St Marks Living

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 dishwashing sanitization temperatures for 1 of 1 dishwashers were appropriately monitored. During the initial kitchen tour, the dietary director stated the dishwasher sanitized dishes with heat, and a temperature log for June 2026 was observed in the dishwasher room. The log showed wash temperatures of 160 degrees F and rinse temperatures of 150 to 175 degrees F, but the rinse temperature was never documented at the required 180 degrees F. Of 43 possible temperature entries for three daily meal services, 16 spaces were blank. During observation, a dietary aide was using the dishwasher to clean silverware from the noon meal and stated the wash temperature should be 160 degrees F and the rinse temperature 180 degrees F. With the dishwasher in operation, the wash gauge reached only 132 degrees F and the rinse reached 170 degrees F. Even after multiple racks were run through the machine, neither temperature reached the required level. The dietary director reviewed the log and acknowledged that no rinse temperatures had been documented at 180 degrees F and stated she did not monitor the logs and could not say how long the required temperatures had not been reached. Additional review of March, April, and May 2026 dishwasher logs showed that out of three months, only one entry documented the required rinse temperature of 180 degrees F. The logs did not list the required temperature parameters or what staff should do if they were not met. A vendor service report dated 6/8/26 stated the wash temperature reached 160 degrees F and the rinse temperature reached 180 degrees F, but the corresponding facility log did not reflect that. Later interviews with the dietary director, maintenance director, vendor representative, vendor manager, DON, interim DON, and RD confirmed the dishwasher had ongoing temperature issues, that staff had to run five loads to reach 180 degrees F, and that the booster had one heating element out.

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 and implement an infection prevention and control program because it did not ensure ongoing surveillance for infections, ongoing review of surveillance data, or documentation of follow-up activity and response. Review of the infection control binder provided on 6/15/26 did not include line listings, mapping, or surveillance data for tracking and monitoring infections in the facility. During interview, the newly hired infection preventionist stated she had just started and could not locate any infection control tracking, data, surveillance, or mapping documents from the prior infection preventionist. The interim DON stated the prior infection preventionist had left on short notice, that no evidence of surveillance or tracking of infections could be found, and that no new method had been implemented. The facility also failed to ensure a glucometer used on multiple residents was disinfected after use on a resident with diabetes. The resident’s records showed diagnoses of diabetes, orders for blood glucose checks, and a care plan addressing blood sugar monitoring. During observation, an LPN obtained a fingerstick blood sugar using a shared glucometer, returned it to a tote with unused needles, and did not disinfect it after use. The same glucometer remained undisinfected later that morning. During interview, the LPN admitted she did not disinfect the glucometer after use and stated she knew she should have used a disinfectant wipe to prevent transfer of germs. The DON was informed of the finding and stated nursing staff were expected to disinfect glucometers after use.

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 a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use, and resistance. Review of the infection control binder showed no antibiotic tracking for correct indications, dosage, duration, resistance, or 72-hour time-outs to review cultures and verify correct antibiotics or resistance to prescribed antibiotics. During interview, the RN who had recently been hired as the infection preventionist stated she had not had time to start an antibiotic stewardship program and could not find any documents from the prior infection preventionist showing that antibiotic usage was being tracked and monitored. The interim DON stated the prior employee responsible for antibiotic stewardship had left on short notice and that there was no evidence of tracking antibiotic usage for correct dosage, duration, resistance, or completion of 72-hour time-outs. The interim DON also stated this was a problem at the facility and that the program would need to be restarted.

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 clean, comfortable, and homelike environment in Golden Oak Hall because the resident hallway carpeting had numerous large, dark stains throughout the walking path. On 6/16/26, observation showed multiple dark brown to gray discolorations embedded in the carpet, with several stains measuring about 1 to 3 feet in diameter and appearing as repeated liquid spills that had penetrated the carpet. The interim director of nursing observed the carpeting and stated it had been shampooed about two weeks earlier, confirmed it was stained, and said it needed to be replaced. Nursing assistants stated the stains were an ongoing concern, had been present for an extended period, and that spills from a beverage cart routinely occurred in the hallway. The facility also failed to repair gaps in an exterior double service door near the kitchen dumpsters. During observation, daylight was visible through the gap where the two doors met, and the dietary director stated the facility had mice in the past and had changed pest control companies. The maintenance director stated he had been aware of the gap but did not know how to fix it and said a new door would be expensive. Resident council minutes documented concerns about rodents, and a family member stated she had seen mice in a resident room within the last month. The administrator later acknowledged awareness of the gap in the service entrance door.

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 accuracy of the Minimum Data Set (MDS) assessment for one resident, R6, when the quarterly MDS did not reflect opioid and diuretic medications that the resident was receiving. R6 had diagnoses of Parkinson's disease, high blood pressure, congestive heart failure, and was receiving hospice care. The MDS indicated moderate cognitive impairment, clear speech, ability to understand and be understood, and substantial assistance or dependence for activities of daily living. Although the MDS section for medications had been signed off as completed by the MDS nurse, it did not include the diuretic and opioid medications that were part of the resident's active regimen. R6's orders showed furosemide 30 mg by mouth twice daily for edema and fentanyl transdermal patch 12 mcg/hr every 3 days for pain. The MAR showed the resident received furosemide twice daily in May and June 2026 and fentanyl patches every third day since the medication was ordered in May 2026. R6's care plan addressed congestive heart failure and diuretic administration, and also noted the resident was at the end stage of life and using hospice services. During interview, the DON reviewed the orders, MAR, and MDS and stated the diuretic and opioid should have been checked on the MDS to show the resident was receiving those medications at the time of the quarterly 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 physician orders during a dressing change for a resident with a right index finger wound. The resident had diagnoses including cerebral palsy and a rash/other nonspecific skin eruption, and the care plan identified the resident as at risk for skin infections due to frequent refusal of showers. The wound care provider order directed staff to cleanse the wound with acetic acid, paint the wound base with Betadine, cover with soft dry gauze, and change the dressing daily. During observation and interview, an LPN stated the dressing change had been completed earlier in the day with acetic acid, but Betadine had not been applied because the nurse did not realize it was part of the order. The LPN later reviewed the order and acknowledged Betadine should have been applied, and also stated Betadine had not been applied during dressing changes the previous week. The resident’s weekly skin assessments did not consistently include assessment and documentation of the finger wound. The skin assessment record showed entries noting the wound on the right hand second digit on several dates, but one weekly assessment did not include a finger assessment, and later assessments documented only buttocks moisture-associated skin damage. The facility’s interim DON and DON confirmed that not all skin assessments included evaluation of the finger wound and stated the wound should have been assessed and documented to determine whether it was improving or worsening. Another LPN stated weekly skin assessments should include the finger wound and documentation describing its appearance over time. The facility also failed to ensure physician orders were carried out for a resident with diabetes mellitus when elevated blood sugar levels were not reported to the provider as ordered. The resident’s orders required notification of the provider if blood sugar was less than 100 or over 400, including for scheduled insulin and sliding-scale insulin. Multiple blood sugar readings were over 400 mg/dl on numerous dates, but provider notification could only be verified for two of those dates. During interview, nursing staff stated they could see the notification requirement in the electronic MAR, and the DON and interim DON could not verify that the provider had been informed for the remaining elevated readings.

Penalty

Inspection fine: $127,00035 days payment denial

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

Summary

The deficiency involves the facility’s failure to ensure safe use of sit-to-stand and total body mechanical lifts, including correct sling/harness sizing, proper strap application, and adherence to care plans and manufacturer instructions. One resident (R4), with diagnoses including heart failure, chronic kidney disease, pancreatic cancer, diabetes, osteoarthritis, and a history of falls, was assessed as high fall risk and required assistance of two staff with a sit-to-stand lift using a large harness for all transfers. Despite this, on a prior date R4 experienced a witnessed fall from a sit-to-stand lift when a nursing assistant transferred the resident alone, contrary to the care plan, and the resident slipped out of the harness and fell to the floor, later reporting left shoulder pain. The facility’s documentation of that incident did not identify the sling size used, did not show a comprehensive assessment to determine the correct sling size for subsequent transfers, and the care plan was not revised to address the resident’s tendency to fall asleep in the lift. On a later observation, two nursing assistants (NA-C and NA-D) prepared to transfer R4 from bed to shower chair using a sit-to-stand lift with an extra-large (XL) harness draped over the lift, which they both believed was the correct size. Neither had a resident care guide in the room identifying the correct harness size. After the surveyor intervened and prompted verification, NA-D checked the resident care guide and discovered R4 was supposed to use a large harness, not an XL, and had to obtain the correct size from another unit because it was not available on R4’s wing. During the same transfer, after the large harness was applied and R4 was raised to standing, the torso strap was not cinched until the surveyor intervened and instructed the staff to tighten it. NA-C acknowledged she knew the torso strap needed to be cinched as the resident stood and that failure to do so could allow a resident to fall out of the lift, but stated she had overlooked this step. Staff also reported they had not received any re-education on proper mechanical lift use or following care plans since initial orientation. A second resident (R9), with diagnoses including heart failure, chronic respiratory failure, and chronic kidney disease, required total mechanical lift transfers and had been assessed via a sling/harness sizing assessment as needing a large sling. However, the resident’s care plan and Kardex directed staff to use an XL sling, conflicting with the sizing assessment. During observation, R9 was seated in a wheelchair on top of a sling whose size markings were washed off; a trained medication aide identified the sling as XL based on its color coding and confirmed via the Kardex that the resident was supposed to be in a large sling. The aide stated the resident could have fallen out of the oversized sling. The DON later confirmed that staff had been using the paper nurse aide care guide to verify sling size and that R9 had not been transferred with the correct sling size. The facility also failed to comprehensively investigate and analyze falls for root cause and to implement appropriate, person-centered interventions for another resident (R3) with malignant brain neoplasm, heart failure, osteoporosis, moderate cognitive impairment, and a history of falls. R3’s fall care plan included general interventions such as following the fall protocol, routine safety checks, anticipating needs, and reviewing past falls to determine causes, but subsequent fall incident documentation and root cause analysis worksheets were incomplete or lacked clear causal analysis and corresponding interventions. After an unwitnessed bathroom fall assisted by a family member, the root cause section was left blank, and the only care plan revision was to encourage family not to transfer the resident and to ask staff for assistance. Later falls, including one where the resident was found on the bathroom floor without a walker and another where the resident independently walked to the bathroom and lost balance, identified factors such as brain cancer, weakness, and self-transfers, but did not show comprehensive analysis or immediate interventions to mitigate further falls. One intervention, placing a dycem mat in the wheelchair seat, lacked a documented rationale linked to the identified causal factors. The DON acknowledged that comprehensive causal analyses had not been completed for each of R3’s falls and that toileting, identified as a root cause, was not addressed in the care plan until several days after repeated falls. The immediate jeopardy began when NA-C and NA-D had to be stopped from using the wrong harness size for R4 and failed to cinch the torso strap during a sit-to-stand transfer, despite R4’s prior fall from a sit-to-stand lift and existing care plan requirements. The medical director stated that any resident being transferred using a mechanical lift without the care plan and/or policy being followed had the likelihood to cause serious harm, serious injury, or death in the event of a fall from the lift.

Removal Plan

• The facility identified all residents who use a sit-to-stand lift, assessed each resident for the correct harness size needed, and educated each member of the nursing staff who will or may use the sit-to-stand lift.
• The facility assessed R4 and all residents using mechanical lifts for proper transfer method, correct sling/harness size, and care plan accuracy.
• The facility verified sling/harness size for each resident through therapy documentation, direct measurement, manufacturer guidelines, and care plan accuracy.
• The facility reviewed and updated the mechanical lift transfer policy to require sling/harness size documented in the care plan and Kardex, require 2-assist transfers when indicated, require staff verification of sling size prior to transfer, and require cinching of waist/middle straps before elevation.
• The facility updated care plans to specifically identify type of lift, assist level, and sling/harness size.
• The facility updated the Kardex to match the care plan.
• The facility updated care sheets to match the care plan.
• The facility provided education to all licensed nurses and other certified individuals on manufacturer recommendations, proper sling application, proper strap placement and cinching, when sit-to-stand lifts are contraindicated, and always following the care plan.

Penalty

Inspection fine: $127,00035 days payment denial

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 comprehensive, ongoing assessment and individualized pressure-relief interventions for residents at risk for or with pressure ulcers, resulting in actual harm to one resident whose facility-acquired stage 2 pressure ulcer deteriorated to stage 3. For one resident with multiple sclerosis, diabetes, heart failure, neurogenic bladder and bowel, and chronic kidney disease, the Braden assessments identified moderate risk and the care plan called for heel elevation, pressure-reducing surfaces, and turning/repositioning in bed and chair. Despite repeated weekly skin assessments documenting “redness to bottom/skin breakdown” over several weeks, these assessments lacked wound location, measurements, type, or other characteristics. When a stage 2 pressure ulcer on the left buttock was first documented, there was a delay in obtaining a specific wound treatment order, and once ordered, subsequent skin assessments continued to list the wound as a stage 2 ulcer with unchanged measurements and minimal description, even after a nurse practitioner later documented that the ulcer had progressed to stage 3 with detailed measurements and wound characteristics. From the time the stage 2 ulcer was identified until the nurse practitioner documented stage 3 status, the record did not show that existing pressure-relief interventions were evaluated for effectiveness or that new interventions were added. The resident’s repositioning schedule in bed and chair was not reassessed for appropriateness, and there was no comprehensive assessment of skin tolerance to pressure over time. Staff interviews revealed that direct care staff were unaware of the ordered frequency for repositioning in the wheelchair and relied on the resident to self-reposition, even though the resident reported sometimes being unable to feel when her buttocks were getting sore due to MS and sometimes forgetting to reposition. The resident’s ROHO cushion had been placed backwards on multiple occasions, and the resident stated that this worsened her bottom when not placed correctly. Documentation also showed that a foam dressing ordered by the nurse practitioner was omitted from the transcribed treatment orders, and treatments were carried out without the foam dressing, while weekly skin assessments continued to record the wound as a healing stage 2 ulcer with the same measurements and no detailed characteristics. Two additional residents with buttock wounds and pressure injury risk also did not receive weekly comprehensive RN wound assessments as required by facility policy. One resident with heart failure, chronic kidney disease, pancreatic cancer, diabetes, and a history of falls had old scarring on the buttocks and was admitted with a buttock wound. Orders were in place for foam dressings and daily assessment, and a nurse practitioner later identified a stage 2 pressure injury to the left medial buttock and incontinence-associated dermatitis with multiple small open wounds. However, subsequent skin assessments lacked full wound descriptions, did not address all wounds identified by the nurse practitioner, and there was a period where no comprehensive wound assessment was documented. During observation, this resident was found lying on a completely deflated, unplugged air mattress with no other barrier between the bedframe and mattress, and staff were unsure how long the mattress had been deflated or when the resident was last repositioned. A new open wound was observed on the right buttock with macerated edges and a foam dressing stuck to the brief instead of the wound. Another resident with heart failure, chronic respiratory failure, and chronic kidney disease had a documented stage 2 pressure ulcer on the left buttock and was assessed as moderate risk on the Braden Scale. The care plan called for turning and repositioning every two hours in bed and chair, pressure-relieving surfaces, and laying the resident down between meals to offload the buttocks. A nurse practitioner ordered a silicone bordered foam dressing and frequent repositioning/offloading, but there was no documentation of a comprehensive assessment to determine the appropriate repositioning frequency or any revision of the existing every-two-hour schedule. Serial skin assessments showed the wound measurements remaining the same for several weeks with minimal description, and when the wound later deteriorated with increased size, the assessment still lacked detailed wound characteristics. A separate weekly wound observation tool documented a stage 2 pressure ulcer with different measurements, indicating inconsistent documentation. Interviews with nursing staff and management confirmed that weekly comprehensive RN wound assessments were not being performed for residents with pressure ulcers, that staff were unclear about who was responsible for staging and comprehensive assessment, and that the DON later recognized that required RN comprehensive assessments, including full wound descriptions and evaluation of pressure-relief measures, had not been completed for these residents. Overall, the deficiency centers on the facility’s failure to ensure that residents with or at risk for pressure ulcers received consistent, comprehensive RN wound assessments, accurate staging and measurement, timely and correctly transcribed treatment orders, and individualized reassessment of pressure-relief interventions. This failure was evidenced by incomplete and inaccurate skin assessments, lack of documented evaluation of repositioning schedules and pressure-relief devices, staff unawareness of ordered repositioning frequencies, improper use of pressure-relieving equipment such as ROHO cushions and air mattresses, and the absence of weekly comprehensive RN wound assessments despite facility policy requiring them.

Penalty

Inspection fine: $127,00035 days payment denial

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

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by not adhering to the rights of medication administration. One resident with diagnoses including heart failure, transient cerebral ischemic attacks, renal insufficiency/failure, and use of anticoagulants was inadvertently given another resident’s full set of morning medications by a trained medication aide (TMA) who was agency staff and unfamiliar with the resident. The TMA prepared medications for the intended resident, verified that resident’s picture and room number in the EHR, but then entered the wrong room and did not verify the room number or the resident’s identity before administering the medications. The TMA administered multiple medications not prescribed to this resident, including antihypertensives, diuretics, antiplatelet, antidepressant, anticonvulsant/mood stabilizer, diabetic medication, and others, and only realized the error when attempting to give an inhaler that the resident stated she did not take. Following administration of the wrong medications, the resident initially had stable vital signs but later became unresponsive, with no response to verbal commands and only a grimace to sternal rub, prompting transfer to the emergency department. Hospital documentation identified accidental drug ingestion, hypotension secondary to accidental drug ingestion, blurry vision, orthostatic hypotension, and an acute kidney injury with elevated creatinine. The resident experienced symptomatic orthostatic hypotension with dizziness and blurry vision on standing and required interventions such as compression wraps, abdominal binder, hydration, and titration of midodrine. The medical director considered this a significant medication error and stated that the resident’s hypotension and acute kidney injury were likely caused by receiving medications not prescribed to her. Additional deficiencies were identified in the facility’s medication administration practices for other residents. One resident with heart failure and GERD was observed during a medication pass when an RN misread an order for an oral antifungal as “swish and spit” instead of the ordered “swish and swallow,” and the RN acknowledged this as a medication error. Another resident with heart failure, Parkinson’s disease, dementia, and hospice services had an order for scheduled lorazepam 1 mg three times daily; this resident received an extra dose of lorazepam when a TMA assumed there was an as-needed order and did not verify the physician’s orders before administering the additional dose. Multiple staff interviews revealed that TMAs and an RN had incomplete or unclear understanding of the rights of medication administration, and that medication pass audits and competencies had been conducted by an administrator who was not a licensed nurse and had no formal training in medication administration, as well as by LPNs, contrary to the DON’s statement that such competencies should have been done by an RN. The facility’s own policy required verification of resident identity and triple-checking the label for right resident, medication, dosage, time, and route, which was not followed in these instances. The facility’s failure to ensure that staff consistently followed the rights of medication administration, verified resident identity, and accurately read and followed physician orders led to a significant medication error causing actual harm to one resident and additional medication errors for two other residents. Staff interviews confirmed lapses in performing the required checks and in understanding all components of the rights of medication administration, despite recent audits and competencies. The documented events show that the facility did not effectively implement its own medication administration policy, resulting in residents receiving medications that were incorrect in recipient, route, or dose.

Penalty

Inspection fine: $127,00035 days payment denial

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 its QAPI committee identified, investigated, analyzed, and responded to high-risk issues related to falls, medication errors, and pressure ulcers, despite consistently collecting data on these events. From May 2025 through January 2026, the facility tracked numbers of falls, pressure ulcers, and medication errors each month, but the documentation did not include root cause analyses, prioritization of high-risk or recurring issues, development of performance improvement projects, implementation of corrective actions, or monitoring of interventions for effectiveness. QAPI records for these months showed counts of falls, pressure ulcers of various stages, and medication errors, but repeatedly noted no documented discussion or action plans, and often lacked information on whether pressure ulcers were facility-acquired or present on admission. The deficiency was further evidenced by specific care failures cited under related tags. For falls and safety, staff used the wrong size harness for a sit-to-stand mechanical lift transfer for one resident after that resident had previously fallen from a sit-to-stand lift and sustained minor injuries. The facility also failed to comprehensively investigate and analyze falls for root cause and to implement appropriate interventions to prevent or reduce the risk of future falls for another resident. For medication administration, one resident experienced a significant medication error when staff did not observe the rights of medication administration and gave the resident another resident’s medication, resulting in the resident becoming unresponsive, requiring hospitalization for hypotension, and developing an acute kidney injury. For pressure ulcer care, the facility failed to monitor, comprehensively assess, and develop and implement individualized interventions to prevent or mitigate the risk of pressure ulcers and prevent deterioration for three residents reviewed for pressure ulcers. One of these residents developed a Stage 2 sacral pressure ulcer that deteriorated to a Stage 3 ulcer. Interviews with the medical director and the administrator confirmed that, although the QAPI committee met monthly and reviewed data on wounds, falls, and medication errors, there were no current action plans addressing these issues, no minutes documenting discussions over the last four quarters, and no evidence that adverse outcomes were being analyzed and acted upon as outlined in the facility’s own written QAA/QAPI plan.

Penalty

Inspection fine: $127,00035 days payment denial

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 notify a physician of a resident’s change in condition following a syncopal episode. The resident had multiple significant diagnoses, including pneumonia, acute respiratory failure, chronic heart failure, chronic kidney disease, atrial fibrillation, and syncope, and the admission MDS indicated no cognitive deficits. On 4/3/26, a trained medication assistant (TMA-A) assisted the resident to stand with a gait belt; upon rising, the resident leaned forward, went limp, and was lowered back into a recliner. The resident then opened his eyes and spoke. TMA-A immediately called for assistance via walkie talkie, and LPN-A, LPN-B, and the RN nurse manager (RN-NM) responded. A health status note later documented that the resident had passed out for a few seconds during the transfer and that a nurse was notified and evaluated the resident. Despite this documented change in condition, there was no indication in the resident’s record that the physician was notified on the day of the event. LPN-A reported that when she entered the room the resident was alert, and she left because it was the end of her shift, stating that a provider should be updated any time a resident has a change in condition. LPN-B stated she responded to the call, found the resident alert and following commands, but did not check vital signs, did not notify the provider, and did not complete a nursing note, explaining there was a lot going on that shift; she also acknowledged that a note and provider notification should occur with a change in condition. RN-NM stated that when she entered, the resident was alert and LPN-B was obtaining vital signs, and confirmed there was no nurse’s note or provider notification documented, despite the resident not having had such an episode previously at the facility. The DON stated the provider should have been notified the day of the event because it was a significant change from baseline, and the physician later reported learning of the dizziness episode days afterward during routine rounds, stating she would have wanted immediate notification. The facility’s Change of Condition policy instructed staff to notify the physician in the event of a status change.

Penalty

Inspection fine: $127,00035 days payment denial

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 maintain a complete, accurate, and readily accessible medical record for a resident who experienced a significant medication error. The resident had diagnoses including heart failure, transient cerebral ischemic attacks, and use of anticoagulants, and was documented on the admission MDS as having moderate cognitive impairment and taking an anticoagulant. On the date of the incident, a progress note recorded that a trained medication aide notified the nurse that the resident had been given another resident’s medications by mistake. A medication error incident report documented that the resident had inadvertently received another resident’s medications and subsequently became unresponsive, requiring transfer to the emergency department. A later progress note described the resident as unresponsive, with eyes closed and not responding to verbal commands, and only a facial grimace in response to a sternal rub, along with recorded vital signs and the decision to call an ambulance. During interview, the LPN on duty stated that she had taken the resident’s vital signs multiple times and performed assessments after the medication error but did not enter any of these vital signs or assessments into the electronic health record. The DON confirmed that these vital signs and assessments should have been documented in the resident’s record to ensure it was complete and accurate, consistent with the facility’s Charting and Documentation Policy, which requires documentation of services provided, changes in condition, and events or incidents involving the resident, and specifies that documentation must be objective, complete, and accurate.

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 comprehensively assess and monitor non-pressure related skin impairments for three residents reviewed for injuries, and did not ensure appropriate interventions were in place to reduce bruising for a resident at risk due to anticoagulant therapy. One resident with diagnoses including heart failure, diabetes, and atrial fibrillation was on anticoagulant medication and had a care plan identifying risk for bruising. Despite documentation of a large bruise on the right upper arm after hitting bed rails, there was no evidence of ongoing monitoring or assessment of the bruise, nor were protective pads placed on the bed rails as recommended. Additionally, new bruising observed on the left forearm was not communicated to the physician, and protective sleeves were not included in the care plan or consistently used. Another resident with chronic kidney disease experienced an unwitnessed fall resulting in multiple bruises on the lower back. The initial assessment documented the presence and size of the bruises but lacked comprehensive details such as units of measurement, specific locations, and characteristics. The care plan was not updated to reflect the injuries, and there was no evidence of ongoing monitoring or documentation of the bruises' progression. Nursing staff interviews confirmed a lack of clear protocol for monitoring bruises, and the DON acknowledged that comprehensive assessments and care plan updates were not completed as expected. A third resident with a history of falls and other chronic conditions sustained a hematoma on the forehead and a skin tear after a fall. The records did not show a comprehensive assessment or ongoing monitoring of the hematoma or bruise. Observations confirmed the presence of a healing bruise, but documentation was incomplete regarding color, pain, and progression. The DON confirmed that physician notification and monitoring orders were not present in the records, and the facility's own policy requiring comprehensive skin assessments and documentation was not followed.

Penalty

No penalty information released

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

Summary

The facility failed to comprehensively assess and evaluate the causal factors for falls and did not develop or monitor the effectiveness of appropriate interventions to reduce the risk of falls for three residents. For one resident with dementia, muscle weakness, and a history of falls, the care plan required staff assistance for transfers and toileting, but the resident frequently self-transferred and toileted independently. Staff interviews revealed that the resident rarely used the call light for assistance, and staff were aware of her self-transferring but did not address it or reassess her needs. The fall investigation documentation was incomplete, with missing root cause analysis and lack of follow-up on intervention effectiveness. The care plan and fall risk assessments were not updated to reflect the resident's actual behaviors and risks, and interventions such as 'call, don't fall' signage were not appropriate for her cognitive status. Another resident with heart failure, diabetes, and atrial fibrillation, who required maximum assistance for transfers and was on anticoagulant therapy, experienced a fall resulting in minor injuries. The fall record and care plan did not include a comprehensive analysis or root cause of the fall, and the intervention implemented was limited to signage. During observation, the resident's call light was found out of reach, and the resident was unable to request assistance when needed, directly contradicting the care plan intervention to keep the call light within reach. A third resident with a history of falls and severe cognitive impairment also experienced deficiencies in the implementation of fall prevention interventions. The facility failed to ensure that identified interventions were consistently implemented and did not reassess or monitor the effectiveness of interventions after falls occurred. Across all cases, documentation was incomplete, care plans were not updated to reflect current risks and needs, and staff did not consistently follow or reassess interventions, leading to repeated deficiencies in fall prevention and supervision.

Penalty

1 days payment denial

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 a history of urinary retention, diabetes mellitus, and chronic kidney disease experienced improper insertion of an indwelling urinary catheter. The resident had a care plan in place to prevent catheter-related trauma, with interventions including care per orders, proper positioning of catheter and tubing, and monitoring for signs of urinary tract infection. Despite these interventions, the resident's catheter was changed to a larger size following complaints of leakage, but the process was not properly documented or assessed. There was no physician order documented for the catheter flush or the size change, and the assessment of catheter placement and the resident's tolerance to the procedure was not completed. The nurse who inserted the new catheter did not confirm urine return before inflating the balloon, which is a critical step to ensure proper placement in the bladder. The nurse also lacked competency training for catheter insertion and was unaware of the correct procedure. After the catheter was inserted, the resident experienced significant pain, hematuria, and eventually developed a urinary tract infection. Staff failed to monitor the resident's urinary output, pain, and catheter patency following the procedure, and there was a lack of communication among staff regarding the resident's condition and the absence of urine return after catheter insertion. Subsequent medical evaluation revealed that the catheter balloon had been inflated within the urethra, causing urethral perforation, hematuria, and infection. The resident required hospitalization, intravenous antibiotics, and urology consultation. Documentation and interviews confirmed that staff did not follow proper catheter insertion protocols, did not obtain necessary physician orders, and did not perform or document ongoing assessments or monitoring after the procedure, all of which contributed to the resident's harm.

Penalty

1 days payment denial

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 enhanced barrier precautions (EBP), specifically the use of gown and gloves during high-contact resident care activities, were consistently implemented for residents requiring these precautions. Observations revealed that staff did not use gowns or gloves when providing care to residents with wounds, foley catheters, or other conditions necessitating EBP, despite signage indicating the need for such precautions. For example, a nursing assistant provided feeding assistance and removed clothing protectors for residents with wounds and catheters without donning the required protective equipment or performing hand hygiene before or after care. In another instance, a licensed practical nurse repositioned a foley catheter bag and applied lotion to a resident's feet, initially using only gloves and not a gown, before later donning both for a transfer. Additionally, the facility did not ensure proper hand hygiene practices were followed. Staff were observed failing to perform hand hygiene before and after direct resident contact, after removing gloves, and when moving between residents or care activities. These lapses occurred even though the facility's policies and posted signage required such practices, and both the infection preventionist and director of nursing confirmed that their expectations were for staff to adhere to EBP and hand hygiene protocols. The facility was unable to provide a copy of its Enhanced Barrier Precaution Policy when requested.

Penalty

1 days payment denial

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

Summary

A resident with Alzheimer's disease and malnutrition, who was unable to communicate needs due to advanced dementia and required extensive assistance with eating, was observed during breakfast sitting at a table with other residents. The resident was not feeding herself and was intermittently assisted by a nursing assistant who stood while feeding her a spoonful of oatmeal before leaving to assist other residents. The nursing assistant returned only briefly to provide another bite before leaving again, resulting in the resident sitting unattended for an extended period with her meal in front of her. Interviews with staff confirmed that the usual practice was to sit with the resident and provide attentive, uninterrupted assistance during meals, but on this occasion, staff were passing trays and only provided sporadic help. The facility's social services director and administrator both stated that staff should sit with residents needing assistance and engage with them to ensure a dignified and respectful dining experience. The facility's policy also states that residents have the right to be treated with respect, kindness, and dignity.

Penalty

1 days payment denial

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 complete, accurate, and readily accessible medical record for a resident with a history of urinary retention, diabetes mellitus, and chronic kidney disease. Multiple gaps were identified in the resident's electronic health record (EHR), including missing physician orders for an indwelling urinary catheter, absent hospital history and physical or discharge summaries following hospitalizations, and lack of documentation from an outpatient urology visit. Staff interviews revealed uncertainty and inconsistency in the process for obtaining, reviewing, and uploading external medical records into the facility's EHR. Some nurses did not have access to outside medical records, and the health unit coordinator (HUC) relied on nursing staff to provide documents for scanning, which did not always occur. The facility's policy on electronic health records did not specify procedures for ensuring the completeness and accuracy of resident records. The director of nursing (DON) confirmed that only a portion of nurses could access external EHRs and that there was no established policy or procedure for integrating this information into the facility's records. As a result, important medical information, such as orders and provider notes, was not consistently included in the resident's chart, leading to incomplete and inaccurate documentation.