Arbors At Stow

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 implement its abuse policy by timely reporting multiple resident‑to‑resident physical altercations as allegations of abuse to the State Agency. In one series of incidents, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, obesity, and documented behavioral symptoms including verbal and physical aggression, wandering, rummaging, and taking others’ belongings was involved in a physical altercation with another resident who also had Alzheimer’s disease, dementia with agitation, depression, anxiety, and wandering and aggressive behaviors. Nursing notes and internal risk reports documented that one resident slammed a dining room chair into a table, the other resident pushed him in the abdomen, and the first resident then struck the other on the back of the head. Staff separated the residents, assessed them, and documented no injuries, and internal incident reports were completed. However, the Administrator and DON confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s policy and abuse flow sheet referencing the reasonable person concept and the need to report resident‑to‑resident physical altercations that could cause injury, pain, or mental anguish. In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst and found the cognitively impaired, wandering resident sitting in his wheelchair eating dinner while the aggressive resident was on the bed. The resident in the wheelchair reported that the other resident had come into his room, gotten onto his bed, and punched him in the face. Nursing documentation and an internal risk report confirmed that the residents were immediately separated, no injuries were observed, and notifications within the facility were made. The resident who reported being punched had Alzheimer’s disease with late onset, unspecified psychosis, vascular dementia, personality disorder, anxiety disorder, and wandering and aggressive behaviors documented on the MDS and care plan. Despite the allegation of being punched in the face and the facility’s written policy defining physical abuse to include hitting and punching and requiring immediate reporting of alleged violations involving abuse, the Administrator and DON again confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents involved could not intend to harm or cause mental anguish. Another incident involved a resident with dementia, delusions, severe cognitive impairment, and extensive behavioral symptoms such as exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, grabbing, kicking, hitting, pushing, cursing, anger, and agitation, who struck another severely cognitively impaired resident with multiple medical conditions including vascular dementia, COPD, heart disease, chronic kidney disease, malnutrition, and pain. An incident audit report and a physical aggression form documented that a CNA witnessed the aggressive resident hit the other resident in the left side of her chest with her hand in a common area, immediately redirected the aggressor, and notified the nurse. The nurse assessed the struck resident, documented no redness or bruising, obtained vital signs, and recorded that the resident stated it hurt but did not know why she had been hit. The physician and family were notified and monitoring was ordered. The DON stated that a self‑reported incident was not completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s abuse policy defining physical abuse to include hitting and requiring reporting of alleged violations involving abuse to the State Agency within specified timeframes. Across these events, the facility conducted internal investigations and documentation but did not treat the resident‑to‑resident physical altercations as reportable abuse allegations under its own policies and procedures.

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 timely self-report multiple resident-to-resident physical altercations to the State Agency (SA) as allegations of abuse, in accordance with federal requirements and the facility’s own Abuse, Neglect and Exploitation policy. For one incident, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, and obesity, who had a documented history of verbal and physical aggression, pushed and struck another cognitively impaired resident in the abdomen after the second resident slammed a dining room chair into a table and attempted to push the first resident’s wheelchair. The second resident then struck the first resident on the back of the head. Nursing notes and internal incident reports documented the altercation, assessments, and that no injuries were observed. The Administrator and DON acknowledged that an internal investigation was conducted but confirmed that no Self-Reported Incident (SRI) was filed because there was no injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s abuse flow sheet indicating that the reasonable person concept should be applied to such physical altercations. In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst. They found the cognitively impaired resident who had a history of aggressive behaviors sitting on the other resident’s bed, while the room’s occupant, who had Alzheimer’s disease with late onset, psychosis, vascular dementia, and other psychiatric and behavioral diagnoses, was in a wheelchair eating dinner. The room’s occupant reported that the aggressive resident had come into his room, gotten onto his bed, and punched him in the face. Nursing documentation and an internal risk report confirmed that the residents were separated and that no injuries were observed. The Administrator and DON again stated that an internal investigation was completed but that no SRI was submitted to the SA because there was no injury and they believed the residents involved did not have the ability to intend harm or cause mental anguish, even though the facility’s policy and abuse flow sheet defined physical abuse to include hitting and required reporting of alleged violations within specified timeframes. Another incident involved a resident with dementia and extensive behavioral symptoms, including exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, and other disruptive behaviors, striking a severely cognitively impaired resident with multiple medical conditions, including vascular dementia, chronic obstructive pulmonary disease, heart disease, and chronic kidney disease. According to the Incident Audit Report and a Physical Aggression Form, a CNA witnessed the aggressive resident hit the other resident in the left side of the chest with her hand in a common area and immediately redirected the aggressor. The nurse assessed the struck resident, documented no redness or bruising, and recorded vital signs within normal limits, though the resident stated that it hurt and did not know why she had been hit. The physician and family were notified, and monitoring for pain or bruising was ordered. The DON stated that no SRI was completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s Abuse, Neglect and Exploitation policy defining physical abuse as including hitting and requiring immediate reporting of alleged violations involving abuse to the SA within the required timeframe. Across these events, record review, interviews, and policy review showed that the facility consistently treated these resident-to-resident physical altercations as internal incidents without reporting them as allegations of abuse to the SA. The facility’s abuse policy and undated abuse flow sheet specified that physical abuse includes hitting, slapping, punching, biting, and kicking, and that alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made, when the events involve abuse or result in serious bodily injury. The abuse flow sheet also clarified that having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions and directed staff to use the reasonable person concept to determine psychosocial impact. Despite this, the Administrator, DON, and RN/VPOC acknowledged that SRIs were not filed for these incidents because they focused on the absence of observed injury and their belief that the residents lacked intent, rather than on the willful nature of the physical acts and the reasonable potential for injury or mental anguish as required by their own 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 deficiency involves multiple failures to provide treatment and care according to physician orders, resident preferences, and goals, as well as failures in comprehensive monitoring after a change in condition. One hospice resident with severe cognitive impairment was lowered to the floor from bed during an early morning episode in which she believed her bed was on fire. Staff documented no pain, no change in range of motion, and no suspected injury immediately after the incident, and planned only to monitor for pain and bruising. Hospice was not notified of the incident at that time. Over the next several days, documentation showed increasing complaints of left hip and leg pain with pain scores up to eight and nine out of ten, bruising to the left buttock and knee, and repeated administration of PRN acetaminophen, which staff recorded as effective. The NP noted soreness and bruising, low suspicion of fracture, and initially ordered but then cancelled x‑rays after discussion with staff, based on the belief the resident had been lowered rather than fallen and had no uncontrolled pain. Hospice staff later assessed the resident, observed significant pain and favoring of the left leg, and requested imaging; x‑rays eventually revealed a probable subcapital fracture of the left femur, and subsequent hospital evaluation confirmed an acute impacted intracapsular subcapital femoral neck fracture requiring surgical fixation. The resident’s son and hospice nurse reported that the resident had complained of pain since the incident, that the facility delayed notifying the son of the event, and that hospice had to reiterate the need for imaging. Another deficiency involved a resident with severe cognitive impairment and multiple cardiovascular diagnoses who had physician orders for three antihypertensive medications (Amlodipine, Hydrochlorothiazide, and Lisinopril) to be held if systolic blood pressure was less than 120. The MAR showed numerous blood pressure readings below the ordered threshold throughout the month, resulting in the medications being held on multiple occasions, including three consecutive days. There was no documentation that the physician or NP was notified of these repeated medication holds. Additionally, on one date when the systolic blood pressure remained below 120, all three medications were administered instead of being held, contrary to the physician’s parameters. The DON confirmed that the provider had not been notified of the repeated holds and that the medications should have been held on the date they were administered. A further deficiency concerned a resident with diabetes, dementia, and a left dorsal foot wound who had a physician order for daily wound care with normal saline, Medihoney, calcium alginate, and appropriate dressings. The TAR for the month showed the treatment as completed daily; however, during observed wound care, the kerlex dressing on the resident’s foot was dated two days prior, indicating the dressing had not been changed as ordered. The LPN performing the dressing change confirmed the date and believed the dressing was to be done daily and as needed, revealing a discrepancy between documentation and actual practice. Additional deficiencies involved failure to implement ordered perimeter mattresses for residents at risk for falls or needing defined bed boundaries. One resident with dementia, muscle weakness, and dependence for transfers had a physician order in place for an air perimeter mattress for several months. Observations showed a bag containing a perimeter mattress topper sitting on the resident’s chair rather than on the bed, and staff, including the LPN and DON, were initially unaware of what was in the bag or that it needed to be applied. The DON later confirmed that the perimeter mattress order had been in place since January and that the topper should have been on the bed. Another resident with dementia and cognitive deficits had a care plan intervention for a bari‑bed with perimeter mattress and a later physician order for a perimeter mattress to assist with bed boundaries. The DON stated she was unsure when this resident actually received the mattress and that the physician order was not entered until weeks after the care plan intervention was documented, indicating a delay in implementing the ordered safety device.

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 pureed foods were prepared in accordance with individual needs and facility recipes, specifically in the preparation of pureed cabbage served at one lunch meal to 22 residents on pureed or mechanical soft diets. During observation of the puree preparation, a staff member removed cooked cabbage from the oven, measured its temperature at 205.2°F, and portioned 33 four-ounce servings of cabbage along with all of the cooking liquid into a food processor. Over the course of the preparation, the staff member added four tablespoons of thickener and reblended the mixture multiple times before placing the pureed cabbage into a steamer for hot holding. The facility’s written recipe for braised cabbage directed that excess water be drained off before pureeing, but this step was not followed. Subsequent observations during trayline service showed that the pureed cabbage, held on the steam table, had a runny consistency that spread across the plate and did not hold its shape when scooped with a #8 scoop. Food temperatures taken before service showed the pureed cabbage at 181°F. The district manager confirmed that residents on pureed or mechanical soft diets received this pureed cabbage and acknowledged that the consistency observed on the plates was not appropriate. A test tray sampled later the same day showed the pureed cabbage remained runny and had broken down while on the steam table, losing some of its consistency. Review of the facility’s therapeutic diet policy indicated that diets are to be prepared according to the approved diet manual and individualized care plans, and review of the cabbage recipe confirmed that draining excess water was required but had not been done.

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 that resident call lights in bathrooms and bathing areas were functional and operating as required. During an observation period with the Director of Maintenance (DOM), call lights for four residents were tested and found not to activate outside the rooms. For two of these residents, the call lights did not light up outside the room when tested, and the DOM stated he thought the light bulbs had gone bad. For the other two residents, their call lights did not activate outside the room and also did not ring at the nurses’ station when pressed, which was confirmed by both a Registered Nurse (RN) and the DOM. Further interviews and record reviews showed that these non-functioning call lights had not been reported through the facility’s work order system. A Maintenance Assistant stated that non-working call lights were an ongoing issue and that he was sure some were outstanding. Review of electronic work orders for the relevant period did not show any entries for the rooms where the call lights were found to be non-functional. The facility’s policy on call lights states that staff are educated on proper use of the call system, including ensuring resident access, and that staff will report problems with call lights or the call system immediately to a supervisor and/or maintenance director and provide immediate or alternative solutions until the problem can be remedied. This policy was not followed for the four residents identified in the complaint investigation.

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 maintain required ambient air temperatures and to ensure accurate monitoring and reporting of those temperatures. During an observation period, multiple resident rooms and common areas on D and E pods were found to have temperatures below the facility’s stated acceptable range of 71°F to 81°F, with readings between 67.6°F and 70.3°F obtained using the facility’s laser thermometer. The Director of Maintenance confirmed these readings and acknowledged that the facility’s policy called for temperatures in common resident areas to be kept between 71°F and 81°F, with any resident preference outside that range requiring an assessment. Review of temperature logs for several days showed all sampled temperatures documented uniformly as 75°F with no variation, and there were no open work orders or prior reports for the rooms where low temperatures were observed. The Maintenance Assistant reported he had been recording temperatures with the same thermometer for two months and denied recent concerns about temperatures being out of range. The deficiency also includes failure to maintain wheelchairs in a clean and sanitary condition. During observation on D pod, a resident was seen seated in a wheelchair near the nurses’ station that was covered in debris of different colors and was noticeably dirty. The Therapy Program Director confirmed the condition of the wheelchair and stated it had been scheduled to be cleaned on a specific night shift but it did not appear that this had been completed. The Unit Manager/LPN reported that nurses and unit managers were responsible for overseeing the wheelchair cleaning schedule carried out by CNAs and that staff were to be disciplined if cleaning was not done, but also verified that the facility did not have a policy specific to wheelchair cleaning. A wheelchair cleaning schedule for D pod showed that this resident’s wheelchair was to be cleaned twice weekly, on Mondays and Fridays.

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 protect a cognitively impaired resident from physical abuse by another resident with known aggressive behaviors and to provide adequate supervision to prevent such abuse. One resident with severe dementia and a documented history of delusions, physical and verbal behaviors, rejection of care, wandering, and physical aggression toward others was care planned for multiple behavioral symptoms, including hitting, kicking, pushing, grabbing, and entering other residents’ rooms. Interventions in the plan of care included medication management, calm approaches, communication before care, leaving and returning if the resident resisted care, observing and documenting inappropriate behaviors, notifying the practitioner when behaviors persisted, providing psychological/psychiatric services as needed, offering choices, and providing a calm, safe environment and structured daily schedule. Despite this, the resident with aggressive behaviors was in a common area where another severely cognitively impaired resident was present. On the date of the incident, a CNA reported hearing yelling in a common area and then observed the aggressive resident strike another resident in the left side of the chest. The CNA immediately intervened and separated the residents. The nurse assessed the resident who was struck and initially found no redness or bruising, with stable vital signs. The resident reported that it hurt and did not know why the other resident had hit her. Over the following days, the resident continued to complain of left chest and breast pain, with pain scores documented as high as 9–10 out of 10. Multiple assessments and diagnostic tests were performed, including chest x‑rays and pain assessments, and the resident was repeatedly administered acetaminophen and topical agents for pain. Notes documented ongoing pain, intermittent anxiety, and discoloration to the left chest. The resident’s pain and chest symptoms persisted, leading to additional diagnostic workup including a STAT chest x‑ray, EKG, troponin level, and eventually transfer to the emergency room after family involvement and insistence on hospital evaluation. In the ER, imaging identified findings including an abdominal aortic dissection and other abnormalities, and the family reported that the ER physician questioned whether the injury pattern could be related to trauma. The family member also reported that the resident had slight discoloration to the chest from being hit and that the hospital took photographs. The DON later stated that the facility did not complete a self‑reported incident to the state agency regarding the altercation between the two residents because the resident was considered not injured. The facility’s abuse policy defined physical abuse to include hitting and punching and required reporting alleged violations to the state agency within specified timeframes, including immediately but not later than two hours after an allegation involving abuse or resulting in serious bodily injury. Despite this policy and the known aggressive behaviors of the resident who struck the other resident, the facility did not self‑report the incident.

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 implement and maintain care-planned fall and accident-hazard interventions for a resident identified as being at risk for falls and injury. The resident was admitted with multiple diagnoses including unspecified dementia, quadriplegia, delusional disorders, early-onset Alzheimer’s disease, anxiety disorder, major depressive disorder, and epilepsy. On admission, the nursing evaluation identified the resident as at risk for falls, and the care plan documented fall risk related to impaired cognition and decreased safety awareness, with goals to reduce injury risk. Interventions included ensuring the room was free from accident hazards, placing a floor mat next to the bed, and later revising this to a mattress on the floor at bedside. The care plan also documented behavioral issues such as verbal aggression, yelling, throwing legs out of bed, resisting care, socially disruptive and attention-seeking behaviors, including a history of yelling fire and pretending to have seizures, with interventions to approach calmly and re-approach if agitated. The resident’s care plan further identified an ADL self-care performance deficit related to quadriplegia, dementia, fluctuating ADLs, Alzheimer’s disease, and cognitive impairment, with documentation that the resident required one-person assistance for ADLs and a two-person assist with a mechanical lift for transfers. The MDS assessment indicated the resident was cognitively intact, had no impairment of upper and lower extremities, and was dependent for rolling in bed and transfers. Despite being care planned as dependent for mobility and at risk for falls, multiple interviews and observations established that the resident was able at times to move, scoot to the edge of the bed, and push herself off the bed. Staff, the POA, and the NP all reported that the resident could and did intentionally push or throw herself from the bed, sometimes to gain attention, and that she had a history of similar behaviors at a previous facility. The facility’s fall protocol required assessment of history of falls, cognitive/behavioral symptoms, mobility, and development and implementation of a plan of care to reduce falls and minimize injury. The incident underlying the deficiency included an unwitnessed fall in which the resident was found on the floor next to the bed after reportedly throwing herself out of bed, with a hematoma near the left eye and an active nosebleed, requiring EMS transport to the hospital. At the time of this fall, the resident had a fall mat on the floor and a tube feeding pole with a feeding machine next to the bed, and staff reported the resident might have hit her head on the pole. Subsequent observations showed the resident with bruising and steri-strips on her forehead, and later lying in bed leaning over the side with an oxygen concentrator, wastebasket, and bedside table positioned near her head. A CNA immediately identified and removed these items as accident hazards, acknowledging the resident was a fall risk who could hit her head on them if she fell. The DON later acknowledged the resident probably hit the cement floor when she rolled off the bed. These findings demonstrate that the care-planned interventions to keep the room free of accident hazards and to provide adequate environmental protection (such as appropriate placement of mattresses and removal of hazardous equipment and furniture near the bed) were not consistently implemented, resulting in a failure to ensure a hazard-free area and adequate supervision to prevent accidents for this resident. Additional interviews reinforced that the resident frequently reached over the side of the bed, grabbed and pulled on the floor mat, and pulled on nearby equipment such as the tube feeding pole. Staff, including the RN, CNA, NP, and DON, described the resident’s fluctuating physical abilities and behavioral components, including faked seizures, reports of chest pain, and self-propelling off the bed. Despite this known pattern and the care plan directive to keep the environment free of accident hazards and to use protective measures at bedside, the resident continued to have accessible objects and equipment within striking distance of her head while in bed. The facility’s failure to consistently remove or reposition these hazards and to fully implement the individualized fall and behavior-related interventions as care planned led to the cited deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.

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 individualized behavioral health interventions were implemented to meet a resident's mental health needs and prevent suicidal ideation with a suicide attempt. The resident was admitted with Alzheimer's disease, personality disorder, and major depressive disorder, and had been transferred from an assisted living facility to a psychiatric hospital following a prior suicide attempt involving placing a garbage bag over his head. On admission, the resident was cognitively intact and required hands-on assistance for activities of daily living. Despite this history, the care plan in place prior to the incident only included general behavioral approaches such as medication administration as ordered, redirection, non-judgmental support, environmental calming strategies, and monitoring and documentation of behaviors. On one occasion, the resident's assigned CNA observed the resident with a plastic bag placed over his head and face while staff were preparing to escort him to dinner. The CNA immediately removed the bag and notified nursing. Upon assessment, the resident expressed active suicidal ideation, stating that he did not want to be there, could not go on like that, and that he would attempt self-harm again if left unsupervised, also stating he should have done it later in the night. The guardian later reported a history of similar behaviors at previous facilities. The DON confirmed that the care plan did not include measurable interventions to address the resident's suicidal ideations and behaviors prior to this event, and the facility’s comprehensive care plan policy required measurable objectives and timeframes to meet residents’ mental and psychosocial needs identified in the assessment.

Penalty

Fine: $123,61525 days payment denial

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

Summary

The facility failed to ensure adequate hydration for its residents, leading to a significant incident involving a resident with severe cognitive impairment. This resident, who had a history of Alzheimer's disease and chronic kidney disease, among other conditions, was hospitalized due to dehydration, which resulted in an acute change in condition, including altered mental status and acute kidney injury. The resident's fluid intake was documented to be significantly below the required amount in the days leading up to the hospitalization, highlighting a failure in monitoring and providing necessary hydration. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's risk for dehydration and the necessary interventions to prevent it. A Licensed Practical Nurse (LPN) admitted to not documenting or recalling important information from the hospital regarding the resident's condition and care needs upon readmission. Additionally, a Certified Nursing Assistant (CNA) was unaware of the resident's recent hospitalization for dehydration and stated that residents were not provided water unless requested, indicating a systemic issue in ensuring residents' hydration needs were met. Further observations and interviews indicated that the facility did not consistently provide sufficient fluids during meals, with reports of inadequate beverage supplies and delays in obtaining additional fluids. This affected multiple residents across different nursing units, with some residents receiving only partial servings of beverages. The facility's policy on hydration, which required offering sufficient fluids to maintain health, was not adhered to, contributing to the risk of dehydration among residents. Additionally, the facility failed to follow dietary orders for another resident, who did not receive the prescribed double portions, further indicating lapses in nutritional care.

Penalty

Fine: $123,61525 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 clean and sanitary kitchen environment, which had the potential to affect all residents receiving food from the kitchen. During an observation, several areas of concern were noted, including a wall-mounted fan with visible black dirt and dust, vents in the commercial hood with an accumulation of dirt and debris, and a six-burner cooktop with dried food and debris around the burners. Additionally, the double convection oven had dried food splatters and burnt-on food residue, and a storage container had a buildup of food crumbs with lids containing dried food particles. The white tiled wall, plate warmer, proofing pan bun rack, and trash can also had food splatter marks and dried food particles. Further observations revealed issues in the dry storage area and walk-in freezer, where food items were improperly stored, such as open bags of sausage patties, vegetable patties, and cinnamon rolls exposed to air. The facility's cleaning schedules were not consistently completed, with only one night shift cleaning schedule filled out over a month-long period. The facility's policies required all food preparation and service areas to be maintained in a clean and sanitary condition, and all foodservice equipment to be clean and sanitary, which were not adhered to, leading to this deficiency.

Penalty

Fine: $123,61525 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 appropriate water temperatures on the 200 unit, affecting seven residents directly and potentially impacting all 23 residents on the unit. Observations revealed that the hot water temperatures in various rooms and the central bathing room were consistently below the facility's policy range of 105 to 120 degrees Fahrenheit. Interviews with staff and residents confirmed the lack of adequate hot water, with reports of water being cold during showers. The facility's water temperature logs indicated temperatures within the acceptable range, suggesting a discrepancy between recorded data and actual conditions. Residents affected by this deficiency included individuals with severe dementia, chronic obstructive pulmonary disease, diabetes, and other significant health conditions. These residents required varying levels of assistance with bathing, ranging from maximum assistance to supervision. The deficiency was identified during an investigation of complaints, highlighting the facility's non-compliance with its policy to provide a safe and comfortable environment for residents.

Penalty

Fine: $123,61525 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 proper infection control practices during wound care and medication administration, affecting several residents. During wound care for a resident with Alzheimer's disease, an LPN placed a foam dressing directly on the bed sheet without a barrier, contrary to the facility's clean dressing change policy. The resident had an unstageable wound on the left heel, and the LPN admitted to not using a barrier, which was a deviation from the established protocol. In addition, the facility did not ensure proper hand hygiene during medication administration for multiple residents. An RN was observed handling medication and water cups with bare hands, contaminating the items before administering them to residents. This included picking up a dropped capsule with bare hands and placing it back into the medication cup. The RN confirmed these actions during an interview, acknowledging the breach in hand hygiene protocol. Another RN and a medication technician were also observed failing to perform hand hygiene before and after administering medications. This included touching the inside of water cups with bare hands and handling medication capsules without washing hands. These actions were verified through interviews with the staff involved, highlighting a consistent failure to adhere to the facility's hand hygiene and medication administration policies.

Penalty

Fine: $123,61525 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 address pharmacy recommendations in a timely manner for three residents, leading to deficiencies in medication management. Resident #7, who had multiple diagnoses including bipolar disorder and schizophrenia, was prescribed aripiprazole, an atypical antipsychotic. A pharmacy recommendation dated 12/02/24 suggested checking a fasting lipid panel and hemoglobin A1C due to the risk of adverse metabolic effects. However, this recommendation was not addressed until over a month later, on 01/07/25, when the necessary lab tests were ordered. Resident #35, diagnosed with conditions such as dementia and diabetes, had a vitamin D level of 80, which was within the normal range. Despite a pharmacy recommendation on 09/03/24 to evaluate and potentially reduce the dosage of vitamin D3 due to the current level, there was no documentation that the physician addressed this recommendation. The Director of Nursing confirmed the lack of documentation or rationale for not implementing the recommendation. Resident #90, with diagnoses including neurocognitive disorder and dementia, was admitted with an order for Quetiapine, an antipsychotic. A pharmacy review on 10/02/24 recommended evaluating the antipsychotic usage within two weeks of admission, as per federal guidelines, and considering a trial dose reduction. However, there was no documentation indicating that the physician was aware of or had addressed the pharmacist's recommendation. The Director of Nursing verified that the recommendations were not communicated to the physician, and there was no follow-up documentation.

Penalty

Fine: $123,61525 days payment denial

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

Summary

The facility failed to ensure that expired medications were discarded appropriately, affecting a resident who was administered expired cholecalciferol (vitamin D3) capsules. The resident, who had a complex medical history including Alzheimer's disease, vascular dementia, and vitamin D deficiency, was prescribed cholecalciferol 125 mg to be taken orally in the morning. However, it was observed that the medication cart contained a container of cholecalciferol with an expiration date of 11/21/24, and 37 doses had been administered to the resident after this expiration date. An interview with an LPN confirmed that the resident received these expired doses. The facility's policy on medication storage required routine inspections by the consultant pharmacist to identify and destroy expired medications, but this was not adhered to in this case. Additionally, the facility's medication administration policy required staff to check expiration dates and notify the nurse manager if a medication was expired, which was also not followed, leading to the administration of expired medication to the resident.

Penalty

Fine: $123,61525 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 complete and accurate documentation for two residents, leading to discrepancies in medical records. For Resident #106, there was a lack of consistency in the documentation of a fall incident. The resident, who had multiple diagnoses including diabetes and schizophrenia, was found on the floor by an LPN and complained of rib pain and difficulty breathing. However, another LPN documented the resident's pain as being in the right leg, not the ribs, and there was no witness statement from the LPN who initially found the resident. This inconsistency in documentation was not explained by the Director of Nursing. For Resident #123, who had Alzheimer's disease and was rarely understood, there were multiple inconsistencies in the documentation of a fall and subsequent assessments. The resident experienced an unwitnessed fall and was noted to have a hematoma on the forehead. However, the fall assessments varied, with some indicating a suspected head injury and others not. The Director of Nursing confirmed the presence of the hematoma but noted that not all assessments reflected this injury. Additionally, there was no documentation of the resident's declining status prior to the fall, which was a factor in the decision to admit the resident to hospice care. These documentation failures highlight the facility's inability to maintain accurate and consistent medical records, which is crucial for ensuring proper resident care and treatment. The discrepancies in the records for both residents indicate a lack of adherence to professional standards in documentation, as required by the facility's policies.

Penalty

Fine: $123,61525 days payment denial

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

Summary

The facility failed to provide adequate hair care for two residents, Resident #35 and Resident #40, who were unable to perform activities of daily living (ADLs) independently. Resident #35, who had a range of diagnoses including dementia, diabetes, and cerebral infarction, was observed multiple times with uncombed hair while sitting in the lounge area. Despite being dependent on staff for personal hygiene, as indicated in his care plan and Minimum Data Set (MDS) assessment, staff members, including CNAs, did not attend to his grooming needs. Interviews with CNAs confirmed that they had not combed Resident #35's hair after his shower or at other times when he was observed. Similarly, Resident #40, who had diagnoses such as chronic obstructive pulmonary disease (COPD), vascular dementia, and a history of adult neglect, was also observed with uncombed hair while in the lounge area. His care plan and MDS assessment indicated a dependency on staff for personal hygiene due to severely impaired cognition. An interview with a CNA confirmed that Resident #40's hair had not been combed. The facility's policy on ADLs, which includes grooming as a necessary service for residents unable to perform these tasks themselves, was not adhered to, resulting in this deficiency.

Penalty

Fine: $123,61525 days payment denial

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

Summary

The facility failed to provide adequate supervision to a resident, leading to the resident obtaining an over-the-counter medication, Tylenol, and potentially ingesting it. The resident, who had a complex medical history including dementia, heart disease, and several psychiatric disorders, was able to take a container of Tylenol from the top of a medication cart left unattended in a common area. The incident was discovered when a certified nursing assistant found the container under the resident's pillow, with eight tablets missing. The resident's vital signs were checked and found to be within normal limits, and poison control was contacted for guidance. The facility's video footage confirmed that the resident took the medication from the cart, which was left unattended by an LPN who was responsible for two nursing units at the time. The LPN admitted to inadvertently leaving the medication on the cart, which was not in compliance with the facility's medication storage policy. The facility's policy required that all medications be stored in locked compartments and be under the direct observation of the person administering them during medication passes. The LPN's failure to secure the medication cart and supervise the resident adequately led to the resident accessing the medication, highlighting a lapse in adherence to the facility's medication storage and supervision protocols.

Penalty

Fine: $123,61525 days payment denial

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

Summary

The facility failed to ensure that Resident #34 received the prescribed speech therapy services for dysphagia. Resident #34, who was admitted with multiple diagnoses including dementia, chronic obstructive pulmonary disease, and dysphagia, had a physician's order for speech therapy to evaluate and treat dysphagia three to five days a week for 30 days. However, during an observation of meal service, the speech therapist assigned to monitor Resident #34 was seen leaning against a pillar with his eyes closed for 15 minutes and did not interact with or assist the resident during the meal. Despite the speech therapist's note indicating that he monitored the resident's mastication and found no difficulty or signs of aspiration, the observation and interview with a certified nursing assistant confirmed that the therapist did not actively engage with the resident as required. The therapy director, upon being interviewed, stated that there were no prior concerns or complaints about the therapist's performance, but the therapist was suspended following the incident. This deficiency was identified during an investigation under Complaint Number OH00160780.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program for a resident, leading to the development of in-house pressure ulcers. The resident, who was cognitively impaired and had a history of skin impairment, was at risk for pressure ulcer development and dependent on staff for bed mobility. Despite these risk factors, the facility did not have comprehensive skin monitoring or effective interventions in place, resulting in the resident developing deep tissue injury (DTI) pressure ulcers on the left heel and sacrum. Upon admission, the resident was assessed as being at moderate risk for pressure injuries, with existing Moisture Associated Skin Damage (MASD) to the coccyx. The care plan included interventions such as applying protective barrier cream, assisting with turning and repositioning, and elevating the resident's heels off the mattress. However, documentation revealed a lack of consistent implementation of these interventions, with no evidence of the resident being turned or repositioned for several weeks and no documentation of the resident's heels being floated on multiple occasions. The facility's failure to consistently monitor and document the resident's skin condition and implement the prescribed interventions led to the development of new pressure ulcers. The resident's condition worsened, with the DTI to the left heel increasing in size and the sacrum wound initially described as maroon/purple with erythema and non-blanchable. Interviews with facility staff confirmed the pressure injuries were acquired in-house, and there were delays in implementing necessary equipment such as Prevalon boots and an air mattress.

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 adequate supervision to prevent a resident with a history of elopement from leaving the facility unsupervised. The resident, who had multiple diagnoses including Alzheimer's disease and vascular dementia, was admitted to the secure unit for safety due to dementia. Despite being identified as at risk for elopement, the resident managed to leave the facility by entering a door code and walking off the unit. The incident occurred when the resident, after being given a glass of water, returned to his room, dressed, and exited the unit by entering the door code. Staff were occupied with other residents and did not notice the resident's absence until later. The resident was eventually found by the police near a country club, having walked several miles from the facility. The facility's investigation revealed that the resident had been able to observe staff entering the door code, which he used to exit the building. Interviews with staff indicated that the door codes were frequently changed due to the resident's ability to figure them out, but this measure was insufficient to prevent the elopement. The facility's policy on elopement prevention was not effectively implemented, as evidenced by the resident's ability to leave the secure unit without detection. The incident highlighted a lapse in supervision and security measures, allowing the resident to elope and necessitating police involvement to ensure his safe return.

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 resident from abuse, specifically an incident of resident-to-resident abuse. Resident #113, who had severe cognitive impairment and a history of delusional behaviors, was involved in an altercation with Resident #133. Resident #113 attempted to intervene when Resident #133 was being aggressive towards staff, resulting in Resident #133 hitting Resident #113 and causing a laceration on the nose. This incident was substantiated as physical abuse by the facility. Resident #133 had a history of aggressive behaviors and was known to be combative when frustrated. On the day of the incident, Resident #133 was upset and displayed aggressive behavior, including pulling the phone from the nurse's station and yelling at staff. Despite being on a medication regimen for impulse control, Resident #133 had skipped doses and refused medication for sleep, anxiety, or depression, contributing to his irritable and frustrated mood. Interviews with facility staff revealed that Resident #133 was known for aggressive behavior, and other residents were fearful of him. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury resulting in physical harm, which was applicable in this case. The incident was reported to the authorities, and Resident #133 was transferred to a hospital for evaluation following the altercation.

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 timely discharge notice as required for a resident's transfer and discharge, affecting one resident out of three reviewed for transfer/discharge. The resident, who had a history of traumatic brain injury, epilepsy, and other mental health conditions, was involved in a violent incident at the facility, leading to an emergency transfer to a hospital for psychiatric evaluation. Despite the transfer being classified as an emergency, the facility did not send an Emergent Discharge Notification to the resident, their guardian, or the Ombudsman, which is a requirement to ensure the resident's rights and appeal opportunities are preserved. Interviews with facility staff, including the Interim Corporate Director of Nursing and the Social Worker, confirmed that the transfer was not handled according to the facility's policy on involuntary transfer and discharge. The Ombudsman, who oversees the facility, was not notified of the resident's emergent transfer or discharge, which hindered the resident's ability to appeal the discharge decision within the required timeframe. The facility's policy mandates proper notification to all interested parties, but this was not adhered to in this case, leading to a deficiency finding.

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 Bed Hold Notification to a resident and the resident's guardian during a transfer to a hospital for psychiatric evaluation. The resident, who had a history of traumatic brain injury, epilepsy, and other mental health conditions, was involved in an incident where they hit a co-resident, prompting a call to 911 and subsequent transfer to the hospital. Despite the transfer being documented as an emergency for psychiatric health, the facility did not provide the required written notification about the bed hold policy to the resident or their guardian. Interviews with the Interim Corporate Director of Nursing and a Social Worker confirmed that although a Bed Hold notice was prepared, it was not sent to the resident or their guardian. The resident was discharged, and billing was stopped without the necessary notification being provided. This oversight was identified during an investigation under Complaint Number OH00158393, affecting one of the three residents reviewed for transfer/discharge in a facility with a census of 131.

Penalty

Fine: $73,73251 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 prevent a significant medication error for a resident with a known history of hypothyroidism and myxedema coma. Upon admission, the resident's Synthroid medication, crucial for managing hypothyroidism, was not ordered or administered from the time of admission until the resident's transfer to the hospital several months later. This oversight led to the resident's condition deteriorating significantly, resulting in a transfer to the hospital where the resident was diagnosed with acute toxic metabolic encephalopathy, likely myxedema coma, and an elevated thyroid-stimulating hormone level. The resident's medical records from the previous skilled nursing facility indicated that Synthroid had been prescribed since 2022. However, upon admission to the current facility, the medication order was not transcribed accurately by the nursing staff. The resident's medical history included severe cognitive impairment, hypothyroidism, and previous episodes of myxedema coma, yet these critical details were not adequately addressed in the resident's care plan or medication administration records. Interviews with facility staff revealed a lack of proper communication and verification processes during the resident's admission. The admitting nurse did not accurately transcribe the medication orders, and there was no evidence of the required two-nurse verification process. Additionally, the consultant pharmacist failed to identify the absence of Synthroid in the resident's medication regimen during monthly reviews, further contributing to the oversight.

Removal Plan

• Resident #150 was transferred to the hospital and did not return to the facility. The resident was subsequently discharged to an alternate facility post-hospitalization.
• The facility completed an ADHOC Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Physician #825 (medical director), the DON, RN #937 (staff development coordinator), LPN UM #906, Admissions #969, LPN UM #860, Social Service Designee (SSD) #884, Licensed Social Worker (LSW) #820, LPN Minimum Data Set (MDS) #809, Human Resources (HR) #872 to discuss the survey concern and to develop an immediate plan of correction/action that was approved by the Medical Director.
• RN Regional #815 educated the DON and RN #937 on a new Medication Reconciliation Addendum which included two nurse verification at the time of admission, speaking directly with the provider Certified Nurse Practitioner (CNP)/physician via phone (no texting, faxing or picture taking) and included orders that were discontinued (on admission) must be noted in the admission progress notes.
• RN #937 educated 37 of 37 licensed nurses on a new Medication Reconciliation Addendum as well as transcribing physician orders and notifying the physician/CNP when a new admission/readmission entered the facility and verifying medications with two nurses and with the provider as well as entering a progress note reflecting verification of medications and any medications that were discontinued at the time of the verification. All nurses were educated prior to working their next shift.
• RN MDS #982 conducted care plan audits for all residents with diagnoses of hypothyroidism and hyperthyroidism to ensure care plans were addressed for their specific health needs. Care plans were revised and updated as needed.
• LPN UM #860 and LPN UM #906 audited all admissions/readmissions in the last two weeks to verify medications were transcribed correctly and verified with the physician/CNP timely.
• The DON completed chart audits on all residents with a diagnosis of hypothyroidism and all residents receiving Synthroid (Levothyroxine) to ensure the orders were transcribed properly, and the medications was administered as ordered.
• RN Regional #815 completed one-to-one education for the two nurses who admitted Resident #150, LPN #822 and LPN #823, on medication reconciliation to include two nurse verification at the time of admission, speaking with the provider CNP/physician via telephone (no texting, no faxing and no picture taking) and any orders that were discontinued must be noted in the admission progress note.
• Regional RN #815 educated CNP #824 and Physician #825 regarding progress notes and the need for a plan (of care) for diagnosis present in each resident's medical records.
• Regional RN #815 educated Pharmacist #840 on ensuring pharmacy reviews included all diagnoses having an appropriate plan of care in place including medications administered to the residents.
• The facility implemented a plan for the DON/designee to review CNP and physician notes weekly for four weeks to ensure the diagnosis of hypothyroidism has an appropriate plan in place.
• The facility implemented a plan for the DON/designee to review pharmacy recommendations monthly for three months to ensure residents with a diagnosis of hypothyroidism have been reviewed and have an appropriate plan of care in place to address the diagnosis of hypothyroidism.
• The DON/designee would complete daily chart audits, Monday through Sunday for three months on all new admissions/readmissions to ensure the orders were transcribed properly, medications were verified with two nurses and with the provider and the progress note entered in the medical record reflected verification of orders as well as any changes made during the verification progress. The audits would continue until compliance could be maintained for three consecutive months.
• The facility would complete weekly QAPI meetings for four weeks to review all audits regarding this action plan.

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 background checks were completed on all employees, including volunteers, which had the potential to affect all 130 residents residing in the facility. The facility's Abuse, Neglect, and Exploitation Policy, dated 07/28/2020, mandates that protections for the health, welfare, and rights of each resident be provided by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. This policy defines staff as including volunteers who provide care and services to residents on behalf of the facility. It requires that potential employees, including volunteers, be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property through background, reference, and credentials checks. A review of the employee file for a housekeeper revealed no evidence that a background check was completed. An interview with the Administrator confirmed that the housekeeper, who was a volunteer, did not have a background check completed. The Administrator explained that the housekeeper was a volunteer on a trial basis, and if hired, a background check would have been conducted.

Penalty

Fine: $18,233

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 Resident #200 was transferred safely using a Hoyer mechanical lift, resulting in a displaced fracture of the right distal humerus. The resident, who required a two-person assist for transfers, was transferred by a single staff member, STNA #702, who admitted to self-transferring the resident despite being educated that two staff members were required. During the transfer, the resident became antsy, grabbed the Hoyer lift bar, and hit herself above the right eye, leading to further complications and a fracture in the right arm. Resident #200's medical records indicated diagnoses including Alzheimer's disease, heart failure, osteoarthritis, and essential hypertension, but no diagnosis of osteoporosis. The resident's care plan specifically required a two-person assist with a Hoyer mechanical lift for transfers. On the day of the incident, STNA #702 was performing incontinence care and preparing to transfer the resident when the injury occurred. The resident's right arm later showed signs of pain and was found to have a displaced fracture after an x-ray. Interviews with various staff members, including LPNs and other STNAs, confirmed that the resident was transferred by a single staff member, contrary to the facility's policy requiring two staff members for mechanical lift transfers. The facility's investigation was inconclusive in determining the exact cause of the injury but suspected that the resident bumped her arm on the mechanical lift bar. The facility's policy on safe lifting and movement of residents, revised in 2022, clearly stated that two staff members should be present during all mechanical lift transfers, which was not adhered to in this case.

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 timely report an allegation of staff-to-resident abuse involving a resident with severe cognitive impairments and multiple medical conditions. The incident occurred when a State Tested Nursing Assistant (STNA) observed another STNA holding the resident by the biceps and guiding her to her room, which was perceived as potentially abusive behavior. The observing STNA did not report the incident immediately, waiting approximately 1.5 hours before notifying the Administrator, which delayed the removal of the alleged perpetrator from the facility. The resident involved had a history of severe protein-calorie malnutrition, dementia, major depressive disorder, and other significant health issues. The resident was cognitively impaired and required assistance with certain activities of daily living. The incident was reported by the observing STNA after her shift ended, and the facility's investigation included interviews with multiple staff members and a review of the resident's condition, which did not reveal any immediate harm or evidence of abuse. The facility's policy required immediate reporting of any suspected abuse, but the delay in reporting by the observing STNA resulted in a failure to protect the resident promptly. The facility's investigation ultimately found the allegation to be unsubstantiated, but the delay in reporting and the subsequent delay in removing the alleged perpetrator from the facility constituted a deficiency in compliance with abuse reporting protocols.