St Peters Rehab And Healthcare Center

Penalty

Inspection fine: $26,180

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 staff used a gait belt and locked the wheelchair brakes before assisting one resident with a transfer from the toilet to the wheelchair. The resident required assistance from one staff member for toileting and transfers, had a history of stroke with hemiplegia, was cognitively intact, and needed substantial to maximal assistance to stand and transfer to and from the toilet. During the transfer, the resident attempted to sit in the wheelchair while the wheelchair was not locked and the resident did not have a gait belt on. The wheelchair moved as the resident went to sit down, and the resident fell to the floor. The resident reported severe left shoulder pain, was sent to the hospital, and was diagnosed with a fracture of the proximal left humerus. The resident stated that the wheelchair moved and that he/she was not sure whether the brakes had been locked. The facility investigation documented that the resident fell during the transfer with the CNA, that the resident said the chair moved when he/she attempted to sit, and that the resident was taken to the emergency room where x-rays showed the fracture. The CNA stated the resident was not positioned correctly in the wheelchair and that he/she walked around to reposition the resident before the resident was found on the floor. The DON stated staff were expected to use a gait belt for every transfer and to lock wheelchair brakes before transferring a resident to a wheelchair.

Penalty

Inspection fine: $26,180

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 documentation showing that an RN was used in the facility for eight consecutive hours a day, seven days a week. The facility census was 83, and the facility assessment updated on 07/20/25 stated that an RN would be used for at least eight consecutive hours a day, seven days a week. However, review of the facility's timecard punches, payroll reports, and schedules showed no RN coverage on Sunday, 04/05/26, and Sunday, 04/26/26. During interview, the Administrator stated the facility did not have a policy addressing RN coverage. The Scheduler said she was responsible for staffing and ensuring RN coverage, knew there was to be an RN in the building for eight consecutive hours each day, and acknowledged there were times the facility did not meet the requirement because an RN could not be found to work. The DON and Administrator both stated they were aware of the RN coverage requirement and reviewed the list of uncovered days provided by the state agency, and both said they did not see RN coverage for the days listed.

Penalty

Inspection fine: $26,180

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 a performance review for each nurse aide at least once every 12 months and failed to provide regular in-service education based on the outcome of those reviews. Surveyors identified six CNAs employed by the facility for more than a year, and four of the six reviewed did not have the required annual performance review or documentation of in-service education based on the review findings. The facility census was 83. Record review showed CNA AA, hired on 04/08/25, had no documentation of an annual performance review since hire. CNA BB, hired on 05/07/25, also had no documentation of an annual performance review since hire. CNA Z, hired on 03/11/25, had an employer evaluation dated 03/11/26 showing fair ratings for work quality and dependability, but there were no additional comments explaining the ratings and no documentation of additional in-servicing. CNA CC, hired on 10/28/24, had an employer evaluation dated 10/28/25 showing a fair rating for dependability, with no additional comments and no documentation that staff educated the CNA based on the review outcome. The Administrator stated the facility did not have a policy to address nurse aide annual performance reviews, and the DON stated staff were to complete annual performance reviews and provide education on areas of deficiency.

Penalty

Inspection fine: $26,180

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 staff training needs identified in the facility assessment and annual in-servicing calendar were met for five of five staff reviewed. The facility also failed to maintain documentation that staff completed 12 hours of annual in-service training. The census was 83. During interview, the Administrator stated the facility did not have a policy addressing 12 hours of annual training. Review of the Facility Assessment Tool dated 07/20/25 showed required in-service training topics included communication, resident rights and facility responsibilities, abuse, neglect and exploitation, infection control, culture change, dementia care, caring for the cognitively impaired, changes in condition, cultural competency, person-centered care, activities of daily living, disaster planning and procedures, medication administration, measurements, resident assessment and examinations, caring for residents with Alzheimer's, caring for residents with mental and psychosocial disorders, and specialized care. The facility's Education Calendar listed monthly topics such as incident/accident prevention, resident rights, infection control, emergency preparedness, body mechanics, dementia care, abuse/neglect, restorative care, and compliance/ethics, but it did not address person-centered care, measurements, resident assessment and examinations, or caring for residents with mental and psychosocial disorders. Review of the education binder showed multiple in-services were provided in 2025 and 2026, including infection control, reporting abuse and neglect, death and dying, customer service, fall prevention, de-escalation of behaviors, resident rights, privacy and dignity, and contact precautions. The record contained sign-in sheets, but the hours of each in-service were not documented, and the binder did not show evidence that the facility covered the topics identified on the Facility Assessment Tool or the Education Calendar. Five CNAs reviewed had no documentation of receiving 12 hours of annual in-service training, and one CNA stated he/she did not regularly attend in-services, did not know when they were held, and did not know he/she was required to attend 12 hours each year covering specific LTC care topics.

Penalty

Inspection fine: $26,180

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 staff consistently provided assistance with showering, bathing, and personal hygiene for five residents who required help with these activities. The cited residents had care plans and MDS assessments showing needs ranging from supervision to total dependence or maximum assistance for bathing/showering. Facility policy stated residents were to receive necessary care and services based on individualized assessment, including bathing and grooming, but no specific shower/ADL policy was provided. Resident #3 was totally dependent on staff for showering/bathing and personal hygiene, with severely impaired cognition. During observation, the resident’s hair was knotted and messy, had white flakes, and the resident was scratching at the scalp. A family member reported staff had not been giving showers, that the resident had only one bath/shower in the prior couple of weeks, and that the family member had to clean and trim the resident’s nails because they were long and dirty. The family member also said the resident needed hair washing. Resident #90 required partial/moderate assistance with bathing, but shower sheets showed multiple gaps of four to six days between showers in May 2026. The resident stated showers twice a week were not being provided consistently, staff missed showers because they looked at the schedule wrong, and missed showers were not made up; the resident also reported feeling itchy and embarrassed. Resident #88 was totally dependent for bathing/showering and had scheduled showers on Mondays and Thursdays, but observations showed long, curved, dirty nails and disheveled, oily hair several days after the last documented shower. Resident #2 required maximum assistance for bathing twice weekly and reported that Saturday showers did not typically occur because there were no scheduled shower aides on weekends and the regular shower aide was on vacation. Resident #37 required supervision for bathing/showering and reported receiving only one shower per week over the last few weeks, with Saturday showers often missed due to staffing. Staff interviews confirmed a full-time shower aide worked Monday through Friday and that hall aides were responsible for showers when the shower aide was not scheduled.

Penalty

Inspection fine: $26,180

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

Summary

The facility failed to ensure proper settings were in place for low air loss (LAL) mattresses for three residents with pressure ulcers. The report states that the LAL mattresses were intended to reduce pressure and support wound healing, but staff did not consistently set the mattress pumps to the residents’ weights or manufacturer guidelines. Instead, the pumps were observed set at very high settings, including one resident’s mattress set at 308 pounds despite a current weight of 157.2 pounds, another resident’s mattress set at 220 pounds despite weights documented around 102 to 106 pounds, and a third resident’s mattress set at the highest setting past 300 pounds despite a weight of 155.8 pounds. Resident #8 had moderately impaired cognition, required assistance with bed mobility, and had an unhealed Stage IV pressure ulcer of the left ischium that had been present for more than 92 days, had worsened, and showed signs of clinical infection. The resident was also returned from the hospital with osteomyelitis and a wound vac in place. During observation, the resident was lying on the LAL mattress with the pump set at 308 pounds, and the resident’s current weight was documented as 157.2 pounds. The resident’s responsible party reported that the resident complained frequently of pain in the buttock and leg area when sitting or lying on the bottom. Resident #44 had severe cognitive impairment, osteomyelitis, dependence on staff for rolling, low body weight, and multiple pressure ulcers including Stage III and Stage IV wounds. The resident’s care plan identified the need for an LAL mattress and pressure relieving/reducing devices. During observation, the resident was lying on the LAL mattress with the pump set to 220 pounds. The wound physician, DON, and corporate wound nurse assessed the resident and found an open wound with moderate greenish drainage, dull pink wound bed, visible muscle and fascia, and undermining. Resident #70 had severe cognitive impairment and a history of Stage III pressure ulcers to the right heel and first right metatarsal head. Although those wounds were later documented as resolved, the resident remained on an LAL mattress. During observation, the mattress pump was set at the highest setting past 300 pounds, and the mattress was described as firm and barely flexed when pressure was applied. The resident’s right heel was reddened, and a CNA described it as squishy. The wound physician, DON, and medical director all stated that the LAL mattress should be set to the resident’s weight or manufacturer guidelines, and that the highest setting would create a harder surface than expected for wound healing.

Penalty

Inspection fine: $26,180

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

Summary

The facility failed to ensure residents were treated with dignity and respect and that care was provided in an environment that promoted quality of life. Surveyors observed staff not assisting residents when they requested help to use the bathroom, including three residents who reported delays or refusal of assistance. One resident with multiple fractures, including fractures of the pelvis, lumbar spine, cervical spine, humerus, radius, and ulna styloid process, said staff sometimes told him/her to soil in an incontinence brief and they would clean him/her up later, which made the resident feel embarrassed, sad, and worthless. The resident was cognitively intact, required moderate assistance for bed mobility and transfers, and was supposed to receive one-staff assistance to the bathroom. Another resident with moderate cognitive impairment and partial to moderate assistance needs for dressing, toileting, and transfers reported that a CNA did not listen when the resident urgently needed the bathroom. The resident said the CNA wanted the resident to get dressed first, but the resident could not wait and went to the bathroom independently. The resident stated the CNA yelled at and scolded him/her like a child and that the resident did not report it because he/she was intimidated and did not know the CNA's name. A third resident, who was cognitively intact and required substantial to maximum assistance for bed mobility, transfers, and toileting, reported that staff were disrespectful, loud during activities and at night, and that a night shift CNA more than once told him/her to soil himself/herself instead of using the bed pan because the CNA did not want to clean it. The report also documented additional dignity concerns during dining and routine care. Surveyors observed a CMT standing beside a resident with hemiplegia, hemiparesis, aphasia, and severely impaired cognition while feeding the resident at the dining table, reaching over the resident for utensils and leaning on the table while talking. During resident council, residents reported staff did not always wear name badges, some agency staff refused to share their names, staff spoke loudly and disrupted activities, and staff wore ear buds or used personal phones while providing care. Facility leadership acknowledged that staff should treat residents with dignity and respect, should not yell or speak down to residents, should not tell residents to soil themselves, and should not use personal phones or ear buds while providing resident care.

Penalty

Inspection fine: $26,180

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 compliance with the Federal requirement for nurse aide training by making nurse aides employed by the facility pay for testing costs associated with the nurse aide training and competency evaluation program. Review of the applicable regulation showed that no nurse aide who is employed by, or has received an offer of employment from, a facility on the date the aide begins the training and competency evaluation program may be charged for any portion of the program. The facility policy, Nursing Assistant (NA)/Certified Nurse Aide (CNA) Training Program, did not identify who was responsible for paying for the training program or testing. Review of one NA's employee file showed the NA was hired after beginning the CNA training program and completed on-the-job training at the facility. During interviews, the NA stated he/she paid $35.00 twice to retake the knowledge test and $103.00 for the physical test, for a total of $173.00, and had not been told he/she would be reimbursed. Human Resources stated the facility paid for the CNA training program but staff had to pay for testing and were reimbursed after passing. The Administrator stated the same and said she was not aware the facility needed to pay for all aspects of the training program, including testing.

Penalty

Inspection fine: $26,180

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 infection control practices, facility policy, and the resident’s care plan for one resident with a urinary catheter, a Stage IV pressure ulcer on the left ischium, a wound vac, bowel and bladder incontinence, and dependence on staff for personal hygiene and toileting hygiene. The resident was on enhanced barrier precautions for the wound and had orders for catheter care every shift, wound care, and Calmoseptine to the sacrum, groin, and buttocks for redness. During observations, the resident’s urinary catheter drainage bag was seen in a cloth bag and lying directly on the floor next to the bed on multiple occasions. The resident’s care plan directed staff to use PPE for high-contact care and to put on gowns and gloves while providing cares, and the facility’s policies stated that catheter drainage bags should avoid contact with the floor. During personal care, Certified Medication Technician S and CNA Y sanitized their hands and put on gloves, but did not put on gowns while repositioning the resident and providing care. CMT S provided perineal care and catheter care, removed gloves, and then continued care without performing hand hygiene between glove changes and between dirty and clean tasks. CMT S also cleaned the resident’s buttocks, removed the incontinence brief, handled soiled items, applied barrier cream, and continued care without performing hand hygiene. CNA Y stated the resident should have had a gown and gloves for all cares, and CMT S stated a gown should have been worn and hand hygiene should have been performed between dirty and clean tasks and glove changes.

Penalty

Inspection fine: $26,180

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 recommendations from PASRR Level II determinations and evaluation reports were incorporated into the care plans for two residents. Facility policy required that PASRR recommendations, including specialized services, be included in the baseline and comprehensive care plans, and that the facility retain the prescreening record in the medical record. Survey review found that the facility did not have a copy of Resident #2’s Level II PASRR in the chart, and the Administrator confirmed the facility did not have it. The state agency copy showed the resident had multiple mental health diagnoses, a history of sexual abuse, a burn injury over a large area of the body, and reported paranoia, auditory hallucinations, and manic symptoms, with recommendations for a structured environment, consistent routines, daily tasks, and support networks. Resident #2’s care plan addressed psychotropic medication use, depression, anxiety, and monitoring for self-harm or harm to others, but it did not document PTSD or interventions to minimize trauma-related triggers or provide mental health support related to the resident’s trauma history. During interview, the resident stated staff were not fully aware of the past trauma and mental health struggles, described a childhood house fire/explosion that caused burns over 85% of the body, and reported a history of sexual assault and the need for staff awareness of these issues to better understand the resident’s mental health needs. Resident #41’s Level II PASRR identified major depressive disorder, personality disorder, bipolar disorder, mood disorder, intermittent explosive disorder, substance abuse, a history of suicide attempt, suicidal and homicidal ideations, and overdose on fentanyl. The PASRR also recommended trauma-informed services, crisis intervention services, and development of a crisis plan with clear steps, contacts, and emergency response guidance. However, the resident’s care plan only addressed verbal aggression, behavior problems, psychosocial follow-up, activities, and monitoring for harm to self or others, and did not identify the positive Level II PASRR, trauma-informed services, suicide history or precautions, or a crisis intervention plan. The Social Services Director stated she was responsible for ensuring the facility had copies of Level I and II PASRRs, and the MDS/Care Plan Coordinator stated she was responsible for care planning but was not aware of the residents’ positive Level II PASRRs or the recommendations unless staff shared them.

Penalty

Inspection fine: $26,180

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 account for and reconcile Ativan maintained in the emergency medication kit. Review of the facility policy showed controlled substances were subject to special ordering, receipt, and record keeping requirements, and that the DON and consultant pharmacist monitored compliance, but the policy did not address recordkeeping for controlled substances kept in the emergency medication kit. A pharmacy delivery manifest showed E-Kit Ativan was delivered to the facility, and observation of the back nurses station medication room showed the refrigerator contained a lock box labeled E-Kit #20 with two 2 mg vials of injectable Ativan and two 30 ml bottles of liquid oral Ativan. Review of the back nurses station narcotic control log book showed no documentation that staff accounted for or reconciled the Ativan maintained in the emergency medication kit. An LPN stated he/she was in charge of the medication room and supplies for the night shift, was not aware the refrigerator contained E-Kit Ativan, and did not complete an inventory count or accountability page for the Ativan when coming on duty. The DON stated she was not aware Ativan was stored in the emergency kit in the back nurses station medication room, and the Administrator stated she expected staff to account for all narcotic controlled substances and reconcile them every shift.

Penalty

Inspection fine: $26,180

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 was free from a significant medication error when staff did not follow the physician’s order for lidocaine external cream 4% applied topically to the right shoulder twice daily for pain. The resident’s physician order sheet and MAR both reflected an order for lidocaine cream, 2 grams to the right shoulder, and there was no order for a lidocaine 4% topical patch. During observation of the morning medication pass, a CMT reviewed the MAR, removed a box of 4% lidocaine topical patches from the medication cart, and applied a single patch to the resident’s right shoulder even though the box was not labeled for any specific resident and had no pharmacy label. During interview, the CMT stated the resident did not have a personal supply of lidocaine, staff used stock patches, and he/she had not noticed that the order was for a cream rather than a patch. The CMT also stated he/she thought the cream was in the patch and did not know what “apply 2 grams” meant. Two other CMTs stated they always applied a lidocaine patch and had never applied a cream. The DON and Administrator stated staff should follow physician orders as written and that a cream order was not the same as a patch order. The pharmacist stated the facility did not fill the order for lidocaine 4% cream, and that a patch and cream do not deliver the same dose; the patch contains 700 mg to 750 mg of lidocaine, while 2 grams of 4% cream contains 80 mg.

Penalty

Inspection fine: $26,180

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 medications and biologicals were securely stored in locked compartments and were not left in residents’ rooms without an order to self-administer or keep medications at bedside. In a review of 23 sampled residents, two residents were found with medications left unsecured in their rooms. The facility policy stated that medication supplies were to be accessible only to authorized staff and that medication rooms, cabinets, and supplies should remain locked when not in use or attended by authorized persons. For one resident, the physician order sheet showed an order for lidocaine 4% external cream applied to the right shoulder, but there was no order for a lidocaine patch or for bedside storage. During observation, an unopened lidocaine 4% topical patch was found on the resident’s bedside dresser. A CMT stated the patch had been given to another CMT to apply after the resident’s shower, and that it had been left in the room. For another resident, the physician order sheet showed an order for Flonase nasal spray, but there was no order to self-administer or keep the medication at bedside. Two open bottles of Flonase were observed sitting on the counter in the resident’s room, while staff interviews gave conflicting accounts about whether the resident self-administered the spray or whether it was kept in the medication cart. The DON and Administrator stated staff should lock and secure medications and not leave them in residents’ rooms without an appropriate order.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure wound care services met professional standards for a resident with a Stage 4 sacral pressure ulcer and known osteomyelitis. The resident was admitted with multiple serious conditions including multiple sclerosis, paraplegia, diabetes, and osteomyelitis of the vertebra, sacral, and sacrococcygeal regions, and had multiple pressure ulcers documented on the care plan. Facility policy required licensed nurses to perform admission, readmission, weekly, and as-needed skin assessments, notify the attending physician and IDT of wounds that worsened or did not respond to treatment, obtain and monitor labs and diagnostics as ordered, and document wound status and treatment effectiveness at least weekly. Despite these policies, the facility did not consistently follow physician orders, did not complete required weekly wound documentation, and did not ensure that diagnostic results and wound status were communicated to appropriate providers. On 01/13/26, the wound care provider assessed the resident’s Stage 4 sacral ulcer, documented poor healing potential, moderate exudate, signs of clinical infection, and recommended continuing current treatment. On 01/20/26, the provider reassessed the sacral wound, noting it had increased in size, had moderate serosanguinous exudate exacerbated by infection, and again documented one or more signs of clinical infection. The provider performed fluorescence imaging, recommended adding mupirocin 2% topical twice daily, and ordered a deep wound culture. However, review of physician orders, the MAR, and the TAR from 01/20/26 through 01/29/26 showed no order for mupirocin and no documentation that mupirocin was applied. Interviews later revealed conflicting accounts: the regional nurse stated a nurse practitioner had ordered mupirocin on 01/20/26, while the NP denied ever seeing the wounds or ordering mupirocin. The regional wound nurse indicated that if the order was written in the wound provider’s note, the facility wound nurse should have checked the report the next day and followed through, but this did not occur. A wound culture of the sacral tissue collected on 01/20/26 and reported on 01/23/26 identified multiple pathogens, listed first-line and alternative systemic antibiotic options, and included mupirocin 2% ointment as an additional option. A handwritten note on the report stated "will see during next rounds" with initials, but the culture results were not entered into the resident’s medical record between 01/21/26 and 01/30/26, and there was no documentation that the primary physician, hospice, or IDT were notified of the culture findings. The DON reported she could not find culture or biopsy results in the record, and the wound nurse stated she did not obtain the culture results until surveyors asked questions, at which point she found the wound provider’s notes in the electronic record. The hospice RN, who assumed wound care on 01/26/26 based on measurements and treatment orders provided by the facility LPN, was not informed that a culture or biopsy had been done and stated that, had the culture report been shared, hospice would have consulted their physician about starting antibiotics. During the period from 01/21/26 through 01/30/26, there was no further documentation of the sacral wound in the resident’s medical record, despite facility policy requiring at least weekly wound documentation and documentation of changes in skin condition. The wound care provider did not return the week of 01/26/26 due to weather, and the LPN did not notify the primary physician or responsible party of the canceled visit or any change in wound status. The biopsy of the sacrum collected on 01/20/26, later reported on 02/04/26, confirmed acute and chronic osteomyelitis, but this result was not present in the facility record during the relevant period and was not communicated to hospice. On 01/30/26, an order for mupirocin 2% to the sacrum with daily dressing changes was finally entered, but the TAR showed the resident was already in the hospital on those dates. Hospital lab results from 01/30/26 documented markedly elevated WBC and neutrophil counts and an elevated lactate level consistent with sepsis, and the family reported the resident required ICU admission, IV antibiotics, and multiple surgeries for the infected sacral ulcer. Facility leadership, including the administrator and medical director, stated they would have expected all lab results, cultures, biopsies, and wound care provider orders to be reviewed, communicated, and followed, but this did not occur in this case.

Penalty

Inspection fine: $12,425

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 certified nurse aide (CNA) physically abused a resident during care. The CNA aggressively moved the resident in bed without explanation, causing the resident to yell for help and report pain. The resident, who had significant medical conditions including flaccid hemiplegia, contractures, generalized anxiety disorder, and Alzheimer's disease, was tearful, upset, and expressed fear of the CNA following the incident. The resident was dependent on staff for bed mobility and toileting, had impaired cognition, and was known to bruise easily due to underlying hematological issues. The incident was witnessed by a licensed practical nurse (LPN), who observed the CNA handling the resident roughly, rolling and moving the resident without communication, and using excessive force. The LPN intervened after the resident screamed for help, instructing the CNA to stop and leave the room. Additional staff entered the room after hearing the resident's distress, and they took over the resident's care. The resident was found to be partially undressed and covered only by a sheet, and the CNA's actions resulted in the resident being placed dangerously close to the edge of the bed and in the spread of feces throughout the room. Subsequent assessments and interviews confirmed the resident sustained multiple bruises to the right arm, as documented in the facility's skin assessments and corroborated by photographs provided by the resident's next of kin. The resident consistently reported being hurt and scared by the CNA, and staff interviews supported the account of rough and aggressive handling. The deficiency was identified based on direct observation, staff and resident interviews, and review of medical records and skin assessments.

Penalty

No penalty information released

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

Summary

A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

No penalty information released

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

Summary

Nursing staff failed to perform appropriate hand hygiene and change gloves during the provision of care for a resident who was dependent on staff for toileting and personal hygiene, incontinent of bowel and bladder, and had open wounds. Staff provided incontinent care, handled soiled linens, and touched various surfaces without removing gloves or performing hand hygiene as required by facility policy. Additionally, staff did not wear gowns or follow Enhanced Barrier Precautions (EBP) during high-contact care activities, and there was no signage posted to alert staff to the need for EBP. Multiple residents with conditions such as wounds, indwelling catheters, and enteral tube feedings were not properly identified for EBP, and staff did not consistently use personal protective equipment (PPE) as required. For example, a resident with an indwelling catheter and a wound infection was observed with catheter tubing and bags touching the floor, and staff failed to don gowns when providing care. Another resident with third-degree burns and an indwelling catheter was not placed on EBP, and staff entered the room and provided care without PPE or appropriate signage. Interviews with staff revealed a lack of awareness regarding EBP requirements and inconsistent implementation of infection control policies. The Assistant Director of Nursing/Infection Preventionist acknowledged delays in identifying residents who met criteria for EBP and confirmed that nurses were expected to implement precautions upon admission or when criteria were met. The Director of Nursing and Administrator both stated that staff were expected to follow hand hygiene and EBP policies, but observations and interviews demonstrated that these protocols were not consistently followed.

Penalty

Inspection fine: $14,050

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 and prevent injury for a resident when staff left the resident unattended in the shower room. The resident, who required assistance for bathing, hygiene, and dressing due to impaired balance and functional limitations, was left alone by a nurse aide who assumed the resident was independent. The resident attempted to dress themselves, lost balance, and fell, resulting in a right hip fracture. The resident's care plan indicated the need for one staff assist for bathing and dressing, which was not followed. The resident was found on the floor after calling for help, having attempted to pull up their pants without assistance. The resident experienced pain and was later diagnosed with a right hip fracture, requiring hospitalization and surgery. Interviews with staff revealed a lack of awareness regarding the resident's need for assistance, and the nurse aide admitted to leaving the resident alone in the shower. The Assistant Director of Nursing and Director of Nursing confirmed that the resident should not have been left alone, and the care plan should have been followed to ensure the resident's safety.

Removal Plan

• Conducted an investigation.
• Notified appropriate parties.
• Educated all facility staff on assistance with showers, to provide assistance with showers per care plan.
• Inserviced all staff.

Penalty

Inspection fine: $14,050

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 respond to call lights in a timely manner for three residents, leading to significant delays in providing necessary assistance. Resident #12, who has dementia, arthritis, and muscle weakness, experienced multiple instances where the call light was activated for extended periods, ranging from 15 minutes to over an hour. The resident expressed frustration during an interview, stating that staff often took a long time to respond, requiring multiple activations of the call light before receiving help. Resident #3, diagnosed with multiple sclerosis and requiring substantial assistance for daily activities, also faced delays in call light responses. The call light log indicated several instances where the call light was activated for durations ranging from 18 minutes to over an hour. The resident reported that staff response times were inadequate, sometimes taking up to 30 minutes, and noted that staff occasionally turned off the call light without providing immediate assistance, leading to further delays. Resident #8, with chronic obstructive pulmonary disease and other mobility issues, experienced similar delays, with call light activations lasting from 18 minutes to over an hour. The resident noted that response times were particularly poor on weekends and that staff sometimes turned off the call light without returning promptly. Interviews with facility staff, including LPNs, RNs, and the Director of Nursing, revealed an expectation for call lights to be answered within five to fifteen minutes, yet the documented response times significantly exceeded these expectations.

Penalty

Inspection fine: $14,050

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 clarify and obtain physician orders for two residents who sustained fractures and had surgery to repair them. Upon admission from the hospital, the facility did not complete the necessary assessments and treatments for the residents' surgical incisions. Specifically, one resident was admitted with fractures requiring surgical repair, but there were no specific orders to monitor the surgical sites on the left ankle or knee. The facility's records showed no documentation of assessments of the surgical sites or dressings, and the staff did not contact the physician for order clarification. Another resident experienced a fall in the facility, resulting in a hip fracture and subsequent surgery. Upon readmission, the facility did not clarify orders for the resident's surgical site care. The facility's records lacked documentation of assessments of the surgical wound dressing, and the staff did not contact the physician for clarification until two weeks after the resident's return. Additionally, the facility did not complete neurological checks per policy following the resident's fall, failing to conduct the required 72-hour monitoring. Interviews with facility staff, including LPNs, the Assistant Director of Nursing, and the Director of Nursing, revealed inconsistencies in following the facility's policies for skin assessments and post-fall procedures. Staff acknowledged the need for full skin assessments on admission and readmission, as well as the necessity to obtain wound care orders from physicians. The facility's failure to adhere to these protocols resulted in deficiencies in the care provided to the 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 provide adequate staffing and oversight, resulting in unmet hygiene and toileting needs for residents. Specifically, the facility did not have enough staff to ensure that residents requiring assistance were showered, clean, had their hair maintained, were shaved, and had their nails trimmed. Additionally, the facility did not respond to resident call lights in a timely manner, leading to unmet toileting needs and episodes of incontinence, with residents being left soiled for extended periods. The facility also lacked sufficient staff to maintain cleanliness and prevent odors within the facility. These deficiencies affected eight residents in a sample of 25, with a total facility census of 81.

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 safe, clean, and comfortable environment for its residents. This deficiency was identified through observation, record review, and interviews conducted by surveyors. The facility, with a census of 81 residents, did not ensure that resident rooms and living spaces were maintained in a clean and good state of repair. This failure compromised the residents' right to a safe and homelike environment, as required by regulations.

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 physician orders for three residents, resulting in a deficiency. Resident #305 did not receive the prescribed insulin, leading to a blood sugar level of 499, which exceeded the physician's acceptable parameters. The staff did not identify the missed insulin dose, failed to document proper notification of the physician, and did not continue assessing the resident's condition. Additionally, the facility did not administer medications as ordered by the physician and did not contact the physician for further instructions when orders could not be followed. These failures were identified through observation, interview, and record review during the survey, with the facility census at 81.

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 food served to residents was palatable and maintained at a safe and appetizing temperature. This deficiency was identified through observation, interviews, and record reviews conducted by surveyors. The issue remains uncorrected, as noted in a previous Statement of Deficiency dated 4/12/24. The facility has a census of 81 residents, indicating that a significant number of individuals may be affected by this ongoing issue.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary care and services for two residents who required assistance with activities of daily living (ADL) to maintain good grooming and personal hygiene. This deficiency was identified through observation, interview, and record review. The issue remains uncorrected, as noted in a previous Statement of Deficiencies. The facility's census at the time was 81 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 provide adequate interventions to address weight loss for two residents, as observed through a review of 25 sampled residents. This included not providing physician-ordered supplements and not following registered dietician recommendations, which were necessary to prevent further weight loss. The deficiency was identified through observation, interview, and record review, and it affected the nutritional status of the residents, compromising their health. The facility census at the time was 81.

Penalty

Inspection fine: $65,24751 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 two residents, R16 and R20, were free from abuse and neglect. On 4/7/24, CNA 7 refused to assist R16 out of bed, resulting in the resident remaining in bed until the next shift arrived. On 4/8/24, R16 used her call light to request help for repositioning, but no one responded. Two agency staff members later entered her room, accused her of calling too much, and one of them yanked the call light out of her hand, threw it on the floor, and threatened her. R16 reported these incidents to facility staff, but no action was taken, and CNA 7 continued to work on R16's hall on 4/9/24, placing the resident at risk for continued abuse and neglect. R20 experienced similar neglect and abuse. On 4/7/24, the CNA assigned to R20 refused to help her get out of bed, told her to hurry up, and pushed her. When R20 asked the CNA not to push her, the CNA told her to hurry up. R20 felt this was mental abuse but did not report it. On 4/8/24, the night shift aide refused to help R20 into bed and provide incontinent care, leaving her in her wheelchair until 3:00 AM. R20 attempted to change her own brief but could not reach it and remained in the same brief until the day shift when NA1 changed it. R20 reported this incident to NA1, who confirmed the neglect but did not take further action. The facility's policy on abuse prevention and prohibition was not followed, as staff failed to report and address the allegations of neglect and abuse. The facility census was 82, and the administrator was notified of the Immediate Jeopardy on 4/9/24. The facility provided an acceptable plan for removal of the immediate jeopardy on 4/11/24, and the survey team validated the removal on the same day. However, the deficient practice remained at a D scope and severity following the removal of the immediate jeopardy.

Penalty

Inspection fine: $65,24751 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 allegations of neglect were reported to supervisors and/or the facility's Abuse Coordinator for two residents. Resident 16, who was cognitively intact and required substantial assistance with transfers, reported that a CNA refused to help her get out of bed and was verbally dismissive. The resident remained in bed until the evening shift when she was assisted by an LPN and another CNA. The LPN did not report the allegation to the on-call supervisor, the Director of Nursing, or the Administrator, who was the facility's Abuse Coordinator, despite being aware of the facility's policy to do so immediately. Similarly, Resident 20, who was also cognitively intact and required moderate assistance with transfers, reported that a night shift aide refused to help her into bed and provide incontinent care, leaving her in the same brief until the day shift. The resident reported the incident to a Nurse Aide, who also failed to report the allegation to her supervisor or the facility's Abuse Coordinator. The Administrator confirmed that he had not been informed of any allegations of neglect related to these residents, despite the facility's policy requiring immediate reporting of such incidents.

Removal Plan

• The facility will re-educate all staff on the Abuse Prevention and Prohibition Program policy, emphasizing the importance of immediate reporting of any allegations of abuse, neglect, or theft.
• The facility will conduct in-service training sessions for all staff members to ensure they understand their roles as Mandatory Reporters.
• The facility will implement a system to ensure that all allegations of abuse, neglect, or theft are reported to the appropriate supervisors and the facility's Abuse Coordinator.
• The facility will audit compliance with the reporting policy by conducting random interviews with residents and staff to ensure that any allegations are being reported and addressed.
• The facility will review and revise, if necessary, the current policies and procedures related to abuse, neglect, and theft to ensure they are comprehensive and up-to-date.
• The facility will ensure that the Administrator, Director of Nursing, and other key personnel are informed of any allegations of abuse, neglect, or theft.
• The facility will monitor and document the implementation of these corrective actions to ensure ongoing compliance and effectiveness.

Penalty

Inspection fine: $65,24751 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 appropriate pain management for a resident (R20) who was without pain medication for three days. R20, who had diagnoses including poly osteoarthritis, polyneuropathy, chronic pain, and fibromyalgia, was prescribed hydrocodone-acetaminophen for pain relief. Despite the prescription, R20 did not receive the medication from 03/28/24 through 03/30/24 due to an unavailable prescription refill. During this period, there was no documented evidence that R20's pain level was assessed, nor were any non-pharmacological interventions attempted to alleviate her pain. Additionally, the Director of Nursing (DON) was not notified of the situation, which resulted in R20 experiencing significant pain without appropriate management or intervention from the staff. R20's medical records indicated that she was frequently in pain, with her pain occasionally interfering with daily activities. She rated her pain at a 9 on a zero to 10 scale. Despite this, the facility did not take necessary actions to manage her pain when the prescribed medication was unavailable. Interviews with R20 and staff confirmed that R20 experienced severe pain during the three-day period without her medication, and no alternative measures were offered to help manage her pain. The DON and Regional Nurse Consultant (RNC) were unaware of the situation until the surveyor's inquiry, indicating a lapse in communication and protocol adherence within the facility. The facility's policy on pain management required staff to assess and document pain levels and to notify the DON if pain medication was unavailable. However, these procedures were not followed in R20's case. The failure to provide timely pain management and to explore alternative interventions resulted in actual harm to R20, highlighting significant deficiencies in the facility's pain management practices and communication protocols.

Penalty

Inspection fine: $65,24751 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 the Activities Program was directed by a qualified professional. The Activity Director (AD) did not possess the required credentials and was not certified, as verified by the Administrator. The AD, who was previously a certified nursing assistant (CNA), had been in the role for about a year and a half without obtaining the necessary certification. The AD admitted to not maintaining activity participation records or documenting activity progress in quarterly notes, as required by the facility's policy. The Administrator, who had been in his position for less than a month, acknowledged that not all responsibilities of the AD were being fulfilled and was in the process of evaluating staff, including the AD. The facility's policy required the Activity Director to develop individualized care plans, review and update them quarterly, and maintain accurate records of each resident's participation in activities. However, the AD was unaware of these requirements and did not document activity participation or progress. This lack of proper documentation and oversight created the potential for the activity program to not meet the needs, interests, and preferences of all 82 residents in the facility.

Penalty

Inspection fine: $65,24751 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 adequate and competent nursing staff were available to meet the needs of residents, resulting in several deficiencies. Residents reported not receiving their medications, having call lights unanswered, and experiencing unmet needs for activities of daily living (ADLs). Specific incidents included residents not receiving their evening medications, with one resident missing pain medication and another missing blood pressure medication, leading to concerns about potential health risks. Additionally, residents reported that agency staff were often unresponsive, did not introduce themselves, and were seen using earbuds and talking on their phones while providing care. These issues were repeatedly raised in resident council meetings but remained unresolved. Weekend staffing was particularly problematic, with reports of only two aides being available for the entire building on some occasions. Residents described long wait times for assistance with toileting and other needs, with one resident waiting up to four hours to be toileted. Another resident reported being left in a wheelchair for extended periods without being changed. The facility's staffing records confirmed frequent shortages, especially on weekends, with several instances of fewer CNAs working than scheduled. This led to delays in care and unmet needs for residents. The facility's policies required sufficient nursing staff to meet resident needs, but these were not adhered to. Interviews with staff and residents revealed that the facility often relied on agency staff who were not adequately trained or familiar with the residents' needs. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the issues but stated that staffing was considered adequate based on the facility's census. However, the persistent complaints and documented incidents indicated otherwise, highlighting a significant gap between policy and practice in ensuring resident care and safety.

Penalty

Inspection fine: $65,24751 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 nourishment refrigerators were free from grime and food residue and that temperatures were checked. Observations revealed that the nourishment refrigerator in the front dining hall had spilled juice at the bottom and contained two sandwiches, while the refrigerator in the back dining hallway contained three gallons of milk without temperature logs. During an interview, the Dietary Manager (DM) was unaware of the responsibility for checking temperatures and maintaining cleanliness, stating that their only job was to stock snacks and beverages. This failure had the potential to affect all 82 residents.

Penalty

Inspection fine: $65,24751 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 the Infection Prevention and Control Program (IPCP) was overseen by a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control (IPC). The IP had only completed a one-day course that awarded six contact hours, which did not cover the comprehensive topics recommended by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). The IP could not recall the specifics of the training and admitted to following instructions from her corporate boss without verifying the adequacy of the training. This deficiency had the potential to affect all 82 residents in the facility. During the survey, it was revealed that the Director of Nursing (DON), who had been employed for two months, had completed the CDC IP training and was actively involved in infection control activities. However, the IP had not completed the CDC's recommended training. The Regional Nurse Consultant (RNC) confirmed that the IP had started but not finished the CDC training. The facility's policy required the IP to coordinate and monitor infection control policies, but the lack of adequate training compromised the effectiveness of the IPCP.

Penalty

Inspection fine: $65,24751 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 an adequate supply of bariatric incontinent briefs to meet the needs of three residents, all of whom were cognitively intact and required larger-sized briefs due to their medical conditions. Resident 4, admitted with severe obesity, reported that the facility frequently ran out of the required 3xl to 4xl briefs, leading to discomfort and the need to borrow briefs from other residents. Similarly, Resident 14, who had muscle weakness and difficulty walking, also experienced frequent shortages of the appropriate size briefs, causing discomfort and necessitating the use of smaller, ill-fitting briefs. Resident 20, suffering from polyarthritis, chronic pain, and fibromyalgia, reported similar issues with the facility's supply of bariatric briefs, often having to wear briefs that were too tight for comfort. Nurse Aide 1 confirmed that the facility had ample supplies of smaller briefs but frequently ran out of the larger sizes needed by these residents. The aide also mentioned that the Assistant Director of Nursing was informed about the shortages but would often respond that a new shipment was expected. The Central Supply Clerk (CS) admitted that the facility had recently changed suppliers and was still adjusting to the new sizing and ordering requirements. The CS also acknowledged that the list of sizes needed for each resident had not been updated to reflect the new supplier's products, contributing to the supply issues. Review of the supply invoices revealed that the facility had been ordering an insufficient number of bariatric briefs, with only two cases delivered weekly until the week of the survey, when the order was increased to five cases. This resulted in an average of only five briefs per day per resident, which was inadequate to meet their needs. The CS confirmed that the facility had recently increased the order to five cases per week but had not yet updated the list of sizes needed for each resident. The Regional Nurse Consultant confirmed the shortage of 3xl briefs during an inspection of the supply closet, further highlighting the facility's failure to adequately accommodate the needs of its residents.

Penalty

Inspection fine: $65,24751 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 grievances raised by the resident council were addressed and attempts were made to resolve the grievances for six residents. The issues included call lights, staff not introducing themselves, staff not responding to residents' needs, staff talking on their phones, and food palatability issues. The facility's policy on grievances did not include specific information related to grievances expressed during the resident council meeting, leading to repeated unresolved concerns from the residents over several months. During a resident council group interview, all six residents stated that the issues raised in the resident council group did not get resolved and the same issues were presented repeatedly. Specific complaints included staff not introducing themselves, dietary issues such as too much rice and beans, and missing clothing. The residents expressed frustration over the lack of progress in addressing their concerns, despite the new Administrator attending a meeting and being aware of the issues. Interviews with facility staff, including the Social Service Director, Activity Director, Director of Nursing, and Assistant Director of Nursing, revealed a lack of a formal process to address grievances raised during resident council meetings. The staff acknowledged repeated concerns but did not initiate grievances for issues raised in the meetings. The Administrator, who had been employed for a month, stated that efforts were being made to address the concerns, including ensuring staff wore name tags and recruiting nursing staff to reduce reliance on agency staff.

Penalty

Inspection fine: $65,24751 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 residents and/or their representatives received written information about and assistance with formulating advance directives for three residents reviewed. Resident 4, who was admitted with diagnoses including osteomyelitis, type 2 diabetes mellitus, and severe obesity, had no documentation in the electronic medical record (EMR) indicating that advance directives were reviewed or that the resident was provided education on the matter. The Social Services Quarterly Note for Resident 4 indicated no change in status but lacked evidence of review or involvement of the resident in the process. Similarly, Resident 16, admitted with diagnoses including contractures, difficulty walking, and hemiplegia and hemiparesis of the left side, also had no documentation in the EMR regarding advance directives. The Social Services Quarterly Note for Resident 16 showed no change in status but did not document any review of resident rights related to advance directives or involvement of the resident in the process. The Social Services Director (SSD) confirmed that advance directives were not reviewed with residents except during care plan meetings, and no education on advance directives was provided during these meetings. Resident 14, admitted with diagnoses including muscle weakness and difficulty in walking, also had no documentation in the EMR related to advance directives. The Social Services Quarterly Note for Resident 14 indicated no change in status but lacked evidence of review or involvement of the resident in the process. The facility's policy on advance directives required that residents be provided with information and assistance upon admission and that the Interdisciplinary Team annually review the advance directive with the resident or responsible party, but this was not followed as per the findings and interviews with the SSD and Regional Nurse Consultant.

Penalty

Inspection fine: $65,24751 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 activities were provided to residents, including one sample resident and five supplemental residents. The deficiencies included not offering activities on weekends or outings, not documenting activity participation, not completing quarterly activity progress notes, and not developing a care plan for one resident as directed by the facility's policy. The facility's policy required a variety of activities to be offered daily, including weekends and evenings, and for activity participation to be documented daily. However, these requirements were not met, leading to a lack of engagement and stimulation for the residents involved. One resident, who was moderately cognitively impaired, expressed dissatisfaction with the activity program, stating that there was not much to do and that she stayed in her room a lot. Observations confirmed that this resident spent significant time in her room without engaging in activities. The Activity Director (AD) admitted to not documenting residents' attendance at activities and not completing quarterly assessments of activities for residents. The AD also confirmed that there were no scheduled activities on weekends and no outings being offered currently. A resident council group interview revealed that residents liked the AD and the activities offered but desired more activities, especially on weekends. They expressed a need for more bingo sessions, music during meals, and outings, such as trips to Walmart. The AD, who was also the van driver, stated that she was the only activity employee for the 82 residents in the facility, which contributed to the lack of scheduled activities and outings. The facility's failure to adhere to its activity program policy resulted in insufficient engagement and stimulation for the residents, impacting their overall well-being.

Penalty

Inspection fine: $65,24751 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 adequate fluids to maintain the health of several residents, as observed during a survey. Specifically, two residents and four supplemental residents were not offered or provided with sufficient fluids such as ice water and other beverages. One resident, who was moderately cognitively impaired and had multiple health conditions including Parkinson's disease and chronic kidney disease, did not have a nutritional assessment completed by the Registered Dietitian since admission. This resident's fluid intake was inadequately documented, and observations revealed that the resident frequently did not have access to ice water or other beverages in her room despite expressing thirst and requesting water multiple times. During a resident council group interview, several residents expressed concerns about the availability of ice water and beverages in their rooms. They reported that they were rarely provided with ice water and often did not receive drinks they preferred, such as coffee, juice, and milk. Instead, they were routinely served Kool-Aid, and iced tea was not available. The facility's policy required CNAs to check water pitchers at the start of their shifts and every two hours, but this was not consistently done. Interviews with staff, including a CNA, LPN, and the Registered Dietitian, confirmed that the facility did not ensure residents had ice water available in their rooms. The Registered Dietitian acknowledged that full nutritional assessments had not been completed for all residents and that she was unaware of the residents' concerns about the lack of beverages. The Director of Nursing and Regional Nurse Consultant stated that the expectation was for residents to have ice water available in their rooms, which was not met in this case.

Penalty

Inspection fine: $65,24751 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 a medication error rate below five percent, resulting in an error rate of 8 percent. During medication administration, two errors were made for a resident out of 25 opportunities. The errors involved the medications Myrbetriq and Allegra, which were not included in the resident's prepared medications. The Certified Medicine Technician (CMT) stated that the medications had not arrived from the pharmacy, and the Licensed Practical Nurse (LPN) was informed about the missing medications. However, it was later found that the Myrbetriq had been delivered but was placed on the wrong medication cart, and the Allegra was a stock medication that needed to be ordered with the stock medications. The resident involved had multiple diagnoses, including fecal impaction, pneumonitis, chronic kidney disease stage II, partial intestinal obstruction, and diabetes mellitus. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) stated that it was their expectation for nurses to notify the pharmacy in advance when a resident's medication was running low to avoid missed doses. Despite this expectation, the resident did not receive the prescribed medications due to the errors in medication administration and handling.

Penalty

Inspection fine: $65,24751 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 condiments were offered and served with meals for three residents. During an initial tour, a resident who had been admitted a few days prior reported that no condiments were served with her meals. An observation confirmed that her breakfast tray lacked condiments such as salt, pepper, sugar, butter, and jelly. A CNA who set up the tray did not ask the resident if she needed anything else and later stated that residents could request condiments if they wanted them. Another resident, who was moderately cognitively impaired, reported that her lunch meal was terrible and that she was not offered salt or pepper, which she believed would have improved the taste of her meal. An observation confirmed that she had not eaten her meal except for the dessert, and she expressed a desire for salt and pepper to enhance the flavor of her food. A third resident, who was cognitively intact, participated in a resident council group interview and stated that the facility did not consistently serve condiments. She provided examples such as not receiving tartar sauce with fish, no butter being available, and a sandwich being served with only mustard and no mayonnaise. She also mentioned that salt and pepper were not always available. The Dietary Manager confirmed that residents who could have condiments per their diet should be offered them, indicating a lapse in the facility's adherence to its policy on providing nutritionally adequate and well-balanced meals that accommodate resident preferences.

Penalty

Inspection fine: $65,24751 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 three residents received services in a manner that promoted their dignity and enhanced their quality of life. One resident was observed with long stubble facial hair and wearing clothing covered with food spills, residue, and crumbs. This resident required substantial assistance with personal hygiene and dressing but was found in a soiled state multiple times over two days. The staff did not document any refusals of care, and the resident's care plan did not specifically address shaving or identify any concerns with refusals of care. Interviews with staff revealed that the resident should have been shaved during showers, which were scheduled twice a week, but this was not consistently done. Additionally, the resident's clothing was not changed despite having clean clothes available in the closet, and the staff failed to maintain the resident's dignity by not addressing these issues promptly. Two other residents required assistance with eating, and facility staff were observed standing over them while assisting with meals. This practice was contrary to the facility's policy and the expectations set by the Registered Dietitian and the Director of Nursing, who stated that staff should be seated while assisting residents to create a homelike atmosphere. The observations and interviews indicated that the staff did not follow the proper protocol for assisting residents with meals, which compromised the residents' dignity and quality of life. The Director of Nursing and the Assistant Director of Nursing confirmed that staff should not stand over residents when assisting them with meals. The facility's failure to adhere to its own policies and procedures regarding resident care and dignity was evident in the observations and interviews conducted. The staff's inactions and lack of adherence to care plans and policies led to the deficiencies observed in the care provided to these residents, impacting their dignity and quality of life.

Penalty

Inspection fine: $65,24751 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 a resident retained their right to exercise their rights. The resident, who was cognitively intact with a BIMS score of 14, was not given the opportunity to make their own decision regarding the use of a cell phone sent to them for communication. The facility opened the resident's mail containing the cell phone, read a note inside the package intended for the resident, and contacted the resident's medical Power of Attorney (POA). The POA instructed the facility to not give the phone to the resident, even though the resident had not been adjudged incompetent by the court and legally retained his rights. The facility did not ask the resident if they wanted to keep the phone and instead followed the POA's instructions, which led to the resident not being able to communicate with their girlfriend, causing the resident to become depressed. Interviews with the Social Service Director (SSD) and a Licensed Practical Nurse (LPN) confirmed that the resident was cognitively able to make their own decisions and that the resident's phone was taken away based on the POA's instructions. The SSD admitted to opening the package containing the phone and contacting the POA without consulting the resident. The facility's Resident Rights policy and the resident's Admission Agreement both indicated that the resident had the right to make their own decisions unless deemed incapacitated, which was not the case for this resident. The failure to respect the resident's rights and autonomy led to a violation of the resident's dignity and self-determination.

Penalty

Inspection fine: $65,24751 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 invite two cognitively intact residents to participate in their care plan meetings, despite their expressed interest in doing so. Resident 11, who had a BIMS score of 15 out of 15, indicating cognitive intactness, was not invited to his care plan meetings. The Social Service Director (SSD) stated that the meetings were scheduled around the availability of Resident 11's Power of Attorney (POA), and there was no documentation that Resident 11 was invited or attended these meetings. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that there should have been documentation of the resident being invited and attending the care plan meetings, but such documentation was missing. Similarly, Resident 4, who also had a BIMS score of 15 out of 15, indicating cognitive intactness, was not consistently invited to her care plan meetings. Although she attended one care plan meeting in November 2023, there was no other documented evidence that she was invited, encouraged, or assisted in attending her care plan meetings. The SSD confirmed that there was no sign-in sheet or other documentation to show that Resident 4 was invited to or attended her care plan meetings. The facility's policy required that residents and their families be invited to care planning meetings and that efforts be made to schedule these meetings at convenient times. However, the lack of documentation and the failure to invite the residents to their care plan meetings indicate that the facility did not adhere to its own policy. Both the DON and the Administrator acknowledged that residents should be invited to their care plan meetings and that there should be documentation of their attendance, which was not done in these cases.

Penalty

Inspection fine: $65,24751 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 written notice to a resident (R43) before initiating a room change. R43, who was cognitively intact with a BIMS score of 15 out of 15, was moved from her room on the same day she was verbally informed of the change. The facility's policy requires that residents receive timely advance written notice of room changes, including the reasons for the change, but this was not followed in R43's case. The Social Service Director (SSD) admitted that the resident was only verbally informed and no written notice was provided. Additionally, there was no documentation in R43's electronic medical record (EMR) regarding the room change or the reasons for it, which included the resident releasing medical information to her roommate's friend and having alcohol in her room. Interviews with the SSD, Licensed Practical Nurse (LPN), Director of Nursing (DON), and Regional Nurse Consultant (RNC) confirmed that the facility's process for room changes involves notifying the resident's family first and then the resident, but this was done verbally and not in writing. The SSD and other staff members verified that R43 was moved without written notice and that the reasons for the move were not documented in the EMR. The facility's policy and the staff's statements indicate that residents should be notified 24 to 48 hours before a facility-initiated room change, but this protocol was not followed in R43's case.

Penalty

Inspection fine: $65,24751 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 complete an investigation for a resident's grievance regarding a missing brooch. The resident, who was cognitively intact with a BIMS score of 15 out of 15, reported the missing brooch in January 2024. However, the facility's grievance logs for that period showed no documented evidence of the grievance. The resident's property inventory list did not include the brooch, and the Social Services Director (SSD) contacted the resident's family, who stated the resident never had a brooch. Despite this, the SSD did not document informing the resident of the investigation's outcome, and no grievance/complaint was filed as per the facility's policy. The Assistant Director of Nursing (ADON) and SSD both admitted to lapses in following the facility's grievance policy, and the resident confirmed that no one from the facility had met with her regarding the investigation. The facility's policy mandates prompt review, investigation, and resolution of grievances, with the findings communicated to the resident. In this case, the facility failed to adhere to its policy, as evidenced by the lack of documentation and communication with the resident. The SSD's unfamiliarity with the current grievance policy further contributed to the deficiency. The resident expressed frustration over the lack of communication and resolution, indicating a failure in the facility's grievance handling process.

Penalty

Inspection fine: $65,24751 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 a bed hold notice within 24 hours of an emergent transfer to the hospital for one resident. The resident, who was moderately cognitively impaired and had diagnoses including benign intracranial hypertension, Alzheimer's disease, diabetes mellitus type two with neuropathy, and adult failure to thrive, was transferred to the hospital due to altered mental status. Despite the facility's policy requiring written notification of bed hold duration, no such notice was given to the resident or their responsible party within the required timeframe. The deficiency was identified during a review of the resident's electronic medical record, which showed no documented evidence of a bed hold notice being provided at the time of the emergency transfer. The facility's Regional Nurse Consultant confirmed that no bed hold notice was issued. This oversight placed the resident and their responsible party at risk of not knowing to request a bed hold to ensure the resident's return to the facility.

Penalty

Inspection fine: $65,24751 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 adequate activities of daily living (ADL) care for a resident (R176) who was totally dependent on staff for personal hygiene and toileting. R176, admitted with chronic kidney disease stage III and dementia, did not receive a shower until nearly three weeks after admission. The resident's care plan indicated a self-care deficit, requiring substantial to maximum assistance with personal hygiene. Despite this, there was no documented evidence of showers being provided until 04/10/24, as confirmed by the resident's ADL sheet and shower/bath sheets. Family members also reported instances where the resident soiled himself due to lack of timely assistance to the bathroom and noted that the resident had not received a shower since admission. Interviews with staff, including a CNA and the Director of Nursing (DON), revealed that the resident had only received one shower since admission. The CNA confirmed giving the resident a shower on 04/10/24 but was unaware of any previous showers. The DON could not find any additional shower sheets for the resident, indicating a failure to provide the necessary ADL care as per the resident's care plan. This deficiency highlights a significant lapse in the facility's duty to ensure proper hygiene and care for its residents.

Penalty

Inspection fine: $65,24751 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 a resident, identified as R16, was offered and wore a smoking apron to prevent accidents while smoking, as per her care plan. Despite the facility's policy requiring residents who are not able to smoke independently and safely to wear a smoking apron, R16 was observed smoking without the apron on multiple occasions. R16 had a history of unsafe smoking practices, including dropping lit cigarettes and causing a fire incident, which necessitated the use of a smoking apron for her safety. However, there was no documentation indicating that R16 refused to wear the apron or that staff were educated on what to do if she refused it. Additionally, staff members were not aware of R16's need for a smoking apron, as evidenced by their failure to identify her as requiring one during interviews. R16's medical history included muscle wasting and atrophy, need for assistance with personal care, contracture of the left hand, and hemiplegia and hemiparesis following a stroke. These conditions contributed to her inability to handle cigarettes safely. An incident note revealed that R16 had a blister on her left upper thigh from a cigarette burn, which she did not report to the staff. Despite this injury and her known unsafe smoking practices, R16 continued to smoke without wearing a smoking apron, and there was no documentation of any steps taken to address this issue. During observations, R16 was seen smoking without a smoking apron, and staff members supervising the smokers did not ensure she wore one. Interviews with R16 and other residents confirmed that she sometimes smoked without the apron. Staff members, including her assigned nurse and aide, were unaware of her need for a smoking apron. The facility's failure to ensure R16 wore a smoking apron and to educate staff on the necessary interventions for her safety led to the deficiency identified in the report.

Penalty

Inspection fine: $65,24751 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 proper care for a resident with an indwelling catheter, leading to potential risks of urinary tract infections. The resident, who was severely cognitively impaired and totally dependent on staff for activities of daily living, had a urinary drainage bag that was repeatedly observed touching the floor or floor mat. The facility's policy required that the collection bag should not touch the floor and should be kept below the level of the bladder to prevent obstruction and kinking of the catheter tubing. However, observations over several days showed that the drainage bag was not properly positioned, and the tubing was often found lying on the floor or improperly secured to the resident's thigh. During an observation with an LPN, it was noted that the securement device on the resident's thigh was not properly attached, and the drainage bag was resting on the floor mat. The LPN acknowledged the need for a new securement device and repositioned the tubing to promote proper drainage. Despite these actions, the LPN incorrectly stated that the privacy covering protected the drainage bag, indicating a misunderstanding of the facility's policy. This series of observations and interviews highlighted the facility's failure to adhere to its own catheter care policy, potentially compromising the resident's health and safety.

Penalty

Inspection fine: $65,24751 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 oxygen therapy equipment for a resident, leading to deficiencies in the care provided. The resident, who was admitted with acute respiratory failure with hypoxia, had oxygen tubing and a humidifier bottle that were not changed or dated as required by the facility's policy. Additionally, the oxygen concentrator filter had a heavy accumulation of gray dust debris. Observations over several days revealed that the oxygen tubing remained unlabeled, the humidifier bottle was not changed timely, and the concentrator filter was not cleaned, despite the facility's policy and physician's orders specifying weekly maintenance. During an interview, a Certified Medication Technician (CMT) confirmed the condition of the equipment and stated that the night shift nurse was responsible for the maintenance tasks, which had not been performed. The CMT attempted to change the humidifier bottle but found that the central supply was out of the correct bottles. The Central Supply Clerk later confirmed that the current supply of humidifier bottles did not fit the oxygen concentrators and that new bottles would need to be ordered from another company.