Arbors At Streetsboro

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 follow physician orders and care plan interventions for a resident with an implanted cardiac pacemaker and multiple cardiac diagnoses, including CHF, cardiomyopathy, atrial fibrillation, and dementia. The resident’s care plan addressed impaired cardiovascular status and included interventions such as administering medications as ordered, observing for CHF symptoms, monitoring weights, and providing oxygen as ordered, but there was no evidence of an intervention to check pacemaker function. The record also showed no evidence that the resident received the ordered daily weights on multiple days, and there was no documentation that the resident refused weights or that the physician or NP was notified when weights were not obtained. The resident experienced repeated episodes of decline while in the facility. At one point, staff documented lethargy, swelling, low oxygen saturation, abdominal distention, and blood in the catheter bag, leading to transfer to the hospital for urinary concerns and later acute on chronic CHF. The hospital records noted heart failure, pacemaker presence, and that daily weight monitoring was crucial. Later, the resident again became lethargic, clammy, sweaty, unable to swallow, and bradycardic, with oxygen saturation unobtainable. EMS transported the resident to the hospital, where bradycardia and pacemaker malfunction were identified, the pacemaker could not be properly interrogated because the battery may have died, and the resident required surgery for a new pacemaker implantation. Facility interviews and record review showed the resident had not had remote pacemaker checks completed in the facility during the relevant period, and staff were unaware of the pacemaker or how to complete the checks. The DON stated all residents with pacemakers should have pacemaker checks in place, and later found the resident’s remote monitoring device in the room unplugged and not working. The device clinic representative stated the bedside monitor needed to remain plugged in and that missed follow-up could occur when residents were lost in follow-up. The resident’s decline was described by staff and the POA as related to the pacemaker not working, and the resident was later discharged back to the facility after pacemaker replacement. The facility also failed to obtain a wound culture from the correct wound for another resident with a right lateral calf wound and a sacral pressure injury. The wound record showed the right lateral calf wound had necrotic tissue, large purulent drainage, deterioration, and signs and symptoms of infection, and a culture and sensitivity was ordered for that wound. However, the TAR documented that a wound culture was collected from the sacrum instead, and there was no documented evidence that the ordered culture from the right lateral calf wound was completed. The RDCS confirmed the specimen should have been collected from the right lateral calf wound and that it had been incorrectly collected from the sacrum.

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 adequate monitoring and care for two residents with urinary issues, including timely identification and response to symptoms of urinary tract infection and catheter-related complications. Resident #59 had an indwelling catheter related to obstructive uropathy and prostate cancer, with care plan interventions to observe for signs of UTI and report blood in urine, cloudiness, foul smell, fever, or mental status changes. Resident #70 was cognitively intact, always incontinent of urine and bowel, and had diagnoses including CHF, diabetes with chronic kidney disease, and right above-knee amputation. The record showed no care plan related to urinary and bowel incontinence or specific interventions to monitor for UTI symptoms such as pain and burning during urination. For Resident #59, the record showed pain complaints, an order for urinalysis and culture, and repeated catheter problems. After the resident reported that his catheter had been pulled out, a new catheter was inserted and blood was observed. The record did not show documented monitoring for blood in the urine until the next day, when the resident had minimal urine output, was lethargic, had a distended and painful abdomen, and blood and clots were seen in the catheter bag. The resident was sent to the ED, where the catheter was found to be misplaced. Hospital records documented a UTI associated with the indwelling catheter, a urethral injury, abnormal urinalysis findings, and treatment with antibiotics. The record also showed additional catheter-related abdominal swelling and blood in the catheter after return from the hospital, leading to another transfer to the ED. For Resident #70, the record showed the resident reported burning with urination and pain rated 6/10, but there was no documented evidence of evaluation or monitoring for those symptoms, no documented urine specimen collected for UA and C&S, and no documented physician notification of the urinary symptoms. The resident later complained of shaking in the right arm, but there was no documented evidence the physician was notified or that the resident was monitored and evaluated for a change in condition. When the resident later insisted on hospital transfer because he had been feeling shaky for several days, the ED found a UTI, rigors, elevated troponin, hypoxia, projectile vomiting, acute cystitis, sepsis with acute organ dysfunction, acute hypoxic respiratory failure, and acute decompensated heart failure.

Penalty

No penalty information released

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

Summary

The facility did not ensure a designated Infection Preventionist provided oversight, monitoring, and management of all components of the Infection Prevention and Control Program. Review of the facility’s Annual Long Term Care Facility Self-Assessment Tool dated 09/03/25 listed Regional Director of Clinical Services #301 as the Infection Preventionist, but the Administrator was unsure whether she was in the facility at least part-time and believed LPN #235, who worked full-time as the MDS nurse, was also serving in that role. During interview, RDCS #301 confirmed the facility did not have at least a part-time Infection Preventionist in place to consistently implement and monitor the program, and stated LPN #235 helped with the infection control log but did not oversee the program. RDCS #301 also stated the facility had used the SDC or several different nurses as Infection Preventionists in the past year and had just hired a new Infection Preventionist the previous week. Record review showed concerns with immunization consent forms for five residents. For Residents #5, #16, #24, #40, and #61, the COVID-19, influenza, and pneumococcal vaccine education and verbal consent forms did not identify the staff member obtaining consent, and there was no witness signature on the forms. In addition, review of the facility’s Infection Surveillance Reports for November 2025, December 2025, and January 2026 showed multiple infections marked as not meeting McGeer’s criteria for antibiotic use, including 18 of 28 infections in November, 18 of 22 in December, and 13 of 18 in January. The report did not indicate whether any follow-up evaluation had been completed regarding the infections that did not meet the standards for antibiotic use.

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 resident room refrigerators were monitored, cleaned, and that outdated food items were disposed of appropriately. Surveyors observed that the food service department was managed by a contracted agency and staff stated they did not go into resident rooms and were unsure whether resident or unit refrigerators were being monitored. The facility identified 13 residents with in-room refrigerators, and the deficiency affected five residents whose refrigerators were observed. Resident #18, who had diagnoses including anoxic brain damage, CHF, and vascular dementia and was on a no added salt diet, had multiple expired and spoiled items in the refrigerator, including sour cream past its use-by date, black raspberry jam past its use-by date, a jar of pickled cauliflower with visible mold and no evident date, and two open packages of chopped deli ham with use-by dates that had passed. Resident #39, who had COPD, cardiomyopathy, and morbid obesity and was on a controlled carbohydrate diet, had a bottle of mustard in the refrigerator with a use-by date that had passed. Resident #39 stated staff checked the refrigerator frequently but was unsure whether expiration dates were checked. Resident #55, who had Alzheimer’s disease, cerebrovascular disease, dementia, hemiplegia, and type II diabetes mellitus, had a refrigerator with multiple dried stains and was not clean. Resident #59, who had type II diabetes mellitus, Alzheimer’s dementia, and obesity, also had a refrigerator that was dirty with multiple dried stains inside. Resident #45, who had mononeuropathy of both lower limbs and epilepsy, had a dirty refrigerator with multiple dried stains and several expired or undated food items, including mayonnaise, dill pickle spears, American cheese slices, and spinach/artichoke dip. Resident #45 stated staff checked the refrigerator temperature almost daily but did not clean it, and that staff did not offer to clean it because he was in a wheelchair and unable to do so himself. Transportation staff stated he was responsible for checking refrigerator temperatures and sometimes cleaned them, but if residents told him not to touch their food, he did not report it to management for over a year. The facility policy stated food brought in by family or visitors must be handled safely and items not maintained are subject to being thrown away if not removed, but it did not specify how often refrigerators would be cleaned or monitored.

Penalty

No penalty information released

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

Summary

The facility failed to implement an effective antibiotic stewardship program. Review of the infection surveillance logs for November 2025 through January 2026 showed multiple residents were placed on antibiotics even though the documented infections did not meet McGeer’s criteria for antibiotic use, and there was no documentation explaining what the facility did to determine why the criteria were not met. The affected residents included those with wound infections, catheter-associated UTIs, symptomatic UTIs, fungal skin infections, pharyngitis, pneumonia, cellulitis, and other unidentified infections. Examples from the logs included residents diagnosed with healthcare-associated wound infections, fungal skin infections, catheter-associated UTIs, symptomatic UTIs, throat infections, pneumonia, and cellulitis who were started on antibiotics such as cephalexin, fluconazole, cefdinir, meropenem, levofloxacin, Augmentin, Macrobid, doxycycline, azithromycin, metronidazole, linezolid, vancomycin, ertapenem, and cefpodoxime. In several cases, no organism was identified, and in others the organism was listed but the infection still did not meet criteria for antibiotic use. Some residents received more than one antibiotic course or repeated courses for the same infection type. During interview, the RDCS confirmed the findings and stated the reason so many residents were marked as not meeting McGeer’s criteria was that staff did not document or assess residents’ symptoms related to the infection. The facility policy stated that the antibiotic stewardship program was part of the infection prevention and control program, that all antibiotic orders were to be reviewed for appropriateness, and that antibiotic use was to be monitored through monthly review and outcome measures. The survey findings showed that these monitoring expectations were not being carried out effectively for the residents identified in the infection surveillance logs.

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 physician orders were followed for medication administration for six residents on the 400 nursing unit. Review of records showed that Resident #70, who had CHF, type 2 diabetes mellitus with diabetic chronic kidney disease and retinopathy, and an above-the-knee right leg amputation, did not have ordered insulin lispro administered per sliding scale before meals and at bedtime on the reviewed date, and there was no evidence that blood sugars were checked at the ordered 11:00 A.M. and 4:00 P.M. times. Resident #59, who had CHF, Alzheimer’s disease, atrial fibrillation, dementia, cardiomyopathy, and type 2 diabetes mellitus, also had no evidence of the ordered 11:00 A.M. blood sugar check and sliding-scale Novolog administration. Resident #66, who had Alzheimer’s disease, dementia, type 2 diabetes mellitus, and chronic diastolic CHF, did not have the ordered daily insulin glargine-yfgn administered at 9:00 A.M. Resident #67, who had unspecified convulsions, pelvic fractures, and obesity, did not have the ordered Phenobarbital 32.4 mg administered at 2:00 P.M., and the controlled drug record did not show it was signed off as given. Resident #17, who had rheumatoid polyneuropathy with rheumatoid arthritis, Ehlers-Danlos syndrome, and major depressive disorder, did not receive ordered Oxycodone 5 mg at 2:00 P.M., and the controlled drug record also did not show it was signed off as administered. Resident #33, who had hypertension, pain, anxiety disorder, aphasia, dysphasia, and post-traumatic seizures, had multiple ordered treatments and medications not documented as completed on the MAR, including tube-feed flushes, tube-feed hold/resume instructions, Guaifenesin, Tylenol, Levetiracetam, and residual checks. Staff interviews confirmed that on the day in question, the former DON had to pass medications on the 400 unit because of a nurse call-off, and the LPN later identified that several residents on that unit had not received medications during that time. The ADON and facility leadership confirmed that the MARs showed no evidence the medications were administered, and they stated they were unaware this had occurred until it was brought to their attention.

Penalty

No penalty information released

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

Summary

The facility did not ensure a thorough investigation was completed for an allegation of misappropriation involving a resident with intact cognition and multiple chronic conditions, including morbid obesity, peripheral vascular disease, major depressive disorder, GERD, chronic pain, hypertension, insomnia, and hypothyroidism. The resident reported that $15 was missing from her room and stated she was unsure when it went missing, estimating it may have been missing for up to two weeks. The incident was reported to the DON, and the facility reimbursed the money and reminded the resident to use her lock box, but the investigation file contained no other staff interviews beyond the reporting nurse and no additional evidence of a broader inquiry. The facility concluded the misappropriation was unsubstantiated after interviewing residents in the 200 hall, all of whom reported no missing money from their rooms. However, the record did not include documentation of interviews with other staff who may have had knowledge of the allegation, and the Administrator later stated she was still waiting for information from the previous Administrator regarding whether additional staff interviews existed. The facility policy required identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegation, and required complete documentation of the investigation. The facility also did not complete a thorough investigation for an allegation of staff-to-resident physical abuse involving a resident with a history of convulsions, pelvic fractures, obesity, and impaired musculoskeletal status related to recent back surgery. The resident alleged that staff rushed her during incontinence care, flipped her, and caused pain while she was sliding in bed. The investigation included statements from two CNAs who provided care, but the record did not show that the nurse assigned to the resident at the time was interviewed or that additional staff witness statements were obtained. Although the facility noted residents were questioned and skin checks were provided to residents unable to be interviewed, the SRI did not contain evidence of those interviews or skin checks, and the documentation did not show a complete investigation as required by facility policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure Resident #5 received a complete dietary assessment. Resident #5 was admitted with diagnoses including dementia with behavioral disturbance, gastric reflux, high blood pressure, atrial fibrillation, and heart disease, and was admitted to the secured dementia unit. The resident’s admission weight was 190.8 pounds, and the most recent weight documented was 189.0 pounds. A Nutrition Data Collection/Evaluation-V2 completed by the former registered dietitian on 12/18/25 documented the resident’s diet order as regular diet, regular texture, and thin liquids, with height, weight, caloric needs, protein needs, and fluid needs recorded, and it recommended continuing the current nutrition plan of care. The assessment also noted that the dietitian went to speak with the resident, but the door was shut with enhanced barrier precautions in place and asked that the resident be spoken to for follow-up. No other dietary assessments were completed, and no dietary progress notes had been documented since admission. The regional director of clinical services confirmed that no other dietary assessments could be found for Resident #5, and the current registered dietitian had not assessed the resident since starting in the position.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a comprehensive care plan was completed for Resident #24, who was admitted on 07/02/25 with diagnoses including Alzheimer's dementia, dementia with behaviors, type II diabetes mellitus, oppositional defiant disorder, and depression. The 01/08/26 quarterly MDS 3.0 showed a BIMS score of 12, indicating moderate cognitive impairment. The assessment also noted that the resident felt down, had trouble falling asleep, and had a poor appetite during 12 to 14 days of the 14-day review period, required supervision for most ADLs, and needed moderate assistance with bathing. Review of the resident's care plan, last reviewed on 01/22/26, showed no evidence of a care plan for monitoring antipsychotic, antidepressant, or anticoagulant medications or related interventions. During interview on 02/25/26 at 3:15 P.M., the DON confirmed she was unable to provide evidence of an antipsychotic, anticoagulant, or antidepressant care plan for Resident #24 as required. The facility policy on Comprehensive Care Plans stated that each resident should have a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs.

Penalty

No penalty information released

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

Summary

The facility failed to ensure staff did not assist Resident #5 with exiting the secured dementia unit without verifying he was a resident. Resident #5 was admitted with diagnoses including dementia with behavioral disturbance, gastric reflux, high blood pressure, atrial fibrillation, and heart disease, and was admitted to the secured dementia unit even though the physician orders did not include an order for him to reside there. The admission assessment documented poor decision-making skills, no unsafe behaviors at the time of admission, and no baseline elopement care plan was initiated. The resident’s comprehensive MDS later described him as moderately cognitively impaired, without behaviors, and independently mobile. Housekeeping staff assigned to clean the secured dementia unit encountered a man near the exit door carrying a suitcase and believed him to be a guest or visitor because he had not seen him before. The staff member unlocked the door and allowed the resident to exit the unit. A CNA later observed Resident #5 heading toward the nurses’ station after exiting the secured unit and returned him to the unit. The CNA statement noted the resident had been demonstrating exit-seeking behaviors, pacing with a suitcase, and stating that he needed to get to the airport. The elopement was reported to the charge nurse, but the DON was not notified until the following day, and camera footage later confirmed the housekeeping staff opened the door and allowed the resident to leave. The facility also failed to ensure safe smoking interventions were in place for Resident #55 during an observed smoking activity. Resident #55 had diagnoses including Alzheimer’s disease, transient ischemic attack, and cerebral infarction, and her care plan and smoking assessments indicated she was to wear a smoking apron and needed a smoking aide because she was not able to safely light her cigarettes. During an observed smoking break, Resident #55 was seen smoking without an apron while two activity assistants monitored the group. She was given cues to ash her cigarette, and one activity assistant stated she did not know whether the resident should be wearing an apron. The administrator later confirmed that Resident #55 should have been wearing an apron while smoking.

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 sufficient supervision was maintained to prevent a resident from exiting the secured dementia unit. Resident #5 was admitted with diagnoses including dementia with behavioral disturbance, gastric reflux, high blood pressure, atrial fibrillation, and heart disease, and was admitted to the secured dementia unit. The admission nursing assessment documented poor decision-making skills, but the elopement/wandering assessment indicated the resident was not cognitively impaired and did not have dementia, organic brain syndrome, Alzheimer’s disease, hallucinations, anxiety, or unsafe behaviors. No admission baseline care plan for elopement was initiated. On 12/20/25, the resident had been demonstrating exit-seeking behaviors, including pacing the hallway with a suitcase, going back and forth from room to door, and stating, “I need to get to the airport.” A housekeeping employee assigned to clean the secured dementia unit exited the unit, saw the resident standing near the exit door with a suitcase, believed him to be a guest or visitor, unlocked the door, and allowed him to exit. The employee stated the resident appeared calm and composed, politely asked to be let out, and spoke clearly and appropriately. The nursing progress notes later documented that the resident had followed someone out the door of the secured unit carrying a suitcase and stating he had to go to the airport, and he was helped back down the hallway to the memory care unit. The resident’s daughter was notified. No documentation was located regarding the resident’s exit-seeking behaviors on 12/20/25, and the DON was not notified until 12/22/25. The facility’s memory care admission determination policy stated that staffing level and skill of unit personnel to meet the individual’s needs are considered in admission decisions, and the unsafe wandering and elopement prevention policy required assessment by the IDT and care plan modification for residents at risk for unsafe wandering.

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 pharmacy recommendations were acknowledged and addressed in a timely manner for two residents reviewed for unnecessary medications. One resident had diagnoses including Alzheimer’s dementia, dementia with behaviors, type 2 diabetes mellitus, oppositional defiant disorder, and depression, and was noted on the MDS to have moderate cognitive impairment and to require supervision or assistance with most activities of daily living. Pharmacy recommendations related to this resident’s medication regimen were documented for Seroquel and Trileptal behavior monitoring, clarification of a MiraLAX order to include liquid administration instructions, clarification of aspirin formulation, administration of Coreg with meals, monitoring for bleeding with Plavix plus aspirin, and clarification of the diagnosis for Zoloft. The report states these recommendations were not signed by the physician within 30 days, and the regional director confirmed the recommendations were not signed in less than 30 days. A second resident reviewed for unnecessary medications had diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, type 2 diabetes, chronic kidney disease, atrial fibrillation, hypothyroidism, ulcerative colitis, metabolic encephalopathy, alcohol dependence, and hypokalemia. This resident was moderately cognitively impaired and required supervision and some assistance with activities of daily living. The pharmacist identified that the resident was receiving omeprazole 40 mg daily as a high dose proton pump inhibitor and recommended reducing the dose to 20 mg daily. The nurse practitioner agreed with the recommendation and signed it, but the resident continued to receive the higher dose until the medication was discontinued. The regional director confirmed the pharmacy recommendation for this resident was not signed in a timely manner. The facility also failed to monitor one resident’s blood glucose levels. This resident had chronic respiratory failure, peripheral vascular disease, COPD, diabetes, bipolar disorder with psychotic features, PTSD, obstructive sleep apnea, morbid obesity, and ventilator dependence. The resident was cognitively intact, could identify medications and explain why they were taken, and was allowed to self-administer diabetes medications stored in a locked box. Physician orders required staff to observe for signs of low and high blood sugar, obtain and document blood glucose readings before meals and at bedtime, and document how much insulin the resident administered. Review of the MAR and electronic record from December 2025 through February 2026 showed no documentation of blood glucose levels or the amount of insulin administered, and the blood glucose entries were not recorded four times daily as ordered. The regional director confirmed nursing should have been documenting the resident’s blood glucose levels and insulin amounts as ordered.

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 nursing documentation was accurate and included information pertinent to resident care for one resident who was admitted with diagnoses including dementia with behavioral disturbance, gastric reflux, high blood pressure, atrial fibrillation, and heart disease and was admitted to the secured dementia unit. The admission nursing assessment documented the resident as not cognitively impaired, with poor decision-making skills, and indicated the resident did not have a diagnosis of dementia, organic brain syndrome, Alzheimer’s disease, hallucinations, or anxiety, despite the resident being admitted to the secured dementia unit. No admission baseline care plan for elopement was initiated, and the comprehensive admission MDS later identified the resident as moderately cognitively impaired, with no behaviors and independently mobile. The resident was involved in an elopement-related incident when housekeeping staff, unaware the resident was not permitted to leave the secured unit alone, unlocked the door and allowed the resident to exit while carrying a suitcase and stating he needed to get to the airport. A CNA later observed the resident exiting the unit and returned him to the secured dementia unit. The incident was reported to the charge nurse, but the DON was not notified until the following day. The nursing progress note documented that the resident had followed someone out of the door while carrying a suitcase and stating he had to go to the airport, but it did not mention the exit-seeking behavior or that the resident had exited the secured unit on the day of 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 facility failed to collaborate with hospice, complete a comprehensive assessment, and implement care planned interventions for a resident who experienced a change in condition after returning from the hospital with hospice services. The resident had multiple diagnoses including CHF, type 2 diabetes mellitus, Alzheimer's disease, dementia, paroxysmal atrial fibrillation, and cardiomyopathy. After the hospital discharge, the resident returned to the facility with instructions that included insulin lispro sliding scale coverage three times daily, comfort measures per hospice, and monitoring for hypoglycemia, but the facility record showed hospice was contacted and planned to admit the resident the next day. The resident's TAR showed repeated missed blood sugar checks on multiple shifts over several days, and there was no evidence that blood sugars were checked on several dates. The record also showed a blood sugar of 269 and later 156 with no evidence that the physician or hospice was notified or that insulin was administered. Although the MAR contained sliding scale insulin orders, progress notes documented that the resident was not safe to swallow on one day and hospice later discontinued routine medications and ordered comfort medications. The care plan addressed hospice collaboration and notification of hospice for changes in condition, but the chart did not show evidence that medications, blood sugar checks, or insulin administration were discussed with hospice during the period reviewed. Interviews showed the resident initially appeared lethargic and was placed on hospice EMC protocol because he was thought to be imminently dying, but he then improved, became alert, ate, drank, attended bingo, and was described as back to baseline. The DON confirmed the resident had not received insulin or routine blood sugar checks during the reviewed period and stated there should have been better communication between the facility and hospice. The hospice nurse stated the resident had improved and that insulin and blood sugar checks could be added back in, and also stated the hospice team had not known the resident was supposed to be receiving sliding scale insulin because the hospital discharge instructions included it but the hospice medication list did not. The facility policy required coordination with hospice staff and immediate communication regarding significant changes in status, but the resident's improving condition and ongoing diabetes management were not reflected in the care provided.

Penalty

No penalty information released

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

Summary

A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.

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

Surveyors observed that the facility failed to maintain a clean and sanitary environment for its residents. In one instance, a resident was found in a room with a strong odor of urine, a wet and soiled incontinence pad on the bed with dried yellowish-brown stains, and multiple gnats present on the soiled area. Additionally, wet soiled clothes were found on the floor outside the bathroom, and soiled linens were left across the room. The resident reported being left in the wheelchair for an extended period without the area being cleaned, and a CNA confirmed that the night shift had left the room in that condition for several hours. The resident's care plan indicated a need for one to two staff assistance with all ADLs and noted incontinence of bowel and bladder. In another case, a different resident's room and the surrounding hallway had a strong urine odor, and the floor was sticky. The bed had an exposed incontinence pad with dried urine and feces, and the bedside table was sticky with dried spills and debris. Staff interviews confirmed that the resident, who had a urinary catheter and moderate cognitive impairment, would empty the catheter bag without assistance, often spilling urine on the floor and bed sheets. The resident also exhibited behaviors such as refusing housekeeping or personal care, requiring staff to clean the room after the resident left. Facility policies required prompt removal of soiled linens and maintenance of a clean, odor-free environment, which was not followed in these instances.

Penalty

No penalty information released

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

Summary

A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

No penalty information released

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

Summary

The facility failed to provide meals in accordance with a resident's documented food preferences. The resident, who had diagnoses including diabetes, end stage renal disease, and major depressive disorder, was cognitively intact and required set up assistance with meals. Documentation in the Nutrition Data Collection/Evaluation and Meal Tracker printout indicated that carrots were listed as a dislike for this resident, and the resident's diet was updated accordingly. Despite this, photographic evidence provided by the resident's family showed that carrots were repeatedly served to the resident, even when tray tickets specified other vegetables such as brussel sprouts, whole kernel corn, or broccoli florets. Interviews with the resident's family and facility staff, including the District Director of Dietary and the DON, confirmed that the resident received food items listed on her dislike list for at least three meals. The facility's policy required that individual tray assembly tickets reflect all food items appropriate for the resident based on diet order, allergies, intolerances, and preferences. Both the Regional Director of Dietary and the DON reviewed and verified the photographs, confirming the discrepancy between the resident's documented preferences and the meals served.

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 an accurate and thorough Facility Assessment, which is essential for determining the necessary resources to care for residents competently during both routine operations and emergencies. The assessment, dated from January 2024 through December 2024, lacked critical information, including the names of the Administrator, Director of Nursing, and Medical Director, as well as a review mark. Additionally, it did not specify the type and number of staff required to provide care and services. This deficiency was confirmed during an interview with the Administrator, who acknowledged the assessment's inadequacies.

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 secure and dispose of sharp objects, which had the potential to affect six ambulatory residents residing on the 600 unit. During an observation, a treatment cart was found with an open compartment containing nine used syringes, three lancets, and one used needle for an insulin injector pen. This compartment lacked a second receptacle for securing these sharp objects, posing a safety risk. A Licensed Practical Nurse verified the presence of these exposed sharp objects at the time of the observation. The facility's policy, titled 'Safe and Homelike Environment,' dated 01/01/2022, mandates providing a safe environment, which includes ensuring that the physical layout does not pose a safety risk to 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 report injuries of unknown origin to the state agency within the required time frame, affecting one resident. The resident, who had intact cognition and required varying levels of assistance for daily activities, was found with three new skin tears of unknown origin. These injuries were documented by a registered nurse but were not reported to the Director of Nursing (DON) or the state agency as required by facility policy. The incident occurred when the resident, who had been incontinent and more agitated than usual, was taken for a shower by two nurses. After the shower, the resident went out to smoke and returned with blood on her arm and three skin tears. The nurses involved did not notify the DON or the on-call nurse about the injuries, and no Self-Reported Incident (SRI) was initiated on the day of the injury. The facility's policy requires immediate investigation and reporting of injuries of unknown origin, but this was not followed. The DON confirmed that neither she nor the on-call nurse was notified, and an SRI was only opened two days later. The failure to report and investigate the injuries promptly was a clear violation of the facility's policy and state regulations.

Penalty

No penalty information released

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

Summary

The facility failed to investigate and report injuries of unknown origin for a resident within the required time frame. The resident, who had intact cognition and required varying levels of assistance for daily activities, was found with three new skin tears of unknown origin. These injuries were documented by a registered nurse, but no immediate investigation or self-reported incident (SRI) was initiated on the day the injuries were discovered. Interviews with the Director of Nursing (DON) and nursing staff revealed that the registered nurse who documented the injuries did not notify the DON or the on-call nurse. Additionally, the licensed practical nurse (LPN) who was present did not conduct any investigation into the cause of the injuries, as they were on orientation and unsure of the procedures. The DON confirmed that neither they nor the on-call nurse were informed of the injuries until two days later, at which point an SRI was opened and an investigation began. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and reporting of injuries of unknown origin. However, the staff failed to adhere to these procedures, resulting in a delay in reporting the incident to the state agency. The policy mandates that such incidents be reported within two hours if they involve abuse or serious bodily injury, or within 24 hours if they do not. This deficiency highlights a lapse in communication and procedural adherence among the facility's staff.

Penalty

No penalty information released

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

Summary

The facility failed to provide therapeutic activities to meet the needs and preferences of its residents, affecting three residents. Resident #47, who has severe cognitive impairment and is dependent on staff for mobility, was observed lying in bed with a flat affect and watching television during multiple observations. The care plan for Resident #47 included daily visits for encouragement and socialization, but the Activity Director admitted that one-on-one activities occurred only once a week and were not documented on the activity calendar. The resident's participation in group activities was minimal, and the facility did not adhere to the care plan's interventions. Resident #2, who has intact cognition but is mostly bed-bound, reported that activity staff did not visit her room for activities and that she was not included in outings. The resident expressed boredom and a desire for more engagement, stating that the activities documented were due to a CNA sneaking her treats from activities. The activity documentation showed limited participation, and the resident felt neglected in terms of being offered activities or outings. Resident #10, who is cognitively intact and dependent on staff for mobility, also reported a lack of engagement from the activity department. The resident stated that the monthly activity calendar was not followed, and he had to purchase his own puzzle books for entertainment. The Activity Director confirmed that one-on-one activities were brief and infrequent, and the resident's care plan for daily visits was not implemented. The facility's policy to provide activities based on residents' preferences and needs was not followed, as evidenced by the limited participation and lack of individualized attention for these 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 maintain a safe and clean refrigerator for a resident's personal use. During an observation, a mini refrigerator in the room of a resident was found to have a temperature log dated September 2024, indicating a lack of recent monitoring. The interior of the refrigerator was dirty, with a pink dried substance present. A Registered Nurse confirmed both the outdated temperature log and the unclean condition of the refrigerator. The facility's policy, dated January 1, 2022, requires daily temperature recording and cleaning of resident-owned refrigerators by housekeeping staff, which was not adhered to in this instance.

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 adhere to its infection prevention and control program by not utilizing proper personal protective equipment during incontinence care for a resident on enhanced barrier precautions. Resident #118, who was admitted with diagnoses including chronic peptic ulcer, hypertension, chronic kidney disease stage four, and diabetes mellitus type two, required enhanced barrier precautions as per their care plan. The resident's care plan specified the use of gowns and gloves during high-contact care activities, such as personal hygiene and changing briefs. During an observation, Certified Nurse Assistants (CNAs) #305 and #360 were seen providing incontinence care to Resident #118 without wearing gowns, despite the presence of a sign indicating enhanced barrier precautions and available personal protective equipment outside the room. This was confirmed by Registered Nurse (RN) #347, who acknowledged that the CNAs should have been wearing gowns. The facility's policy on enhanced barrier precautions, which aims to reduce the transmission of multidrug-resistant organisms, was not followed, leading to this deficiency.

Penalty

Inspection fine: $10,842

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 for a resident who was assessed to be at high risk for elopement. This resident, who resided in a secured memory care unit and had a history of exit-seeking behavior, managed to follow a dietary staff member through a secured door and subsequently eloped from the facility. The resident's wander guard alarmed as designed when he exited through the front door, but staff failed to respond in a timely manner and did not adequately investigate the source of the alarm. The resident was found approximately 0.7 miles away by local police after a neighborhood resident reported seeing him fall. Another incident involved a second resident who also eloped from the facility without staff knowledge. This resident was found by a staff member who was on their way to work. Both residents were identified as being at high risk for elopement, and the facility's failure to supervise them adequately resulted in their unsupervised departure from the premises. The facility's policies and procedures for preventing elopement were not followed, as evidenced by the lack of timely response to alarms and failure to conduct resident headcounts. Staff interviews confirmed that the facility did not adequately monitor residents at risk for elopement, leading to these incidents.

Removal Plan

• Upon discovery Resident #18 had eloped from the facility, a head count was initiated by Licensed Practical Nurses (LPNs) #136 and #137 and all additional residents were accounted for.
• LPN #249 completed a head-to-toe assessment on Resident #18.
• Resident #18 was placed on one-on-one staff supervision, which would continue pending the outcome of a guardianship hearing.
• LPN #144 was notified by the LPD Resident #03 had been located off facility grounds.
• LPN #144 initiated a resident head count to ensure all other residents were accounted for.
• The LPD and Emergency Medical Services (EMS) arrived at the facility with Resident #03. EMS and LPN #144 assessed the resident, and the resident was returned to the secured memory care unit.
• Resident #03 was placed on one-on-one supervision. This would continue while the facility worked with the resident's guardian to determine any additional interventions or alternative placement.
• The DON and LPN/UM #248 reviewed the facility cameras and completed a root cause analysis. It was determined Resident #03 was able to elope when staff exited the secured memory care unit without ensuring no residents were following, lack of timely staff response when the wander guard set off the front door alarm and lack of adequate staff response upon investigating the front door alarm.
• The DON completed a wander guard audit for all residents (#03, #53 and #54) with wander guards to ensure the intervention was appropriate, orders were in place and care plans were updated with no discrepancies identified.
• The DON and LPN/UM #248 reviewed and updated the resident elopement binder to ensure accuracy of information.
• The DON completed a second audit of the facility elopement binder with no discrepancies identified.
• The DON and LPN/UM #248 completed a reassessment of all facility residents for elopement risk. Care plans for residents at risk for elopement (#03, #18, #53 and #54) were reviewed and updated as appropriate.
• An elopement drill was completed by the DON and LPN/UM #248.
• The DON educated all facility staff in-person and by phone on ensuring residents do not follow them through the locked door of the secured memory care unit, the facility policy for elopement, responding to door alarms and missing resident with 100% of staff receiving the education.
• The DON educated all Certified Nursing Assistants (CNA) in-person and by phone on resident supervision, to include checking on residents every two hours, and if unable to locate a resident, to immediately notify the nurse so a headcount of facility residents can be initiated and search conducted per facility policy with 100% of the CNAs receiving the education.
• LPN #249 and LPN #139 completed a whole facility audit of windows and doors to validate all security measures were in place with no concerns identified.
• Dietary Manager (DM) #156 completed one-on-one education with Dietary Aide (DA) #157 to ensure no residents were following when exiting the secured memory care unit.
• The DON/designee would review all risk for elopement assessments and nursing quarterly assessments for four weeks to ensure accuracy and appropriate interventions are in place.
• The DON/designee would observe food carts going off the secured memory care unit five times per week for eight weeks to ensure staff are following procedures to prevent residents from following behind them when exiting the unit.
• The DON/designee would randomly observe staff entering and exiting the secured memory care unit for eight weeks to ensure procedures are followed to prevent residents from exiting the unit.
• The Administrator/designee would complete daily elopement drills on random shifts for two weeks then monthly elopement drills (one on each shift per quarter).
• The DON would review progress notes for all residents daily, Monday through Friday, for any documentation of exit seeking behaviors for four weeks to ensure appropriate interventions are implemented and care plans revised.
• The Interdisciplinary Team (IDT) would continue to identify residents at risk for elopement upon admission/re-admission and change in condition to ensure appropriate interventions are implemented and care planned to address elopement risk.
• DOM #246 would continue to monitor and validate door alarms and function per facility policy and procedures.
• An ad hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held, which included the Administrator, DON, Medical Director (MD) #247, Activities Director (AD) #255 and LPN/UM #248 to review the root cause analysis, policies and procedures and corrective action plan.
• The QAPI Committee met to review the first week audit findings with no concerns identified.

Penalty

Inspection fine: $10,842

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 incidents of elopement involving two residents to the State Agency, which was identified during a complaint investigation. Resident #03, who had diagnoses including dementia and Alzheimer's disease, eloped from the secured memory care unit. The resident was found by the police approximately 0.7 miles away from the facility, disoriented and on his hands and knees. The facility staff were unaware of the resident's absence until contacted by the police. The incident was not reported to the state agency as required. Resident #18, diagnosed with unspecified dementia and other conditions, was found in a church parking lot 1.1 miles from the facility. The resident had left the facility without informing the staff, which was treated as an elopement. Despite the resident being her own responsible person, the facility did not report this incident to the state agency. The facility's policy required reporting all alleged violations and substantiated incidents to the State Agency, which was not followed in these cases. Interviews with facility staff, including the DON and Regional Directors, confirmed the lack of reporting for both incidents. The facility's failure to report these elopements was an incidental finding during the investigation, highlighting a deficiency in adhering to reporting protocols as outlined in their policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Resident #42 consistently received a divided plate with all meals as requested. Resident #42, who has diagnoses including Alzheimer's dementia, dysphagia, and failure to thrive, had a documented preference for a divided plate on her diet ticket. However, observations on two separate days revealed that her lunch meals were not served on a divided plate. Resident #42 confirmed that she was not provided with a divided plate as requested on these occasions. Additionally, her current care plans, including the nutritional care plan, did not include information related to her preference for a divided plate. Interviews with the District Manager confirmed that Resident #42's meal ticket indicated a preference for a divided plate due to her desire to keep different food types from touching. Despite this, the facility's policy on Resident Food Preferences, which states that the resident's clinical record should document likes, dislikes, and special dietary instructions, was not followed. This deficiency was investigated under Complaint Number OH00152644.

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 care planned and physician-ordered protective barrier cream was applied after incontinence care for two residents. Resident #43, who had a stage two pressure ulcer on the right buttock, reported that staff had not been applying the prescribed zinc oxide cream. During an observation, it was confirmed that Resident #43 was not wearing an incontinence brief and had no zinc oxide cream applied, despite the resident stating she had never refused the treatment. This was corroborated by the State tested Nursing Assistants (STNAs) who were present during the observation. Similarly, Resident #53, who had a raw and painful peri area, was also not receiving the prescribed barrier cream. Despite physician orders and care plan instructions to apply zinc oxide cream after each incontinence episode, an observation revealed that no barrier cream had been applied. The Licensed Practical Nurse (LPN) confirmed that the cream should have been applied, and the STNA admitted to not applying it. Both residents had intact cognition and were able to communicate their discomfort and the lack of care they received.

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 dental services as requested for Resident #42, who had diagnoses including Alzheimer's dementia, dysphagia, and failure to thrive. The resident experienced weight loss and had an order for a dental consultation due to improper fitting dentures. Despite the order being placed on 04/02/24, the resident was not seen by the dentist when they visited the facility on 04/16/24. Interviews with the Registered Dietitian, Social Worker, and Director of Nursing revealed a lack of awareness and follow-through regarding the dental concerns and consultation order. The facility's policy on dental services, revised on 10/30/23, stated that residents with lost or damaged dental appliances would be promptly referred for dental services, which was not adhered to in this case.