Picayune Rehabilitation And Healthcare Center

Penalty

No penalty information released

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

Summary

The facility failed to maintain sanitary conditions in the dietary department by not ensuring dishes washed in the low-temperature dishwasher were sanitized with the required chlorine concentration before reuse. During observation, a dietary aide operating the dishwasher used a chlorine test strip that remained white, indicating no detectable chlorine sanitizer, and the district manager confirmed there was no chlorine present. The dietary aide stated she routinely tested the chlorine level during each wash cycle but was unsure why the sanitizer was not registering, and she acknowledged documenting estimated chlorine values such as 61 and 62 ppm rather than actual readings. Another dietary aide later washed dishes in the same dishwasher without checking the chlorine sanitizer concentration first and stated she had been trained to wash all dishes before checking sanitizer levels. The district manager confirmed staff continued to use the dishwasher after observing no detectable sanitizer and acknowledged the dishwasher should have been producing adequate chlorine sanitizer during operation. The facility also failed to wash and sanitize used beverage pitchers before returning them to refrigerated storage. A dietary aide was observed bringing three used beverage pitchers from the resident care unit and placing them back into the kitchen refrigerator with remaining beverage still inside, without emptying, washing, or sanitizing them. She stated it was her standard practice to return pitchers that were at least half full to the refrigerator after meal service. The district supervisor confirmed used beverage pitchers returned from the resident care units should be emptied, washed, and sanitized before being placed back into refrigeration. The administrator stated she expected dietary staff to maintain sanitary food service practices, including proper dish sanitation and washing used beverage pitchers before reuse.

Penalty

No penalty information released

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

Summary

The facility failed to implement Contact Precautions in accordance with CDC guidance by not providing designated disposal containers for contaminated PPE, contaminated linens, and other contaminated materials in the rooms of two residents on Contact Precautions. Surveyors observed that PPE was available outside the rooms, but the required containers for contaminated waste and linens were not present in the rooms or bathrooms for either resident during multiple observations. One resident was admitted with acute cystitis with hematuria and was on Contact Precautions for ESBL in the urine. Surveyors observed a bedside commode lined with clear plastic bags, but no designated biohazard waste container or contaminated linen receptacle was present. Staff interviews confirmed that PPE had been discarded in the regular trash container, contaminated gowns had been placed in routine linen bags with other facility linens, bed linens were placed in routine laundry, and bedside commode liner bags were discarded in regular trash. An RN also observed PPE being discarded in the regular trash while providing IV antibiotics. The second resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus with diabetic peripheral angiopathy, and peripheral vascular disease, and had a right foot/toe wound with MRSA. Surveyors observed Contact Isolation signage and PPE outside the room, but no designated disposal containers for contaminated PPE, linens, or other contaminated materials were present in the room. The resident stated staff wore gowns and gloves and discarded PPE in the regular trash container, and staff interviews confirmed contaminated linens were placed in routine laundry bags and PPE was discarded in regular trash. The DON and Administrator acknowledged that residents on Contact Precautions were expected to have designated disposal containers in their rooms and that staff were expected to follow Contact Precaution procedures.

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 promote resident self-determination and honor resident rights by not allowing residents to choose their dining location on weekends and by requiring meals to be served in residents’ rooms for 3 of 20 residents reviewed. The facility policy on Resident Rights stated residents should be encouraged in the exercise of their rights, be treated as individuals in a manner that supports dignity, and be assured choice and privacy with the opportunity to act autonomously. Interviews showed that residents routinely ate breakfast, lunch, and dinner in their rooms on weekends because the dining room was closed or staffing was not available to supervise and assist residents there. Resident interviews confirmed the practice: one resident stated meals were served in rooms on weekends because there was not enough staff, another stated residents were not allowed to eat in the dining room on weekends and that the dining room doors were usually closed except for a periodic Saturday activity, and a third resident stated he enjoyed dining in the dining room to socialize but was required to stay in his room for all weekend meals. Staff interviews also confirmed that residents routinely received meals in their rooms on Saturdays and Sundays due to staffing shortages, with the dining room occasionally used on Saturdays if staffing permitted and not used on Sundays. The DON stated he was not aware residents were routinely receiving meals in their rooms on weekends, and the Administrator stated she was unaware of this practice and confirmed residents have the right to choose where they eat. The affected residents included one with a lumbar vertebra fracture and type 2 diabetes with a BIMS of 14, one with paranoid schizophrenia and borderline intellectual functioning with a BIMS of 15, and one with hemiplegia and hemiparesis following cerebral infarction with a BIMS of 11.

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 residents who had not executed an Advance Directive were informed of their right to formulate one and were offered assistance in establishing an Advance Directive for two residents reviewed for Advance Directives. Facility policy stated that upon admission residents were to be provided written information about the right to refuse or accept medical treatment and to formulate an advance directive, and that if a resident had not established one, staff were to offer assistance and document the offer in the medical record. However, the clinical records for two residents contained no documentation that they or their resident representatives received this information or were offered assistance. Resident #11 was admitted with diagnoses including Alzheimer's Disease, Major Depressive Disorder, and Schizoaffective Disorder, and had a BIMS score of 10, indicating moderately impaired cognition. Resident #75 was admitted with diagnoses including Paranoid Schizophrenia and Borderline Intellectual Functioning, and had a BIMS score of 15, indicating intact cognition. During interviews, the LVN and Administrator stated the SSD was responsible for educating residents and resident representatives about Advance Directives and maintaining the documentation in the medical record, and both confirmed the facility could not provide documentation showing either resident received the required information or an offer of assistance.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement an individualized comprehensive person-centered care plan for a resident who required mechanical lift transfer assistance. Record review showed the resident had an active diagnosis of pathological fracture in neoplastic disease and metastatic bone disease, and the discharge MDS indicated moderate cognitive impairment with a BIMS score of 10. The resident also had an order for therapy evaluation and treatment, but the care plan did not include individualized interventions directing staff to use a Hoyer lift, identify the required sling type or size, or describe resident-specific transfer techniques or precautions. Facility interviews confirmed the missing care plan details. The MDS/Care Plan RN stated the comprehensive care plan should communicate each resident’s individualized care needs and include specific transfer interventions for residents requiring mechanical lift assistance. The Rehabilitation Director confirmed the care plan contained no interventions identifying Hoyer lift use, sling type, sling size, or resident-specific transfer precautions, and noted the resident had complained of neck pain before hospitalization, later found to be associated with a cervical fracture. The Charge Nurse also confirmed there was no physician order identifying Hoyer lift transfers, no therapy documentation identifying sling type or size, and no care plan interventions directing staff regarding Hoyer lift use or sling requirements.

Penalty

No penalty information released

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

Summary

The facility failed to provide an ongoing program of activities designed to meet residents’ interests, preferences, and psychosocial well-being by not implementing scheduled weekend activities and by not providing activity opportunities for bedbound residents. The facility’s policies stated that residents have choices about participation in preferred activities and that activity programs are designed to meet residents’ interests, support psychological well-being, encourage maximum individual participation, and are scheduled 7 days a week. The July 2026 activity calendar listed activities for Saturdays and Sundays, but interviews showed the weekend program was not being carried out as scheduled. Resident #63 stated the facility did not provide activities on weekends and that residents had nothing to do for two days, with only an occasional movie shown in the dining room for residents who could attend. The Activities Director stated the department was only present on Saturdays for about 30 minutes to conduct one activity for residents able to attend the activity room, and confirmed staff did not conduct room-to-room activities for bedbound residents on Saturdays and could not confirm bedbound residents received activities during Sunday church visits. Resident #13, who was admitted with diagnoses including hypertensive heart disease, chronic kidney disease with heart failure, and stage 1 through stage 4 chronic kidney disease, and had a BIMS score of 11, stated she remained in bed most of the time and was not offered weekend activities. Resident #63, admitted with a lumbar vertebra fracture sequela and a BIMS score of 14, also reported boredom and lack of weekend activities.

Penalty

Inspection fine: $16,985

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 protect a resident from neglect by not ensuring safe transfers, timely post-fall assessment, neurological monitoring, and prompt physician notification after a fall with a head injury. The resident had Alzheimer’s disease and a severely impaired cognitive status, with a BIMS score of 3, and physician orders for a Hoyer lift with two staff for transfers. She was also receiving aspirin and Plavix, both antiplatelet medications. On the night in question, while a CNA was providing incontinent care and repositioning the resident onto her side, the resident grabbed the bed or sheet and pulled herself toward the edge, slipping between the bed and the wall and falling to the floor on her right side. Following the fall, the CNAs manually lifted the resident back into bed by her arms and legs without using the ordered mechanical lift and without a licensed nurse present to assess her at the time of the incident. Although CNA staff reported that they notified certain LPNs, those LPNs later denied being informed at the time of the fall. The facility’s incident report and late nursing documentation did not accurately capture the actual date and time of the fall, instead reflecting later dates and omitting the true timing of the event. The incident report also documented that the resident was assessed only after bruising was noted on the right shoulder, and it did not specify when the fall actually occurred. Over the next one to two days, staff identified bruising and a hematoma on the resident’s head and right shoulder, with tenderness and guarded but functional range of motion. Neurological checks were not initiated immediately after the fall, and when a hematoma on the resident’s head was observed by an LPN, the medical provider was not notified at that time because the nurse believed the injury appeared old. The DON was not informed of the fall until two days after it occurred and did not review the earlier nursing notes documenting the hematoma, nor did he physically assess the resident’s head when he did assess her. The medical provider was not informed of the head hematoma and was only notified of the fall days later, at which point he ordered a right shoulder X-ray but no immediate evaluation for the head injury. The resident continued to receive aspirin and Plavix from the time the head injury was first documented until she was later transferred to the hospital for altered mental status, where imaging revealed a large right hemispheric subdural hematoma with midline shift. The facility’s failures in safe transfer technique, immediate licensed nurse assessment, timely neurological monitoring, and prompt physician notification after the fall and head injury were determined to constitute neglect and resulted in serious harm to the resident.

Removal Plan

• The Director of Nursing was notified by a Licensed Practical Nurse regarding discoloration observed on Resident #1's right shoulder.
• A Registered Nurse assessed Resident #1 and obtained an order for a right shoulder X-ray.
• The Director of Nursing contacted a Licensed Practical Nurse to inquire about any knowledge regarding Resident #1's fall.
• The Director of Nursing interviewed a Certified Nurse Assistant regarding Resident #1's fall and obtained a verbal account of the incident.
• The Director of Nursing interviewed a Licensed Practical Nurse regarding Resident #1's fall and obtained a verbal account of the incident.
• A Licensed Practical Nurse initiated a facility-based incident report regarding Resident #1's fall and completed the associated documentation of the event.
• The Director of Nursing reviewed Resident #1's neuro check log to ensure no abnormalities and continued neuro checks to monitor for neurological deficits.
• Nursing staff completed neuro checks for Resident #1 and found no neurological deficits, with the resident remaining at baseline.
• Resident #1 was noted to have drooping to the left side and slurred speech; the Nurse Practitioner was notified and orders were obtained to transfer to the local hospital.
• Resident #1 was transferred to the local hospital.
• The Director of Nursing conducted an audit of all current residents who had an accident or incident in the past thirty days to determine whether any other residents were potentially affected.
• The Director of Nursing provided education to all licensed nurses and Certified Nursing Assistants on fall prevention, safe handling, and proper resident transfers, including neuro checks, change in condition notifications, Abuse and Neglect protocols, Resident Rights, and the Vulnerable Adult Act, with staff required to complete the training before returning to work.
• The Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing, and Corporate Clinical Specialist held an ad hoc QAPI meeting regarding Resident #1's fall, the investigation, the immediate jeopardy, and the corrective action plan; the fall prevention policy was evaluated and reviewed to incorporate updated procedures and training for new staff on adhering to the Interact Care Path for acute mental status changes.
• A Resident Council meeting was held to inform residents that the facility received an Immediate Jeopardy citation due to inadequate lifting techniques and failure to assess a resident after a fall.
• The Administrator, Director of Nursing, and Corporate Clinical Specialist conducted a comprehensive review of the investigation to perform a root cause analysis and identified a failure in communication as the primary issue.
• A Certified Nurse Assistant received individual training on identifying each resident's lifting status per the care plan and safe handling/lifting procedures and received a disciplinary action.
• A Licensed Practical Nurse received a one-to-one inservice on Abuse and Neglect, Resident Rights, the Vulnerable Adults Act, notification of change in condition, fall prevention, and safe patient handling/moving protocols and received a disciplinary action.
• A Certified Nursing Assistant received individual training on identifying each resident's lifting status per the care plan and safe handling/lifting procedures and received a disciplinary action.
• The Director of Nursing conducted a training session for all licensed nursing staff regarding adherence to the Interact Care Path for acute mental status changes following post-fall assessments, with completion mandatory prior to return to work.

Penalty

Inspection fine: $8,281

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

Summary

The facility failed to protect a resident from verbal abuse by a staff member, specifically a Certified Nursing Aide (CNA). The incident occurred when the CNA used profanity during an argument with the resident and pointed a spray bottle of chemical cleaner toward him. This incident left the resident feeling nervous and afraid. The facility did not immediately remove the CNA from the premises, which placed the resident and others at risk for similar abuse. The incident began when the resident, who had a history of anxiety disorder and was cognitively intact, was involved in a verbal altercation with the CNA. The resident was speaking with a Licensed Practical Nurse (LPN) in the dining area when the CNA entered. The resident, still upset from a previous disagreement with the CNA, used profanity toward her. The CNA responded by arguing back, using profanity, and threatening the resident with a spray bottle. Despite the escalating situation, the CNA was not removed from duty immediately and continued to work in the facility until the incident was reported to the administration four days later. Interviews with staff revealed that the incident was reported to the Director of Nursing (DON) on the day it occurred, but the DON did not view it as abuse and did not instruct staff to send the CNA home. The CNA continued to work in the facility until the administration was made aware of the incident days later. The facility's failure to follow its abuse policy and protocol, specifically the immediate removal of the CNA, contributed to the deficiency.

Removal Plan

• The Treatment Nurse conducted a routine head-to-toe body assessment on Resident #17 to review for any skin abnormalities or concerns. Resident #17 had no negative skin issues or concerns.
• The Director of Nursing and Administrator interviewed Resident #17 regarding the allegation of abuse. Resident #17 provided statement of events.
• CNA #1 was interviewed, statement obtained and suspended pending investigation by the Administrator. CNA #1 was subsequently terminated.
• An allegation of abuse involving Resident #17 was reported to the State Agency (SA) by the Facility Risk Manager.
• An allegation of abuse involving Resident #17 was submitted to the Attorney General (AG) complaint website by the Risk Manager regarding allegation of abuse.
• Referral was sent to Psychologist Nurse Practitioner by the Director of Nursing for evaluation and follow up.
• The Medical Director was notified of the allegation by the Administrator.
• The Administrator notified ombudsman with no answer and left message.
• The DON conducted Trauma Assessment on Resident #17 with no negative findings.
• The Risk Manager initiated Life satisfaction rounds on residents with BIMS of 12 or higher regarding Abuse and Safety in the facility. Two negative findings on unprofessional behavior resulted with a report of being rude and loud. No allegations of abuse resulted.
• Peer reviews initiated by Risk Manager regarding Abuse and Safety in the facility involving CNA #1. One finding resulted in witnessing the allegation involving Resident #17.
• An Abuse Drill Evaluation completed with Station I and II by the DON and Administrator as part of an ongoing monitoring plan. Life satisfaction rounds with two residents having a BIMS of twelve or higher will be completed by the Administrator/DON or Risk Manager weekly times four weeks, every other week times eight and monthly thereafter for three months. The QAPI committee will evaluate additional action based on results.
• The DON will conduct two random interviews on residents with BIMS of twelve or higher for any allegations of abuse or neglect weekly times four weeks, every other week times eight weeks and monthly times three months thereafter.
• The DON, Assistant Director of Nursing, or Risk Manager will conduct two random body audits on residents with BIMS below twelve for any indicators of abuse or neglect weekly times four weeks, every other week for eight weeks and monthly times three months thereafter. The QAPI committee will evaluate additional action based on results.
• The QAPI Committee will review potential trends and patterns and provide recommendations as needed.
• An in-service initiated by Risk Manager/DON/ADM on Abuse and Neglect, Resident Rights, Vulnerable Adult, along with the reporting guidelines including how to address if abuse is noted. No staff was allowed to return to work prior to completion.
• QAPI Committee held a Quality Assurance Meeting to include Medical Director, Director of Nursing, Assistant Director of Nursing, Risk Manager/Infection Preventionist, Medical Records, Director of Rehabilitation, Office Manager, Activity Director and Minimum Data Set Nurse to discuss allegations of abuse along with corrective action and monitoring in place. Policies were reviewed with no revisions needed.
• State Agency (SA) notified the Administrator of Immediate Jeopardy with past noncompliance. The State Agency (SA) provided the facility with the Immediate Jeopardy templates.
• Facility is alleging that all activities to remove the Immediate Jeopardy were completed and the Immediate Jeopardy was removed.

Penalty

Inspection fine: $8,281

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 report an allegation of abuse within the required two-hour timeframe for one of the sampled residents. The incident involved a verbal altercation between a resident and a Certified Nurse Aide (CNA), where the CNA used profanity and aimed a spray bottle of chemical cleaner toward the resident. This incident was witnessed by a Licensed Practical Nurse (LPN) but was not reported to the State Agency until four days later, delaying the facility's ability to protect the resident from further mistreatment. The incident occurred when the CNA entered the dining room and encountered the resident, who began yelling expletives at the CNA. The CNA responded by arguing back with the resident using profanity and picked up a spray bottle, pointing it toward the resident. The LPN present did not take immediate action to remove the CNA from the situation or report the incident to the appropriate authorities in a timely manner. The Director of Nursing (DON) was informed of the incident on the same day but did not report it to the State Agency, as he did not perceive it as an abuse situation based on the information provided by the nurses. The delay in reporting the incident increased the risk of harm to the resident and left them in a situation that was likely to cause serious injury or harm. The facility's failure to ensure immediate reporting of the abuse incident was determined to be Immediate Jeopardy and Substandard Quality of Care. The State Agency notified the facility of these findings and provided an Immediate Jeopardy Template.

Removal Plan

• The Treatment Nurse conducted a routine head-to-toe body assessment on Resident #17 to review for any skin abnormalities or concerns. Resident #17 had no negative skin issues or concerns.
• The Director of Nursing and Administrator interviewed Resident #17 regarding the allegation of abuse. Resident #17 provided statement of events.
• CNA #1 was interviewed, statement obtained and suspended pending investigation by the Administrator. CNA #1 was subsequently terminated.
• An allegation of abuse involving Resident #17 was reported to the State Agency (SA) by the Facility Risk Manager.
• An allegation of abuse involving Resident #17 was submitted to the Attorney General (AG) complaint website by the Risk Manager regarding allegation of abuse.
• Referral was sent to Psychologist Nurse Practitioner by the Director of Nursing for evaluation and follow up.
• The Medical Director was notified of the allegation by the Administrator.
• The Administrator notified ombudsman with no answer and left message.
• The DON conducted Trauma Assessment on Resident #17 with no negative findings.
• The Risk Manager initiated Life satisfaction rounds on residents with BIMS of 12 or higher regarding Abuse and Safety in the facility. Two negative findings on unprofessional behavior resulted with a report of being rude and loud. No allegations of abuse resulted.
• Peer reviews initiated by Risk Manager regarding Abuse and Safety in the facility involving CNA #1. One finding resulted in witnessing the allegation involving Resident #17.
• An Abuse Drill Evaluation completed with Station I and II by the DON and Administrator as part of an ongoing monitoring plan. Life satisfaction rounds with two residents having a BIMS of twelve or higher will be completed by the Administrator/DON or Risk Manager weekly times four weeks, every other week times eight and monthly thereafter for three months. The QAPI committee will evaluate additional action based on results.
• The DON will conduct two random interviews on residents with BIMS of twelve or higher for any allegations of abuse or neglect weekly times four weeks, every other week times eight weeks and monthly times three months thereafter.
• The DON, Assistant Director of Nursing, or Risk Manager will conduct two random body audits on residents with BIMS below twelve for any indicators of abuse or neglect weekly times four weeks, every other week for eight weeks and monthly times three months thereafter. The QAPI committee will evaluate additional action based on results.
• The QAPI Committee will review potential trends and patterns and provide recommendations as needed.
• An in-service initiated by Risk Manager/ DON/ADM on Abuse and Neglect, Resident Rights, Vulnerable Adult, along with the reporting guidelines including how to address if abuse is noted. No staff was allowed to return to work prior to completion.
• QAPI Committee held a Quality Assurance Meeting to include Medical Director, Director of Nursing, Assistant Director of Nursing, Risk Manager/Infection Preventionist, Medical Records, Director of Rehabilitation, Office Manager, Activity Director and Minimum Data Set Nurse to discuss allegations of abuse along with corrective action and monitoring in place. Policies were reviewed with no revisions needed.
• State Agency (SA) notified the Administrator of Immediate Jeopardy with past noncompliance. The State Agency (SA) provided the facility with the Immediate Jeopardy templates.
• Facility is alleging that all activities to remove the Immediate Jeopardy were completed and the Immediate Jeopardy was removed.

Penalty

Inspection fine: $8,281

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

Summary

The facility failed to ensure the resident's right to reasonable accommodation by not having a call light within reach for one of the sampled residents. During an observation, the call light for Resident #39 was found draped over a shelf and out of reach. This was confirmed by a CNA who acknowledged the call light was not accessible to the resident. Interviews with facility staff, including an LPN, CNAs, the Administrator, the CNA Supervisor, and the Director of Nursing, revealed that the expectation is for call lights to be left within reach of residents after each visit and for CNAs to make rounds every two hours. Resident #39, who was admitted to the facility in December 2021, has diagnoses including Hemiplegia and Hemiparesis following a cerebral infarction affecting the right dominant side. The resident's cognition was assessed as severely impaired, requiring a staff interview for evaluation. The facility's policy and in-service training emphasize the importance of ensuring call lights are within reach of residents at all times, yet this was not adhered to in the case of Resident #39.

Penalty

Inspection fine: $8,281

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 comfortable and homelike environment for its residents, as evidenced by the uncomfortably cold temperatures in several rooms. Observations and interviews revealed that five residents consistently complained about the cold conditions in their rooms. These residents were often seen wearing extra layers of clothing and using additional blankets to keep warm. The temperatures in their rooms were recorded as being below the federal requirement of 71 degrees Fahrenheit, with some rooms measuring as low as 65 degrees Fahrenheit. The facility's maintenance director acknowledged the difficulty in maintaining consistent temperatures due to the building's layout and vent placement. An igniter malfunction in January 2025 further complicated the situation, taking three days to repair. Staff members, including CNAs and LPNs, confirmed that residents frequently complained about the cold and that extra blankets were provided as a temporary measure. Despite these efforts, the issue persisted, affecting the residents' comfort and well-being. The facility's administrator admitted that while they usually meet the federal temperature requirement, the building's age and traffic patterns contribute to the temperature inconsistencies. The maintenance director attempted to address complaints by adjusting thermostats, but the problem remained unresolved. The deficiency highlights the facility's failure to provide a safe and comfortable environment for its residents, as required by their own policy and federal regulations.

Penalty

Inspection fine: $8,281

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 revise the comprehensive care plan for a resident to include the use of zinc oxide as per a physician's order. The deficiency was identified during an observation of incontinence care, where a CNA applied zinc oxide to the resident's buttocks after providing perineal care. A review of the resident's care plan revealed that it did not include interventions for applying zinc oxide, despite a physician's order dated February 15, 2025, which instructed the application of a zinc barrier cream to the sacrum every day shift. Interviews with the Director of Nursing, the Administrator, and a Registered Nurse confirmed that the care plan was not updated to reflect the physician's order. The Director of Nursing explained that the Care Plan Nurse is responsible for updating the care plan daily by reviewing physician's orders. The resident involved was admitted to the facility with diagnoses including acute and chronic respiratory failure with hypoxia and was cognitively intact, requiring assistance for bathing, toileting, and personal hygiene due to bowel and bladder incontinence.

Penalty

Inspection fine: $8,281

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 professional standards of practice when a Certified Nurse Assistant (CNA) applied a medicated cream to a resident, which is against the facility's policy and state regulations. During an observation of incontinence care, a Licensed Practical Nurse (LPN) provided a CNA with zinc oxide cream to apply to a resident's sacrum, despite the facility's policy that only registered nurses or licensed practical nurses are permitted to administer medications, including medicated ointments. This action was confirmed by the LPN, the Director of Nursing (DON), and the Administrator, all of whom acknowledged that CNAs are not allowed to administer medications. The resident involved, identified as Resident #22, was admitted to the facility with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, and required partial to moderate assistance for personal care due to incontinence. The facility's failure to adhere to its own policies and state regulations regarding medication administration led to this deficiency, as the CNA was improperly directed to apply the medicated cream.

Penalty

Inspection fine: $8,281

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 food storage and cleanliness of serving bowls, as observed during a survey. In the kitchen's Walk-In Cooler #1, an opened cheesecake box was found without a date indicating when it was opened, and the cheesecake was not fully wrapped or covered. In Freezer #1, an opened container of frozen mixed vegetables and an opened box of beef patties were also not fully wrapped or covered, leaving them exposed. Additionally, serving bowls that were supposed to be washed had dried and stuck-on food residue. The Dietary Manager confirmed that these dishes were washed and stacked by the night shift. The Dietary Aide acknowledged the importance of cleaning and sanitizing plates and dishes to prevent illness among residents. The Administrator stated that her expectation is for kitchen staff to prepare, store, label, and date foods according to facility policy.

Penalty

Inspection fine: $8,281

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 proper infection control practices during perineal care for a resident, leading to potential cross-contamination. During an observation, a CNA, assisted by another CNA, used premoistened wipes to clean the resident's front area and then proceeded to the buttocks area. The CNA, with contaminated gloves, pulled additional wipes from the pack, touching the package with soiled gloves. This action was repeated after the resident had a bowel movement, further contaminating the wipes container. The resident involved was admitted with a diagnosis of unspecified dementia and was cognitively intact, requiring partial to moderate assistance with toileting. The CNA had previously received training and performed a return demonstration on perineal care. Interviews with the CNA, the Risk Manager/Infection Preventionist, and the Director of Nursing confirmed the contamination of the wipes container and acknowledged the potential for infection due to improper handling of the wipes.