Laurel Brook Rehabilitation And Healthcare Center

Penalty

No penalty information released

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

Summary

A deficiency occurred when a housekeeping staff member was observed verbally and physically abusing a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified dementia, depression, and a history of falls, was totally dependent on staff for activities of daily living. On the date of the incident, an activity department employee witnessed the housekeeping staff yelling at the resident and kicking them in an attempt to get the resident to return to their room. The activity staff immediately intervened, instructing the housekeeping staff to stop, and reported the incident to supervisory staff and the administrator. The resident was later assessed and found to have no new injuries or signs of distress, and was unable to recall the event due to cognitive impairment. The facility's investigation included staff interviews and a review of the incident, but was unable to corroborate the allegation through additional witnesses or resident recall. However, the activity staff's account was consistent, and the facility administrator acknowledged that the abuse was substantiated. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention was not followed by the housekeeping staff, as confirmed by the administrator. The expectation, as outlined in the policy, is for all staff to protect residents from abuse by anyone, including facility staff.

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 conduct a thorough investigation into an allegation of verbal abuse involving one resident. The incident began when a resident's representative expressed concerns about rough handling and rude behavior by staff during a room transfer. Documentation showed that a grievance was filed and a care conference was held to discuss the concerns, but there was no evidence that the facility initiated or documented an investigation into the alleged verbal abuse. The facility's own policies require that all grievances and allegations of abuse be reviewed and investigated, with findings documented in a timely manner. Interviews with facility leadership confirmed that no investigation was conducted regarding the grievance about staff rudeness, and the current Director of Nursing and Licensed Nursing Home Administrator were unable to explain why, as they were not employed at the facility at the time. The facility's policies on grievances and incident investigations outline specific steps for prompt review and documentation, but these procedures were not followed in this case. The lack of an investigation was confirmed through review of facility records and direct questioning of staff.

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 adhere to proper hand hygiene protocols during a wound care treatment for a resident, as observed by a surveyor. The resident, who was cognitively intact, had a sacral wound and was receiving treatment as per physician's orders. During the treatment, the LPN did not wash her hands with soap and water before putting on gloves, nor did she perform hand hygiene after removing the resident's soiled dressing. Instead, she continued the wound care with contaminated gloves, which was against the facility's policy and CDC guidelines. The UM/LPN and the DON confirmed the surveyor's observations that the LPN did not follow the facility's hand hygiene and wound care policies. The Infection Preventionist also stated that the LPN should have performed hand hygiene before and during the wound care treatment to prevent potential infection. The facility's policies clearly outlined the steps for hand hygiene and wound care, which were not followed in this instance, leading to the deficiency.

Plan Of Correction

1. Resident #1 still resides at the facility. NJ Exec Order 26.4b1 has resulted in the deficient practice. 2. All residents have the potential to be affected by this deficient practice. 3. The Infection Preventionist re-educated all licensed nurses on the facility infection prevention policy to include but not limited to performing hand hygiene before preparing and administering wound treatments/dressing changes. Resident #1 was reviewed by the licensed nurse with NJ Exec Order 26.4b1 noted. The Infection Preventionist re-educated LPN #1 on the facility infection prevention policy to include but not limited to performing hand hygiene before preparing and NJ Exec Order 26.4b1 of any care treatment. An audit was completed during wound treatments with dressing changes to determine if nurses were following proper infection control and hand hygiene. No further variances were noted. 4. The Infection Preventionist/designee will audit during wound treatments/dressing changes to determine if nurses were following proper infection control and hand hygiene protocols. Variances will be addressed. These audits will be conducted weekly x 4 weeks, then monthly x 2 months. The findings of the audits will be submitted by the Infection Preventionist to the QAPI Committee for review and recommendation monthly for 3 months or ongoing until compliance is sustained.

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 notify a resident's physician when multiple ordered medications were unavailable and not administered. The resident, who had diagnoses including aftercare following joint replacement, atrial fibrillation, and anxiety, had intact cognition as indicated by a BIMS score of 14 out of 15. On two consecutive days, several of the resident's prescribed medications, including Cartia XT, Azathioprine, Azelastine HCl, and Sotalol HCl, were not administered due to unavailability. The Medication Administration Record (MAR) reflected that these medications were not given, and progress notes indicated the facility was awaiting pharmacy delivery. However, there was no documentation that the resident's physician was notified about the unavailability of these medications. Interviews with the DON and an RN confirmed that facility policy required nursing staff to notify the physician when medications were unavailable, document the notification, and attempt to obtain the medications from the pharmacy or the facility's automated dispensing system. Despite these requirements, there was no evidence in the resident's medical record that the physician was informed of the missed doses or the circumstances surrounding the unavailable medications. This lack of notification and documentation was contrary to both facility policy and regulatory requirements.

Penalty

Fine: $48,350

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

Summary

The facility failed to implement its smoking policy effectively, leading to a situation where a resident was smoking in their room, creating potential hazards. Resident #144, who had a history of smoking in their room, was observed by a surveyor with a cigarette-like smoke scent in their room. The resident admitted to smoking in their room due to delays in staff assistance to go outside, despite being aware of the facility's no-smoking policy indoors. The resident had been previously reported for smoking in their room on multiple occasions, and interventions were noted in their care plan, but these were not effectively enforced. The facility's staff, including CNAs and the DON, were aware of the resident's smoking behavior but failed to take consistent action to prevent it. Reports of cigarette smoke in the resident's room were made by staff and visitors, yet the resident continued to have access to smoking materials. The facility's policy required smoking materials to be stored at the front desk for supervised smokers, but this was not consistently followed, allowing the resident to smoke unsupervised in their room. Additionally, the facility did not complete a timely smoking evaluation for another resident, Resident #191, who was identified as a smoker only after the surveyor's inquiry. The resident was found with matches and cigarettes, which were against the facility's policy. The lack of a smoking assessment upon admission and the failure to update the resident's care plan to reflect their smoking status contributed to the oversight. This deficiency highlights the facility's inadequate monitoring and enforcement of its smoking policy, posing safety risks to residents.

Removal Plan

• The resident was placed on one-to-one (1:1) supervision
• The resident was re-educated on the facility's smoking policy and relinquished their smoking materials
• A smoking evaluation was completed
• The facility will conduct routine safety rounds in Resident #144's room
• The ICCP was updated

Penalty

Fine: $48,350

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 safe, sanitary, and homelike environment across all five resident units, as evidenced by multiple observations of unclean and poorly maintained equipment and living areas. On the East Unit, an air conditioner unit was found with black discolorations and dust accumulation, and the Licensed Nursing Home Administrator acknowledged that housekeeping and maintenance should ensure weekly cleaning. On the North 2 Unit, several rooms had dust on air conditioner units, peeling paint on bathroom doors, and an uncovered mattress with visible red spots. The Maintenance Director was unaware of any maintenance orders for the peeling paint, and the Director of Housekeeping stated that floor mats and mattresses should be cleaned. On the North 1 Unit, yellow tape was observed on the hallway floor, and a strip of flooring was partially raised. A resident's room had a hardened brown substance on the floor, which remained uncleaned for several days despite the resident's complaint. The Director of Housekeeping and the Regional Director of Housekeeping stated that resident rooms were cleaned daily, but the hardened substance was not addressed. In the Central Unit, a room had a hole in the ceiling covered with plastic and tape, and a resident reported that it had been in that condition since early in the year. The Maintenance Director stated that repairs should have been made immediately, and the Director of Housekeeping noted that air conditioner vents should be cleaned daily. On the [NAME] Unit, an IV pole had hardened spillage and dust, and several geri-chairs had debris and tears. The Director of Nursing stated that both nursing and housekeeping were responsible for cleaning equipment, but there was uncertainty about cleaning schedules. The Maintenance Director and Director of Housekeeping acknowledged that air conditioning units should be cleaned to prevent health issues, but there was no official documentation for environmental rounds. The facility's policies on cleaning and maintenance were not consistently followed, leading to the observed deficiencies.

Penalty

Fine: $48,350

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 handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed in the kitchen and five refrigerators designated for resident food. During a tour of the kitchen, the surveyor, accompanied by the Food Service Director (FSD), found two sealed bags of cooked rice with expired use-by dates in the Korean Refrigerator, which were subsequently discarded by the FSD. In the East unit pantry, the surveyor and a Registered Nurse/Unit Manager (RN/UM) discovered multiple single-serving containers of cranberry cocktail juice, apple juice, and orange juice with expired use-by dates, as well as undated containers of fat-free lactose-free milk. Additionally, two blue reusable tote bags containing unlabeled, undated food were found, with one leaking a sticky liquid. The RN/UM was unsure who was responsible for maintaining the unit pantry. Further observations in the Central unit revealed the absence of a thermometer and temperature log in the refrigerator, along with unlabeled, undated plastic beverage cups and expired yogurt and parfait. LPN #2, who was present, stated she would discard the expired items but was uncertain about who was responsible for maintaining the refrigerator. In the [NAME] Unit pantry, the refrigerator temperature was found to be 22 degrees Fahrenheit, and a frozen nutritional supplement was discovered. LPN/UM #2 removed the supplement and other undated items, stating that nurses were responsible for maintaining the unit pantry and refrigerator temperatures. In the North 2 unit pantry, expired milk was found and discarded by LPN/UM #3, who stated that housekeeping maintained the unit pantry while nursing staff monitored refrigerator temperatures. In the North 1 unit pantry, two sealed cheese sticks without use-by dates and unlabeled, undated plastic beverage cups were found, with LPN/UM #1 stating the items belonged to staff. Interviews with the FSD and the Licensed Nursing Home Administrator (LNHA) revealed expectations that nursing staff should check unit pantries for expired food and monitor refrigerator temperatures, while dietary staff should inspect kitchen food items. The facility's policies on refrigerator maintenance and food brought by family/visitors were reviewed, highlighting the need for proper labeling and monitoring of food items.

Penalty

Fine: $48,350

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's Licensed Nursing Home Administrator (LNHA) failed to ensure that staff implemented policies and procedures to provide residents with care and services to achieve their highest practical well-being and maintain a safe, sanitary, and homelike environment. This deficiency was observed across all five nursing units. One resident was found smoking in their room due to delays in staff assistance, despite being assessed as an independent smoker. The facility's Director of Nursing (DON) acknowledged the resident's smoking in their room, and the Medical Doctor (MD) expressed concerns about the resident's smoking habits. The facility also failed to maintain a clean and safe environment, as evidenced by unclean floor mats, mattresses, and air conditioning units with thick dust coatings, which could pose health risks to residents with respiratory issues. The Director of Housekeeping (DHK) admitted that the air conditioning units were not cleaned as required, and the LNHA acknowledged that housekeeping and maintenance should ensure regular cleaning. Additionally, the facility did not handle potentially hazardous foods safely, as expired food was found in unit pantries, and personal food was stored in refrigerators designated for resident food. The Food Service Director (FSD) stated that nursing staff should monitor refrigerator temperatures and check for expired food. Furthermore, the facility failed to complete a required level II PASARR for a resident with a positive screening for intellectual or developmental disabilities. The LNHA acknowledged that the level II PASARR should have been completed before admitting the resident.

Penalty

Fine: $48,350

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 complete a Preadmission Screening and Resident Review (PASARR) for a resident with diagnoses of intellectual disability, schizophrenia, and generalized anxiety. The PASARR Level I Screening Tool indicated a positive screening for intellectual disability, requiring a Level II PASARR evaluation. However, the screening outcome was incorrectly marked as negative, and there was no evidence of a completed Level II PASARR in the electronic medical record (EMR). Interviews with the social worker (SW) and the Director of Social Work (DSW) revealed confusion and errors in the PASARR documentation process. The DSW acknowledged that the Level I PASARR was initially uploaded incorrectly and later corrected to reflect a positive screening. Despite this correction, the Level II PASARR had not been completed, and the DSW was unsure of the timeline for its completion. The DSW stated that the full Level II application would be completed by a psychiatrist on a future date, indicating a delay in the process. The Licensed Nursing Home Administrator (LNHA) confirmed that the expectation was for the Level II PASARR to be completed before admitting the resident. The facility's policy required a referral to the state PASARR representative for a Level II evaluation if the Level I screen indicated potential mental disorder or intellectual disability. The failure to complete the Level II PASARR prior to the surveyor's inquiry was acknowledged by the LNHA and other facility leaders.

Penalty

Fine: $48,350

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

Summary

The facility failed to revise the individualized comprehensive care plans (ICCP) related to smoking for three residents, leading to deficiencies in their care. Resident #102 was observed with cigarettes and a lighter on the patio table, indicating a lack of adherence to the care plan, which stated that the facility would store these items for safety. Despite the resident's intact cognition, the care plan was not updated to reflect the resident's current practice of keeping smoking materials in their room and not using a smoking apron. Resident #198 was observed smoking outside and keeping smoking materials in their room, contrary to the care plan's conflicting interventions. The ICCP included contradictory instructions about whether the resident or the facility should store smoking materials. Interviews with staff revealed confusion about the resident's smoking material storage, highlighting a lack of clarity and consistency in the care plan documentation. Resident #73, with severely impaired cognition, had a care plan with conflicting interventions regarding smoking material storage. The resident's ICCP was not updated to reflect the actual practice of storing cigarettes and lighters in the medication cart. Staff interviews indicated a lack of awareness about the resident's smoking material storage, and the care plan was only revised after the surveyor's inquiry. The facility's policy required ongoing assessments and care plan revisions, which were not adequately followed.

Penalty

Fine: $48,350

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 gradual dose reductions (GDR) and non-pharmacological interventions for psychotropic medications, as well as ensure proper monitoring and documentation for residents receiving these medications. For Resident #17, despite recommendations from a psychiatric evaluation to stop bupropion and olanzapine due to reported hallucinations, the nurse practitioner did not address these recommendations, and the medications continued to be administered. The resident's care plan included consulting with a physician for dosage reduction, but this was not followed through, and there was no evidence of behavior monitoring. Resident #167 had a PRN order for Lorazepam without a specified duration, contrary to the CMS 14-day rule, which requires reassessment and documentation for continued use. The facility's Director of Nursing acknowledged that PRN orders should be time-limited and documented, but this was not done. Additionally, there was no evidence of behavior monitoring for the resident, despite being on Quetiapine for mood disorder. Resident #358 was on multiple psychotropic medications, including Xanax, without a stop date, and there was no behavior monitoring documented. The facility's staff confirmed that behavior monitoring was not conducted for residents on long-term psychotropic medications unless there was a change in behavior. Similar issues were observed with Resident #40, who was on Xanax and Zoloft without behavior monitoring, and Resident #109, who had no behavior monitoring documented until after the surveyor's inquiry.

Penalty

Fine: $48,350

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 dental care services in a timely manner for a resident who had lost their bottom denture a year prior. The resident, who was on a mechanical soft diet due to difficulty swallowing, reported the loss of the denture to the Social Worker, but no replacement was provided. The resident's care plan included coordinating dental care, but there was no follow-up on the grievance filed regarding the missing denture. The Social Worker filed a grievance in the portal, which was supposed to be routed to housekeeping, laundry, and the business office. However, there was no documentation of follow-up actions, and the grievance was not found in the system by the Business Office Manager. The Director of Social Services acknowledged that the delay could have been prevented with proper follow-up, but there was no evidence of such actions being taken. Interviews with various staff members, including the Business Office Manager, Regional Director of Operations, and Director of Nursing, revealed a lack of communication and follow-up on the grievance. The grievance process was not completed, and the resident's dental needs were not addressed until after the surveyor's inquiry, highlighting a lapse in the facility's grievance handling and dental care coordination.

Penalty

Fine: $48,350

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 timely report an allegation of staff-to-resident abuse involving a resident who was fully cognitively intact and had a history of chronic kidney disease, major depressive disorder, heart failure, hypertension, pleural effusion, and traumatic subarachnoid hemorrhage. The resident expressed distress over an interaction with a Nurse Practitioner (NP) who allegedly told them they would die if they did not take their potassium medication. The resident preferred a natural approach to treatment and was upset about the discontinuation of their diuretics, fearing fluid buildup. Despite discussing the incident with the Social Worker and psychiatry, the resident's care plan did not address their refusal of medications or noncompliance with related interventions. The NP documented the resident's refusal to take potassium and medications, noting the resident's use of headphones to avoid further discussion. The NP consulted with a doctor and adjusted the resident's medication regimen accordingly. However, the Licensed Practical Nurse/Unit Manager (LPN/UM) did not report the resident's allegations of maltreatment to the facility administrator or the New Jersey Department of Health (NJDOH) as required. The LPN/UM acknowledged the resident's preference for natural treatments but did not recognize the need to report the incident as potential abuse. The facility's Licensed Nursing Home Administrator (LNHA) confirmed that no incidents or investigations related to the resident were documented. The Director of Nursing (DON) and Social Worker were aware of the resident's noncompliance with the NP's recommendations but did not perceive it as an abuse allegation. The facility's policies required immediate reporting of abuse or neglect, but these protocols were not followed, resulting in a failure to investigate and report the incident within the mandated timeframe.

Penalty

Fine: $48,350

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 complete and transmit the Minimum Data Set (MDS) assessments for two residents within the required timeframe. Resident #108 was discharged to home, and the discharge MDS was completed 17 days late. Resident #406 experienced multiple discharges to the hospital, with each discharge MDS being completed late by varying days, ranging from four to ten days overdue. These delays were identified during a surveyor's record review. The MDS Coordinator, an LPN, acknowledged the delays, attributing them to a high volume of admissions and discharges. The facility's administrative staff, including the Regional Director of Clinical Services, the License Nursing Home Administrator, the Director of Nursing, and the Regional Director of Operations, were informed of the issue. The CMS validation reports confirmed the late completion of the MDS assessments, and the facility's policy on MDS completion and submission timeframes was reviewed, highlighting the non-compliance with the required timelines.

Penalty

Fine: $48,350

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

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with anxiety upon admission. This deficiency was identified during a survey when it was observed that the care plan for the resident did not include a focus area or interventions addressing their anxiety, despite having an active diagnosis of anxiety and being prescribed lorazepam for treatment. The resident's admission record indicated diagnoses of major depressive disorder, bipolar disorder, and generalized anxiety disorder, yet the care plan lacked measurable objectives and timelines to address these psychological needs. During an interview, the Director of Nursing acknowledged that a resident with a diagnosis of anxiety and receiving treatment should have this condition included in their care plan. The facility's policy on comprehensive person-centered care plans, revised in March 2022, mandates that care plans include measurable objectives and timeframes to ensure the resident's highest practicable physical, mental, and psychosocial well-being. The failure to include the resident's anxiety in the care plan was a clear deviation from this policy.

Penalty

Fine: $48,350

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 was assessed by a Registered Nurse (RN) after sustaining a fall and was not evaluated by a physical therapist as per a physician's order. This deficiency was identified for one resident who was admitted with diagnoses including seizures, muscle wasting and atrophy, hemiplegia and hemiparesis, and legal blindness. The resident had a moderately impaired cognition and required partial assistance with activities of daily living. The resident's care plan included a focus on fall risk due to impaired mobility and unsteady gait. On a specific date, the resident sustained a fall during a transfer from the bed to a wheelchair, as reported by a Certified Nursing Assistant (CNA). There was no evidence that an RN assessed the resident after the fall. Additionally, a Nurse Practitioner (NP) recommended a follow-up with Physical Therapy (PT) for chair safety, but there was no evidence that the resident was evaluated by PT. Interviews with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) confirmed that the PT evaluation was not conducted, and the DON stated that an RN assessment was conducted after the fall, although no documentation was found to support this.

Penalty

Fine: $48,350

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 timely and appropriate care for a resident with a suspected Deep Vein Thrombosis (DVT). The resident, who had a history of spinal fusion and was fully cognitively intact, exhibited symptoms of increased swelling and bruising in the left leg. A Nurse Practitioner ordered a STAT venous doppler to rule out DVT, but the test was not conducted promptly. Despite multiple attempts by the Licensed Practical Nurse/Unit Manager to contact the imaging company, the test was delayed, and the resident was eventually transferred to the hospital by emergency services. The facility did not document the resident's change in status or the confirmed hospital diagnosis in the medical record, and the New Jersey Universal Transfer Form was incomplete. Another resident experienced a delay in receiving a CT scan for symptoms of nausea, weight loss, and indigestion. The resident, who was fully cognitively intact and diagnosed with malnutrition and weight loss, had missed multiple appointments due to transportation issues and miscommunication regarding test preparation. Despite the order for a CT scan being placed months earlier, the test was not completed, and there was no documentation of follow-up or rescheduling until after surveyor inquiry. The facility's staff failed to ensure the resident's diagnostic needs were met in a timely manner, and there was a lack of communication and documentation regarding the missed appointments. The facility's policies on diagnostic services and documentation were not followed, leading to delays in treatment and inadequate communication of residents' conditions. The Director of Nursing acknowledged the expectation for timely completion of STAT orders and proper documentation of resident transfers and changes in status. However, the facility did not adhere to these protocols, resulting in deficiencies in the care provided to the residents.

Penalty

Fine: $48,350

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

Summary

The facility failed to perform and document a skin assessment, obtain a treatment order, and implement timely interventions to prevent the development of a pressure ulcer for a resident identified to be at risk. The resident, who was fully cognitively intact, had a history of pressure ulcers, morbid obesity, and chronic pain syndrome. Despite being at risk for pressure ulcer development, the resident's care plan and treatment administration record did not reflect appropriate interventions or documentation of existing wounds. During the survey, it was observed that the resident had a wound on their buttocks, which was not being treated in a timely manner. The resident reported delays in receiving care and pain medication during the night shift. Interviews with staff revealed inconsistencies in wound care documentation and treatment orders. The LPN stated that the resident had a wound on their left buttock treated with normal saline solution and Medi honey, but there was no documented treatment order for these interventions. Further investigation revealed that the resident's skin assessments did not document any skin impairments, despite the presence of an open area on the gluteal cleft. The facility's policy required comprehensive skin assessments and timely reporting of new skin alterations, which were not followed. The Director of Nursing acknowledged that the nurse should have evaluated the wound and obtained a treatment order upon identification of the skin breakdown.

Penalty

Fine: $48,350

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

Summary

The facility failed to ensure proper care for residents with urinary catheters, specifically regarding the positioning of catheter drainage bags and adherence to physician orders for changing these bags. Resident #188 was observed multiple times with a urinary catheter drainage bag and tubing touching the floor while seated in a wheelchair. The drainage bag was not changed as per the physician's order, which specified a weekly change on shower day. The facility's records did not provide a rationale for the missed change, and the care plan lacked specific interventions to prevent the drainage bag and tubing from touching the floor. Resident #174 was also observed with a urinary catheter drainage bag and tubing touching the floor. The resident's care plan included catheter care every shift but did not specify measures to keep the drainage bag and tubing off the floor. The facility's policy on catheter care emphasized keeping the catheter tubing and drainage bag off the floor but did not include instructions for changing the drainage bag as ordered by the physician. Interviews with facility staff, including a CNA, LPN, RN/UM, and the DON, confirmed that catheter drainage bags and tubing should not touch the floor for infection control reasons. The staff acknowledged the oversight in following physician orders and the importance of accurate documentation to maintain continuity of care. The facility's failure to adhere to these standards resulted in deficiencies in the care provided to residents with urinary catheters.

Penalty

Fine: $48,350

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 fortified foods as prescribed by the physician for two residents, Resident #91 and Resident #7, who were reviewed for nutrition. Resident #91, diagnosed with mild protein-calorie malnutrition and Vitamin D deficiency, was supposed to receive fortified pudding with lunch and dinner as per the physician's order. However, observations on two separate occasions revealed that the resident received regular pudding instead. The Food Service Director confirmed the absence of fortified pudding and admitted to not notifying the Registered Dietician, who was unaware of the issue and had not developed alternative interventions. Additionally, the facility did not obtain weekly weights for Resident #91 as recommended by the Registered Dietician. The resident had experienced significant weight loss, and the dietician had recommended weekly weights to monitor the situation. However, the facility failed to document these weights in the resident's electronic medical record. Interviews with staff, including CNAs and LPNs, revealed a lack of communication and adherence to the dietician's recommendations, resulting in the omission of necessary weight monitoring. For Resident #7, the facility failed to obtain re-weights according to its policy. The resident, who had a history of abnormal weight loss and protein-calorie malnutrition, experienced significant weight fluctuations without appropriate re-weighing. The Registered Dietician noted the resident's weight changes but did not ensure re-weights were conducted as required. The facility's policy mandated re-weighing for weight changes of 5% or more, but documentation showed inconsistencies and missed re-weighs, indicating a failure to follow established protocols.

Penalty

Fine: $48,350

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 store respiratory equipment in a safe and sanitary manner for a resident with Chronic Obstructive Pulmonary Disease (COPD). During an initial tour, a surveyor observed a nebulizer machine on a crowded table with personal belongings, with the mask not stored in a bag and condensation present in the chamber. A brown substance was noted on the nebulizer machine, and it was placed above a dusty air conditioning unit. The resident confirmed that the mask was usually stored in a bag but could not identify the brown matter. Interviews with staff revealed that the nebulizer machine was dirty and needed cleaning. A Licensed Practical Nurse (LPN) acknowledged the mask should be stored in a bag without condensation and that the nebulizer machine should be wiped down. The Registered Respiratory Therapist (RRT) and the Director of Nursing (DON) confirmed that improper storage and cleanliness could lead to contamination and infection risks. The facility's policy required nebulizer equipment to be cleaned and stored aseptically, which was not followed in this instance. The facility's failure to adhere to its policy and maintain a clean environment for respiratory equipment posed a risk of infection to the resident. The nebulizer machine was not cleaned promptly, and the air conditioning unit remained dusty, increasing the potential for contamination. Staff interviews highlighted the importance of proper storage and cleanliness to prevent cross-contamination and infection, which was not adequately addressed in this case.

Penalty

Fine: $48,350

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 complete a performance review of all Certified Nurse Aides (CNAs) at least every twelve months and provide regular in-service education based on the outcome of employee job performance reviews. This deficiency was identified for two CNAs. For CNA #12, the Annual Staff Performance Appraisal was not signed by the employee, supervisor, or department head, despite the requirement for signatures to confirm the evaluation was reviewed and acknowledged. The Regional Human Resources Director admitted that while employees were not necessarily required to sign, the supervisor should have signed to confirm the evaluation was completed. The Licensed Nursing Home Administrator confirmed that both the employee and their supervisor were required to sign the appraisal. For CNA #8, the facility failed to provide in-service education following an unsatisfactory performance. The CNA received a verbal notice for unsatisfactory performance, including failure to follow instructions and respond timely to a resident, but there was no evidence of in-service training after the incident. The facility's policy requires that all nursing staff meet specific competency requirements and that gaps in education are identified and addressed. However, the facility did not adhere to this policy, as evidenced by the lack of in-service training for CNA #8 after the noted deficiencies in performance.

Penalty

Fine: $48,350

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 current resident census was accurately reflected and recorded on the Nursing Home Resident Care Staffing Report before posting it in prominent areas for residents and the general public. This deficiency was identified on three of six survey dates. On multiple occasions, discrepancies were noted between the reported resident census and the actual census recorded on the facility's daily staffing sheet. For instance, on one occasion, the Licensed Nursing Home Administrator stated the census was 207, while the staffing sheet indicated 208, and the posted report showed 203. Similar inconsistencies were observed on other dates, with the posted census figures not matching the actual numbers. Interviews with facility staff revealed that the discrepancies were due to the Staffing Coordinator using outdated computer software for census calculations, which did not reflect the midnight census report generated by the Business Office. The Director of Nursing acknowledged that inaccurate census reporting could affect staffing accuracy, potentially leading to either overstaffing or understaffing. The facility's policy on staffing requires adherence to minimum state-imposed staffing requirements and mandates that direct care daily staffing numbers be posted for every shift.

Penalty

Fine: $48,350

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

Summary

The facility failed to ensure proper accountability and security of narcotics as per their policy. During a survey, it was observed that the narcotic shift count logs for the North 1 Unit's medication B Cart were incomplete, with missing signatures from nurses for several shifts and a blank column for verifying the count's accuracy. Both the Registered Nurse and the Director of Nursing confirmed that the narcotic count should be performed and documented by both incoming and outgoing nurses at each shift change, with no missing signatures or documentation. Additionally, the surveyor found that the narcotic lock box on the North 1 Unit's medication B Cart was not properly secured. The lock box could be opened without a key, indicating a failure to secure narcotics under two locks as required by the facility's policy. The Director of Nursing acknowledged that the lock box should be adequately secured and locked, preventing unauthorized access to its contents. The facility also failed to administer a medication as per a physician's order for a resident who was on anticoagulant therapy. The resident's medication, Xarelto, was marked as 'hold' on the Medication Administration Record without documentation explaining why it was not administered. Interviews with nursing staff revealed that the medication was unavailable in the medication cart, backup house stock, or Automated Medication Dispensing System, and the nurse did not contact the pharmacy or physician to address the unavailability. The Director of Nursing confirmed that the nurse should have notified the pharmacy and physician and documented the issue in the Progress Notes.

Penalty

Fine: $48,350

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 was found to have a medication administration error rate of 6.25%, exceeding the acceptable threshold of 5%. During a medication pass observation, an LPN administered a probiotic instead of the prescribed ascorbic acid to a resident. The LPN mistakenly believed that the probiotic was equivalent to ascorbic acid and did not verify the medication with the central supply or check the medication supply room. This error was compounded by the LPN's lack of familiarity with the resident's medication order for ascorbic acid. Additionally, the same LPN crushed an oxybutin chloride ER tablet, which is not intended to be crushed, for a resident who takes medications in crushed form. The facility's policy requires medications to be administered according to prescriber orders and verified three times before administration, which was not adhered to in this instance. The consultant pharmacist confirmed that the oxybutin ER tablets should not be crushed, indicating a breach in medication administration protocol.

Penalty

Fine: $48,350

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 dispose of expired medical equipment and maintain clean and sanitary medication storage areas. This deficiency was observed in two of three medication storage rooms and one of five medication carts reviewed. In the East Medication Storage Room, a box of Shiley inner cannulas with ten expired cannulas was found. Additionally, in the North One nursing unit's medication storage room, an expired tracheostomy care tray, two expired gastrostomy feeding tubes, and an expired VAD access kit were identified. Furthermore, the North One nursing unit's B medication cart contained 13 unidentifiable loose pills of various shapes, colors, and sizes in the bottom of the cart drawers. The Registered Nurse present acknowledged that there should not have been any loose pills in the medication cart. The Director of Nursing confirmed that expired items should not have been present in the medication storage areas and that medication carts should not contain loose pills. The facility's Medication Labeling and Storage policy requires nursing staff to maintain medication storage and preparation areas in a clean, safe, and sanitary manner.

Penalty

Fine: $48,350

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 was found to have deficiencies in its infection prevention and control practices during a survey. Specifically, the surveyor observed that a Licensed Practical Nurse (LPN) failed to perform hand hygiene before preparing and administering medications to a resident. Additionally, the LPN did not maintain a non-touch technique when returning excess medication to the original bottle, as they touched the resident's medication with bare hands. This incident occurred during the medication administration observation for Resident #92, who was prescribed Tylenol extra strength tablets. Furthermore, another LPN was observed not disinfecting the blood pressure cuff after taking a resident's blood pressure. During interviews, both the LPN and the Infection Preventionist acknowledged the importance of hand hygiene and the need to clean equipment after each use. The facility's policy, revised in October 2023, emphasizes the importance of hand hygiene and cleaning practices to prevent healthcare-associated infections, but these practices were not followed during the observations.

Penalty

No penalty information released

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

Summary

The facility failed to provide documented evidence of care for a resident, identified as Resident #2, who was admitted with multiple diagnoses including Obstructive Sleep Apnea, Difficulty Walking, Major Depressive Disorder, Hypertension, and Muscle Wasting. The resident was assessed to be cognitively intact with a BIMS score of 15/15 and required total assistance for most Activities of Daily Living (ADLs) due to an unstageable sacral pressure ulcer. However, the review of the Electronic Medical Record (EMR) and ADL documentation revealed numerous blank spaces for various care tasks, indicating that these tasks were not documented as completed by the Certified Nursing Assistants (CNAs). The specific ADL tasks that were left undocumented included bathing, bed mobility, bladder and bowel continence, boosting up in bed/wheelchair, CNA skin checks, dressing, locomotion on and off the unit, mobility, personal hygiene, preventive skin care, and toileting, among others. These omissions occurred across multiple shifts on several days in July 2023. Interviews with the CNA and the Director of Nursing (DON) confirmed that the ADL sheets should be signed off daily by the CNAs, and the presence of blank spaces indicated that the tasks were not completed or documented. The facility's policies and the CNA job description require that all care entries be recorded in an informative and descriptive manner, and that residents receive necessary assistance with ADLs to maintain or improve their ability to carry out these activities. The failure to document the care provided to Resident #2 is a violation of these policies, as it does not provide evidence that the resident received the required care and assistance as per their care plan.