West Lawrence Care Center, L L C

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 cited for not being administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the Recertification and Complaint Survey from 07/28/2025 to 08/04/2025, surveyors reviewed staffing, residents’ food preferences, dignity, home-like environment, resident assessment, and abuse, and found that administration did not ensure the facility was sufficiently staffed to meet residents’ needs, that residents’ assessments were accurate, or that dietary preferences were met. The report also states that the Administration did not monitor and enhance the quality of care and services, with repeated deficiencies cited from prior recertification surveys including F584 and F657. The findings further state that nursing services were not administered adequately to ensure residents’ rights and preferences were provided, that a home-like environment was maintained, and that participation in care planning occurred. The facility’s QAPI policy stated that quality assurance and performance improvement principles would drive decision making to promote excellence in quality of care, quality of life, resident choice, person-directed care, and resident transitions. During interviews, the Administrator stated they were not aware of environmental issues or concerns about residents’ food choices and preferences, acknowledged that sufficient nursing staffing was an issue, and said there was an oversight in not posting all surveys. The DON stated they were unaware of the extent of staffing issues, aware that agency staff posed a challenge, aware of inaccuracies in residents’ assessments, and unaware of several cited issues including F584, F600, F657, and F675, indicating lack of oversight.

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 did not ensure residents’ food preferences, choices, and beliefs were honored because it operated as a strict kosher facility and restricted access to non-kosher food for residents who were not kosher. The resident handbook stated that no non-kosher food of any kind could be brought into the facility, and a sign at the entrance stated that no outside food was permitted at any time. Staff interviews showed that residents were told outside food could only be brought in with prior arrangements and could only be eaten in a designated recreation area on the first floor, not in resident rooms or on the unit. Multiple residents reported dissatisfaction with these restrictions and described being unable to eat food brought by family or food they wanted from outside. One resident stated family could not bring food for them and that when a child did bring food, it had to be taken back home. Another resident said outside food such as pizza was only obtained on Fridays, while another stated they could not afford to order outside food regularly and had to rely on the facility’s food. A resident with diagnoses including CAD, HTN, ESRD, and hemiparesis, whose MDS documented intact cognition and a need for snacks between meals, stated that a child brought Jello cups that were confiscated and not returned because the facility was kosher, even though the resident was not kosher. Additional interviews confirmed that residents were limited to food ordered once weekly through the recreation department, with options such as Chinese, Italian, pizza, or deli food, and that family-brought food had to be eaten only in the recreation room or another designated area. Residents stated they were not allowed to eat outside food in their rooms or on the unit, and some said they were not informed of the kosher restriction before admission. During the resident council meeting, residents stated their food was not allowed in the facility and that they could only order food on Fridays, which limited their ability to eat foods they wanted. The facility assessment stated it would provide food and nutrition choices to meet personal preferences, but the observed practices and resident reports showed that residents’ individual food preferences were not consistently honored.

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 did not provide sufficient nursing staff on a 24-hour basis to meet resident needs, and did not maintain the licensed nurse coverage described in its facility assessment. The assessment documented 43 beds on each floor from the 3rd through 6th floors, with staffing par levels of 1 RN per floor on the day shift, 1 RN for the whole facility on evening and night shifts, 1.5 LPNs on the 3rd, 4th, and 6th floors and 1 LPN on the 5th floor for day shift, and 1 LPN on each floor for evening and night shifts. It also documented 4 CNAs per floor for day shift, 3 CNAs per floor for evening shift, and 2 CNAs per floor for night shift. Review of the weekend Daily Staffing sheets from 01/04/2025 through 03/30/2025 showed repeated staffing shortages. The facility had 1 RN for the whole facility during day shift instead of 1 RN on each floor for day shift as listed in the assessment. The records also showed multiple dates when the 0.5 LPN was not present, including several Sundays and one Saturday, and numerous instances where CNA staffing fell below the par level on different floors and shifts. Examples included fewer CNAs than required on the 6th floor, 5th floor, 3rd floor, 4th floor, and 6th floor across day, evening, and night shifts. During interviews, CNAs stated staffing was short most weekends when staff called out, agency CNAs also called out, and residents had to wait longer for care and remain in bed instead of transferring to wheelchairs when staffing was short. The DON stated they were not aware of the staffing shortage issue for the period reviewed, said the RN supervisor called staff for overtime when scheduled staff did not report, and acknowledged the unit would be short if replacement staff could not be obtained. The DON also stated the RN had to cover LPN duties when LPNs were short, and the Administrator stated they were not aware of the weekend staffing shortage issue despite the PBJ report showing excessively low weekend staffing and a one-star staffing rating.

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 did not ensure it had a policy regarding the use and storage of foods brought to residents by family members and visitors that allowed safe and sanitary storage, handling, and consumption. The written policy dated 01/2025 stated that no food or drink may be brought into and stored in the facility by family members or visitors without prior consent of Administration, and that approved outside food had to be consumed in a recreation office or designated area. The policy also stated that nursing staff would monitor resident rooms, unit pantries, and refrigeration units for outside food for disposal, and that unlabeled and undated foods and beverages must be discarded. The facility assessment updated 6/13/2025 stated that the facility would provide food and nutrition choices to meet resident preferences, and the Resident Handbook stated the facility was a strict kosher facility and no non-kosher food of any kind may be brought into the facility. On entrance to the facility, surveyors observed signs stating that no outside food was permitted in the facility at any time. Interviews showed inconsistent understanding and implementation of the policy: some staff stated outside food could be brought in with arrangements and eaten in the recreation room, while other staff stated residents were not allowed to have outside food on the units or in their rooms. Resident interviews showed that several residents and a resident representative were told they could not bring food into the facility or could not eat it in their rooms, and that food brought by family had to be taken back home or eaten downstairs in the recreation room. One resident with diagnoses including CAD, HTN, ESRD, and hemiparesis, whose MDS documented intact cognition and a need for snacks between meals, stated that Jello cups brought by a child were confiscated and not returned because the facility was kosher. During the Resident Council meeting, residents stated that food was not allowed in the facility, that they could only order food on Fridays, and that they were not allowed to bring in food when they wanted it. Staff interviews also reflected conflicting practices, with some stating residents could order outside food through Recreation and others stating no outside food could be delivered or brought in except under limited supervised arrangements.

Penalty

No penalty information released

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

Summary

A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.

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 all alleged violations involving abuse were reported to the State Survey Agency immediately, but not later than 2 hours after the allegation was made, as required by policy and regulation. Specifically, an incident occurred in which one resident, who had diagnoses including non-Alzheimer's dementia, anxiety disorder, and schizophrenia, accused another resident of theft and struck them with a wheelchair leg rest. Both residents were evaluated and denied injuries, and the police were notified. The incident was documented at 10:00 AM, and the Administrator was informed at 10:45 AM. However, the report to the New York State Department of Health was not made until 2:52 PM, exceeding the required 2-hour reporting window. Both residents involved had cognitive impairments and no prior behavioral symptoms directed towards others, according to their most recent assessments. The facility's policy, last reviewed in January 2025, clearly states that the Administration or Director of Nursing is responsible for reporting such allegations immediately, but not later than 2 hours after the event. During an interview, the Administrator acknowledged awareness of the incident but was uncertain about the specific regulatory requirements for reporting resident-to-resident interactions within the mandated timeframe.

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 transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident-centered care and safe transition planning.

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 Resident #90 was treated with respect and dignity and cared for in a manner that promoted quality of life. Resident #90 had diagnoses including osteoarthritis, diabetes, and bipolar disorder, and the quarterly MDS documented moderately impaired cognition, dependence for toileting and showers, supervision with personal hygiene, and frequent bladder incontinence with bowel incontinence always present. The resident also had a history of refusing care, including incontinence care and showers. During multiple observations, a strong urine odor was detected outside the resident’s room, in the hallway, at the nurses’ station, and from the resident’s person while seated in a wheelchair. The resident stated the odor was coming from themself and said the smell was still strong, especially on the mattress, and that this did not make them feel good about themself. The room was observed to be clean at times, but the odor persisted, and later the room was observed with an uncovered mattress and continued urine odor. Staff interviews confirmed the resident often refused briefs changes, showers, and other care, and sometimes removed the incontinence brief and urinated on the floor or bed. Record review showed multiple nursing notes documenting refusals of care, refusal of incontinence brief changes, and an episode where the resident refused all care and urinated on the floor. Psychiatric and psychology notes reviewed did not document evidence that the resident’s hygiene-related behaviors and environmental issues were addressed. Staff interviews described repeated reapproaches, encouragement, and daily cleaning of the room, but also acknowledged the persistent urine odor, the resident’s ongoing refusal of care, and that mattress and wheelchair cushion changes occurred periodically without a clearly documented date.

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 did not ensure that Resident #34 participated in the development, review, and revision of the comprehensive care plan to the extent practicable. Resident #34 was admitted with diagnoses including Diabetes Mellitus, Pneumonia, and Malnutrition, and the admission MDS documented intact cognition, no behaviors, and participation in assessment and goal setting. However, the resident stated during interview that they did not recall being invited to or attending a care plan meeting, and there was no documented evidence that a care plan meeting had been scheduled or that the resident had been invited to attend. Review of the care plan meeting schedule log showed that Resident #34’s care plan meeting had not been scheduled. The Social Worker Director stated residents are notified by invitation sheets and reminded on the morning of the meeting, and also confirmed there was no scheduled care plan meeting for Resident #34 even though one should have occurred. The MDS Coordinator stated they were responsible for scheduling the meeting, that care plan meetings are usually scheduled within 7 days of the MDS due date, and that Resident #34’s MDS assessment was completed, but the meeting likely did not transfer into the EMR and was missed.

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 did not ensure reasonable accommodation of a resident’s needs and preferences. Resident #151 had diagnoses including anxiety disorder, osteoarthritis of the knee, and pain, and Minimum Data Set assessments documented intact cognition, use of a wheelchair for mobility, dependence for toilet transfer, partial/moderate assistance with upper and lower body dressing, and frequent bowel incontinence. The resident’s preferences also included choosing what clothes to wear and taking care of personal belongings. During observation and interview, Resident #151 was seen in the room bathroom leaning forward in the wheelchair to wash hands because there was limited room at the sink, and the bathroom mirror was tilted and not positioned low enough for grooming. The resident stated the mirror was not low enough to see their face while shaving, they required assistance to get on and off the toilet in that room, and they could not use the closet comfortably because the door opened in a way that required bending forward in the wheelchair. The resident also stated the closet drawers, bathroom dresser shelf, and toilet paper dispenser were difficult or impossible to reach from the wheelchair. The Director of Maintenance observed the room and stated the resident needed another room to meet their needs, and also stated the room had been renovated and set up by an outside company and the facility did not check the installation.

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 did not ensure that a resident or the resident’s designated representative received appropriate notification at the termination of Medicare Part A benefits. For Resident #27, who was discharged from skilled rehabilitation services and remained in the facility, the Notice of Medicare Non-Coverage documented that the MDS Coordinator spoke by telephone with the resident’s sibling and explained that rehabilitation services would end. The sibling verbalized understanding of the notification, but there was no documentation that a copy of the Notice of Medicare Non-Coverage was mailed to the resident’s representative. During interviews, the MDS Coordinator stated that the facility’s procedure was to mail the Notice of Medicare Non-Coverage two days before the end of services so the resident or representative would have time to appeal the decision. The MDS Coordinator stated they were unable to mail it themselves and asked another staff member to mail it, and the Director of Social Work confirmed it was mailed by certified mail, but the facility could not locate the receipt to confirm it was sent the same day as the telephone notification. The DON stated the notice should be mailed the same day as telephone notification and that the matter involved resident 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 did not ensure the Comprehensive Care Plan for Resident #90 was reviewed and revised based on changing goals, preferences, needs, and current interventions. Resident #90 had diagnoses including osteoarthritis, diabetes, and bipolar disorder, and the Quarterly MDS documented moderately impaired cognition with a BIMS score of 12. The MDS also documented that the resident required supervision for eating, dependent care for toileting and showers, supervision with touch assistance for personal hygiene, and was frequently incontinent of bladder and always incontinent of bowel. During observations, Resident #90 was repeatedly noted with a strong urine odor on their person and in their room. On 07/28/2025, a strong urine odor was observed outside the resident’s room during initial pool observations. On 07/29/2025, a strong urine odor was detected in the hallway outside the room, and the resident stated the odor was coming from themself, that the smell was still strong on the mattress, and that they refused showers because they were scared they would fall. On 07/30/2025, the strong urine odor continued to emanate from the room and could be detected in the hallway, even though the resident’s clothing appeared clean and had been changed from the previous day. On 07/31/2025, the resident was observed at the nurses’ station with a strong urine odor detected. The resident’s Comprehensive Care Plan for ADL tasks and functional decline, last evaluated on 06/20/2025, did not contain personalized interventions to address the ongoing strong urine odor in the room and on the resident’s person, and instead documented only the level of ADL assistance required. The behavior care plan for resists care/noncompliance, last evaluated on 06/11/2025, also did not contain personalized interventions to address the ongoing strong urine odor. Nursing progress notes documented refusals of care, including refusal of care on 03/28/2025, refusal of care on 03/31/2025, and refusal of incontinence brief change on 06/05/2025 despite encouragement and educational counseling. The RN Supervisor stated they were responsible for initiating and updating care plans and could personalize the care plan to include interventions for hygiene, infection risk, and keeping the environment clean, and the DON stated care plans should be person-centered and based on each resident’s individual needs.

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 did not ensure that a therapeutic diet was provided when a resident had a nutritional problem and a physician’s order for an altered diet. Resident #83 had diagnoses including malnutrition, GERD, and altered mental status, and the quarterly MDS documented impaired cognition, need for supervision with eating, and a mechanically altered diet. The resident also had care plans and speech therapy guidance indicating pureed solids and honey thickened liquids with aspiration precautions, and progress notes documented repeated behaviors of taking food from other residents’ trays. During the survey, Resident #83 was observed moving another resident’s leftover tray closer, identifying it as their own, and then eating several pieces of chopped beans and drinking apple juice from that tray. The tray belonged to another resident who was prescribed a chopped diet and thin liquids. The tray remained accessible on the table after staff were alerted, and it still contained food items and an unopened coffee creamer. The resident’s physician order documented pureed consistency and honey thickened liquids, and the speech therapy assessment stated the resident was to remain on pureed solids and honey liquids with aspiration precautions. Staff interviews confirmed that Resident #83 was on a pureed diet with thickened liquids and had a history of taking food from other residents’ trays. The LPN stated the resident must be supervised closely because of impaired cognition and the tendency to eat food off other residents’ trays, and the RD stated the resident could not handle other food consistencies and could choke if they consumed them. The RN supervisor, speech therapist, and DON all acknowledged that consuming another resident’s food created an aspiration, choking, cross-contamination, and infection control issue, and the report documented that the resident had previously been noted trying to take food from other residents and needed close monitoring at mealtime.

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 safe, functional, sanitary, and comfortable environment for residents, staff, and the public in the 1st floor visitor and staff female bathroom. During observations from 07/28/2025 through 07/30/2025, surveyors observed a large rusted area on the bottom of the bathroom barrier on the left side of the toilet, a missing tile creating an open area at the back of the toilet on the left side, an uncovered light fixture, and mismatched paint on the walls. The facility policy titled Maintenance/Housekeeping, last revised 12/2024, stated that staff will survey, check, and inspect all common areas, mechanical spaces, and resident rooms during regular inspections. On 08/04/2025, the Maintenance Director stated they were responsible for making rounds and fixing issues around the building, but were not aware of the rusted area and missing tile in the female restroom and had not been informed of them. The Administrator stated they were not made aware of any environmental issues and that the Maintenance Director does not report small issues to the Administrator.

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 did not ensure that notice of the availability and location of the most recent New York State Department of Health survey report and plan of correction was posted in areas that were prominent and readily accessible to the public. During observations from 07/28/2025 through 08/01/2025, the survey results binder was seen in the lobby on the wall opposite the receptionist's desk, but there were no prominent postings of notices of availability throughout the facility, including on the units. The binder contained only the results of the last recertification survey dated 07/14/23, and there were no complaint surveys in the binder. During a Resident Council meeting, seven residents were present, and two residents stated they had not seen any sign or posting indicating the location of the NYSDOH survey results. The Administrative Assistant stated they were responsible for posting the survey results and that they were not aware the notice of the location of the survey results was supposed to be on all the units and that the binder should contain all recertification and complaint surveys for the past 3 years. The Administrator later stated they were aware the binder should include all surveys for the past 3 years, but it was an oversight that the binder was not updated, and they were not aware the notices for the location of the survey binder should have been posted on the units and on the 1st floor.

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 did not ensure Minimum Data Set (MDS) 3.0 assessments accurately reflected resident status for two residents. For one resident with diagnoses including hypertension, seizures, and dementia, the admission MDS documented no dental issues even though the resident was observed stating they had no teeth, and dental consults and the dental care plan documented the resident was completely edentulous. The MDS Coordinator stated that if the dental consult said the resident was edentulous, it should have been coded that way on the MDS, and also stated they had not physically seen the resident because they completed the assessment remotely by reviewing the chart. For another resident admitted with diagnoses including diabetes mellitus, pneumonia, and malnutrition, the admission MDS documented no fall in the 2-6 months before admission, despite the hospital discharge summary stating the resident had been admitted after a ground-level fall with loss of consciousness. The MDS Coordinator stated they reviewed the medical record, including the discharge summary, but missed the fall and it should have been coded on the MDS. The DON stated the facility audits assessments for accuracy and that the staff completing specific MDS sections are responsible for the accuracy of those sections.

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 resident's right to be free from physical restraints, as evidenced by an incident involving a resident whose left arm was tied to the siderail of their bed with a sock. This incident was discovered on the morning of October 4, 2023, when a Certified Nursing Assistant (CNA) observed the restraint and reported it to a Licensed Practical Nurse (LPN). The resident, who had a history of hypertension, hyperlipidemia, and severe contractures, reported being tied up all night and experiencing pain, although no bruises or injuries were noted upon physical assessment. The facility's investigation revealed that the resident was not provided with any care during the night shift by the assigned CNA, who admitted to not performing any activities of daily living for the resident. Surveillance footage confirmed the lack of care, and the facility concluded that another CNA, who was the last known staff member to care for the resident, was responsible for the restraint. This CNA was reported to have called the facility the following morning, expressing urgency about the situation. Interviews with various staff members, including the Director of Nursing and the Social Worker, corroborated the findings of the investigation. The Director of Nursing concluded that the CNA who last cared for the resident was responsible for the restraint, leading to their immediate removal from the schedule and subsequent termination. The facility's policies on resident abuse and physical restraints were not adhered to, resulting in this 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

During an abbreviated survey, it was found that a resident did not receive necessary assistance with activities of daily living, specifically personal hygiene care, during the 11:00 PM-7:00 AM shift. A Certified Nursing Assistant (CNA) failed to provide incontinent care to the resident, who was later observed saturated with urine. The CNA admitted to forgetting to provide care and falsely documented that care was given. Surveillance video confirmed that no care was provided during the shift. The resident involved had a history of hypertension, hyperlipidemia, and age-related muscle weakness, with moderately impaired cognition. The resident required dependent assistance for incontinent care every shift, as documented in their care plan. Despite this, the CNA did not perform the necessary care, leading to the resident being found in a state of neglect. The facility's policies on resident care and neglect were not adhered to, resulting in the termination of the CNA for neglect and falsification of documentation.

Plan Of Correction

Plan of Correction: Approved February 28, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #1 On 10/4/23, the resident was immediately provided with ADL care by the assigned CNA for the day shift after it was determined that the resident had not received ADL care on the 11-7 shift. On 02/25/2025 the resident’s ADL self-care deficit care plan and CNA nursing care instructions were reviewed by the Interdisciplinary Team (IDT) to ensure that necessary services to maintain good nutrition, grooming, and personal and oral hygiene were properly addressed. No revisions were needed to the plan of care. The Nurse Manager reviewed the plan of care with the unit staff and the staff’s responsibility to provide ADL care for this resident who requires total assistance with ADL care. CNA #3 was terminated on 10/4/23. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially affected by the same practice. Between 02/25/2025 and 03/25/2025 a full facility audit will be conducted by the IDT members to identify and assess all residents who require assistance with ADLs. This assessment will involve reviewing care plans to ensure that the necessary ADL assistance is clearly identified and outlined for each resident. Any immediate needs will be addressed promptly with staff providing the required care and support. Any revisions to a resident’s ADL plan of care will be reviewed with the responsible unit staff. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Administrator, DNS, and RN/MDS Coordinator will review and revise, as needed, the policy and procedure for Activities of Daily Living (ADL) including staff responsibility to provide ADL care as outlined in the individual plan of care for dependent residents. The DNS/designee will provide additional education to all CNAs regarding their responsibilities in providing ADL care for dependent residents. The education will focus on the importance of providing timely and appropriate assistance with ADLs, understanding and adhering to individual care plans and CNA nursing instructions, and recognizing signs of unmet ADL needs. This training will be incorporated into the orientation of new Nursing staff members and will be reviewed annually and as needed. RN Supervisors will monitor compliance through routine observational rounds to ensure that ADL care is provided consistently and in accordance with each resident’s care plan. Immediate corrective actions, including staff re-education and, if necessary, disciplinary action, will be implemented for any deviations or failure to provide required ADL care. The IDT will be responsible for reviewing and updating each resident’s care plan to ensure it accurately reflects their ADL needs and preferences. Care plans will include specific details regarding the frequency and type of assistance required, as well as any special considerations (e.g., preferred timing or specific requests for assistance). IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with the provision of ADL care per the plan of care. The RN/designee will audit 20% of residents requiring different levels of ADL assistance monthly for the next three months, then quarterly for the following three quarters. Each audit sample will include ADL dependent residents. All audit findings will be reported to the Administrator and DNS monthly. Corrective actions, such as staff reeducation or revision to the plan of care, will be implemented as needed. The DNS/designee will report ADL audit findings to the QA Committee on a quarterly basis for evaluation, discussion, and follow-up corrective action. At the end of the fourth quarter, the QAPI Committee will assess the need for ongoing monitoring and determine the appropriate frequency.

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 resident's right to be free from physical restraints not required to treat medical symptoms, as evidenced by an incident involving a resident whose left arm was tied to the siderail of their bed with a sock. This incident was discovered on the morning of October 4, 2023, when a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) found the resident in this condition. The resident reported being tied up all night and experiencing pain, although no bruises or injuries were observed, and an x-ray showed no fractures or dislocations. The facility's investigation revealed that the resident was under the care of a CNA during the night shift, who was later found not to have provided any care to the resident during their shift. Surveillance footage confirmed the lack of care provided. Another CNA, who was on the previous shift, was implicated in the incident after reportedly calling the facility the following morning and asking another CNA to check on the resident. This CNA was later identified as the last known staff member to have cared for the resident before the incident. The facility's policies on resident abuse and physical restraints, which emphasize the residents' right to be free from such restraints unless medically necessary, were not adhered to in this case. The Director of Nursing concluded that the CNA from the previous shift was responsible for restraining the resident, leading to their immediate removal from the schedule and subsequent termination. The incident highlights a significant breach of the resident's rights and the facility's failure to protect them from unauthorized restraints.

Plan Of Correction

Plan of Correction: Approved February 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Resident #1 On 10/4/23, the resident was seen and examined by the Assistant Director of Nursing Services (ADNS), with no visible signs of injury. The attending physician was notified, and an order for [REDACTED]. The resident does not exhibit any medical symptoms that would necessitate the use of a restraining device. On 10/4/23, the Social Work (SW) Director contacted the local police department to report the incident for further investigation. The case was subsequently referred to the district attorney's office for review. The resident was re-examined by the attending physician on 10/6/23, who reviewed the left-hand x-ray results. CNA #2 was terminated on 10/4/23. The Potential for Abuse Care Plan was reviewed on 12/16/24 and again on 2/25/25, the interdisciplinary team (IDT) determined that there was no need to revise the plan of care. The IDT continues to monitor for any signs or symptoms of abuse or unnecessary use of physical restraint devices. There have been no restraint concerns since this event in 2023. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents in the facility have been identified as potentially affected by the same practice. A comprehensive audit was conducted by the Nurse Supervisors and the Interdisciplinary Care Plan Team (IDCPT) on 02/25/2025 for all residents to identify any use of physical restraint devices. No residents were found to be using any physical restraint devices. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Administrator, Director of Nursing (DNS), and Medical Director will review and revise, as necessary, the facility’s policies and procedures related to physical restraints. This review will include protocols for assessing the use of restraints, obtaining physician orders, securing resident representative consent, and ensuring proper care planning for restraints. The DNS/designee will continue to provide additional education to all staff regarding their responsibilities related to the policies and procedures for physical restraint. This education will be included in the orientation for new clinical team members and reviewed annually or as needed. RN Supervisors will monitor compliance through routine observational rounds and review physician orders [REDACTED]. Immediate corrective actions, including staff re-education and reassessment of restraints will be taken as needed. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with protocols related to the use of restraints. The DNS/designee will audit all residents identified with restraint devices monthly for the next 3 months, and then quarterly for the following 3 quarters. The DNS will report all restraint audit findings to the Administrator monthly for the first 3 months, and then at the end of each subsequent quarter for the next 3 quarters. Corrective actions, including education and obtaining physician orders [REDACTED]. The DNS will report all physical restraint audit findings to the QA Committee monthly for the first 3 months, and then at the end of each subsequent quarter for the next 3 quarters. At the end of this period, the Committee will evaluate the need for continued monitoring, determine the appropriate frequency, and decide on any additional corrective actions to implement.