Alaris Health At Belgrove

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 proper kitchen sanitation practices to prevent food borne illness when a cook took the temperature of Veal [NAME] without sanitizing the food thermometer before use. During the observation, the cook stated, "I forgot to sanitize the thermometer before using." The Regional Food Service Director then discarded the Veal [NAME] in the garbage. The facility policy titled "Temperature Monitoring During Meal Service" with a reviewed date of 1/2026 stated that the probe must be sanitized before and after each 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

The facility failed to ensure that specialty low air loss mattresses were accurately set and monitored according to resident weight for multiple residents. Surveyors observed several residents lying on air mattresses that were set to weights that did not match the residents’ current body weights, and in one case the mattress was in place without a physician order or documentation that it was being monitored. The facility policy stated that air mattresses are to be provided based on individual assessment and are to be ordered, monitored, and documented, with function checked every shift. Resident #3 was observed in bed on a low air loss mattress set at 180 lb, while the resident’s most recent documented weight was 102 lb. The resident had diagnoses including dysphagia, gastrostomy, and cerebral infarction, and the care plan identified a deep tissue injury pressure ulcer to the left heel with an intervention for a pressure relieving device on the bed. Resident #4 was observed with a low air loss mattress set at 100 lb, while the resident’s documented weight was 228.8 lb. This resident had diagnoses including osteomyelitis, a sacral pressure ulcer, and protein-calorie malnutrition, and the care plan identified a stage 4 sacral wound with a low air loss mattress intervention. Resident #123 was observed with the mattress set at 180 lb, while the resident’s documented weight was 78 lb. This resident had diagnoses including acute respiratory failure with hypoxia, a sacral pressure ulcer, and protein-calorie malnutrition, and the care plan identified a stage 2 pressure ulcer to the right hip with a pressure relieving device on the bed. Resident #11 was observed with the mattress set at 120 lb; the resident weighed 88 lb and had dementia, severe cognitive impairment, hospice services, and a stage 4 pressure ulcer of the left lower back. Resident #12 was observed with the mattress set at 260 lb; the resident weighed 179.2 lb and had a history of cerebral infarction, severe cognitive impairment, and a pressure-reducing device on the bed. Resident #127 was observed with the mattress set at 220 lb, with a hospital weight of 124.3 lb, and the record showed no physician order for a low air loss mattress, no monitoring on the TAR, and a care plan that did not include the mattress as an intervention. Staff, including the UM and LPNs, acknowledged that the settings were incorrect and stated that the mattress settings should have matched the residents’ weights.

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

Medication storage was found to be out of compliance in 2 of 2 medication refrigerators inspected. During an inspection of the 1st floor medication room, the surveyor observed the refrigerator thermometer reading 25 degrees F, and the 1st floor Unit Manager stated that this was too cold and should be between 36 degrees F and 46 degrees F. The Unit Manager stated they would adjust the refrigerator control. During inspection of the 2nd floor medication room, the surveyor observed the refrigerator thermometer reading 32 degrees F, and the 2nd floor Unit Manager stated that the temperature should be between 36 degrees and 46 degrees F and that they would put in a work order for the refrigerator. The Consultant Pharmacist’s regional supervisor stated that medication refrigerator temperatures were checked on 4/27/26 and were found to be in range. The survey team later met with the LNHA and DON to discuss the medication storage concerns, and the DON stated that the 1st floor medication refrigerator was adjusted and the 2nd floor medication refrigerator was replaced. The facility policy titled, Storage of Medications, did not reflect medication refrigerator temperatures.

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

Incontinence care was not provided in a timely manner for two dependent residents observed on the 3rd floor nursing unit. Resident #126 was found in bed with an incontinence brief saturated with urine, and CNA #1 confirmed the brief was saturated. The resident’s record showed diagnoses including hemiplegia and hemiparesis, a BIMS score of 15/15, and that the resident was always incontinent of bowel and bladder and dependent on staff for toileting hygiene. The care plan directed staff to offer or assist with toileting during care, before and after meals, at bedtime, and when needed. Resident #85 was also observed in bed with an incontinence brief saturated with urine, and CNA #1 confirmed the brief was saturated. The resident’s record showed a diagnosis of traumatic subdural hemorrhage, a quarterly MDS with a BIMS score of 9/15, frequent bladder incontinence, and a need for staff assistance with toileting hygiene. The care plan directed staff to offer or assist with toileting during care, before and after meals, and during activities. The LPN/UM stated the facility’s staffing regulation was 1:14 on the night shift and that the 11-7 CNAs each had 20 and 21 residents. CNA #2 and CNA #3 each stated they were responsible for 21 and 20 residents, respectively, and were unable to provide incontinence care every 2 hours as required. The DON confirmed that incontinence care should be provided every 2 hours, and the facility policy stated incontinent residents should be checked at least every 2 to 4 hours.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received proper assistance with hearing assistive devices. The resident had diagnoses including essential hypertension, overactive bladder, and dysphagia, and a quarterly MDS showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact. The care plan included an intervention for CNA staff to check that the resident had hearing aids, and the eTAR reflected an order to check hearing aids to both ears every shift, with documentation showing the hearing aids were applied on day and evening shifts from 4/2/26 through 4/26/26. During multiple observations, the surveyor did not see the resident wearing hearing aids or other hearing assistance devices. The resident was observed in the room and hallway with difficulty hearing, and when asked about the hearing aids, the resident indicated the nurse helps and later stated they were broken. The unit manager initially believed the resident put the hearing aids in independently and later stated staff probably did help and that the hearing aids should be in. The surveyor also observed the hearing aids in a case on a table, while staff documentation indicated they were being used.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the Registered Dietitian completed a nutritional reassessment in a timely manner for a resident who had been readmitted to the facility. Resident #123 was observed in bed with eyes open and noted to be confused. The resident had recently been readmitted from a short-term general hospital and had diagnoses that included acute respiratory failure with hypoxia, a sacral pressure ulcer, and protein-calorie malnutrition. Record review showed the resident’s nutrition reassessment was completed on 4/27/26 at 2:30 PM, which was 9 days after readmission. The RD stated she generally tries to complete initial and readmission assessments within 24 hours but has 72 hours to complete them, and acknowledged that the nutrition note was not completed until the ninth day after readmission. The LNHA and DON stated that initial and readmission nutrition assessments should be completed within 5 days of admission or readmission, and the facility policy titled Medical Nutrition Therapy (MNT) Documentation also stated that the initial comprehensive MNT assessment for a new or readmitted individual is generally initiated and/or completed within 5 days of admission.

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 assure that the physician responsible for supervising resident care completed monthly progress notes for Resident #6. Resident #6 was observed in bed in their room on 4/28/26, alert, oriented, and able to converse with the surveyor. The resident’s admission record listed diagnoses including bullous pemphigoid, anemia, and essential hypertension, and a quarterly MDS with an ARD of 3/29/26 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of the EMR showed that the primary physician, who was also the facility’s medical director, had not written any monthly medical progress notes in the electronic or paper chart from 8/3/25 through 4/1/26. During meetings with the LNHA and DON, the survey team informed them that the physician did not have completed progress notes in the medical record for that period, and the LNHA stated that the physician was not satisfying the regulation requirements for documentation. The facility policy titled Physician Visits and Services stated that the attending physician shall visit the resident in accordance with the resident’s needs and that progress notes and orders must be written, signed, and dated at each physician visit.

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 the required minimum direct care staff-to-resident ratios and failed to ensure sufficient and competent staff were available to provide incontinence care to dependent residents. Review of staffing reports showed repeated CNA shortages on day shifts across multiple two-week periods, including 12 of 14 day shifts in one period and 14 of 14 day shifts in another period, with the number of CNAs scheduled below the minimum required for the resident census on those dates. The staffing coordinator stated she was aware of the CNA staffing ratios and that night shift staffing was more difficult, and the DON confirmed the facility had not met the minimum CNA-to-resident ratio on the 11:00 PM to 7:00 AM shift. During an incontinence tour of the 3rd floor nursing unit, the surveyor observed two residents in bed with incontinence briefs saturated with urine. CNA #1 confirmed both briefs were saturated. The 11:00 PM to 7:00 AM CNA assignment sheet showed the 3rd floor had a census of 41 residents with only 2 aides assigned, with one CNA responsible for 20 residents and the other for 21 residents. The LPN/Unit Manager stated the expectation was that CNAs provide incontinence care every 2 hours, and both CNAs later stated they were unable to provide incontinence care every two hours because of the number of residents assigned to them. The facility policy stated that adequate staffing would be maintained on each shift to ensure resident needs and services were met, that CNAs would be available on each shift to provide needed care, and that incontinent residents would be checked at least every two to four hours. The report documented that the facility did not meet the minimum staffing requirement and that two dependent residents on the 3rd floor were found with saturated briefs during the survey observation.

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 Consultant Pharmacist failed to clarify medication routes during the monthly drug regimen review for one resident who was receiving tube feeding and was documented as NPO. The resident had diagnoses including dysphagia, gastrostomy, and cerebral infarction, and the MDS showed intact cognition with a BIMS score of 13 out of 15. The resident’s April 2026 physician orders included Mylanta Suspension ordered to be given orally every 4 hours as needed and Milk of Magnesia Suspension ordered to be given by mouth as needed, despite the resident being NPO and not consuming anything by mouth. The resident’s progress notes showed a pharmacy consultant review with no recommendations made. The Unit Manager and DON confirmed the resident was NPO and had two medication orders for milk of magnesia by mouth, and the DON stated the discrepancy should have been identified by the CP and facility staff. The DON also provided the CP report for the month, which did not mention the resident’s medication discrepancy, and the facility policy required the Consultant Pharmacy to document medication irregularities on a separate written report and notify the attending physician and DON.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that one resident received a medication that was appropriate for the resident’s diagnosis, indication, and documented effectiveness. Resident #6 was admitted with diagnoses including bullous pemphigoid, anemia, and essential hypertension, and the quarterly MDS reflected that the resident was cognitively intact and always incontinent of urine. The resident’s order summary and eMAR showed tamsulosin 0.4 mg ordered daily for BPH, even though the resident was female and the manufacturer package insert states that Flomax is indicated for BPH and is not indicated for use in women. The medical record did not contain monthly physician progress notes from the primary physician documenting a diagnosis, indication, or benefit-versus-risk discussion for tamsulosin use. The NP note referenced urinary retention, but there were no notes documenting the use of tamsulosin, its effectiveness, or that the resident was incontinent. The consultant pharmacist’s notes also did not mention off-label use or request physician documentation. During interview, the regional CP stated that supportive documentation should be requested for tamsulosin use in females, and the DON acknowledged that BPH was not appropriate for the resident. The DON later stated the resident had seen urology in the hospital and had a diagnosis of urinary retention, and that the BPH indication was missed at several levels including admission nurses, chart checks, and pharmacists.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that medications were administered without error at a rate of 5% or greater. During observation of four nurses administering medications to six residents, surveyors identified two medication administration errors out of 28 opportunities, resulting in a 7.1% error rate. The deficient practice was identified for two residents and involved two of the four nurses observed. For one resident, an RN prepared and administered a multivitamin tablet even though the active physician order was for a multivitamin-minerals tablet. When asked to compare the bottle label to the eMAR, the RN acknowledged that the medication should have been with minerals. For another resident, an RN documented a blood pressure in the eMAR for Midodrine without the surveyor observing the blood pressure being obtained at the time of administration. The RN stated the blood pressure had been taken around 7:30 AM and that the medication was being held because the blood pressure was 148, while the DON stated the blood pressure should be taken just before administration.

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

Facility staff failed to document the completion of physician-ordered treatments on the Treatment Administration Record (TAR) for three residents. Specifically, there were blank entries for the order to keep the call bell within reach every shift, as required by physician orders and facility policy. These omissions were identified during a review of the TARs for multiple months, where specific shifts lacked documentation that the call bell was within reach for each resident. The residents involved had various medical conditions, including acute pyelonephritis, depression, hypertension, chronic kidney disease, restless legs syndrome, type 2 diabetes, major depressive disorder, hyperglycemia, encephalopathy, transient ischemic attack, cerebral infarction, acute kidney failure, hyperlipidemia, and COPD. Their cognitive and functional statuses ranged from cognitively intact and independent to severely impaired and requiring assistance with activities of daily living. Despite these needs, the required documentation confirming that the call bell was within reach was not consistently completed by staff. Interviews with facility leadership, including the Administrator and Director of Nursing (DON), confirmed that staff did not sign off on the TAR as required by physician orders and facility policy. Nursing staff interviewed acknowledged that they either forgot to document or were unaware of the need to sign off, despite performing the required checks. The facility's Clinical Charting and Documentation Policy required that all services provided be documented, including the name and title of the individual providing care, but this standard was not met in the cited instances.

Penalty

Inspection fine: $25,635

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

Summary

The facility failed to provide necessary emergency tracheostomy equipment at the bedside for a resident with a tracheostomy, identified as Resident #86. During the survey, it was observed that the required emergency supplies, such as an obturator and appropriately sized inner cannulas, were not available at the resident's bedside or in the supply room. The primary nurses responsible for the care of the resident were not familiar with the obturator or its use, indicating a lack of training and awareness among the staff. Additionally, the facility did not ensure the cleanliness of oxygen concentrator filters for three residents, identified as Resident #33, Resident #44, and Resident #60. Observations revealed that the concentrator inlet filters for these residents were covered with a gray/white substance, indicating they had not been cleaned as required. The Maintenance Director, who was responsible for cleaning the filters, admitted that the filters had not been cleaned until the day of the survey, despite documentation suggesting otherwise. These deficiencies highlight a failure in the facility's processes to ensure the availability of critical medical supplies and the maintenance of equipment necessary for resident care. The lack of emergency tracheostomy equipment and unclean oxygen concentrator filters posed significant risks to the residents' health and safety.

Plan Of Correction

Resident #86 was provided with the proper emergency equipment at his bedside and nursing staff were educated and competencies were completed. Resident #86 is the only resident currently in Alaris Health at Belgrove with [R]. On 12/3/24 upon receiving notification of the Immediate Jeopardy situation, the Director of Nursing in serviced LPN3 and RN1 assigned to work 3-11 shift on the first floor where Resident #86 resides on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. Director of Nursing and/or Infection Preventionist also inserviced the LPN4 and RN2 assigned to the 1st floor for 12/3/24 11-7 shift on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. This was completed prior to start of the shift. Director of Nursing and/or Infection Preventionist repeated this process for RN3, LPN2 and RN4 assigned to the first floor on 7-3 shift 12/4/24 prior to the start of their shift. Starting on 12/4/24, this education and competency will then be completed on all nurses in the facility. Any nurse caring for Resident #86 will be inserviced prior to the start of their shift. Any nurse that is on leave or vacation will receive this education and competency on their first shift upon return. This education and competency will be incorporated in the orientation process for all new hires starting on 12/4/24. The [R] for residents #33, #44, and #60 were cleaned by the Director of Maintenance and replaced back on the [R]. All residents with tracheostomies and all residents that use oxygen supplementation via oxygen concentrators are potentially affected. Nursing Supervisor will check the supplies in Resident #86 room and any residents with tracheostomy q shift for the next 3 months to assure that all required supplies are present in the room. For Resident #86 these supplies include Tracheostomy Care Kit, Ambubag, Suction Machine, Suction Kit, Normal Saline Bottles, Sterile Water Bottles, Drain Gauze, Sterile Gauze, Inner Cannulas (#6), Tracheostomy Set for Emergency Use (includes outer cannula, inner cannula, obturator, trachea ties, size #5), Corrugated Tubing, Yankeauer Suction Catheter, Velcro Trach Ties, Suction Connecting Tubes, Aerosol Drainage Bag w/ Y-Adaptor and Straight Adaptor. Central Supply Coordinator will maintain a weekly inventory of trach supplies. Inventory will be submitted to the Director of Nursing on a weekly basis for review. Director of Nursing will instruct Central Supply Coordinator on a weekly basis of any supplies that need to be ordered. If a potential admission is identified requiring trach supplies, the Director of Nursing will identify supplies needed and assure supplies are available in building prior to admission. Director of nursing or designee will inservice nurses upon hire and annually on tracheostomy care and care of the tracheostomy in an emergency. Director of nursing or designee inserviced the maintenance department on properly cleaning oxygen concentrators filters. Policy of care of the oxygen concentrator was revised to clean filters weekly by the maintenance department. QAPI was implemented to not only address immediate rectification, but also to maintain an ongoing system to ensure proper trach care and supplies present for residents who need. Within this QAPI there will be continued education with all nurses on Trach Care, Emergency Trach Care and supplies needed. The Director of Nursing, Infection Preventionist and/or designee will conduct 5 observations per week of nurses performing trach care and reviewing emergency trach care and supplies starting 12/9/24. Any nurses noted with deviation from standard of practice will be immediately reinserviced and have a successful competency completed prior to being able to care for a resident with a trach. Maintenance director or designee will audit 5 oxygen concentrators weekly to assure they are properly cleaned. Results of these audits will be reported to the Administrator on a weekly basis for review for the next 3 months. QAPI meeting will be held on a monthly basis to ensure proper procedures regarding cleaning of the concentrator filters, trach care, emergency trach care and availability of proper supplies are in place and followed for the next 2 months and quarterly thereafter for the next year.

Removal Plan

• All nurses, including new hires, will be educated on tracheostomy care, emergency tracheostomy care, and identifying supplies needed with competency and return demonstration.
• A nursing supervisor will check the supplies in Resident #86's room to assure all required supplies are present in the room.
• Central supply will maintain inventory of tracheostomy supplies.
• The DON will assure tracheostomy supplies are available prior to admission.

Penalty

Inspection fine: $25,635

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 meet the delayed egress locking requirements as specified in the NFPA 101 Life Safety Code (2012 Edition). During an observation, it was noted that an exit door between rooms 101 and 118 did not sound an audible alarm after 15 seconds of pressure was applied, as required. The signage on the door indicated that the locks would unlock after 15 seconds and an alarm would sound, but this did not occur. This deficiency had the potential to affect staff and 12 residents. During an interview conducted at the time of the observation, a staff member confirmed the finding and stated that the facility was unaware that the delayed egress lock was not functioning properly.

Plan Of Correction

The delayed egress door for exit between rooms 101 and 118 was repaired to initiate an audible alarm after 15 seconds of pressure is applied to the door. All residents have the potential to be affected by this deficient practice. The Maintenance Director checked all delayed egress doors in the building to assure all had audible alarm after 15 seconds of pressure is applied to the door. All doors were found to be in working order. The Maintenance Director will make monthly rounds to ensure all delayed egress door initiates an audible alarm after 15 seconds of pressure is applied to the door. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.

Penalty

Inspection fine: $25,635

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 the fire resistance rating of stairwells as required by the NFPA 101 Life Safety Code. During an observation, a door opening into a five-story stairwell was found to lack the necessary latching fire exit hardware. Instead, the door was secured closed by a magnetic locking device. This deficiency was identified during an observation and interview, where it was confirmed that the facility was unaware of the requirement for latching hardware to secure the door in the frame. The magnetic locking device was designed to release upon activation of the fire alarm, allowing the door to swing freely into the exit stairwell. This issue had the potential to affect 40 residents.

Plan Of Correction

The proper latching fire exit hardware was installed on the stairwell lower-level annex door. All residents have the potential to be affected. The Maintenance Director audited all stairwell exit doors to assure they had a proper latching fire exit hardware. All other stairwell doors were found with proper latching hardware. The Maintenance Director will make monthly rounds to ensure the proper latching fire exit hardware is installed on all doors. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.

Penalty

Inspection fine: $25,635

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 smoke detectors and heat detectors in accordance with NFPA 101, NFPA 70, and NFPA 72 standards. During an observation, it was found that the smoke detector and heat detector in the elevator equipment room were not securely attached to their device bases and were hanging from the wires. This deficiency was identified during an observation on December 3rd, 2024, at 11:45 AM. The issue had the potential to affect 120 residents. During an interview at the time of the observation, the responsible individual was not aware of the deficient installation.

Plan Of Correction

The smoke detector and heat detector devices were secured to the device base in the elevator equipment room. All residents have the potential to be affected. The Maintenance Director audited all smoke and heat detector devices in the building to assure they were secured to the device base. No additional issues were identified. The Maintenance Director will make monthly rounds to ensure all smoke and heat detector devices are properly secured to the device base. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.

Penalty

Inspection fine: $25,635

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 sprinkler system was electronically supervised in accordance with NFPA 101, 2012 Edition, Section 19.3.5.1 and section 9.7. During an observation, it was found that the domestic and sprinkler riser water line shared the same main water line from the city. The sprinkler system's water line had two unsupervised outside screw and yoke (OS&Y) valves. Without supervisory devices on these OS&Y valves, the nursing home staff would not be alerted if the sprinkler system was impaired, such as if the water flow was cut off. This deficiency had the potential to affect 88 residents. The main water riser room for both the nursing home and corporate offices was located in a corporate office storage room. During an interview, it was confirmed that the unsupervised OS&Y valves were on the water line for the facility's sprinkler system.

Plan Of Correction

Two tamper switches and two fire sprinkler control valve signs on the OS&Y valves coming from the street were installed. All residents have the potential to be affected. The Maintenance Director will make monthly rounds to ensure all the automatic sprinkler system supervisory attachments are properly installed. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.

Penalty

Inspection fine: $25,635

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 residents and their representatives with written transfer or discharge notices that included the option to appeal the transfer or discharge. This deficiency was identified for nine residents who were transferred to hospitals for various medical reasons, such as dehydration, urinary tract infections, and altered mental status. The notices provided to these residents did not contain essential appeal information, including the contact name, telephone number, or address of the entity to which appeals could be directed. The review of the facility's documentation revealed that the Notice of Emergency Transfer forms lacked the necessary details about the residents' rights to appeal the transfer decisions. For instance, the forms did not include the name, address, and telephone number of the entity that receives appeal requests, nor did they provide information on how to obtain and complete an appeal form. This omission was consistent across all reviewed cases, indicating a systemic issue in the facility's discharge process. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that the current forms used for discharge notices did not include the required appeal rights information. The staff believed that the facility was compliant with regulations because residents were given the bed hold policy upon admission and were always allowed to return to the facility. However, the forms used were not in alignment with the guidance provided by the New Jersey Department of Health, which mandates the inclusion of specific contact information for appeal processes.

Plan Of Correction

1/7/25 The Emergency [R] Notice letter was updated to include the appeal information required before NJ Ex Order 26.4(b)(1). Residents R21, R27, R75, R9, R60, R69, R71, R91, R86 were previously provided an Emergency Letter of [R] prior to their discharge. All residents have returned from their NJ Ex Order 26.4(b)(1) stay. All residents discharged/transferred to the hospital have the potential to be affected. The Emergency [R] Notice letter was revised by the Administrator to include more detailed appeal information. The Administrator inserviced the [R] and all facility social workers on the regulatory requirements for the appeal information for Emergency Transfer Notification (ETN) to the resident, the resident's representative and the NJ Long Term Care Ombudsman's office. The Social Service Director will submit the Emergency Transfer Notifications to the Administrator on a monthly basis to assure the appeal information is in the letter. Administrator will audit this on a monthly basis. The Director of Social Services will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.

Penalty

Inspection fine: $25,635

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 residents and their representatives with a written bed hold notice that included the cost per day information, which is necessary for informed consent. This deficiency was identified for nine residents who were transferred to a hospital for various medical reasons, such as severe lethargy, low blood sugar, altered mental status, and respiratory distress. The bed hold notices issued to these residents or their representatives only indicated the length of the bed hold but omitted the daily cost, which is a requirement under Medicaid guidelines. The facility's policy on temporary discharge and bed hold did not specify the daily rate or cost per day for holding a resident's bed during their absence. This omission was consistent across multiple documents, including the facility's Temporary Discharge (Bed-Hold) policy and the Admission Agreement. The lack of this critical information in the bed hold notices and facility policies meant that residents and their representatives were not fully informed about the financial implications of holding a bed during a hospital transfer. During an interview, the facility's Administrator and President of Operations acknowledged that the bed hold notices did not include the reserve bed payment policy. They believed that since residents were given the bed hold policy upon admission and were always allowed to return to the facility, the omission was justified. However, this belief did not align with the regulatory requirements, which mandate that the cost per day must be clearly communicated to ensure informed consent.

Plan Of Correction

Bed hold letter was revised reflecting cost for services for future issued bed hold letters. No corrective measures were done for residents R21, R27, R75, R9, R60, R69, R71, R91, and R86 as residents were issued bed hold letters and have already returned to the facility from their acute care stay. All residents issued bed hold letters have the potential to be affected. U.S. FOIA (b) (6) was in serviced by Administrator on the revised bed hold letter that now includes the bed hold cost. Director of Admission will present all future acute discharged residents and/or responsible parties with the revised bed hold letter. The Administrator will audit 5 residents weekly to ensure the revised letter reflecting bed hold cost was issued. Director of Admissions or designee will review all issued bed hold letters weekly for 3 months then monthly. Results of these audits will be provided to the Administrator on a monthly basis. All findings will be reported and reviewed monthly and reported quarterly during the QAPI meeting for the next 2 quarters by Director of Admission or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.

Penalty

Inspection fine: $25,635

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

Summary

The facility failed to ensure that residents had the cognitive ability to understand and sign binding arbitration agreements. This deficiency was identified for four residents who were assessed to have severely impaired cognition, as indicated by their Brief Interview for Mental Status (BIMS) scores. Resident 71 had a BIMS score of six, while Residents 84, 75, and 44 each had a BIMS score of one, all indicating severe cognitive impairment. Despite this, these residents signed arbitration agreements without the necessary cognitive capacity to understand the terms. In the case of Resident 71, the resident's niece was present during the signing but did not have power of attorney. The niece understood the agreement but chose not to sign it herself, allowing the resident to sign instead. For Resident 84, the Admissions Coordinator communicated with the resident's grandson over the phone, who explained the agreement in Spanish to the resident. However, the Admissions Coordinator could not verify the resident's understanding due to the language barrier. Resident 75's daughter, who did not have power of attorney, explained the agreement to her mother in Spanish and permitted her to sign it. Resident 44, who had no legal representative or family, signed the agreement after a friend, contacted by phone, gave verbal consent. Interviews with the Admissions Director and Admissions Coordinator confirmed that these residents lacked the cognitive ability to comprehend the agreements they signed. The facility's Administrator acknowledged that it was unacceptable for residents to sign arbitration agreements without understanding them and stated that such instances should be considered refusals if the resident or their representative did not wish to sign.

Plan Of Correction

1/7/25 The [R] Agreements for R71, R84, R75 and R44 were rescinded. A facility wide audit was completed on all signed [R] Agreements in comparison to Brief Interview for Mental Status (BIMS) Assessment score and were corrected. All residents have the potential to be affected by this deficient practice. The Administrator inserviced the Admissions Department on the proper procedure for conducting Arbitration Agreements in accordance to their Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will audit 3 new admissions per month for accurate Arbitration Agreements signature in accordance to Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will report the results of these audits to the Administrator on a monthly basis. The Minimum Data Set (MDS) Coordinator will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.

Penalty

Inspection fine: $25,635

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 functional Antibiotic Stewardship Program that adhered to the McGeer criteria for antibiotic usage over a four-month period. During this time, the facility did not adequately document whether infections met the criteria for appropriate antibiotic treatment. Specifically, in January 2024, only one McGeer surveillance form was completed despite 36 facility-acquired infections being documented. In February, no McGeer forms were filled out for 24 documented infections. Similarly, in March, no forms were completed for 18 infections, and in April, only two forms were filled out for 23 infections. This lack of documentation meant that it was unclear if the infections met the criteria for antibiotic treatment. Interviews with facility staff revealed that the unit managers were responsible for completing the McGeer criteria forms for each facility-acquired infection. However, the Infection Preventionist (IP) nurse noted that these forms were not submitted regularly during the months in question. The Director of Nursing (DON) expected the unit managers to complete and forward these forms to the IP nurse for review. The facility's policy on Antibiotic Stewardship emphasized the importance of appropriate antibiotic use to prevent drug-resistant bacteria, increased hospitalizations, higher mortality, and escalating costs. Despite this policy, the facility's failure to document and review infections according to the McGeer criteria potentially led to unnecessary antibiotic prescriptions.

Plan Of Correction

No residents were identified to be affected by the deficient practice. All residents have the potential to be affected by the deficient practice. All nurses and the Infection Preventionist nurse were in-serviced by the Director of Nursing on completing and submitting the Revised McGeer Criteria for Infection Surveillance Checklist. A Revised McGeer Criteria for Infection Surveillance Checklist is to be completed for each facility acquired infection by unit managers or designee. The Infection Preventionist nurse will ensure a Revised McGeer Criteria for Infection Surveillance Checklist is collected and reviewed for each facility acquired infection. The Director of Nursing will audit the Antibiotic Stewardship Program monthly to ensure a Revised McGeer Criteria for Infection Surveillance Checklist is completed for each facility acquired infection. Results of these audits will be reported to the Administrator on a monthly basis. All findings will be reported and reviewed monthly and reported quarterly during the QAPI meeting for the next 2 quarters by the DON or designee to the QAPI committee. Evaluation by the committee will determine the continuing frequency of audits.

Penalty

Inspection fine: $25,635

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 resident's advanced directive in the medical record after the resident decided to change it from full code to a do not resuscitate (DNR) status. This deficiency was identified for one of nine residents reviewed for advanced directives. The resident, who had a moderately impaired cognitive status, expressed their wish not to be resuscitated if found without vital signs. However, the electronic medical record (EMR) and the paper chart continued to reflect a full code status, contrary to the resident's documented wishes on the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Social Service Director (SSD), revealed discrepancies between the resident's documented wishes and the information in the medical records. The SSD and the Administrator acknowledged that the resident's POLST form, signed by both the resident and their physician, indicated a DNR status, but the EMR and paper chart were not updated accordingly. This oversight had the potential to result in the resident receiving unwanted cardiopulmonary resuscitation (CPR).

Plan Of Correction

1/7/25 Resident #66 medical records were immediately updated to reflect NEX Ord order. All residents with Advance Directives could have the potential to be affected. U.S. FOIA (b) (6) and licensed nursing staff were in-serviced by Administrator or designee on updating Medical Records and Physician Orders with any changes with Advance Directives/POLST. Director of Social Services will present Advance Directive/POLST updates to the team during Morning meeting on a daily basis, and nursing will ensure orders are updated accordingly. Director Of Nursing will conduct audits on a sample of 10 residents per month to ensure that medical records reflect the most updated Advance Directive orders. Director of Social Services or designee will review all resident medical records to ensure Advance Directives are updated weekly for 3 months, then monthly thereafter. Results of these audits will be provided to the Administrator on a monthly basis. Director of Nursing and Director of Social Services will report results of all audits at the quarterly QAPI meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.

Penalty

Inspection fine: $25,635

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 written copy of the baseline care plan to a resident and/or their responsible party within 48 hours of admission, as required by their policy. This deficiency was identified for one resident, who was admitted with multiple diagnoses including diabetes mellitus, metabolic encephalopathy, obstructive and reflux uropathy, and dementia. The resident's care plan was completed within the required timeframe, addressing various risks and needs, but the written summary was not provided to the resident or their family member. Interviews with facility staff revealed that the Social Services Director did not document the provision of the baseline care plan to residents or their representatives. The Director of Nursing confirmed the expectation that a written summary should be given within 48 hours of admission. The facility's policy mandates the development of a baseline care plan within 48 hours and the provision of a written summary to the resident and/or their representative, which was not adhered to in this case.

Plan Of Correction

A written summary of the baseline care plan was provided to R203 and [R] representative. All residents have the ability to be affected by this practice. The Administrator inserviced the Interdisciplinary Team members to provide a written summary of the baseline care plan to the resident or resident representative within 48 hours of admission to the facility. The MDS Coordinator will audit 5 admissions per month to ensure a written summary of the baseline care plan was provided to the resident or resident representative. Results of these audits will be provided to the Administrator on a monthly basis. The MDS Coordinator will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.

Penalty

Inspection fine: $25,635

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 care plan with resident-specific goals and interventions for the use of antipsychotic medications for one resident. This resident, identified as R69, was admitted with diagnoses including hallucinations and schizoaffective disorder and had an order for Quetiapine Fumarate, an antipsychotic medication. Despite the presence of a Care Area Assessment trigger for psychotropic medication use, the care plan did not include specific goals or interventions related to the use of these medications. During an interview, the MDS Coordinator acknowledged that the care plan for R69 was not updated with the necessary goals and interventions for psychotropic medications. The facility's policy requires that the use of psychotropic medications be reflected in the resident's care plan with measurable objectives. However, the MDS Coordinator mistakenly believed that a goal related to behaviors was sufficient, as the medication was ordered due to behaviors. This oversight was contrary to the facility's policy, which mandates a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident.

Plan Of Correction

The care plan for resident #69 for [R] use was implemented. Unit managers on each unit reviewed all residents on antipsychotic medication to ensure care plans are in place. Those that did not have were implemented. All residents on antipsychotic medication are potentially affected. Director of Nursing inserviced unit managers on care planning all residents with orders for antipsychotic medication. Unit managers or designee will review new admission charts daily for antipsychotic medication and will review residents with new or changes in antipsychotic orders and will implement the care plan. Director of Nursing or designee will review 5 residents on antipsychotic medication weekly to assure care plan is in place and will report all findings to Administrator on a monthly basis. All findings will be reported quarterly during the QAPI meeting for the next 2 quarters by Director of Nursing or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.

Penalty

Inspection fine: $25,635

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 store medications, as evidenced by the presence of loose tablets and capsules in the medication carts for the 300 hall rooms. During an observation, surveyors found four loose tablets and one loose capsule in one medication cart, and ten and a half loose tablets in another cart. These medications were unsecured and not properly accounted for, increasing the potential for drug diversion. Licensed Practical Nurses (LPNs) 5 and 7 were responsible for destroying the unsecured medications using the drug buster solution, but they were unable to determine the ownership of the medications. Interviews with LPN5, LPN7, and the Director of Nurses (DON) revealed that it was the responsibility of all nurses to ensure medication carts were clean and that any loose pills should be disposed of in the drug buster solution. The facility's policy on the disposal and destruction of medication indicated that non-controlled medications, which are expired, refused, or adulterated, should be destroyed by nurses without the need for a second nurse. The policy also outlined the procedure for disposing of unused medications during medication pass. However, the presence of loose medications in the carts indicated a failure to adhere to these procedures.

Plan Of Correction

No residents were affected by this deficient practice. All loose medication were disposed of properly. LPN5 and LPN7 were unable to determine who the medications belonged. Both nurses were inserviced on proper handling of medication cards and the responsibility of keeping their medication carts clean and free of loose medications. All residents with medication orders are potentially affected. Director of Nursing or designee inserviced all nurses on the responsibility of maintaining cleanliness of the medication cart and proper disposal of medication. Inservice will be completed upon hire and annually thereafter. All nurses are to check assigned medication cart on their shift. The unit manager or designee will check med carts once per week to assure compliance with proper medication storage. Unit Managers will check med carts once per week to assure compliance with proper medication storage. The findings of these audits will be reported to the Director of Nursing on a monthly basis. All monthly audits will be reported quarterly during the QAPI meeting for the next 2 quarters by Director of nursing or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.

Penalty

Inspection fine: $25,635

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 Enhanced Barrier Precautions (EBP) for a resident receiving dialysis, which could lead to cross-contamination among vulnerable residents. The resident, identified as R12, was admitted with end-stage renal disease and was receiving dialysis. Despite the resident's care plan and physician orders indicating the need for monitoring and reporting signs of infection, there was no order for EBP, and no signage or personal protective equipment (PPE) was available outside the resident's room. Observations and interviews revealed that staff did not use gowns when providing care to R12, and there was a lack of understanding among staff about the necessity of EBP for dialysis patients. The Director of Nursing and other staff members believed that EBP was not required according to CDC guidelines, despite the facility's policy indicating that residents with indwelling medical devices should be under EBP. This oversight in implementing EBP for R12, who had a dialysis shunt accessed multiple times a week, was a deficiency in infection prevention and control measures.

Plan Of Correction

NJ Ex Order 26.4(b)(1) per facility policy was initiated on 12/5/24 for Resident 12. All dialysis residents with access sites are potentially affected. All staff were inserviced by Infection Preventionist Nurse to ensure all dialysis residents with access sites have enhanced barrier precautions per facility policy. All dialysis residents with access sites will be placed on enhanced barrier precautions per facility policy. Unit Manager and/or designee will be responsible to assure residents with dialysis access sites are identified and have physicians order for enhanced barrier precautions on admission and with status changes. Infection Preventionist and/or designee will make rounds weekly on dialysis patients to assure compliance with enhanced barrier precautions. Results of these audits will be reported to the Administrator on a monthly basis. The Infection Preventionist will report the results of these audits quarterly during the QAPI meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.