Pelican Health At Charlotte

Penalty

Fine: $26,685

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 recognize the severity of an injury and the increased risk of bleeding in a resident receiving daily anticoagulant therapy, and to initiate timely emergency medical intervention. The resident had multiple diagnoses including diabetes mellitus, a prior tibia fracture, hypertension, osteoporosis, history of DVT, and was on Eliquis 5 mg twice daily for DVT prevention. Her care plan identified anticoagulant use as a risk factor, with interventions to observe for abnormal bleeding or bruising. On the day of the incident, a nurse aide was providing a bed bath and then assisted the resident into a wheelchair, placing her feet on pillows on the leg rests. While pulling the wheelchair backward alongside the bed, the resident’s left lower leg struck the damaged corner of the bed footboard, where laminate was missing and pressboard was exposed. The resident immediately cried out in pain, reporting pain at 10/10, and her lower left leg began bleeding. The nurse aide attempted to control the bleeding by first using paper towels, which became saturated, and then a regular bath towel, while calling for a nurse. Nurse #1 entered, observed a one‑inch laceration on the resident’s left lower leg with increased bleeding, applied pressure for about five minutes, and then applied a pressure dressing. Nurse #1 documented the injury as a skin tear and noted that the resident’s anticoagulant was held, but did not initiate EMS or transfer the resident to a higher level of care, stating she did not think the resident needed to go to the hospital. Vital signs were documented as within or near normal limits, and no pain score was recorded in the SBAR note. The DON, who was in the facility at the time, did not go to the room or assess the wound and understood from Nurse #1 that the bleeding was controlled and that the resident did not need to be sent out immediately. The Medical Director later stated he was not informed that the resident’s leg had been struck on the footboard and that he would have sent her to the hospital due to her increased bleeding risk. After staff left the room, the resident called her Responsible Party, who came to the facility, observed red blood on the white dressing, and, after learning the facility was not sending her out, called 911. EMS records show they were told by the nurse that the resident had a 1–2 inch laceration to the left lower leg, that bleeding had been controlled with gauze and tape, and that pain medication had been administered. EMS noted the resident was in emotional distress with a pain level of 10/10, elevated blood pressure and heart rate, and bruising and swelling of the left lower leg. At the hospital ED, the resident was found to have a 2 cm skin tear with drainage and a large associated hematoma measuring approximately 4 x 7 inches, with difficulty controlling bleeding at the facility cited as a reason for referral. During hospitalization, imaging and assessment identified a large superficial soft tissue hematoma measuring 16.2 cm, with a documented decline in hemoglobin from 11.1 to 7.3 over two days, consistent with acute blood loss anemia requiring transfusion, and subsequent necrosis over the hematoma that required surgical evacuation, debridement, and wound VAC placement. The facility’s failure to adequately assess the injury, consider the impact of anticoagulant therapy, and promptly initiate emergency medical intervention for active bleeding in this anticoagulated resident constituted the cited deficient practice. Following discharge back to the facility, the resident required ongoing wound care and pain management. Wound care NP notes documented a large wound area on the left lower leg with necrotic tissue requiring daily dressing changes with Santyl and Dakin’s solution initially, later transitioning to xeroform and abdominal pads, with the wound described as improving but with a large surface area and low probability of full skin healing. The resident continued to report pain, particularly with dressing changes, and received frequent doses of oxycodone and acetaminophen for pain levels ranging from 0 to 10 on the pain scale. The Medical Director and Wound Care NP confirmed that the resident had sustained a significant hematoma requiring surgical intervention and that the wound remained a large open area. The surveyors determined that the facility’s failure to recognize the severity of the injury and the resident’s increased bleeding risk due to anticoagulant use, and to initiate timely emergency medical intervention, resulted in serious complications related to acute blood loss and extensive wound care needs for this resident. The survey findings also noted that Nurse #1 was an agency nurse working her first day in the facility and did not follow facility policy on anticoagulants or significant change in condition, including appropriate monitoring and physician notification for residents on anticoagulation who exhibit excessive bruising or bleeding. The DON and Administrator acknowledged that they were informed of the incident after it occurred and that the primary focus at the time was obtaining an order to hold the evening dose of the anticoagulant, rather than assessing the full extent of the injury or the need for immediate transfer. The Medical Director later stated that a “red flag” such as increased bleeding and pain in an anticoagulated resident would warrant consideration of hospital transfer. The survey concluded that Immediate Jeopardy began when Nurse #1 failed to recognize the severity of the injury and the resident’s increased risk of bleeding due to anticoagulant use, and that this deficient practice affected one of three residents reviewed for quality of care.

Removal Plan

• ADON audited the electronic health record order listing report to identify all residents receiving anticoagulant therapy and established this as an ongoing audit updated with each admission.
• DON audited all incident and accident reports for the past 30 days to ensure any incident resulting in injury received timely and appropriate treatment.
• Licensed nurses completed a facility-wide skin assessment for all residents receiving anticoagulant therapy to ensure no excessive bruising or bleeding and documented results in the electronic health record.
• Administrator and DON completed a root cause analysis identifying lack of recognition by an agency nurse of the need to transfer a resident to the ED and failure to follow the anticoagulant/significant change in condition policy.
• Held an ad hoc QAPI meeting to review the deficient practice and plan of correction.
• Administrator reviewed facility policy and clinical protocol for anticoagulation and change in condition and determined no changes were warranted.
• DON educated all licensed nurses, including agency nurses, on recognition and assessment of abnormal bruising and bleeding for residents on anticoagulants, use of e-interact tools, notifying MD/NP when an anticoagulated resident sustains an injury, and seeking a higher level of treatment for continued bleeding after 15 minutes of pressure or a pressure dressing.
• Incorporated the licensed-nurse education into orientation and onboarding for newly hired nursing staff, including agency nurses, with DON or designee to provide education and electronic training at onboarding.
• DON and ADON track and maintain education records to ensure staff receive the licensed-nurse education prior to start of their next shift.
• DON educated all nurse aides on recognizing changes in condition including excessive bleeding and on using the Stop and Watch Tool to immediately alert licensed nursing staff.
• Incorporated the nurse aide education on Stop and Watch and change in condition into orientation for newly hired staff, including agency staff, provided by DON or designee.
• Administrator is responsible for execution of the credible allegation and immediate jeopardy removal plan.

Penalty

Fine: $26,685

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 maintain a safe environment and provide adequate supervision to prevent accidents for multiple residents, including a dependent resident receiving anticoagulant therapy. One resident with diabetes mellitus, right tibia fracture, hypertension, muscle weakness, osteoporosis, history of DVT, and physical debility required two-person assistance with transfers and was on Eliquis, a medication with manufacturer guidance warning of serious bleeding risks. A PT evaluation documented severely decreased bilateral lower extremity range of motion, contractures, and an inability to tolerate upright positioning without both legs elevated on pillows and leg rests. Despite these needs, on the day of the incident a nurse aide performed a one-person mechanical lift transfer from bed to wheelchair and then pulled the resident’s wheelchair backward alongside the bed, striking the resident’s lower left leg against a damaged bed footboard with missing laminate and exposed pressboard. Following the impact with the damaged footboard, the resident immediately cried out in pain, reported severe pain at a level of 10/10, and had active bleeding from a one-inch laceration on the lower left leg. The aide initially attempted to control the bleeding with paper towels and then a bath towel, which became saturated, before calling a nurse. The nurse assessed a one-inch slit on the left lower leg, noted increased bleeding related to anticoagulant therapy, applied pressure for approximately five minutes, and then applied a pressure dressing. Documentation indicated the resident’s anticoagulant was held and that the wound nurse and NP were notified. EMS records later described the nurse reporting difficulty controlling bleeding at the facility and that the resident continued to complain of severe pain, with elevated blood pressure and heart rate during EMS assessment. Hospital records documented a large superficial soft tissue hematoma of the left lower extremity, a significant drop in hemoglobin consistent with acute blood loss anemia requiring transfusion, and subsequent skin necrosis over the hematoma that required operative evacuation, surgical debridement, and wound VAC placement. The deficiency also includes the facility’s failure to ensure environmental safety and adherence to policies for other residents. One cognitively intact resident with rheumatoid arthritis, generalized muscle weakness, diabetes mellitus, and a care plan identifying fall risk due to impaired mobility, lower extremity weakness, psychoactive medication use, and visual impairment reported falling in the shower after using a loose grab bar. During a therapy session in the shower room, the resident told the OT that the grab bar was loose, but the OT did not respond and instructed the resident to rinse off. When the resident stood and pulled on the grab bar, it moved significantly, causing her to fall back onto the shower chair and then slide to the floor on her buttocks. The resident could not get up due to chronic knee and leg weakness and the wet, slippery floor, and therapy staff had to use a mechanical lift to transfer her to her wheelchair before she was later evaluated at the hospital. Additional deficiencies were identified related to supervision and environmental safety for residents who smoked. The facility failed to follow its smoking policy by allowing residents to keep smoking materials on their person and in their rooms instead of having them locked at the nurses’ station. This practice was identified for multiple residents reviewed for supervision to prevent accidents. The combination of unsafe transfer practices, use of damaged furniture that created an accident hazard, failure to respond to a reported loose grab bar in the shower, and noncompliance with the smoking materials policy led surveyors to determine that the facility did not ensure a safe environment free from accident hazards or provide adequate supervision to prevent accidents for several residents.

Removal Plan

• Provided 1:1 education to NA #1 regarding following the mechanical lift policy requiring 2-person assistance for all mechanical lift transfers and safe movement of residents in their room/environment.
• Completed an audit of the electronic health record order listing report to identify all residents receiving anticoagulant therapy and established this as an ongoing audit updated with each admission.
• Conducted a 100% audit of the Resident Kardex to identify residents requiring a mechanical lift and reinforced that transfer status is evaluated by the IDT on admission/readmission/significant change/quarterly with care plan updates populated to the Kardex by the MDS nurse/designee.
• Reviewed all incidents and the accident log for the prior 30 days to identify any other residents injured while being maneuvered in their wheelchair in their environment.
• Reviewed Resident #25’s care plan by the MDS Nurse, Administrator, and DON.
• Replaced Resident #25’s damaged footboard.
• Inspected resident furniture/rooms (including bed frames and bedside tables) to ensure no rough edges or hazardous surfaces were present and immediately replaced any damaged/broken furniture identified.
• Completed a Root Cause Analysis identifying failure to follow 2-person mechanical lift transfer policy and lack of education on safely maneuvering residents in their environment.
• Provided education to nurses and nurse aides on the facility’s safe resident transfer policy and required return demonstration using the mechanical lift with competency validation on a skills checklist (including verifying transfer status via the Kardex).

Penalty

Fine: $26,685

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 improper disposal and maintenance of garbage and refuse in the outdoor trash receptacle area behind the kitchen. During an observation with the Head [NAME], surveyors noted three used disposable gloves and a clear trash bag containing trash on the ground next to the trash receptacle, as well as another clear trash bag with trash hanging out of an open receptacle door. There were five collapsed cardboard boxes floating in approximately 5 inches of standing water in the trash and recycling area, which spanned about 15 to 20 feet, and a blue trash bag containing trash was floating in the standing water between the trash and recycling receptacles. An empty cardboard carton was also observed under the front of the recycling receptacle. The Head [NAME] stated that many staff members used the dumpster area, staff frequently forgot to close the receptacle doors, and rainwater pooled under the dumpster area without draining, causing the standing water. A second observation showed that the trash receptacle door remained open, with a clear trash bag containing trash hanging out, a used glove on the ground, two collapsed cardboard boxes floating in about 3 inches of standing water between the trash and recycling receptacles, and an empty carton under the recycling receptacle. The Regional Housekeeping Supervisor reported that many staff from multiple departments used the dumpster area, that staff were continually reminded to keep the doors closed, and that the trash pick-up service often caused materials such as collapsed cardboard boxes to fall out of the receptacles. A third observation with the Dietary Manager and Administrator again found the trash receptacle door open with a clear trash bag containing trash hanging out, two collapsed cardboard boxes in about an inch of standing water next to the recycling receptacle, and an empty carton under the recycling receptacle. The Administrator stated she had not been aware of the standing water and expected all staff who took out trash to maintain the area, while the Dietary Manager indicated that the trash pick-up company dumped items out of the dumpster and did not place them back inside.

Penalty

Fine: $26,685

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

Summary

The facility failed to ensure an accurate MDS assessment for a resident in the areas of range of motion and mobility devices. The resident was admitted with diagnoses including a right tibia fracture, muscle weakness, and physical debility, and had a care plan indicating the need for assistance with ADLs and use of a mechanical lift with two staff for transfers. A Physical Therapy evaluation documented decreased bilateral lower extremity range of motion due to contractures and weakness, limited bed and wheelchair mobility, and the need for the resident’s bilateral lower extremities to be elevated on pillows and leg rests when in a wheelchair. The physical therapist confirmed that the resident’s range of motion was severely decreased and that her legs remained elevated on pillows and leg rests with wheelchair use. Despite these documented impairments and use of a wheelchair, the quarterly MDS assessment coded the resident as having no range of motion impairment in the upper or lower extremities and no use of mobility devices during the assessment period. The MDS Coordinator, who completed the assessment, later acknowledged that review of the Physical Therapy notes showed the resident did have bilateral lower extremity impairment and used a wheelchair as a mobility device, and stated that the MDS had been completed incorrectly. The Administrator also confirmed that the MDS should have been coded to accurately reflect the resident’s range of motion status and mobility device use.

Penalty

Fine: $26,685

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 properly secure and store a prescribed medication, specifically a potassium citrate capsule, for a resident who did not have an order or care plan to self-administer medications. The resident, cognitively intact and admitted with acute systolic heart failure and hypokalemia, had a physician’s order for a daily 20 mEq potassium citrate capsule. Surveyors observed a large white pill in a medication cup left on the bedside table while the resident was in bed. Review of the EMR confirmed there were no orders or assessments authorizing self-administration of medications for this resident. During interviews, the nurse assigned to administer medications that morning acknowledged she had given the resident her medications and confirmed the pill at the bedside was the potassium citrate capsule. She stated the resident preferred to take that pill later and admitted she left it at the bedside after being called away by another staff member, instead of returning it to the medication cart. The resident confirmed she did not like to take the large white pill with her other medications and that the nurse did not remove it. The NP stated the resident had never had an order to self-medicate and would not be able to self-medicate, and that medications should never be left at the bedside. The DON and Administrator both indicated the resident had no self-medication order and that the nurse should have removed the pill rather than leaving it at the bedside.

Penalty

Fine: $26,685

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 identified a deficiency in kitchen sanitation and food service practices when they observed visible dirt and grime buildup on a large fire suppression tank and its tubing located above a toaster in a food preparation area, as well as visible food debris and grease buildup in the grout lines of the floor tiles in front of the cooking range. During the initial kitchen tour with the Head Cook, it was noted that these areas were not clean, and the Head Cook reported that housekeeping was responsible for cleaning the kitchen floors but was unsure of the cleaning schedule. The Head Cook acknowledged that grease and food debris would accumulate in the floor grout and stated she was unaware of the visible dirt and grime on the fire suppression tank. These conditions were found in one of two food preparation areas and were determined to have the potential to affect food served to residents. Interviews with the Housekeeping Supervisor and the Administrator confirmed that the kitchen floors had been recently pressure washed and that a new degreasing product had been ordered due to the prior product not adequately cleaning the floors, but at the time of the survey the buildup of grime, grease, and food debris remained present in the identified areas.

Penalty

Fine: $26,685

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 staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) policy and posted instructions for use of personal protective equipment (PPE) during high-contact care activities for residents on EBP. The facility’s undated EBP policy required staff to wear gowns and gloves for high-contact resident care activities, including dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care such as urinary catheter care. For one resident on EBP with a urinary catheter, a nurse entered the room where an EBP sign was posted on the door and PPE was available behind the door. The sign indicated that both gloves and a gown were required for high-contact care such as urinary catheter care. The nurse performed urinary catheter care wearing only gloves, without donning a gown, then discarded supplies and gloves and performed hand hygiene. In a subsequent interview, the nurse acknowledged awareness that the resident was on EBP but stated she did not know a gown was required for urinary catheter care. A second deficiency occurred when a nurse aide provided high-contact care to another resident on EBP without using all required PPE. This resident’s room also had an EBP sign posted outside the door instructing staff to wear a gown and gloves for high-contact activities such as transfers and urinary catheter care, and PPE was available on the back of the door. The nurse aide applied hand sanitizer and donned gloves but did not put on a gown before assisting the resident with a stand-pivot transfer from wheelchair to bed and handling the resident’s urinary catheter bag, including moving the bag and emptying it into a urinal, then disposing of the urine and cleaning the urinal. In an interview, the nurse aide stated she was not aware the resident was on EBP, reported she did not notice the dark gray EBP sign because she was used to light blue signs with red stop signs, and stated she did not know a gown was required for transferring and providing care to residents with urinary catheters. The DON/Interim Infection Preventionist and the Administrator both stated that staff were expected to use PPE according to the EBP signs posted for each resident.

Penalty

Fine: $26,685

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 honor a cognitively intact resident’s clearly expressed preference to return to bed immediately after dialysis, despite staff awareness of this routine. The resident had chronic kidney disease stage 4 requiring hemodialysis three times weekly and type 2 diabetes mellitus, and was dependent on staff for transfers via mechanical lift. Her MDS indicated it was very important for her to choose her bedtime, and she had a dialysis care plan noting scheduled treatments on specific days. The resident reported that her dialysis days began at 2:00 AM and that she was extremely tired and ready to return to bed upon arrival back at the facility, yet she sometimes waited until after lunch to be placed back in bed. On an observed dialysis return day, the resident arrived back on the unit around 10:40 AM and activated her call light at 10:43 AM. An agency nurse aide (NA #10) entered the room at 10:45 AM, turned off the call light, and told the resident she was completing rounds and would return, but did not allow the resident to state her needs and did not request assistance from other staff. The call light remained off and the resident was not assisted back to bed at that time. The resident later reactivated her call light at 11:25 AM. Another nurse aide (NA #7) responded at 11:28 AM, turned off the call light, and informed the resident she needed another staff member to assist with the mechanical lift transfer, as two staff were normally required for such transfers. NA #7 attempted to assist the resident at 11:34 AM but had to leave to obtain help, stating she had requested assistance from another staff member. The resident reactivated her call light again at 11:40 AM. At 11:43 AM, the certified occupational therapy assistant (COTA #1) and NA #7 returned and transferred the resident back to bed with the mechanical lift without concerns. During this period, the resident reported feeling very tired and lightheaded from dialysis and stated she had been waiting over 45 minutes. Interviews with regular staff and the unit manager confirmed that staff were generally aware that the resident preferred to go to bed as soon as possible after dialysis, and that usual practice was to assist her within about 10–15 minutes. NA #10, however, as agency staff, reported not receiving a full report, was unaware of the resident’s preference, did not communicate the need to other staff, and did not return to the resident after assisting another resident, resulting in an extended delay in honoring the resident’s request to return to bed after dialysis. Additional interviews further clarified the sequence of inactions that led to the deficiency. NA #10 acknowledged that she was assigned to the resident that day for bathing and dressing, that the resident had voiced she was ready to lie down after dialysis, and that she did not notify or request assistance from other staff members despite being occupied with another resident on a different hall. She also stated she believed it was not the responsibility of other staff to address needs for residents on her assignment and that she had not received report regarding the resident’s post-dialysis preference. NA #7 and COTA #1 both confirmed that staff were aware the resident liked to go to bed upon return from dialysis and that the delay on the observed day was atypical. Facility leadership, including the unit manager, DON, and administrator, confirmed that staff were expected to respond promptly to call lights and that the resident, being alert and oriented, could clearly communicate her preferences and choices, including the request to return to bed after dialysis, which was not honored in a timely manner on the observed occasion.

Penalty

Fine: $26,685

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 bed footboards in good repair in a shared room occupied by two residents, resulting in exposed, rough particle board surfaces on both beds. During observation, one resident’s footboard was missing banding, leaving a 3–4 inch rough area of exposed particle board, while the other resident’s footboard had multiple damaged areas, each about 6 inches long, where the laminate covering was missing and particle board was exposed. Review of the facility’s online maintenance work order system over an approximately one-year period showed no documented requests for repair of these bed footboards. A nurse aide reported that the outer coating on one resident’s footboard had been missing for some time, exposing rough particle board, and confirmed that both footboards had exposed particle board, but she had not notified any staff members. An agency nurse stated she had observed damage to the outer coating of both residents’ footboards a couple of weeks earlier but assumed Maintenance was already aware and did not report it. The Maintenance Director, who had been employed since the previous April, stated he was unaware of the damage until notified by the Administrator and that staff were expected to submit work orders when beds were in disrepair. The DON and Administrator both stated they were not aware of any damage to the footboards until it was brought to their attention during the survey, despite nursing staff having access to a system to request maintenance concerns at all times.

Penalty

Fine: $26,685

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

Summary

The facility failed to provide a safe transfer for a resident using a mechanical lift, resulting in a fall. During the transfer, a frayed strap on the lift pad broke, causing the resident to fall approximately three feet to the floor, hitting her head and landing on her right side. The resident was assessed by a nurse and found to have a large hematoma on the back right side of her head and reported pain on her entire right side. The resident was transported to the emergency department for further evaluation, where CT scans and x-rays showed no fractures or acute injuries. However, the resident experienced acute respiratory insufficiency related to rib pain and/or narcotic administration while in the emergency department. The incident was attributed to the failure of the staff to inspect the lift sling for wear and tear before use, as required by the manufacturer's instructions. The nurse aides involved in the transfer did not ensure the sling was in good condition, leading to the strap breaking during the transfer. Additionally, the facility failed to secure the mechanical lift brake when transferring another resident, which could have resulted in a similar accident. These deficiencies were observed in two of the six residents reviewed for accidents. The facility's failure to adhere to safety protocols and inspect equipment before use placed residents at risk of serious injury. The incident with the mechanical lift highlighted the need for staff to follow proper procedures and ensure equipment is in good repair before use. The facility's lack of compliance with these safety measures resulted in immediate jeopardy, which was later removed after implementing corrective actions.

Removal Plan

• One on one competency assessments were completed for the two nurse aides involved in the incident by Licensed Charge Nurse with emphasis on safety procedures including how to inspect lift slings for rips, tears, and frays, and to immediately remove any slings that are defective.
• The two nurse aides demonstrated correct usage of the mechanical lift.
• In-person education was provided to all nurse aides and licensed nurses on duty by the Maintenance Director on proper lift usage and safety procedures including how to inspect lift slings for rips, tears, and frays before each use, as well as to immediately remove any slings from use if they are defective and take them to their immediate supervisor.
• The in-person training was continued for all direct care staff, including agency staff, for those not on duty the day of the incident.
• All agency staff were in-serviced during facility orientation.
• The Director of Nursing was responsible for tracking the staff that required education and for providing the education.
• Staff were not allowed to work until education was completed.
• New hires, including agency staff, are required to complete education during orientation.

Penalty

Fine: $26,685

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 accommodate the bariatric needs of two residents by not providing the correct size briefs and fitted sheets. Resident #64, who was admitted with diagnoses including cerebral infarction, obesity, and stress incontinence, reported that the facility often ran out of 2X briefs, leading staff to use smaller, uncomfortable briefs that left red marks on her thighs. Additionally, Resident #64 experienced a lack of fitted sheets for her bariatric bed, with staff citing a shortage of linens. Observations confirmed the absence of linens and towels in the supply closet, and staff interviews corroborated the ongoing issue of insufficient supplies. Resident #28, diagnosed with morbid obesity, chronic kidney disease, and amyotrophic lateral sclerosis, also faced similar issues with the facility running out of 2X briefs and having to use smaller, uncomfortable briefs. She reported that staff would hand out multiple briefs per resident as a sign of low supplies and mentioned that wipes were also in short supply. Resident #28 experienced having linen with holes and occasionally went without a fitted sheet. Staff interviews confirmed the frequent shortage of large briefs and linens, with some sheets having holes and residents sometimes going without fitted sheets. Interviews with various staff members, including nurse aides and nurses, revealed that the facility had been experiencing supply issues, particularly with bariatric briefs and linens. The supply clerk had quit four weeks prior, and staff had to ration supplies, often running out before the next shipment. The Regional Housekeeping Director mentioned that a linen cart was available for the third shift, but staff reportedly did not retrieve it. The facility administrator acknowledged the supply issues and stated that a new company had been hired to purchase briefs, and more linens had been ordered.

Penalty

Fine: $26,685

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 neglected to provide an adequate supply of linens and size 2x incontinent briefs for two residents who required bariatric goods. This deficiency was identified through record reviews, observations, and interviews with both staff and residents. The facility failed to accommodate the specific bariatric needs of these residents by using the incorrect size briefs and not providing fitted sheets, which are essential for their care and comfort.

Penalty

Fine: $26,685

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

Summary

The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least 8 consecutive hours per day, 7 days a week, as required. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Reports and the facility's daily assignment schedules. Specifically, there were multiple dates across several months in 2024 where no RN coverage was documented, including specific days in January, February, March, May, June, October, November, and December. The absence of RN coverage was confirmed by the facility's Staff Scheduler, who acknowledged the difficulty in finding replacements when scheduled RNs called out, particularly on weekends. The facility's Administrator confirmed the lack of RN coverage on the identified dates and noted that the facility had come under new ownership in December 2024. Despite efforts to hire additional nursing staff, including the use of staffing agencies, the facility was unable to provide records of RN coverage for the dates in question. The Administrator acknowledged the requirement for RN coverage and the ongoing challenges in maintaining adequate staffing levels.

Penalty

Fine: $26,685

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) assessments for two residents, leading to deficiencies in the areas of functional abilities and discharge status. Resident #76, who was admitted with a right tibia fracture, muscle weakness, and cognitive communication deficit, was documented as requiring substantial to maximal assistance with transfers in the MDS. However, staff interviews and nursing summaries indicated that the resident was totally dependent on staff and required a mechanical lift for transfers. The MDS Nurse was unable to recall if she verified the resident's transfer status with direct care staff, resulting in an inaccurate coding of the resident's dependency level. For Resident #82, the discharge MDS assessment inaccurately indicated a discharge to a general hospital, while nursing progress notes confirmed the resident was discharged home with family. The MDS Nurse attributed the error to the Social Worker, who was responsible for coding the discharge status. The Director of Nursing and the Administrator both emphasized the importance of accurate MDS coding, highlighting the discrepancies in the discharge information.

Penalty

Fine: $26,685

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 a comprehensive care plan for a resident receiving hospice services. The resident, who was admitted with chronic obstructive pulmonary disease and respiratory failure, was cognitively intact and receiving hospice care. However, upon review, it was found that there was no hospice care plan documented in the resident's comprehensive care plan. The MDS Nurse, responsible for completing the care plans, acknowledged the absence of the hospice care plan as an oversight. The Director of Nursing confirmed that the MDS Nurse was responsible for developing comprehensive care plans and was unaware of the missing hospice care plan. The Administrator also stated he was not aware of the deficiency.

Penalty

Fine: $26,685

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 obtain a physician's order for the use of supplemental oxygen for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and respiratory failure. The resident, who was cognitively intact, had been receiving oxygen therapy at a setting of 3.5 liters per minute via nasal cannula since admission. Despite the ongoing use of supplemental oxygen, a review of the resident's physician's orders revealed no documented order for this treatment. Interviews with facility staff, including a nurse, the unit manager, and the Director of Nursing (DON), confirmed that there should have been a physician's order for the resident's oxygen use. The nurse and unit manager both acknowledged the absence of the order and expressed uncertainty as to why it was missing. The DON also confirmed that an order should have been present in the resident's chart, indicating a lapse in the facility's protocol for managing oxygen therapy orders.

Penalty

Fine: $26,685

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

Summary

The facility failed to adhere to its infection control policies and procedures during wound care for a resident with a full-thickness wound. Nurse #1 did not wear a gown as required by the Enhanced Barrier Precautions (EBP) policy during high-contact care activities. Additionally, Nurse #1 did not perform hand hygiene after removing a soiled dressing, cleaning the wound, and before applying a new dressing. This deficiency was observed during wound care for a resident who required EBP due to the presence of a wound. Nurse #1, who was not the regular Wound Care Nurse, was unaware that the resident required EBP and did not notice the EBP sign at the head of the resident's bed. The Director of Nursing (DON), who also served as the Infection Control Nurse, confirmed that staff should perform hand hygiene and change gloves between each step of the wound care process. The DON acknowledged that the EBP sign was not properly placed on the resident's door, and gowns were not available outside the room, which contributed to the oversight.

Penalty

Fine: $26,685

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 record of the daily posted nurse staffing sheets for 472 out of 519 days during the period reviewed from September 1, 2023, through January 31, 2025. The deficiency was identified through record review and staff interviews, revealing that no nurse staffing information was available for each month from September 2023 through mid-December 2024. This lack of documentation was attributed to a change in facility ownership on December 16, 2024, which resulted in the loss of access to the previous records. Interviews with the Scheduler and the Administrator confirmed the absence of these records. The Scheduler, responsible for completing and maintaining the daily staffing sheets for 18 months, indicated that the change in ownership led to the unavailability of records prior to December 16, 2024. The Administrator corroborated this, stating that the records should have been maintained for 18 months but were not available due to the ownership transition.