Brunswick Health & Rehab 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 deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.

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 provide safe, appropriate pain management and assessment for a severely cognitively impaired resident following an unwitnessed fall and subsequent onset of significant hip pain. The resident had a history of right femur fracture, osteoporosis, and dementia, and was admitted with an order for PRN acetaminophen 650 mg for unspecified pain. Prior to the incident, the resident required limited assistance with transfers, bed mobility, and toileting, used a wheelchair, and only occasionally had pain that rarely interfered with activities. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no assessment of the left lower extremity, and no assessment of changes in transfer, ambulation, or mobility, despite the nurse on duty documenting a pain level of 0. The nurse later stated he did not assess the resident for pain or range of motion and acknowledged the resident was cognitively impaired and had an impaired ability to request pain medication. Over the following days, multiple staff observed or were informed of the resident’s significant pain and changes in mobility, but assessments, documentation, communication, and pain management remained inadequate. During the night after the fall, another nurse documented that the resident was having “a lot of pain in her hip” and placed a note in the doctor’s book, but did not document a pain or head-to-toe assessment, did not administer PRN acetaminophen, and nevertheless recorded a pain score of 0 on the MAR. Nurse aides reported that the resident was screaming, crying, yelling out with transfers, unable to ambulate as before, and required care in bed due to pain with movement. One nurse documented, as a late entry, that the resident reported she had fallen the previous day and was screaming in pain when moved; this nurse contacted the NP, who stated the resident complained of pain all the time and instructed staff to give PRN acetaminophen and indicated he would evaluate the resident the next day. The late entry note did not document a pain level, a lower extremity assessment, or that the unwitnessed fall was communicated to the NP. The MAR showed PRN acetaminophen was given once and marked only as “slightly effective,” with no numerical pain monitoring, while pain scores of 0 continued to be documented on subsequent shifts despite ongoing pain behaviors. When the NP evaluated the resident, the chief complaint was hip pain, and nursing staff had reported that the resident was having pain. The NP documented that the resident was oriented to person only, had dementia and anxiety, appeared sleepy and groggy, and had non‑specific pain. The NP’s assessment did not include an examination of the lower extremities, and the plan was to treat presumed nerve and hip pain with PRN acetaminophen and to educate the resident to request pain medication, despite her severe cognitive impairment and inability to reliably rate or request pain. The NP later stated he was unaware of the fall and that, had he known, he would have ordered x‑rays immediately, and acknowledged that new onset severe pain should prompt imaging. Over the next several days, aides continued to observe the resident’s pain with transfers, ambulation, and repositioning, including wincing, grimacing, holding her hip, and needing increased assistance, but some aides did not report these findings to nurses, assuming the nurses were already aware. Nursing documentation remained sparse, with no progress notes on some days, inconsistent pain scores, limited use of PRN analgesics, and no thorough pain or mobility assessments recorded. Eventually, a nursing supervisor documented that the resident appeared to be in discomfort and verbalized hip pain, and mobile x‑rays were ordered. The progress note did not include a pain level or a detailed assessment of the left lower extremity. The x‑ray, completed days after the onset of severe pain, showed an acute displaced left femoral neck fracture. The following day, a nurse documented the x‑ray results and arranged for the resident’s transfer to the emergency department. At the hospital, the resident reported hip pain and was treated with IV hydromorphone, cyclobenzaprine, and acetaminophen, and underwent a left hip hemiarthroplasty without complications before returning to the facility. Throughout the period from the unwitnessed fall to the diagnosis of the fracture, the facility failed to ensure timely and thorough pain assessment, accurate pain documentation, effective communication of the fall and subsequent changes in condition to the NP and physician, and appropriate pain management for a resident who was unable to verbalize or request pain medication due to severe cognitive impairment. The DON stated that her expectation was that residents with pain would be thoroughly assessed regardless of cognitive status, that staff would monitor for pain and report increased pain or changes in condition to the physician, and that this resident was unable to rate or request pain and should have been assessed using non‑verbal indicators and provided pain medication as needed.

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 determine whether self-administration of medications was clinically appropriate for a cognitively intact resident on dialysis who was reviewed for self-administration of drugs. The resident had diagnoses including renal dialysis, end stage renal disease, gastrointestinal hemorrhage, and anemia, and the quarterly MDS showed the resident was cognitively intact with no behaviors. Despite this, the resident was not care planned for self-administration of medications, and there was no assessment in the electronic medical record regarding the resident’s ability to self-administer medications. The physician’s orders did not include naproxen sodium or lidocaine-prilocaine cream, nor did they include any order authorizing the resident to self-administer medications. Surveyor observation found an opened bottle of naproxen sodium 500 mg and four opened tubes of prescription lidocaine-prilocaine cream on the resident’s overbed tray table while the assigned medication aide was outside the room at the medication cart and unaware that these medications were present. The resident reported that he kept naproxen in his room to take for headaches and that he applied the lidocaine cream to his fistula prior to dialysis, stating that his responsible party had brought these medications from an outside pharmacy. The physician stated that the resident should not self-administer naproxen or lidocaine cream without supervision and that residents were to be assessed for safe self-administration. The unit manager and DON both confirmed that residents must be assessed for self-administration, require a physician’s order specifying which medications may be self-administered, must have medications stored properly, and must have the care plan updated, and both stated they were unaware that this resident was self-administering and keeping these medications unsecured in the room.

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 transfer a resident according to the care plan, specifically by not using a slide board and required assistance during a wheelchair-to-bed transfer. The resident had been admitted with a recent CVA, right-sided hemiplegia, hemiparesis, and expressive aphasia, and her care plan identified her as at risk for falls with an ADL functional deficit related to limited transfer ability. The care plan interventions required use of a slide board for transfers from wheelchair to bed, and the MDS documented that she had moderately impaired cognition and required substantial assistance for transfers. On the night in question, a nurse aide transferred the resident from her wheelchair to her bed without following the prescribed method. According to the resident and her cognitively intact roommate, the aide lifted or hoisted the resident by the back of her pants instead of using the slide board and a second person, resulting in the resident’s pants being ripped. The resident reported that the aide did not transfer her correctly, that she needed a slide board and two-person assistance, and that she felt upset, cried, and did not feel safe during the transfer because she could not use her right arm or right leg. The roommate stated she witnessed the transfer, saw the aide hoist the resident by her pants without assistance, and noted that the aide declined an offer to use the roommate’s gait belt. Staff accounts and documentation further described the events leading to the deficiency. A nurse progress note recorded that the roommate approached the nurse supervisor at the start of shift with concerns about the resident’s mood and the way the aide had transferred her, and the resident confirmed that the aide had pulled her up by her pants, ripping them. The nurse supervisor’s written statement indicated that when she arrived on the unit, the roommate reported concerns that the aide had needed assistance and should have used a gait belt, and that the aide responded argumentatively, stating she did the best she could because they were short staffed. The supervisor later found both residents upset and was told that the aide had returned to the room and told the roommate to come to her directly if she had a problem. The nurse practitioner’s note documented that the resident stated the aide was rough with her, although no physical injuries were found on exam. The assistant director of nursing and another aide reported that the aide did not request assistance with the transfer during the shift.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to follow physician orders for a resident on hemodialysis who required a renal diet with double protein portions and a 1000 mL/24-hour fluid restriction. The resident had end stage renal disease, renal dialysis, hyperkalemia, and heart failure, and was care planned for increased nutrition and hydration risk related to these conditions, including a therapeutic renal diet and fluid restriction. The physician’s order and RD note specified a renal diet with double protein at every meal and a 1000 mL fluid restriction, with 600 mL to be provided by Dietary (240 mL at breakfast, 240 mL at lunch, 120 mL at dinner) and 400 mL by Nursing (200 mL on first shift and 200 mL on second shift). The care plan interventions included maintaining the fluid restriction as ordered and encouraging compliance with the prescribed diet. During a lunch observation, the resident’s tray ticket correctly listed a renal diet, a 1000 mL/day fluid restriction with a 240 mL limit at lunch, and double protein portions, but the actual tray contained items inconsistent with these orders. The tray included a small serving of beef ravioli with tomato sauce, potatoes and carrots, a dinner roll, strawberry ice cream, 8 ounces of water, and 8 ounces of ginger ale, totaling 600 mL of fluid at that meal alone, exceeding the 240 mL lunch allowance. Double portions of protein were not provided. The Medical Records Manager, who is a nurse aide assisting with meal delivery, did not recognize that the tray exceeded the fluid restriction or that the protein portion was not doubled, and she stated she was not sure what a renal diet consisted of. The resident reported that the facility did not follow his renal diet, that he was often served inappropriate foods such as potatoes and processed lunch meats, and that staff were not aware of his fluid restriction. An additional observation of the resident’s bedside table showed a large 12-ounce cup of orange juice that he stated had been provided with breakfast despite his fluid restriction. Interviews with dietary staff further demonstrated failures in implementing the ordered renal diet and fluid restriction. The Dietary Manager acknowledged that the small serving of ravioli did not meet the double protein requirement, that potatoes should not have been served due to the renal diet restriction, and that the tray ticket listing 8 ounces of water, 8 ounces of a beverage of choice, and 4 ounces of sherbet exceeded the resident’s 240 mL fluid limit at lunch. She also stated there was no system in place to ensure residents consistently received the correct diet or appropriate tray items. A dietary staff member who prepared the lunch tray stated she relied on the tray card and did not check the posted renal diet restriction list. A subsequent breakfast observation showed the resident received one fried egg and one slice of toast with 4 ounces of coffee, which the RD confirmed did not meet the ordered double protein portion, noting that a double portion would be 3–4 eggs. The DON stated she expected fluid and diet restrictions to be followed as ordered, with Dietary responsible for preparing trays per orders and Nursing responsible for reviewing tray tickets and being knowledgeable about special diets such as renal diets.

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 that prescribed medications were properly administered and not left unattended at a resident’s bedside. A cognitively intact resident with diagnoses including renal dialysis, end stage renal disease, gastrointestinal hemorrhage, and anemia had multiple medications ordered: Velphoro 500 mg three times daily for hypokalemia at 7:00 AM, 11:00 AM, and 4:00 PM; sucralfate 1 gram four times daily, to be given 30 minutes before meals and at bedtime; and midodrine 10 mg once daily and 5 mg twice daily, to be held if systolic blood pressure exceeded 130 mmHg. During observation, four plastic medication cups containing a large round brown tablet (Velphoro), a white oblong tablet (sucralfate), and a small white pill (midodrine) were found on the resident’s bedside table while the Medication Aide assigned to the cart was outside the room and could not see the resident. The Medication Aide confirmed the medications belonged to the resident and stated they must have been left from a prior shift’s medication pass, acknowledging she had not yet administered that morning’s medications and had not been in the room. She reported being assigned to the resident on the prior day’s 7:00 AM–3:00 PM shift but did not recall leaving medications at the bedside, and stated that medications should never be left at the bedside and residents should be observed swallowing them. A nurse assigned to the resident on the 3:00 PM–11:00 PM shift the same day also did not recall leaving medications at the bedside but agreed it was not appropriate to leave medications unattended and unsecured. The resident reported that nurses often left medications at the bedside for self-administration and did not always inform him that the medications were there or that he was expected to take them. The physician stated that the resident not receiving Velphoro, sucralfate, and midodrine as prescribed had the potential to result in significant adverse effects, and the Unit Manager and DON both stated that medications were not to be left at the bedside and that staff were expected to remain with residents to observe medication ingestion unless the resident had been assessed and approved for self-administration, which had not occurred in this case.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide food that accommodated a documented tomato allergy for one resident. The resident’s care plan, initiated on 8/19/25, listed food allergies to tea and tomatoes, and subsequent hospital discharge documentation and a cardiology progress note confirmed allergies including anaphylaxis to tea and mouth and throat swelling in response to tomatoes. The resident’s electronic health record and clinical dashboard also listed food allergies to tea and tomatoes, and a nutritional status problem dated 3/30/26 noted a tea allergy with an intervention to ensure allergen avoidance, but did not include the tomato allergy in the care plan. On 4/7/26 at lunchtime, the resident received a meal tray that included beef ravioli with tomato sauce, despite the documented tomato allergy. The tray ticket listed a renal diet, tea allergy, fluid restriction, and double protein portions, but did not list a tomato allergy. The actual meal observed on the tray included beef ravioli with tomato sauce, potatoes and carrots, a dinner roll, strawberry ice cream, water, and ginger ale. The resident informed the Medical Records Director, who was delivering the tray, that he was allergic to tomatoes and requested an alternate meal, stating he could not eat processed deli meat and chose an egg salad sandwich instead. Interviews revealed that the resident reported being served tomatoes and tomato sauce previously and had told staff delivering trays that he could not eat tomatoes. The Medical Records Manager, who also worked as a nurse aide when delivering trays, stated she checked tray tickets for allergies and diets and was unaware of the tomato allergy because it was not on the tray ticket. A nurse aide familiar with the resident also stated she was not aware of a tomato allergy and relied on tray tickets for allergy information. The Dietary Manager reported she was unaware of the tomato allergy, explained that nursing entered allergies into the clinical record and that she was responsible for ensuring allergies appeared in the meal tray ticket system, and noted that tea was listed as an allergy in her system but tomatoes were not. The DON stated she expected food allergies to be communicated from nursing to dietary and honored, and that allergies were supposed to transfer from the clinical dashboard to the Dietary Manager’s system and be included on the diet order slip provided to dietary.

Penalty

Fine: $267,005

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 assess, diagnose, and medically treat a resident who exhibited signs of Clostridium Difficile (C. difficile) infection. The resident presented with symptoms such as loose stools with a foul odor, abdominal discomfort, tiredness, loss of appetite, and inability to get out of bed. Despite these symptoms, the facility did not recognize the seriousness of the condition and failed to implement effective interventions. The resident's condition deteriorated, leading to decreased urine output, which was not identified as a medical emergency by the facility. The resident's medical records showed a pattern of frequent loose stools, yet there was no care plan or interventions related to bowel incontinence or loose stools. Nursing staff and therapists reported the resident's condition to the Nurse Practitioner (NP), but no significant action was taken. The NP ordered banana flakes and later loperamide, which is contraindicated in C. difficile cases, but did not order any diagnostic tests for C. difficile. The resident's responsible party also expressed concerns about the resident's condition, but these were not adequately addressed by the facility. The resident was eventually transferred to the hospital at their request, where they were diagnosed with septic shock secondary to C. difficile and passed away. The facility's failure to properly assess and treat the resident's symptoms, as well as the lack of communication and follow-up on reported issues, contributed to the deficiency. The report highlights the facility's inadequate response to the resident's deteriorating condition and the lack of appropriate medical intervention.

Penalty

Fine: $267,005

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 involved a Nurse Practitioner (NP) who failed to communicate and collaborate with the Medical Director regarding a resident's persistent symptoms indicative of Clostridium Difficile (C. diff) infection. The resident, who had been admitted with a subdural hematoma, experienced 42 stools in 24 days, many of which were loose and foul-smelling. Despite these symptoms, the NP did not consult with the Medical Director or order a stool sample for analysis, even after the resident's Responsible Party (RP) reached out to a Gastroenterologist for advice. The NP's progress notes consistently documented the resident's loose stools but did not indicate any communication with the Medical Director. The NP prescribed banana flakes and later loperamide to manage the symptoms but did not assess the effectiveness of these treatments or consult with the Medical Director. The resident's condition worsened, leading to a high panic level white blood cell count, which was not communicated to the Medical Director. Eventually, the resident requested to be transferred to the hospital, where he was diagnosed with septic shock secondary to C. diff and subsequently passed away. Interviews with facility staff revealed a lack of a system for communication between the NP and the Medical Director regarding significant changes in residents' conditions. The Medical Director was not informed of the resident's critical lab values or the severity of his symptoms. The Director of Nursing (DON) was also unaware of the communication protocols between the NP and the Medical Director, assuming that changes were reported as needed. This lack of communication and oversight contributed to the resident's deteriorating condition and eventual death.

Removal Plan

• The Medical Director will review the provider notes for all residents with a change in condition that were seen by any of the Nurse Practitioners and/or Physician Assistants. Any new orders or suggestions made by the Medical Director will be communicated to the Nurse Practitioner/Physician Assistant and the Director of Nursing for follow-up.
• The Medical Director educated all Providers working with the facility on the clostridium difficile protocol. The protocol indicates that residents with three or more watery or loose stool in a 24 hour time span should have a medication review to ensure laxatives are not contributing to the loose stool. If the loose stool does not resolve within 24 hours of the laxatives being stopped or the resident was not receiving laxatives, a clostridium difficile test will be performed. The NP was included in the provider education.
• The Director of Nursing was educated by the Regional Director of Clinical Services on providing the Medical Director with a list of residents that were seen by a Nurse Practitioner and/or Physician Assistant in the previous seven days, due to a change in condition, weekly for the Medical Director to review.
• The Director of Nursing will review all progress notes weekly to determine the residents that were seen in the past 7 days for a change in condition.
• The Medical Director will review the Nurse Practitioner and/or Physician Assistant progress notes weekly and communicate any suggestions to the Nurse Practitioners and/or Physician Assistants and the facility.
• The Regional Director of Clinical Services communicated the new review process to the provider groups Nurse Practitioners and/or Physician Assistants.
• The Medical Director was informed of the new review process by the Director of Nursing and is in agreement with the system of communication and collaboration.

Penalty

Fine: $267,005

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 uphold residents' rights to dignity and self-determination, as evidenced by two separate incidents involving inappropriate care by a nurse aide. In the first incident, a resident admitted for rehabilitation following acute respiratory failure and with a history of hypertensive heart disease and chronic kidney disease, was denied assistance to the bathroom by Nurse Aide #9. Despite being cognitively intact and capable of using a walker, the resident was told to urinate in bed, leading to feelings of embarrassment and distress. The nurse aide's actions were contrary to the facility's policy, which did not require therapy evaluation before ambulation, and the resident's request for assistance was ignored, resulting in a loss of dignity. In the second incident, another resident, who was cognitively intact and required assistance with activities of daily living, was subjected to undignified incontinence care. The resident was changed while standing over a wheelchair, holding onto a walker, rather than being assisted to a bed or bathroom. This method of care was deemed rude and insensitive by the resident, who expressed discomfort with the practice. The nurse aide involved admitted to using this method previously with other residents, indicating a pattern of behavior that compromised resident dignity. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, confirmed that the actions of Nurse Aide #9 were inappropriate and not in line with the facility's standards for providing dignified care. The nurse aide's approach to care, characterized by loud and rough behavior, had previously resulted in disciplinary actions, highlighting ongoing issues with maintaining resident dignity and respect within the facility.

Penalty

Fine: $267,005

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 manage food storage and expiration effectively, as observed during a survey. In the dry storage room, several expired food items were found, including twelve bottles of sugar-free breakfast syrup, multiple bags of corn chips, a case of chocolate chip cookies, and fruit punch powder mix with no expiration date. The Dietary Manager admitted to not knowing how long the fruit punch powder had been stored and acknowledged that the expired items were overlooked despite a weekly stock rotation process. This oversight was attributed to a failure in the routine checks meant to prevent expired items from remaining in storage. Additionally, in one of the two nourishment rooms, the refrigerator designated for resident use was found to be at an incorrect temperature of 22 degrees Fahrenheit, and it contained expired supplemental shakes. The Dietary Manager indicated that the Dietary Aide was responsible for monitoring refrigerator temperatures and removing expired products, but the expired items were not removed despite being logged as checked. The Administrator expressed an expectation that dietary staff should adhere to guidelines for discarding expired food to prevent potential foodborne illnesses among residents.

Penalty

Fine: $267,005

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 proper medication management protocols, as evidenced by the presence of expired medications and loose pills in medication carts. During an observation of Medication Cart #4, expired doses of loperamide HCL were found, along with loose white pill halves. Nurse #7 acknowledged the presence of these expired and loose medications, stating it was the nurse's responsibility to check for expired medications. Similarly, Medication Cart #2 was found to contain 12 loose pills of various colors, shapes, and sizes. Nurse #8 admitted that loose pills should not be present and suggested that pills might pop out of blister packs during handling. The Director of Nursing confirmed that expired medications should not be on the carts and that it was the responsibility of the nursing staff to maintain the carts. Additionally, the facility failed to ensure the secure administration of medications to a severely cognitively impaired resident. During an observation, a medication cup with three pills was found on the bedside table of a resident diagnosed with atrial fibrillation, COPD, and hypertension. The resident indicated that the nurse had brought the medications earlier. Nursing Supervisor #2 admitted to leaving the room before ensuring the resident had taken all the medications, which included Xarelto, Losartan, and Prednisone. The Director of Nursing stated that nurses should ensure residents take all medications before leaving the room.

Penalty

Fine: $267,005

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 communicate complete medical information for a resident transferred to the hospital. The resident, who was admitted to the facility, requested to be sent to the hospital due to decreased urination and inability to eat. The nursing supervisor completed a transfer form indicating the resident's vital signs and reason for transfer but did not provide a complete verbal report to the hospital. The resident was later diagnosed with septic shock secondary to Clostridium Difficile upon arrival at the hospital, with critically high white blood cell count and other severe symptoms. Interviews revealed that the nursing supervisor attempted to call the hospital to provide a verbal report but was disconnected and did not attempt to call back due to other duties. The resident's responsible party and the medical director expected a complete report to be given to the hospital, which was not done. The Director of Nursing also expected nurses to provide a full report to the hospital, which was not fulfilled in this case.

Penalty

Fine: $267,005

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 care during incontinence care for a resident, resulting in the resident being lowered to the floor. The resident, who was admitted with a history of muscle weakness and falls, required two-person assistance for all transfers as per his care plan. However, on the day of the incident, a nurse aide attempted to provide incontinence care alone, without the assistance of another staff member, and without using a gait belt. The resident was stood up using a walker, and during the process of sitting him back down, he lost balance and was lowered to the floor. The nurse aide involved in the incident had not worked with the resident for over a month and was unaware of the current transfer requirements. She believed the resident's condition had improved and attempted to manage the transfer alone. The care plan, which indicated the need for two-person assistance, was not followed, leading to the incident. The resident did not sustain any injuries from the fall, but the failure to adhere to the care plan and provide necessary assistance during transfers was a significant oversight.

Penalty

Fine: $267,005

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 care for a resident with an indwelling urinary catheter, leading to potential risks of infection. During a sacral pressure ulcer dressing change, the Wound Treatment Nurse placed the resident's catheter drainage bag on the bed, level with the resident's bladder, instead of keeping it below the bladder. This action was contrary to the care plan, which required the drainage bag to be positioned below the bladder to prevent backflow of urine and potential infection. The resident, who was cognitively intact and dependent on staff for mobility and activities of daily living, had a neurogenic bladder and an unstageable pressure ulcer. Additionally, the facility failed to provide appropriate catheter care. During an observation, a Nurse Aide did not use soap while cleaning the catheter and did not clean the urethral meatus or the entire catheter tubing as per the facility's protocol. The Nurse Aide started cleaning below the catheter insertion site and did not pull back the urethral meatus to clean around the penis, which is necessary to prevent contamination and infection. The Nurse Aide acknowledged the deviation from the training she had received. Interviews with the Director of Nursing and the Medical Director confirmed that the catheter care provided was not in line with the facility's protocol and expectations. Both the Wound Treatment Nurse and the Nurse Aide did not adhere to the established procedures, which are critical in preventing infections in residents with indwelling urinary catheters.

Penalty

Fine: $267,005

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

Summary

The facility failed to prevent significant medication errors for two residents. In the first case, a nurse in orientation administered medications intended for another resident to a severely cognitively impaired resident. The medications included several antihypertensives, which were not prescribed for the resident, leading to a temporary decrease in heart rate and blood pressure. The error occurred when the orienting nurse was left to administer medications unsupervised, resulting in the wrong medications being given to the wrong resident. In the second case, a resident with anxiety disorder missed three doses of a prescribed antianxiety medication due to the facility running out of the medication. The nursing staff failed to ensure the medication was reordered in a timely manner, and alternative medications available in the automated dispensing machine were not considered. The resident was at risk for withdrawal symptoms, although no adverse effects were documented. Interviews with staff revealed communication and procedural lapses, such as the failure to monitor the resident for withdrawal symptoms and the lack of timely medication reordering. The facility's automated medication dispensing machine inventory log showed discrepancies in medication availability, contributing to the missed doses. The medical director expressed concern over the recurring issue of medication shortages at the facility.

Penalty

Fine: $267,005

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 effectively communicate a therapy order for a left hand splint to the nursing staff for a resident with a contracture and limited range of motion. The resident, who had a history of stroke with left side weakness, was supposed to receive a splint to prevent further contracture of the left hand. Despite the occupational therapist's (OT) efforts to order and create a splint, there was a lack of follow-through in ensuring the splint was applied and maintained as part of the resident's care plan. The occupational therapist initially assessed the resident and determined the need for a splint, but the splint was delayed due to being on back order. A temporary splint was made by the OT, but there was no clear communication or documentation in the resident's care plan or medication administration record regarding the application and maintenance of the splint. Nursing staff were not adequately informed or trained on the use of the splint, leading to its absence in the resident's care routine. Interviews with various staff members revealed a lack of awareness and understanding of the resident's need for the splint. The splint was eventually found in the resident's closet, but it was missing a Velcro band necessary for its application. The interim Therapy Rehab Director and the Director of Nursing acknowledged the oversight in communication and documentation, which resulted in the resident not receiving the necessary care to maintain range of motion and prevent further contracture.

Penalty

Fine: $267,005

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 an antianxiety medication, Lorazepam, was available for administration as ordered by the physician, resulting in three missed doses for a resident diagnosed with an anxiety disorder. The resident was admitted with a physician's order for Lorazepam 0.5 mg to be administered three times a day. On a specific day, the resident missed all three scheduled doses because the medication was not available in the facility's automated medication dispensing machine, which was supposed to have a stock of 8 tablets but was recorded as having none. Nurse #4, who was on duty, did not administer the medication due to the shortage and documented the missed doses in the medication administration record. The nurse had been informed by Nurse #6, who worked the previous shift, that the medication was out and that an escript was needed. Despite notifying the pharmacy, the medication was not delivered until late that evening, resulting in the missed doses. The facility's usual process for ordering controlled medications was disrupted as the Evening Supervisor Nurse, responsible for checking medication needs, was out sick, leaving the responsibility to the floor nurses, who failed to ensure the medication was reordered in time. Interviews with various staff, including the Psychiatric Physician Assistant and the Director of Nursing, revealed that alternative medications were available in the automated dispenser, but the staff did not notify the provider to consider these options. The Pharmacy Manager confirmed that the medication was sent out for delivery late, and the Director of Nursing emphasized the expectation for nursing staff to reorder medications before they run out. The Medical Director expressed concern over the recurring issue of medication shortages at the facility.

Penalty

Fine: $267,005

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

Summary

The facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident with chronic wounds. The Wound Nurse was observed providing care to a resident with multiple open wounds on the lower extremities and toes without wearing a gown, although gloves were used. The facility's policy required EBP, including the use of gowns and gloves, for high-contact care activities involving residents with chronic wounds to prevent the transmission of multi-drug resistant organisms. However, the Wound Nurse mistakenly believed that EBP was only necessary for residents with chronic wounds, not realizing that it also applied to the care activities she was performing. The Infection Control Preventionist Nurse acknowledged that the resident was initially placed on EBP upon admission due to chronic wounds but was later placed on contact precautions due to a COVID-19 outbreak. After the resident was removed from contact precautions, the facility failed to reinstate EBP. The Director of Nursing confirmed that staff had been trained on EBP and should have used a gown and gloves during wound care. The oversight in continuing EBP after the resident's contact precautions ended led to the deficiency in infection control practices.