Beeghly Oaks Center For Rehabilitation & Healing

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 prepare an adequate amount of the main entree for the lunch meal on March 3, 2025, which resulted in meals being delivered late and not served at the correct temperatures. The lunch menu included country chicken and dumplings, glazed carrots, cornbread, diced pears, juice, and milk. The tray line for the 1300 unit was scheduled to start at 12:20 P.M. and be delivered by 12:45 P.M. However, the staff ran out of chicken and dumplings at 12:50 P.M., causing a delay. The last cart and test tray left the kitchen at 1:05 P.M., and the final tray was delivered at 1:10 P.M. Upon sampling the test tray, the food temperatures were found to be below the required levels, with carrots at 124 degrees F, chicken and dumplings at 146 degrees F, milk at 47 degrees F, and juice at 58 degrees F. The facility's policy requires hot food to stay above 135 degrees F and cold food below 41 degrees F. Interviews with the cooks revealed that they frequently run out of food because most residents request double portions. This deficiency was investigated under Master Complaint Number OH00162819.

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 investigate and address significant weight gain for a resident with congestive heart failure (CHF). Resident #43, who had multiple diagnoses including CHF, morbid obesity, and dementia, experienced a significant weight gain of 34 pounds over a 13-day period. Despite the resident's return from the hospital with a recommendation for daily weight monitoring, the facility did not implement this recommendation, and the weight gain was not promptly communicated to the dietitian for further evaluation. The Director of Nursing (DON) acknowledged that the facility's policy required re-weighing residents with significant weight changes and notifying the dietitian, but this process was not followed. The dietitian, who covered multiple facilities, was not informed of the confirmed weight gain in a timely manner, delaying potential interventions. The physician involved also questioned the accuracy of the weight measurements, suggesting that the scale used might have been improperly calibrated, but this was not addressed with the facility. The facility's policy indicated that significant weight changes should be retaken and confirmed, with the dietitian being notified for undesired weight gains. However, this protocol was not adhered to, resulting in a lack of timely intervention for Resident #43's significant weight gain. The communication breakdown between nursing staff, the dietitian, and the physician contributed to the deficiency in care for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to promptly investigate a significant weight loss in a resident, which was necessary to determine if additional nutritional interventions were required. The resident, who had a history of morbid obesity, type two diabetes mellitus, and vascular dementia, experienced a 7.76% weight loss over two months. The care plan for the resident included monitoring for signs of malnutrition and having the dietitian evaluate and recommend diet changes as needed. However, despite the resident's weight loss being recorded in December, the facility did not conduct a re-weigh as requested by the dietitian, and the weight loss was not addressed in a timely manner. The Director of Nursing (DON) and the dietitian both acknowledged the failure to obtain a re-weigh after the dietitian's request. The dietitian, who managed nutritional assessments for multiple facilities, relied on staff to alert her to significant weight changes. The physician involved noted that some weight loss was expected due to the resident's medication but expressed concern that the weight loss had not been addressed by the dietitian. The lack of timely action and communication among the facility's staff contributed to the deficiency in addressing the resident's nutritional 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 timely report possible misappropriation of narcotic medications to the appropriate state agency, affecting two residents and potentially impacting 33 additional residents on narcotic medications. Resident #83, with diagnoses including altered mental status and arthritis, had discrepancies in the administration of tramadol, an opioid pain medication. The controlled drug disposition form showed multiple instances where tramadol was signed out by LPN #420, but there was no documented evidence on the medication administration record (MAR) that the medication was administered. Similarly, Resident #106, with diagnoses including unspecified convulsions and cerebral infarction, had discrepancies in the administration of oxycodone, another opioid pain medication. The controlled drug disposition form indicated that oxycodone was signed out by LPN #420, but again, there was no documented evidence on the MAR that the medication was administered. Additionally, there was an instance where LPN #323's name was forged on the controlled drug disposition form, and she was not working at the time the medication was signed out. The Director of Nursing (DON) was informed of these discrepancies and the forgery on 09/27/24, but the facility did not report the allegation of misappropriation of narcotics to the state agency as required. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting of all alleged violations to the state agency. The failure to report these incidents represents non-compliance investigated under Complaint Number OH00158476.

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 accurate documentation of narcotic medication administration for two residents, which was identified during a review of medical records, interviews, and facility policy. Resident #83, who had diagnoses including altered mental status and arthritis, had a physician's order for tramadol. However, discrepancies were found in the medication administration record (MAR) and the controlled drug disposition form, where several instances of tramadol being signed out by LPNs were not documented as administered on the MAR. Similarly, Resident #106, with diagnoses including unspecified convulsions and cerebral infarction, had a physician's order for oxycodone. The review revealed multiple instances where oxycodone was signed out but not documented as administered on the MAR, including a case where a tablet was signed out by an LPN who was not on duty at the time. The Director of Nursing verified these discrepancies during an interview, confirming the issues with the controlled drug disposition forms and the MARs for both residents. The facility's policy on administering medication requires the individual administering the medication to initial the MAR after giving each medication, which was not adhered to in these cases. This deficiency was investigated under a complaint and was a recite to the annual survey completed earlier.

Penalty

Fine: $288,26098 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 timely and appropriate care to a resident who experienced a fall, resulting in actual harm. The resident, who had a history of falls and was at moderate risk, fell while attempting to transfer from bed to chair. Despite expressing severe pain, rated ten out of ten, the resident did not receive pain medication, and the physician was not notified until ten hours after the incident. The resident was eventually diagnosed with a closed displaced fracture of the right acetabulum at the hospital. The resident's care plan indicated an increased risk for falls due to generalized weakness and diabetes mellitus, with interventions to anticipate and meet needs, ensure the call light was within reach, and encourage its use. However, the resident attempted to transfer without assistance, resulting in a fall. The incident report and progress notes lacked documentation of a fall evaluation, pain assessment, or physician notification. The resident was assisted into a wheelchair by staff but continued to experience severe pain without receiving pain medication. Interviews with staff revealed that the LPN on duty did not document the administration of Tylenol or notify the physician effectively. The Director of Nursing confirmed that the resident's severe pain warranted immediate medical attention, which was not provided. The resident remained in pain throughout the night, and it was not until the morning shift that the resident was sent to the hospital for evaluation.

Penalty

Fine: $288,26098 days payment denial

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

Summary

The facility failed to develop and implement an effective, comprehensive, and individualized fall prevention program for a resident, leading to a severe fall incident. The resident, who was severely cognitively impaired and at moderate to high risk for falls, was left unattended in a chair in the activity room without proper footwear and clothing. This resulted in the resident sustaining multiple fractures after an unwitnessed fall. The resident had not been toileted for five hours prior to the fall, and the care plan was not updated following previous falls. The resident had a history of falls, with incidents occurring on multiple occasions, yet the care plan was not revised to include new interventions. The facility's staff failed to conduct accurate and complete fall risk assessments, as evidenced by discrepancies in the assessments. The resident's fall risk assessments were not updated after each fall, and the facility did not establish voiding patterns for the resident, despite frequent incontinence. Another resident was also affected by the facility's failure to complete fall risk assessments. This resident had a history of falls and was identified as a moderate risk for falling, but no fall risk assessments were completed for several months. The facility's policy required fall risk assessments to be done quarterly and annually, but this was not adhered to, contributing to the deficiency.

Penalty

Fine: $288,26098 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 timely and appropriate pain management for a resident, resulting in actual harm. The resident, who had a history of osteonecrosis of the right femur and other fractures, experienced severe pain in her right knee following a significant change in condition. Despite the resident's repeated complaints of pain, the facility staff did not conduct a thorough assessment, notify the physician, or administer pain medication. This led the resident to call the local police multiple times for assistance, ultimately resulting in her transfer to a hospital where an acute fracture of the distal right femur was diagnosed. The resident's care plan included interventions for pain management, such as administering analgesics as ordered and responding immediately to complaints of pain. However, there was no documented evidence that these interventions were followed. The resident's pain was not assessed using a pain scale, and the physician was not notified of the resident's significant change in pain level. The facility's failure to adhere to its pain management policy and procedures contributed to the resident's untreated pain and subsequent distress. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's pain complaints. The dialysis nurse reported the resident's severe pain to facility nurses, but there was no documentation of this communication. Additionally, the facility's self-reported incident tracking and investigation were delayed, and the resident's allegations of being hurt during a transfer were not substantiated. The facility's inadequate response to the resident's pain and the lack of timely medical intervention resulted in the resident's unnecessary suffering and hospitalization.

Penalty

Fine: $288,26098 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 pressure ulcer care and prevention for several residents, leading to the development and deterioration of pressure ulcers. Resident #32, who was at high risk for pressure ulcers due to impaired mobility and incontinence, developed a Stage III pressure ulcer on the sacrum and a deteriorating surgical wound on the right below-knee amputation site. Despite physician orders for frequent turning and repositioning, as well as specific wound care treatments, documentation revealed these interventions were not consistently implemented. The lack of timely assessment and treatment led to the resident's condition worsening, resulting in hospitalization for osteomyelitis. Resident #1, also at high risk for pressure ulcers, was found to have a deep tissue injury on the sacrum, which was not adequately evaluated or treated according to the medical record. The facility's failure to conduct regular pressure ulcer risk evaluations and follow care plans contributed to the development of pressure ulcers in multiple residents. The facility's documentation practices were inadequate, with missing records of required treatments and assessments, indicating a systemic issue in care delivery. Interviews with family members and staff highlighted concerns about inconsistent care, particularly in the long-term care unit, where residents were not turned or repositioned as needed. Family members reported having to remind staff to elevate Resident #32's right stump to prevent pressure, and staff interviews confirmed that treatments were not consistently completed. The facility's policy on pressure injury prevention was not effectively implemented, leading to actual harm for the residents involved.

Penalty

Fine: $288,26098 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 food was stored, prepared, and served under safe and sanitary conditions, potentially affecting all 100 residents who received meals from the kitchen. Observations revealed multiple issues with food storage, including undated containers of food in the reach-in cooler, moldy strawberries in the walk-in cooler, and improper labeling and dating of food items. The kitchen environment was also found to be unsanitary, with dried food splatters and dust on equipment, and bread and buns stored on the floor in a puddle of water. During meal preparation, staff failed to adhere to hygiene protocols. A dietary aide was observed not wearing a hair net, touching their face and hair without washing hands, and using dirty oven mitts after picking up a dropped plate from the floor. Another staff member was seen preparing pureed diets without properly washing or sanitizing equipment between different food items. These actions were confirmed through interviews with the staff involved, who acknowledged their failure to follow proper hygiene practices. Additionally, the facility lacked proper documentation of temperature logs for refrigeration units and meal temperatures, with missing records for several days in September and no logs available for June and July. The facility's policies on food storage, safety, and sanitation were not followed, as evidenced by the lack of proper waste disposal practices, with trash cans in the kitchen left uncovered. These deficiencies indicate a systemic failure to maintain a safe and sanitary food service environment, as required by the facility's policies.

Penalty

Fine: $288,26098 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 effectively manage pressure ulcer prevention, accident prevention, and pain management programs, impacting the well-being of its residents. Resident #32, who was at risk for pressure ulcers and dependent on staff for mobility and care, developed a Stage III pressure ulcer and a complication with a below-the-knee amputation stump. The facility did not provide timely assessments or interventions, leading to the resident's hospitalization for osteomyelitis. Family members reported inadequate care, including failure to reposition the resident and improper use of support props. Resident #197, severely cognitively impaired and at high risk for falls, experienced an unwitnessed fall resulting in multiple fractures. The resident had been left unattended in an activity room and was not toileted for five hours prior to the fall. Despite previous falls, the facility did not implement effective fall prevention interventions or update the care plan. The resident's daughter expressed concerns about the lack of appropriate fall interventions and delayed notification of the fall. Resident #7 experienced a fall and severe pain, but the facility failed to contact a physician or provide pain medication for ten hours. The resident was eventually sent to the hospital and diagnosed with a fracture. The DON confirmed that proper procedures were not followed, including the failure to call 911 when the resident reported severe pain. These incidents highlight the facility's lack of comprehensive and effective administrative oversight, affecting the quality of care provided to residents.

Penalty

Fine: $288,26098 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 concerns in a timely manner and did not ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated and identified areas in need of improvement. This deficiency was observed through a series of surveys, including an annual survey and multiple complaint surveys, all of which resulted in citations related to kitchen and dining services. Despite having approved corrective action plans in place, the facility did not monitor for quality assurance issues related to these services, except for dietary preferences, and failed to address repeated concerns raised in Resident Council meetings about food temperatures, condiments, portions, and variety. Interviews with the Administrator and Director of Nursing revealed that the facility had undergone a complete change in kitchen staffing, including the director, supervisor, and several cooks and aides, but there was no evidence that newly hired staff were educated on previously cited deficient practices. Observations during the annual survey indicated that the facility did not ensure recipes were followed, food was palatable, food was stored appropriately, and the kitchen was maintained in a clean and sanitary condition.

Removal Plan

• Ensuring staff were educated regarding appropriate kitchen and dining services
• Ensuring staff were educated on policies and procedures
• Conducting audits of resident meals

Penalty

Fine: $288,26098 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 essential kitchen equipment, specifically the garbage disposal, which was not functioning for about a month. Observations revealed that the table sink in the dish room, which led into the dishwasher, lacked a garbage disposal or connected pipes. Instead, a hole under the sink allowed water and food scraps to fall into a basin on the floor, which was filled with brown water, food scraps, and a mug. Kitchen staff continued to use this setup, rinsing dirty dishes in the sink, causing water and food scraps to accumulate in the basin. Interviews with the Maintenance Director and Dietary Manager confirmed that the garbage disposal had been disconnected for approximately a week, and a new one could not be ordered because replacement parts would not fit the current sink. The facility was waiting for quotes to replace the table sink. The lack of a functioning garbage disposal had the potential to affect 100 residents who received meals from the kitchen, with two residents identified as not receiving meals from the kitchen. The facility census was 102, indicating a significant impact on meal service operations.

Penalty

Fine: $288,26098 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 timely meal delivery, affecting up to 100 residents who received meals from the kitchen. The meal delivery schedule was not adhered to, as evidenced by observations and interviews. Breakfast, lunch, and dinner were consistently delivered later than scheduled times across various hallways. Resident Council meeting minutes from several months indicated ongoing complaints about the timeliness of meal deliveries. Observations and interviews with staff, including a State Tested Nurse Aide and a Dialysis Nurse, confirmed the persistent issue of late meal deliveries. The Dialysis Nurse highlighted that the delay in meal delivery impacted residents who required in-house dialysis services, causing them to be late for their treatments. This delay also led to residents refusing meals to avoid being late for dialysis, which could have adverse effects on their health if they ate just before treatment.

Penalty

Fine: $288,26098 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 residents' dignity by not providing knives with meal trays, affecting two residents directly and potentially impacting 15 others on the same hallway. Residents were observed having to tear their food apart with their fingers due to the absence of knives. The Dietary Manager confirmed that the facility had run out of both metal and plastic knives, and the 1200 hallway was consistently the last to receive meal trays, which contributed to the issue. The facility's policy on resident rights emphasizes the right to a dignified existence, which was not upheld in this instance. Additionally, the facility did not ensure that a resident's urostomy bag was covered with a privacy cover, as required by the physician's orders. The resident was found with her ostomy bag lying uncovered on the floor, instead of being placed in the designated black bag attached to her bed. An LPN confirmed that the ostomy bag should have been properly covered and not on the floor, indicating a lapse in following the care plan and physician's orders for maintaining the resident's dignity and privacy.

Penalty

Fine: $288,26098 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 safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations and interviews. Resident #13, who has diagnoses including colon cancer, congestive heart failure, and dementia, was found to have soiled incontinence products thrown on the floor by a State tested Nurse Aide (STNA) during incontinence care. The STNA acknowledged the inappropriate action and corrected it by placing the items in the trash can. For residents receiving tube feeding, the facility did not ensure clean and sanitary conditions for the tube feed pumps and poles. Resident #60, with diagnoses such as cerebral infarction and epilepsy, had a tube feed pump and pole with dried feed residue observed on multiple occasions. Similarly, Resident #84, who is cognitively intact but dependent on staff for activities of daily living, had hardened tube feed residue on the base of the pole. These conditions were verified by staff during observations. Resident #197, who has Alzheimer's disease and returned from a hospital stay with a feeding tube, also had a tube feed pump with dried feed and Triad cream residue. An LPN confirmed the lack of cleanliness and mentioned a supposed cleaning schedule for night staff, which the Director of Nursing was unaware of. The facility's policy on maintaining a clean and homelike environment was not adhered to, as evidenced by these findings.

Penalty

Fine: $288,26098 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 care plans were updated to reflect the current needs and interventions for residents, affecting four residents and potentially impacting all 102 residents in the facility. Resident #22's care plan inaccurately included antipsychotic medication interventions, despite the resident not taking such medications. The Director of Nursing (DON) confirmed awareness of the issue with care plans not being updated when resident needs changed. Resident #60 experienced multiple falls, yet the care plan was not updated with appropriate interventions after each incident. The care plan, last updated in July 2024, did not reflect the resident's fall history or the interventions implemented after each fall. The DON confirmed that the care plan was not updated with appropriate interventions for falls occurring between April and July 2024. Resident #81's care plan did not accurately reflect her current diet orders, as it listed a regular diet instead of the mechanically altered, ground texture diet prescribed. Similarly, Resident #197's care plan was not updated after each fall, and no new interventions were put in place. The DON confirmed that investigations were completed for each fall, but they did not determine the root cause. The facility's policy required care plans to be revised as changes in residents' needs arose, but this was not adhered to.

Penalty

Fine: $288,26098 days payment denial

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

Summary

The facility failed to ensure proper medication management and storage, as observed on three out of four medication carts. On the 1200-unit medication cart, a vial of Novolog insulin for a resident was found opened with a sticker indicating it should not be used after a certain date, yet it was still present past that date. Additionally, a vial of Lantus insulin was not dated when opened, and there were loose medications found in the cart. Interviews with staff confirmed these findings and the lack of alternative insulin for the resident. Further observations on the 1300-unit medication cart revealed expired and improperly labeled over-the-counter medications, spilled liquid protein, and numerous loose medications. The 1400-unit medication cart also contained open but undated medications. Interviews with nursing staff confirmed these deficiencies, which were in violation of the facility's medication storage policy. These issues had the potential to affect a significant number of residents in the facility.

Penalty

Fine: $288,26098 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 implement appropriate transmission-based precautions and infection control measures, affecting five residents. Resident #71, who was on contact isolation for Vancomycin Resistant Enterococci (VRE) and klebsiella, did not have the necessary contact precautions sign on the exterior door of his room. This oversight was confirmed by an LPN who found the sign in the resident's closet instead. Additionally, Resident #252's oxygen tubing was observed lying on the floor, which was confirmed by an STNA as inappropriate, as the tubing should be off the floor when not in use. Resident #254, who had an ostomy, was found with her ostomy bag lying on the floor uncovered, contrary to the care plan that required the bag to be kept in a black bag attached to her bed. This was confirmed by an LPN during an interview. Furthermore, Resident #24, who was in enhanced barrier precautions due to an open wound, was not provided with the required gown and gloves by the STNAs during incontinence care. This was confirmed by the Director of Nursing and observed again when a Unit Manager also failed to wear a gown during hands-on care. Resident #62, who was cognitively impaired, was left with a cup of medication at her bedside without supervision. The resident struggled to take the medication, spilling pills in the process. An LPN, who had left the medication, picked up the spilled pills with bare hands and gave them back to the resident without performing hand hygiene. This was confirmed during an interview with the LPN. The facility's Infection Prevention and Control Plan and hand hygiene policy were not adhered to, as staff failed to follow proper hand hygiene procedures before and after direct contact with residents.

Penalty

Fine: $288,26098 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 timely notification of a resident's representative following multiple falls. Resident #60, who was moderately cognitively impaired and had a history of cerebral infarction, diabetes, and other medical conditions, experienced several falls at the facility. Despite the facility's policy requiring notification of a resident's representative in the event of an accident or incident, there was no documented evidence that Resident #60's representative was informed of the falls that occurred on three separate occasions. The medical record review revealed that Resident #60 was found on the floor by staff members on multiple dates, with no negative findings reported. However, the progress notes lacked documentation of any notification to the resident's representative. An interview with the Director of Nursing confirmed the absence of such documentation, indicating a failure to adhere to the facility's policy on notifying a resident's representative of changes in condition or status.

Penalty

Fine: $288,26098 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 written notification of its bed hold policy to a resident or the resident's representative, affecting one resident out of four reviewed for hospitalization. The resident in question was admitted with multiple diagnoses, including Alzheimer's disease and severe cognitive impairment. The resident experienced hospitalizations on two occasions, during which the facility did not ensure that the bed hold policy was communicated in writing to the resident's designated emergency contact. The Admission Coordinator, who is responsible for providing the bed hold policy, stated that she does not have an office at the facility and typically leaves a copy of the policy in the resident's hospital room. She also mails the policy to the first emergency contact but does not use certified mail or document the delivery in the electronic medical record. The resident's daughter, who is the emergency contact, reported not receiving any notification or documentation of the bed hold policy and expressed concerns about the lack of communication from the facility.

Penalty

Fine: $288,26098 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 the care plan for Resident #252 was comprehensive and included all necessary care needs. Resident #252, who was admitted with diagnoses of hypertension, kidney failure, muscle weakness, and chronic obstructive pulmonary disease (COPD), was severely cognitively impaired and required supervision for oral and personal hygiene, set up help for eating, and substantial assistance with toileting and showering. The resident was also on oxygen. However, a review of the care plan dated 08/28/24 revealed that it did not address the use of oxygen, which was confirmed by the Director of Nursing during an interview. This oversight affected one resident reviewed for comprehensive care plans and had the potential to affect all 102 residents in the facility. The facility's policy on comprehensive person-centered care plans, dated December 2016, stated that care plans should describe all services that assist residents in achieving their highest level of physical, mental, and psychosocial well-being.

Penalty

Fine: $288,26098 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 a resident, identified as Resident #84, received appropriate therapy and restorative services to prevent a decline in their ability to perform activities of daily living (ADLs). Resident #84 was admitted with several diagnoses, including pneumonitis, dysphagia, pseudobulbar affect, and macular degeneration, and was discharged from hospice services. The care plan for Resident #84 included interventions for contractures in the wrists and ankles and recommended referrals to physical and occupational therapy for assistance with positioning aids and splints. However, the facility did not provide adequate therapy services, particularly for the resident's upper extremities, which contributed to the resident's inability to feed themselves. Observations and interviews revealed that Resident #84 was being fed by staff due to weakness and contractures in their hands, despite being cognitively intact and capable of feeding themselves with setup assistance. The Director of Rehab and other staff members were unaware that Resident #84 was not feeding themselves and had not received a referral for therapy services. The restorative aide worked with the resident on lower extremity exercises but did not address the upper extremities, which were crucial for the resident's ability to feed themselves. The facility's policy on restorative nursing services indicated that residents could be started on a restorative program upon admission or during their stay. However, there was a lack of communication and coordination among staff members, resulting in the resident not receiving the necessary therapy services to maintain their ADL abilities. Interviews with various staff members, including the Director of Rehab, registered nurse, and occupational therapist, highlighted the oversight in providing comprehensive therapy services for Resident #84, particularly for their upper extremities.

Penalty

Fine: $288,26098 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 timely assistance to a resident, identified as Resident #54, who was dependent on staff for personal care and required a mechanical lift for bed transfers. The resident, who was cognitively intact, had activated the call light to request assistance in going to bed. Despite the call light being on for approximately 30 minutes, the resident remained in a wheelchair without sheets on the bed, as observed by surveyors. The Unit Manager acknowledged the request but did not ensure immediate assistance, leading to further delays. The delay was attributed to staffing issues, as revealed in interviews with two State Tested Nursing Assistants (STNAs). One STNA mentioned that another aide was not performing duties and was sent home, causing a shortage of available staff to assist the resident. The resident expressed discomfort from sitting too long and had a preference to be in bed by a specific time, which was not met. Eventually, two STNAs were required to use the mechanical lift to transfer the resident to bed, but this occurred significantly later than the resident's request.

Penalty

Fine: $288,26098 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 timely incontinence care for a resident, identified as Resident #197, who was severely cognitively impaired and dependent on staff for all activities of daily living, including incontinence care. The resident had a history of urinary tract infections and was at risk for skin integrity issues due to incontinence and diabetes. Observations revealed that the resident was left in a saturated state with urine for extended periods, indicating a lack of timely care and repositioning by the staff. On multiple occasions, the resident was observed lying on her back, saturated with urine, and not turned or repositioned as required. Interviews with staff confirmed that the resident had not received the necessary incontinence care or repositioning. The facility's policy required routine checks for residents dependent on incontinence care every two hours, which was not adhered to in this case. Additionally, during an observation of incontinence and wound care, staff failed to perform appropriate incontinence care, leaving visible stool on the resident's backside. The staff also did not follow the correct wound care protocol for the resident's coccyx wound, applying an incorrect dressing instead of the ordered Triad cream. These actions and inactions contributed to the deficiency in providing adequate care for the resident.

Penalty

Fine: $288,26098 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 oversight of nutritional needs for three residents, leading to significant deficiencies in their care. Resident #71, who was severely cognitively impaired and required assistance with daily activities, experienced a significant weight loss from 200.0 pounds to 167.8 pounds over a short period. Despite being ordered weekly weights, there was a failure to obtain a weight during one week, and the physician was not notified of the significant weight loss. The dietitian confirmed that the weight was not addressed until much later, indicating a breakdown in the system for monitoring and responding to weight changes. Resident #75, who was moderately cognitively impaired, experienced a significant weight gain from 197.2 pounds to 206.7 pounds in one day. The facility failed to obtain daily weights as ordered, and the physician was not notified of the weight gain. The dietitian was unaware of the weight gain, and the Director of Nursing confirmed the failure to notify the physician and obtain the required weights, highlighting a lack of clarity in responsibility for monitoring and reporting weight changes. Resident #81, who was severely cognitively impaired, was observed not receiving a prescribed nutritional supplement, a Magic cup, with her meal. Despite the LPN being aware of the order, the supplement was not provided during the observed meal. The facility's policy required immediate notification and intervention for significant weight changes, but the deficiencies in monitoring and providing nutritional support indicate a failure to adhere to these protocols.

Penalty

Fine: $288,26098 days payment denial

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

Summary

The facility failed to ensure proper administration and care of oxygen therapy for three residents, leading to deficiencies in respiratory care. Resident #35, who was diagnosed with chronic respiratory failure and COPD, was observed using a portable oxygen tank set at two liters, despite a physician's order for three liters continuously. This discrepancy was confirmed by a State Tested Nurse Aide (STNA) during the observation. Resident #252, who was severely cognitively impaired and diagnosed with COPD, was observed with her oxygen set at 3.5 liters, contrary to the physician's order of four liters continuously. This was also confirmed by an STNA at the time of observation. The facility's policy on oxygen administration, which requires reviewing physician's orders prior to administering oxygen, was not adhered to in these cases. Resident #2, with a history of chronic respiratory failure and other significant health issues, had inconsistencies in the dating and changing of her oxygen tubing. The tubing had multiple dates, with some dating back several months, and a nasal cannula was found on the floor not stored in a bag as required. An STNA verified these discrepancies, and the resident reported that the tubing was not changed as per the facility's policy, which mandates changing the oxygen cannula and tubing every seven days or as needed.

Penalty

Fine: $288,26098 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 competent nursing staff, as evidenced by a nurse leaving a cognitively impaired resident with a cup of pills to take independently. The resident, who was diagnosed with Alzheimer's disease, dysphagia, flaccid hemiplegia, and a history of medication refusals, was observed struggling to take the medication without assistance. This incident involved one resident out of 47 sampled, with the facility census being 102. The resident's medical record indicated a range of diagnoses, including Alzheimer's disease and cognitive impairment, requiring assistance with various daily activities. Despite these needs, the LPN admitted to leaving the medication at the resident's bedside, a practice she normally follows, intending to return later to check if the medication was taken. This action was observed during a survey, highlighting a deficiency in ensuring the nursing staff's competency in administering medication safely to residents with cognitive impairments.

Penalty

Fine: $288,26098 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 parameters were in place for the administration of pain medications for Resident #22, leading to the administration of unnecessary drugs. Resident #22, who was cognitively intact and had diagnoses including panic disorder, depression, alcohol dependence, respiratory failure, and osteoarthritis, was prescribed Tramadol and Acetaminophen for pain management. However, the facility did not provide clear guidelines for the administration of these medications, resulting in instances where pain medications were administered without proper assessment of the resident's pain level. The Medication Administration Record (MAR) for August 2024 showed that Resident #22 received doses of Acetaminophen and Tramadol for varying pain levels, including instances where the pain level was recorded as zero. The Director of Nursing confirmed that the facility did not offer a lower-level pain medication before administering a stronger one and lacked parameters to guide nursing staff on which pain medication to administer. This deficiency was identified through record review, interviews, and facility policy review, highlighting a failure to adhere to the facility's policy on administering pain medications.

Penalty

Fine: $288,26098 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 significant medication errors for two residents, Resident #60 and Resident #149. Resident #60, who had a history of cerebral infarction, epilepsy, and other medical conditions, was prescribed Keppra for seizure management and metoprolol for hypertension. The medication administration records showed that metoprolol was frequently held due to blood pressure readings before dialysis, but there was no documented communication with the physician regarding these decisions. Additionally, Resident #60's Keppra levels had not been checked since November 2023, despite the resident experiencing seizure-like activity and being hospitalized for breakthrough seizures in August 2024. Resident #149, who had intact cognition and required assistance with various activities of daily living, was prescribed insulin for diabetes management. During medication administration observations, an LPN failed to perform hand hygiene before and after administering insulin, did not cleanse the insulin pen with alcohol, and did not waste two units of insulin as per the manufacturer's instructions. This was confirmed by the LPN, who questioned the necessity of wasting two units each time the insulin pen was used. The facility's policy on medication errors defines a medication error as any preparation or administration of drugs not in accordance with physician's orders, manufacturer specifications, or accepted professional standards. The actions and inactions observed in the administration of medications to Residents #60 and #149 were not in compliance with these standards, leading to the identified deficiencies.

Penalty

Fine: $288,26098 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 notify the physician in a timely manner regarding the lab results for a resident, identified as Resident #81. The resident, who was admitted with multiple diagnoses including a compression fracture of the vertebrae, asthma, depression, osteoporosis, dementia, and muscle weakness, was noted to have a pustule-like rash on her bilateral gluteal folds. A culture with sensitivity was ordered on 09/04/24. The lab results, which indicated heavy growth of lactose fermenter, probable non-hem strep, and diphtheroid bacillus, were reported to the facility on 09/05/24 at 12:31 P.M. However, there was no documented evidence that the physician was notified of these results. An interview with an LPN on 09/12/24 confirmed that the physician had not reviewed the culture results for the resident. The facility's policy, dated November 2018, required that test results be reviewed by a nurse and the physician be notified within 24 hours using various communication methods. The policy also required documentation of when, how, and to whom the information was provided, along with the response. Despite these requirements, the physician was not informed of the lab results until 09/12/24, and no new orders were given at that time.

Penalty

Fine: $288,26098 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 food served to residents was appealing and palatable, affecting two residents directly and potentially impacting 100 others. On the morning of September 9, 2024, the breakfast menu included a ham and hash brown skillet with a blueberry muffin. However, the Dietary Manager (DM) #576 was observed serving a grayish-blue food item instead of a recognizable muffin. Resident #45 was unable to identify a dark brown crusty item on his tray, which was supposed to be a muffin, and a State Tested Nurse Aide (STNA) confirmed it appeared overcooked and not in the shape of a muffin. Similarly, Resident #152 pointed out a similar unidentifiable food item, which was confirmed by the STNA to be a blueberry muffin. Further interviews revealed dissatisfaction with the facility's food quality. Resident #44 expressed that the food was unappealing and often inedible, leading him to order food from outside. He reported receiving burnt food frequently. DM #576 admitted to not using muffin tins due to their unavailability and instead used an edged cookie sheet, resulting in muffins being served as scoops rather than whole muffins. On a subsequent day, Resident #44 was served a burnt item resembling a slice of bread, which he assumed was meant to be French toast. DM #576 acknowledged cutting the muffins into squares and was unsure if the correct portion size was served.

Penalty

Fine: $288,26098 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 the necessary assistive devices for a resident, specifically a sectional plate, which was required to aid in maintaining independence while eating. This deficiency was identified during an observation of the resident's lunch, where it was noted that the resident did not have the sectional plate as indicated on her meal ticket. The resident, who was severely cognitively impaired and required supervision and assistance for various activities, was observed eating lunch in her room without the necessary adaptive equipment. The resident's medical history included conditions such as dementia, depression, and muscle weakness, which necessitated the use of assistive devices to support her nutritional needs. The care plan for the resident included providing adaptive equipment as needed, yet this was not adhered to during the observed meal. The facility's policy on assisting impaired residents with in-room meals emphasized the importance of providing necessary items, including special devices, but this was not followed in the case of the resident.

Penalty

Fine: $288,26098 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 accurate documentation of a resident's medical records, specifically regarding the resident's transfer to and return from the hospital. Resident #61, who was severely cognitively impaired and had multiple medical diagnoses including dementia and fractures, was found sitting on the floor with a nosebleed. The Nurse Practitioner assessed the resident and ordered a transfer to the emergency room for evaluation. However, there was no documentation in the progress notes about the resident's departure to the hospital or their return, which occurred between the evening of June 7 and the afternoon of June 8. The facility's policy on Charting and Documentation requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. Additionally, any events, incidents, or accidents involving the resident must be recorded. Despite these requirements, the Director of Nursing confirmed the absence of documentation regarding the resident's hospital transfer and return, indicating a lapse in maintaining accurate and complete medical records for Resident #61.

Penalty

Fine: $288,26098 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 all residents were offered and received the influenza vaccine, affecting two residents out of five reviewed for vaccinations. Resident #7, who had a history of heart disease, head injury, diabetes, hypertension, anxiety, kidney disease, and overactive bladder, was admitted on an unspecified date. There was no documentation indicating that Resident #7 had been offered or refused the influenza vaccine. Although Resident #7 consented to the influenza vaccine on 10/23/23, he never received it. Similarly, Resident #255, who had diagnoses including heart disease, hypertension, depression, diabetes, hyperlipidemia, vitamin D deficiency, and muscle weakness, was admitted and discharged on unspecified dates. There was no evidence that Resident #255 had been offered or refused the influenza vaccine, despite consenting to it on 10/23/23. An interview with the Director of Nursing (DON) revealed that both residents had consented to the influenza vaccine but subsequently refused it when the nurse attempted to administer it. However, there was no evidence to support that the residents were offered and refused the vaccine, as required by the facility's policy. The facility's policy, dated October 2019, stated that all residents would be offered vaccines unless medically contraindicated, and any refusals would be documented in the medical record. The lack of documentation and follow-through on vaccine administration led to the deficiency identified in the survey.

Penalty

Fine: $288,26098 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 all residents were offered the COVID-19 vaccine, affecting two residents out of five reviewed for vaccinations. Resident #7, who was admitted with diagnoses including heart disease, head injury, diabetes, hypertension, anxiety, kidney disease, and overactive bladder, had no evidence in her immunization history of being offered the COVID-19 vaccine. Similarly, Resident #255, who was admitted and later discharged with diagnoses including heart disease, hypertension, depression, diabetes, hyperlipidemia, vitamin D deficiency, and muscle weakness, also had no evidence of being offered the vaccine. An interview with the Director of Nursing (DON) revealed that the facility had been asking residents if they wanted the COVID-19 vaccination, but most residents declined, and the facility did not document any declinations. The DON could not provide evidence that Residents #7 and #255 had been offered the COVID-19 vaccination. The facility's policy on vaccination, dated October 2019, stated that all residents would be offered vaccines unless medically contraindicated, and any refusals would be documented in the medical record.

Penalty

No penalty information released

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

Summary

The facility failed to ensure food was stored and prepared in a sanitary manner, affecting the potential health of 98 residents who receive food from the kitchen. During a kitchen tour, it was observed that the dishwasher was not reaching the appropriate temperatures for the rinse cycle since March 2024. The Dietary Manager reported that a repair was needed, but the part was on backorder, and no formal in-service was conducted regarding emergency procedures. Staff were running dishes through the dishwasher twice and rinsing them in a sanitizer sink, which lacked proper plugs, using dish towels instead. The sanitizer sink tested at 280 parts per million. Additionally, a Dietary Aide was observed without a hair net, and an unsealed, undated bag of bacon bits was found in the walk-in cooler. Interviews with staff confirmed the ongoing issues with the dishwasher and the lack of proper hair net usage. The Administrator was unaware of the dishwasher problem until informed by the Dietary Manager, and the Maintenance Director confirmed the issue had been ongoing since March 2024. The dishwasher had been temporarily fixed in March, but the problem persisted. The facility's policies on food handling and employee hygiene were not adhered to, as evidenced by the lack of hair nets and improper dishwashing procedures. This deficiency was identified during a 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 facility failed to maintain the privacy and confidentiality of medical records for two residents, identified as Resident #26 and Resident #46. During an observation, it was noted that a medication cart was left unattended with a laptop open, displaying Resident #26's medication list, diagnosis, and demographic information. This occurred while LPN #603 was attending to another resident in a different room. LPN #603 confirmed that she left the medical information exposed on the laptop while she was in the other room, acknowledging that she was aware of the privacy breach. Similarly, another incident involved Resident #46, where a medication cart was left with a laptop open, exposing the resident's medication list and demographic information. LPN #565 was found in a different room, and upon exiting, confirmed that she had left the information exposed, despite knowing it was against policy. The facility's policy on confidentiality, revised in October 2017, mandates safeguarding the personal privacy and confidentiality of all resident records. These incidents were part of a deficiency investigation under Master Complaint Number OH00154250.

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 the menus as written and did not offer appropriate portion sizes of foods on the menu, which compromised the nutritional needs of the residents. On the date in question, the lunch meal was supposed to consist of barbeque pork loin, cowboy baked beans, and buttered spinach. However, during an observation, it was found that the pork loin was not served because it was not done cooking and was placed in the cooler. Instead, stuffed peppers were served, which was not on the planned menu. This deviation from the menu was confirmed by the Assistant Kitchen Manager (AKM), who admitted to the change due to the pork loin not being ready in time for lunch service. Additionally, during the dinner meal, the facility failed to provide the correct portion size of tuna salad sandwiches. The menu specified that each sandwich should contain four ounces of tuna salad, but observations revealed that only three ounces were used. This was confirmed by both the cook and the Dietary Manager (DM), who acknowledged that the kitchen staff did not follow the provided menus and portion sizes. The deficiency was further supported by interviews with two Ombudsmen who reported numerous food complaints from residents, including issues with food temperature, palatability, and adherence to the menu.

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 palatable foods were served at meals, potentially affecting all residents receiving meals from the kitchen except one resident who ate nothing by mouth. Interviews with two ombudsmen and several residents revealed numerous complaints about the food, including hot foods being served cold, unpalatable food, and dietary staff not serving what was on the menu. Observations of the kitchen tray line showed that while the food met minimum temperature requirements for safety, a test tray revealed that the green beans were served cold and lacked flavor, and the cherry crisp was also served at an unappetizing temperature. The Dietary Manager confirmed these findings during an interview, verifying that the green beans were not served at a palatable temperature. This deficiency was investigated under Master Complaint Number OH00152706 and Complaint Number OH00152341.