Arbors At Milford

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 complete annual performance reviews for Certified Nursing Assistants (CNAs). Review of the employee file for CNA #228 showed a hire date of 09/14/22, and the file did not include an annual performance review. Review of the employee file for CNA #229 showed a hire date of 12/19/18, and the file also did not include an annual performance review. During an interview on 03/12/26 at 7:36 A.M., the Administrator confirmed that annual performance reviews had not been completed for CNAs #228 and #229. The facility census was 69 residents.

Penalty

No penalty information released

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

Summary

The facility failed to properly store food in the kitchen dry storage area, walk-in freezer, and walk-in refrigerator. During observation, three containers of cereal had ill-fitting lids and were left open to air, and a bag of rice was unsealed and open to air. In the walk-in freezer, a box of Salisbury steak patties and a box containing cookie dough balls were each in unsealed bags and open to air. In the walk-in refrigerator, a tray of individual cups of apple juice was dated 03/08/26, and a tray of individual cups of orange juice had no date on the cups or the tray. The Assistant Kitchen Manager confirmed the open and improperly stored items and stated the cereal, rice, Salisbury steak patties, and cookie dough should be discarded, and that the apple juice was expired while the orange juice was not dated and could not be determined to be expired or not.

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 deficiency involves the facility’s failure to ensure staff spoke to a resident in a respectful manner, thereby not honoring the resident’s right to dignity and respectful communication. The resident involved was admitted with diagnoses including spinal muscular atrophy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and type 2 diabetes. A nurse progress note documented that a CNA had not treated this resident respectfully. An MDS assessment showed the resident was cognitively intact and required moderate to maximal assistance with staff for all ADLs. The resident later confirmed in an interview that he did not want this CNA to care for him anymore due to how she had treated him. The facility’s SRI documented that the resident made an allegation of abuse involving the CNA. While the facility’s investigation did not substantiate abuse, it did determine that the CNA spoke to the resident in a disrespectful manner. The DON reported that the resident had complained that when he asked the CNA if she was ignoring him, the CNA responded that she was ignoring him. The DON confirmed that the CNA admitted the resident’s account of the incident was correct. This conduct constituted a failure to ensure that staff communicated with the resident in a respectful manner, affecting one resident reviewed for dignity and respect out of a facility census of 69.

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 protect a cognitively intact resident from emotional/verbal abuse when a staff member engaged with the resident through personal social media and sent her an upsetting video. The resident, who had diagnoses including generalized anxiety, major depressive disorder, and insomnia and used a motorized wheelchair, reported to nursing staff that she was emotionally upset after receiving a YouTube video titled "Folgers Incest Commercial" via Facebook from an employee with whom she was Facebook friends. The video depicted a brother and sister in a romantic and sexual relationship. The resident also reported that she had used vaginal soap to eliminate odors after hearing that others had complained about her smell and posted about it on Facebook. During the facility’s investigation, the resident consistently stated that she found the video emotionally upsetting and triggering due to her personal history of sexual abuse by her father and brother during childhood. The employee acknowledged being Facebook friends with the resident and confirmed that he had sent her the video because he thought it was funny, stating he was unaware of her sexual abuse history and denying that he had made any comments about her body odor. The DON and Administrator confirmed that the investigation substantiated that the employee had sent the incest-themed video to the resident via social media, and the facility concluded that the employee’s actions were emotionally abusive and upsetting to the resident.

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 deficiency involves the facility’s failure to prevent significant medication errors for two residents. For one resident with end stage renal disease, diabetes, and osteomyelitis, the physician ordered Cubicin 700 mg IV every other day for 34 days to treat an abdominal abscess. On one occasion, staff administered Cubicin 500 mg IV that was intended for another resident, resulting in the resident not receiving the full prescribed dose. The DON reported that the nurse recognized the error only after the IV bag had been completely administered and she saw the other resident’s name on the bag. The resident later confirmed being informed by the facility that a medication error had occurred and that she had not received the full dose of Cubicin. The facility’s medication administration policy required licensed nurses to identify the resident by photo in the MAR and compare the medication source with the MAR to verify resident name, medication name, form, dose, route, and time of administration. The second resident, admitted with acute and chronic respiratory failure, polyneuropathy, and anxiety disorder, had a physician’s order for routine oxycodone 10 mg every four hours for pain at specified times throughout the day and night. Review of the MAR showed that the 8:00 A.M. dose of oxycodone was administered at 11:18 A.M. on one date. During observed medication administration on another date, an LPN gave the resident’s 8:00 A.M. oxycodone dose at 10:05 A.M. The LPN confirmed that the medication was late and acknowledged that medications were supposed to be administered within one hour before or after the scheduled time. A regional RN also confirmed that the resident’s oxycodone doses had been administered late on both dates. The facility’s medication administration policy specified that medications should be administered within 60 minutes prior to or after the scheduled time.

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 hold quarterly care conferences for two residents. Resident #7 was admitted with diagnoses including acute osteomyelitis of the right ankle and foot, epilepsy, end stage renal disease, type 2 diabetes mellitus, and systolic and diastolic heart failure, and had intact cognition on the 02/13/26 MDS. Review of the record showed only one documented care conference from March 2025 through March 2026, held on 12/11/25. Resident #1 was admitted with diagnoses including multiple sclerosis, osteomyelitis of the vertebra, generalized anxiety disorder, and neuromuscular dysfunction of the bladder, and had intact cognition on the 02/06/26 MDS. Review of the record showed only one documented care conference from March 2025 through March 2026, held on 09/16/25. The SSD confirmed on interview that only one care conference had been held for each resident during that period and that resident care conferences should be held quarterly.

Penalty

Inspection fine: $34,690

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

Summary

A deficiency occurred when facility staff failed to notify the physician or nurse practitioner in a timely manner following a significant change in a resident's condition. The resident, who had a complex medical history including Type I diabetes mellitus, end-stage renal disease, and a tracheostomy, was found to have an extremely elevated blood glucose level. Although the nurse practitioner was initially notified and additional insulin was ordered, the resident refused the insulin. The nurse did not inform the physician or nurse practitioner of the resident's refusal, nor were any further blood glucose checks performed or documented. Subsequently, the resident was found on the floor, unresponsive to questions, with noticeable swelling on the right side of the face. Despite these findings, no neurological assessment was completed, and there was no notification to the physician or nurse practitioner regarding the resident's change in condition. The resident remained in this state until the following morning, when staff found the resident unresponsive with bluish skin tone, abdominal breathing, and significant head edema. Emergency services were called, and the resident was transported to the hospital. At the hospital, the resident was diagnosed with acute encephalopathy, multiple metabolic and infectious abnormalities, and acute metabolic acidosis, with a blood glucose level exceeding 784 mg/dL. The resident ultimately died. Interviews and record reviews confirmed that neurological checks were not performed and that neither the physician nor the family were notified of the resident's change in condition until after the resident was sent to the hospital.

Removal Plan

• Resident was sent to the ED with notification made to the physician.
• Administrator and Minimum Data Set (MDS) Nurse reviewed the 24-hour report and self-identified a concern with resident's refusal of an order for insulin and failure to notify the physician/nurse practitioner during clinical meeting.
• Administrator and RDCO obtained statements and conducted interviews with relevant staff.
• RDCO was notified by Administrator of the situation and arrived at the facility to assist with the investigation.
• RN/Staff Development Coordinator (SDC) assessed all residents who had a recent fall and completed a neurological check.
• LPNs and RDCO assessed all residents for a change in condition.
• Administrator suspended DON pending investigation for failure to notify Nurse Practitioner of resident's refusal to be administered insulin and subsequent change in condition. DON was terminated from employment.
• RN/SDC provided all nurses, medication technicians, and CNAs with education related to fall assessment protocols, notification of physicians for resident change of condition, the importance of initiating treatment, the importance of rounding every two hours, the importance of obtaining neurological checks when it was suspected the resident had a head injury and/or was on blood thinners, and the importance of initiating the risk management application in the electronic medical record.
• RDCO and Administrator notified facility Medical Director of the incident and reviewed the policy and procedure for change in condition/notification of change.
• A Quality Assurance and Performance Improvement (QAPI) meeting was held with Administrator, RDCO, and Medical Director. The policy for change in condition/physician notification was reviewed with no recommended revisions. The result of the facility's root cause analysis (RCA) was reviewed and the staff completed education was reviewed.
• RN and LPNs completed walking rounds for resident change in condition. One resident was found with a change in condition, and it was addressed.
• RDCO reviewed all resident blood sugars to ensure notification of variances was made to the physician.
• RDCO/designee provided education on resident change in condition and notification to the physician/nurse practitioner to all newly hired nurses and CNAs.
• RDCO/designee conducted a daily clinical meeting to review residents with a change in condition and/or transfer to the hospital to ensure proper physician notification was made timely. The clinical meetings continue indefinitely.
• RDCO/designee monitored the results of the daily clinical meeting for residents with a change in condition and notification to the physician and submitted the findings to the QAPI committee for review and recommendations. This continued monthly with QAPI meetings and then as needed.
• Two additional resident medical records were reviewed for change in condition and notification of change with no concerns identified.
• Staff interviews verified they received education from the facility regarding a resident change in condition or mental status change from the resident's baseline.

Penalty

Inspection fine: $34,690

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

Summary

A deficiency occurred when a resident with multiple complex medical conditions, including Type I diabetes mellitus, end-stage renal disease, and a tracheostomy, was not provided with appropriate and timely assessment, treatment, and physician notification following a significant change in condition. The resident had a history of non-compliance with insulin administration and repeatedly refused prescribed doses, including a critical dose ordered after a blood glucose reading of 583 mg/dL. Despite being educated on the risks of refusal, the resident continued to decline insulin, and the nurse did not notify the physician or nurse practitioner of this refusal, nor were additional blood glucose checks performed or documented. Later, the resident was found on the floor, unresponsive to questions but able to move extremities, and with noticeable facial swelling. No neurological assessment was completed, and again, there was no notification to the physician or nurse practitioner regarding the resident's change in condition. The resident remained in this state without further assessment or intervention until the following morning, when she was found unresponsive with bluish skin tone, abdominal breathing, and significant head edema. At this point, emergency services were called, and the resident was transported to the hospital. Upon hospital admission, the resident was found to have a blood glucose level greater than 784 mg/dL, was diagnosed with acute encephalopathy, multiple metabolic/infectious abnormalities, and acute metabolic acidosis, and ultimately died. Throughout this period, there was a lack of timely assessments, failure to follow physician notification protocols, and inadequate documentation, all of which contributed to the resident's serious deterioration and death. Interviews with staff and review of records confirmed that required neurological checks and physician notifications were not performed as per facility policy.

Removal Plan

• Resident was sent to the ED with notification made to the physician.
• Administrator and Minimum Data Set (MDS) Nurse reviewed the 24-hour report and self-identified a concern with resident's refusal of an order for insulin and failure to notify the physician/nurse practitioner during clinical meeting.
• Administrator and RDCO obtained statements and conducted interviews with LPN Unit Manager, Medication Technician, LPNs, Respiratory Therapists, Certified Nurse Aides, and previous DON.
• RDCO was notified by Administrator of the situation that involved the resident and arrived at the facility to assist with the investigation.
• RN/Staff Development Coordinator (SDC) assessed all residents who had a recent fall and completed a neurological check.
• LPNs, RDCO, and LPN Unit Manager assessed all residents for a change in condition.
• Administrator suspended previous DON pending investigation for failure to notify Nurse Practitioner of resident's refusal to be administered insulin as ordered and subsequent change in condition. Previous DON was terminated from employment.
• RN/SDC provided all nurses, medication technicians, and CNAs with education related to fall assessment protocols, notification of physicians for resident change of condition, the importance of initiating treatment, the importance of rounding every two hours, the importance of obtaining neurological checks when it was suspected the resident had a head injury and/or was on blood thinners, and the importance of initiating the risk management application in the electronic medical record. All staff were educated.
• RDCO and Administrator notified facility Medical Director of the incident and reviewed the policy and procedure for change in condition/notification of change.
• A Quality Assurance and Performance Improvement (QAPI) meeting was held with Administrator, RDCO, and Medical Director. The policy for change in condition/physician notification was reviewed with no recommended revisions. The result of the facility's root cause analysis (RCA) was reviewed and the staff completed education was reviewed.
• RN, LPNs completed walking rounds for resident change in condition. One resident was found with a change in condition, and it was addressed.
• RDCO reviewed all resident blood sugars to ensure notification of variances was made to the physician.
• RDCO/designee provided education on resident change in condition and notification to the physician/nurse practitioner to all newly hired nurses and CNAs.
• RDCO/designee conducted a clinical meeting to review residents with a change in condition and/or transfer to the hospital to ensure proper physician notification was made timely. The clinical meetings continue.
• RDCO/designee monitored the results of the clinical meeting for residents with a change in condition and notification to the physician and submitted the findings to the QAPI committee for review and recommendations. This continued with QAPI meetings and then as needed.
• Two additional resident medical records were reviewed for abuse and neglect with no concerns identified.
• All staff were interviewed to verify receipt and understanding of education regarding a resident change in condition or mental status change from the resident's baseline.

Penalty

Inspection fine: $34,690

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 thoroughly assess and monitor the skin condition of a resident who was admitted with a stage IV sacral pressure ulcer and multiple high-risk factors, including impaired cognition, dependence on staff for activities of daily living, and a history of pressure ulcers. Despite these risks, the facility did not complete a pressure ulcer risk assessment until over two weeks after admission, and licensed nurses did not perform documented skin checks during this period. Certified Nursing Assistant (CNA) documentation indicated no new skin issues, and the wound nurse and wound nurse practitioner did not identify any wounds on the resident's right shoulder during wound rounds conducted one week prior to the discovery of a new ulcer. On a subsequent wound round, the wound nurse and wound nurse practitioner discovered an unstageable pressure ulcer with slough and necrotic tissue on the resident's right shoulder, which had not been previously identified or documented. The wound was covered with an undated Xeroform gauze dressing, and facility staff were unable to determine when the wound developed or who applied the dressing. The lack of timely and thorough skin assessments, as well as the absence of communication and documentation regarding new skin issues, contributed to the pressure ulcer progressing to an advanced stage before it was detected. Facility policy and national guidelines require prompt identification of at-risk residents and implementation of interventions to prevent pressure ulcers, as well as ongoing comprehensive skin assessments. In this case, the facility did not follow these standards, resulting in actual harm to the resident, who developed a new, advanced-stage pressure ulcer that was not identified until significant tissue damage had occurred.

Penalty

Inspection fine: $34,690

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 allegations of neglect to the Administrator and State Survey Agency for four residents reviewed for neglect. In one case, a resident with multiple complex medical conditions, including diabetes mellitus type I, tracheostomy, and end-stage renal disease, experienced a series of missed insulin doses due to refusal, followed by a significant change in condition. After being found on the floor unresponsive with facial swelling, the resident did not receive neurological checks, and neither the physician nor the family was notified of the change in condition until after the resident was transported to the hospital. The resident was later admitted to the hospital in critical condition and subsequently expired. There was no evidence that this incident was reported to the State Survey Agency as required. In another instance, a certified nurse aide failed to provide timely care to three dependent residents, resulting in them being found lying on soiled sheets, with one resident also having a dislodged tube feeding and another with wounds saturating the sheets. The DON was aware of the incident and disciplined the aide but did not report the allegation of neglect or conduct a thorough investigation, citing the aide's previous good performance and lack of complaints. The aide admitted to being behind on care and not seeking assistance, while the wound nurse confirmed the residents' compromised conditions and the importance of timely care. The facility's policy required immediate investigation and reporting of suspected abuse, neglect, or exploitation, with specific timelines for reporting to authorities. Despite this, the facility did not follow its own procedures in these cases, failing to notify the appropriate parties or conduct comprehensive investigations into the allegations of neglect. Staff interviews confirmed the lack of reporting and investigation, and documentation review supported the findings of unreported neglect.

Penalty

Inspection fine: $34,690

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 the results of an investigation regarding resident neglect to the State Survey Agency in a timely manner and did not thoroughly investigate allegations of neglect, affecting four out of five residents reviewed. In one case, a resident with multiple complex medical conditions, including diabetes, tracheostomy, and end-stage renal disease, experienced a significant change in condition after refusing insulin doses and being found on the floor with facial swelling. Despite clear changes in the resident's status, neurological checks were not performed, and the physician and family were not notified until after the resident was transported to the hospital, where the resident was later pronounced deceased. The facility did not notify the State Survey Agency of this incident within the required timeframe. In another instance, a certified nurse aide failed to provide timely care to three residents, leaving them soiled and not repositioned, which was discovered during wound rounds. The DON was aware of the aide's failure to provide care but did not report the incident as neglect or conduct a thorough investigation, citing the aide's generally good performance and lack of prior complaints. The aide admitted to being behind on her assignments and not seeking assistance, while the wound nurse confirmed the residents were found in soiled conditions, with one resident having a dislodged tube feeding and another with fragile skin exposed to wet sheets. The facility's policy required immediate investigation and reporting of suspected neglect, including thorough documentation and notification to state agencies within specified timeframes. However, the facility did not follow these procedures, as evidenced by the lack of timely reporting and incomplete investigations into the incidents involving the affected residents.

Penalty

Inspection fine: $34,690

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

Surveyors identified a deficiency in the facility’s handling of insulin medications, specifically regarding the labeling and storage of insulin pen-injectors. During observations of medication carts across multiple nursing units, it was found that insulin pens for several residents were not dated when removed from refrigerated storage and placed in the medication carts. This practice was confirmed through interviews with LPNs responsible for medication administration, who acknowledged that the insulin pens lacked the required dating. Additionally, some insulin pens remained in use beyond the manufacturer-recommended 28-day period after removal from refrigeration, and in one case, an insulin pen was still present in the cart after the physician’s order for its use had been discontinued. The residents affected by this deficiency had complex medical histories, including diagnoses such as diabetes mellitus type II, end-stage renal disease, congestive heart failure, cerebrovascular accident, malignant neoplasm of the brain, and other significant comorbidities. Many of these residents required extensive assistance with activities of daily living, and some were dependent on enteral feeding tubes or had tracheostomies. The improper labeling and storage of insulin affected a total of ten residents who were identified as receiving insulin therapy at the time of the survey. Interviews with the consulting pharmacist and the Director of Nursing confirmed that facility policy and manufacturer guidelines require insulin vials and pen-injectors to be dated when first used and to be discarded 28 days after removal from refrigerated storage. The facility’s policy on medication storage also specifies that medications and biologicals must be stored according to manufacturer or pharmacy recommendations to maintain their integrity. Despite these requirements, the survey found multiple instances where insulin pens were not properly dated or discarded, resulting in noncompliance with accepted professional standards for medication management.

Penalty

Inspection fine: $34,690

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 follow the planned breakfast menu for all 47 residents on a regular diet. On the observed date, the posted menu included assorted juice, a choice of hot or cold cereal, scrambled eggs, bacon, hash browns, and milk or beverage. However, during breakfast service, bacon was not provided as there was not enough available, and no substitute such as sausage was prepared, as the kitchen was also out of sausage. This deviation from the menu was confirmed by a dietary staff member, who stated that no notification or substitution was made. Facility policy requires that menus be followed as posted and that any deviations be promptly communicated, with substitutions of comparable nutritive value provided.

Penalty

Inspection fine: $34,690

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

Surveyors observed multiple deficiencies in the facility's food storage and preparation practices. In the kitchen, two packages of pie crusts, two packages of English muffins, and six packages of rolls were found undated and unlabeled in the dry food storage area. Additionally, garbage cans located by the primary preparation station and in the dishwashing room did not have lids. Four ceiling air ventilator covers had black spots and a black substance built up on them. The Food Service Director confirmed these findings and stated that the maintenance department was responsible for cleaning the air ventilators. Facility policies required all food to be stored wrapped or in covered containers, labeled and dated, and for kitchen areas to be kept clean and free from litter. Further observation revealed a dietary staff member serving food on the tray line while wearing gloves, then using the same gloves to handle bread for the toaster without changing them. The staff member acknowledged forgetting to change gloves and confirmed touching food with gloved hands that had been used for other tasks. Facility policy required all staff to perform hand hygiene procedures to prevent the spread of infection. These actions and inactions had the potential to affect all residents who received food from the facility kitchen.

Penalty

Inspection fine: $34,690

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 when a resident's advance directive form, specifically the DNR Comfort Care (DNRCC) document, was found to be incomplete. The form was signed by the physician but lacked a date, and required sections under 'Certification of DNR Comfort Care Status' were left blank. These sections included options for 'Do-Not-Resuscitate-Order' or 'Living Will (Declaration) and Qualifying Condition,' with instructions to select only one, but neither was marked. The deficiency was confirmed through medical record review and staff interview. The resident involved had multiple significant diagnoses, including chronic obstructive pulmonary disease, end stage renal disease, heart failure, and dysphagia, and was dependent on staff for all activities of daily living due to impaired cognition. Despite an active physician order for DNRCC, the incomplete documentation on the advance directive form was verified by an LPN, who acknowledged that the physician's date and proper selections were required but missing.

Penalty

Inspection fine: $34,690

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

Summary

The facility failed to accurately code the status of a non-invasive mechanical ventilator on the Minimum Data Set (MDS) assessment for one resident. The resident, who had multiple diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, congestive heart failure, asthma, and chronic kidney disease, was admitted to the facility and was cognitively intact. She was dependent on staff for medication administration, toileting, lower body dressing, and required maximum assistance with showers. The MDS assessment incorrectly indicated that the resident required an invasive mechanical ventilator. Medical record review and staff interviews confirmed that the resident was actually using an Average Volume Pressure Support (AVAPS) ventilator, which is a non-invasive device, and was connected to it nightly via a CPAP/BiPAP mask. Observation showed the resident was not connected to the device at the time of the survey. The MDS nurse acknowledged the error, confirming that the resident should have been coded as using a non-invasive mechanical ventilator. Reference materials, including the RAI User's Manual and a government website, supported that AVAPS is a non-invasive ventilation modality and should not be coded as invasive on the MDS.

Penalty

Inspection fine: $34,690

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's Preadmission Screening and Resident Review (PASRR) was accurately completed. Medical record review showed that the resident was admitted with multiple diagnoses, including bipolar disorder, anxiety disorder, and major depressive disorder, and was receiving hospice services. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and required varying levels of staff assistance for daily activities. However, the PASRR documentation did not accurately reflect all of the resident's mental health diagnoses, as only mood disorder was marked, omitting the diagnoses of anxiety disorder and bipolar disorder. During an interview, the Director of Social Services confirmed that the PASRR was completed incorrectly and that the facility did not have a corrected PASRR on file for the resident. Review of the facility's PASRR policy confirmed the requirement for accurate completion and coordination with the state's PASRR program, including the need for a Level 1 screen upon admission and notification for a Level II screen if required. The deficiency was identified for one of two residents reviewed for PASRR, with a facility census of 72.

Penalty

Inspection fine: $34,690

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

Summary

The facility failed to develop and implement a care plan addressing dental care needs for a resident with significant dental concerns. The resident, who had end stage renal disease, congestive heart failure, and oropharyngeal dysphagia, was found to have no natural teeth and was not assessed as having loose-fitting dentures in the most recent MDS assessment. Despite the resident reporting that his dentures did not fit due to recent weight loss and experiencing gum pain from loose dentures, there was no care plan in place to address these issues. Staff interviews confirmed the absence of an active dental care plan for this resident, even after concerns were raised during a care conference regarding weight loss and dental discomfort.

Penalty

Inspection fine: $34,690

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

Summary

The facility failed to ensure that a resident was assessed by a physician within the required timeframe following readmission from the hospital. Medical record review showed that the resident, who had multiple diagnoses including morbid obesity, respiratory failure, obstructive sleep apnea, hypothyroidism, bipolar disorder, diabetes mellitus, peripheral vascular disease, anxiety disorder, major depressive disorder, and alcohol dependence, was admitted with hospice services and was dependent on staff for most activities of daily living. Documentation revealed that the resident had not been seen by a physician since a date prior to her hospital readmission, and this was confirmed by the medical director, who acknowledged that the resident should have been assessed within thirty days of readmission but was not.

Penalty

Inspection fine: $34,690

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

Staff failed to adhere to infection prevention and control protocols in several instances involving residents with complex medical needs. In one case, a laboratory technician did not wear a gown while performing venipuncture on a resident under enhanced barrier precautions for dialysis and enteral tube care, despite physician orders and care plan interventions requiring gown and glove use for high-contact activities. The technician also failed to perform hand hygiene between contact with two residents, did not have hand sanitizer available, and did not wash hands before leaving the room after handling blood specimens and supplies. In another instance, an LPN disposed of a blood-contaminated glucometer strip in a resident's regular trash can and placed a used lancet in the nurse's cart trash, rather than using a sharps or biohazard container as required by facility policy. The LPN acknowledged not being trained to dispose of glucometer strips in sharps containers but was aware that lancets should be disposed of properly. These actions were observed during care for residents with diagnoses including diabetes, end stage renal disease, heart failure, and psychiatric disorders, all of whom were cognitively intact and did not reject care.

Penalty

Inspection fine: $34,690

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 as outlined in the care plan for a resident with multiple medical conditions, including chronic obstructive pulmonary disease, epilepsy, type II diabetes, major depressive disorder, and stage III chronic kidney disease. The resident was identified as being at risk for falls due to generalized weakness, poor balance, decreased strength and endurance, and a need for assistance with activities of daily living. The care plan specified several interventions, including the use of fall mats on both sides of the bed to reduce the risk of injury from falls. During observations conducted at two separate times on the same day, only one fall mat was present on the right side of the resident's bed, with no additional mats found in the room, closet, or bathroom. This was confirmed by a registered nurse, who acknowledged that the resident was care-planned for two fall mats but only had one in place. The lack of full implementation of the care-planned interventions constituted a deficiency in ensuring the area was free from accident hazards and that adequate supervision and assistance were provided to prevent accidents.

Penalty

Inspection fine: $34,690

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

Summary

The facility failed to maintain a safe and clean environment for its residents, as evidenced by multiple observations in resident rooms. In one instance, a resident with atrial fibrillation, congestive heart failure, hypertension, diabetes mellitus type II, and dementia was found to have an unpainted drywall area below the HVAC unit in their room, which was stained with a black substance. Another resident, admitted with cerebrovascular accident, hemiplegia, chronic obstructive pulmonary disease, diabetes mellitus type II, morbid obesity, alcoholic cirrhosis, and congestive heart failure, had a hole in the wall to the right of the television measuring approximately seven inches long and three inches wide. These deficiencies were confirmed by the Maintenance Director during an observation and interview. Additionally, a third resident with hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease with exacerbation, and contracture of the left hand, was found to have a hole in the wall behind the door of their room, which had a towel stuffed into it. This was verified by the Assistant Director of Nursing during an interview. These findings demonstrate that the facility did not ensure the physical environment was properly maintained, resulting in unsafe and unclean conditions for multiple residents.

Penalty

Inspection fine: $66,291

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 administer appropriate respiratory care for a resident with a compromised respiratory status, resulting in Immediate Jeopardy. Resident #10, who had a history of respiratory disorder, dependence on respiratory support, chronic obstructive pulmonary disease (COPD), diabetes mellitus type two, and congestive heart failure, was not placed on a ventilator at night as ordered by the physician. The resident was found unresponsive the following morning and required cardiopulmonary resuscitation (CPR) and hospitalization due to acute respiratory failure. The deficiency occurred when the order for the ventilator at night was not confirmed by the physician and was not entered into the resident's Medication Administration Record (MAR). Despite the order being transcribed into the electronic medical record (EMR) by a respiratory therapist, it was not acted upon, and the ventilator was not applied. The resident had been on a ventilator continuously prior to readmission, and the hospital's continuity of care orders specified the need for a ventilator at night. Interviews with staff confirmed that the ventilator order was not seen or acted upon, and the resident was last observed with a tracheostomy and oxygen in place, breathing normally. The failure to apply the ventilator as ordered led to the resident's critical condition, highlighting a significant lapse in the facility's adherence to physician orders and care protocols.

Removal Plan

• The DON or designee(s) evaluated all residents with ventilators to ensure the residents with ventilators had proper orders and ventilator settings and care plans in place.
• The DON or designee reviewed all physician's orders for all residents residing in the facility to ensure that there were no orders in queue or pending confirmation status.
• The DON/designee visually observed all residents in house with ventilators to ensure the ventilators were in place and functioning per physician's orders.
• The DON/designee reviewed new/readmission resident charts to ensure all orders were transcribed appropriately.
• The DON/designee began education of licensed nurses and respiratory therapists on ensuring orders were transcribed correctly and confirmed with the physician and were not left in queue or pending confirmation status.
• The DON/designee began audits of all new physician's orders for residents on ventilators to ensure all orders were transcribed appropriately and confirmed by the physician.
• The facility had an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to discuss the incident involving Resident #10.
• The DON/designee will audit ventilator/tracheostomy assessment/documentation for up to five residents weekly.
• The DON/designee will review all new admission/readmission orders to ensure that all ventilator orders are in place and transcribed appropriately.
• The DON/designee began to observe for completion of walking rounds at the change of shift between RTs to be completed.
• The oncoming RT will audit the previous shift to ensure all ventilator settings are accurate.