Wellbridge Of Clarkston

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 provide care in a safe manner to prevent an accident during ADL care, resulting in a resident’s fall from bed and subsequent fractures. The resident was an older adult with recent and significant medical issues, including a displaced intertrochanteric fracture of the right femur requiring surgery, a fracture of the manubrium, multiple right rib fractures, trigeminal neuralgia, Meniere’s disease, and psychosis. A recent MDS showed the resident had intact cognition, used a walker and wheelchair, required substantial/maximal assistance for bed mobility, and was dependent for toileting hygiene. The care plan identified the resident as at risk for falls related to multiple conditions, including recent fractures, and included an intervention to encourage and assist the resident to be positioned in the middle of the bed prior to rolling, as well as a transfer status of one-person assist with a two-wheeled walker and non-ambulatory status. During the night, while a CNA was providing incontinence/ADL care, the resident rolled out of bed and onto the floor. The nurse’s progress note documented that the CNA reported the resident rolled out of bed in the middle of ADL care and was found on the floor on her left side, with a broken left pinky nail and later complaints of left shoulder pain. The CNA’s written witness statement and subsequent interview described that the bed was elevated to a working height, the resident was being turned for care, and the CNA rolled the resident away from herself. The CNA reported that the resident began exhibiting unusual jerking and jolting movements and then fell to the floor. The CNA acknowledged rolling the resident away from her during repositioning and stated she did not stop care to seek additional help when the resident’s movements became unusual, explaining that she believed others were busy and she informed the nurse afterward. The DON later stated that the expectation is to roll residents toward the caregiver or get help, and to stop care and notify the nurse when there is a sudden change in condition. Following the fall, the resident complained of pain in the shoulder, ribs, and hip, and later reported dizziness, new visual changes, and a different type of headache. An NP note documented right upper extremity weakness, edema, limited arm elevation, bruising to the right temple, and ongoing rib pain, with the resident reporting she had hit her head during the fall. The NP ordered transfer to the hospital for CT imaging due to head injury complaints. Hospital CT imaging identified a minimally displaced fracture of the right anterior superior manubrium and fractures of the right 1st and 2nd ribs, and the hospital H&P recorded that the resident stated she rolled out of bed as she was being turned by staff. The facility’s internal investigation concluded that the resident rolled too far and slid off the bed during repositioning, characterized the fall as not preventable, and documented that the bed height was appropriate, but did not address the CNA’s description of sudden jerking/jolting movements, the elevated bed during care, or the technique of rolling the resident away from the caregiver despite the resident’s recent hip fracture and need for substantial assistance with bed mobility. Discrepancies were noted between the investigation documents and the clinical record regarding staff presence, continence status at the time of the incident, and environmental details. The surveyor also identified that the facility did not have a specific written policy on positioning, with corporate clinical staff stating that positioning was considered a basic skill staff should know. The facility’s QA tool for the fall with fracture indicated the fall was deemed not preventable and referenced new interventions, but left sections for staff education and QA committee review incomplete. The investigation and documentation did not reconcile or fully incorporate the CNA’s account of the resident’s unusual movements during care, nor did it analyze whether the resident’s functional limitations and recent right hip fracture affected safe repositioning during ADL care. These actions and omissions, including the manner of positioning and rolling the resident away from the caregiver on an elevated bed, the failure to stop care and seek assistance when the resident’s condition changed, and the incomplete and inconsistent internal investigation, led to the cited deficiency for not ensuring care was provided in a safe manner to prevent accidents.

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 failure to ensure controlled medications were securely stored in a locked compartment as required by facility policy and professional standards. During observation of the 800 hall narcotic wall storage unit, surveyors found the outer door not properly secured and able to be opened completely, and the inner door, which also had a locking mechanism, was unlocked. The inner door’s lock had several rubber bands around the locking mechanism and one around the lock and top of the inner door, while multiple resident narcotic medications were stored inside with no staff present in the hallway. When the Administrator arrived and was informed of the unlocked controlled substance wall unit, they attempted to locate the nurse responsible for the medications. Shortly thereafter, a nurse approached the wall unit and stated they thought it was locked. The nurse attempted to engage the outer door lock, which was already in the locked position and therefore unable to close, then used a key to lock the outer door. When questioned about the inner door, the nurse attempted to use the same key but reported it did not work and believed the lock had recently been changed or fixed. The DON then attempted to secure the inner door with the same keys and confirmed there was no working key for that door. The nurse reported last accessing the narcotic wall unit at approximately 9:00 AM. Later, during the exit conference, the DON confirmed there were six controlled medication wall units in the facility and that no issues had been found with the others. A corporate nurse acknowledged prior awareness of the need for repair to that specific wall unit’s lock and that they had been working on having it fixed, and did not provide an explanation when asked why controlled medications had not been removed from that storage area despite knowing it was not locking properly. The facility’s policy states that only authorized licensed nursing and pharmacy personnel have access to controlled medications and that the medication nurse on duty maintains possession of the key to controlled medication storage areas.

Penalty

No penalty information released

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

Summary

Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During an environmental tour of the kitchen, the ice machine was found to have an expired filter with a 'change by date' that had passed, and the Regional Kitchen Manager was unable to explain why it had not been changed. Additionally, a tour of the laundry room revealed that the area behind multiple dryers had a floor surface covered with dried liquid spillage from cleaning chemicals, and the tops of the dryers were covered with a thick layer of lint. The facility Administrator acknowledged the presence of these unsanitary conditions.

Plan Of Correction

1.) The laundry room, including all machines and the floor behind the machines, was cleaned and dusted, and the ice machine filter was changed. 2.) A one-time audit was completed to ensure that dusting was completed throughout the facility and all ice filters were clean and changed. The housekeeping and maintenance departments were re-educated. 3.) System Change: All water filters will be changed according to manufacturer guidelines. The administrator/designee will complete rounds weekly to ensure the facility, including appliances/machinery, is kept clean. 4.) The administrator/designee will complete weekly rounds for 12 weeks to ensure the facility, including appliances/machinery, is dust free and will also conduct routine rounds to ensure there are no expired water filters. Any non-adherence will result in 1:1 education. All audits will be taken to QA for review. 5.) The administrator is responsible for ongoing 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 ensure that a resident received complete and accurate vital sign monitoring and documentation per physician orders and professional standards of practice. The resident, who had Alzheimer's disease, diabetes, and hypertension, was on two blood thinners (Plavix and Eliquis) and a blood pressure medication (Metoprolol Tartrate). After experiencing a fall in the bathroom and hitting her head, the resident was found with a bump on her head and a skin tear on her right arm. The nurse initiated neuro checks and contacted the provider, but there was no detailed documentation of the head wound in the medical record, and the neuro check documentation was not initially found in the electronic medical record (EMR). Further review revealed that the resident's blood pressure readings were not consistently documented prior to the administration of Metoprolol, as required by physician orders. The Medication Administration Record (MAR) showed the medication was given twice daily, but blood pressure readings were only recorded five times over a two-week period, despite 29 opportunities. This lack of consistent monitoring made it impossible to determine if low blood pressure contributed to the resident's fall. Additionally, the neuro check documentation began 15 minutes after the fall, and vital signs at the time of the fall were not initially available in the EMR. A paper copy of the neuro check sheet with hand-written vitals was later produced, but it had not been previously scanned or included in the EMR. Interviews with nursing staff and the Director of Nursing (DON) confirmed that vital sign monitoring was not consistently performed or documented as required. The DON acknowledged the absence of a detailed skin assessment and the incorrect entry of older vital signs in the change of condition form. The facility's policies required vital sign monitoring prior to medication administration and neurological assessment after falls with suspected head trauma, but these standards were not met in this case.

Plan Of Correction

1.) Resident #64 was assessed and no acute issues were noted. All residents have the potential to be affected. 2.) A one-time review of all guests on hypertensive medications from the last 30 days was completed to ensure hypertensive parameters are being followed. A one-time review of falls within the last 14 days was reviewed to ensure neuro checks were being completed as ordered. 3.) Licensed nurses were re-educated on following parameters on hypertensive medications and on completing neuro checks with unwitnessed falls. System change: The nurse managers will review all new hypertensive medications for parameters if needed and will review all falls to ensure neuro checks were completed for unwitnessed falls. 4.) DON/Designee will review 5 medical records weekly x 12 weeks to ensure that hypertensive medications with parameters are being followed. Any non-adherence will result in 1:1 education. All audits will be taken to the QA committee for review. DON/Designee will review 5 medical records weekly x 12 weeks to ensure that neuro checks were being completed for unwitnessed falls. Any non-adherence will result in 1:1 education. All audits will be taken to the QA committee for review. 5.) The Executive Director is responsible for maintaining compliance with the regulation.

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 assess, monitor, and document skin wounds or growths for two residents who were reviewed for non-pressure skin conditions. This deficiency was identified through observation, interview, and record review. The facility did not ensure that care and treatment for these residents were provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, as required by regulations. The lack of assessment, monitoring, and documentation specifically pertained to non-pressure skin conditions for the two residents involved.

Plan Of Correction

1.) Residents #66 & #57 were reassessed, and no acute changes were noted. All residents have the potential to be affected. 2.) A one-time skin sweep was completed to ensure that all impaired skin integrity had treatments or were identified in other parts of the medical record as needed. 3.) Licensed nursing staff were re-educated on skin assessment, documentation, and treatment orders with impaired skin integrity. System change: The nurse managers will review skin assessments and 24-hour summary on the next business day to ensure the MD/provider was notified of impaired skin integrity. 4.) DON/Designee will review 5 medical records weekly x 12 to ensure that residents with impaired skin integrity had documentation and an order for treatment. Any non-adherence will result in 1:1 education. All audits will be reviewed by the QA committee. 5.) DON is responsible for ongoing 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 a resident with fragile skin and multiple comorbidities, including lumbar vertebra compression, sick sinus syndrome, postural dizziness, cirrhosis, and kidney failure, sustained a skin tear on their right forearm after hitting it on the armrest of their wheelchair. The incident happened while the resident was in the bathroom, and the injury was attributed to a missing plastic cap on the right armrest, which exposed a sharp metal edge. The missing cap was not visible to the resident while seated but was observable to someone inspecting the wheelchair from the front. Despite the resident reporting the injury and the presence of a visible dressing, no one inspected the wheelchair for hazards following the incident. Multiple observations over several days revealed that the resident continued to use the same wheelchair with the exposed sharp edge, and staff, including the assigned LPN and therapy staff, did not identify or address the missing cap. The LPN, who was present at the time of the incident and on subsequent days, reported checking the wheelchair but did not notice the hazard until it was pointed out by the surveyor. The resident's care plan noted the risk of skin impairment and included general interventions, but there were no updates or specific interventions added after the incident. The facility did not initiate a thorough investigation or root cause analysis immediately following the event, and no incident or accident report was completed until the surveyor brought the issue to the attention of facility leadership. Interviews with staff, including the DON and therapy staff, confirmed that a comprehensive inspection of the wheelchair was not performed in relation to the resident's injury. The facility's policy required prompt investigation and documentation of accidents, including a detailed account of the circumstances and contributing factors, but this process was not followed. The deficiency was identified due to the lack of timely and thorough investigation, failure to identify and remove the accident hazard, and inadequate follow-up to prevent further harm.

Plan Of Correction

1.) Resident #61 is no longer in the facility. All residents have the potential to be affected. 2.) A one-time review of residents in-house was completed to ensure that a root cause analysis was completed for any accident/incident that resulted in an injury. A one-time audit of all wheelchairs was completed to ensure no safety issues were identified. If any were found, they were corrected by IDT. 3.) Licensed nursing staff were re-educated on assessing potential cause of injury due to an accident/incident. System change: Nurse Managers will complete documentation on root cause analysis resulting in injury from accident/incident. 4.) Don/Designee will review 5 E-interact change of condition assessments weekly x 12 weeks to ensure that all injuries from an accident/incident are reviewed for root cause analysis. Any non-adherence will result in 1:1 education. All audits will be taken to QA for review. 5.) The Executive Director is responsible for maintaining compliance with the regulation.

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 regarding the lack of proper skin assessment and documentation for a resident with a significant skin abnormality. Upon observation, a resident was found to have a cutaneous horn on the scalp, as well as similar protrusions on the hand and forearm. Despite the presence of this lesion, there was no documentation of the skin protrusion in the resident's admission assessment, progress notes, or by any nursing or medical staff. Interviews with nursing staff and the DON revealed uncertainty about whether the lesion was present at admission, and the attending physician confirmed the presence of a cutaneous horn but stated it was not something he would typically document. Hospital discharge paperwork did note the lesion, but this information was not incorporated into the facility's clinical record or baseline assessment. Another deficiency was noted in the management of a wound for a different resident. The resident was observed with an adhesive foam bandage on the right forearm, which showed signs of drainage and was undated. Review of the clinical record indicated the wound resulted from a fall, but there was no physician order for the dressing or wound care. The dressing was changed by a unit manager, who admitted to not dating the initial dressing due to lack of a marker and was unable to confirm how old the previous dressing was. The DON acknowledged that wound treatments should have a physician order and that all dressings should be dated, but these practices were not followed. Additionally, the facility's policy provided for review addressed only pressure ulcers and did not include guidance for non-pressure skin conditions. This lack of comprehensive policy, combined with the absence of documentation, assessment, and physician orders for wound care, contributed to deficiencies in the facility's skin and wound management practices for both 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 document a required battery test during the monthly inspection of the facility's generator. Specifically, the records did not include documentation of either the specific gravity of the battery fluids or the cold crank amperage for maintenance-free batteries, as required to ensure the operational condition of the generator's battery. This omission was identified during a record review conducted by surveyors. The deficiency was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of record review. The lack of proper documentation and testing could affect all 87 occupants in the event of a facility-wide power outage or fire emergency, as the generator's reliability could not be assured according to NFPA standards.

Plan Of Correction

The Maintenance Director has completed the required monthly battery test inspection of the facility's generator on June 2nd. The Maintenance Director/Designee has been educated to ensure that the monthly battery test inspection of the facility's generator is being conducted and recorded to ensure compliance with the regulation. The Maintenance Director/Designee will conduct a routine review of the life safety binder to ensure that monthly battery test inspections of the facility's generator are conducted and recorded. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.

Penalty

No penalty information released

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

Summary

During an observation on May 13, 2025, at approximately 12:05 PM, it was found that the facility did not maintain residential hallways free of non-essential or easily movable equipment. Specifically, gown and isolation cabinets located in the #500 hallway were not equipped with wheels, which would allow for quick movement to clear the hallway in case of a fire emergency. This issue was confirmed by both the Facility Maintenance Director and the Administrator during interviews conducted at the time of observation. The deficiency was noted to potentially affect 20 out of 87 occupants in the event of a fire emergency, as the means of egress was not continuously maintained free of all obstructions as required.

Plan Of Correction

The facility's added wheels to the isolation bins, and the hallways are equipped with isolation bins with wheels to aid in the quick movement to clear a hallway during a fire emergency. The Maintenance Director/Designee has been educated to ensure that the hallways are equipped with isolation bins with wheels to aid in the quick movement to clear a hallway during a fire emergency. The Maintenance Director/Designee will conduct routine rounds to ensure that there are wheels on isolation bins to ensure compliance with the regulation. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.

Penalty

No penalty information released

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

Summary

During an observation on May 13, 2025, at approximately 9:45 AM, it was found that the facility failed to document the required monthly maintenance for a portable fire extinguisher located in the kitchen service hallway. The inspection and maintenance tag, which is necessary to demonstrate compliance with NFPA 10 standards, was missing from the unit. This issue was confirmed by both the Facility Maintenance Director and the Administrator during interviews conducted at the time of observation. The deficiency could potentially affect 16 out of 87 occupants in the event of a fire emergency, as noted in the findings.

Plan Of Correction

The facility added the fire extinguisher inspection tag to document the required monthly maintenance on the portable fire extinguisher located in the kitchen service hallway. The Maintenance Director/Designee has been educated to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. The Maintenance Director/Designee will conduct routine rounds to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.

Penalty

No penalty information released

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

Summary

During an observation conducted on May 13, 2025, at approximately 9:45 AM, it was found that the facility did not maintain the required minimum clearance of 36 inches around the breaker panels located in the maintenance office. Combustible materials were observed placed in front of these breaker panels. This situation was confirmed by both the Facility Maintenance Director and the Administrator during interviews at the time of observation. The deficiency pertains to the facility's failure to ensure that equipment using gas or gas-related piping complies with NFPA 54 and that electrical wiring and equipment comply with NFPA 70, as required by regulatory standards. The report notes that this practice could affect 16 out of 87 occupants in the event of a fire emergency.

Plan Of Correction

The facility removed the combustible and there is no longer obstructions at the front of the breaker panels. The Maintenance Director/Designee has been educated to ensure that the maintenance office will maintain a minimum of 36 inches of clearance around the breaker panel. The Maintenance Director/Designee will conduct routine rounds to ensure that the maintenance office is maintaining a minimum of 36 inches of clearance around the breaker panel and they are not obstructed. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper labeling of oxygen cylinder storage racks inside the oxygen storage room located on hallway #800. During an observation, it was found that the storage rack did not have the required warning sign indicating whether the oxygen cylinders were EMPTY or FULL. This labeling is necessary to comply with NFPA 99 standards for the storage of nonflammable gases. The deficiency was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of observation. The lack of proper labeling could affect 16 out of 87 occupants in the event of a fire emergency, as noted in the findings. No additional details about specific residents or their medical conditions were provided in the report.

Plan Of Correction

The storage rack inside the oxygen storage room on hallway #800 has the proper warning sign indicating that the oxygen cylinders are full. The Maintenance Director/Designee has been educated to ensure that oxygen storage racks are labeled with the proper warning sign indicating if the oxygen cylinders are either empty or full. The Maintenance Director/Designee will conduct routine rounds to ensure that the oxygen storage racks are labeled with the proper warning sign indicating if the oxygen cylinders are either empty or full. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.

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 nursing staff failed to follow professional standards of practice in the care of a resident who sustained a thermal burn to the left upper thigh. The resident, who had diagnoses including urogenital implants and neuromuscular dysfunction of the bladder, required staff assistance with most activities of daily living and had intact cognition. The burn was identified as a second-degree, in-house acquired injury, and was first noted by the resident, who reported it to nursing staff after returning from an eye appointment where they had spilled hot coffee on themselves. Upon assessment, the wound was described and measured, and a treatment plan involving a wound cleanser and silver sulfadiazine was indicated. However, there was no evidence that a physician's order for the silver sulfadiazine was transcribed into the electronic medical record, nor was there documentation of the treatment being applied on the treatment administration record for the date the wound was identified. Additionally, the nurse who first identified the burn did not notify the Director of Nursing or the Administrator about the new injury, nor did they document the application of an abdominal pad or the completion of the identified treatment in the resident's record. The lack of timely transcription and implementation of physician orders, failure to document wound care, and failure to notify administration of a new skin injury resulted in the facility not meeting professional standards of quality for nursing services. These actions and omissions were confirmed through observation, record review, and interviews with facility staff.

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 the physician of a change in condition for a resident, R901, following a fall. R901, who had a history of significant cardiac disease, lung cancer, COPD, and diabetes, was found on the floor with a head injury and shoulder abrasion. Initial assessments by RN D and RN A revealed discrepancies in the severity of the injuries, with RN A noting a more severe gash on the forehead than initially reported. Despite concerns about the resident's condition, including elevated blood pressure and cognitive impairment, the on-call physician was not adequately informed of these changes. The nursing staff, including RN A, failed to use their judgment to escalate the situation appropriately. RN A, who was unfamiliar with R901, relied on vague reports and did not immediately send the resident to the hospital despite recognizing the severity of the injuries. The on-call provider, who was not familiar with the resident's medical history, was not informed of the resident's deteriorating condition, including increased bleeding and changes in mental status. The Director of Nursing and the Nursing Home Administrator acknowledged that the facility lacked a charge nurse or nurse manager as a resource on weekends, which may have contributed to the inadequate response. The resident's son, upon visiting, expressed concern about the lack of communication and the resident's condition, ultimately requesting the transfer to a hospital where the resident was admitted under trauma surgery service. The facility's failure to notify the physician and adequately assess and respond to the resident's condition led to a deficiency in care.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its policy on oxygen administration for a resident, identified as R404, who was admitted with multiple serious health conditions including acute on chronic systolic congestive heart failure, atrial fibrillation, chronic kidney disease, cardiac murmur, cardiac pacemaker, and dyspnea. Upon admission, the resident was noted to be on oxygen at a rate of 1 liter per minute, but there was no initial physician order documented for this oxygen administration. The facility's policy requires verification of a physician's order for oxygen administration, which was not followed in this case. The deficiency was further highlighted by the fact that the resident's oxygen orders were not implemented until three days after admission, despite nursing notes indicating the resident was on varying levels of oxygen during this period. The Director of Nursing, who was not employed at the time of the incident, acknowledged the concern but could not provide an explanation for the delay in implementing the orders. The lack of timely implementation of physician orders for oxygen administration represents a failure to provide safe and appropriate respiratory care 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 implement timely resident-specific interventions and provide adequate supervision to prevent falls for a resident identified as R702. R702, who had severe cognitive impairment and was at high risk for falls, experienced two falls within nine days of admission to the facility. The first fall resulted in a transfer to the emergency room, and the second fall led to a right hip fracture requiring surgery. Despite being aware of R702's high fall risk, the facility did not have appropriate interventions in place prior to the falls. R702 was admitted to the facility for a short-term stay following hospitalization for a left hip fracture. The resident's medical history included dementia, osteoarthritis, and osteoporosis. Upon admission, a fall risk assessment indicated a high risk for falls, yet the initial care plan lacked specific fall prevention measures. It was only after the first fall that interventions such as a toileting schedule and settling the resident in bed after dinner were initiated. However, these measures were insufficient, as evidenced by the second fall. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, revealed inconsistencies in the implementation of fall prevention strategies. Staff members mentioned various potential interventions, such as frequent rounding, low beds, and floor mats, but these were not consistently applied to R702's care. The facility's failure to provide adequate supervision and timely, resident-specific interventions contributed to the resident's falls and subsequent injury.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that call lights were within reach and answered promptly for several residents, leading to a deficiency in accommodating the needs and preferences of residents. Observations and interviews revealed that call lights were not placed within reach and were not answered in a timely manner, with some residents waiting over an hour for assistance. This issue was highlighted in multiple complaints reported to the State Agency and was also a concern raised during a resident council meeting. Specific instances included a resident whose call light was activated for over 40 minutes without response, and another resident who was observed with their call light out of reach on multiple occasions. Despite the facility's claim of average response times between 10-12 minutes, the documentation provided did not reflect this, and there was a lack of proper documentation for call light activations. Additionally, staff were observed not addressing activated call lights promptly, further contributing to the deficiency. The facility's procedures for responding to call lights were not effectively implemented, as evidenced by the repeated observations of call lights being out of reach and not being answered promptly. The Director of Nursing acknowledged the issue and noted that staff should ensure call lights are within residents' reach, but this was not consistently practiced. The deficiency was further compounded by the facility's inability to provide accurate call light reports, indicating a lack of proper monitoring and response to residents' 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 provide adequate assistance with activities of daily living (ADL) care, including personal hygiene, bathing, facial hair care, and dressing, for eight residents. This deficiency was identified through observations, interviews, and record reviews. Several residents, including those with intact cognition and those with cognitive impairments, reported not receiving showers or baths for extended periods, despite being scheduled for such care. For instance, one resident did not receive any showers or baths for 16 days, and another resident reported only receiving assistance from an occupational therapist for their first shower during their stay. Residents expressed frustration and embarrassment due to poor personal hygiene, with some residents having unshaven facial hair for several days and others wearing the same clothing repeatedly. Interviews with residents and their families revealed complaints about the lack of assistance with changing clothes and grooming. The facility's documentation often did not reflect refusals of care, and there were discrepancies between reported care and documented care in the electronic medical records. Staff interviews indicated that CNAs documented ADL care using electronic medical records, but there was a lack of oversight and monitoring to ensure that residents' needs were met. The Director of Nursing acknowledged the concerns and mentioned that residents were typically scheduled for two showers per week, with additional showers as needed. However, the documentation and resident reports indicated that this schedule was not consistently followed, leading to the identified deficiencies in care.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate below five percent, resulting in a 22.22% error rate during a medication administration observation. This was observed when six medication errors occurred out of 27 opportunities for error involving three residents. The errors included incorrect dosages and failure to administer medications as prescribed. For instance, a Licensed Practical Nurse (LPN) administered Docusate Sodium 250 mg instead of the prescribed 100 mg to one resident. Another LPN failed to administer the correct dosage of Omega-3 and Vitamin B Complex to a second resident and marked Magnesium as given on the Medication Administration Record (MAR) despite not administering it. Additionally, a third resident received a Multivitamin without minerals, contrary to the physician's order for Multivitamins with minerals. The report also highlighted procedural errors during medication administration. An LPN was observed not priming a NovoLog FlexPen before injecting insulin, contrary to the manufacturer's instructions, which require an airshot to ensure proper dosing. The Director of Nursing (DON) confirmed that insulin pens should be primed before each use and acknowledged that medications should not be marked as given until they are administered. These observations indicate a lack of adherence to medication administration protocols, contributing to the high error rate.

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 verify the credentials of an employee, identified as Staff 'M', who was employed as a Registered Nurse (RN) without having the required education, experience, and valid nursing license. This oversight was discovered after a complaint was filed with the State Agency, alleging that the facility allowed Staff 'M' to work 12 shifts before it was found they did not possess a valid RN license. The investigation revealed that Staff 'M' had used the identity of another individual, RN 'O', to obtain employment and had never been a nurse, although they had experience in phlebotomy. The facility's President of Clinical Services, Staff 'L', identified discrepancies in Staff 'M's license and registry information during a routine check. An interview with Staff 'M' confirmed that they had falsified their credentials and had never been a nurse. Staff 'M' admitted to using the knowledge gained from their phlebotomy experience to impersonate a nurse. The facility's investigation included a review of Staff 'M's time-punch reports, which showed they worked multiple shifts as an RN, including three days of orientation. The former HR Manager, Staff 'K', who was responsible for verifying employee credentials, failed to identify the discrepancies in Staff 'M's documentation and has since resigned. The facility conducted a thorough review of all employee files to ensure the accuracy of their credentials and found no further concerns. The investigation concluded that Staff 'M' had used RN 'O's license and was never a registered nurse, although no negative outcomes were reported for patients under their care during the time they worked at the facility.

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 treatment in a dignified manner for three residents, resulting in potential feelings of embarrassment. A complaint was received by the State Agency alleging that residents were not being treated with dignity. The facility's policy on Quality of Life-Accommodation of Needs emphasizes maintaining residents' dignity and well-being. However, observations and interviews revealed that some staff were not respectful, argued, and were rude to one another, making residents feel like they were in a facility rather than a home. Specific incidents included a resident expressing dissatisfaction with staff behavior, another resident being told to use an incontinence brief instead of being assisted to the restroom, and a third resident being given instructions about bathroom use loudly enough to be overheard from the hallway. The Director of Nursing acknowledged that it was inappropriate for staff to be overheard giving such instructions and that residents should not be told to use their incontinence briefs. These actions and inactions by the staff led to the deficiency in maintaining resident dignity.

Penalty

No penalty information released

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

Summary

The facility failed to honor a resident's personal preferences for care, specifically regarding shower and catheter change schedules. The resident, who is cognitively intact and requires assistance with activities of daily living, expressed a preference for morning showers instead of the scheduled Tuesday and Friday afternoons. However, the facility did not accommodate this request, citing that the day shift nurse aides were too busy. Additionally, the resident preferred their indwelling urinary catheter to be changed during the day rather than at night, but this preference was also not honored. The Director of Nursing confirmed that the resident's request for morning showers could not be accommodated due to the full schedule of the day shift CNAs. The facility's Resident Rights Handbook states that residents have the right to choose schedules consistent with their interests, which was not upheld 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 promptly follow up and resolve a grievance for a resident, resulting in feelings of frustration. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 15/15, was admitted with diagnoses including Parkinson's, neuropathy, depressive disorder, anxiety disorder, and muscle weakness. The resident and their family reported grievances about not receiving showers or baths for several days, despite multiple complaints to facility leadership. However, the facility did not have any documentation of these grievances. Interviews with facility staff, including the Director of Care Transitions, Director of Nursing (DON), and the Administrator, revealed that the facility had a grievance process in place, which involved documenting grievances and following up within 24 hours. However, the DON and Administrator were not aware of any grievances related to the resident, and the Assistant Director of Nursing, who was reportedly handling grievances, did not document or follow up on the complaints. The facility's Resident Concerns Policy outlined a procedure for addressing grievances, but it appears this process was not followed 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 timely and accurately transcribe physician orders for admission medications for a resident who was admitted with diagnoses including lung transplant status and idiopathic pulmonary fibrosis. Upon admission, the resident's discharge summary from the hospital included a list of medications, such as anticoagulant and antirejection medications, which were crucial for their condition. However, the resident did not receive the majority of their medications until two days after admission, with only a few medications administered on the first day. The Director of Nursing (DON) acknowledged that the nurse responsible for admitting the resident did not input any medication orders, leading to a delay in transcription. Although a second nurse attempted to rectify the issue, they also failed to transcribe the resident's tacrolimus, an essential antirejection medication. This oversight resulted in the resident not receiving their necessary medications in a timely manner, as confirmed by a review of the medication administration record and the medication order summary.

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 splint was applied per the physician's order for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident, who had intact cognition with a BIMS score of 13, was observed on two separate occasions without the prescribed resting hand splint on their right arm. The splint was noted to be on the dresser, and the resident indicated that staff did not offer to apply it. The physician's order, dated December 22, 2023, required the splint to be donned during nighttime hours for contracture prevention, but there was no schedule or frequency attached to the order. A review of the resident's comprehensive care plan and treatment/medication administration records for May and June 2024 showed no documentation that the splint had been applied as ordered. The Director of Nursing confirmed that the order was entered incorrectly into the record, lacking a schedule, which resulted in the nursing staff not being prompted to apply the splint. This oversight led to the failure in providing the necessary care to maintain or improve the resident's range of motion as per the physician's directive.

Penalty

No penalty information released

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

Summary

The facility failed to follow physician orders and ensure accurate documentation for a resident with an indwelling urinary catheter. The resident, who was cognitively intact and required assistance with activities of daily living, reported that their catheter was supposed to be changed monthly. However, it had been a month and four days since the last change. The Medication Administration Record (MAR) indicated that the catheter change was marked as completed by an LPN, despite the procedure not being performed. The LPN admitted to not changing the catheter as the resident preferred the procedure to be done during the day shift rather than the midnight shift. Despite this, the MAR was inaccurately marked as completed. The Director of Nursing confirmed that documentation should only occur after a task is completed and that any resident refusal should be recorded. The oversight in documentation led to the Director of Nursing being unaware that the catheter change had not been performed.

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 and accurately transcribe and administer physician-ordered medications, including anticoagulant (warfarin) and antirejection medicine (tacrolimus), for a resident who had undergone a lung transplant. The resident was admitted to the facility with a discharge medication list from the hospital, which included critical medications such as tacrolimus and warfarin. However, upon review of the resident's medication administration record, it was found that the resident did not receive any medication on a specific date except for calcium carbonate, metformin, and acetaminophen. Notably, there was no documentation of the administration of the antirejection medication, tacrolimus, during the resident's stay. The deficiency occurred because the nurse responsible for admitting the resident failed to input any medication orders, leading to a delay in the administration of most medications until two days after admission. A second nurse attempted to rectify the situation by entering the medication orders, but still failed to include the tacrolimus. This oversight was identified during a conversation with the Director of Nursing, who confirmed the transcription errors and the subsequent delay in medication administration.

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 storage and inventory of medications in a resident's room, leading to a deficiency. During an observation, several medications were found in clear storage cubes on the over-bed tray table of a resident, identified as R53. These included a bottle of Rolaids, eye drops, two inhalers, and two bottles of medications with unreadable labels. The resident explained that while the inhalers were theirs, the other medications belonged to a family member who would collect them after work. This situation persisted over multiple days, as the same medications were observed in the same location on subsequent visits. The facility's Director of Nursing (DON) was interviewed and acknowledged that the resident refused to allow the removal of the medications from their room. The DON admitted to not having discussed the issue with the resident's family member and was unaware of the specific medications being stored. The facility's policy on medication storage, which includes regular monitoring and quality assurance checks, was not effectively implemented in this case, as evidenced by the continued presence of the medications in the resident's room.