Altercare Thornville Inc.

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 was shaved according to preference upon admission and during the first shower. Resident #54 was admitted with diagnoses including other displaced dens fracture, muscle weakness, and hemiplegia. An order dated 02/15/26 required extensive assistance for bathing and limited assistance for personal hygiene and shaving. A shower sheet showed the resident received a shower on 02/16/26, but when observed on 02/17/26, he was sitting in bed wearing non-skid socks and a hospital gown, with disheveled hair and long, unkempt facial hair. The resident stated he would like to be shaved, and CNA #104 confirmed he had not been cleaned up and that his facial hair needed trimmed. On 02/18/26, the Social Worker was observed leaving the resident’s room and stated that the resident was very happy when she shaved him the day before. The resident later stated he had been shaved and felt much better. CNA #117 stated that if a new admission arrived with disheveled hair and unkempt facial hair, hygiene care could be provided as soon as the nurse finished the admission process, and confirmed there had been plenty of time from the resident’s admission to 02/17/26 for him to have been shaved. The facility policy titled Shaving a Resident stated the facility should promote resident hygiene by assisting with removal of facial hair as needed.

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 newly identified skin impairment was assessed timely for a resident with diagnoses including heart failure, muscle weakness, altered mental status, and diabetes. The resident had a medical boot on the right foot and reported that staff had recently told him he had a new open wound on the right foot and had placed a bandage over it. A progress note documented a new area on the right foot, but wound assessments and wound reports were not completed during the review period. When the ADON removed the boot and bandage, a red area about the size of a nickel was observed on a bony prominence of the right foot, and the ADON stated the area was from shearing and friction from the boot. The ADON confirmed the facility did not have a completed assessment or description of the skin impairment and stated she would assess it on the day of the survey, noting she believed she had a week to complete the wound/skin impairment assessment. Later that day, the ADON stated the area was non-blanchable and that she would contact the medical provider to verify treatment and preventative orders. The DON stated nursing staff should assess a new skin impairment or wound and document the assessment on the shift it was identified, including a description of size, location, redness, and drainage. The facility also failed to address a change in condition for another resident with diagnoses including dementia, muscle weakness, and edema. The resident had care plans for impaired ADLs, urinary incontinence, and impaired cognition, and bladder documentation showed a pattern of increased incontinence. Staff interviews described increased confusion, increased assistance needed for transfers, and a change from occasional incontinence to being incontinent more often and soaking the bed. A CNA reported notifying the nurse of the decline, and an LPN later called the provider about the incontinence and obtained a new UA and culture order. The DON stated she did not consider the resident's decline to be a change in condition and did not provide documentation showing a complete assessment, provider notification, or other documentation addressing the change.

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

Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident at risk for pressure ulcers. Resident #2 was admitted with diagnoses including unspecified dementia, heart failure, chronic kidney disease, hypotension, restless leg syndrome, anemia, and muscle weakness. His quarterly MDS showed moderately impaired cognition, no behaviors or rejection of care, supervision/touching assistance with bed mobility, and that he was at risk for pressure ulcers. His care plan, initiated for risk of skin breakdown related to impaired cognition, anemia, liver disease, renal disease, and abnormal weight loss, included an intervention to encourage or assist him to float his heels as tolerated. During observation, the resident was found lying in bed in a supine position with his heels in direct contact with the mattress and not floated or offloaded as directed by the care plan. A CNA stated she did not consider the resident to be at risk for pressure ulcers and did not identify heel floating as an intervention in place. When she accompanied the surveyor to the room, she confirmed the resident's heels were still in direct contact with the mattress and not floated as planned. The facility policy stated residents at risk for pressure injuries were to have interventions and preventative measures implemented based on risk factors.

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 implement a fall risk intervention for a resident after an unwitnessed fall. Resident #4 had diagnoses including dementia, muscle weakness, cognitive communication deficit, cardiac arrhythmia, peripheral vascular disease, and neuropathy. The resident’s Brief Interview for Mental Status score was 09, indicating moderately impaired cognition, and the fall risk assessment showed a score of 18, indicating a high fall risk. After the fall, the investigation report identified non-skid strips as the immediate safety measure to be implemented due to the circumstances of the event. However, observation later showed no non-skid strips in the resident’s room, and the DON confirmed they were not present at the time of interview. The DON also confirmed there was no documentation that this intervention had been in place. The facility policy stated that a root cause analysis after a fall is used to update the resident’s plan of care with interventions to reduce the risk of recurrent falls.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident receiving Midodrine for hypotension was held when the resident’s systolic blood pressure was greater than 130 mmHg, as required by the physician’s order. Resident #2 was admitted with diagnoses including heart failure, atrial fibrillation, and hypotension, and had an order for Midodrine 2.5 mg twice daily with instructions to hold the medication when SBP exceeded 130 mmHg. Review of the eMAR showed multiple instances in January 2026 when the resident’s SBP was documented above 130 mmHg and the Midodrine was still administered, including readings of 133, 132, 134, 137, and 135 mmHg. The eMAR also showed another administration in February 2026 when the resident’s SBP was 133 mmHg before the dose was given. The DON confirmed the order included hold parameters and acknowledged that the medication had been given six times when it should have been held.

Penalty

Inspection fine: $97,56523 days payment denial

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

Summary

The facility failed to develop and implement an accurate, comprehensive, and individualized pressure ulcer program for two residents who were at risk for and had existing pressure ulcers. For one resident, who had multiple comorbidities including weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease, the facility did not obtain timely treatment orders for known pressure ulcers upon admission. There were also errors in entering treatment orders, resulting in incorrect wound care being provided. The resident's pressure ulcers worsened, and prevention interventions such as repositioning and offloading were not implemented as required. This led to the resident being hospitalized for infection and sepsis related to pressure ulcers, and ultimately being placed on hospice due to complications from multiple antibiotic use for worsening wounds. Another resident, also requiring maximum assistance with bed mobility and transfers and at risk for pressure ulcer development, experienced a worsening of a right buttock pressure ulcer from stage 3 to stage 4. This occurred because medicated treatments, specifically Leptospermum Honey and Alginate Calcium, were not ordered or administered for several days. The wound increased in size and severity, with significant necrotic and slough tissue developing. The lack of timely and appropriate wound care interventions directly contributed to the deterioration of the resident's condition. Throughout the review period, there were repeated failures to ensure that wound care physician recommendations were accurately transcribed into physician orders and that the correct treatments were administered as prescribed. Documentation was inconsistent or missing, and there were lapses in implementing general pressure ulcer prevention measures such as regular repositioning, use of specialized mattresses, and prompt reporting of skin changes. These deficiencies resulted in serious, life-threatening harm to both residents, including hospitalization for infection, sepsis, and progression of pressure ulcers.

Removal Plan

• Resident #300 was assessed by Wound Care Physician #70 with orders received and followed by a licensed nurse, Assistant Director of Nursing (ADON)/Wound Nurse# 33.
• Resident #800 was assessed by Wound Physician #70 with new orders received and followed by a licensed nurse ADON/Wound Nurse# 33.
• An in-service was completed for ADON/Wound Nurse #33 by DON #40 and Regional Nurse #68 on the policy of Pressure Injuries: assessment, prevention, and treatment and the policy of physician notification.
• An in-service was completed for Minimum Data Set (MDS) Nurse #42, Registered Nurse (RN) #34, RN #27, RN #56, Licensed Practical Nurse (LPN) #44, LPN #25, LPN #65, LPN #30, and 26 Certified Nursing Assistants (CNA) by DON #40 on the policy of pressure Injuries: assessment, prevention, and treatment policy; completing head to toe assessment and documenting on skin sheet, if resident has skin alterations; documenting the initial wound observation; and contacting House Physician #66 to obtain treatment orders if not provided from the hospital.
• Any staff who had not received education will not work until education is completed. All staff had received the education.
• An in-service was completed for MDS Nurse #42, RN #34, RN #27, RN #56, LPN #44, LPN #25, LPN #65, LPN #30 by the DON #40 on notifying physician of any resident change in condition.
• Any staff who have not received education will not work until education is completed. All staff have received the education.
• A whole facility skin sweep was completed for 48 residents to identify any skin alterations by LPN #30 and ADON/Wound Nurse #33.
• Any residents with new skin alterations were reviewed by the DON #40 and House Physician #66 notified.
• No new pressure injuries were identified during whole house skin sweep.
• Treatment orders for 48 residents were reviewed by the Regional Nurse #68 to ensure that treatment orders are appropriate for any skin alterations.
• A list of any residents being followed by the wound care physician will be maintained by DON #40.
• For newly admitted residents, based on the admission skin assessment, the resident will be added to the wound consult as applicable.
• For current residents, any new skin alteration identified will be reviewed and added to the wound consult as applicable.
• An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with House Physician/Medical Director #66 and facility leadership DON #40, Administrator #41, MDS/RN #42, ADON/Wound Nurse #33, Regional Administrator #69, and Regional Nurse #68 on pressure ulcer care and plan of correction.
• An audit to ensure pressure ulcer care is being completed per policy will be conducted for five residents three times a week for four weeks and as needed (PRN) by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow up.
• An audit to ensure wound consults are accurate on the consult sheet and orders from wound consults are entered appropriately and assigned to the correct physician will be completed once a week for four weeks and PRN by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up.
• An audit to ensure residents being followed by the wound care physician is being maintained by the DON, newly admitted residents are added to the wound consult list as applicable, and current residents with any new skin alterations are added to the wound consult list as applicable will be conducted once per week for four weeks and PRN by the regional nurse consultant or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up.
• QAPI plan completed.

Penalty

Inspection fine: $97,56523 days payment denial

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

Summary

The facility failed to appropriately manage and document the treatment of a non-pressure skin alteration for one resident and did not obtain daily weights as ordered for three residents. For one resident with multiple comorbidities, including heart failure, diabetes, and chronic kidney disease, there was an incident involving trauma to the right third and fourth toes. The initial wound assessment and documentation were incomplete, as only the third toe was documented and treated, while the fourth toe was not described or treated at the time of discovery. The cause of the trauma was not documented, and subsequent wound care orders did not accurately reflect the areas requiring treatment. Additionally, there were days when prescribed dressing changes were not completed for the affected toes. The same resident, along with two others with diagnoses such as heart failure, dementia, and risk of fluid imbalance, had active physician orders for daily weights due to their medical conditions. However, the facility failed to obtain and document daily weights on multiple occasions for all three residents. There was no documentation to indicate that the missed weights were due to resident refusals or any other justifiable reason; rather, the weights were simply not obtained as required by physician orders. Interviews with facility staff, including the wound nurse and the Director of Nursing, confirmed the lack of documentation and the failure to follow through with both wound care and daily weight monitoring as ordered. The deficiencies were identified through interviews and record reviews, and the facility census at the time was 47 residents.

Penalty

Inspection fine: $97,56523 days payment denial

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

Summary

The facility failed to provide safe and appropriate pain management for three residents who required such services. For one resident with multiple diagnoses including fractures, chronic kidney disease, and a new wound, pain assessments documented pain ratings of 3 to 5 during weekly wound reviews, but no pain medication was administered despite physician orders for as-needed oxycodone-acetaminophen for moderate to severe pain. Another resident with pressure ulcers and intact cognition had no as-needed pain medication ordered, even though weekly wound reviews consistently documented pain ratings of 3 to 4. In both cases, there was no evidence that pain was managed according to the care plan interventions, which included administering pain medication as ordered and monitoring for effectiveness. A third resident with pressure ulcers and a history of chronic conditions had orders for both hydrocodone-acetaminophen for severe pain and acetaminophen for mild pain. Despite regular wound pain assessments showing pain ratings between 5 and 6, no as-needed pain medication was administered during the documented periods. Additionally, weekly wound pain assessments were not consistently completed as required by facility policy, and there was no follow-up after non-pharmacological interventions to determine if further treatment was needed. Interviews with facility staff, including the Assistant Director of Nursing and the wound nurse, confirmed that pain medications were not given prior to wound care treatments and that there was a lack of follow-up after interventions. The facility's policy required assessment, monitoring, treatment, and evaluation of pain to ensure effective management, but these steps were not consistently followed for the residents reviewed.

Penalty

Inspection fine: $97,56523 days payment denial

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

Summary

The facility failed to maintain a medication administration error rate below five percent, as evidenced by four errors out of 25 opportunities during observation, resulting in a 16% error rate. A resident with multiple diagnoses, including thoracic vertebra fractures, depression, anxiety, heart disease, and constipation, was observed during medication administration. The registered nurse (RN) administered incorrect medications and dosages, including giving enteric coated aspirin instead of chewable aspirin, buspirone 5 mg instead of the ordered 10 mg, and senna 8.5 mg instead of the ordered 8.6-50 mg. Additionally, the I-vite supplement was not administered, though it was documented as given. Further observations revealed lapses in medication security and documentation. The RN left the medication administration record open and out of sight, left a sealed lidocaine patch unattended on top of the medication cart, and failed to lock the medication cart when leaving it unsupervised. The RN also did not label the medication bubble pack to indicate a change in the buspirone order, as required by facility policy. These actions were inconsistent with the facility's medication administration and storage procedures, contributing to the identified deficiency.

Penalty

Inspection fine: $97,56523 days payment denial

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

Summary

The facility failed to maintain up-to-date and complete medical records for three residents who were receiving wound care from an outside wound consultant group. For each of these residents, documentation of wound physician visits was missing from their medical records, despite evidence that such visits had occurred. Specifically, one resident with multiple diagnoses, including a recent open wound and sepsis, had no wound physician visit notes in her closed record, and the DON confirmed that these notes were not present and would need to be obtained from the facility wound nurse. Another resident admitted with a skin alteration also had no wound physician visit documentation in the record, which was verified by the facility wound nurse, who acknowledged that the notes should have been uploaded after each visit. A third resident with several chronic conditions and a skin alteration on admission similarly lacked wound physician consultant notes in the medical record, with the regional nurse confirming that the notes were only accessible on the consultant's server and had not been uploaded as expected. These deficiencies were identified through interviews and record reviews, which revealed that the facility did not ensure that wound care documentation from external consultants was consistently incorporated into the residents' medical records. The expectation, as stated by facility staff, was that the wound nurse would upload these notes after each visit to keep the records current and complete for ongoing care. The absence of these records was discovered incidentally during a complaint investigation.

Penalty

Inspection fine: $97,56523 days payment denial

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

Summary

The facility failed to ensure proper hand hygiene and sanitation of medical equipment before and after resident use, as observed with two residents. A registered nurse was seen preparing medications while wearing a glove on one hand, touching the medication cart, medications, and computer with the same glove, and then removing the glove without sanitizing her hands. She entered the residents' rooms, took their blood pressure and pulse oximetry readings with the same machine, administered medications, and left the rooms without performing hand hygiene or cleaning the equipment. These actions were repeated for both residents observed. During an interview, the nurse confirmed she did not change gloves after touching surfaces other than the residents' medications, did not sanitize her hands before and after entering the residents' rooms, and did not clean the blood pressure and pulse oximetry equipment before or after use. Facility policies reviewed indicated that proper hand hygiene and equipment cleaning are required to prevent and control infection, but these procedures were not followed during the observed medication administration process.

Penalty

No penalty information released

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

Summary

The facility failed to maintain the ice machine in the main kitchen in a sanitary manner, which had the potential to affect all 49 residents who received iced beverages from this source. During an observation, a red slimy substance was found next to the prepared ice, and a white crusty build-up was noted on the inside of the ice machine near the cooling mechanism. These findings were confirmed by the Dietary Director during an interview. The Assistant Director of Dietary Services later confirmed that the ice machine was deep cleaned by an outside company, and bagged ice was obtained for resident use. However, a subsequent observation revealed that while the red slimy substance had been removed, the white crusty build-up remained. The facility's policy, dated October 2020, requires ice machines to be free of rust, lime, and mildew at all times, indicating a failure to adhere to this standard.

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 homelike environment and ensure resident equipment was clean and well maintained, affecting four residents. Resident #3, who had diagnoses including heart failure and bipolar disorder, was observed sitting in a wheelchair with a cushion caked in food debris and extended brakes covered in frayed duct tape. Interviews with the Regional Nurse Consultant and Physical Therapy Assistant confirmed these observations, noting the tape was used as a visual cue and needed replacement. The facility's policy required maintenance in a clean and sanitary manner, which was not adhered to in this case. Resident #13's room was noted to have a strong urine odor, confirmed by the MDS Nurse. Resident #37's bathroom had a dark gray stain on the floor and discolored caulking, which the Lead Receptionist confirmed could not be cleaned despite attempts. Resident #42's bathroom floor was dirty and stained, with debris and discolored caulking, as confirmed by the Activity Director. These observations indicate a failure to maintain a clean and sanitary environment as per the facility's policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident was treated with dignity during and after dining, affecting one resident. The resident, who had diagnoses including heart failure, dysphagia, and bipolar disorder, required supervision during meals and assistance with personal care. Observations revealed the resident was often left with food stains on her clothing, wheelchair, and the floor, and was not always provided with a clothing protector. The resident expressed discomfort with being seen in such a state, indicating a lack of dignity in her care. Interviews with staff confirmed the resident's condition during meals, with food debris often left on her clothes and wheelchair. The resident struggled with eating due to tremors, which caused spills and stains, and staff intervention was delayed. The facility's policy on resident rights emphasized treating residents with kindness, respect, and dignity, which was not upheld in this case. The observations and interviews highlighted a failure to maintain the resident's dignity, as she was left in soiled clothing and surroundings after meals.

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 advanced directives were prominently placed in the medical records of two residents, affecting their ability to have their treatment preferences clearly communicated. Resident #100, who was admitted with multiple diagnoses including surgical aftercare of the digestive system and malignant neoplasm of the prostate, did not have a code status prominently displayed in either the electronic or physical medical records. Interviews with the RN Supervisor and the Director of Nursing confirmed the absence of advanced directives in Resident #100's chart, which contradicted the facility's policy requiring such documentation to be included and prominently displayed. Similarly, Resident #149, admitted with diagnoses including altered mental status and dementia, also lacked a prominently displayed code status in their medical records. The Director of Nursing confirmed the omission and noted that Resident #149 had a Full Code status, which was not initially documented in the medical records. The facility's policy mandates that staff should inquire about and document any existing advanced directives upon admission, ensuring they are included in the resident's medical record. The failure to adhere to this policy resulted in the deficiency noted by the surveyors.

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 resident with adaptive equipment for meals as per physician orders, affecting the resident's ability to perform activities of daily living independently. The resident, who had diagnoses including heart failure, dysphagia, and tremors, was observed multiple times without the prescribed adaptive equipment, such as a left-handed weighted glove and built-up curved utensils. Despite having physician orders for these items, the resident was seen struggling to eat, resulting in food and drink spilling onto her clothes, wheelchair, and the floor. Interviews with staff confirmed the absence of the adaptive equipment during meals, and the Assistant Director of Dietary Services was unaware of the weighted glove requirement. The resident expressed discomfort with the situation, as she was often left with food stains on her clothing and wheelchair, which she found embarrassing. The facility's policy on adaptive equipment, which mandates the provision of assistive devices to residents requiring them, was not followed. The policy also requires therapy evaluation and physician orders for such equipment, which were in place but not implemented. This oversight led to the resident's difficulty in eating independently and maintaining personal dignity during meals.

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 alternating air mattresses were functional and set correctly for pressure ulcer prevention, affecting two residents. Resident #12, who was admitted with diagnoses including senile degeneration of the brain, dysphagia, dementia, and chronic obstructive pulmonary disease, was at risk for pressure ulcers due to various health conditions. Despite having an order for an alternating air mattress, observations revealed that the mattress was unplugged and set to 210 pounds, which was likely inappropriate given the resident's weight of 114.5 pounds. Interviews with staff confirmed the incorrect settings and the unplugged status of the mattress. Similarly, Resident #13, who was admitted with diagnoses including senile degeneration of the brain and dementia, was also at risk for skin breakdown. The resident's care plan included the use of an air mattress, but observations showed the mattress was set to static, normal pressure at 225 pounds, which was likely too high for the resident's weight. Staff interviews confirmed the incorrect settings. The facility's policy on pressure injury prevention emphasized the use of pressure redistribution mattresses, but the implementation was inadequate, as evidenced by the incorrect settings and functionality of the mattresses.

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 implement fall prevention interventions for a resident, as outlined in their care plan. The resident, who has a history of falls and medical conditions including senile degeneration of the brain, dementia, depression, and a traumatic brain injury, was admitted with a care plan that included the use of non-skid strips in front of the toilet to prevent falls. However, during an observation, it was noted that these non-skid strips were not present in the resident's bathroom. This oversight was confirmed by the Assistant Director of Nursing, who acknowledged the absence of the strips despite the existing order in the medical record.

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 store respiratory equipment in a sanitary manner, affecting a resident who was admitted with diagnoses including Alzheimer's disease, depression, and hypertension. The resident had a physician's order for Ipratropium-Albuterol solution for nebulization due to wheezing, cough, and congestion. During an observation, the resident's nebulizer was found on the floor, plugged into the wall, and covered in small, brown spots. An interview with the Lead Receptionist confirmed the nebulizer's unsanitary condition and improper placement on the floor, noting that the resident sometimes moved it. The facility's policy on respiratory therapy infection prevention required the nebulizer to be cleaned and stored properly after use, which was not adhered to in this instance.