The Manor Of Farmington Hills

Penalty

No penalty information released

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

Summary

A resident with severe cognitive impairment, dementia, and a history of significant weight loss was assessed as requiring 1:1 feeding assistance during meals, as documented in the care plan and physician orders. Despite this, the resident was left unsupervised with a meal tray during lunch in the dining room. The tray was placed in front of the resident without a staff member present to provide the required 1:1 assistance. Multiple staff interviews and documentation revealed that no one was directly assisting or supervising the resident at the time the choking incident occurred. The resident began to choke on corned beef, and the event was not immediately witnessed by staff assigned to provide feeding assistance. When the choking was noticed, staff responded with chest thrusts, back blows, suctioning, and oxygen administration, but the resident ultimately expired shortly thereafter. Interviews with staff, hospice personnel, and the resident's family indicated ongoing concerns and previous reports that the resident was not consistently receiving the required 1:1 feeding assistance, despite repeated notifications to facility administration. The facility's investigation into the incident was incomplete, lacking thorough documentation of staff interviews and a clear timeline of events. There was no evidence that all potential witnesses were interviewed or that a comprehensive root cause analysis was conducted. The facility's own policy required documentation and interviews for incidents and accidents, but these steps were not fully carried out. The failure to provide the ordered 1:1 feeding assistance and to conduct a thorough investigation contributed to the deficiency cited.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and goals of the resident. Specific details regarding the resident’s medical history and condition at the time of the deficiency were not provided in the report.

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 timely admission orders and nursing assessments for two residents upon admission, resulting in missed medication administration. For one resident with diagnoses including Type 2 Diabetes and Congestive Heart Failure, the hospital discharge orders listed multiple medications to be administered upon admission. However, only two medications were transcribed into the facility's physician order summary, and the resident did not receive any medications during their stay. Additionally, there was no nursing assessment completed at the time of admission for this resident. For another resident admitted in the evening with diagnoses of pneumonia, diabetes, heart disease, and high blood pressure, hospital discharge instructions required administration of night-time medications, including atorvastatin and Lantus insulin. Although these medications were ordered in the facility's system, the start dates were set for the day after admission, resulting in the resident not receiving their scheduled night-time medications on the day of admission. The DON confirmed that the expectation was for nursing staff to complete initial assessments and transcribe medication lists promptly upon admission, which did not occur in these cases.

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 ensure that a resident's call system was operational. The resident, who had diagnoses including dysphagia, end stage renal disease, and congestive heart failure, required assistance with most activities of daily living and had intact cognition. The resident reported that their call light was not answered in a timely manner, sometimes waiting hours or not being answered at all. During observation, the resident activated their call light to request water, but after 45 minutes, no staff had responded, and the indicator light above the doorway was not illuminated. A Certified Nursing Assistant confirmed that the call light button was working, but the indicator light was out, so staff were unaware of the resident's request. The CNA stated that the call light had been broken all weekend and that there was no maintenance staff available on weekends. The Maintenance Director later explained that the batteries in the call light system were depleted and needed replacement, but maintenance was not notified of the issue until the following morning. Facility policy required staff to notify maintenance if a call light was not working, but this procedure was not followed.

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 an LPN brought their 15-year-old daughter onto the 300 Hall unit during their shift, allowing her to be present while preparing and administering medications, as well as providing resident care. The daughter was introduced to other staff, escorted the LPN into resident rooms, and observed the LPN taking a resident's blood pressure and administering medications to residents, including a male resident in the hallway. The LPN admitted to asking a female resident for permission for her daughter to observe care and acknowledged the inappropriateness of the situation, recognizing it as a violation of HIPAA regulations. Multiple staff members confirmed the daughter's presence and involvement, and video footage corroborated that the daughter was at the medication cart, observed medication administration, and was behind the nurse's station desk. The Nursing Home Administrator and Director of Nursing reviewed the footage and acknowledged that the LPN's actions had the potential to violate resident privacy and confidentiality of protected health information (PHI), as required by federal regulations.

Plan Of Correction

F-583 ELEMENT I Residents residing on Unit 300 hall (short stay rehab unit) on May 24, 2025, no longer reside in the facility. LPN “D” is no longer employed at the facility. ELEMENT II Residents residing within the facility have the potential to be affected. Residents residing on Unit 300 hall with the potential for unauthorized disclosure of protected health information had no negative effects due to this practice. Rounds were made throughout the facility to validate that no HIPAA-related information is discussed or visible in non-confidential areas; no concerns were noted. ELEMENT III The facility policies with respect to HIPAA, Standard of Nursing Practice, and Notice of Privacy were reviewed and deemed appropriate. Active staff were re-educated on the facility's policy regarding HIPAA to ensure compliance with maintaining personal privacy and medical records in accordance with CFR (s): 483.10(h)(1)-(3)(i)(ii). In addition, the professional license nurses were re-educated on the Standard of Nursing Practice. ELEMENT IV The DON/designee will audit the resident areas to validate that no HIPAA-related information is discussed or visible in non-confidential areas weekly for 4 weeks and monthly for 2 months. Any areas of concern will be addressed immediately. Findings from the audit will be brought to the Monthly QAPI Meeting for further review and recommendations. The DON is responsible for obtaining and maintaining compliance.

Penalty

Fine: $56,905

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 new wounds, provide timely wound care, and accurately document new skin impairments for two residents. One resident, with diagnoses including peripheral vascular disease, dementia, and malnutrition, was at high risk for skin breakdown and required staff assistance for care. Despite care plans specifying weekly head-to-toe skin assessments and immediate reporting of new skin issues, there were significant lapses in documentation and assessment. Multiple wounds, including on the right lateral hip, heel, toes, lateral ankle, and lateral foot, were not identified or treated in a timely manner. There were gaps in weekly skin assessments, and no treatment orders or documentation of wound care were present until after the wounds were discovered by the resident’s daughter and the wound care coordinator. Another resident, dependent on staff for all activities of daily living and diagnosed with multiple sclerosis, had multiple pressure wounds, including stage 3 and 4 ulcers. Review of medication and treatment administration records revealed numerous omitted wound care treatments over several months. The wound nurse reported that when assigned to work as a floor nurse, other nurses were responsible for wound care, but treatments were often not completed as required. The facility’s own policy required identification, evaluation, and appropriate treatment for residents with wounds or at risk for skin compromise, but this was not consistently followed. Interviews with the wound care nurse and DON confirmed ongoing issues with timely and accurate skin assessments, reporting of changes in condition, and completion of wound care treatments. The facility acknowledged problems with staff not completing required wound care and documentation, leading to delays in treatment and lack of adherence to physician orders and care plans for residents with wounds.

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 care and supervision for a resident, identified as R702, which resulted in an accident. On the date of the incident, R702 was being turned by a Certified Nursing Assistant (CNA) when they hit their head against the wall. The resident reported that the CNA should have used a second person to assist with the turning. The CNA involved in the incident was described by the resident, who noted that the CNA is no longer allowed to care for them. The resident also mentioned that they would hold onto a large stuffed animal to protect their head in the future. The facility's investigation into the incident revealed that the resident's bed was positioned against the wall, and the CNA admitted to hearing the resident complain of a headache after being turned. The CNA believed the resident was a one-person assist, contrary to the care plan, which required two-person assistance for bed mobility. The facility's investigation concluded that the resident's head was likely hit unintentionally due to the bed's positioning and the presence of many items on the bed. The facility's records showed that R702 had a history of disability and required assistance with self-care and mobility. Despite the incident, there was no complete neurological assessment documented in the resident's record, which is against the facility's policy for evaluating a resident's neurologic status after a potential head injury. The Administrator and Director of Nursing acknowledged the lack of documentation and noted that only partial neurochecks were provided at the end of the survey.

Penalty

No penalty information released

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

Summary

The facility failed to implement effective interventions and accurate wound treatments for two residents with pressure injuries. For the first resident, R901, the facility did not initiate treatment orders for a Stage 3 sacrum wound upon admission. The resident was admitted with a pressure ulcer, but treatment orders were not implemented until four days later. The Wound Care Nurse acknowledged that the admitting nurse should have contacted the doctor to implement a treatment order immediately upon admission. For the second resident, R902, the facility failed to provide adequate care to prevent a pressure wound. During an observation, an open area with maceration was identified on the left buttock, but no treatment was applied. Additionally, there were duplicate treatment orders for the right buttock, which were not clarified or corrected until after the surveyor's observation. The Wound Care Nurse was unaware of the left buttock impairment and the duplicate orders, indicating a lack of communication and oversight in wound care management. Both cases highlight the facility's failure to ensure timely and appropriate wound care interventions, as well as the lack of proper documentation and communication among staff. The Director of Nursing confirmed that all skin impairments should be reported to the physician and have treatment in place, but this protocol was not followed in these instances.

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 obtain and monitor weights for a resident, identified as R902, who was reviewed for weight loss. The resident was readmitted to the facility with diagnoses including end-stage renal disease and dependence on renal dialysis. During an observation, R902 was seen eating without assistance, despite having food scattered on a towel covering their chest. The resident mentioned that staff had offered help, but they declined. A review of the resident's weight summary showed significant discrepancies between the facility's recorded weights and those documented by the dialysis center. The facility's records did not account for the resident's amputations, which affected their baseline weights. An interview with the Director of Nursing (DON) revealed that the facility had not identified the inaccurate weights obtained for September and October 2024. The DON acknowledged the discrepancies and mentioned that a strategy was being implemented to ensure accurate and consistent weight measurements. However, the DON was unsure of when the issue was first recognized, and no further explanation or documentation was provided regarding the failure to compare weights with those from the dialysis center.

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 assessment and monitoring of an IV catheter and Permacath site for a resident reviewed for wounds. During an observation, it was noted that the resident had a split catheter on the right side of the chest with a dressing dated two weeks prior, and an IV port on the left side with no date on the dressing. The medical chart lacked documentation, physician orders, or a care plan identifying the type and location of each catheter, as well as orders or care plans for monitoring and assessing the catheter sites. The Director of Nursing (DON) was interviewed and acknowledged that staff should follow policies regarding IV care and that each dressing should be dated. However, no additional explanation or documentation was provided by the end of the survey. A physician's progress note on the day of the survey indicated that both catheter sites were clean, dry, and intact, but no further documentation was available to clarify the care and monitoring of the catheter sites.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate treatment and interdisciplinary collaboration to prevent further decrease in range of motion for a resident with a right-hand contracture. The resident, who was moderately cognitively impaired and had a history of stroke, heart failure, diabetes, and other conditions, was observed in their room with their right hand contracted and the prescribed hand brace/splint not applied. The resident expressed frustration, stating that the staff had not assisted in applying the brace since their transfer from a previous facility, despite their inability to do so independently. A review of the resident's care plan and treatment records revealed that an order for a right-hand splint was placed, but it was not included in the care plan interventions, nor was there documentation of its application in the Treatment Administration Record for several months. The Director of Nursing and Unit Manager were informed by the resident about the lack of application, and they appeared unaware of the situation. An occupational therapist later assessed the resident and created a new order for the splint, indicating a lapse in communication and documentation regarding the resident's care needs.

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 physician orders were transcribed and implemented for a resident with a colostomy, leading to a deficiency in care. The resident, who had diagnoses including constipation and colostomy status, was experiencing abdominal pain and was evaluated by a Nurse Practitioner. The evaluation resulted in orders for an abdominal X-ray, monitoring of vital signs, and administration of bisacodyl 5mg via the stoma for constipation. However, the bisacodyl order was not entered into the resident's medical record, and there was no documentation of its administration. Despite the physician's order for bisacodyl to be administered via the stoma, the medication was not given, and the resident's condition worsened, leading to unresponsiveness and eventual death. The Director of Nursing confirmed the lack of documentation and acknowledged that a new order should have been entered and administered. The failure to implement the physician's order for bisacodyl contributed to the deficiency identified during the survey.

Penalty

Fine: $60,900

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 implementation of physician orders and care plans for a resident with acute and chronic respiratory failure, COPD, and asthma. Upon admission, the resident was supposed to receive supplemental oxygen and use a CPAP machine as per the hospital's discharge instructions. However, there was no documentation of a physician order for the CPAP or oxygen administration, and the resident refused to use the CPAP due to discomfort. The facility did not notify the physician or interdisciplinary team about the CPAP settings issue or the resident's refusal, nor did they document any interventions to address the discomfort or explore alternative treatments. The facility also failed to administer prescribed antibiotics and did not provide the necessary CPAP/BiPAP ventilation as needed. The resident experienced multiple incidents of respiratory distress, leading to a fall and a fracture, which ultimately resulted in the resident's death. The medical record lacked documentation of the CPAP or BiPAP being applied while the resident was resting, and there were no physician orders for these devices or for oxygen administration. Additionally, the facility staff did not administer the resident's antibiotic on two occasions as prescribed. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's care needs. The nurse who readmitted the resident was unaware of the CPAP/BiPAP requirements, and the Director of Nursing was not informed about the CPAP settings issue or the failure to implement necessary orders. The facility's centralized admission personnel and the DON were responsible for reviewing referral packets to ensure the facility could provide the required care, but this process failed in this instance. The facility did not have care plans or interventions in place for the resident's primary diagnosis of respiratory failure and the use of supplemental oxygen and CPAP/BiPAP.

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 the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) to four residents, resulting in complaints about not being informed timely of private pay charges and the inability to file an appeal. The deficiency was identified during a survey, where it was found that the facility did not provide these notices to residents R169, R27, R42, and R62. The lack of timely notification affected the residents' ability to understand their financial liability and to appeal the decision if desired. Resident R169 was admitted under Medicare A and later became private pay without any documented discussion of costs or billing details in the clinical record. The facility failed to provide any NOMNC or SNFABN forms for R169, resulting in a current amount due of $5,306.00. Similarly, resident R27's NOMNC form was signed after the services ended, and the SNFABN was not signed until the day financial liability began, preventing the resident from appealing the decision. Resident R42's NOMNC form was signed on the day services ended, with no prior notification documented, and the SNFABN was not signed at all. For resident R62, the facility did not provide the NOMNC or SNFABN forms, citing the absence of the previous Business Office Manager as the reason. The facility's administrator acknowledged the issues with beneficiary notices, attributing them to the transition in the business office management and communication problems between the business office and clinical staff. Despite requests, the facility did not provide their policy regarding beneficiary notices by the end of the survey.

Penalty

No penalty information released

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

Summary

The facility was cited for failing to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations, interviews, and record reviews. Residents and staff reported significant staffing shortages, particularly on weekends and during night shifts, leading to delays in care and unmet needs. Residents expressed concerns about long wait times for call light responses, assistance with getting out of bed, and receiving scheduled showers. These issues were corroborated by resident council meeting minutes, which documented ongoing staffing concerns over several months. Interviews with Certified Nurse Aides (CNAs) and other staff members revealed that they were often assigned an excessive number of residents, making it difficult to provide adequate care. CNAs reported having to prioritize tasks and sometimes resorting to bed baths instead of showers due to time constraints. The staffing coordinator and Director of Nursing acknowledged the staffing challenges and efforts to recruit and retain staff, but the issues persisted, affecting the quality of care provided to residents. Specific residents, such as those with significant medical needs or cognitive impairments, were observed to be particularly affected by the staffing shortages. For instance, one resident with a wound VAC and cognitive impairment reported not receiving adequate assistance with personal hygiene, despite repeated requests. Another resident expressed frustration over delays in receiving pain medication and assistance with dressing. These deficiencies highlight the facility's failure to maintain adequate staffing levels to ensure timely and appropriate care for all 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 residents were treated with dignity and respect, as evidenced by multiple observations of staff not assisting a resident in a wheelchair and entering rooms without knocking or announcing themselves. One resident was observed struggling to propel themselves in a wheelchair due to engaged brakes, with several staff members passing by without offering assistance. Additionally, a CNA was seen entering and exiting resident rooms without knocking or wearing a name badge, which is against the facility's policy. The Director of Nursing acknowledged that staff should knock and announce themselves before entering rooms and wear name badges, but noted issues with temporary badges for new staff. The facility also failed to respect a resident's right to personal possessions. A resident expressed frustration over not being allowed to keep a plastic storage bin they had purchased, which was stored at the receptionist's desk. The facility's Administrator cited infection control concerns due to the bin not having wheels, despite similar bins being present in other rooms. The facility's policy states residents have the right to retain personal possessions unless it infringes on the rights or safety of others, but no specific safety concerns were identified in this case.

Penalty

No penalty information released

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

Summary

The facility failed to reasonably accommodate the needs and preferences of several residents, leading to discomfort and frustration. Resident R170, who was 74 inches tall and weighed 241 pounds, was observed on multiple occasions with their feet hanging over the end of the bed, indicating that the bed was too short. Despite the resident's complaints of discomfort, there was no record of staff addressing the issue or communicating it to the administrative team. The Director of Nursing was unaware of the concern until it was brought to their attention during the survey. Additionally, residents R34, R76, and R89 were observed with their water cups placed out of reach, preventing them from hydrating independently. R34, who had severe cognitive impairment and was not ambulatory, had their water cup placed approximately six feet away. Similarly, R76 and R89 had their water cups placed out of reach, with R76 having no fluids available at the bedside at one point. The Unit Manager acknowledged that water should be within the residents' reach, but this was not consistently ensured.

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 the confidentiality of resident health information, as observed on 8/20/24. A piece of paper containing personal resident information, including room numbers, names, current weights, and types of scales used, was taped to the nursing station desk in a manner visible to anyone passing by. This breach of privacy affected five residents, identified as R119, R120, R121, R122, and R123, whose sensitive information was exposed. During an interview conducted on the same day, the unit manager, Nurse 'A', acknowledged the inappropriate display of resident information, stating it should not have been left in such a manner. The facility's policy on resident rights and responsibilities, dated 5/14/2024, clearly states that residents have the right to personal privacy and confidentiality of their personal and medical records. The failure to adhere to this policy resulted in a deficiency concerning the protection of resident privacy.

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 a physician order for the use of supplemental oxygen was obtained for a resident, identified as R42, who was receiving continuous oxygen therapy via nasal cannula from an oxygen concentrator with humidified air. Upon observation, it was noted that the humidifier attached to the oxygen concentrator was empty, and the resident reported having to remind staff to fill it, as their nose became dry and sore. Despite the resident's continuous use of oxygen since admission, there were no physician orders for oxygen use or monitoring of the resident's respiratory status documented in the clinical records. Interviews with nursing staff revealed a lack of awareness and responsibility for maintaining the humidifier's water level. Nurse 'K', assigned to R42, acknowledged not noticing the empty humidifier and admitted it should have been filled. The Unit Manager, Nurse 'L', confirmed the absence of orders for oxygen use and monitoring in the resident's records and stated that nurses were responsible for monitoring the humidification level. The facility's documentation for respiratory care did not address resident care but focused on staff fit testing and 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 ensure consistent dialysis communication documentation and assessments for two residents, R94 and R270, who required hemodialysis. Both residents had been long-term residents with diagnoses including end-stage renal disease. The facility's care plan required the use of a dialysis communication form to communicate with the dialysis center, but a review of the electronic medical records (EMR) revealed a lack of recent communication forms. The last documented communication for R94 was approximately five months ago, and for R270, it was about seven months ago. Interviews with staff, including a Licensed Practical Nurse (LPN), Unit Manager (UM), and Director of Nursing (DON), confirmed the absence of these forms in the EMR, indicating a lapse in the facility's communication process with the dialysis provider. Additionally, the facility failed to provide a meal for resident R269 before their hemodialysis appointment. R269, admitted for short-term skilled nursing and rehabilitation, reported not having eaten since the previous night and expressed frustration over the situation. The resident's EMR included a physician order indicating nutritional risk, yet the nursing progress note only documented the resident's leave of absence to dialysis. An interview with the Registered Dietician (RD) revealed that bagged meals were prepared the night before and left in the kitchen fridge for nursing staff to distribute, but it was unclear why R269 did not receive their meal. The report highlights the facility's failure to maintain proper communication with the dialysis center and ensure residents received necessary meals before dialysis appointments. Despite the facility's policy requiring communication forms to be sent and reviewed, the absence of these forms in the EMR and the lack of a meal for R269 indicate significant lapses in the facility's processes. Interviews with various staff members, including the DON, confirmed awareness of these issues, but no additional information or corrective actions were provided before the survey exit.

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 properly label, store, and discard expired medications and biologicals, as observed in four out of seven medication carts. Specific issues included the presence of expired fish oil and [NAME] oil supplements, a COVID-19 test reagent stored with oral medications, and a bag of potato chips in a medication cart. Additionally, bleach disinfecting wipes were stored with oral medications, and a vial of Aplisol Tuberculin Purified Protein Derivative was not stored at the required refrigerated temperature. Furthermore, insulin flex pens were found without open dates, and a transdermal lidocaine patch was left unattended on a medication cart. The report also noted that a Breo Ellipta inhaler and vials of albuterol inhalation solution were left on top of unattended medication carts. An orange round pill, identified as aspirin, was found on a trash shield of a medication cart, with the LPN unable to explain its presence. The Director of Nursing acknowledged that medications should not be left unattended, highlighting a lack of adherence to the facility's policy on medication storage and expiration dating.

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 menu items listed on meal tickets were provided to seven residents during meal services. Observations revealed that several residents did not receive the nutritional supplements, desserts, or beverages as indicated on their meal tickets. For instance, one resident was supposed to receive a nutritional juice supplement but did not receive it during the meal service. Another resident was to be provided a magic cup supplement, which was also not observed during the meal service. Additionally, a resident's meal ticket indicated a double dessert and a nutritional juice supplement, but they only received a single dessert and no juice. Further observations highlighted that residents were not provided with coffee or tea as indicated on their meal tickets. During breakfast service, it was noted that there were no coffee mugs or disposable foam cups available for serving hot beverages, resulting in residents not receiving their requested coffee or tea. Interviews with the dietician revealed that the dietary department was responsible for placing items on trays during the tray line, and Certified Nurse Aides were responsible for providing coffee and tea at the point of service. The facility's policy on food preferences did not address the responsibility to provide food and beverages per resident 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 facility failed to ensure that residents received fresh water and assistance with consuming fluids, which is essential for maintaining adequate hydration. Observations revealed that four residents had foam cups of water at their bedsides that were room temperature and lacked ice. The cups were dated with the previous night's shift time, indicating they had not been refreshed throughout the day. Additionally, the straws in the cups remained in their paper wrappers, suggesting that residents were not assisted in drinking the water provided. Interviews with the Unit Manager revealed that the midnight shift was responsible for providing the cups, and staff were expected to refresh them with ice and water throughout the day. However, the Unit Manager acknowledged the concern that the staff had not been fulfilling this responsibility, as evidenced by the room temperature water and the untouched straw wrappers. The facility's policy on oral hydration, revised in November 2021, states that it is the facility's policy to assist residents in maintaining adequate hydration, which was not adhered to in this instance.

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 meals were served in a timely manner and in accordance with the scheduled mealtimes for residents, leading to late meals and resident dissatisfaction. On a specific day, the first lunch cart left the kitchen at 1:05 PM, and the last cart left at 1:55 PM, which was significantly later than the scheduled lunch time of 12:30 PM. The Certified Dietary Manager (CDM) explained that a call-in for the morning shift caused delays throughout the day. This issue was not isolated, as a confidential resident group meeting revealed that residents frequently experienced inconsistent meal times, with breakfast sometimes served as late as after 10 AM, depending on who was cooking in the kitchen. Individual interviews with residents and family members corroborated these findings, with reports of lunch being served between 2:30 PM and 3:00 PM and dinner around 8:00 PM on multiple occasions. The CDM acknowledged the residents' concerns and attributed the delays to staffing challenges, particularly when there were call-offs for breakfast shifts. These delays in meal service were consistent across different meals and days, contributing to ongoing dissatisfaction among residents.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to proper infection control standards and practices, specifically in the use of Personal Protective Equipment (PPE) and hand hygiene, which could potentially lead to the spread of infection among residents. On August 21, 2024, a Licensed Practical Nurse (LPN X) was observed administering medication without performing hand hygiene. The LPN donned gloves to administer eye drops but failed to change gloves and perform hand hygiene after picking up a resident's phone from the floor. The LPN acknowledged the oversight when prompted. Resident 15, who was admitted to the facility with severe cognitive impairment and a history of urinary tract infections, was observed receiving care from LPN F without the proper PPE as required by Enhanced Barrier Precautions (EBP). LPN F manipulated the resident's suprapubic catheter without wearing a gown and did not perform hand hygiene before and after the procedure. Additionally, LPN F disposed of a urine-filled catheter bag improperly, carrying it through the facility without performing hand hygiene after removing gloves. Another resident, R172, was found to have a midline catheter and open wounds but was not placed on EBP upon admission. Despite having orders for IV antibiotics, there was no signage or PPE indicating EBP. The Unit Manager and Director of Nursing acknowledged that EBP should have been implemented upon admission, but the process was not followed. The facility's policy requires EBP for residents with wounds or indwelling medical devices, but this was not adhered to for R172.

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 all corridor areas used by residents were equipped with safe and secure handrails. During observations conducted over two days, surveyors noted multiple sections of handrails and hard plastic corner caps/molding in the 100 and 200 hallways were broken, jagged, or missing, exposing sharp plastic and metal. Additionally, a handrail near the exit hallway closest to the kitchen was found to be pulled away and down from the wall. An interview with the Maintenance Director revealed that audits of the facility's handrails were not conducted regularly, with checks occurring infrequently. The Maintenance Director acknowledged awareness of some broken areas but was unaware of the specific issues identified during the survey. The facility uses an electronic system for staff to report maintenance issues, but it appears this system was not effectively utilized to address the handrail deficiencies.

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 address grievances for a resident who expressed concerns about not receiving new, sterile urinary catheters, leading to the reuse of catheters and a suspected urinary tract infection (UTI). The resident reported experiencing pain, burning, and cloudy urine, indicative of a UTI, and had communicated these concerns to the facility staff. Despite the resident's complaints during a care conference and the nurse's documentation of the issue, there was no follow-up action taken, such as ordering a urinalysis or addressing the catheter supply issue. Interviews with the staff revealed a breakdown in communication and grievance handling. Nurse 'J' claimed to have informed the unit managers and left a note for the physician, but the Unit Manager 'E' was unaware of the resident's concerns. The Director of Nursing acknowledged that the concerns should have been communicated and addressed promptly. The facility's policy on resident rights and grievance resolution was not followed, resulting in unresolved concerns 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 provide necessary care and services consistent with the needs and choices of a resident, identified as R47, who was admitted with multiple medical conditions including hypertension, heart disease, peripheral vascular disease, diabetes, and multiple myeloma. R47 underwent a debridement and partial calcanectomy of the left foot, requiring a Wound VAC and antibiotic treatment. Despite being care planned for a decline in ambulation and requiring substantial assistance, R47 reported not receiving adequate help from staff to get out of bed or maintain personal hygiene. Observations noted R47 in an unkempt state, wearing a food-stained gown, and expressing frustration over not receiving a bath or assistance to clean up, despite multiple requests. The report highlights discrepancies in documentation and communication among staff regarding R47's care. On one occasion, a CNA documented that R47 refused to get out of bed, which R47 disputed, stating they were finishing breakfast and requested assistance later. Further, the facility's shower/bathing task records showed inconsistent documentation, with a CNA marking both 'Yes' and 'No' for a bed bath, which R47 denied receiving. The Director of Nursing and other staff were informed of the situation, but R47 continued to report not being cleaned up, indicating a failure in the facility's care processes and documentation practices.

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 necessary meal set-up and one-to-one feeding assistance for a resident who was legally blind and had severe cognitive impairment. Observations revealed that the resident was left to eat independently despite requiring assistance, as indicated on their meal ticket and care plan. The resident was seen struggling to consume meals, using their fingers to eat, and spilling food on themselves and their surroundings. Interviews with the resident's roommate and family confirmed that staff did not regularly assist the resident with eating, and the family had to adjust their visits to help during meal times. The resident's clinical record showed a history of dysphagia, stroke, falls, and legal blindness, with a care plan specifying the need for one-to-one assistance with meals. Despite these documented needs, staff, including a CNA, failed to provide the required assistance during multiple meal observations. The facility's Director of Nursing acknowledged that assistance should have been provided, but a policy on one-to-one feeding assistance was not made available during the survey.

Penalty

No penalty information released

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

Summary

The facility failed to provide consistent monitoring and assessment of changes in skin condition and implement pressure-relieving interventions for two residents, leading to deficiencies in pressure ulcer management. One resident, admitted with multiple health conditions including diabetes and peripheral vascular disease, had a wound VAC applied to their left foot. Despite being care planned for a decline in ambulation and requiring assistance, the resident reported being left in bed and developed sores on their lower back and buttock area. A skin assessment identified non-blanchable redness, but no further monitoring or evaluation was documented, resulting in the development of stage 2 pressure ulcers. Another resident, with severe cognitive impairment and multiple diagnoses including vascular dementia and seizures, was observed without heel protectors despite being at risk for pressure ulcers. The resident's care plan included the use of soft heel protector boots, but these were not implemented. Staff members, including a CNA and a unit manager, were unaware of the intervention, and the heel protectors were found unused in the medication room. The facility's failure to adhere to its skin management policy, which mandates the identification, evaluation, and treatment of residents at risk for skin compromise, contributed to the development and worsening of pressure ulcers in these residents. The lack of documentation and implementation of care plan interventions highlights a significant oversight in the facility's pressure ulcer management practices.

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 assessment, monitoring, and provision of supplies for two residents using urinary catheters, leading to potential urinary tract infections. One resident, who self-catheterizes due to paraplegia, reported reusing catheters because the facility did not regularly supply new, sterile ones. Despite the resident's complaints of pain and discharge, indicating a possible urinary tract infection, no catheter kits were observed in their room. The facility had catheter kits in stock, but the resident was not provided with them, and staff were unaware of the resident's concerns. Another resident, managed under hospice care with a history of neurogenic bladder dysfunction, was observed with cloudy, white milky sediment in their catheter tubing over several days. Despite the care plan's directive to report signs of urinary tract infection, there was no documentation of physician notification regarding the abnormal urine observations. The resident's urine was noted to be dark amber, suggesting dehydration, but the facility failed to act on these observations.

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 monitor the weight of a long-term resident, identified as R29, who was at risk for nutritional deficiencies due to multiple health conditions including seizures, hemiplegia, diabetes, dysphagia, and chronic pain. R29 exhibited significant weight fluctuations over several months, with variations ranging from a loss of 19 pounds to a gain of 9 pounds. Despite these fluctuations, there was no timely follow-up or re-weighing to ensure the accuracy of the recorded weights. The facility's Registered Dietician (RD) and Interdisciplinary Team (IDT) did not address these variations promptly, and there was no updated plan to monitor R29's weight more frequently. Observations revealed that R29 did not consume their breakfast, which was consistent with their mechanical soft diet, and reported not being hungry. The dietary progress notes indicated a significant weight loss over 180 days, but there was no updated intervention plan. The RD's notes highlighted concerns about the accuracy of the weights and the lack of timely follow-up, yet no corrective actions were taken. The facility's process for ensuring weight accuracy was questioned, and the RD admitted to being aware of the weight fluctuations but did not provide a satisfactory explanation for the lack of frequent monitoring. Interviews with the RD and the Director of Nursing (DON) revealed a lack of coordination and timely response to R29's weight issues. The RD mentioned that any weight variation of 5 pounds should trigger a re-weight, but this was not consistently followed. The DON acknowledged the concerns but did not provide evidence of a systematic approach to address the significant weight loss and ensure accurate monitoring. The facility's weight monitoring policy was requested but not provided before the survey exit, indicating a potential gap in procedural adherence.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely laboratory services for two residents, leading to deficiencies in care. One resident, who had a physician's order for routine valproic acid level checks every six months, did not have the required lab tests completed in June 2024. Despite the presence of a physician's order dated December 2023, the lab results were not found in the resident's clinical record, and the facility staff, including an LPN and a Unit Manager, confirmed the oversight. The Unit Manager later reported that the lab order was not completed and took steps to contact the physician for an immediate order. Another resident, who experienced symptoms indicative of a urinary tract infection (UTI), did not have a urinalysis ordered or conducted in a timely manner. The resident reported reusing urinary catheters due to a lack of new supplies, which they believed led to a UTI. Despite the resident's complaints of pain and symptoms, and a progress note by a nurse indicating the need for a urinalysis, no order was found in the resident's records. The Unit Manager and the Director of Nursing acknowledged the communication breakdown and the failure to notify the physician for necessary lab 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 coordinate and obtain radiology services for a resident, identified as R42, who required an MRI for their left thigh as per their cancer doctor's recommendation. The resident, who had a history of malignant neoplasm of connective and soft tissue of the left lower limb, expressed concerns about the delay in scheduling the MRI, which was ordered to be scheduled within 48 hours. Despite the active order for the MRI being in place since July, there was no documentation indicating that the MRI had been scheduled or completed by the time of the survey. Interviews with the Director of Nursing and Staff 'W', who was responsible for scheduling, revealed a lack of follow-up and documentation regarding the MRI appointment. Staff 'W' admitted to waiting for a call back from the hospital but failed to document the date of the initial call or any subsequent follow-up actions. The facility's policy on coordination with outside providers did not address radiology services, contributing to the oversight. The only documented appointment for the resident was with a cardiologist, indicating a lapse in the facility's process for ensuring timely diagnostic services.

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 sufficient staffing to meet the needs of residents, as evidenced by observations, interviews, and record reviews. Two residents, identified as R303 and R304, reported inadequate care due to staffing shortages. R303 expressed that they did not receive regular showers and were unable to have their facial hair shaved due to aides being rushed. R304 reported long wait times for call light responses and having to sit in urine for extended periods, which affected the healing of a wound. Both residents attributed these issues to the facility being short-staffed. Interviews with staff members, including CNAs and the staffing personnel (SP A), revealed that the facility did not adjust staffing levels based on resident census or acuity, instead following standard numbers. SP A confirmed that staffing numbers remained constant regardless of changes in resident needs. CNAs reported being overworked and unable to complete all care tasks, such as providing showers, due to insufficient staffing. The facility had 12 open aide positions, indicating a significant staffing gap. The Director of Nursing acknowledged the staffing concerns and stated efforts were ongoing to improve and retain staff.

Penalty

Fine: $43,053

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 neglect, resulting in the resident being abandoned at a chemotherapy appointment. The resident, who had diagnoses including malignant neoplasm of the breast and cerebrovascular disease, was left waiting for approximately five hours without transportation, shelter, or medical care. The resident had to rely on family members to pick them up and was forced to stay in a motel overnight before being able to go to the hospital for medical care. This incident occurred because the facility canceled the return transportation and discharged the resident while they were at their chemotherapy appointment, without proper communication or arrangements for their return or further care. The resident reported that after their chemotherapy appointment, they called the transportation company, which informed them that there was no order to pick them up. When the resident contacted the facility, they were told by a nurse that they had been discharged and could not return. The resident's belongings were still in their room, and the nurse suggested that someone could come to pick them up later. The resident's family had to intervene, with the resident's niece eventually picking them up around 10 PM and taking them to a motel for the night. The resident experienced severe pain and incontinence during the night and had to go to the emergency room the next morning. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's transportation and discharge. Nurse B, who was involved in the incident, admitted to canceling the return transportation and calling the physician to send the resident to the hospital due to the resident's aggressive behavior and pain. However, Nurse B was unaware of the resident's chemotherapy appointment and did not review the facility's communication dashboard. The Director of Nursing and the Administrator were also involved but failed to ensure the resident's safe return and proper care. The facility's actions left the resident without necessary medical assistance and supervision, resulting in significant distress and harm to the resident.

Removal Plan

• Resident # 611 is scheduled to return. The Administrator has been suspended pending investigation.
• The facility currently has 104 residents residing in the facility, the administrative nurses reviewed residents with scheduled appointments to ensure transportation was set/confirmed to ensure residents are returned back to the facility. In addition, newly admitted residents or readmitted residents, will be reviewed M-F during the clinical meetings; to ensure residents who requires transportation to scheduled appointments are set/confirmed to ensure residents are being returned back to the facility safely. As well as, communicated on the dashboard.
• The License Professional Nurses education began and they were re-educated on the facility's Routine Resident Care Policy, Medication Administration Policy, and the Standard of Nursing Practice Policy to residents' needs are met. There are 44 Licensed Nurses who will be in-serviced on Routine Resident care Policy, Medication Administration Policy and Standards of Nursing Practice Policy. 40 nurses have been in-serviced and in-servicing continues. This will be on-going until all licensed nurses have been re-educated. The remaining nurses will receive education on the above policies on or before their next scheduled day.
• The Certified Nursing Assistances (CNA/CENA) education began and they were re-educated on the facility's Routine Resident Care Policy to ensure residents' needs are met. There are 46 CENA'S who will be in-serviced on the Routine Resident Care Policy. 38 CENA'S have been in-serviced and in-servicing continues. This will be on-going until all licensed nurses have been re-educated. The remaining CENA'S will receive education on the above policies on or before their next scheduled day.
• Scheduler, Receptionist, and Central Supply was educated on residents who have scheduled appointments will ensure transportation is set/confirmed to ensure residents are returned back to the facility.
• The DON/Admin Nurses reviewed the appointment book to ensure upcoming scheduled appointments, were confirmed for pick-up and return trip to the facility.
• Any areas of concern will be addressed. Finding will be taken to the monthly QAPI (quality assurance process improvement) meeting for further review and recommendations. The DON is responsible obtaining and maintaining compliance.
• DON will sustain and maintain compliance.

Penalty

Fine: $43,053

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 two of six staff members reviewed for criminal background checks were properly screened for eligibility to work in a nursing home. This failure was identified during a survey on 5/22/24. The facility was asked to provide personnel files, including background checks, for six employees. While the facility provided most of the requested documentation, it failed to provide completed background checks for two nurses, Nurse B and Nurse H. Nurse H's file was missing education, training, and a background check with fingerprint results. Nurse B's background check was only completed on the day of the request, and Nurse H's background check was outdated. Both nurses were allowed to work without the necessary background clearance, and Nurse B did not sign a conditional letter of employment pending the results of the fingerprint check. The Director of Nursing and Human Resources confirmed that staff should not work without a completed background check clearance. Despite multiple requests for additional documentation and explanations, the facility was unable to provide the necessary background clearances and hire dates for Nurse B and Nurse H. This oversight resulted in the potential for abuse or neglect to occur, affecting all residents in the facility. The facility's failure to ensure proper background checks for these employees was confirmed by the administration and corporate staff, who acknowledged that the staff should have had completed background checks before working their shifts. No further information was received by the exit of the survey.

Penalty

No penalty information released

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

Summary

The facility failed to notify a resident's guardian of significant changes in the resident's condition. Specifically, the resident, who had severe cognitive impairment and required assistance with activities of daily living, had their percutaneous endoscopic gastrostomy (PEG) tube removed. There was no documentation of how or when the PEG tube was removed, who removed it, or that the resident's guardian was notified of the removal. Additionally, the resident was started on hypodermoclysis for fluid administration without the guardian's notification or consent. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the guardian should have been notified but admitted that no such notification was made or documented. The resident's medical history included diabetes, depression, and stroke, and they were admitted to the facility with these diagnoses. The facility's policy on Notification of Change, which requires informing the resident, consulting with the resident's practitioner, and notifying the resident's representative of significant changes in status, was not followed. The failure to notify the guardian of the PEG tube removal and the initiation of hypodermoclysis represents a significant lapse in communication and adherence to the facility's policies.

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 and address grievances raised by a resident's family member, resulting in verbalized complaints and frustration. The family member reported concerns about the resident being left wet and soiled for five hours and not being placed back into bed, but no follow-up was conducted by the facility administration. The Social Work Director acknowledged receiving the complaint and verbally communicated it to the Director of Nursing, who left the facility shortly afterward. However, the complaint was not documented as required by the facility's grievance policy. The resident's medical record indicated that they had intact cognition and required partial assistance with personal hygiene. Despite the family member's efforts to communicate their concerns, no grievance or concern forms were completed, and no investigation was conducted. The facility's compliance program mandates that all concerns be documented and investigated promptly, but this procedure was not followed in this case. The lack of documentation and follow-up led to unresolved grievances and frustration for the resident's family.

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 assessments for a resident (R703) who developed intense pain from a blood clot requiring hospitalization. R703, who was admitted for rehabilitation from back surgery, reported severe pain, swelling, and a warm sensation in the left leg during the early hours of 01/17/24. Despite pressing the call light and requesting help, the nurse only provided pain medication and did not assess the leg or call Emergency Medical Services (EMS) as requested by R703. The nurse indicated that the doctor would assess the leg in the morning, but R703 insisted on being taken to the hospital, where they were diagnosed with a blood clot requiring surgery to remove it. A review of the clinical records revealed that the medication administration record (MAR) documented the pain medication as ineffective, and the Situation, Background, Appearance, and Review (SBAR) Evaluation form was incomplete, lacking specific details about R703's leg pain and assessment. There was no further documentation of assessments, progress notes, or communication between the nurse, physician, and EMS transfer. The Director of Nursing (DON) confirmed that nursing should have assessed for a possible blood clot given the symptoms. Hospital records indicated that R703 arrived at the Emergency Department with severe pain and swelling in the left leg, which was diagnosed as an extensive blood clot requiring immediate surgical intervention.