Cura Of Sandstone

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 infection prevention and control during laundry services and failed to maintain an effective infection surveillance program specific to culture results, organisms identified, and transmission-based precautions. During a laundry room tour, a staff member was observed sorting dirty laundry without wearing gloves and a gown, lifting dirty laundry from a bin and holding it against themselves while placing it into a washing machine. The same staff member was later observed removing clean laundry from a dryer and folding and hanging resident clothing. The laundry manager stated staff should wear gloves and a gown when handling dirty laundry because of concern for cross contamination with clean laundry, and the facility policy instructed employees sorting or washing laundry to wear a gown and gloves and to consider all dirty laundry potentially infectious. Review of the infection surveillance reports for January, February, and March showed that the logs included resident name, room number, onset date, infection type, signs and symptoms, status, and pharmacy order, but did not document the date cultures were obtained, organisms identified from culture results, whether organisms were resistant to prescribed antibiotics, or any transmission-based precautions initiated. Review of one resident’s urine culture dated 3/2/26 identified a susceptibility profile consistent with probable ESBL. During interview, the infection preventionist stated the facility did not track organisms on the surveillance reports and that culture results were kept in the resident record. The infection preventionist and RN-C confirmed that the culture results indicated the resident should have been placed on contact precautions, and the DON stated the organism was expected to be tracked in the infection surveillance program. The facility also failed to ensure proper glove use and hand hygiene during perineal care for a resident with dementia and epilepsy who was always incontinent of bowel and bladder and dependent on staff for toileting hygiene. During observation, a nurse assistant performed peri-care, applied barrier cream, and then, while still wearing contaminated gloves, placed a clean brief on the resident, secured it, pulled the resident’s pants up, returned cream to the bedside drawer, and handled trash before removing gloves and washing hands. The nurse assistant stated gloves were only changed when stool got on them and otherwise were wiped down to finish the task. The infection preventionist stated staff were expected to remove gloves after peri-care and sanitize before touching clean items, and the DON stated staff should change gloves when moving from dirty to clean parts of 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 follow care planned interventions intended to prevent avoidable accidents for two residents reviewed for falls and accidents. One resident had a history of cerebral infarct, moderate cognition, and required assist of one staff member, a gait belt, and a 4-wheeled walker for ambulation and transfers. The care plan and therapy communication both stated that a gait belt was to be used at all times when transferring or ambulating the resident, but during observation the resident walked from the bathroom toward a recliner with the DON without a gait belt in place. The DON acknowledged that the resident’s care plan required a gait belt during all mobility and transfers, and the facility policy stated a transfer belt should be used when assisting a resident who requires physical assistance with a transfer. Another resident with significant cognitive impairment, dementia, disorientation, atrial fibrillation, and hypertension had a care plan stating the resident was not safe to ambulate independently and needed one staff assist with a belt and walker. During observation, the resident was walking in the hallway to the dining room with an NA while wearing black socks without grippers and no shoes. Staff interviews confirmed the resident should have been wearing shoes or non-slip socks when walking, and the DON stated staff were expected to ensure appropriate footwear, use the walker, remain close, and provide verbal cueing. The facility policies on safety, supervision, and fall management directed staff to identify accident hazards and implement care plan interventions consistently to reduce fall risk. The facility also failed to ensure the safety of a resident with suicidal ideations and did not follow provider orders for safety precautions. The resident had diagnoses including major depressive disorder with psychotic symptoms, bipolar disorder, hallucinations, parkinsonism, insomnia, chronic pain syndrome, and mild cognitive impairment, and the record documented suicidal statements and an order to keep all cords out of the resident’s reach. Observations showed multiple cords in the resident’s room, including long call light cords, television cords, a fan cord, charging cords, a refrigerator cord, and a cord hanging from a light fixture, all within reach of the resident in a wheelchair. Staff interviews showed some were aware of suicidal statements and safety checks, but several did not know about the cord restriction, and the DON stated the order to remove cords was active and should have been followed. The facility further failed to evaluate a resident with increased aspiration risk. The resident had dementia, epilepsy, and was on a mechanically altered diet. The care plan addressed altered nutritional status and included a mechanically altered diet and monitoring for signs of dysphagia, but it lacked interventions for meal monitoring and assistance. The record showed repeated choking and coughing episodes with food and liquids, including choking immediately after drinking, coughing with food in the mouth, red face, difficulty chewing and swallowing, and vomiting after choking. Despite these events, the chart lacked documentation of a speech/swallow evaluation, documentation of guardian notification for some episodes, and documentation explaining the need for thickened liquids or a risk-versus-benefit form. During observation, the resident was eating lunch in the dining hall without staff present to monitor or assist with the meal.

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 resident’s family/guardian when the resident had a change in condition involving choking and possible aspiration. The resident had moderate cognitive impairment, diagnoses of dementia and epilepsy, and was on a mechanically altered diet. The care plan identified a risk for altered nutritional status due to hospice and directed staff to observe, document, and report signs or symptoms of dysphagia such as pocketing, choking, coughing, and holding food in the mouth. Provider orders identified a mechanical soft textured solid food diet with thin liquids. Progress notes showed that on 1/12/26 the resident was eating lunch, started choking and coughing on a piece of meat, and then vomited; the note stated staff would monitor for signs and symptoms of aspiration, but did not document that the guardian was notified. On 2/26/26 the resident started coughing with food in his mouth during mealtime, his face became red, and he appeared to have difficulty chewing and swallowing; staff attempted to listen to lung sounds because it sounded like he may have aspirated, and hospice was notified, but the documentation did not show that the guardian was notified. Interviews with LPN, RN, and the DON confirmed that family/guardian notification was expected for choking, aspiration concerns, and other changes in condition. Facility policy stated the nurse would notify the resident’s provider and representative when there was a significant change in physical, emotional, or mental health or a need to significantly alter medical treatment.

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 with constipation received assessment, effective intervention, and provider notification when bowel interventions were repeatedly used without documented resolution. For one resident with slow-transit constipation and occasional bowel incontinence, the record showed standing bowel protocol interventions and dietary measures were used multiple times, including repeated use over a one-week period, but the electronic medical record did not contain evidence of a nurse assessment or notification of the provider regarding the unsuccessful constipation interventions. Staff interviews indicated the resident needed assistance with toileting and that bowel movements were tracked by aides, while the RN stated she would typically wait several days before escalating interventions and would only later check orders for progressive steps. A second resident, who was continent of bowel, able to make needs known, and independent with toileting hygiene, had a care plan that directed staff to give medications as ordered, observe for effectiveness and adverse effects, follow the bowel protocol, record bowel movements every shift, and update the provider with changes in bowel pattern. The resident’s record showed a pattern of repeated bowel protocol use, including MOM, prunes/prune juice/BAP, and repeated “day 4/day 5/day 7 no BM” entries, but the resident’s PRN polyethylene glycol order was not used. The EMR did not contain evidence of bowel assessments or provider notification for ongoing constipation and repeated PRN use. During interviews, the resident stated she thought she was backed up and had not gone since the prior Monday. Nursing staff stated aides or nurses asked residents each shift about bowel movements and documented them, and the ADON stated the overnight nurse was responsible for running the bowel report and entering orders for day shift. The DON stated that when bowel protocol measures were not working, staff should reach out to the provider and perform an assessment because they were going on without effectiveness. The facility’s standing orders outlined a bowel protocol beginning on day two without a bowel movement, with escalation to MOM or lactulose, then bisacodyl suppository and tap water enema if no results were obtained.

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 perform a passive range of motion (PROM) program for one resident who was cognitively intact and had diagnoses of multiple sclerosis and paraplegia. The resident’s annual MDS indicated impairment to one upper extremity and both lower extremities, and the care plan identified a potential for injury related to impaired mobility from paraplegia and MS. The care plan directed staff to complete a PROM/stretching program once each shift, in the morning and evening, and copies of the program were available at the nurse station. Review of the resident’s PROM documentation from 3/10/26 to 4/8/26 showed 10 shifts marked as not performed, 14 shifts marked as not applicable, and 6 shifts with no documentation. During observation, the resident was noted to have contractures of the right upper extremity and both lower extremities. The resident stated staff were always forgetting to do the PROM to those extremities and said the contractures had been present for some time due to MS. A nurse assistant stated the resident was on a PROM program that needed to be done daily on the day and evening shifts, that documentation should be yes or refused, and that there was no reason to document no or not applicable. The DON stated the expectation was for the NA to perform the PROM when scheduled and document yes or refused, with refusal reported to the charge nurse.

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 attempt to elevate the head of bed (HOB) for a resident receiving tube feeding while the resident was lying flat with the feeding running. The resident had moderate cognitive impairment, diagnoses including abdominal distention and hemiplegia, and received 51% or greater of intake through tube feeding. The care plan identified a nutritional problem related to hemiplegia and also noted a risk for aspiration related to tube feeding and inconsistent maintenance of HOB greater than 30 degrees secondary to resident preference/refusal. Interventions included positioning the resident with the head elevated greater than 30 degrees during feedings and holding the tube feeding if refusal for HOB elevation was found. During observation, the resident was seen in bed lying on her back with the HOB flat while Jevity 1.2 was running continuously at 30 milliliters per hour. The nurse assistant confirmed the resident was lying flat with tube feeding running and stated the resident needed HOB greater than 30 degrees to prevent aspiration, but also stated the resident often lowered the HOB herself. The nurse assistant did not attempt to raise the HOB or report the condition to the charge nurse. An LPN stated residents with tube feeding were to have the HOB elevated over 30 degrees and staff should attempt to raise it and report it if below that level. The DON stated staff were expected to attempt to raise the HOB over 30 degrees and, if the resident refused, report it to the charge nurse for education and possible risk-versus-benefit review.

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 its antibiotic stewardship program for one resident who was reviewed for antibiotic use. The resident had multiple sclerosis, dysuria, obesity, diabetes mellitus type 2, paraplegia, and dementia, and was documented as cognitively intact on the annual MDS. The care plan identified urinary incontinence and an indwelling catheter. Nursing documentation showed that staff sent a portal message to the provider about urinary color, vaginal discharge, and increasing confusion and agitation, and later documented urinary odor, vaginal discharge, and increasing confusion and agitation. The provider ordered Macrobid for dysuria before there was documentation of established criteria, such as McGeer criteria, being used to determine infection. The medical record also lacked documentation that non-pharmaceutical interventions were initiated before requesting the antibiotic order. The urine culture later showed a probable ESBL organism greater than 100,000 CFU/ml and resistance to cefuroxime. During interviews, the IP stated staff should identify at least three symptoms when suspecting a UTI and confirmed there was no documentation that McGeer criteria were completed before the antibiotic order. RN-C stated the urine specimen was obtained after the antibiotic order and noted the resident had a history of refusals. The DON stated staff were expected to monitor symptoms, assess, follow McGeer criteria, initiate standing orders for UTI-stat and increased fluids, and question antibiotic orders before specimen collection.

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 develop and implement care plans that included Enhanced Barrier Precautions (EBPs) for residents requiring such precautions, and failure of staff to use required personal protective equipment (PPE) during high-contact care. Surveyors observed an EBP sign on the door of a resident’s room and a PPE cart outside the door, indicating that EBPs were required. During wound care to the resident’s coccyx, a nursing assistant (NA), who was an agency aide, assisted a registered nurse (RN), also an agency nurse, while wearing only gloves and a mask. The RN entered the room wearing a mask, gloves, and a gown but did not instruct the NA to don a gown, even though the NA was performing high-contact care by turning and holding the resident in position. The resident did not participate in bed mobility and was dependent on staff for all care and mobility. The resident’s admission MDS documented diagnoses of Alzheimer’s disease and a stage IV pressure ulcer, with severely impaired cognition and total dependence on staff. The resident’s care plan directed assistance of one to two staff for all care but did not include directions for EBPs during high-contact care. The NA reported receiving only verbal instructions about resident care upon starting work and stated she had not been shown how to access residents’ care plans or the Kardex. She did not see the EBP sign on the door and did not know the PPE cart was intended for that resident, although she was aware of EBP practices in general. The ADON/infection control nurse acknowledged that EBPs, including gown and gloves, should be used for identified residents during high-contact care, that NAs are to reference the Kardex for required precautions, and that EBPs had been missed in the resident’s care plan. Facility policies on EBPs and comprehensive person-centered care plans required incorporation of identified problems, risk factors, and current standards of practice, including targeted gown and glove use for MDRO control, which were not reflected in this resident’s care plan or consistently implemented by 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 deficiency involves the facility’s failure to follow its own infection prevention and control practices, including hand hygiene, glove use, surface disinfection, and Enhanced Barrier Precautions (EBPs), for three residents on EBPs during high-contact care. For one resident with multiple pressure injuries and a Foley catheter, the DON repeatedly failed to perform hand hygiene between glove changes and between care of different wounds. During wound care to the left foot, the DON removed soiled dressings, discarded gloves, and applied new gloves without hand hygiene, then cleansed and dressed a stage II heel wound and a stage III lateral foot wound without changing gloves or performing hand hygiene between steps until later in the procedure. The DON also attempted Foley catheter insertion multiple times, changing to sterile gloves and opening new catheter kits without performing hand hygiene between attempts. When providing care to the resident’s stage IV coccyx and left gluteal fold wounds, the DON removed dressings without changing gloves and performing hand hygiene, handled paper tape measures between the wounds and the bedside table without hand hygiene, and did not change gloves or perform hand hygiene between cleansing the two separate wounds. The same resident’s care involved additional infection control lapses related to contaminated items and environmental surfaces. The DON placed used paper tape measures on the bedside table and on top of an open box of facial tissues, then later on the flap of an open box of ostomy bags, after the tape measures had been in contact with the resident’s wounds and the bedside table. The nurses did not disinfect the over-bed table where the soiled tape measures had been placed before exiting the room. This resident’s quarterly MDS documented diagnoses including Type 2 diabetes mellitus, paraplegia, encephalopathy, and multiple pressure ulcers (two stage III, one stage IV, and one deep tissue injury). The resident’s care plan indicated she was on EBPs per CDC recommendations for wounds, with a goal to remain free of multidrug-resistant organisms (MDRO), and that she was cognitively intact but dependent on staff for all care and mobility. For a second resident on EBPs with a stage IV pressure ulcer and severely impaired cognition, staff failed to implement required gown use during high-contact care. An EBP sign and PPE cart were present outside the room, but an NA entered wearing only gloves and a mask while an RN, an agency nurse, entered with a mask, gloves, and gown and did not instruct the NA to don a gown. The NA assisted with positioning the resident for coccyx wound care, with her scrubs in contact with the resident’s bedding and handrail, and had been providing care for this resident for weeks without using a gown. The NA reported she did not see the EBP sign, did not know the PPE cart was intended for that resident, and had not been shown how to access residents’ care plans, while the ADON later acknowledged EBPs had been missed on this resident’s care plan. For a third resident on EBPs with stage III coccyx and stage IV left gluteal wounds, the DON again failed to follow infection control practices during wound care. The DON used a paper measuring tape on the coccyx wound, wrote measurements on it, and placed the tape directly on the bedside table where red liquid was observed on the back of the tape, and it touched the resident’s water mug. The DON changed gloves but did not perform hand hygiene before measuring the left gluteal wound with a new paper tape measure. At the end of the procedure, the DON picked up the marker and soiled tape measures with bare hands, placed them in her scrub pocket, and later placed them on the treatment cart next to a laptop in the hallway. The nurses did not disinfect the bedside table after wound care. Facility policies on hand hygiene, PPE, and EBPs required hand hygiene before and after glove use, between contaminated and clean body sites, after handling used dressings or contaminated equipment, and after glove removal, and directed that gloves do not replace handwashing and that gowns and gloves be used for high-contact care for residents with wounds or indwelling devices under EBPs.

Penalty

Inspection fine: $17,345

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 staff failed to ensure a safe transfer of a resident using an EZ Way smart lift, resulting in the resident falling from the sling and sustaining a scalp contusion and a closed wedge compression fracture of the T4 vertebra. The resident, who had diagnoses of intellectual disabilities and osteoporosis and was fully dependent on staff for transfers, required two staff members and the use of a mechanical lift for all transfers according to her care plan. On the day of the incident, two nursing assistants, both under the age of eighteen, attempted to transfer the resident without following facility policy or the manufacturer's instructions. During the transfer, one nursing assistant attached only the upper right sling strap and was distracted by another resident's needs, leaving the area. The other assistant, also underage, began operating the lift without verifying that all straps were secured and without the required adult supervision. As a result, the resident leaned forward and fell out of the lift onto the floor. Interviews confirmed that both staff members were aware that at least one adult should have been present and that all straps needed to be checked before operating the lift, but these procedures were not followed. The EZ Way representative confirmed that the lift and sling were functioning properly and that the incident was due to improper use. The facility's policies and the manufacturer's instructions both required two staff to be present, with one being at least eighteen years old, and for all four sling straps to be checked before lifting. The medical director confirmed that the injuries were acute and directly resulted from the fall during the transfer.

Removal Plan

• Reviewed policies on use of mechanical lifts.
• Re-assessed R1 and all residents who utilize a mechanical lift.
• Re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing.
• Completed audits observing staff transferring residents with mechanical lifts; results would be brought to Quality Assurance and Performance Improvement (QAPI) committee.
• Developed an ongoing plan for safe transfer education in QAPI meeting.

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 weekend mail delivery for residents, impacting all 41 residents residing at the facility. During interviews, residents confirmed that while mail and packages were delivered to the facility on weekends, they were not distributed to them. Some residents noted that mail and packages were left unattended in the facility over the weekend. The facility's policy requires mail to be delivered to residents within 24 hours, unopened and unread, unless assistance is requested. Interviews with staff revealed a lack of clarity and consistency in the mail delivery process on weekends. The activities staff, responsible for mail delivery, only distributed mail that was already in the activities department and did not retrieve newly delivered mail from the office on weekends. This resulted in residents not receiving their mail until the following week. The activities director acknowledged the inconsistency in mail delivery and indicated plans to address the issue.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the use of alcohol-based hand sanitizer in the hand hygiene dispensers throughout the facility. Observations revealed that the hand sanitizer dispensed from the hallway and resident room dispensers felt watery and was odorless. Housekeeping staff were responsible for refilling the dispensers and used a product provided by Ecolab, which was benzalkonium chloride 0.89% and water, a non-alcohol-based sanitizer. The facility's policy required the use of an alcohol-based hand rub containing at least 62% alcohol, but the staff, including the administrator and the director of nursing, were unaware that the product in use did not meet this requirement. Additionally, the facility failed to change the oxygen tubing timely for a resident receiving oxygen therapy. The resident, who had a diagnosis of COPD and used oxygen, had oxygen tubing dated 2/2, which was not changed weekly as required by the facility's infection control policy. The tubing was verified by an LPN to be overdue for a change, and the director of nursing confirmed that the tubing should be replaced weekly to minimize infection risk.

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 surety bond to protect the account balance of the resident trust fund, which had the potential to affect 23 of 41 residents with trust accounts managed by the facility. During an interview, the office manager, responsible for the resident trust funds, was unable to locate a copy of the surety bond and indicated a need to follow up with the corporate office. The administrator later provided a document titled 'Erisa Dishonesty Bond Edition of 10/1/17' from Spring Valley Mutual Insurance Company, which covered employees insured by employee benefit plans but did not include coverage for residents with trust accounts. Despite additional requests, no further documents specific to the resident trust accounts were received. The facility's policy on handling resident finances and property requires that any party responsible for managing residents' personal funds be bonded or insured in sufficient amounts to cover losses of resident funds and provide proof of such bond or insurance.

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 temperature-controlled medications were properly stored, affecting six residents and any resident needing medications from the pharmacy-provided emergency kit, stock vaccine, and tuberculin testing medication. During a tour of station three's medication room, it was observed that the medication refrigerator temperature log recorded temperatures out of the safe range. The refrigerator contained insulins, neurontin, vaccines, and other medications, and the temperatures were noted to be 48 degrees Fahrenheit in the morning and 53 degrees Fahrenheit in the afternoon. Despite adjusting the temperatures, the staff did not notify anyone about the issue. The temperature records for the medication refrigerator showed multiple instances of temperatures being out of the safe range from October 2024 to February 2025. The safe range was identified as 36 degrees Fahrenheit to 46 degrees Fahrenheit, but the records revealed several dates where the temperatures were either below or above this range. The medications stored in the refrigerator included liquid gabapentin, Trulicity, Semglee, Copaxone, Novolog, Lantus, Arexvy kit, and Aplisol, all of which required storage between 36 degrees and 46 degrees Fahrenheit according to the manufacturer's guidelines. Interviews with the director of nursing, consultant pharmacist, and maintenance staff revealed that there was an expectation for staff to notify maintenance if the medication refrigerator was out of the temperature range. However, maintenance staff could not recall being notified, and the consultant pharmacist expressed concern about the viability of medications stored out of the safe range for months. The facility's medication guidelines required that medications needing refrigeration be stored within standard temperature parameters based on CDC recommendations, which was not adhered to 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 adhere to provider orders for medication administration and fluid management for two residents, leading to deficiencies in care. Resident R18, who had moderately impaired cognition and diagnoses of hypertension and repeated falls, was prescribed furosemide with specific parameters to hold the medication if the systolic blood pressure (SBP) was below 110. However, the medication was administered on two occasions when R18's SBP was below the threshold, potentially risking further health complications. Interviews with nursing staff revealed an expectation that provider orders should be followed, and failure to do so could result in adverse effects such as lower blood pressure and electrolyte imbalance. For Resident R142, the facility did not follow provider orders for a fluid restriction and daily weight monitoring. R142, diagnosed with heart failure, stomach cancer, anemia, and hypertension, had orders for a fluid restriction of 64 ounces daily and daily weight monitoring due to ascites. The care plan did not include the fluid restriction, and the Kardex used by staff to guide care was not updated with this critical information. Interviews with nursing assistants and registered nurses indicated a lack of awareness and documentation regarding the fluid restriction and daily weights, leading to inconsistencies in care delivery. The facility's policy on medication administration emphasized the importance of following provider orders and ensuring the six rights of medication administration. Despite this, the facility's failure to document and communicate essential care instructions for R142, such as fluid restrictions and daily weights, resulted in a lack of adherence to prescribed care plans. This oversight in communication and documentation contributed to the deficiencies observed during the survey, highlighting the need for accurate and timely updates to care plans and staff awareness of resident-specific care 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 aspiration precautions were followed for a resident reviewed for accidents. The resident, who had a history of cerebral infarction and dysphagia, was identified as cognitively intact and had specific instructions to avoid using straws, as per speech therapy recommendations. Despite these instructions, the resident was observed with a large plastic cup containing a straw. The resident confirmed that they always had a straw in their water cup. A registered nurse verified that the resident was not supposed to have straws and acknowledged that the use of a straw would increase the risk of aspiration. The facility did not provide a policy on aspiration precautions when requested.

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 oxygen was administered as ordered for a resident with chronic obstructive pulmonary disease (COPD). The resident, who was moderately cognitively intact, had an active order for oxygen at two liters per nasal cannula at bedtime. However, the treatment record for the past three months showed that the resident had been receiving oxygen at three liters per minute on multiple occasions. Additionally, observations revealed that the resident's oxygen flow meter was set at 2.5 liters per minute, which was higher than the prescribed amount. Interviews with staff confirmed that the oxygen flow rate was not being maintained as per the medical provider's order. A licensed practical nurse acknowledged that the oxygen should have been set at two liters per minute and expressed concern that a higher flow rate could lead to the resident retaining carbon dioxide, potentially causing respiratory failure. The director of nursing stated that staff were expected to check the oxygen flow meter daily and document oxygen saturations, emphasizing the importance of following the medical provider's orders, especially for residents with COPD.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the use of a PRN psychotropic medication, specifically lorazepam, was limited to a 14-day period or re-evaluated by the provider for ongoing need and efficacy for a resident. The resident, who was moderately cognitively intact, had multiple diagnoses including anxiety disorder and was receiving palliative care. Despite the resident's active order for lorazepam being valid through end of life, the facility did not receive a documented rationale from the physician for extending the PRN order beyond 14 days, as required by policy. The pharmacist had made multiple recommendations to the providers in November, December, and February to document the rationale for the PRN order extension, but no response was received. Interviews with the hospice RN and the DON revealed a lack of clarity regarding the need for a stop date for the PRN lorazepam order, with the DON unsure if the medical director had communicated with the hospice physician about this issue. The consultant pharmacist confirmed that the request for a stop date had been discussed in a quality meeting, but no action was taken to address the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that resident call lights were accessible from the bathroom floor in multi-resident bathrooms for three residents. During observations, it was noted that the call light cords in the shared bathrooms of these residents were not within reach from the floor. Specifically, one resident's call light was looped and attached to a hook approximately four feet from the floor, while the other two residents had call light cords that were 10 and 14 inches from the floor, respectively. Further investigation revealed that the maintenance staff confirmed the call lights were not easily accessible, with measurements showing cords at 17 to 18 inches from the floor when unhooked. A resident confirmed that the call light had always been hooked to the wall, and no request was made for it to be looped. The facility administrator acknowledged that having the call light cords reach closer to the floor would increase the likelihood of residents being able to reach them in case of a fall. Despite a request, the facility did not provide a policy on call lights.