The Laurels Of Kent

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

Keep all essential equipment working safely. The facility failed to keep the kitchen dish machine in a state of repair that allowed it to meet its operational requirements. On 2/22/26 at 10:00 AM, surveyors observed that the dish machine was not reaching proper temperature or pressure for the wash and rinse cycles. The machine data plate listed minimum requirements of a wash temperature of 150F-160F, a rinse temperature of 180F from the manifold for a contact temperature of 160F, and a final rinse pressure of 20 psi. During five observed cycles, the wash gauge read 140F-146F, the rinse pressure gauge read 35-50 psi, and the dish plate thermometer showed contact temperatures of 137F-150F. Review of the Dishmachine Temperature / Sanitizer Log showed the morning rinse temperature was recorded low with no corrective action noted, and eight recorded hot water sanitizing rinse temperatures were below the required 180F from the manifold. On 2/22/26 at 11:15 AM, a follow-up kitchen tour found the dish machine still was not meeting the minimum manufacturer requirements, and a CDM ran a thermo-tape test strip that did not trigger the required 160F contact temperature.

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 consistently honor resident food preferences for 5 of 11 residents reviewed for dining. During observations and interviews, residents were served foods that were listed as dislikes on their tray tickets, including iceberg lettuce and tomatoes for one resident who stated she hated tomatoes and did not care for iceberg lettuce, and an open-faced turkey sandwich on white bread and mixed vegetables that included lima beans for the same resident, who reported frustration when served items on her dislike list. Another resident with a BIMS score of 12 was served mixed vegetables that included peas, carrots, and beans listed as dislikes, stated the food made her sick, and did not eat the vegetables. Two additional residents were also served mixed vegetables despite documented dislikes for green beans or green peas, and each left the vegetables untouched. A cognitively intact resident with diagnoses including depression and anxiety reported that some meals were terrible because of the combinations of foods served and being given items she disliked, and that she would not eat the meal and would wait for the next meal. Her care plan identified nutritional and/or dehydration risk related to being allergic to oranges and leaving more than 25% of food uneaten at mealtimes, and included an intervention to provide diet preferences and offer substitutes as needed. Her food preference assessments listed dislikes including gravy, lima beans, and corn, and her tray tickets also listed multiple dislikes, including a note for no beans of any kind. Despite these documented preferences, she was served an open-faced turkey sandwich with mashed potatoes and gravy, mixed vegetables, a beef taco with cheese and tomato, Spanish rice, and refried beans. She stated she would not eat the gravy or foods that were all mixed up, and she did not like the Spanish rice or refried beans. The facility's Food Preferences policy stated that food preferences would be identified on tray tickets to ensure residents were provided with appropriate food items, and the Dietary Manager stated cooks were responsible for referencing tray tickets before plating meals to ensure residents were served items consistent with their diet and preferences.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to scheduled pain management. A cognitively intact resident with chronic pain, including right knee and back pain, had a long-standing order for oxycodone 10 mg at bedtime for chronic pain, with no PRN pain medications. The resident reported that her pain was very bad without the scheduled dose and that she relied on one pain pill at bedtime. In January, the resident stated that the facility did not have her pain medication in the building, the pharmacy would not send it, and staff were obtaining doses from a backup supply box. She reported that on one night she did not receive her pain medication at all, her pain escalated to 10/10, was unbearable, and she did not get much sleep. Record review showed the last tablet from the resident’s primary oxycodone supply was given on 1/6, and backup oxycodone 10 mg tablets were pulled on 1/7, twice on 1/9, and on 1/10 and 1/12, with no backup tablet pulled on 1/8 or 1/11. The January MAR documented the 10 mg oxycodone as held on 1/8 with a note that a new prescription was needed and that the physician was aware. The LPN who made this entry later stated she likely held the dose because it was not available, then gave it late from the backup supply but failed to document the late administration or correct the original “held” entry. The DON confirmed that the last regular tablet was given on 1/6, that backup doses were used on specific subsequent days, and that there was no clear source for the dose documented as given on 1/11, concluding it appeared the resident did not receive a dose that night despite documentation indicating otherwise. Pharmacy records showed a new supply of oxycodone was not delivered until later in the month, supporting that there was at least one missed scheduled dose of oxycodone associated with the resident’s reported severe pain and sleep difficulty.

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 issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for Medicare Part A services for two residents, Resident #73 and Resident #92, when their Medicare-covered skilled nursing benefits changed before all benefit days were exhausted. Review of Resident #73’s SNF Beneficiary Protection Notification Review showed a last covered day of Part A service of 11/12/25, that the facility/provider initiated discharge from Medicare Part A services when benefit days were not exhausted, and that a SNF ABN, Form CMS-10055, was not provided, with no explanation recorded. A similar review for Resident #92 showed a last covered day of Part A service of 2/19/26, that the facility/provider initiated discharge from Medicare Part A services when benefit days were not exhausted, and that a SNF ABN was not provided, with no explanation recorded. In interview, the NHA confirmed the documents were accurate and that both residents had not received the required ABN notifications. The NHA stated the facility had recently hired a new BOM responsible for providing notifications when insurance benefits changed, and the BOM stated she had forgotten to issue the ABN notifications when the residents’ benefits changed.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision for a resident with mild cognitive impairment, a history of falls, and a BIMS score of 8/15 indicating moderate cognitive impairment. The resident’s care plan identified him as a fall risk due to deconditioning, fear of falling, gait and balance problems, unsteadiness, impaired mobility, and a history of falling. The care plan and Kardex also directed that he require supervision or touching assistance with one helper for transfers and ambulation with a 4-wheeled walker, and the Kardex noted that he continued to ambulate without assistance. During observation, the resident was seen standing and moving around his room and doorway area without staff intervention. He was observed manipulating his walker while standing between the footrests of his wheelchair, with his urine collection bag still hanging from the wheelchair. Later, he was observed standing in the doorway and hallway, unsteady and turning in circles, and at one point he grabbed the wall handrail to steady himself after becoming off balance. Although staff members were present in the hallway and at the nurses’ station and appeared to observe him, none intervened while he remained standing and unsteady. Interviews and record review showed the resident had 5 documented falls since admission. Family reported several falls, and multiple staff members described him as a fall risk with an unsteady or shuffling gait. Some staff stated he was independent or could transfer and ambulate without assistance, while therapy staff stated he was unsafe to transfer or ambulate independently and required touching assistance or one-person assist with his walker. The care plan update book available to staff also reflected that he required supervision or touch assistance with ambulation, yet staff observed him standing and moving without assistance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review was acted upon for Resident #2, who had diagnoses including schizophrenia and bipolar disorder and was cognitively intact with a BIMS score of 14. Review of the December 2025 medication regimen review showed the pharmacist identified an irregularity and recommended decreasing Escitalopram from 20 mg to 10 mg daily because the dose exceeded the maximum recommended daily dose for an older adult and included a note about QT prolongation risk. The document did not include a physician/provider response. During record review and interviews, the DON reported she could not initially locate the irregularities report, then later found the pharmacist’s recommendation, but the facility provider had not acknowledged it. The DON also reported that BCS provider notes indicated the resident had been receiving an incorrect dose of Escitalopram while in the hospital in November 2025 and that the same dose was continued after return to the facility. The resident’s current physician order remained Escitalopram Oxalate 10 mg, give 2 tablets by mouth once daily for bipolar disorder.

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 accurate documentation in the medical records for two residents, resulting in inaccurate documentation of services provided and inaccurate physician notes. For one resident with diagnoses of right knee pain and chronic pain, the record showed a scheduled oxycodone order for bedtime pain management, but the MAR and eMAR documentation did not match what actually occurred. The resident reported that the medication was unavailable in the building at times, that staff retrieved it from the backup supply box for several days in January, and that one night she did not receive the pain medication at all. For that resident, the MAR documented the oxycodone as held on one date with a nurse’s note stating a new prescription was needed and the physician was aware. The LPN later stated she recalled calling the on-call provider for a new script and believed she documented the medication as on hold because it was not available, then gave it later from the backup box without documenting the late administration. The DON confirmed the last tablet from the resident’s supply had been given earlier, that the chart showed a dose as held with no late-entry documentation of administration, and that another documented dose appeared to have been entered even though the medication source could not be verified. The DON stated the documentation was inaccurate. For a second resident with schizophrenia and bipolar disorder, the current physician order was for escitalopram 20 mg daily, but the provider visit notes listed escitalopram 10 mg daily from the facility medication list. The DON confirmed the resident’s current order was for two 10 mg tablets and had not changed since return from the hospital, while the provider note reflected a different dose. The report states this information was inconsistent with the resident’s current physician orders.

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 enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.

Penalty

No penalty information released

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

Summary

The facility failed to monitor and prevent resident-to-resident sexual abuse among several residents with severe cognitive impairments and guardianship status. Multiple incidents were documented where residents with limited or no capacity to consent were found engaging in sexual activities with other residents. In several cases, staff observed or were informed of inappropriate sexual contact, such as fondling or oral sex, but did not consistently report these incidents to the abuse coordinator or follow up to determine if proper consent had been obtained from guardians for such interactions. For example, one resident with a traumatic brain injury and severe cognitive impairment was found in another resident's room, partially undressed, with the other resident also partially undressed and fondling her. Staff had previously observed these two residents together and had redirected them, but did not seek or document guardian consent for their relationship until after the incident occurred. In another case, a resident was observed groping another resident's breasts in a public area, but the incident was not reported or documented as abuse, and there was no evidence that guardian consent for sexual activity had been obtained or clarified beyond holding hands. Additionally, there were incidents involving residents with full guardianship engaging in sexual acts, such as oral sex, where one guardian explicitly did not consent to sexual activity, only to limited physical affection like holding hands and kissing. Despite this, staff did not report the incident to the state agency, did not conduct an investigation, and did not follow up with the residents or their guardians. The facility's own abuse prohibition policy defines sexual abuse as non-consensual sexual contact of any type and requires monitoring and evaluation of residents' capacity to consent, but these procedures were not followed in the documented cases.

Plan Of Correction

F600 Free from Abuse and Neglect Resident #101 still resides in the facility. Resident does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #102 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #104 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #105 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Residents who appear to be in a relationship have the potential to be affected. Residents who appear to be gravitating towards a relationship will be met with to discuss what level of relationship to have. If resident has a guardian or DOPA, they will be met with to discuss what level of relationship they permit for the residents to have. Any concerns identified will be addressed immediately. Staff have been re-educated on the Abuse Prohibition Policy. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Abuse Prohibition Policy was reviewed by the QA committee and deemed appropriate. Management team will complete quality rounds to evaluate for inappropriate sexual interactions weekly x 4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further recommendations. Administrator is 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 ensure that staff implemented the abuse policy by immediately reporting allegations of abuse to the abuse coordinator for four residents who were reviewed for abuse. Multiple staff members, including RNs, LPNs, and CNAs, observed or were made aware of incidents involving sexual contact or interactions between cognitively impaired residents, but did not report these incidents to the abuse coordinator as required by facility policy. In several cases, staff were unsure if the residents involved had the capacity to consent or if their guardians had provided consent for sexual relationships, yet no immediate reporting or investigation was initiated. Specifically, one RN observed a resident groping another resident's chest in a lounge area but did not document or report the incident, stating she was unaware of the need to report it to the abuse coordinator. Another LPN witnessed similar behavior and also failed to report, believing that documentation in nursing notes was sufficient. In another incident, a CNA found two residents engaged in a sexual act, reported it to the unit manager, and the DON was notified, but the abuse coordinator was not informed, and no follow-up investigation was conducted. The DON confirmed awareness of the incident but did not report it, rationalizing that the residents had a longstanding relationship. All residents involved were documented as severely or moderately cognitively impaired and had full guardianship in place, indicating a lack of capacity to independently consent to sexual activity. The facility's abuse prohibition policy clearly requires immediate reporting and investigation of all allegations of abuse, including resident-to-resident sexual contact, especially when capacity to consent is in question. Despite this, staff failed to follow policy, resulting in unreported incidents and a lack of appropriate investigation or intervention.

Plan Of Correction

F0607 Develop/Implement Abuse/Neglect Policies Resident #103 still resides in the facility. Resident does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #104 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #105 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #106 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Residents who appear to be in a relationship have the potential to be affected. Residents who appear to be gravitating towards a relationship will be met with to discuss what level of relationship to have. If resident has a guardian or DOPA, they will be met with to discuss what level of relationship they permit for the residents to have. Any concerns identified will be addressed immediately. Staff have been re-educated on the Abuse Prohibition Policy. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Abuse Prohibition Policy was reviewed by the QA committee and deemed appropriate. Management team will complete quality rounds to evaluate for inappropriate sexual interactions weekly x 4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further recommendations. Administrator is 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 develop and implement comprehensive, person-centered care plans for multiple residents who were involved in romantic or sexual relationships with other residents. Several care plans were either not initiated in a timely manner or lacked specific interventions and boundaries regarding the relationships. For example, one resident with cognitive communication deficit and major depressive disorder was involved in an incident of inappropriate sexual behavior with another resident, but his care plan was not updated until a week after the incident and did not address boundaries for the relationship. Another resident with muscle weakness and adult failure to thrive had a care plan that did not address his relationship with a specific female resident, despite documented episodes of hypersexuality and staff observations of inappropriate physical contact. Similarly, a resident with cognitive communication deficit and depression had a care plan that was only recently initiated and did not specify boundaries for her relationship with a male resident, even after staff witnessed inappropriate touching in public areas. Staff interviews confirmed a lack of awareness regarding established boundaries for these relationships, and social services staff admitted to forgetting or missing updates to the care plans. Additionally, two residents with dementia, depression, and cognitive communication deficits were in a long-term relationship involving sexual interactions, but their care plans were not updated to reflect boundaries or interventions until much later. Staff, including CNAs and nurses, reported not knowing what boundaries were in place and relied on care plans for this information, which were not kept current. The facility's own care planning policy requires individualized, resident-centered plans that communicate needs to direct care staff, but this was not consistently followed, resulting in unmet care needs and the potential for negative outcomes.

Plan Of Correction

F656 Develop/Implement Comprehensive Care Plan Resident #102 still resides in the facility. Care plan was reviewed and updated as needed. Resident #103 still resides in the facility. Care plan was reviewed and updated as needed. Resident #104 still resides in the facility. Care plan was reviewed and updated as needed. Resident #105 still resides in the facility. Care plan was reviewed and updated as needed. Residents who appear to be in a relationship have the potential to be affected. Residents who appear to be gravitating towards a relationship will be meet with to discuss what level of relationship to have and have been care planned. If resident has a guardian or DOPA, the will be meet with to discuss what level of relationship they permission for the residents to have and have been care planned. Any concerns identified will be addressed immediately. IDT has been re-educated on the Care Plan Policy. Care Plan Policy was reviewed by the QA committee and deemed appropriate. IDT will meet weekly to review residents who appear to be in a relationship care plans for any changes needed weekly x 4, then monthly and findings will be reported to QA committee for further recommendations. Administrator is 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 occurred when the facility failed to implement and monitor interventions, treatments, and assessments necessary to prevent and manage pressure ulcers for a resident at risk. The resident, who had diagnoses including muscle weakness and diabetes mellitus, was dependent on staff for mobility and personal care and was identified as being at risk for pressure ulcers. Despite this, documentation shows that staff did not consistently assess, report, or initiate timely treatment for new wounds, specifically on the resident's sacrum and right ear. Initial signs of skin breakdown were documented, but no treatment orders were initiated for several days, and there was a lack of communication among staff and with the facility's provider and DON regarding the resident's condition. Multiple staff interviews revealed that several CNAs and nurses observed significant wounds on the resident's coccyx and right ear, but these findings were not promptly or adequately reported or addressed. Nursing documentation was inconsistent, with some assessments failing to note the presence of wounds, and some staff not following up on abnormal findings. The facility's care plan and skin management policy required regular assessments and prompt notification of new skin impairments, but these protocols were not followed. The resident's wounds worsened, and there was a delay in both provider assessment and the initiation of appropriate wound care treatments. As a result of these failures, the resident developed unstageable pressure ulcers on the sacrum and right ear, which progressed to infection, sepsis, and required hospitalization. The sacral wound ultimately led to osteomyelitis and gangrene, necessitating surgical intervention. Interviews with facility leadership confirmed a lack of awareness and oversight regarding the resident's wounds, and documentation review showed that required notifications and interventions were not completed in accordance with facility policy.

Plan Of Correction

F686 Treatment/Services to Prevent/Heal Pressure Ulcer Resident #3 readmitted to the facility on 4/17/25. Skin assessment completed: Stage 4 pressure to sacrum and healed pressure injury to right ear. Care plan updated and currently being followed by the wound certified NP. Residents who reside in the facility have the potential to be affected. Skin sweep completed. Any concerns were addressed immediately. Nursing staff re-educated on Skin Management program. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Skin Management policy was reviewed by QA committee and deemed to be appropriate. The DON and/or designee will review Clinical Alerts, PCC dashboard, physician orders, and complete skin assessments weekly x 4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further review and recommendations. Administrator is 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 a staff member failed to interact with a resident in a dignified and respectful manner. The resident, who has Down syndrome, unspecified dementia, and a history of severe cognitive impairment, was observed calling out, moaning, and crying in her room. During this time, a housekeeping staff member entered the room, asked what the resident needed, and, upon not receiving a clear response, told the resident, "We're not just gonna sit and cry," instructed her not to call out and to use her call light, and then left the room after one to two minutes. The staff member did not offer any diversionary activities or seek assistance from nursing staff, despite the resident's ongoing distress. The resident later expressed negative feelings about the interaction, indicating that the staff member had spoken to her in this manner before. The staff member admitted to making the statement and acknowledged that it sounded harsh, but justified it as preferable to yelling. The staff member also reported that other staff sometimes used a harsh tone with the resident when she called out frequently, although she could not provide specific details. The resident's care plan included interventions for behavioral issues such as yelling and crying, recommending diversional activities and supportive, nonpharmacologic interventions, none of which were implemented during the observed incident. Facility policy requires staff to interact with residents in a way that maintains and enhances their dignity and self-worth. The staff member's actions did not align with this policy or with the resident's care plan, as the interaction lacked supportive responses and failed to provide recommended diversional activities. The incident was confirmed by both the Director of Nursing and the Nursing Home Administrator as inappropriate and not in accordance with facility expectations for resident interactions.

Plan Of Correction

F550 Resident Rights/Exercise of Rights Resident #9 still resides within the facility. Social Services followed up with resident and has had no emotional or mental effects from the interaction. Housekeeping staff F received 1:1 education. Residents who reside within the facility have the potential to be affected. Inter-viewable residents were queried regarding Resident Rights. Any concerns were addressed immediately. Staff were re-educated on Resident Rights policy. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Resident Rights policy was reviewed by QA committee and deemed to be appropriate. Management team will complete quality rounds to evaluate for inappropriate interaction by staff members weekly x4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further review and recommendations. Administrator is 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 timely report an injury of unknown origin to the State Agency for a resident with severe dementia, depression, anxiety, high blood pressure, heart disease, and muscle weakness. The resident, who had a moderate cognitive impairment, was found to have a large bruise on her right inner thigh, which was first noticed by a family member. The family member reported the bruise to the facility staff, but the facility did not have an explanation for the injury. Despite the family member's concern, the bruise was not reported or investigated by the facility. The facility's records revealed that the resident had a fall five days prior to the bruise being identified, but no injuries were noted at that time. The Director of Nursing and the Administrator acknowledged that the bruise was not reported to the State Survey Agency. Additionally, a Registered Nurse indicated that an incident report should have been completed for any new injury or bruise of unknown origin, but no such report or investigation was conducted for the bruise on the resident's thigh.

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 thoroughly investigate an injury of unknown origin for a resident with severe dementia and other health conditions, resulting in an incomplete investigation. A family member noticed a large bruise on the resident's right inner thigh during a visit and reported it to the facility. The facility had no explanation for the bruise, and the family member expressed concern that it was neither reported nor investigated. The resident had a history of agitation and self-transferring, which the Director of Nursing believed could have caused the bruise. However, there was no incident report or investigation conducted regarding the bruise. The resident's medical records indicated a fall five days prior to the bruise being identified, but no injuries were noted at that time. A total body skin assessment conducted two days after the fall did not reveal any new skin issues. Despite the facility's policy requiring an incident report for new injuries of unknown origin, no such report was completed for the bruise. Interviews with staff confirmed that management was responsible for investigating such incidents, yet no investigation was documented for the bruise on the resident's thigh.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurate medical records for two residents, resulting in discrepancies in personal hygiene documentation and dental care follow-up. For one resident, observations revealed poor personal hygiene, including long and dirty nails, overgrown facial hair, and greasy hair. Despite these observations, the resident's personal hygiene task record indicated no refusals of care, and daily tasks were marked as completed, which was inconsistent with a CNA's report that the resident refused grooming. The social worker was unaware of any refusals, as they were not documented in the medical record dashboard. For another resident, a family member reported a broken tooth that required dental attention. Although the Director of Nursing (DON) was informed and assessed the resident, finding no issues with pain or eating, the resident was not referred to a dentist, and the assessment was not documented. Consequently, the resident was not on the list for the upcoming dental visit, and the Nursing Home Administrator was not informed of the need for dental 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 post the required nurse staffing information on a daily basis for all 98 residents, resulting in a lack of available staffing information for residents and visitors. During observations and reviews of the Report of Nursing Staff Directly Responsible for Patient Care document in the main entryway on two consecutive days, it was found that the total hours columns were not filled in. In an interview, the Medical Records/Scheduler (MRS) responsible for posting the daily staffing report admitted to only recording the number of staff and was unaware that the total hours worked needed to be included. Additionally, the Nursing Home Administrator (NHA) also reported being unaware that nursing hours needed to be reflected on the posting.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision and accurately implement the elopement policy for three residents, resulting in the potential for injury. Resident #203, who was cognitively impaired and had a history of stroke and seizure disorder, was able to leave the facility unsupervised. The receptionist, who was newly hired and had only received one day of orientation, mistakenly allowed the resident to exit the building, believing he was permitted to do so. The resident was later found walking on the sidewalk by a staff member driving to work, who then alerted another staff member to retrieve the resident and bring him back to the facility. The facility's documentation and assessments for Resident #203 were inconsistent and inaccurately documented. Despite having a wanderguard bracelet and being identified as at risk for elopement, the resident's elopement risk assessments were not accurately completed. The resident's care plan for elopement was only initiated after the incident occurred. Additionally, the facility's review revealed that several other residents had been inaccurately assessed for elopement risk, leading to inappropriate use of wanderguard bracelets. Residents #208 and #209 also had inconsistencies in their elopement risk assessments. Both residents had orders for wanderguard bracelets despite their assessments indicating no risk for elopement. The facility's policy on elopement required accurate documentation and regular reassessment of residents' elopement risk, which was not followed in these cases. The failure to accurately assess and document elopement risk, along with inadequate staff training and supervision, contributed to the deficiencies identified in the report.