Crestview Health & Rehabilitation

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 accurate and consistent advance directive information for several residents, as evidenced by discrepancies and incomplete documentation in both paper and electronic medical records. For one resident, the paper record contained a signed Medical Orders for Scope of Treatment (MOST) form indicating a Do Not Resuscitate (DNR) status, but the electronic health record and physician orders listed conflicting code statuses, including both DNR and Full Code. Interviews with nursing staff and management confirmed that the process for updating code status was not followed correctly, resulting in outdated and conflicting information remaining in the resident's records. Additionally, three other residents had MOST forms in the advance directive binders that were not properly signed by the resident or their representative. In one case, the form indicated verbal consent from a representative but lacked documentation of the date, time, or the identity of the person who obtained the consent. The social worker responsible for advance directives stated that she believed signatures were optional based on the form's language, and when verbal consent was obtained, she did not consistently document the required details. The DON and Administrator both confirmed that signatures and complete documentation are required for these forms. The affected residents included individuals who were both cognitively intact and severely cognitively impaired, with diagnoses such as paraplegia, chronic pain, Parkinson’s disease, chronic kidney disease, end-stage renal disease, and diabetes mellitus. The deficiencies were identified through record reviews and staff interviews, revealing a pattern of incomplete or inconsistent documentation of advance directives and code status across multiple 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 post cautionary signage indicating oxygen use outside the rooms of four residents who were receiving supplemental oxygen therapy. Multiple observations over several days confirmed that oxygen concentrators were in use via nasal cannula for these residents, but no warning signs were present on their doors. This deficiency was noted for residents with significant respiratory diagnoses, including heart failure, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and acute respiratory failure with hypoxia. Staff interviews revealed a lack of clarity and consistency regarding responsibility for placing oxygen in use signs. Agency nursing staff were unaware of who was responsible for posting the signs, and some had not noticed the absence of signage. Unit Managers and nurses described a process in which the nurse on the hall was supposed to place the sign when a resident was admitted with an oxygen order, with Unit Managers attempting to double-check compliance. However, the absence of signs persisted during the survey period. The Director of Nursing (DON) and the Administrator both acknowledged that oxygen in use signage should be posted for all residents using oxygen, whether continuously or as needed. The DON stated that the facility had run out of oxygen signs and had to order more, which contributed to the deficiency. The lack of signage was observed repeatedly for each affected resident, despite ongoing oxygen therapy and clear physician orders for its use.

Penalty

No penalty information released

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

Summary

Surveyors observed that expired milk was present in both the walk-in and reach-in refrigerators in the facility's kitchen. Specifically, one opened gallon of whole milk with a use by date that had already passed was found in the reach-in refrigerator, and in the walk-in refrigerator, one unopened gallon, one opened gallon of whole milk, and one individual carton of 2% milk were all found with expiration dates that had already passed. These expired items were available for use in food preparation and as fluid milk for residents. Interviews with the Dietary Manager revealed that dietary aides were responsible for daily checks of expired food, with the manager also conducting follow-up checks. The Dietary Manager acknowledged that he had overlooked the expired milk during his last inspection. The Administrator confirmed that the expectation was for daily checks and for food to be used on a first-in, first-out basis, and stated that the expired milk should have been removed on its expiration date.

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 assess a resident for the use of side rails prior to their installation. A resident with diagnoses including dementia with behaviors, bipolar disorder, polyneuropathy, and anxiety disorder was readmitted to the facility and had a physician's order for 1/4 side rails to promote independence. Documentation showed that side rails were installed and in use, and the treatment administration record was signed off by a nurse. However, review of the resident's electronic medical record revealed that the required initial side rail assessment was not completed prior to the installation of the side rails. The only assessment found was a quarterly assessment marked as 'in progress' and dated after the installation. Interviews with facility staff, including the Maintenance Director, Unit Manager, and Director of Nursing, confirmed that there was no documented initial side rail assessment before the side rails were installed. Staff interviews revealed confusion regarding responsibility for ensuring the assessment was completed, with the Maintenance Director stating he did not verify assessments and the Unit Manager and Director of Nursing acknowledging the assessment was not done. The Administrator, who was new to the facility, was not familiar with the side rail policy but expected the assessment to be completed prior to installation.

Penalty

No penalty information released

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

Summary

The facility failed to implement its infection control policy for Enhanced Barrier Precautions (EBP) during wound care for a resident with chronic wounds. During an observed wound care procedure, the Wound Nurse did not don a gown as required by the facility's EBP policy, despite signage and available personal protective equipment indicating the need for both gloves and a gown for high-contact care activities. The nurse performed hand hygiene and donned gloves but omitted the gown, then proceeded with wound care on multiple sites. Additionally, the Wound Nurse did not consistently change gloves or perform hand hygiene between wound sites, contrary to the facility's infection prevention and control policy. Specifically, after cleaning one wound, the nurse removed only one glove, performed hand hygiene on one hand, and then continued care on another wound without changing both gloves or performing full hand hygiene. The nurse also reapplied gloves without hand hygiene at certain points during the procedure. The nurse later acknowledged awareness of the EBP requirements and attributed the lapses to nervousness. The Director of Nursing confirmed that EBP and hand hygiene protocols were expected to be followed for residents with chronic wounds.

Penalty

Fine: $23,10035 days payment denial

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

Summary

A deficiency occurred when a resident with a history of stroke, left-sided hemiparesis and hemiplegia, left above-knee amputation, and other comorbidities fell from her bed during incontinent care. The resident was dependent on staff for bed mobility and toileting, requiring assistance from one to two staff members as indicated in her care plan. On the day of the incident, a single nurse aide provided a bed bath with the bed elevated to waist height. During the process, the resident, who typically held onto the privacy curtain for support, became startled, let go, and rolled off the bed, hitting her head and reporting immediate pain in her right leg. The incident resulted in a right femur fracture, and the resident was transported to the hospital for evaluation and treatment. Interviews with staff and the resident confirmed that only one staff member was present during the bed bath, despite the care plan indicating the need for assistance from two staff members. The nurse aide involved stated that she was familiar with the resident's routine and typically performed care alone, while the Director of Nursing and other staff confirmed that the standard of care required two-person assistance for such tasks. The care plan and Kardex did not consistently reflect the required level of assistance, contributing to the failure to provide adequate supervision and safe care during the incident. A second deficiency involved another resident who was dependent on others for transfers and required a mechanical lift with two staff for safe transfers. During a transfer, two nurse aides attempted to adjust the resident in his chair while he was still attached to the mechanical lift. The lift tipped to the side, and the handle grazed the resident above his left eye, causing a skin tear. Both aides reported that the incident occurred while trying to reposition the resident, and the mechanical lift immediately settled back into position. The incident was reported, and the resident received treatment for the skin tear. The root cause was identified as a failure to remove the sling from the lift prior to repositioning, resulting in the injury.

Penalty

Fine: $23,10035 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 notify the family member or resident representative of an accident involving a resident who was struck in the eye area by a mechanical lift handle, resulting in a skin tear with minor bleeding that required a wound covering. The incident occurred during a transfer performed by two nurse aides, who immediately notified the hall nurse. The nurse assessed and treated the wound, but did not document any notification to the resident's family or representative. The incident report included designated sections for recording family notification, but these were left blank by the nurse who completed the report. The resident, who was cognitively intact and had multiple medical diagnoses including epilepsy, diabetes, heart disease, and hypertension, was unaware if his family had been informed of the incident. Interviews with the nurse aides involved confirmed that they believed it was the nurse's responsibility to notify the family and that they did not make any such notification themselves. Attempts to interview the nurse responsible and the family member were unsuccessful. The former Director of Nursing recalled the incident and stated that staff were expected to complete the incident report fully, including family notification, but acknowledged that the lack of documentation indicated the family was likely not notified. The deficiency centers on the facility's failure to ensure timely notification to the resident's representative following an accident resulting in injury.

Penalty

Fine: $23,10035 days payment denial

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

Summary

A deficiency occurred when the facility failed to implement a care planned intervention for a resident with a history of falls. The resident, who had diagnoses including Parkinson’s disease, epilepsy, and dementia, was identified as being at risk for falls due to cognitive impairment and impulsive attempts to get up without assistance. The care plan, revised on 5/7/25, specified that a fall mat should be placed at the right side of the resident’s bed. However, during two separate observations on 6/26/25, the fall mat was not present at the designated location while the resident was asleep in bed. The bed was in the lowest position with the left side against the wall, and the head of the bed elevated, but no fall mat was observed on the right side as required by the care plan. Staff interviews revealed that a nurse aide, who was new to the facility, was unaware of the fall mat intervention and had not seen the directive in the care guide. The nurse aide stated that information about fall precautions was typically obtained from the care guide and shift change reports. The nurse on duty could not recall if the fall mat was present earlier that morning and suggested it may have been moved after the resident experienced a seizure the previous night. Both the DON and the Administrator confirmed that all nursing staff are responsible for ensuring fall mats are in place for residents with a history of falls, and that information about such interventions is communicated through care plans, care guides, and shift reports.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. Resident #1, who has a history of traumatic spinal cord dysfunction, anoxic brain injury, and paraplegia, was observed being physically restrained by Resident #2. Resident #2 covered Resident #1's mouth and pinched her nose, causing her distress and difficulty breathing. This incident was witnessed by two nurses during a shift change, who intervened to stop the behavior. Resident #1 was cognitively intact and required assistance with activities of daily living due to her physical limitations. Despite this, she was left vulnerable to abuse by Resident #2, who was also cognitively intact but had no documented history of such behavior. The incident occurred in a public area of the facility, suggesting a lack of adequate supervision and monitoring of residents' interactions, particularly those in close relationships. The nurses involved in the incident reported the event to the Director of Nursing and the Administrator, who instructed them to separate the residents and place Resident #2 under one-on-one observation. However, the Administrator did not initially consider the incident as abuse, indicating a potential gap in recognizing and addressing abusive behavior. The facility's response to the incident highlights a deficiency in ensuring the safety and protection of residents from abuse by others within the facility.

Penalty

No penalty information released

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

Summary

The facility failed to implement its abuse policy in the areas of reporting and investigating an incident involving two residents. The policy requires immediate investigation and reporting of any allegations of abuse, neglect, or exploitation to the Administrator, State Agency, Adult Protective Services, and law enforcement within specified timeframes. However, in this case, the facility did not submit an initial report or a 5-day investigation report to the State Agency, nor did it notify law enforcement and Adult Protective Services. The incident involved two residents who were often seen together and were in a relationship. During a shift change, a nurse observed one resident covering the mouth and pinching the nose of the other resident, causing distress and a frightened expression. The nurse intervened, separated the residents, and reported the incident to the Director of Nursing, the Administrator, and the resident's representative. Despite the apparent distress of the resident involved, the Administrator did not initially perceive the situation as abuse and failed to follow the facility's abuse policy. Interviews with the staff revealed that the incident was not reported as required by the facility's policy. The Administrator acknowledged that, in retrospect, the incident should have been perceived as abuse, and the appropriate procedures should have been followed. This failure to report and investigate the incident as per the facility's policy constitutes a deficiency in the facility's compliance with its abuse prevention and reporting obligations.

Penalty

Fine: $119,32740 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 Nurse Aides (NAs) #3 and #4 were adequately trained and certified in cardiopulmonary resuscitation (CPR) for Healthcare Providers, which led to an ineffective response during a medical emergency involving Resident #70. On the day of the incident, Resident #70 experienced sudden cardiac arrest, and NAs #3, #4, and #5 initiated CPR without using a backboard, which is necessary for effective chest compressions. Observations by Nurse #4 and the Staff Development Coordinator revealed that NA #3's compressions were not deep enough to allow for adequate chest recoil, prompting intervention and a switch in personnel. Further investigation revealed that neither NA #3 nor NA #4 had received proper orientation or skills competencies related to emergency situations, including CPR certification. Their training files lacked documentation of orientation or job descriptions, and NA #3 admitted to having an expired CPR certification and no training in emergency response since joining the facility. Similarly, Nurse #4 and the Staff Development Coordinator had not received orientation on responding to medical emergencies, although they possessed valid CPR certifications. The facility's orientation program was found to be inadequate, as it did not ensure that staff were trained in emergency preparedness or the location of emergency equipment. The Director of Nursing (DON) acknowledged the lack of consistent staff and oversight in the training program, which contributed to the deficiency. The absence of a comprehensive training and competency assessment system for emergency response placed all residents at risk, as staff were not adequately prepared to handle medical emergencies effectively.

Removal Plan

• The Staff Development Coordinator, Director of Nursing and Unit Manager will ensure that all staff to include nursing staff, administrative staff, dietary staff, laundry/housekeeping staff, and maintenance staff complete competency checklists based on their job descriptions for medical and clinical emergencies, medical and clinical codes and location of medical and clinical emergency equipment to ensure staff is aware of how to respond in clinical and medical emergencies. Staff will not be allowed to participate in medical and clinical emergencies without completing the competency.
• The Staff Development Coordinator will ensure all staff to include the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapists, housekeeping/laundry staff, dietary staff, social services, administrative staff, weekend staff, agency and prn staff complete competency checklists to include medical and clinical emergencies, medical and clinical facility codes and the location of medical and clinical emergency equipment.
• The Director of Nursing and Staff Development Coordinator (SDC) will educate the facility staff to include the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapists, housekeeping/laundry staff, dietary staff, social services staff, administrative staff, weekend staff, agency and prn staff on emergency responses to include how to respond, when to respond, and their role during medical and clinical emergency situations in the facility and where to find the medical and clinical emergency equipment located at the nursing stations.
• The night shift licensed nurses will complete the medical and clinical emergency equipment check list daily.
• The DON will check the medical and clinical emergency equipment and the completed medical and clinical check list weekly to ensure compliance.
• The Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring licensed nurses, weekend staff, CNAs, therapists, housekeeping/laundry staff, dietary staff, social services staff, administrative staff and CMAs including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the education is completed.
• The Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.

Penalty

Fine: $119,32740 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 effective administration of Cardiopulmonary Resuscitation (CPR) when a resident went into sudden cardiac arrest. CPR was initiated by three nurse aides without the use of a backboard, which is essential for effective chest compressions. Two of the nurse aides involved were not certified in CPR for Healthcare Providers. Observations revealed that the compressions performed by one of the aides were not deep enough to create the necessary chest recoil, and the staff had to instruct and eventually replace him with another member. The resident involved was admitted with diagnoses including Parkinson's disease, chronic respiratory failure, and a history of pulmonary embolism. At the time of the incident, the resident was found unresponsive in his room, and CPR was initiated by the staff. However, the absence of a backboard and ineffective compressions compromised the CPR efforts. Emergency Medical Services (EMS) arrived and questioned the lack of a backboard, which was only placed under the resident after their arrival. Interviews with staff revealed a lack of awareness regarding the location of the crash cart and the necessary equipment for CPR. The Director of Nursing (DON) and other staff members acknowledged that the facility's training program had gaps, and the staff involved in the CPR were not adequately trained or certified. The facility's CPR policy required properly certified staff to be available at all times, but this was not adhered to during the incident.

Removal Plan

• The Staff Development Coordinator (SDC) will complete an audit of the current CPR status of the nursing staff to include licensed nurses, certified nursing assistants, certified medication aides and agency nursing staff.
• The SDC will provide a CPR list of the nursing staff with current CPR certifications at each nursing station.
• Only certified CPR staff that are listed on the CPR list will be allowed to perform CPR.
• The Director of Nursing (DON), SDC, and nursing supervisor will be responsible for reviewing the daily staffing to ensure a CPR certified staff is working each shift.
• The facility CPR carts were checked by the Staff Development Coordinator to ensure missing supplies were replaced on the carts and both carts have back boards.
• The DON will place the crash cart checklist on nursing station #1's crash cart and ensure that the crash cart checklist is in place on nursing station #2's crash cart.
• The SDC will educate the night shift licensed nurses on completing the crash cart checklist sheet on nursing station #1 and nursing station #2.
• The night shift licensed nurses will be responsible for completing the crash cart checklists each night and ensuring the carts are stocked, and the back boards are in place.
• The Director of Nursing and the Staff Development Coordinator (SDC) will educate the nursing staff to include the licensed nurses, certified medication aides, and the certified nursing assistants on the CPR policy to include ensuring only nursing staff certified to perform CPR with current CPR certification status will be allowed to perform CPR, and making sure the back board is in place before initiating CPR to ensure that chest compressions are effective and allow for chest recoil.
• A list of the nursing staff with current CPR certifications will be placed at each nursing station.
• Nursing staff will not be allowed to perform CPR without their name listed on the CPR list and without a current CPR certification.
• The CPR list will be updated weekly by the SDC, to include newly hired and/or agency staff's CPR expiration and renewal dates.
• The Director of Nursing/Staff Development Nurse will conduct a mock Code Blue drill for training purposes on the 7am -7pm shift and 7pm- 7am shift.
• The Director of Nursing/Staff Development Nurse will conduct a mock Code Blue drill monthly thereafter.
• The Staff Development Coordinator (also a Certified CPR instructor) will begin teaching the American Heart Association CPR class and certifying staff pending their post class passing test scores.
• The class will be provided for staff whose CPR certifications are expired or staff without CPR certification.
• The Director of Nursing and the SDC will educate the licensed nurses on ensuring that the CPR crash carts are being checked daily, after use and the back board is in place.
• The night shift licensed nurses will be responsible for completing the crash cart checklist sheet each night and ensuring that the CPR crash carts are stocked, and the back boards are in place.
• The DON will be responsible for checking the CPR crash carts and reviewing the daily CPR crash cart checklist for completion weekly to ensure continual compliance.
• The Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all nursing staff to include licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), weekend, agency and prn staff receive the CPR education.
• Staff including new hires and prn staff will not be allowed to work without completing this education.
• The education will be ongoing to include new hires and prn staff.
• The Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.

Penalty

Fine: $119,32740 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 effective pain management for a resident after a fall, which resulted in an acute fracture of the proximal left femur. The resident, who was deaf and mute, was found face down on the floor with an obvious deformity in the left hip and leg. Despite the resident's advanced directive indicating that he should not be hospitalized unless his comfort needs could not be met at the facility, the staff did not transfer him to the hospital immediately. Instead, they administered a one-time dose of Ibuprofen and continued with the scheduled oxycodone-acetaminophen, but the resident continued to exhibit signs of severe pain. The nursing staff, including Nurse #3, failed to adequately assess and document the resident's pain levels or the effectiveness of the pain management interventions. The resident was noted to be in significant pain, with grimacing and moaning, yet the on-call provider was not informed of the ongoing pain throughout the night. The resident's pain was only reassessed and documented as severe the following day, leading to a delayed transfer to the hospital for further evaluation and pain management. Interviews with staff revealed a lack of communication and failure to follow up on the resident's pain management needs. The Director of Nursing and other staff members were not aware of the resident's increased pain, and the on-call provider was not notified of the severity of the situation. This lack of communication and inadequate pain management resulted in immediate jeopardy for the resident, highlighting a significant deficiency in the facility's care practices.

Removal Plan

• The Director of Nursing and the licensed nurses will complete new pain assessments of the current residents to include review of progress notes, care plans and resident pain regiments to ensure resident pain is being managed and/or prevented. Interviewable residents will also be interviewed by the licensed nurse to ensure that their current pain regime is adequate.
• The Chief Nursing Officer reviewed the Maple Health Pain Management Prevention Plan with the Director of Nursing.
• Director of Nursing and the Staff Development Coordinator will educate the licensed nurses, certified nursing assistants (CNA), and the certified medication aides (CMA) on identifying signs and symptoms of pain, and pain management and prevention to include follow up with the provider if pain management interventions are not effective. Pain will be assessed every shift, after a fall, with changes in condition and before and after pain medication administration and documented in the medication administration record or the progress notes.
• The Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring licensed nurses, weekend nursing staff, CNAs, and CMAs receive the education to include identifying sign and symptoms of pain, and pain management and prevention to include follow up with the provider if pain management interventions are not effective. Staff including new hires and prn staff and agency staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the education is completed.
• The Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.

Penalty

Fine: $119,32740 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 protect a resident from neglect by not conducting a comprehensive assessment after the resident sustained a fall with injury. The resident, identified as Resident #40, fell on 5/27/2024 and was found face down on the floor. Despite the obvious signs of injury, including the resident's left leg being internally rotated and shorter than the right leg, the staff did not perform a thorough assessment before moving the resident back to bed. Nurse #3 initially summoned Emergency Medical Services (EMS) but was instructed to cancel the call by the Director of Nursing (DON) due to the resident's advance directive, which stated not to hospitalize unless comfort needs could not be met at the facility. The facility also failed to provide effective pain management for the resident following the fall. Despite administering a one-time dose of Ibuprofen and the resident's routine oxycodone-acetaminophen, the resident continued to experience severe pain, as evidenced by a pain scale rating of 8 out of 10 and non-verbal signs such as crying, moaning, and grimacing. An x-ray performed the following day revealed an acute fracture of the proximal left femur, necessitating the resident's transfer to the hospital for further evaluation and pain management. This incident was identified as a deficient practice for one of the three residents reviewed for neglect and pain management. The failure to provide necessary care and services, including immediate medical treatment and effective pain management, constituted immediate jeopardy, which began on the date of the fall. The facility's actions, or lack thereof, resulted in the resident suffering from unmanaged pain and delayed medical intervention.

Removal Plan

• Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
• Ensure Resident #40 receives the necessary care and services from a higher level of care after sustaining an obvious injury, effective pain management strategies identified through his assessment, and implement identified services according to Resident #40's MOST form.
• Review Resident #40's medical records documentation to ensure he's receiving all necessary care and services.
• Review risk management events of falls with obvious injuries, as well as alert and oriented interviews with pain issues.
• Educate the Director of Nursing on the process at the time of an event ensuring residents receive a higher level of care for obvious injuries, effective pain management strategies implemented, and understanding MOST forms in relation to residents' immediate needs after an event.
• Review all falls/incidents in the clinical meeting to determine if the event required residents to receive a higher level of care and/or the need for additional care and services.
• Review the pain assessment conducted with each event during the clinical meeting for immediate interventions implemented and real-time effectiveness.
• Review the MOST forms to ensure facility's compliance with resident/responsible party's wishes.
• Notify clinicians of ineffectiveness of pain interventions and implement additional and/or alternative measures as indicated.
• In-service all facility staff (including contracted agency staff) on Neglect, including failing to provide the necessary care and services from a higher level of care and effective pain management strategies following an event with obvious injuries.
• Educate all new hires during orientation and scheduled contracted agency nurses prior to working their shift.
• Ensure all facility staff (including contracted agency staff) are educated.
• Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.

Penalty

Fine: $119,32740 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 perform a comprehensive assessment and seek immediate medical treatment for Resident #40 after a fall with injury. On the night of the incident, multiple staff members responded to the resident's room after hearing a call for help. The resident was found face down on the floor, and despite signs of injury, such as an internally rotated and shortened left leg, the staff moved the resident back to bed without conducting a proper assessment or obtaining vital signs. Emergency Medical Services (EMS) was initially summoned but later canceled based on the resident's advance directive, which led to a delay in appropriate medical intervention. An x-ray the following day confirmed an acute fracture of the proximal left femur, and the resident was eventually transferred to the hospital for further evaluation and pain management. In another incident, the facility failed to follow up on an abnormal radiology report and obtain necessary laboratory testing for Resident #196, who was admitted with respiratory failure. The resident's condition worsened, showing signs of confusion and respiratory distress, but the staff did not notify the on-call provider of the abnormal chest x-ray results or the inability to obtain lab results. The resident was only transferred to the hospital after becoming unresponsive to anything but painful stimuli, where they were diagnosed with pneumonia and acute hypoxemic respiratory failure. These deficiencies highlight the facility's failure to adequately assess and respond to changes in residents' conditions, leading to delays in necessary medical care. The lack of timely communication with medical providers and failure to adhere to protocols for assessing residents after falls or changes in condition contributed to the harm experienced by the residents involved.

Removal Plan

• The Director of Nursing will review falls to ensure residents were assessed by licensed nurses identifying obvious injuries prior to being moved to determine if the resident required a higher level of care.
• The Chief Nursing Officer will educate the DON on directing the staff that call regarding falls with injury to the MOST forms and when to notify family and/or EMS.
• The Director of Nursing will educate licensed nurses on assessing resident status post falls, to include vital signs, neuro checks, range of motion, skin assessment and pain assessment, prior to being moved.
• Residents assessed with obvious injuries will be transferred to a higher level of care warranted by their MOST form.
• The Director of Nursing and clinical team will review falls in clinical meetings to ensure assessments were completed and if indicated, resident receive a higher level of care.
• The MOST forms will be reviewed/updated by the Social Workers and kept in a binder at both nursing stations.
• Staff will notify Resident/Resident's responsible party, along with the provider, on assessment findings and guidance to determine if a higher level of care and services are warranted.
• The Director of Nursing and the SDC will educate the licensed nurses to review resident MOST forms before calling Emergency Medical Services and if obvious deformity to include indications of fracture are observed residents should be immediately transferred to a higher level of care because resident's comfort needs cannot be met at the facility.
• The Director of Nursing and the Staff Development Coordinator will educate all staff to include the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapy staff, housekeeping/laundry staff, dietary staff, social services, administrative staff, weekend staff, agency and prn staff on ensuring that residents that experience falls are not moved prior to an assessment by a licensed nurse and reporting any changes from baseline immediately to the nurse.
• The Staff Development Coordinator and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), dietary staff, social services, housekeeping/laundry staff, therapy staff, maintenance staff, administrative staff, weekend staff, agency staff and prn staff receive the education.
• Staff including new hires and prn staff will not be allowed to work without completing this education.
• The education will be ongoing to include new hires and prn staff.
• The SDC will be responsible for ensuring the education is completed.
• The Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.

Penalty

Fine: $119,32740 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 permit a resident to return after hospitalization, violating the bed-hold policy. Resident #346, who required skilled nursing services, was sent to the Emergency Department (ED) for evaluation after self-harming with a soda can. Despite being cleared by in-house psychiatric services and no longer requiring acute care, the facility refused to readmit him. The hospital attempted to place the resident in 50 other skilled nursing facilities without success, resulting in the resident remaining in the ED for an extended period before being discharged home to elderly parents unable to care for him. Resident #346 had a history of aggression, depression, and suicidal ideation, and was admitted to the facility with multiple psychiatric diagnoses. The resident required maximum assistance for daily activities and had a deep tissue injury requiring wound care. The facility's care plan noted aggressive behaviors but did not address the resident's suicidal ideation. The Director of Nursing (DON) and staff documented incidents of aggression and self-harm, leading to the decision to send the resident to the ED. However, the facility did not follow up with the hospital or provide necessary discharge documentation, resulting in the resident's prolonged stay in the ED. Interviews with facility staff and the resident's responsible party revealed a lack of communication and coordination regarding the resident's return. The Admissions Coordinator and DON decided not to readmit the resident due to concerns about managing his behaviors, despite the hospital's clearance. The facility's actions and inactions led to the resident being discharged to an unsafe environment, highlighting a deficiency in adhering to the bed-hold policy and ensuring appropriate care transitions.

Penalty

Fine: $119,32740 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 Medical Director (MD) was aware of resident care policies related to Cardiopulmonary Resuscitation (CPR) and Emergency Response. During an interview, the MD admitted to not being familiar with the CPR or Emergency Response protocols in the building, although she instructed the facility to call EMS before contacting her. The MD's service agreement outlined her responsibilities, including the implementation of resident care policies and coordination of medical care. Despite the MD's involvement in major medical decisions and attendance at Quality Assurance meetings, she was not informed of these critical protocols, which had the potential to affect all current residents in the facility.

Penalty

Fine: $119,32740 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 advance directive information and ensure accurate documentation of residents' code status in their medical records. This deficiency was identified for six residents, all of whom had discrepancies or missing documentation regarding their advance directives. For instance, Resident #81, who was severely cognitively impaired, had an advanced directive order for Full Code, but the paperwork was not completed or placed in the code status notebook due to the inability to connect with the resident's family. Similarly, Resident #83, who was cognitively intact, had conflicting information in their care plan and electronic health record regarding their code status. The care plan indicated Full Code, while the electronic health record showed a Do Not Resuscitate (DNR) order. The social worker responsible for updating the care plans admitted to missing the update, and the Physician Assistant (PA) was unsure why the paperwork was not in the code status notebook, suggesting it might not have returned from the hospital with the resident. Other residents, such as Resident #86 and Resident #72, also had incomplete or missing advance directive paperwork due to issues like impaired cognition and difficulties in contacting family members or guardians. The Director of Nursing (DON) and the PA were unaware of these discrepancies, indicating a lack of communication and follow-up in ensuring that residents' advance directives were accurately documented and accessible in the facility's code status notebook.

Penalty

Fine: $119,32740 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 safe and appropriate respiratory care for three residents, as observed by surveyors. Resident #40, diagnosed with chronic obstructive pulmonary disorder (COPD), was ordered to receive continuous oxygen at 2 liters per minute. However, multiple observations revealed that the resident was not wearing oxygen, and the nasal cannula was out of reach. Additionally, the oxygen concentrator was found to be dusty, indicating a lack of regular cleaning. Interviews with nursing staff confirmed the oversight, and it was noted that the resident's oxygen saturation levels were not consistently monitored, with a recorded level of 89% when checked by a nurse. Resident #45, who also required continuous oxygen therapy due to chronic respiratory failure and COPD, was observed to be wearing oxygen as ordered. However, there was a failure to post cautionary signage outside the resident's room to indicate oxygen was in use. This oversight was acknowledged by the nursing staff and the Director of Nursing, who stated that signage should have been placed upon the resident's admission. Resident #34, with a diagnosis of chronic respiratory failure, was observed using oxygen therapy, but the oxygen concentrator filters were found to be dusty and not cleaned as required. Furthermore, there was no cautionary signage on the resident's door to indicate oxygen use. Interviews with nursing staff revealed a lack of awareness regarding the policy for cleaning oxygen filters and posting signage, contributing to the deficiency. The Director of Nursing confirmed that the filters should be cleaned weekly and that the signage should have been moved when the resident changed rooms.

Penalty

Fine: $119,32740 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 properly manage and secure medications in several instances, leading to deficiencies in medication storage and labeling. Observations revealed that insulin pens were left unattended and unsecured on top of medication carts in the 500/700 halls, with multiple staff and a visitor walking past the unlocked cart. Nurses acknowledged the oversight, admitting that the insulin pens should have been secured and locked. Additionally, an open and undated foil pouch of duoneb vials was found on the 300 hall medication cart, with the nurse unaware of the appropriate duration for keeping the vials in an open pouch. Further deficiencies were noted in the medication rooms, where expired medications were found on the shelves and in the refrigerator, including bisacodyl, melatonin, omeprazole, tuberculin protein derivative, and cephalexin. A nurse, new to the facility, was unsure of the procedure for handling expired items. In the back medication room, a controlled substance box was found unlocked, containing lorazepam gel packs, and an open vial of tuberculin solution was past its discard date. The nurse responsible for the oversight admitted to forgetting to lock the controlled substance box after counting the medication. The Director of Nursing confirmed that controlled substances should always be double-locked and that expired medications should have been disposed of during weekly checks by day shift nurses.

Penalty

Fine: $119,32740 days payment denial

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

Summary

The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in one of the seven hallways affecting resident rooms. Observations revealed flies in multiple resident rooms, landing on beds, residents, and wheelchairs. The pest control logs from April to June 2024 indicated regular inspections and treatments, but the presence of flies persisted, particularly in rooms with open food containers and other attractants. The pest control technician noted that food and bodily fluids in rooms were likely attracting flies, and recommended thorough cleaning and possibly replacing contaminated mattresses and pillows. Interviews with staff, including a nurse aide and housekeeper, revealed awareness of the fly issue, with the housekeeper attributing the problem to open food and body odor, as well as the proximity to a smoking exit door. The Maintenance Director had attempted to address the issue by installing an air curtain at the smoking exit door and using a chemical spray provided by the pest control company. However, the air curtain was ineffective, and the door remained propped open, allowing flies to enter. The pest control technician confirmed the presence of flies and suggested additional measures, such as external fly bait stations. The Director of Nursing and the Administrator were aware of the fly problem, with the DON noting flies in her office and the Administrator acknowledging the issue after discussions with residents. Despite efforts to address the problem, such as replacing window screens and offering to deep clean affected rooms, the facility had not identified the extent of the issue as noted by the surveyor. The deficiency highlights a need for more effective pest control measures and better housekeeping practices to prevent fly infestations.

Penalty

Fine: $119,32740 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 assess a resident for the ability to self-administer medications, which is a requirement for residents who wish to manage their own medication. The resident, who was cognitively intact, had several medications in her room, including an Albuterol inhaler, Fluticasone nasal spray, fiber tablets, and antacid tablets. These medications were brought to her by her sister shortly after her admission. Despite the resident's self-administration of these medications, there was no physician order or assessment conducted to determine her capability to self-medicate safely. Interviews with facility staff, including a Medication Aide and the Director of Nursing, revealed a lack of awareness and adherence to the facility's policy that requires an assessment for self-medication. The Medication Aide incorrectly believed the resident had an order to self-medicate, while the Director of Nursing confirmed that no residents, including this one, had been assessed or approved to self-administer medications. The medications were eventually removed from the resident's room, and she declined an assessment since she was scheduled for discharge soon.

Penalty

Fine: $119,32740 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 accurately code the Minimum Data Set (MDS) for anticoagulants and Pre-Admission Screening and Resident Review (PASRR) information for three residents. Resident #68, who was admitted with serious mental health diagnoses, was not coded as having a Level II PASRR on the annual MDS, despite having a care plan indicating such a determination. The MDS Nurse confirmed the error, stating that someone else completed the assessment inaccurately. Similarly, Resident #196, who was prescribed apixaban for anticoagulation, was not coded for anticoagulant use on the discharge MDS, even though the medication was administered as per the physician's orders. The MDS Nurse acknowledged the oversight, noting that she did not complete the discharge assessment. Resident #346, admitted with mental health diagnoses, was also inaccurately coded on the admission MDS as having a Level I PASRR, despite documentation confirming a Level II PASRR. The MDS Nurse attributed this error to reliance on demographic information rather than the PASRR documentation. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of familiarity with MDS coding requirements, with the DON deferring to the MDS Nurse for accuracy. The Administrator expressed an expectation for correct MDS coding.

Penalty

Fine: $119,32740 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 update a care plan regarding smoking for a resident with a history of cerebral vascular accident and dementia. The resident was admitted with these diagnoses and had a safe smoking screening indicating they could smoke independently. However, the care plan, revised later, contained conflicting information stating the resident required supervision while smoking and could also smoke unsupervised. This discrepancy was acknowledged by the social worker responsible for the care plan, who admitted to making a mistake. The Director of Nursing expected the care plan to accurately reflect the resident's ability to smoke unsupervised.

Penalty

Fine: $119,32740 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 adhere to regulations regarding the use of psychotropic medications for a resident, specifically concerning the lack of a stop date or indication for extending a PRN order beyond 14 days. Resident #32, who was admitted with diagnoses including antianxiety disorder, bipolar disorder, depression, and schizoaffective disorder, was prescribed a compound lorazepam gel to be applied topically every 4 hours as needed for agitation. However, the order did not include a stop date or an indication for use beyond 14 days, which is a requirement for PRN psychotropic medications. This oversight was acknowledged by the Consultant Pharmacist, Physician Assistant, and Director of Nursing during interviews. Additionally, the facility did not implement monitoring tools for side effects of psychotropic medications for Resident #32, despite the resident being on multiple psychotropic medications since admission. The resident's care plan included interventions for monitoring adverse reactions, but the Medication Administration Records (MAR) from November 2023 through June 2024 showed no documentation of such monitoring. The Director of Nursing confirmed the absence of monitoring tools on the MARs, and the Consultant Pharmacist admitted to not using specific monitoring tools, instead relying on psychiatry and PA notes during monthly reviews. Interviews with staff revealed that Resident #32 exhibited verbal and physical behaviors, and there were challenges in managing her medications due to her fluctuating moods and behaviors. The Medical Director and Social Worker described the resident's behaviors and the facility's attempts to manage them, including psychiatry referrals and talk therapy. However, the lack of proper documentation and monitoring of psychotropic medication side effects indicates a deficiency in the facility's medication management practices.

Penalty

Fine: $119,32740 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 notify the medical provider that the ordered laboratory tests were not obtained for a resident who was admitted with a diagnosis of respiratory failure and was severely cognitively impaired. The physician had ordered a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) due to increased confusion observed by the resident's family. However, there was no documentation in the progress notes indicating that the medical provider was informed of the laboratory results or the inability to obtain them. Nurse #6, who was on duty during the night shift, did not collect the laboratory samples as she was not accustomed to drawing blood at night and did not document the failure to collect the samples. Nurse #5, who worked the following day shift, assumed the labs had been completed since Nurse #6 had checked them off on the Medication Administration Record (MAR). The Physician Assistant (PA) who ordered the tests was not informed of the results or the failure to obtain them. The Director of Nursing (DON) confirmed that the laboratory tests were never collected and that the on-call provider should have been notified of the situation.

Penalty

Fine: $119,32740 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 implement its abuse policy in the areas of reporting and investigating an incident involving two residents. The policy requires immediate investigation and reporting of any allegations of abuse, neglect, or exploitation to the Administrator, State Agency, Adult Protective Services, and law enforcement within specified timeframes. However, in this case, the facility did not submit an initial report or a 5-day investigation report to the State Agency, nor did it notify law enforcement and Adult Protective Services regarding the incident involving Resident #1 and Resident #2. The incident occurred when Nurse #1 observed Resident #2 covering Resident #1's mouth and pinching her nose, causing Resident #1's face to turn red and her head to fall backward. Nurse #2 intervened and separated the residents, noting that Resident #1 appeared frightened and in shock. Despite the severity of the situation, the facility's Administrator did not perceive the incident as abuse and failed to follow the established procedures for reporting and investigating the allegation. Interviews with the staff revealed that Resident #1 and Resident #2 were in a relationship and often seen together, which may have influenced the initial perception of the incident. However, the failure to recognize and report the incident as potential abuse led to a deficiency in the facility's compliance with its abuse policy, leaving the residents without the necessary protections and oversight required by the policy.

Penalty

Fine: $119,32740 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 submit a 5-Day Investigation Report within the required timeframe to the State Agency for a resident who experienced misappropriation of property. The facility's Abuse Policy mandates that all alleged violations involving misappropriation of resident property be reported immediately to the Administrator, who is responsible for ensuring that both the initial report and the 5-day investigation report are submitted to the state agency. In this case, the Director of Nursing (DON) completed the Initial Allegation Report after being informed by the Social Services Director that a resident's personal bank card was missing and had been used without consent. This initial report was faxed to the State Agency on the same day. However, the 5-day Investigation Report was not received by the State Agency as required. The DON stated that she completed the 5-day report but could not locate the fax confirmation to verify its submission. Despite being aware of the requirement, the report was not sent, leading to a deficiency. The Administrator, who assumed his position after the incident, confirmed his awareness of the requirement but was not involved at the time of the event.

Penalty

Fine: $119,32740 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 develop and implement a person-centered care plan for a resident with a history of suicidal ideation. The resident, identified as Resident #346, was admitted with diagnoses including bipolar disorder, anxiety, post-traumatic stress disorder, and major depressive disorder. Upon admission, the resident was noted to have cognitive intactness but exhibited symptoms of depression and suicidal thoughts. Despite these indicators, the care plan dated shortly after admission did not address the resident's history of suicidal ideation. The deficiency was further highlighted when the resident engaged in self-harm by cutting himself with a soda can and expressed suicidal thoughts, leading to hospitalization. Interviews with facility staff, including the MDS Nurse, Social Worker, Director of Nursing, and Administrator, revealed a consensus that the resident should have been care planned for suicidal ideation. However, there was a lack of awareness and oversight, resulting in the omission of this critical aspect of the care plan.

Penalty

Fine: $119,32740 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 nail care for a dependent resident, identified as Resident #40, who was admitted with severe cognitive impairment and required assistance with personal hygiene. Observations over several days revealed that Resident #40 had long, dirty fingernails with a brown substance underneath, despite being dependent on staff for hygiene care. Interviews with nursing aides and the unit manager indicated that nail care was supposed to be performed on shower days and as needed, but it was not consistently done for Resident #40. The Director of Nursing and the Administrator were unaware of the issue, highlighting a lack of communication and monitoring. Another deficiency was noted in the facility's failure to provide a haircut for Resident #78, who was cognitively intact but required assistance with personal hygiene due to decreased mobility and other health conditions. Despite expressing the need for a haircut to various staff members, including the Nurse Supervisor and the Administrator, Resident #78 had not received a haircut since December 2023. The facility had not had a beautician since August 2023, and there was no clear plan in place to address residents' grooming needs, leading to Resident #78's hair becoming long and falling into her eyes, causing discomfort. Interviews with staff, including social workers, medication aides, and nurses, revealed a lack of awareness and a clear protocol for addressing residents' grooming needs, such as haircuts. The Director of Nursing acknowledged the absence of a beautician and the difficulty in hiring one due to financial constraints. The Administrator was attempting to address the issue by reaching out to the corporation for support, but no immediate solution was in place, leaving residents like Resident #78 without necessary grooming services.

Penalty

Fine: $119,32740 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 safe transfer method for a resident, leading to a fall incident. Resident #346, who was admitted with diagnoses including anxiety, PTSD, and major depressive disorder, was dependent on assistance for transfers. A physical therapy evaluation indicated the resident required maximum assistance for transfers using a slide board. However, the resident's care plan did not include the use of a slide board, and nursing staff had not been trained on its use with this resident. On 7/6/2023, the resident fell off the slide board during a transfer, as the nursing assistant was not aware of the proper technique and the resident's feet were not positioned correctly. The PT Director confirmed that nursing staff had not been educated on using the slide board with this resident due to concerns about the resident's impulsive behavior. Additionally, the facility failed to complete quarterly safe smoking assessments for another resident, Resident #62, who had a history of cerebral vascular accident, hemiplegia, and dementia. The last safe smoking screening was conducted on 03/31/23, and the resident was deemed able to smoke independently. Despite the requirement for quarterly assessments, no further screenings were completed. The social worker responsible for the assessments acknowledged the oversight but could not explain why the screenings were not conducted as required. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of awareness and training regarding the use of the slide board for Resident #346 and the missed smoking assessments for Resident #62. The Director of Nursing confirmed that therapy was responsible for educating nursing staff on transfer techniques, and the Administrator expressed surprise that a slide board was left in the resident's room without proper clearance for use by nursing staff.

Penalty

Fine: $119,32740 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 secure an indwelling catheter for a resident, leading to potential discomfort and risk of displacement. The resident, who was cognitively intact and had a diagnosis of urinary retention, was observed multiple times with an unsecured catheter. The catheter tubing was noted to rest on the resident's leg without being anchored, which the resident reported caused discomfort due to pulling and tugging. Despite the care plan indicating the need for catheter care every shift, the catheter was not secured during several observations. Interviews with staff revealed a lack of communication and responsibility regarding the anchoring of the catheter. A nurse aide confirmed that she had not provided care to the resident and stated that nurses were responsible for securing the catheter. However, she would inform the nurse if she noticed it was not anchored. The nurse and medication aide both indicated that they had not been informed about the unsecured catheter, and the Director of Nursing stated that the catheter should be anchored to prevent tension and displacement, with checks every shift.

Penalty

Fine: $119,32740 days payment denial

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

Summary

The facility failed to maintain a medication error rate of less than 5%, resulting in an 11.11% error rate. This deficiency was identified through observations, record reviews, and staff interviews, affecting two residents. Resident #99, who was admitted with diagnoses including exacerbation of COPD and allergies, was supposed to receive Prednisone and Tiotropium bromide. However, on the observed date, the medication aide administered only one Prednisone tablet instead of three and failed to provide the Tiotropium bromide inhaler, mistakenly believing the resident had it at their bedside. Resident #51, admitted with a diagnosis of GERD, was prescribed famotidine 20 mg twice daily. During the medication pass, the aide administered only one 10 mg tablet instead of the required dosage. Upon review, the aide confirmed the error, acknowledging a need to pay closer attention to medication labels. These errors contributed to the facility's medication error rate exceeding the acceptable threshold.

Penalty

Fine: $119,32740 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 accurate medical records for a resident when laboratory tests were incorrectly documented as collected. A physician order dated December 25, 2023, required a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) due to the resident's increased confusion as observed by family members. The Medication Administration Record (MAR) indicated that Nurse #6 collected the CBC and BMP on December 25, 2023, at 1:24 am. However, during an interview, Nurse #6 stated that she did not draw blood that night and was unable to recall documenting the collection of the labs. The Director of Nursing (DON) confirmed that Nurse #6 had documented the collection of the labs, but was unaware that the labs were never actually obtained.