Heritage Care Center

Penalty

No penalty information released

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

Summary

The facility failed to ensure residents could communicate freely with the State Survey Agency when the Social Service Director and Administrator confronted a resident after the resident voiced concerns about calling the SSA hotline. The facility’s grievance policy stated residents have the right to voice grievances without discrimination, reprisal, or fear of reprisal, and the resident rights policy stated residents have a right to communication with persons and services inside and outside the facility. Resident #15’s quarterly MDS showed no cognitive impairment, no behaviors, independence with activities of daily living, and diagnoses including hypertension, diabetes, anxiety disorder, depression, bipolar disorder, and schizophrenia. Behavior notes showed the resident was spoken to by the Social Worker, Administrator, and Social Service Director after calls were made to SSA. On one occasion, the resident said peers had asked him/her to call for them and that he/she did not want to do that anymore, and staff told the resident he/she was not obligated to contact SSA for peers. On another occasion, the resident contacted SSA with false allegations, and staff contacted the guardian about the resident’s actions. During interview, the resident stated the Administrator and SSD spoke with him/her about calling the SSA hotline and that he/she felt threatened and was told he/she would be kicked out of the facility. The guardian stated the resident had a right to express concerns and would not have a problem if the resident needed to call the SSA hotline. The SSD and Administrator stated they were trying to find out why the resident called SSA, and the Administrator acknowledged residents have the right to call the SSA hotline without intimidation or retaliation; SSA stated asking why the resident called could be seen as intimidation.

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 residents’ rights to choose their own attending physician after discontinuing services with Physician A, who had been providing care to 15 residents. The facility’s Resident Rights policy states that residents have the right to choose a personal attending physician, be fully informed in advance about care and treatment and any changes that may affect their well-being, and participate in planning their care and treatment. Despite this, when corporate notified the Administrator via email that Physician A would no longer have privileges at the facility, the Administrator and DON implemented the change by informing residents and their representatives that their primary physician would be changed, without offering a choice or obtaining resident input. No written notices or letters were sent to residents, responsible parties, or guardians about the physician change. Resident #2, who had no cognitive impairment and diagnoses including stroke, cancer, and diabetes, was documented as having a call placed to a “guardian” about the primary doctor change, even though the medical record contained no documentation of a legal guardian and the resident stated he/she was his/her own guardian and power of attorney. The resident reported being told that Physician A would no longer be at the facility and that he/she had to go with another physician, despite expressing a desire to remain with Physician A. Resident #7, who also had no cognitive impairment and diagnoses including high blood pressure, stroke, and depression, was notified via a progress note that Physician A would no longer have privileges and that he/she would have a new physician. In interview, this resident stated he/she was not asked to change physicians, would have liked to stay with Physician A, and would have appreciated being asked. The DON acknowledged that she informed residents of the change but did not ask if they wanted to change physicians, and both the Administrator and DON stated the resident rights policy should have been followed as written.

Penalty

Inspection fine: $81,430

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

Summary

The deficiency involves the facility’s failure to ensure a resident with a known history of elopement from prior facilities received adequate supervision and monitoring, resulting in the resident’s absence from the facility going unrecognized for at least 4.5 hours. The resident had diagnoses including schizoaffective disorder, bipolar type, lack of coordination, and muscle weakness, and had a legal guardian. The resident’s care plan identified a problem of elopement risk due to a history of elopement from a prior secure facility, with an intervention for face checks/intensive monitoring per facility protocol. Despite this, the resident’s elopement assessments on two prior dates scored the resident as not at risk for elopement, and no additional elopement risk assessment was completed after the guardian requested that the resident be moved to a secured unit because of prior elopements and recent marijuana use at the facility. On the day of the incident, the resident’s room was located adjacent to an exit door at the end of a hall. Staff accounts showed that the resident was last definitively seen by an LPN between approximately 2:00 P.M. and 2:30 P.M. The resident did not come out to smoke at 11:45 A.M., and later did not come for dinner. Instead of personally checking on the resident, the LPN sent another resident to the room; that resident reported back that the missing resident did not want to be bothered and was asleep, and the LPN did not verify this information before leaving at shift change. The oncoming LPN reported that when the shift began at 7:00 P.M., the resident was already not in the facility, and a CNA informed the oncoming nurse that the resident had not been seen, prompting a search and a code white. The oncoming LPN stated they were unaware of any elopement history for the resident and had not been told the resident might leave. Additional documentation and interviews showed that routine rounds were expected every two hours, primarily by CNAs and CMTs, to ensure residents were present and safe, and that intensive monitoring was understood by some staff to mean constant visual ability to see the resident. However, staff reported that when they believed they knew where residents were, they simply passed that information to the next shift without directly confirming the resident’s presence. The facility’s own investigation noted that a door alarm to the smoking area sounded between approximately 1:15 P.M. and 1:30 P.M., and a CNA obtained a key from the nurse’s station and turned the alarm off, with no documented verification that a resident had exited. The Administrator later stated that the alarm was not reported and that it was unknown whether anyone checked to see if a resident had gotten out. Medication administration records showed multiple scheduled medications, including psychotropic and other chronic medications, were not administered later that day and the following morning, with documentation indicating the resident was out of the building. The resident’s guardian reported that while out of the facility, the resident was not dressed appropriately for the weather, did not have a cell phone or wallet, and later told the guardian that the intent had been to get out for a while, and that the resident was “out of touch” and did not think clearly during this time.

Penalty

Inspection fine: $81,430

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

Facility staff failed to conduct a thorough investigation of a resident-to-resident altercation in which one resident attempted to stab another with a sharp object, contrary to the facility’s Incidents and Accidents and Abuse and Neglect policies. The policies required use of the electronic risk management system, completion of incident reports for resident-to-resident altercations, obtaining written witness statements, conducting a root cause analysis, and fully investigating all allegations of abuse, including certain resident-to-resident altercations. The policies also required that the facility protect residents during an investigation, document actions taken in the medical record, and revise care plans when residents’ needs or behaviors changed as a result of an incident. In this case, the facility did not follow these procedures after the altercation. Resident #1, who was cognitively intact and diagnosed with a psychotic disorder and schizophrenia, became increasingly violent and aggressive toward staff and another resident on the date of the incident. Nursing documentation initially stated that Resident #1 obtained a screwdriver and attempted to stab another resident, with no physical contact or injury due to immediate staff intervention and initiation of a behavior emergency code. That note was then stricken and rewritten to replace “screwdriver” with “object.” Resident #1 was sent to the hospital for psychiatric evaluation. Resident #2, also cognitively intact and diagnosed with a psychotic disorder and schizophrenia, later reported that Resident #1 pulled a screwdriver from a pocket, tried to “shank” and take Resident #2’s life, and that there was close physical contact, including Resident #2 hitting Resident #1. A CMT who witnessed the event reported that the two residents argued about money, engaged in a physical fight, and that Resident #1 pulled a screwdriver from a back pocket; the CMT stated there was physical contact and that this was also reported to police. Despite these accounts, the facility’s investigation was incomplete and did not comply with policy. The written investigation documented that a behavior code was called for erratic behaviors between the two residents and that staff reported there was almost a resident-to-resident altercation with no harm or physical contact. The Administrator later interviewed Resident #1, who stated that Resident #2 approached after misinterpreting Resident #1’s yelling, and that Resident #1 pulled out a screwdriver and waved it around without making contact, and claimed to have obtained the screwdriver from a maintenance closet. However, the investigation did not include written statements from staff who were involved or witnessed the incident, did not include written statements from either resident, and did not include a statement from the maintenance employee whose cart the screwdriver was allegedly taken from. There was no documentation that either resident’s care plan was updated to reflect the altercation or to add interventions, and Resident #2’s nurses’ notes contained no documentation of the incident. The Administrator acknowledged that an investigation should have been done, that she was not initially aware of the object or attempted stabbing as documented in the progress note, and that no in-service education or comprehensive investigation had been completed prior to the on-site surveyor investigation. The facility’s failure to follow its own incident and abuse policies extended to documentation and care planning. Resident #1’s care plan in use at the time of the investigation contained no documentation or interventions related to the most recent resident-to-resident altercation, and no interventions were added before the on-site investigation. Resident #2’s care plan similarly lacked any documentation or interventions related to the altercation, and there were no nursing notes describing the event for Resident #2. The facility’s Abuse and Neglect policy required investigation of all allegations and types of incidents listed, including certain resident-to-resident altercations, and required that the Administrator or designee complete an administrative investigation with personal statements, root cause, and a plan of action. The Administrator later stated there was no investigation, that she only considered the clinical aspects such as sending the resident out and completing risk management documentation, and that she did not obtain statements from others involved. These omissions demonstrate that the facility did not operationalize its policies for prevention, identification, investigation, and reporting of abuse and resident-to-resident altercations in this incident.

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 conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not address required staffing ratios per shift, the need for a Registered Nurse (RN) for at least eight consecutive hours daily, or the designation of an RN as the Director of Nursing (DON). Additionally, the assessment lacked documentation regarding the ratios of direct care staff, restorative therapy staff, social services staff, dietary staff, housekeeping, and laundry staff needed on each shift to meet resident needs. There was also no information provided about staff competencies and skill sets required to care for the resident population. The facility's policies and admission agreements indicated that it serves residents with skilled nursing needs, including those with Alzheimer's disease, dementia, and other complex medical and behavioral conditions. The facility's resident matrix showed a diverse population with diagnoses such as Alzheimer's/dementia, hospice care, dialysis, intravenous therapy, PTSD/trauma, and various medication requirements, including insulin, anticoagulants, antianxiety, antipsychotic, antidepressant, and hypnotic medications. Despite these complex care needs, the facility did not have a full-time DON or a full-time social worker or social service designee at the time of the survey. During the survey, the administrator acknowledged responsibility for completing the facility assessment but stated that it was incomplete due to missing maintenance and nursing information. The only documented information in the assessment pertained to contact information for external resources or when to use another facility, rather than a thorough evaluation of internal resources and staffing. As a result, the facility did not have a complete or thorough facility-wide assessment as required.

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 an effective QA/QAPI program and did not correct ongoing, systemic issues affecting infection control. The facility’s QAPI plan, dated 5/14/21, stated that the QAPI committee would review data from areas such as the infection control log, infection prevention and control program, antibiotic utilization reports, CMS Quality Measures, medication audits, and state survey results. However, review of the annual DHSS statements of deficiencies for the past four years showed repeated citations for F880 infection control in July 2018, July 2019, September 2023, and again in the current survey dated 9/9/25. The current survey found that the facility did not have an active Legionnaires program in place and staff did not pick up or replace oxygen or nebulizer tubing left on the bedroom floor for 3 of 3 sampled residents receiving oxygen and breathing treatments. The Maintenance Director said he had worked at the facility since March 2025 and had not conducted water testing, and the facility had no water test kits until regional staff brought two kits on 9/9/25. The Administrator also stated the facility had no procedure for antibiotic stewardship or tracking antibiotic use, and that antibiotics were not monitored or data collected. During interview, the Administrator said the biggest issue found during QAPI was re-capping, and that QAPI meetings had not been consistent, with standup meetings having “slacked and fell off.”

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 acceptable infection control standards when it did not ensure an active Legionella program was in place. The infection prevention and control program stated that the designated infection preventionist was responsible for oversight of the program, and the Legionella surveillance policy stated that Legionella surveillance was part of the facility’s water management plan. During interview, the Maintenance Director said he had worked at the facility since March 2025 and had not conducted water testing since he was employed. He also stated that on 9/9/25 the Regional Maintenance Director brought two Legionnaires’ test kits, that he completed one test, that results take 24 hours, and that testing would be completed every 3 months. He said the facility did not have any water test kits before the regional staff delivered them and he could not locate any prior facility water testing. The facility also failed to ensure oxygen and nebulizer tubing were not left on the floor for residents receiving respiratory treatments. One resident had diagnoses including GERD, hyperlipidemia, aphasia, hemiplegia, seizure disorder, depression, schizophrenia, asthma, and cataracts, and had an order for oxygen at 2 liters continuous for shortness of breath while in bed or sleeping. Observations on multiple occasions showed the resident’s oxygen tubing on the floor, with tape on the tubing handwritten with a date of 7/15, while the oxygen concentrator was turned on and set at 4 liters. The resident’s care plan addressed shortness of breath and oxygen use, but the tubing remained on the floor during repeated observations. Two other residents with COPD also had nebulizer equipment left on the floor. One cognitively intact resident had an order for nebulizer treatment every 6 hours as needed for COPD, and observations showed the nebulizer machine, tubing, and mask laying on the floor at the head of the bed, with dusty and dirty buildup and what appeared to be animal scat along the wall. The resident stated the equipment was on the floor because there was not enough room to place it elsewhere, and that maintenance staff were aware of a mice problem. Another cognitively intact resident with COPD and acute respiratory failure with hypoxia had an order for nebulizer treatment every 4 hours as needed for shortness of breath. Observations showed the nebulizer machine placed on a plastic bin on the floor at the head of the bed, with the tubing and mask laying on the floor and visible dirt buildup around the bed. Staff interviews stated the oxygen tubing should be picked up and not allowed on the floor, and that tubing should be changed weekly.

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 an antibiotic stewardship program was in place and being used as part of its infection prevention and control program. The infection prevention and control policy stated that an antibiotic stewardship program would be implemented, with antibiotic use protocols and a system to monitor antibiotic use, and that the IP, with oversight from the DON, would lead the program. However, the facility had no procedure in place to provide antibiotic stewardship or track antibiotic use, and antibiotics were not monitored or data collected. Five residents receiving antibiotics were reviewed and issues were identified with all five. Resident #9 and Resident #34 each had an order for amoxicillin-pot clavulanate for sinusitis, but their care plans did not reflect antibiotic use. Resident #2 had an order for doxycycline with no diagnosis included, and the care plan did not reflect antibiotic use. Resident #72 had an order for clindamycin for prophylaxis related to other asthma, and the care plan did not reflect antibiotic use. Resident #64, who had traumatic spinal cord dysfunction, heart disease, high blood pressure, GERD, neurogenic bladder, hyperlipidemia, quadriplegia, malnutrition, and depression, was cognitively intact and receiving long-term amoxicillin for bacteria; the care plan did not document the long-term antibiotic use, and a pharmacy review noted the need for a stop date and a more appropriate diagnosis. The RN Supervisor stated the resident's amoxicillin did not have a stop order and expected all antibiotics to have a diagnosis attached, and the Administrator stated the facility had no procedure in place for antibiotic stewardship or tracking.

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 designate one or more individuals with specialized training and certification in infection prevention and control as the Infection Control Preventionist for its infection prevention and control program. The facility’s infection prevention and control program, revised 5/7/24, stated that the designated infection preventionist is responsible for oversight of the program and serves as a consultant to staff on infectious diseases, room placement, isolation procedures, staff and resident exposures, and surveillance and epidemiological investigations. During interview, the Administrator identified ADON A as the IP and stated she had completed IP training, but later stated ADON A had not completed the CDC IP training. The Administrator also stated that a separate staff person, the transportation driver, had completed non-medical infection control training, but that this training did not meet the needs of the facility residents, the infection control program, or ICP qualifications.

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 multiple deficiencies in the facility's maintenance and cleanliness of resident areas. Numerous rooms and shared bathrooms had unpainted drywall, exposed holes, missing or damaged cove base, and crumbling drywall. Several rooms had holes in the walls, some with visible mice droppings and black, hairy-like substances protruding. There were also instances of overhead bed light covers missing, exposing light bulbs, and air conditioning units with gaps between the unit and the wall. Shared bathrooms had chipped and cracked paint, brown stains, and sinks pulled away from the wall with cracked paint and caulk. Floors in several rooms and bathrooms were described as dirty and sticky, with baseboards pulled away from the walls and plaster peeling. A broken ceiling tile near the D-hall entrance exposed electrical wires and the space above the ceiling tiles. During interviews, the Maintenance Assistant explained that staff are required to fill out work order sheets for repairs, which are collected daily. However, the Maintenance Assistant stated that due to budget cuts, the supplies needed to make repairs are slow to arrive, contributing to the ongoing issues with the facility's environment. The observations and interviews indicate that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents throughout the building.

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 a full-time Director of Nursing (DON) who did not serve as a charge nurse when the resident census exceeded 60, as required by both facility policy and federal regulations. At the time of the survey, the census was 105 residents. The facility's policy defined full-time as 40 or more hours per week and specified that the DON may only serve as a charge nurse if the census is 60 or fewer. Review of staffing records and interviews revealed that the DON was on medical leave, and there was uncertainty among staff regarding who was fulfilling the DON role during this period. The RN Supervisor was identified as the interim DON, but also provided RN coverage on several days, which conflicted with the policy prohibiting the DON from serving as a charge nurse when the census is above 60. Further interviews confirmed that on specific days, the facility did not have an interim DON present, and RN staff from corporate provided coverage intermittently. The lack of a consistent, full-time DON who was not also serving as a charge nurse was discussed in the facility's QAPI meeting, and there was consideration of the DON performing some duties remotely. However, at the time of the survey, the facility was not in compliance with the requirement for a full-time DON who was not assigned as a charge nurse, given the census of 105 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 implement its Medication Regimen Review policy by not ensuring that physician or provider responses to pharmacy recommendations were documented in a timely manner for multiple residents. The policy required a licensed pharmacist to review each resident’s drug regimen monthly, review the medical chart, communicate irregularities in writing, and have the facility act on recommendations according to its procedures. During survey review, the facility could not provide physical copies of consultant pharmacist recommendations or physician responses for some residents, and the Administrator/acting DON stated that recommendations were sent in packets for DON, ADONs, and the Medical Director to address, with documentation expected in the resident record. For Resident #2, the record showed duplicate orders for amlodipine and Tylenol remained active despite pharmacy recommendations to discontinue the duplicates. Resident #7 had a PRN hydroxyzine order that the pharmacist recommended discontinuing, but the record showed the discontinue order was still pending confirmation. Resident #11 had multiple pharmacy recommendations, including discontinuing duplicate vitamin D, cyclobenzaprine, and amlodipine orders, adding a maximum daily acetaminophen limit, and adding Miralax administration instructions; the POS still showed the duplicate orders and missing directions during survey review. Additional residents had unresolved pharmacy recommendations. Resident #72’s record showed PRN hydroxyzine without a linked diagnosis, missing Miralax instructions, and acetaminophen orders without the recommended maximum daily dose language. Resident #64 had recommendations to add a stop date and diagnosis for amoxicillin, update Miralax, eye drop, cyclosporine, and tamsulosin instructions, yet the POS still contained the cited orders as reviewed. Resident #13 had duplicate vitamin D orders with no end dates, and the pharmacist documented that clarification was still needed, with no August MRR documented and no physical copies of recommendations or responses available. Resident #67 had PRN Haldol injection without a stop date despite repeated pharmacist notes that antipsychotic PRN orders should be limited to 14 days. Resident #35’s Lasix order remained without a proper diagnosis, and Resident #85’s aspirin order remained without the more appropriate diagnosis requested by pharmacy. The surveyor also noted that the facility did not address the pharmacy recommendations for these 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 offer and vaccinate, as desired, eligible residents with the influenza and pneumococcal vaccines for 5 of 5 residents sampled for immunizations. The report states that the facility’s policy required residents or their legal representatives to be educated on the benefits and potential side effects of the vaccines, to be offered the influenza vaccine yearly and the pneumococcal vaccine upon admission, and to have consent or refusal documented in the clinical record. However, the medical records reviewed for the sampled residents did not show documented offers or declinations for one or both vaccines in multiple cases. Resident #85 was cognitively intact and had diagnoses including epilepsy, schizoaffective bipolar disorder, anxiety, skin infection, and vitamin deficiency. The annual MDS indicated the influenza vaccine was not received because it was declined, and the pneumococcal vaccine was not up to date because it was not offered. The medical record did not contain documentation showing the flu or pneumococcal vaccines were offered or declined for the 2024 season, and the resident stated during interview that neither vaccine had been offered and that he/she would consider them. Resident #72 was also cognitively intact with diagnoses including schizoaffective disorder, seizure disorder, and vitamin deficiency; the MDS showed both vaccines were not received because they were not offered, and the record contained no documented offering or declination. The resident stated he/she had not been offered either vaccine. Resident #67, admitted 4/19/24, was cognitively intact with diagnoses including schizoaffective disorder, bipolar disorder, epilepsy, and anxiety. The quarterly MDS showed the pneumococcal vaccine was not up to date because it was not offered, and the physician order sheet included an order that the resident may have the pneumococcal vaccine every 5 years with written or verbal consent. The record contained no documented offer or declination, and the resident stated he/she had not been offered the pneumococcal vaccine. Resident #54 had moderate cognitive impairment and diagnoses including stroke with paralysis, lung disease, and Alzheimer’s disease; the annual MDS showed the influenza vaccine was declined and the pneumococcal vaccine was not offered, but the medical record contained no documented offer or declination for either vaccine. Resident #45 had moderate cognitive impairment and diagnoses including bipolar disorder, personality disorder, hepatitis C, heart failure, lung disease, and anxiety; the quarterly MDS showed the influenza vaccine was not received because the resident was not in the facility and the pneumococcal vaccine was not offered, while the record again lacked documentation of an offer or declination for either vaccine. The Administrator stated residents or the responsible party should be offered the influenza and pneumococcal vaccines upon admission or re-admission if not previously offered or administered, and that the resident or RP should sign either a declination or acceptance form for the record.

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 an accurate and properly reconciled accounting system for resident trust fund accounts, as required by their own policy and proper accounting principles. Review of facility records showed that monthly reconciliations of the resident trust fund were either not completed or, when attempted, did not match the residents' current balances. Bank statements and reconciliation forms from several months revealed discrepancies, including unexplained differences between the reported cash on hand and the actual cash counted in the safe. For example, the bank reconciliation reports showed significantly higher cash on hand amounts than what was physically present. Interviews with the Business Office Manager (BOM), Activity Director (AD), and Corporate Business Office Manager (CBOM) confirmed inconsistent practices in tracking and reconciling petty cash, which is drawn from the resident trust fund. The BOM and AD described daily and monthly cash counts and receipt tracking, but were unable to explain the discrepancies between the physical cash and the amounts reported on reconciliation forms. The administrator and CBOM both stated expectations that the petty cash and trust fund accounts be accurately reconciled each month, but this was not occurring in practice.

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's right to be free from physical abuse was violated after a staff member, Floor Tech N, placed the resident in a head lock during an altercation. The incident began when the resident, who had diagnoses including depression and schizophrenia and was noted to have intact cognition, became physically aggressive. The resident first engaged in a resident-to-resident altercation during a smoke break, after which he was placed on 1:1 supervision. While being escorted back inside by Floor Tech N, the resident attacked a CNA, who was also Floor Tech N's family member, by hitting and pulling hair. In response, Floor Tech N intervened by grabbing the resident from behind and placing him in a head lock, which is not an approved restraint technique according to the facility's policies and CPI training protocols. Multiple staff interviews confirmed that Floor Tech N used a head lock to restrain the resident, and that the proper CPI technique was not followed. The resident reported being choked and stated that Floor Tech N threatened him verbally. Other staff present during the incident indicated that there was confusion and fear among staff, with some not intervening as expected. The Administrator and Staffing Coordinator both noted that Floor Tech N did not de-escalate the situation as directed and did not use the correct CPI-approved restraint methods. The Administrator was also physically attacked by the resident after the restraint was released, and staff struggled to manage the situation safely. The facility's policies require that all residents be protected from abuse, including improper use of physical force or restraint, and that staff use only approved de-escalation and intervention techniques. Despite having completed CPI training, Floor Tech N did not adhere to these protocols, resulting in the use of an unauthorized physical restraint. The incident was further complicated by the involvement of Floor Tech N's family member and the lack of coordinated staff response, which contributed to the violation of the resident's rights and the facility's failure to prevent abuse.

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

Facility staff failed to prevent the misappropriation of a resident's patient trust funds, resulting in unauthorized withdrawals totaling $7,877.01 over a one-week period. The Business Office Manager (BOM) withdrew funds from the resident's account to make purchases, including clothing, furniture, and a recliner, without first obtaining the resident's permission or signature as required by facility policy. The BOM relied on input from Certified Nurse Aides (CNAs) regarding what the resident might need and proceeded with purchases without direct resident involvement or consent. The BOM also admitted to forgetting to have the resident sign the ledger receipt for a cash withdrawal given for shopping with family. The resident, who had no cognitive impairment but diagnoses including schizophrenia, anxiety disorder, depression, and dementia, stated that they did not authorize the purchases and did not want several of the items bought with their funds. Observations confirmed that some purchased items were not present in the resident's room, and some items, such as a recliner, were unwanted by the resident. The facility's policy required resident consent and signatures for all withdrawals, which 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

A resident with multiple serious diagnoses, including COPD, kidney disease, heart failure, lung cancer, and dementia, was re-admitted to the facility with hospital discharge orders recommending a hospice evaluation and referral. The care plan and physician documentation indicated that the resident had elected hospice services, and interventions were outlined to work cooperatively with hospice to maintain comfort. However, the resident was not actually enrolled in hospice services upon re-admission, and no hospice orders were documented in the re-admission physician orders. Progress notes indicated that the hospice referral was initially made, but the referral was closed and a new referral was to be sent to a different hospice provider. There was no documentation confirming the resident's enrollment in hospice services prior to their decline and subsequent death. On the day of the resident's decline, staff noted a significant change in condition, including low blood pressure, irregular breathing, and low oxygen saturation. The LPN on duty attempted to contact the next of kin and notified the physician of the resident's declining status, but did not inform the physician that the resident was not enrolled in hospice services after discovering this fact. The LPN also failed to document the assessment and vital signs in the medical record, instead writing them on a piece of paper and forgetting to enter them later. The resident expired several hours after the change in condition, and there was no evidence that hospice services were initiated or that the physician was made aware of the lack of hospice enrollment. Interviews with facility staff and the physician confirmed that there was an expectation for the resident to be on hospice services, and that the physician should have been notified if the resident was not enrolled. The physician stated that, had he been informed, he would have considered sending the resident to the hospital for evaluation and treatment. The facility's policy required clinicians to be notified of changes in condition and for all assessments and vital signs to be documented in the medical record, but these procedures were 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 ensure a resident with bilateral finger amputations had an accessible device to call for staff assistance. The resident’s significant change MDS dated 8/11/25 showed the resident was cognitively intact, able to make needs and wants known, and required physical assistance for eating, hygiene, transfers, and daily care. The resident’s diagnoses included superficial frostbite of both hands, schizoaffective disorder, bipolar type, polyneuropathy, and drug induced subacute dyskinesia. The care plan identified an upper extremity movement disorder, noted the resident had lost all fingers on both hands to frostbite in March 2020, and included interventions to encourage use of a bell to call for assistance and to provide adaptive equipment. During observation and interview on 9/3/25, the resident was sitting in bed with no call light next to the bed. The resident stated the roommate used a cell phone to call for assistance, said the facility call light system was being repaired, and reported the roommate had been supplied with a whistle. The resident was unable to use a whistle and said the facility had not provided another way to communicate, relying instead on the roommate to call for help. During interview on 9/10/25, the Administrator stated that during the call-light repair residents were to receive hourly checks, that whistles had been used when effective, that most residents did not effectively utilize the whistle system, and that a bell had also been tried with 15-minute checks. The Administrator stated all residents should have access to call for staff assistance and that it was not appropriate for residents to rely on roommates to obtain staff assistance.

Penalty

No penalty information released

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

Summary

The facility failed to notify the resident and/or the resident’s representative in writing of transfer or discharge to the hospital and failed to provide the facility’s bed hold policy at the time of transfer for three residents who were sent to the hospital. The facility’s admission agreement stated that it offers a bed hold policy for temporary absences due to therapeutic leave or hospital admission, and that paying to hold a bed is voluntary. However, for the three sampled residents, the medical records did not contain bed hold notices. Resident #119 was hospitalized after expressing suicidal thoughts, stating he/she had a plan and would not disclose it, and reporting that there were objects in the room that could be used for self-harm. The nurse documented red marks on the resident’s arm, notified the Administrator, DON, social worker, guardian, mother, and psych physician, and EMS and police transported the resident to the hospital. Review of the resident’s record showed no bed hold notice. A hospital RN later reported that the facility communicated in mid-January that the resident was being discharged for being out of the facility for an extended period, an appeal was made, and the discharge was waived and the bed was held. Resident #69 was sent to the hospital after staff observed a mental status change, weakness, sleepiness, and left-sided weakness, with the physician advising transfer due to possible a-fib or stroke. Family and the Administrator, DON, and corporate nurse were notified, and ambulance transport occurred, but the record contained no bed hold notice. Resident #114 was transferred to the hospital after an incident involving aggression toward staff, refusal of medication, statements suggesting self-harm, and the discovery of a screw in the resident’s pouch during a search with consent. Guardian, management, physician, psych, and EMS were involved, but the medical record showed no documentation that transfer notice(s) were given.

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 two residents received accurate assessments that reflected their status at the time of assessment by not identifying their hospice admission in the MDS. Resident #10 had diagnoses including malignant neoplasm of the cecum, secondary malignant neoplasm of the liver and intrahepatic bile duct, and secondary malignant neoplasm of the left lung. The resident had an order for hospice evaluation and treatment, the hospice agreement was signed, and the care plan stated the resident was admitted under hospice services due to cancer with metastases to multiple sites. However, the significant change MDS dated 6/16/25 indicated the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. Resident #36 had diagnoses including heart failure, pulmonary hypertension, and chronic kidney disease. The resident's POS included an order to admit to hospice, and the hospice agreement was signed with a diagnosis of left MCA stroke. The care plan identified the resident as being on hospice and included comfort-focused interventions, but the quarterly MDS showed the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. During interview, the Administrator stated corporate completes the MDS and that she expected it to be accurate and completed timely.

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 complete smoking assessments for two residents and failed to evaluate their smoking behavior risks. Resident #7 had intact cognition and diagnoses of schizoaffective disorder and delusional disorder. The resident’s care plan identified the resident as a supervised smoker, with interventions stating the resident required supervision while smoking, but the Smoking and Safety Evaluation dated 4/25/25 was incomplete with only one question answered and the evaluation dated 6/12/25 was blank. Resident #108 also had intact cognition and diagnoses including schizoaffective disorder, unspecified disorder of psychological development, anxiety, personality disorder, and drug induced subacute dyskinesia. The resident’s care plan likewise identified the resident as a supervised smoker, but the Smoking and Safety Evaluation dated 3/12/25 was incomplete and the evaluation dated 6/12/25 was blank. During observation, both residents were resting in bed in a room where the floor had dirt around the perimeter, the windowsill had ash-like substance over more than half of the ledge, the window was open about six inches, and there were 13 cigarette butts and cigarette ash in the window tracking. Ash-like substance was also observed on the floor in front of the window. Later, CNA H and ADON A stood in the doorway, stated the room smelled like cigarette smoke, and asked whether anyone was smoking; Resident #108 denied smoking, and both staff members left without further investigation. The window remained open with cigarette ash in the tracking, and the cigarette butts were later no longer present. The Administrator stated staff were expected to follow the smoking policy and report concerns immediately to the charge nurse, and that all residents who smoke were expected to have a smoking assessment completed annually and quarterly.

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

Safe, appropriate pain management was not provided for a resident with chronic osteomyelitis with drainage sinus involving the right tibia and fibula, chronic pain most severe in the right knee, muscle weakness, and difficulty walking. The facility’s pain management policy required staff to recognize pain, assess it, and manage it according to the resident’s condition and preferences, including observing for nonverbal indicators and using a pain scale. The resident’s care plan included giving medications as ordered for pain and monitoring for excessive pain, yet the record showed repeated pain assessments and treatment documentation that did not reflect effective follow-through on the resident’s prescribed narcotic pain medication. The physician ordered Percocet 10/325 mg for right knee pain, first as a three-times-daily order for two weeks and then as 1 tablet every 8 hours as needed. However, the pharmacy representative stated no order had been received from the facility, and the MAR showed no Percocet was administered. During interviews, the resident reported that staff were not properly caring for the right knee wound, that the dressing had not been changed as expected, and that staff were only giving Tylenol or ibuprofen, which did not help the pain. The resident also stated he/she stopped asking for pain medication because staff were not providing it, and later reported pain levels as high as 9/10 and 10/10. Observation of the wound showed the dressing was not dated, initialed, or timed, was coming off, and the wound had discoloration, purulent and serosanguinous drainage, erythema, and yellow drainage with slough. Interviews with nursing staff and the RN supervisor showed confusion and breakdowns in the process for handling controlled substance orders, including faxing orders to the pharmacy, verifying receipt, and following up on new medications. One nurse stated the Percocet order was found and refaxed later, while another said the pharmacy never received the fax because another resident’s prescription had been faxed twice. The RN supervisor stated that 12 days without addressing the resident’s pain was excessive and that the chart should have triggered a pain assessment, but the resident’s record showed no Percocet administration during the period reviewed.

Penalty

No penalty information released

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

Summary

The facility failed to ensure residents were free from significant medication errors when staff attempted to administer insulin using an incorrect technique for one resident. The resident had diagnoses including diabetes, morbid obesity, COPD, metabolic encephalopathy, and kidney failure. The resident’s care plan identified a problem of being at risk for elevated or low blood sugar levels related to diabetes, with interventions for diabetes medication as ordered and monitoring/documenting side effects. The physician order sheet showed an order for Aspart Flex pen insulin, 3 units three times a day. During observation, an LPN checked the resident’s blood sugar, which was 149, verified the order for 10 units of Aspart insulin, and went to the medication cart to obtain the insulin pen. The LPN verified the resident’s name on the pen and dialed it to 10 units without priming the Flex pen with 2 units as required by facility policy. The LPN nearly administered the insulin before being stopped when the pen showed 50 units of air and was leaking. During interview, the LPN stated, “This is how we do things all the time.” The ADON stated the insulin should have been primed at 2 units per policy and said the resident may not have received the full dose or any insulin because of the air inside the Flex pen. The ADON also stated the pen needed to be replaced and that the amount of air indicated the pen was not calibrated correctly.

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 keep controlled substances in a restricted area until they could be destroyed. Observation of the B and D hall medication cart showed narcotics for two discharged residents still stored on the cart for several weeks. One resident had two cards of acetaminophen with codeine tablets with 20 tablets documented and 19 actually present, including one missing tablet and one blister pack seal broken. The other resident had one card of oxycodone tablets with 37 documented and 35 actually present, with two tablets missing from the blister pack. The discharged residents involved had significant medical histories. One resident’s diagnoses included bipolar disorder, anxiety, PTSD, personality disorder, and schizophrenia. The other resident’s diagnoses included difficulty walking, lower back pain, anxiety, muscle weakness, and Parkinson’s disease. The narcotics remained on the medication cart instead of being secured in a separate locked area labeled for destruction, as described in the facility’s Narcotic Destruction Policy. During interviews, the ADON stated the narcotics should not have been on the cart. A CMT said staff were responsible for cleaning out carts and would give any discharged resident narcotics found to the charge nurse. The RN Supervisor said the ADONs and RN Supervisor were responsible for pulling narcotics from carts and expected medications for residents leaving the facility to be removed within 24 hours, but also stated the facility did not have a destroy cabinet and could not explain why the medications remained on the cart or why the narcotics were left in circulation.

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

Facility staff failed to implement an effective pain management regimen for a resident who had a physician's order for Percocet 5/325 mg every four hours as needed for pain. Despite the order being present on the resident's Physician Order Sheet and care plan, staff did not administer the medication at any point during the months reviewed. The Medication Administration Record showed no documentation of Percocet being given, and progress notes did not indicate its use. Instead, the resident received Tylenol intermittently, which was documented as administered on select dates, but the stronger, physician-ordered medication was not provided. The resident, who had diagnoses including high blood pressure, dementia, schizophrenia, and depression, reported experiencing severe back pain that affected mobility and radiated down the leg. The resident stated that Tylenol was not effective and expressed a need for stronger pain relief, but was told by staff that only Tylenol was available. Interviews with staff revealed that the CNA reported the resident's pain to the nurse, and the LPN was unaware of the Percocet order, stating that it was not available on the medication cart and had never been administered. The interim Director of Nurses and the Administrator both confirmed they were unaware of the Percocet order, with the Administrator noting that the order had never been sent to the pharmacy. Facility policy required a systematic approach to pain recognition, assessment, and management, including administering medications as ordered and monitoring their effectiveness. However, the failure to transcribe and process the Percocet order resulted in the resident not receiving the prescribed pain management, despite ongoing complaints of severe pain and repeated communication with pain management providers.

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 cited under F689 for failure to ensure that an area of the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The citation remains uncorrected, as referenced in the current and previous survey events. Specific details regarding the actions or inactions that led to the deficiency, as well as information about the residents involved or their conditions at the time, are not provided in the report. The deficiency is ongoing, with references to previous uncorrected citations and supporting documentation in earlier statements of deficiencies.

Penalty

Inspection fine: $146,16299 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 a documented history of major depressive disorder, anxiety disorder, PTSD, and repeated self-harming behaviors was assessed as high risk for suicide, with multiple recent incidents of self-harm and a high score on the Columbia Suicide Severity Rating Scale. The resident's care plan required 1:1 monitoring and close supervision, defined as staff being within three to five feet of the resident at all times, and removal of items that could be used for self-harm. Despite these interventions, the resident was left unsupervised in their room with the door closed when the staff member assigned to provide 1:1 supervision was reassigned to other duties due to short staffing. During the period the resident was left alone, they broke the window in their room and used a piece of glass to inflict multiple deep cuts on themselves, requiring medical intervention. Staff discovered the incident during routine rounds, and interviews confirmed that the resident was left unsupervised for approximately 15 to 20 minutes. The resident reported taking advantage of the absence of supervision to harm themselves, and staff interviews corroborated that 1:1 supervision was not maintained as required by the care plan and facility policy. Facility policies on supervision and suicide prevention explicitly required that residents at high risk for self-harm not be left alone and that 1:1 supervision be maintained at all times, with staff responsible for ensuring coverage if they needed to leave. Multiple staff and administrative interviews confirmed that the expectation was for continuous supervision, and that the failure to maintain 1:1 supervision directly led to the resident's opportunity to self-harm. The deficiency was identified as Immediate Jeopardy due to the facility's failure to provide adequate supervision and prevent a serious accident.

Penalty

Inspection fine: $146,16299 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 cognitively intact resident with a history of sex offender status was admitted to the facility and immediately placed on a secured/locked unit without being allowed to participate in the development or implementation of their person-centered plan of care. The resident was transferred from a sister facility without being informed of the transfer, not given any paperwork, and not consulted about their preferences or options for placement. Upon arrival, the resident was visibly upset, expressed not wanting to be at the facility, and reported not understanding why they were placed in a locked unit or why the transfer occurred. Facility policy required sex offenders to be placed on a locked unit, but there was no documentation in the resident's care plan or medical record regarding the rationale for this placement, any assessment of risk, or communication with the resident about the transfer and placement. The resident's medical record showed no evidence of recent or past sexually aggressive or abusive behaviors, and the care plan did not address the secured unit placement. The resident was described as having no unwanted behaviors and was adjusting well, with no documentation of behavioral issues that would warrant such restrictive placement. Interviews with facility staff, including the Social Service Director and Regional Nurse Director of Operations, confirmed that the transfer and admission process was not conducted properly. The resident was not given the opportunity to express their preferences or participate in care planning, and the decision to place the resident on the locked unit was based solely on their sex offender status, contrary to facility policy requirements for individualized assessment and anti-discrimination laws.

Penalty

Inspection fine: $146,16299 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, who was cognitively intact and their own responsible party, was placed on a secured/locked unit within the facility solely due to their status as a registered sex offender. There was no clinical justification, assessment, or documentation indicating that the resident met the criteria for admission to a secured unit. The facility's policy required sex offenders to be placed on the locked unit, but the policy itself stated that placement decisions should be based on risk assessment and not solely on registry status. The resident had no documented history of sexually aggressive or abusive behaviors, and medical records showed no behavioral issues or risk assessments related to sexual abuse. The resident expressed not wanting to be at the facility, was not informed about the transfer, and did not receive any paperwork or options regarding their placement. Interviews with facility staff, including the Social Service Director and the Regional Nurse Director of Operations, confirmed that the resident was transferred from a sister facility without proper discharge or admission procedures. Staff acknowledged that the resident was upset, unaware of the transfer, and not given the opportunity to choose their placement or receive their belongings. Documentation in the resident's care plan and medical record did not address the placement on the secured unit, and there was no evidence of an individualized assessment to justify the restriction. The facility's actions were based on a blanket policy for sex offenders rather than an individualized evaluation, resulting in the resident being confined to a locked unit without appropriate clinical or legal basis.

Penalty

Inspection fine: $146,16299 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 residents had reasonable and reliable access to, and privacy in, their use of electronic communications, including email, video communications, internet research, and television viewing, due to the lack of WiFi services. Documentation showed that the facility was notified by its Internet Provider of a violation of the Acceptable User Policy after sharing its business/office-only internet with residents, which was not permitted under the provider agreement. Despite multiple notifications from the provider, the facility continued to allow residents to use the business internet, resulting in the suspension and eventual disconnection of internet services. At the time of the survey, some residents still did not have internet access. Interviews with residents revealed that they were unable to watch TV, listen to music, or use the internet for an extended period, though they could not specify the exact duration. The Administrator acknowledged being unaware of the length of the issue and stated that the facility did not have the correct internet account to support resident use. The Regional Nurse Consultant also indicated a lack of awareness regarding the requirement to provide WiFi to residents. The Internet Provider confirmed that the facility was in breach of its agreement by sharing the business internet with residents and that a bulk service package was needed for resident use.

Penalty

Inspection fine: $146,16299 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 an effective pest control program as evidenced by the presence of mice, mice droppings, and roaches in multiple resident rooms and a common area. Observations revealed mice feces in the rooms of three residents, with one room also having a visible hole in the wall and separated cove base, and another room containing a chocolate chip cookie on the floor near mice droppings. Residents reported seeing mice in their rooms and noted that staff did not clean areas where droppings were present. Staff interviews confirmed sightings of mice in various areas, including resident rooms and hallways, and one staff member was unaware of a system for reporting pest sightings. In the common/activity area, live and dead roaches with egg sacs were found inside a cabinet, further indicating inadequate pest control measures. Review of facility records showed that the pest control policy required regular services from a qualified vendor, but only two recent invoices were available, with a gap in service after the previous pest company stopped coming. The new pest control company had only recently started, and there was no documentation of consistent pest control services during the interim. The administrator acknowledged the expectation for a pest-free environment, but the facility was unable to provide evidence of ongoing, effective pest management during the period in question.

Penalty

Inspection fine: $146,16299 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 provide proper written notification to a resident prior to a transfer or discharge, as required by both facility policy and federal regulations. Specifically, the resident, who was cognitively intact and their own responsible party, was transferred to a sister facility without receiving a written notice detailing the reason for the move, the effective date, the new location, or information about the right to appeal the decision. There was also no evidence that the required notifications were sent to the resident representative or the Office of the State Long-Term Care Ombudsman. Record review revealed that the resident's care plan included interventions to address potential relocation stress, but there was no updated documentation reflecting the resident's desires or needs regarding the transfer. Progress notes indicated that the resident was spoken to about relocating and was discharged the following day, but there was no documentation of written notification, family or physician notification, medication reconciliation, or ombudsman notification. Additionally, there was no evidence of referral inquiries or discussions with the resident or prospective facilities about the transfer. Interviews with facility staff confirmed that the established discharge process was not followed. The Social Services Director acknowledged that documentation related to discharge communications and referrals was expected but not present. The Regional Nurse Director of Operations also stated that the process was not followed, the resident was not offered other placement options, and communications with the resident and family were not properly documented. The facility's own policy requires comprehensive written notification and documentation, which was not adhered to in this case.

Penalty

Inspection fine: $146,16299 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

Facility staff failed to meet professional standards by not clarifying unclear discharge instructions from an eye clinic for a resident who had been referred for cataract surgery. The resident, who was cognitively intact and had diagnoses including diabetes, thyroid disorder, and schizophrenia, was seen by an optometrist and referred to an ophthalmologist for cataract surgery in both eyes. The resident attended a follow-up appointment at the eye center, but the discharge paperwork only stated 'return for cataract evaluation' without specifying a date, location, or procedure, and did not include contact information for further clarification. Upon return to the facility, the assigned nurse did not seek clarification from the eye center regarding the next steps for the resident's care, as the discharge paperwork lacked specific instructions. Interviews with staff revealed that the nurse was responsible for reviewing discharge paperwork and making necessary follow-up appointments, but in this case, no action was taken due to the lack of clear instructions. The medical records staff uploaded the paperwork to the resident's electronic medical record, but also did not follow up, as she was unaware of the need for a return visit to the eye center for surgical evaluation. Multiple interviews with facility leadership, including the Administrator, DON, and medical staff, confirmed that their expectation was for nursing staff to clarify any unclear discharge instructions and ensure appropriate follow-up. However, this did not occur, resulting in the resident's cataract surgery not being scheduled as intended. The failure to clarify and act on the discharge instructions directly led to the deficiency cited in the report.

Penalty

Inspection fine: $146,16299 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

Facility staff failed to complete a comprehensive discharge summary for one resident who was discharged to another skilled nursing facility. Review of the resident's closed medical record showed that the discharge summary was incomplete, lacking a final summary of the resident's status, a reconciliation of all pre- and post-discharge medications, and a post-discharge plan of care. The resident's physician order sheet did not contain a discharge order, and the Minimum Data Set (MDS) assessment had unanswered sections regarding the resident's overall goal and whether a referral had been made to the local contact agency. According to facility policy, a discharge summary must be provided upon a resident's discharge, addressing discharge goals, needs, caregiver support, and referrals, and must include a recapitulation of stay and medication reconciliation. The Director of Nursing confirmed that the discharge summary should include information from all departments, medication lists, recapitulation of stay, home health orders, and follow-up appointments, but these elements were missing from the resident's record.

Penalty

Inspection fine: $146,16299 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 sufficient and competent staff were available to meet the behavioral health needs of a resident who required 1:1 supervision for safety and behavioral concerns. The resident, who had diagnoses including anxiety disorder, depression, and bipolar disorder, was care planned for close monitoring, avoidance of power struggles, and consistent routines to manage symptoms. On the night in question, the assigned 1:1 staff left before the replacement arrived, leaving the resident without the required supervision. As a result, the resident was brought to the nurse's station and told by an LPN that they would have to remain there until the 1:1 staff arrived or potentially all night. The resident expressed a desire to go to their room to sleep, but the LPN insisted the resident remain at the nurse's station, citing the lack of available staff. This interaction escalated, with the resident becoming increasingly agitated and ultimately aggressive, leading to a physical altercation with the LPN. The situation further deteriorated when the resident attempted to leave, threw objects, and fell from their chair, prompting a call to emergency services and the resident being sent to the hospital. Interviews with staff and review of staffing records confirmed that the facility was short-staffed at the time, and the LPN involved was relatively new and had not effectively implemented the care plan interventions, such as avoiding power struggles and ensuring the resident's needs were met. The failure to provide appropriate supervision and to follow the resident's care plan directly contributed to the escalation of the resident's behavior and the subsequent incident requiring hospital transfer.

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 resident, who required supervision, was served the correct diet as ordered by the physician. The resident had a physician's order for a mechanical soft texture diet, which is food altered to be soft and easy to chew. However, during lunch, staff served the resident a regular textured ham sandwich. As a result, the resident began to choke, and staff were unable to completely clear the resident's airway. Emergency medical staff eventually dislodged several pieces of regular textured thinly sliced meat, but the resident was hospitalized and subsequently expired.

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 abuse and neglect policy by not conducting a thorough investigation following an incident involving a resident who was served an incorrect diet. The resident, who had an order for a mechanical soft diet, was mistakenly given a regular diet, leading to choking and subsequent death in the hospital. This incident was part of a sample of 10 residents, with the facility having a total census of 110.

Penalty

Inspection fine: $108,179

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 resident who required supervision was served the correct diet as ordered by the physician. The resident, who had a mechanical soft diet order due to a condition that caused swallowing difficulties, was served a regular textured ham sandwich instead of the prescribed mechanical soft meal. This led to the resident choking, and despite staff intervention, the resident's airway could not be completely cleared, resulting in hospitalization and eventual death. The incident occurred when the resident refused the mechanical soft lunch provided and requested sandwiches. A Certified Medication Technician (CMT) requested sandwiches from the dietary staff but did not specify the need for a mechanical soft consistency. Consequently, the resident was given regular ham and cheese sandwiches, which were not suitable for their dietary needs. The dietary staff did not inquire about the resident's dietary requirements, and the nursing staff failed to communicate the resident's specific diet order. Interviews with various staff members revealed a lack of communication and verification regarding the resident's dietary needs. The dietary manager and staff confirmed that the sandwiches provided were of regular consistency, and the Registered Dietitian emphasized that sliced meat should never be served to a resident on a mechanical soft diet. The Speech Therapist noted that the resident was at risk for aspiration and should have been supervised during meals. The failure to adhere to the prescribed diet and provide adequate supervision directly contributed to the resident's choking incident and subsequent death.

Penalty

Inspection fine: $108,179

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 abuse and neglect policy by not conducting a thorough investigation into an incident involving a resident who was found with unknown pills and allegedly consumed a bottle of magnesium citrate. The resident, who had no cognitive impairment and was independent in activities of daily living, was found on the ground with foam coming from his mouth and exhibiting semi-jerky movements. Despite the resident's claim that the pills and solution were given by a hospital doctor, there was no documentation of an investigation into the origin of these items or the circumstances surrounding their consumption. Interviews with staff revealed a lack of communication and action regarding the incident. A CNA witnessed the resident shaking and called a code blue, but did not see the resident consume any pills or solution. An RN took a picture of the pills and solution and sent it to management but did not initiate an investigation. The LPN who admitted the resident did not inquire about any medications or solutions the resident might have had, and the RCC did not report the incident to the DON, believing it was unnecessary. The DON was unaware of the incident until much later and stated that an investigation would have been initiated had she been informed. The Administrator and Regional Nurse Consultant also expected an immediate investigation. The lack of a timely and thorough investigation into the incident represents a failure to adhere to the facility's policies on abuse and neglect, as well as a breakdown in communication among staff members.

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 protect a resident from physical abuse, as evidenced by multiple altercations between two residents. Resident #2, who had moderate cognitive impairment and diagnoses including schizophrenia, was involved in three altercations with Resident #3, who had no cognitive impairment but exhibited physical and verbal behaviors. These incidents occurred on 4/29/24, 8/17/24, and 9/1/24, with Resident #2 being physically assaulted by Resident #3. Despite these altercations, the facility did not update the care plans for either resident with appropriate interventions after each incident. The facility's Abuse and Neglect Policy mandates immediate reporting of abuse allegations and protective measures during investigations. However, the facility did not adhere to these guidelines, as evidenced by the lack of timely intervention and care plan updates following the altercations. The policy also requires that residents who allegedly mistreat others be removed from contact during investigations, but Resident #2 was only moved to another hall after the third altercation on 9/1/24. Interviews with staff, including an LPN and a Hall Monitor, revealed that Resident #2 should not have been placed on a hall with more aggressive residents. The Director of Nursing acknowledged that Resident #2 had aggressive behaviors and expressed that the resident should have been moved sooner. The facility's failure to follow its abuse policy and update care plans contributed to the ongoing risk of resident-to-resident altercations.

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 staff failed to adhere to infection control practices, specifically regarding the use of N95 masks during an active Covid-19 outbreak. Observations revealed that despite signage at the entrance indicating the presence of Covid-19 and the requirement for all staff and visitors to wear N95 masks, compliance was not maintained. Several staff members, including Certified Nurse Aides and maintenance workers, were observed either not wearing masks or wearing them improperly. Additionally, external personnel such as pest control workers and a soda vendor were seen in the facility without masks, despite acknowledging the signage. Interviews with staff and external workers confirmed awareness of the mask requirement due to the Covid-19 outbreak. However, there was a lack of enforcement or instruction from the facility staff to ensure compliance. The facility's policy on Personal Protective Equipment, updated in June 2024, mandates the use of N95 masks to prevent the transmission of airborne pathogens, yet this policy was not effectively implemented, potentially affecting all 112 residents in 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 maintain a medication error rate of less than 5%, resulting in a 22.22% error rate. This deficiency was identified through observation, interview, and record review. During a medication administration observation, a Certified Medication Technician (CMT) administered the wrong inhaler to a resident and failed to provide instructions for its use. Additionally, the CMT did not administer several prescribed medications, including Lasix, Meloxicam, and Sertraline. The CMT acknowledged the errors and reported them to the Charge Nurse after the administration. The errors were compounded by a miscommunication following a telehealth visit, where a Nurse Practitioner was unable to enter a medication order change. The Assistant Director of Nurses (ADON) entered a new order for Haloperidol but failed to remove the previous order, leading to a medication error. The Director of Nursing (DON) confirmed the error and stated that it was corrected after being brought to the facility's attention by the surveyor. The facility's Medication Administration Policy emphasizes the importance of following the six rights of medication administration and reporting discrepancies immediately, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to prevent a significant medication error involving a resident who was prescribed antipsychotic medication. The error occurred when staff did not correctly transcribe the physician's orders for the resident's medication. The resident was supposed to receive Haloperidol 5 mg twice a day, as ordered on 6/21/24, but the previous order of Haloperidol 2 mg three times per day was not removed from the Medication Administration Record (MAR). This resulted in the resident receiving both dosages, leading to an incorrect total dosage of the antipsychotic medication. The error was identified during a survey when it was observed that the resident was administered both 2 mg and 5 mg doses of Haloperidol. The Certified Medication Technician (CMT) involved reported the medication administration to the Charge Nurse only after administering the medication, rather than verifying the orders beforehand. The Director of Nursing (DON) confirmed that the error stemmed from a failure to update the MAR correctly after a telehealth visit, where the Nurse Practitioner was unable to enter the order change directly and communicated it via email to the Assistant Director of Nurses (ADON), who then failed to remove the outdated order.

Penalty

Inspection fine: $16,801

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

Summary

The facility failed to provide adequate supervision to a resident with a history of elopement, hallucinations, and mental illness symptoms requiring 24-hour monitoring. The resident was able to leave the facility without staff knowledge, as staff failed to conduct visual checks and follow up on the resident's whereabouts. The resident was missing for over 24 hours before being located by a local police department. The resident had a documented history of elopement risk, and assessments consistently identified them as at risk. Despite this, the facility's staff did not perform the required hourly face checks, and documentation was falsified to indicate checks were completed when they were not. Additionally, the facility's exit doors were not functioning properly, allowing the resident to leave the premises undetected. Interviews with staff revealed a lack of awareness and communication regarding the resident's risk and recent move from a locked unit to a main area. The resident's family had expressed concerns about the resident's anxiety and desire to leave, but this information was not effectively communicated to the facility. The facility's failure to ensure proper door security and staff supervision contributed to the resident's elopement.

Removal Plan

• Conducted an investigation and in-serviced staff regarding Code white, secured doors, shift reports and rounds, falsifying documentation.
• Completed elopement assessments on all residents to ensure appropriate placement.
• Monitored exit doors one on one until verified all working properly.
• Charge nurses do checks and document.
• Management audits face check documentation.
• Administrator created a department head rotation schedule for completing random rounds in the facility to include evening and night shift.