Bishop Rehabilitation And Nursing 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

Resident #145, who had diagnoses including cerebral palsy, major depressive disorder, and dementia, was observed on multiple occasions with long, untrimmed fingernails containing brown and black debris underneath. The resident was assessed as having severe cognitive impairment and was dependent on staff for most activities of daily living, including personal hygiene. Facility documentation, including the care plan and Kardex, indicated that the resident required maximum assistance with all hygiene needs and did not refuse care. Despite these documented needs, staff interviews revealed that nail care was expected to be provided on shower days and as needed, but was not consistently performed. Certified nurse aides responsible for the resident's care did not notice or address the unclean and long fingernails, even though they acknowledged the importance of nail care for hygiene and infection control. The facility's policy required nail care to be provided as needed, but this was not followed for the resident, resulting in the observed deficiency.

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 significant medication error occurred when a Licensed Practical Nurse (LPN) administered medications intended for one resident to another. The LPN, who was new to the unit and working as agency staff, parked the medication cart between two residents' rooms, prepared medications for a resident with diabetes and other chronic conditions, but mistakenly entered the room of a different resident. The LPN informed the resident that medications and insulin were to be administered, and the resident consented. Upon returning to the medication cart, the LPN realized the error and immediately reported it to the Nurse Manager. The resident who received the incorrect medications had diagnoses including schizophrenia, dementia, congestive heart failure, and chronic obstructive pulmonary disease, and was not prescribed insulin. The medications administered included both long- and short-acting insulin, psychotropic, and antihypertensive drugs, none of which were prescribed for this resident. Following the administration, the resident exhibited asymptomatic hypoglycemia and hypotension, with vital signs showing low blood pressure and heart rate, as well as fluctuating blood glucose levels. The resident was lethargic and dizzy, with intermittent confusion, which was noted as baseline due to advanced dementia. The facility's policy required staff to verify the right medication, dosage, time, and method of administration, and to ensure medications ordered for one resident are not given to another. The LPN failed to correctly identify the resident before administering the medications, leading to the error. The incident was discovered and reported promptly, and the resident was closely monitored and treated for the effects of the medication error.

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 prompt resolution of grievances for residents, as evidenced by the experiences of 11 anonymous residents and one additional resident, Resident #127. During a resident group meeting, all 11 residents reported that their grievances were not addressed in a timely manner, and they were not provided with explanations for the delays. Additionally, Resident #127's family member filed three grievances, none of which received prompt resolutions. Resident #127, who had diagnoses including unspecified dementia and aphasia related to a stroke, had a health care proxy in place. The proxy filed grievances on three occasions: on August 7, 2024, regarding tube feed administration and other concerns; on September 23, 2024, regarding medical treatment complaints; and on November 13, 2024, regarding incontinence care. The investigations for these grievances were completed within a week, but the resolutions were communicated to the resident's representative months later, far exceeding the facility's policy of providing resolution within 7 business days. Interviews with facility staff, including the Director of Social Work and the Administrator, revealed that while grievances were investigated promptly, the communication of resolutions was significantly delayed. The Director of Social Work acknowledged the importance of timely follow-up to address concerns and prevent potential medical issues. The Administrator admitted there was a breakdown in the process and was working on improving the timeliness of grievance resolution follow-up.

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 privacy and confidentiality of residents' personal and medical records for 14 out of 29 residents on the 2 North Unit. During a recertification survey, it was observed that a Narcotics Logbook containing sensitive information, including resident names, room numbers, prescribed narcotic medications, and corresponding diagnoses, was left unsecured in a resident's room. This occurred when a Licensed Practical Nurse (LPN) left the logbook on a dresser in a resident's room, where it remained for several hours. The resident was present in the room, and the LPN admitted to being distracted by an incident on the unit, which led to the oversight. Interviews with facility staff, including the LPN, a Registered Nurse Unit Manager, and the Assistant Director of Nursing, confirmed that the Narcotics Logbook should be kept locked in the medication cart or medication room to maintain confidentiality. The LPN acknowledged the mistake and stated that the logbook should not have been left in the resident's room, as it violated resident confidentiality. The facility's policy on Resident Rights, revised earlier in the year, clearly documented the residents' right to privacy and confidentiality, which was not upheld in this instance.

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 consistent and appropriate dialysis care for two residents, both of whom required dialysis due to end-stage renal disease. The facility did not consistently assess the medical condition of these residents or monitor for complications before and after dialysis treatments. There was also a lack of consistent communication and collaboration with the dialysis facility regarding the care and services for these residents. Resident #14, who had diagnoses including end-stage renal disease and hypertension, required dialysis five times a week. The facility's records showed multiple instances where pre-dialysis and post-dialysis assessments were not documented. Additionally, there were missing dialysis communication logs on several dates. The facility's policy required open communication with the dialysis center and completion of a dialysis communication form, which was not consistently followed. Resident #29, with diagnoses including end-stage renal disease and type 2 diabetes mellitus, also required dialysis. Similar to Resident #14, there were numerous instances where pre-dialysis and post-dialysis assessments were not documented. The facility failed to maintain proper communication logs with the dialysis center, and there was no documented follow-up from the facility on the dialysis communication logs. Interviews with facility staff revealed a lack of awareness regarding the missing assessments and communication logs, highlighting a breakdown in the facility's processes for managing dialysis care.

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 food was prepared, distributed, and served in accordance with professional standards in the main kitchen. During the recertification survey, it was observed that two of the four walk-in coolers were out of service for an extended period, and the working coolers had unclean and uncleanable surfaces. Specifically, the front walk-in cooler had food spills and debris under the shelving, and the produce walk-in cooler had several broken floor tiles, which were not smooth or easily cleanable. The facility's policies required that food service equipment be maintained in good repair and that staff report any equipment failures, but these procedures were not followed. The facility's work orders from September to December 2024 did not document the issues with the walk-in coolers or the broken tiles. The Food Service Director acknowledged that the cook's walk-in cooler had been out of service for a few weeks, and the Pull walk-in cooler had been down since September 2024. They also admitted that the broken tiles in the produce cooler had not been noticed or reported. Although staff were trained to report broken equipment, there was a lack of documentation and communication with the maintenance department. This deficiency highlights a failure in maintaining a clean and functional kitchen environment, which is essential for preparing meals for residents.

Penalty

No penalty information released

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

Summary

The facility was found to be operating an unapproved dialysis den during a recertification survey. Observations revealed that the dialysis area had seven stations set up in a space that was not approved according to the facility's plans. The construction of the dialysis den did not align with the approved plans, as the wall was added at the wrong end of the corridor, and the double doors accessing the room were not changed. The Administrator was unaware of the construction requirements and the approved plans until informed by the Department of Health. Despite receiving the approved plans, the necessary construction was not completed. During the survey, it was observed that a resident was receiving dialysis treatment in the unapproved dialysis den. The Administrator stated that the dialysis vendor was responsible for the dialysis operations, including construction to meet the approved plans. However, the Administrator was unsure why the construction had not been completed or if the vendor intended to amend the plans to match the existing facility. The facility's failure to comply with Federal, State, and local laws and professional standards resulted in the deficiency.

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 dignity and quality of life for Resident #110, who was observed to be unshaven with visible chin and lip hair. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and dementia, required assistance with activities of daily living due to severely impaired cognition. Despite the facility's policy that residents should be groomed according to their preferences and needs, Resident #110 was not shaved as desired, which was confirmed during interviews with the resident and their family member. The family member, who previously assisted with shaving, had moved away and expected the facility staff to take over this responsibility. Observations and interviews revealed that the certified nurse aides were responsible for shaving residents, typically on shower days or as needed. However, Resident #110 was not shaved during their shower due to poor lighting, and the resident expressed a desire to be shaved. Staff interviews indicated that not shaving a resident who wished to be shaved could affect their emotional well-being and sense of dignity. The facility's failure to provide this basic grooming service as per the resident's preference was identified as a deficiency in maintaining the resident's dignity and quality of life.

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 a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the presence of black and gray buildup on the floor near the base of the wall in the resident's room. Observations over several days revealed a persistent dirt shadow and grime extending 1 to 3 inches from the baseboard, which was not addressed by the housekeeping staff. The resident expressed dissatisfaction with the cleanliness of their room, specifically noting the dirt shadow around the bottom molding of the wall. The facility's policy required daily cleaning of resident rooms, including dust mopping and damp mopping of floors, with particular attention to baseboards to prevent buildup. However, interviews with housekeeping staff and the Acting Director of Environmental Services revealed that the buildup was not addressed during regular cleaning, and the last deep cleaning of the resident's room occurred weeks prior. The Acting Director acknowledged the oversight and stated that the buildup should have been cleaned during daily cleaning routines, but they were unaware of the issue until it was brought to their attention during the survey.

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 treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the deficiency involved Resident #127, who did not have their Scopolamine patch monitored for placement as ordered. The Scopolamine patch, used to treat nausea, vomiting, and decrease respiratory secretions, was not consistently checked for placement every shift as required by the physician's orders. Resident #127 had a history of dementia and dysphagia following a stroke, which necessitated tube feeding and increased the risk of aspiration. The resident's care plan included monitoring for signs of aspiration and managing oral secretions with the Scopolamine patch. However, observations revealed that the resident was often without the patch, leading to increased coughing and secretions. The Medication Administration Record and Treatment Administration Record showed inconsistencies in documenting the patch's placement, and there was no evidence that the provider was notified when the patch was not in place. Interviews with nursing staff indicated a lack of routine checks and communication regarding the patch's status. Licensed Practical Nurse #33 admitted to expecting Certified Nurse Aides to inform them if the patch fell off, but this did not always happen. The Nurse Practitioner confirmed that the patch was crucial for managing the resident's secretions and should have been monitored and reported if not in place. The failure to ensure the patch was consistently applied and monitored contributed to the resident's increased secretions and coughing, highlighting a lapse in following physician orders and facility policy.

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 comply with the requirement to post daily nurse staffing information in a location that is prominent and readily accessible to residents and visitors. During the recertification survey conducted from December 16 to December 20, 2024, it was observed that the daily resident census and nurse staffing data were posted in an enclosed glass bulletin board across from the elevators in the 918 building, approximately five feet from the ground. This location was not easily accessible to all residents and visitors, as it was not in a prominent place such as the lobby where visitors typically enter. Interviews with facility staff revealed a lack of awareness and understanding of the proper posting requirements. The receptionist was not familiar with the census and staffing document, and the staffing coordinator acknowledged that the posting was not visible to all residents and visitors due to its height and location. The Director of Nursing was unaware that the staffing information was not posted in a more accessible location, such as the lobby, and agreed that it should be visible to all residents and visitors. This deficiency was noted for all five days reviewed during the survey.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to provide adequate pain management for three residents, leading to unresolved pain and diminished quality of life. Resident #28 did not receive their prescribed diclofenac gel consistently, despite it being documented as administered. The resident frequently reported not receiving the gel, which they stated helped alleviate their knee and shoulder pain. Interviews with staff revealed a pattern of signing off on medications before they were administered, and a lack of proper follow-up when the resident was not available or refused the medication. Resident #37 experienced a lapse in receiving their prescribed Lyrica for neuropathy, missing doses over a three-day period. The medication was not available in the facility's automated dispensing system, and there was a failure in communication and follow-up with the pharmacy to ensure timely delivery. The resident reported significant pain and difficulty in daily activities due to the missed medication, which was only addressed after the resident was sent to the hospital. Resident #64 was not informed of their as-needed pain medication orders and was not offered these medications when experiencing pain. Despite having orders for diclofenac gel and acetaminophen, these were not administered throughout the month, even when the resident reported pain levels as high as 10. The facility's documentation and communication failures contributed to the residents' unmanaged pain and compromised their well-being.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to provide medically related social services to help residents achieve the highest possible quality of life, as evidenced by deficiencies in the care plans and interventions for five residents with mental health issues. Resident #41, with a history of schizoaffective disorder, anxiety, and depression, did not have person-centered mental health interventions in their care plan. Despite recommendations from a licensed psychologist, the care plan was not updated to include these interventions, and there were no documented social services follow-ups after the resident exhibited behaviors such as attempting to leave the facility and expressing suicidal and homicidal ideations. Resident #126, who had a significant mental health history, also lacked person-centered interventions for their behaviors and refusals of care and medications. Similarly, Resident #153, with a traumatic brain injury and major depressive disorder, did not have the psychologist's recommendations implemented into their care plan, and there was no evidence of follow-up on the recommendation for a traumatic brain injury program. The resident exhibited aggressive behavior and medication refusals, yet there were no documented social services progress notes addressing these issues. Resident #235, diagnosed with dementia and major depressive disorder, displayed aggressive behaviors, including threatening staff with scissors, which required police intervention. The care plan did not include person-centered interventions for the resident's history of delusions and aggressive behavior. Lastly, Resident #250, with paranoid schizophrenia, did not have person-centered interventions for their behavioral symptoms. The lack of appropriate interventions and follow-ups placed all residents with mental health disorders at risk for harm, constituting Immediate Jeopardy and Substandard Quality of Care.

Removal Plan

• 100% of social work department staff educated on medically related social services.
• Post-tests reviewed.
• Staff education sign in sheets reviewed and compared to the current social work staff list with no discrepancies identified.
• Staff education verified during an onsite visit, all social work department staff interviewed to determine retention of education provided and able to accurately report content of the education.
• All five identified residents' records reviewed, and documentation reflected each had a social work assessment completed.
• All five identified resident plans of care reviewed and had updated person-centered interventions for their mental health.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to promptly notify the ordering physician of abnormal laboratory results for three residents, leading to serious health consequences. Resident #529 had abnormal lab results indicating possible dehydration and infection, including a high white blood cell count and high sodium levels, which were not reviewed or communicated to the medical provider in a timely manner. This delay resulted in the resident being hospitalized with pneumonia and dehydration three days later. Resident #153, who had a history of Type 2 diabetes, experienced a critically low blood glucose level of 49 milligrams/deciliter. Despite the critical nature of this result, there was no documentation that a medical provider was notified or that the resident was assessed for signs of hypoglycemia. The lab had communicated the critical result to a nurse, but the necessary follow-up actions were not taken. Resident #260, who was on anticoagulant therapy, had a high INR result indicating a risk of bleeding. The critical lab results were communicated to the facility, but there was no documentation of physician orders to hold the anticoagulant medication, and the results were not reviewed by the medical provider until the following day. This lack of timely communication and action could have led to serious health risks for the resident.

Removal Plan

• 86% of all licensed nursing staff have been educated on laboratory services.
• The remaining staff will be educated prior to the start of their next shift.
• Post-tests were reviewed.
• Staff education sign in sheets were reviewed and compared to the current nursing staff list and no discrepancies were identified.
• 100% of licensed nursing staff currently working received education.
• Staff education was verified during an onsite visit, multiple licensed nursing staff on multiple units were interviewed to determine retention of education provided and were able to accurately report content of the education.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that residents' ability to self-administer medications was clinically appropriate, affecting five residents. Specifically, medications were left in the rooms of four residents, some of which were unidentified, and there was no documented evidence that these residents were assessed for their ability to safely self-administer medications. Additionally, there were no physician orders for self-administration of medication for these residents. This oversight placed all 248 residents at risk for serious harm or adverse outcomes, resulting in Immediate Jeopardy to resident health and safety. Resident #239, who had a history of substance abuse and was cognitively intact, was not observed by nursing staff to ensure their controlled substance, Suboxone, was taken as prescribed. The resident admitted to flushing the medication down the toilet because they did not need it. Despite receiving Suboxone daily, there was no care plan or assessment for the resident's ability to self-administer medications. The nursing staff failed to monitor the resident for the required time after administration, allowing the resident to potentially hoard or misuse the medication. Resident #64, who was cognitively intact but dependent for activities of daily living, had unidentified pills left at their bedside by a nurse who assumed the resident could take them without supervision. The resident did not take the medications because they lacked something to drink, and some pills were found on the floor. Similarly, Resident #72, who had impaired vision, had eye drops left at their bedside without an order for self-administration. The resident was unaware of the medication's presence and could not self-administer the drops. These incidents highlight the facility's failure to adhere to its policies on medication administration and self-administration, leading to potential medication errors and safety risks.

Removal Plan

• Staff will be educated prior to the start of their next shift.
• Post-tests were reviewed.
• Staff education sign in sheets were reviewed and compared to the current nursing staff list and no discrepancies were identified.
• Licensed nursing staff received education.
• Staff education was verified during an onsite visit, multiple licensed nursing staff on multiple units were interviewed to determine retention of education provided and were able to accurately report content of the education.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure timely notification of physicians and resident representatives when there were significant changes in residents' conditions, affecting four residents. One resident did not receive their prescribed medication, Lyrica, for several days due to the facility not having the medication in stock, and the provider was not notified. This resulted in the resident experiencing uncontrolled pain. Another resident refused critical medications, including heparin and insulin, for six months without the medical provider being informed, and no assessment was conducted to determine the outcome of these refusals. A third resident experienced a critically low blood glucose level, which was reported by the laboratory, but the provider was not notified. Additionally, a fourth resident exhibited symptoms such as lethargy, loose stools, medication refusal, and poor intake, yet was not assessed by a qualified professional, and neither the medical provider nor the resident's representative was notified. This resident was subsequently hospitalized with severe dehydration. The facility's policies required staff to monitor residents for changes in condition and notify the physician and responsible party of significant changes. However, these policies were not followed, as evidenced by the lack of documentation of assessments, provider notifications, and communication with resident representatives. Interviews with staff revealed a lack of clarity and adherence to the chain of command, resulting in significant lapses in care and communication.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that services provided met professional standards of quality in several critical areas, including medication administration, pressure ulcer prevention, and physician notification for changes in condition. Observations revealed that residents were in possession of medications without documented assessments for their ability to self-administer, and there were no physician orders for self-administration. This oversight placed all residents at risk for serious harm. Additionally, there were instances where residents did not receive their prescribed medications due to lack of availability, and the medical provider was not notified, resulting in immediate jeopardy to resident health and safety. The facility also failed to provide adequate care for residents with pressure ulcers and those requiring assistance with activities of daily living. Residents with pressure injuries were not assessed or treated in a timely manner, leading to further hospitalizations. Furthermore, residents did not receive necessary oral hygiene or assistance with eating as outlined in their care plans. These deficiencies resulted in harm and substandard quality of care for the affected residents. In addition, the facility did not maintain acceptable standards for pain management, respiratory care, and laboratory testing notifications. Residents experienced unresolved pain due to missed or improperly administered medications, and respiratory equipment was not maintained appropriately. Laboratory results were not reviewed or communicated to medical providers in a timely manner, leading to serious health consequences for residents. The lack of timely notification and intervention for significant changes in residents' conditions further contributed to the immediate jeopardy and substandard quality of care.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to provide necessary treatment and services for residents with pressure ulcers, leading to harm for several residents. Resident #826, who had severe cognitive impairment and was at risk for pressure ulcers, was not properly assessed or treated for pressure injuries. The resident developed an unstageable pressure injury to the sacral region and a deep tissue injury to the right heel, which were not documented or treated in a timely manner. This lack of care resulted in the resident being hospitalized with chronic sacral osteomyelitis and cellulitis, requiring surgical intervention. Resident #271, who had a history of stroke and diabetes, developed a deep tissue injury on the right heel due to the facility's failure to follow orders for pressure relief boots and other wound care recommendations. The resident's care plan included interventions to minimize moisture exposure and offload pressure, but these were not consistently implemented. Observations revealed that the resident often did not have protective boots on, and their wheelchair cushion was inadequate, contributing to skin breakdown. Resident #222, admitted with osteomyelitis and an unstageable pressure ulcer, did not receive daily pressure ulcer care as ordered. The facility's failure to monitor and treat the resident's wounds as per the care plan resulted in further deterioration of their condition. The report highlights systemic issues in the facility's wound care management, including inadequate documentation, lack of timely interventions, and poor communication among staff, leading to substandard quality of care for residents with pressure ulcers.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility's Medical Director failed to ensure the coordination of medical care with interdisciplinary teams and the implementation and evaluation of resident care policies, which did not reflect current professional standards. This deficiency was identified during an extended recertification survey. The Medical Director did not develop and implement policies and procedures to monitor the delivery of care and services to residents in critical areas such as self-administration of medication, pain management, laboratory services, and medically related social services. This failure resulted in actual harm with the potential for serious harm, classified as Immediate Jeopardy. Several residents were affected by these deficiencies. Residents were not assessed for their ability to safely self-administer medications, nor did they have physician orders for self-administration, placing all residents at risk for serious harm. Additionally, some residents experienced unresolved pain that impacted their daily functional abilities and quality of life, indicating a failure in pain management. Furthermore, residents with mental health disorders were not provided with necessary medically related social services, risking their physical, mental, and psychosocial well-being. The facility also failed to promptly notify physicians of critical laboratory results for certain residents, increasing the likelihood of serious injury or harm. Interviews with facility staff revealed that the Medical Director had limited involvement in policy development and oversight, as corporate policies dictated the facility's operations. The Medical Director expressed concerns about not being heard and having no input into facility assessments or policy changes, which were managed at the corporate level.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that food and drink provided to residents were palatable, flavorful, and served at appetizing temperatures during the extended recertification and abbreviated surveys. Specifically, during lunch meals on two consecutive days, food was observed to be served at incorrect temperatures, with hot foods not being hot enough and cold foods being too warm. Residents consistently reported dissatisfaction with the taste and temperature of the food, with nine residents at a Resident Council meeting expressing that the food was not appetizing. Interviews with residents further confirmed these issues, with complaints about food being too tough, cold, and generally unappetizing. Observations during meal service revealed significant temperature discrepancies. For instance, on one occasion, corn was served at 115 degrees Fahrenheit, and cold items like yogurt and coleslaw were served at temperatures well above the acceptable range. Similar issues were noted on subsequent days, with cold items such as yogurt, pudding, and chocolate milk being served at temperatures between 54 and 71 degrees Fahrenheit. The Food Service Director acknowledged that the expected temperatures for hot and cold foods were not met, and the practice of placing cold food on trays with hot food contributed to the problem. The facility's policies on meal service and food temperatures were not adhered to, leading to these deficiencies.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that licensed nurses possessed the necessary competencies and skills to provide safe and effective care to residents. This deficiency was identified during an extended recertification survey, which revealed that 12 out of 16 licensed nurses lacked appropriate competencies in areas such as medication administration, wound care, and documentation. Specific issues included incomplete or inaccurately completed re-education for some nurses, missing skills competencies, and untimely completion of annual written competencies. The facility's job description for the Facility Educator outlined responsibilities for planning and implementing educational programs to ensure compliance with regulatory requirements. However, interviews with staff indicated gaps in the execution of these responsibilities. For instance, the Assistant Director of Nursing/Nurse Educator admitted to not remembering providing education beyond orientation and acknowledged the need for better organization of employee files. Additionally, some nurses reported not receiving necessary education or observation in critical areas like medication administration and wound care. The report highlighted several instances where nurses did not have documented evidence of required competencies. For example, one LPN had documented needs for re-education that were not addressed, and another LPN was observed leaving medications at the bedside. Furthermore, interviews with various nursing staff revealed inconsistencies in the education and competency verification process, with some nurses expressing a desire for more education and others noting that they had not been observed performing essential tasks. The lack of proper documentation and follow-through on competency assessments contributed to the facility's failure to ensure that nursing staff were adequately prepared to meet residents' needs.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that a licensed pharmacist conducted a thorough monthly drug regimen review for Resident #147, as required by their policies and procedures. The resident, who had diagnoses including diabetes mellitus type 1 and end-stage renal disease, had physician orders for heparin and insulin. However, these medications were consistently documented as refused on the Medication Administration Record, and there was no evidence that these refusals were reviewed or addressed during the monthly medication regimen reviews conducted by the pharmacists. The pharmacists, identified as #92 and #93, conducted drug regimen reviews remotely using the electronic health record. They focused on checking resident allergies, medication dosing, and ensuring no duplication of therapy, among other things. However, they did not review the medication administration records for refusals unless it involved as-needed medications. The pharmacists stated that it was the responsibility of the nursing staff to notify medical providers of medication refusals, and they did not include refusals in their recommendations unless specifically asked. Interviews with the Director of Nursing and the Medical Director revealed that the medication regimen reviews should have included a review of all medications and any irregularities, such as consistent medication refusals. The medical provider was not made aware of Resident #147's consistent refusals, which could have led to significant health risks. The facility's failure to document and address these refusals in the drug regimen reviews contributed to the deficiency.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards, leading to several deficiencies in the main kitchen. During the survey, it was observed that food items in the cook's prep box walk-in cooler were not maintained at safe temperatures, with a large pan of turkey salad measuring between 47-49 degrees Fahrenheit, exceeding the safe limit of 41 degrees Fahrenheit. The Food Service Director acknowledged that the turkey salad, which contained ground deli turkey and mayonnaise, should have been kept below 41 degrees Fahrenheit and admitted that potentially hazardous food should not be out of temperature for more than 30 minutes during preparation. However, the turkey salad had been in the cooler for 15 hours, and there was no documented evidence of the recorded temperature at the time of preparation. Further observations revealed that the main kitchen front walk-in cooler was not maintaining safe temperatures, with a hanging thermometer reading 46 degrees Fahrenheit. Various food items, including dairy products and drinks, were measured at unsafe temperatures ranging from 46 to 49 degrees Fahrenheit. The Assistant Food Service Director noted that the back of the condenser in the cooler was encased in ice, potentially affecting its functionality. Despite the temperature log indicating that the cooler was checked and recorded as 40 degrees Fahrenheit, the actual temperatures of the food items were significantly higher, leading to the voluntary disposal of numerous crates and cases of milk, juices, and other perishable items. Additionally, the facility had uncleanable surfaces and equipment in disrepair, contributing to the deficiencies. The kitchen floor by the tray line and the cook's prep box walk-in cooler was rough concrete, making it difficult to clean. The pull box walk-in cooler door did not close properly, remaining ajar by about an inch. The kitchen pantry wall was in disrepair, with a fallen mop board and stained, sagging ceiling tiles. The Food Service Director admitted to being unaware of the wall and ceiling issues and acknowledged that the floor had been problematic for a long time. No work orders had been submitted for these issues until they were identified during the survey.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility was found to be deficient in administering its resources effectively and efficiently, failing to ensure the highest practicable physical, mental, and psychosocial well-being of each resident. The administration did not properly identify, communicate, and implement policies and procedures, and was unaware of the extent of the deficient practices cited. Additionally, the facility lacked an effective training program for all staff, as necessary based on the facility assessment, and did not maintain documented records of staff completing required trainings. Several residents were affected by these deficiencies. Residents were not assessed for their ability to safely self-administer medications, nor did they have physician orders for self-administration, placing all residents at risk for serious harm. Additionally, residents with unresolved pain had their daily functional abilities, psychosocial well-being, and quality of life diminished, posing an immediate jeopardy and substandard quality of care. Furthermore, residents with mental health disorders were not provided medically related social services to attain or maintain their highest practicable well-being, again placing them at risk for harm. The facility also failed to promptly notify ordering physicians of critical laboratory results, which could lead to serious injury or death. The training program was inadequate, with no recorded completion of required trainings in areas such as communication, resident rights, abuse and neglect, and infection control. The facility's administration and medical staff expressed concerns about the lack of involvement in policy development and the corporate-driven nature of policies, which contributed to the deficiencies observed.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure an effective training program for all new and existing staff, as evidenced by the lack of documented training in 33 out of 36 staff files reviewed during the extended recertification survey. The facility's assessment outlined mandatory training topics such as abuse/neglect/mistreatment reporting, fire safety, resident rights, and infection control, among others. However, the survey revealed that many staff members did not receive documented education in key areas, including communication with non-verbal or English as a second language residents, resident rights, abuse prevention, quality assurance, infection control, compliance and ethics, and mental/behavioral health. Interviews with various staff members, including LPNs, CNAs, and other personnel, highlighted inconsistencies in the training provided. Some staff recalled receiving general orientation and specific job training, while others did not remember receiving any training on essential topics such as communication with non-verbal residents or quality improvement goals. Several staff members indicated that they had to rely on previous experience or education from other facilities to fill in the gaps left by the facility's training program. Additionally, there was a lack of clarity on how to bring quality improvement suggestions to the committee, and some staff were unaware of the current quality improvement goals. The facility's administration acknowledged the focus on the plan of correction and the need for improved record-keeping for staff education. Despite efforts to provide mandatory training through town hall meetings and orientation processes, the facility's training program did not adequately address the needs identified in the facility assessment. The Director of Nursing and the Administrator admitted that while dementia care education was provided, other mental health management training was lacking, and there was no definitive system for tracking staff education.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment across multiple units and areas, as observed during a recertification survey. The survey identified numerous environmental deficiencies, including damaged and unclean walls, windows, ceilings, floors, furniture, and sinks across all eight resident floors, the main kitchen, and one of the basement floors. Specific issues included torn chairs, broken light covers, water leaks, stained and soiled surfaces, and rodent droppings. Additionally, there were reports of strong odors of urine and stool in certain areas, indicating inadequate cleaning and maintenance. The facility's maintenance policy required work orders to be submitted for any non-compliance issues, either through yellow binders at nursing stations or electronically via kiosks. However, the facility was unable to provide work orders for the identified environmental issues, suggesting a breakdown in the reporting and maintenance process. Interviews with staff revealed that while there were systems in place for reporting maintenance issues, there was a lack of awareness and follow-through, as many staff members were not informed of the environmental problems, and work orders were not consistently submitted or acted upon. Interviews with various staff members, including CNAs, LPNs, and the Director of Maintenance, highlighted a lack of communication and coordination in addressing maintenance issues. Staff members reported that they were either unaware of the issues or believed that work orders had been submitted, but the Director of Maintenance confirmed that no work orders were found for the identified problems. This lack of effective communication and follow-up contributed to the persistence of the environmental deficiencies, compromising the residents' right to a safe and homelike environment.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions were referred for a Level II Preadmission Screening and Resident Review (PASARR) as required by federal regulations. This deficiency was identified during an extended recertification survey, where it was found that three residents were not properly assessed and referred for a Level II PASARR despite significant changes in their mental health conditions. Resident #41, who had a diagnosis of schizoaffective disorder, exhibited severe behavioral symptoms, including refusing medication, attempting to leave the facility unsafely, and expressing suicidal and homicidal ideations. Despite these significant changes, there was no documentation of a new Screen Level I or a Level II referral. Similarly, Resident #235, who had a history of aggressive behavior and was hospitalized for psychiatric evaluation, did not have a new Screen Level I completed or a Level II referral initiated after significant behavioral changes and medication interventions. Resident #250, diagnosed with schizophrenia, was documented to have a care plan for a Level II PASARR evaluation, but there was no evidence of a completed Level II evaluation. The resident had a history of assaultive behavior and paranoid delusions, yet the necessary assessments and referrals were not conducted. Interviews with facility staff revealed a lack of awareness and implementation of the PASARR process, contributing to the oversight in addressing the residents' mental health needs appropriately.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during an extended recertification survey. Specifically, two medication carts and three medication rooms were found to have deficiencies. On the A unit, a Lantus insulin pen was not labeled with the date it was opened, and the medication room refrigerator was at an unacceptable temperature of 28 degrees Fahrenheit with a white fuzzy substance on the back wall. Licensed Practical Nurse #28 confirmed the insulin pen was opened without a date, and the refrigerator's condition was unknown to them. On the 3rd floor, the medication room refrigerator was found to be at 62 degrees Fahrenheit, which is above the acceptable range. Licensed Practical Nurse #29 acknowledged the issue, stating that the refrigerator should not exceed 42 degrees Fahrenheit to maintain medication integrity. It was later discovered that the refrigerator was unplugged, leading to the high temperature, and the insulin stored there was discarded due to potential efficacy loss. On the 4th floor, a Novolog insulin pen was found with an expired open date, and the medication room refrigerator was at 30 degrees Fahrenheit. Licensed Practical Nurse #4 and the Assistant Director of Nursing confirmed the importance of labeling insulin with the open date and maintaining proper refrigerator temperatures. The maintenance staff was responsible for checking and adjusting refrigerator temperatures, but the unit staff was responsible for cleaning the refrigerators.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to provide necessary assistance with activities of daily living for two residents, leading to deficiencies in oral hygiene and nutritional support. Resident #154, who had a history of cerebral vascular accident, hemiplegia, and dysphagia, was dependent on staff for most activities of daily living and required specific oral care involving toothbrush, toothpaste, and suctioning twice daily. Despite these orders, observations revealed that the resident's teeth were not brushed as required, evidenced by a white substance around the teeth and gums, and a clean, empty suction canister. Interviews with staff confirmed that oral care was not consistently provided as ordered, and documentation was inaccurately completed, indicating care was given when it was not. Resident #226, diagnosed with Alzheimer's disease and adult failure to thrive, required substantial to maximal assistance with eating due to severe cognitive impairment and significant weight loss. The care plan specified that the resident needed encouragement and cueing during meals, yet observations showed the resident was left unattended during meals without the necessary assistance. This lack of support was corroborated by staff interviews, which acknowledged the resident's need for help and the potential impact on their nutritional intake and weight status. Staff also noted challenges in providing adequate assistance due to workload and staffing levels. The deficiencies in care for both residents highlight a failure to adhere to care plans and provide essential support for activities of daily living. The lack of oral hygiene for Resident #154 and inadequate feeding assistance for Resident #226 were directly observed and confirmed through staff interviews, indicating systemic issues in the facility's ability to meet the needs of its residents as per their care plans.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure adequate supervision and the use of assistive devices to prevent accidents for two residents. Resident #41, who had a history of exit-seeking behavior and cognitive impairments, was able to leave the facility through the main entrance. The security guard mistook the resident for a visitor and allowed them to exit, despite the resident's history of removing their wander alert device. The facility's policies on wandering residents and wander alarms were not effectively implemented, as there was no documented evidence of training provided to the security guard on identifying residents at risk for elopement. Resident #250, diagnosed with schizophrenia and moderately impaired cognition, was identified as a high risk for elopement upon admission. However, there was inconsistent documentation regarding the implementation and monitoring of a wander alert device for this resident. The resident was found in the lobby intending to leave the facility, and it was unclear whether the wander alert device was in place as ordered. The facility lacked a log of when wander guards were placed, and there was no clear documentation of the resident's initial high elopement risk score. Interviews with staff revealed gaps in communication and training regarding the identification and management of residents at risk for elopement. Security personnel and nursing staff were not adequately informed or trained on the specific needs and risks associated with these residents. The facility's failure to ensure proper supervision and the use of assistive devices contributed to the deficiencies identified during the survey.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that a resident maintained acceptable nutritional status, as evidenced by the lack of timely notification to the medical provider regarding the resident's severe weight loss and the absence of discussions about potential interventions such as an appetite stimulant. The resident, who had diagnoses including major depressive disorder, diabetes, and adult failure to thrive, experienced significant weight loss over several months. Despite the facility's policy requiring regular weight monitoring and prompt action in response to significant weight changes, the medical provider was not informed of the resident's condition in a timely manner. The resident's weight dropped from 97 pounds in February 2024 to 80.2 pounds by June 2024, indicating a severe weight loss. The facility's policies outlined specific thresholds for significant weight changes and required reweighs and notifications to the dietitian and medical provider. However, there was no documented evidence that the medical provider was notified of the resident's severe weight loss or the recommendation for an appetite stimulant until much later. Interviews with facility staff revealed that there was a breakdown in communication, as the registered dietitian and diet technician expected the nursing staff to relay the information to the medical provider, which did not occur promptly. Observations during the survey period showed that the resident's meal intake was inconsistent, with many meals consumed at 0-25%. Despite the resident's high nutritional risk and the facility's awareness of the weight loss, the necessary steps to address the issue, such as notifying the medical provider and discussing potential interventions, were delayed. This lack of timely communication and intervention contributed to the resident's continued weight loss and failure to maintain acceptable nutritional parameters.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to provide appropriate respiratory care for Resident #64, who required a Bilevel Positive Airway Pressure (BiPAP) machine for breathing assistance due to chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive sleep apnea. The resident's care plan included the use of a BiPAP machine at bedtime, but the facility did not have a policy on its use. The resident's physician order specified detailed settings for the BiPAP machine and required monitoring of the mask placement and skin integrity every shift. Observations and interviews revealed that the resident did not consistently receive the BiPAP treatment as prescribed. On multiple occasions, the resident reported that staff did not apply the BiPAP machine at night, and when it was applied, it was not always tolerated for the full duration. Additionally, the mask used had unblocked ports, which compromised the machine's effectiveness. The resident was observed using supplemental oxygen via nasal cannula instead of the BiPAP machine. Interviews with staff, including LPNs and a respiratory therapist, indicated a lack of training and understanding regarding the proper use of the BiPAP machine and mask. The respiratory therapist noted that the resident did not refuse the treatment and emphasized the importance of the BiPAP machine for the resident's respiratory condition. However, the staff responsible for applying the mask and operating the machine were unsure of the correct procedures, leading to inconsistent and inadequate respiratory care for the resident.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure an effective transfer or discharge planning process for a resident who was transferred to a local acute care hospital. The deficiency involved the lack of required documentation and communication with the receiving health care institution. Specifically, the resident was discharged without necessary documentation, including contact information of the responsible practitioner, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plan goals, and other essential medical information such as recent vital signs, diagnoses, allergies, medications, and recent lab results. The resident, who had diagnoses including cervical disc disorder, radiculopathy, and a displaced fracture of the right femur, was transferred to the hospital after experiencing an emergency involving vomiting and uncontrollable shaking. Despite the facility's policy requiring a transfer packet, there was no evidence that such records were provided to the hospital. The LPN Supervisor involved in the transfer stated that they completed a transfer form and gathered necessary paperwork, but the documents were not found in the hospital's records. The facility's Director of Nursing confirmed that a transfer packet was not sent with the resident.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with chronic pain, leading to a deficiency. The resident, who had diagnoses including right shoulder and left knee pain, was receiving scheduled and as-needed pain medications, including opioids, acetaminophen, ibuprofen, and lidocaine cream. Despite this, the resident's comprehensive care plan did not document pain management interventions, and there was no evidence of non-pharmacological interventions being attempted. Nursing progress notes indicated that pain medications were administered and effective, but they lacked documentation of any non-pharmacological interventions for pain relief. Interviews with facility staff revealed that the care plan should have included pain management interventions, but it was overlooked. The resident expressed concerns about not receiving pain medication due to their Suboxone treatment for opioid dependence and mentioned being advised to see a pain management specialist, although no appointment had been made. Staff interviews confirmed that the care plan was not updated to reflect the resident's pain management needs, which could impact the resident's safety and well-being.

Penalty

Fine: $378,43750 days payment denial

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

Summary

The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Specifically, Resident #64, who had diagnoses including chronic obstructive pulmonary disease, chronic pain syndrome, and hand contractures, did not have bilateral hand splints in place as ordered and care planned. The resident was cognitively intact and dependent for activities of daily living, with no functional limitation in range of motion documented in the Minimum Data Set assessment. The care plan and physician orders specified that the resident should have a left grip splint applied at night on Tuesday, Thursday, and Saturday, and a right grip splint on Monday, Wednesday, and Friday. However, observations and interviews revealed that the resident's hand splints were not consistently applied as ordered. The resident's family and staff members, including CNAs and LPNs, reported that they had not seen the resident with hand splints, and the splints were found stored improperly in the resident's room. Interviews with staff, including the Director of Rehabilitation and nursing staff, confirmed that hand splints were necessary to prevent worsening of contractures. The failure to apply the splints as ordered was acknowledged as a documentation error by one LPN, who incorrectly signed for the application of a right hand splint that was not ordered. The lack of adherence to the care plan and physician orders resulted in the resident's contractures not being managed as intended, potentially leading to worsening of the condition.