Utica Rehabilitation & 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

Drugs and biologicals were not labeled and stored in accordance with accepted professional principles in two medication carts and one medication room refrigerator. On Unit 3 South, the medication cart contained expired Refresh ophthalmic solution with an opened date of 11/04/2025 and Fluticasone nasal spray with an opened date of 12/18/2025, which staff identified as expired and needing to be discarded. Staff stated they were supposed to check carts for expired medications, but the expired items remained in the cart during the survey observation. On Unit 4 North, the medication cart contained an opened Trelegy Ellipta inhaler without an open date, two Lantus insulin pens with labeling problems, and opened eye drops. One Lantus pen had no pharmacy label, resident name, or date opened, and the second pen had a pharmacy label but no opened date. The eye drops, including Artificial Tears and Visine, were observed opened on 11/11/25. Staff stated inhalers, insulin, and eye drops needed to be labeled when opened, and that an insulin pen without a pharmacy label should be discarded and not used. The Unit 4 medication room refrigerator was also not maintained at the required temperature. Surveyors observed temperatures of 56 degrees Fahrenheit and 68 degrees Fahrenheit on the facility thermometer, while staff reported different readings from other thermometers. Additional observations showed the refrigerator at 56 degrees Fahrenheit, 60.3 degrees Fahrenheit, and 58 degrees Fahrenheit on separate occasions, with staff placing thermometers inside and later reading 54 degrees Fahrenheit. Facility policy required the refrigerator to remain between 36 and 46 degrees Fahrenheit, and staff stated overnight nurses were responsible for checking and documenting temperatures.

Penalty

No penalty information released

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

Summary

The facility failed to honor a resident’s advance directive when Resident #14, who had intact cognition, a documented do not resuscitate/do not intubate status, and a MOLST order for do not attempt resuscitation allowing natural death, was found in acute distress in the dining room. The resident had diagnoses including peripheral vascular disease and atherosclerosis. The care plan documented that the resident’s DNR status and wishes would be honored, and the MOLST form had been signed by the resident and a provider and later reviewed with no changes. According to the investigative summary and staff interviews, the resident was coughing and appeared to be choking. Back pats were given, the Heimlich maneuver was attempted, and when the resident went limp and became unresponsive, staff lowered the resident to the floor. At that point, no pulse was felt and a code blue was called. LPN #3 initiated chest compressions, and an AED was applied by the RN supervisor; no shock was advised. Staff later verified that the resident had a DNR order, and compressions were stopped. The record and interviews showed that CPR was started before the resident’s code status was confirmed. LPN #3 stated compressions began immediately after the resident became unresponsive and that it took over two minutes to verify the code status. The RN supervisor stated the code status ideally should have been checked before CPR was initiated and that staff hoped the MOLST would be checked prior to compressions. Another LPN stated they started CPR if a resident was found unresponsive prior to checking code status.

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficiency involved two residents: one resident with diabetes, morbid obesity, and an open left hip wound with a history of MRSA infection, and another resident with diabetes and a Stage 4 pressure ulcer of the right heel who had severely impaired cognition and was dependent for all activities of daily living. For the resident with the left hip wound, the care plan and physician order documented contact precautions, including gown and glove use for contaminated linens and wound-related care. During observation, an activities aide entered the room without a gown or gloves, searched through drawers and the closet, cleaned the resident’s shoe with a wet towel, and later re-entered the room without PPE to retrieve items from the resident’s bed. On another observation, two CNAs entered the room without gowns or gloves and performed care, including transfer and perineum care, while stating they were unsure whether the resident was on precautions and had not followed the sign posted outside the door. For the resident with the right heel wound, the care plan and provider order documented enhanced barrier precautions. During wound care, an LPN donned gloves but did not wear a gown. The LPN later stated they did not believe the resident was on enhanced barrier precautions because the treatment was skin prep, and only after checking the chart did they confirm the precautions were in place and that a gown should have been worn. The infection control nurse and unit manager stated that wound care for residents on enhanced barrier precautions required gowns and gloves, and that contact isolation also required staff to follow the posted sign.

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 resident environment was free of accident hazards, resulting in three residents being served a cleaning solution stored in an unlabeled pitcher in the kitchenette refrigerator. Residents consumed or were served the solution, mistaking it for juice, which led to physical and psychosocial harm. The facility's policy required that all foods and substances be properly labeled and stored separately from cleaning compounds, which was not adhered to in this instance. Resident #72, who had diagnoses including end-stage renal disease, hypertension, and diabetes, was cognitively intact and required assistance with eating. On the evening of the incident, the resident inadvertently ingested a gulp of the cleaning solution, resulting in a terrible taste in their mouth and subsequent anxiety about drinking fluids. The resident experienced intermittent nausea and a sore throat following the incident. Resident #75, with moderately impaired cognition, was served the solution but did not consume it, while Resident #98, with severely impaired cognition, took a sip but did not swallow it due to the taste. The investigation revealed that the cleaning solution was mistakenly served as juice due to a lack of labeling and improper storage. The Food Service Aide, who poured the drinks, assumed the liquid was juice and did not notice any scent indicating otherwise. The Dietary Supervisor identified the issue when they noticed the liquid's odd appearance and chemical smell. The facility's failure to adhere to proper labeling and storage protocols led to the incident, posing a risk of serious harm to the residents involved.

Removal Plan

• The Administrator provided an immediacy removal plan when all the chemicals were removed from the kitchenettes and secured in the locked service closet on the first-floor service corridor.
• All food service staff were to be educated on the process of taking cleaning chemicals from the secured chemical closet after meal service to clean the kitchenettes, and no chemicals were to be left in the kitchenettes.
• All staff were educated that any unlabeled drinks were to be disposed of immediately.
• The Certified nurse aides, food service staff, licensed practical nurses, and registered nurses were educated with emphasis on the fact drinks were to be identified with a label and date.
• The facility would educate 100% of staff prior to the start of their next scheduled shift.
• The Dietary Cook/Supervisor completed an audit of all three kitchenettes to ensure there were no unsecured cleaning agents, or unlabeled drinks.
• The Director of Food Services completed floor round and confirmed there were no chemical bottles in the kitchenettes.
• The Food Service Director completed an audit of the first-floor kitchen and removed unsecured cleaning agents and placed them in the locked first floor corridor kitchen closet.
• 86 of 147 employees (59%) were educated and the plan was to continue to educate employees over the phone and prior to their next scheduled shift.
• 85% of staff, 125 had been educated about storing cleaning products in the kitchen and kitchenettes, labeling all resident drinks in pitchers with the date and juice type, and immediately disposing of anything unlabeled in a pitcher.

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 list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the Ombudsman and the New York State Nursing Home Complaint Hotline, were posted in a manner accessible to residents and their representatives. During a resident group meeting, 13 anonymous residents reported that they did not know where to find this information. Observations confirmed that there were no postings of the Ombudsman program or the New York State Nursing Home Complaint Hotline in the main lobby or on the 4th floor during the survey period. Interviews with facility staff revealed that the signs containing this critical information were removed during a construction process and were either damaged or missing. The Social Services Director acknowledged that the information was included in the resident handbook provided upon admission, but the physical signs had not been re-posted since the renovation. The Administrator confirmed that new signage was ordered, and paper versions were temporarily put up but were removed during construction or by residents. This oversight resulted in residents not having easy access to important contact information, which is a violation of their rights.

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 the results of the most recent Federal and State surveys were posted in a location that was easily accessible to residents, family members, and legal representatives. During the recertification survey conducted from February 3 to February 11, 2025, it was observed that the state inspection binder located in the front lobby did not include the most recent standard health survey results from March 2023 or any subsequent complaint survey results. Additionally, there was no posted notification of the availability of the previous three years of survey reports, which is a requirement according to the facility's policy on Resident Rights dated October 2017. Observations made on February 4 and February 10, 2025, revealed that the binder only contained the Life Safety survey results from March 7, 2023, and the facility's star rating from the Medicare website. Interviews with the receptionist and the administrator confirmed that the binder was the administrator's responsibility, and it was supposed to include the last survey results and any updates between surveys. However, the administrator had only recently added the last complaint results and the star rating, indicating a lapse in maintaining the binder's contents as required by regulations.

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 residents were aware of the grievance process and how to file grievances, as evidenced by the findings during the recertification survey. Thirteen residents present at a resident group meeting expressed that they did not know who the grievance officer was or how to file a grievance. The facility's grievance policy, revised in 2020, stated that residents had the right to voice grievances with the expectation of resolution, and this information was supposed to be provided upon admission and prominently posted throughout the facility. However, the residents reported not receiving this information, indicating a lack of communication and accessibility regarding the grievance process. Interviews with the Social Services Director and the Administrator revealed inconsistencies in the grievance process. The Social Services Director, who was designated as the Grievance Officer, stated that grievances could only be filed through them, and if a resident wanted to file anonymously, they would not include the resident's name on the form. The Administrator confirmed that the grievance process involved the Social Services Director and that the information was included in the welcome packet, but acknowledged that there were no signs posted in the facility to inform residents of the grievance officer or the process. Additionally, the Administrator was unaware that residents had the right to file grievances anonymously, highlighting a gap in the facility's adherence to its own policy and regulatory requirements.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an accurate system of records and accounts for controlled drugs on Unit 3, as observed during a recertification survey. Specifically, the controlled substance reconciliation process was not properly executed between oncoming and outgoing nurses. The narcotic count log form was completed and signed without an actual count being performed, and narcotic keys were not transferred securely between nurses. This led to discrepancies in the medication count for Resident #65, whose Controlled Substance Record was not accurately reconciled after clonazepam was administered. Resident #65 had a physician order for clonazepam, a narcotic anti-anxiety medication, to be administered twice daily. However, a discrepancy was noted when the narcotic compartment contained 52 tablets, while the Controlled Substance Record indicated there should have been 53 tablets. This discrepancy was attributed to a nurse not signing out the medication the previous night. Additionally, the shift-to-shift count log was inaccurately completed, documenting 54 tablets when the actual count was different. Interviews with nursing staff revealed systemic issues with the transfer and counting of narcotic keys. Nurses admitted to not performing required counts during shift changes, and keys were sometimes left unsecured at the nursing station. The lack of a full-time night supervisor contributed to these lapses, as floor nurses were often tasked with dual roles, leading to improper handovers. Despite awareness of these issues, the facility had not effectively addressed the problem, resulting in potential risks to medication security and accountability.

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 establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the recertification survey. On Units 2 and 3, there was a lack of proper signage for transmission-based precautions, and personal protective equipment (PPE) was not readily accessible. Specifically, Resident #100's room lacked precautionary signs and PPE, despite the resident being on contact isolation for antibiotic-resistant organisms. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for ensuring appropriate signage and PPE availability. Additionally, Licensed Practical Nurse #37 was observed performing wound treatment for Resident #100 without the necessary PPE, and the waste was disposed of improperly in a regular garbage bag instead of a red biohazard bag. This indicates a failure to adhere to the facility's policies on contact precautions and PPE usage, which are critical for preventing cross-contamination and protecting both staff and residents from infection. Resident #31's suction equipment was not maintained in a sanitary manner, with the suction canister and tubing not dated and the Yankauer catheter left uncovered on the nightstand. The resident was on enhanced barrier precautions due to a tube feeding, yet the necessary PPE was not used during high-contact activities such as medication administration and dressing changes. These observations highlight significant lapses in infection control practices, potentially exposing residents to harmful microorganisms.

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 develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #59, who had a diagnosis of type 2 diabetes mellitus and was receiving insulin, did not have a care plan that included diabetes management or insulin administration. Interviews with staff revealed a lack of awareness and understanding of the resident's diabetic condition and the necessary monitoring for hyperglycemia and hypoglycemia. Resident #88, diagnosed with atrial fibrillation and on an anticoagulant, did not have a care plan addressing the use of the anticoagulant or monitoring for related symptoms. Staff interviews indicated a lack of knowledge about the care plan and the importance of monitoring for signs of bleeding or bruising, which are critical for residents on anticoagulants. The resident's care plan was not updated when they transferred from another floor, leading to the oversight. Resident #100, with multiple diagnoses including diabetes, atrial fibrillation, and Parkinson's disease, was on high-risk medications such as insulin, anticoagulants, and antipsychotics. However, their care plan did not reflect these medications or the necessary monitoring and interventions. Staff interviews highlighted a lack of clarity on whether high-risk medications should be included in care plans, and the responsibility for initiating and updating care plans was not clearly defined among the nursing 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 ensure that drugs and biologicals were stored according to professional standards, as observed during a recertification survey. Specifically, three out of four medication carts contained expired medications and improperly labeled drugs. On the 3rd floor North medication cart, several medications, including an inhaler, eye drops, and insulin, were either expired or lacked proper labeling, such as opened dates. Additionally, a medicine cup filled with acetaminophen tablets was unlabeled, and the nurse on duty admitted to administering some of these medications without verifying their expiration dates. On the 4th floor, both North and South medication carts had similar issues with expired and unlabeled medications. An opened bottle of Geri Care mucus relief was found with an expiration date that had already passed before it was opened, and aspirin bottles lacked proper expiration dates. Nurses interviewed during the survey were unsure of who was responsible for checking the expiration dates, and it was noted that expired medications had been administered to residents. The Registered Nurse Manager confirmed that each nurse was supposed to check expiration dates before administering medications, but there was confusion about who was responsible for monitoring the medication carts.

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 stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, surveyors observed unclean surfaces in the kitchenettes on Units 3 and 4 and the main kitchen. Specific issues included food debris and grime in various areas of the main kitchen, such as the dry storage room, freezer, and around kitchen equipment. Additionally, there were discrepancies in thermometer readings in the walk-in cooler and economy refrigerator, indicating inaccurate temperature monitoring. Moldy bread was found in the fourth-floor kitchenette, and food spills and debris were noted in the third-floor kitchenette refrigerator. The facility's policies on cleaning and sanitizing equipment, food storage, and temperature control were not adhered to, as evidenced by the observations made during the survey. The Food Service Director acknowledged the inaccuracies in thermometer readings and the presence of moldy bread, which could pose a health risk to residents. The director also noted that the kitchen and equipment should be cleaned after use, and the floors should be maintained daily. However, the survey revealed that these practices were not consistently followed, leading to unsanitary conditions and potential contamination risks.

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 residents across multiple units. On Unit 2, the activity room contained a stove/oven with accessible and operational knobs, which was left plugged in and unattended at times, posing a potential safety hazard. The Director of Activities acknowledged that the room was not locked, and residents had access to it, which could be unsafe if they entered unsupervised. The Director of Environmental Services confirmed that the stove/oven lacked safety features and was accessible to both staff and residents. On Unit 3, Resident #31's tube feeding pole was observed to be unclean on multiple occasions, with a large amount of splattered residue. Interviews with staff revealed that housekeeping was responsible for cleaning equipment, but nursing staff should also clean it if needed. The unclean state of the pole was acknowledged by both housekeeping and nursing staff, indicating a lapse in maintaining sanitary conditions for resident care equipment. On Unit 4, Resident #6's enabler bar was improperly secured and not attached to the bed, rendering it unusable. Observations showed that the bar was missing a bolt and had black electrical tape wrapped around it. Despite being aware of the issue, staff did not submit a work order for repairs. The Director of Environmental Services stated that beds, including enabler bars, were inspected biannually, but there was no record of a request to fix the enabler bar for Resident #6.

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 two residents maintained acceptable parameters of nutritional status. Resident #6 experienced significant weight fluctuations, including a 12.1% weight loss in one month and a subsequent 15% weight increase in another month. Despite these changes, there was no documented evidence that the resident's nutritional needs were reassessed. The resident's weight records were inconsistent, with some weights being struck out, and there was a lack of follow-up on the resident's nutritional status after significant weight changes. The resident's diet and fluid intake were not adequately monitored, and there was no staff encouragement observed during meals. Resident #31, who had a feeding tube due to dysphagia, did not receive the ordered water flushes as prescribed. The resident was supposed to receive 30 milliliters of water every hour, but observations showed that the water flush settings on the feeding pump were incorrect, ranging from every 2 to 4 hours. This discrepancy was not addressed by the nursing staff, who continued to sign off on the medication administration record as if the correct flushes were being provided. The resident's fluid needs were not met, putting them at risk for dehydration. The facility's policies on nutrition assessment and gastrostomy tube feeding were not followed, leading to inadequate monitoring and reassessment of the residents' nutritional and hydration needs. The registered dietitian and diet technician did not effectively communicate or address the significant weight changes and incorrect feeding pump settings. These deficiencies highlight a failure in the facility's processes to ensure residents' nutritional and hydration needs are met, as evidenced by the lack of reassessment and incorrect implementation of physician orders.

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, including the current resident census and the actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. This deficiency was observed during a recertification survey conducted from February 3, 2025, to February 11, 2025. The facility did not post the required information in a prominent location accessible to residents and visitors for six consecutive days. Specifically, the staffing information was not displayed at the beginning of the shift on February 3, 4, 5, 6, 7, and 10, 2025, as mandated. Interviews conducted during the survey revealed that the facility's policy, effective April 1, 2022, required staffing to be evaluated and adjusted at the beginning of each shift, with the information to be posted by the night supervisor and updated by shift supervisors as needed. However, observations showed that the staffing information was not posted in the main lobby, on the main entrance doors, or at the reception desk. The Administrator acknowledged that the information should have been posted in the front lobby but noted that items had gone missing from the front desk. The Human Resources/Staffing Scheduler confirmed awareness of the posting requirement and observed that the staffing information was not in its designated location, which was usually a clear frame on the receptionist desk.

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 a nourishing, well-balanced diet that considered the preferences of Resident #24, who had diagnoses of diabetes and chronic obstructive pulmonary disease. The resident's dietary needs and preferences were not met as evidenced by the breakfast meal ticket indicating four fried eggs, yogurt, and cold cereal, but the resident only received one fried egg and none of the other items. The resident expressed that they would have eaten the yogurt and cereal if provided. Additionally, the resident reported not being asked about their drink preferences, not receiving a menu, and not being informed about food alternatives, which led to dissatisfaction with meal options. Interviews with staff revealed inconsistencies in meal preparation and service. Certified Nurse Aide #7 and Dietary Aide #39 acknowledged discrepancies in the meal served to Resident #24, with the latter admitting to possibly confusing the resident's meal with another's. Staff also noted that menus and alternative options were not readily available to residents due to remodeling, and residents frequently inquired about meal options. The dietary ticket, which should reflect the resident's preferences, was not accurately followed, contributing to the deficiency in meeting the resident's nutritional needs.

Penalty

Inspection fine: $141,063

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

Summary

The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nurse Aide (CNA) and a resident. The CNA was observed by a Dietary Aide to have struck the resident on the face with an open hand after the resident requested ice and ginger ale. This incident was not reported immediately, as the Dietary Aide waited three days before notifying the Director of Nursing. Other staff members were aware of the incident but also failed to report it in a timely manner. The resident involved had a history of dementia, unspecified psychosis, and anxiety disorder, with intact cognition and independence in transfers and ambulation. The resident's care plan noted potential for being abused due to kleptomaniac behaviors that could annoy others. During the incident, the resident was reportedly slapped by the CNA after a verbal exchange, and the resident retaliated by striking the CNA. Despite the altercation, the resident was assessed with no injuries or signs of psychological distress. Multiple staff members, including a Licensed Practical Nurse and a Housekeeper, were aware of the incident but did not report it promptly. The CNA involved continued to work with access to residents until the incident was reported. The facility's failure to ensure timely reporting and protection from abuse resulted in Immediate Jeopardy and Substandard Quality of Care for the resident, placing all residents at risk for serious harm.

Removal Plan

• Certified Nurse Aide #8 was terminated.
• All staff that were aware of the abuse and failed to report it were terminated.
• All staff were educated on abuse and reporting abuse, and education occurred shift to shift until 100% of all staff were educated.
• Resident #1 was assessed by the medical provider and seen by the psychiatric nurse practitioner.
• All residents on the affected unit were evaluated to determine if they were victims of abuse or witness to any abuse.
• All staff received education on abuse, types of abuse, requirements for reporting abuse, the timeframe in which to report abuse, and the ramifications of not reporting abuse timely. Any staff who were not present during the training will be educated on their first day back to work prior to beginning their shift.
• Verification interviews were completed with multiple staff from multiple departments to ensure understanding of the abuse education.

Penalty

Inspection fine: $141,063

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 report an incident of staff abuse towards a resident to the State Agency and law enforcement in a timely manner. Dietary Aide #4 witnessed Certified Nurse Aide #8 strike Resident #1 on the face with an open hand, but did not report the incident to the administration until three days later. Multiple staff members were aware of the abuse allegations but failed to report them to the administration. Upon receiving the report, the facility did not notify the State Agency or law enforcement as required. Resident #1, who had diagnoses including dementia, unspecified psychosis, and anxiety disorder, was assessed to have intact cognition and was independent with transfers and ambulation. The incident occurred when Resident #1 requested ice and ginger ale from Dietary Aide #4, and Certified Nurse Aide #8 intervened, telling the resident to sit down and subsequently striking them. Resident #1 retaliated by striking back and then sat down. The Director of Nursing and Administrator were notified of the incident three days later, and an assessment of Resident #1 showed no injuries or signs of psychological distress. Certified Nurse Aide #8 continued to work after the incident until they were suspended on the day the administration was notified. There was no documented evidence that the aide was immediately removed from resident contact or that law enforcement was notified of the alleged abuse. The facility's failure to report the abuse in a timely manner resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #1, placing all residents at risk for serious harm.

Removal Plan

• Local law enforcement was notified of the alleged abuse toward Resident #1.
• Resident #1 was assessed by the medical provider and assessed by the psychiatric nurse practitioner.
• All residents on the affected unit were evaluated to determine if they were victims of abuse or witness to any abuse. No other residents identified.
• The Administrator and Director of Nursing were educated by the Corporate Administrator on the need to report all allegations of staff abuse towards a resident to local law enforcement. Education included the process for reporting, whom to report, the timeframe in which to report, and the professional and criminal ramifications of not reporting.
• The Administrator and Director of Nursing reported they had received the education.
• Certified Nurse Aide #8 was terminated.
• All staff that were aware of the abuse and failed to report it were terminated.
• All staff working were educated on abuse and reporting abuse, and education occurred shift to shift until 100% of all staff working were educated.
• 88% of all staff received education on abuse, types of abuse, requirements for reporting abuse, the timeframe in which to report abuse, and the ramifications of not reporting abuse timely. Any staff who were not present during the training will be educated on their first day back to work prior to beginning their shift.
• Verification interviews were completed with multiple staff from multiple departments to ensure understanding of the abuse education.

Penalty

Inspection fine: $56,362

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

Summary

The facility failed to protect residents from sexual abuse, specifically involving two residents. One resident, with intact cognitive function and a history of sexually inappropriate behaviors, continued to exhibit such behaviors without documented interventions to address them or protect other residents. This resident made verbal sexual requests to others and was found in a compromising situation with another resident who had severe cognitive impairment. The facility did not assess the cognitively impaired resident timely, nor did they notify the resident's representative, medical provider, or the police in a timely manner. Additionally, interventions to protect this resident and other vulnerable residents were not implemented promptly. The facility's policy on abuse prevention was not effectively followed, as there was a lack of analysis and intervention for residents with behaviors that could lead to conflict or neglect. Despite the resident's history of sexually inappropriate behavior, including touching others and making explicit comments, the facility's response was inadequate. Staff were advised to ignore the resident's comments and keep them away from female residents, but no substantial measures were taken to prevent further incidents. The resident was moved to a unit primarily for residents with dementia, which increased the risk of abuse due to the vulnerability of the other residents. Interviews with staff revealed a lack of awareness and action regarding the resident's behaviors and the risks posed to others. The Director of Social Services and other staff were aware of the resident's inappropriate behaviors but failed to implement effective interventions. The resident continued to make inappropriate comments and engage in sexual acts with other residents, yet remained on the same unit without adequate supervision or intervention. The facility's inaction and failure to protect residents from abuse resulted in immediate jeopardy and substantial quality of care issues.

Removal Plan

• A comprehensive review of all current residents' records (progress notes, incidents) was completed by the Corporate RN. The review included direct care staff interviews by the Corporate RN to identify any potential unidentified behavioral concerns.
• A review of all behavioral consults was completed to ensure any recommendations were addressed.
• A Regional Administrator/Licensed Master Social Worker and telehealth psychology services were identified for availability for consultation as needed.
• 100% of all staff currently working have been educated on abuse, sexual abuse prevention, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse.
• 86% of the total staff population have received education, with education planned to continue until 100% is reached.
• 100% of all supervisors were educated on response to abuse allegations, including documentation and protection of residents.
• The remaining staff will be educated prior to the start of their next shift or upon return from their leave.
• Staff education sign in sheets were reviewed and compared to the current staff list and no discrepancies were identified.
• Staff education was verified during an onsite visit. Multiple staff including nursing, therapy, dietary, housekeeping, and activities were interviewed.
• Staff were able to report content of education and confirmed the day they received the education and the facility staff who presented the education (Corporate Registered Nurse, Educator/Assistant Director of Nursing, and the Director of Social Services.)

Penalty

Inspection fine: $56,362

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 treatment and care to several residents, leading to significant deficiencies. One resident experienced episodes of vaginal and rectal bleeding, but was not assessed by a qualified professional for over 11 hours, and the medical provider was not notified until more than 8 hours after the onset of bleeding. Despite being on anticoagulant medications, there was no evidence that the medication was reviewed by the provider to determine if it should be held. The resident was eventually sent to the hospital with gastrointestinal bleeding and acute blood loss anemia, requiring a blood transfusion. Another resident had an intact left heel blister for which a treatment was ordered, but there was no documentation of monitoring or assessment of the wound after the treatment was ordered. The resident's care plan was not updated to include necessary interventions, and there was no follow-up to ensure the wound was healing or deteriorating. This lack of documentation and follow-up indicates a failure to adhere to the facility's policy on pressure injury prevention and management. Additionally, a resident's ordered Lidocaine Pain Patch was not obtained or administered in a timely manner on multiple occasions. There were no corresponding nursing notes explaining why the patches were unavailable, and the issue was not communicated effectively to the provider to seek an alternative treatment. This repeated failure to provide the prescribed pain management treatment highlights a breakdown in the facility's medication management process.

Removal Plan

• 83% of nursing staff and therapy staff had been educated on recognizing a change in condition, actions for staff to take when a change in condition was identified, notification of the registered nurse, notification of the medical provider, monitoring and follow-up, and follow-up responsibilities.
• The remaining staff would be educated prior to the start of their next shift.
• Staff education sign in sheets were reviewed and compared to the current nursing/therapy staff list and no discrepancies were identified.
• 100% of nursing staff and therapy staff currently working received education.
• Staff education was verified during an onsite visit, multiple nursing staff on multiple units along with therapy staff were interviewed.
• Staff were able to report content of education.
• 30 days of 24-hour reports were reviewed to identify other affected residents related to change in condition.

Penalty

Inspection fine: $56,362

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 thorough investigations of abuse and neglect allegations for several residents. In one instance, a cognitively impaired resident was found in another resident's room engaging in a sexual act. The facility did not assess the involved residents promptly, nor did they notify the police, family, or medical provider in a timely manner. Additionally, protective interventions were not implemented immediately, and a staff member left the residents after discovering them in the act. Another incident involved a physical altercation between two residents, where neither was assessed by a qualified professional in a timely manner. A staff member reported the incident to a supervisor, who declined to assess the residents at that time. There was no documentation of assessments or notifications to the residents' representatives until the following day. In a separate case, a resident received vaccinations from an unqualified staff member, and the staff member was not suspended pending the investigation. The facility's investigation did not address the type of vaccination administered, discrepancies in the medication administration records, or the lack of medical provider notification related to the medication error. Additionally, there was no disclosure to the resident about the medication error or the unqualified staff member who administered the vaccination.

Penalty

Inspection fine: $56,362

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 comprehensive care plans were reviewed and revised to meet the needs of three residents, leading to deficiencies in addressing sexually inappropriate behaviors and protecting vulnerable residents. Resident #5, who had a history of sexually inappropriate behaviors, did not have an individualized care plan to address these behaviors. Despite multiple incidents of inappropriate comments and actions towards other residents, the care plan was not updated to include specific interventions to prevent further occurrences or protect other residents. Resident #4, who had severe cognitive impairment and a history of wandering, was at risk of being sexually abused. The care plan did not include updates or interventions to address the risk posed by Resident #5's inappropriate sexual requests. An incident occurred where Resident #4 was found in Resident #5's room engaging in a sexual act, yet there were no documented care plan updates to prevent such incidents. Resident #13, with severe cognitive impairment, was involved in an incident where they kissed Resident #5 after being asked for a kiss. Despite this interaction and the potential risk of abuse, there were no updates to Resident #13's care plan to address the risk posed by Resident #5. The facility's failure to update and individualize care plans for these residents resulted in ongoing inappropriate behaviors and potential harm.

Penalty

Inspection fine: $56,362

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 medically related social services to ensure the highest practicable physical, mental, and psychosocial well-being for three residents. Resident #5, who had intact cognitive function and a history of sexually inappropriate behaviors, was moved to a unit with cognitively impaired residents without implementing person-centered mental/behavioral health interventions. The responses to Resident #5's inappropriate behaviors were ineffective and punitive, and the recommendations from a licensed psychologist were not incorporated into the resident's care plan. Additionally, the facility's social work staff lacked the necessary academic degrees or licensure, and the contracted Licensed Master Social Worker was not consulted regarding Resident #5's high-risk behaviors. Resident #4, who exhibited wandering behaviors and resided on the same unit as Resident #5, had instances of entering Resident #5's room. There were no documented interventions from social services to address Resident #4's risk of entering Resident #5's room, despite the potential for abuse. Furthermore, Resident #13, who had cognitive impairment, was subjected to an inappropriate request from Resident #5, which was not addressed appropriately by social services. There were no documented interventions to mitigate the risk posed to Resident #13 by Resident #5. The facility's Director of Social Services failed to consult with the Psychiatric Nurse Practitioner or the psychologist regarding Resident #5's ongoing behavioral concerns. The Director of Social Services also did not implement the psychologist's recommendations, which included close supervision and engaging Resident #5 in activities to prevent inappropriate behaviors. The facility's social services department did not effectively address the behavioral issues of Resident #5, nor did they implement protective measures for other residents at risk of abuse.

Penalty

Inspection fine: $56,362

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 residents were free from sexual abuse and did not implement timely interventions to protect residents from further abuse. Resident #5, with a history of sexually inappropriate behaviors, was placed on a floor primarily for residents with dementia, leading to an incident where Resident #4, a cognitively impaired resident, was found engaging in a sexual act with Resident #5. Despite multiple reports of Resident #5's behaviors, the Director of Social Services did not implement effective interventions or recall the psychologist's recommendations. The Administrator acknowledged that Resident #5 should have been moved sooner to prevent abuse. The facility's investigations into incidents were inadequate, failing to identify concerns or implement timely protective interventions. Resident #4 was not assessed by a qualified professional immediately after the incident, and notifications to family, medical providers, and police were delayed. Additionally, Resident #5 was involved in a physical altercation with another resident, and the staff failed to assess the residents involved promptly. An unqualified staff member administered vaccinations, and there was no immediate suspension pending investigation. The facility did not provide medically-related social services to maintain residents' well-being. Resident #5, with intact cognitive function and a history of inappropriate behaviors, was moved to a unit with cognitively impaired residents without person-centered interventions. The Director of Social Services did not seek consultation from the facility's Licensed Master Social Worker or implement the psychologist's recommendations. The facility's social work staff lacked appropriate academic degrees or licensure, and the contracted Licensed Master Social Worker was not consulted for high-risk behaviors.