other conditions, exhibited sexually inappropriate behaviors, including nudity and aggressive actions towards staff and other residents. Despite being on 15-minute checks, he was able to inappropriately touch a female resident, Resident #62, who has severe cognitive impairments. This incident was not properly reported or investigated as an allegation of sexual abuse by the staff or management. Resident #59, who also has severe cognitive impairments, was found inappropriately touching himself in the presence of Resident #62 in an activity room. This incident was reported to the Director of Nursing but was not considered an allegation of abuse, and no investigation was conducted. The facility's staffing levels were insufficient to monitor all residents adequately, leading to these incidents occurring without timely intervention. Interviews with staff revealed that the facility often operated with minimal staff, making it difficult to provide adequate supervision and care. Housekeeping staff also reported assisting with resident care due to the lack of sufficient nursing staff. The facility's failure to maintain appropriate staffing levels and adequately address and report incidents of inappropriate behavior and potential abuse compromised the safety and well-being of the residents involved.

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 for three residents, resulting in allegations of sexual abuse that were not reported to the State Agency. Resident #13, a male with Alzheimer's and other conditions, exhibited sexually inappropriate behaviors, including nudity and making sexual comments to female residents and staff. On multiple occasions, he was observed engaging in inappropriate behaviors, such as attempting to touch a female resident's groin and making sexually explicit comments. Despite these incidents, there was no evidence that these allegations were reported to the proper authorities or that an investigation was completed. Resident #62, a female with dementia and other conditions, was involved in an incident where Resident #13 attempted to touch her inappropriately. Housekeeping staff witnessed the incident and reported it to a Licensed Practical Nurse (LPN), but there was no follow-up or investigation documented. Additionally, Resident #59, a male with advanced dementia, was found inappropriately touching himself in front of Resident #62. This incident was reported to the Director of Nursing (DON), but it was not reported to the State Agency, and no investigation was conducted. Interviews with staff revealed that there were significant gaps in reporting and investigating allegations of abuse. Some staff members were unsure if incidents were reported to management, and others did not recall receiving abuse training. The Nursing Home Administrator (NHA) and DON both acknowledged that the incidents should have been reported and investigated but were not. The facility's failure to report and investigate these allegations of abuse resulted in a deficiency in ensuring the safety and well-being of the 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 ensure the protection of residents and thoroughly investigate allegations of abuse involving three residents. Resident #13, a male with Alzheimer's and other conditions, exhibited sexually inappropriate behaviors, including nudity and making sexual comments. Despite being on 15-minute checks, he was observed attempting to touch a female resident inappropriately. Staff did not report this incident as an allegation of sexual abuse, and no investigation was conducted. Additionally, there were multiple documented instances of Resident #13's inappropriate behavior that were not followed up with proper incident reports or investigations. Resident #62, a female with severe cognitive impairment, was involved in an incident where Resident #13 attempted to touch her inappropriately. Housekeeping staff witnessed the event and reported it to a nurse, but no further action was taken to investigate or report the incident as abuse. Another incident involved Resident #59 and Resident #62, both with severe cognitive impairments, being found with their hands down each other's pants. This incident was reported to the Director of Nursing, but no investigation was conducted, and it was not reported to the state agency. Interviews with staff revealed that there were significant gaps in reporting and investigating these incidents. Some staff members were unsure if incidents were reported to management, and others did not recognize the behaviors as potential abuse. The facility's Administrator and Director of Nursing were unaware of some incidents and did not follow through with required investigations and reports. Additionally, there were issues with staffing levels, making it difficult to monitor residents adequately, and some staff had not received proper abuse training.

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 comprehensive care plans for a resident, resulting in the potential for unmet care needs and impaired wound healing. The resident, who was admitted with diagnoses including unspecified dementia, adult failure to thrive, difficulty in walking, generalized muscle weakness, and a pressure ulcer of the right heel, was observed multiple times without the required heel protection boots. Despite an order for the boots to be worn every shift, the resident was frequently seen without them, both in bed and in a wheelchair. Observations revealed that the resident's heels were often in direct contact with the mattress or wheelchair foot cradle, contrary to the care plan and medical orders. Interviews with staff confirmed that the resident's heels were not consistently offloaded as required. The care plan and Kardex did not accurately reflect the need for the boots to be worn while the resident was in the wheelchair, leading to inconsistent application of the prescribed treatment. The medical record indicated ongoing issues with the resident's right heel pressure ulcer, which required the use of heel suspension/protection devices. Despite documentation showing the boots were signed out as in place, observations and staff interviews revealed that the boots were not consistently used. The facility's failure to ensure the resident's care plan was comprehensive and accurately implemented contributed to the deficiency in care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that opened medications were appropriately labeled and that expired medications were disposed of, as observed in two of three medication carts reviewed. During a review of the Oak Hall Medication Cart, an opened Lantus Solostar Insulin Pen for a resident was found without an open date, making it impossible to determine if it had been used beyond the recommended 28 days. The Registered Nurse/Unit Manager confirmed the issue and disposed of the pen. Similarly, the Maple Hall Medication Cart contained an opened Fluticasone Propionate Inhaler and a Latanoprost Ophthalmic Solution bottle, both lacking open dates. The Licensed Practical Nurse confirmed the medications were active but could not verify their open dates, leading to their disposal due to potential expiration concerns. The medical records of the affected residents showed active orders for the medications in question, with regular administration documented. The Director of Nursing stated that the facility's policy required nurses to label medications with the open date upon initial use and to check expiration dates before each administration. However, the review revealed that this policy was not consistently followed, resulting in the presence of potentially expired medications in the carts. The facility's Medication Storage Guidance form also indicated specific discard timelines for these medications, which were not adhered to in these instances.