Bethesda Care Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide a resident’s representative with requested facility policies necessary to support participation in the person-centered care planning process. The resident involved was admitted on 08/12/24 and had multiple diagnoses, including chronic kidney disease stage IIIA, hypertension, hyperlipidemia, polyneuropathy, osteoarthritis, dementia, hypothyroidism, chronic pain, generalized muscle weakness, cardiac murmur, amnesia, photokeratitis, and dermatitis. The most recent quarterly MDS assessment showed a BIMS score of three, indicating severe cognitive impairment, and documented that the resident required at least limited assistance with all activities of daily living, including eating, hygiene, toileting, dressing, transferring, and ambulation. Between 03/30/26 and 04/02/26, interviews with family and staff revealed that the resident’s daughter requested facility policies related to medication administration and bed alarms, but the facility did not provide them. In an interview on 04/01/26 with the Administrator, the Regional Director of Operations, and the Regional Director of Clinical Services, facility leadership confirmed that the daughter had requested these policies and that they were not provided. During the exit conference on 04/02/26, the Regional Director of Operations again acknowledged that the request was not fulfilled and explained that the facility did not provide the policies because they were undergoing revisions and the facility could not ensure distribution of updated versions. Review of facility policies further showed there was no policy addressing the provision of facility policies to residents or their representatives upon request.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for multiple residents, particularly in the coding of respiratory services and oxygen therapy. For three residents with diagnoses including chronic obstructive pulmonary disease, obstructive sleep apnea, and dependence on a respirator/ventilator, quarterly or annual MDS assessments were coded to indicate use of an invasive mechanical ventilator. Physician orders for these residents specified use of average volume-assured pressure support (AVAPS), described as ventilator/volume targeted pressure support with detailed settings and daily use requirements. However, observations of these residents during the survey showed them in wheelchairs or in their rooms without invasive mechanical ventilation in place. Further clarification from the state RAI/OASIS Education Coordinator and reference to NIH StatPearls identified AVAPS as a form of non-invasive ventilation most closely aligned with BiPAP, which should be coded as BiPAP on the MDS rather than as invasive mechanical ventilation. The RAI manual instructions for coding invasive mechanical ventilation specify that it applies to residents receiving closed-system ventilation via endotracheal tube or tracheostomy, or those being weaned from such devices, and explicitly state not to code this item when the ventilator is used only as a substitute for BiPAP or CPAP. Despite this, the MDS nurse confirmed that the three residents’ MDS assessments were coded as receiving invasive mechanical ventilation, stating that he believed the MDS manual directed him to do so. The facility also failed to accurately assess and document oxygen therapy for another resident with diagnoses including acute respiratory failure with hypoxia, COPD, heart failure, hypertension, type 2 diabetes, and generalized anxiety disorder. This resident’s quarterly MDS indicated that oxygen therapy was not required, and multiple care plans over several months did not include oxygen therapy. Physician orders during the review period contained no order for oxygen administration. In contrast, progress notes on multiple dates documented that the resident was receiving oxygen via nasal cannula, and an LPN confirmed the resident was on 2 L/min oxygen without a corresponding physician order, believing it to be as-needed and longstanding. The DON verified that the resident had been receiving oxygen therapy for an extended period without a physician order, that oxygen was not included in the care plan, and that the MDS assessment was inaccurate regarding oxygen use, contrary to the facility’s policy requiring comprehensive assessments and attestation to MDS accuracy.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide activities that met the needs and cognitive capabilities of residents on the memory care unit, affecting 24 residents. Review of the March 2026 memory care activity calendar showed that scheduled programming for one week consisted only of “juice and news” and “table talk” every day, with “morning stretch” offered only once weekly. Observations on multiple days showed residents sitting in the dining room with only music playing on the television and no other structured or spontaneous activities provided, despite the facility’s policy stating that memory care programming would offer a diverse variety of events throughout the day, with activities adapted and modified based on resident abilities and dementia progression. On one observed morning, five residents were seated around the dining room table with only television music available. On another morning, seven residents were seated in the dining room with only television music until an activity aide began distributing word searches to residents at the table, while three other residents remained in recliners in front of the television and were not offered any activity. A CNA from agency who frequently worked on the memory care unit stated there were no activities for residents and confirmed residents were not offered mental stimulation between scheduled activities. The activity aide reported that one resident was blind and therefore was not offered activities beyond sitting next to the aide, acknowledged that this resident should be offered alternative activities, and stated that two other residents who wandered or became easily agitated were also not offered activities, and in one case the aide did not know the resident’s name.

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 identified a deficiency related to accident hazards and inadequate supervision when they observed that the soiled linen room on the 200 Memory Care hall was unlocked and did not require a code for entry, allowing unrestricted access. A CNA was seen opening the soiled linen room door without entering a code, confirming that the door was not secured. During an interview, the Business Office Manager confirmed the door did not require a code and was unlocked, and further verified that an unlocked cabinet above the sink inside this room contained multiple medications and a chemical product, including antifungal powder (miconazole nitrate 2%), two tubes of antifungal cream (miconazole nitrate 2%), moisture barrier cream (12% zinc oxide and 1% dimethicone), and Spill Magic all-purpose spill clean-up absorbent powder, all labeled to be kept out of reach of children. The facility had identified 10 cognitively impaired and independently mobile residents on the 200 hall who could have been affected by this unsecured access to medications and chemicals. Review of the facility’s policy titled “Hazardous Areas, Devices, and Equipment,” revised July 2023, showed that the facility’s stated practice was that all hazardous areas, devices, and equipment would be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible, which was not followed 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 deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring proper use of personal protective equipment (PPE) and hand hygiene for a resident on contact precautions and for multiple residents during meal tray delivery. One resident with multiple medical conditions, including Type 2 diabetes mellitus, chronic kidney disease, osteomyelitis, and a wound infection of the left lower extremity requiring IV antibiotics via a PICC line, had a physician’s order for single room isolation with contact precautions. The resident’s door displayed a contact isolation sign instructing staff and visitors to perform hand hygiene and don gloves and a gown before entering. Despite this, the resident reported that staff were not using the required PPE when entering her room. Surveyor observations confirmed multiple instances of noncompliance with contact precautions for this resident. A CNA delivered a breakfast tray into the resident’s room, placed it on the bedside table next to the bed, and did not perform hand hygiene or don any PPE before entering, which the CNA later confirmed. A social services assistant entered the same resident’s room to assist with her needs without performing hand hygiene or donning the required PPE, and acknowledged this during interview. Additionally, an LPN was observed sitting on the resident’s bed and accessing the resident’s PICC line without wearing a gown as required for contact precautions, and confirmed she had not donned a gown. Training records showed that both the CNA and LPN had previously received in-service education on contact precautions and PPE use. The facility also failed to ensure appropriate hand hygiene during meal tray delivery for four residents. A CNA was observed delivering breakfast trays to four residents, including the resident on contact precautions, without performing hand hygiene between residents. During these deliveries, the CNA touched bedside tables in each room, touched one resident directly, and handled a water cup and personal belongings on another resident’s bedside table. The CNA confirmed she did not perform hand hygiene while passing the breakfast trays. Facility policy on handwashing/hand hygiene required staff to perform hand hygiene before and after direct contact with residents and after contact with objects in the immediate vicinity of residents, but this was not followed during the observed tray pass. This deficiency was investigated under two complaint numbers.

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 found that the facility failed to provide a comfortable and homelike environment on the Memory Care (MC) unit, potentially affecting all 24 residents residing there. On one observation, wall carpet on the MC unit was peeling and unsightly, wallpaper between resident rooms was peeling, two air vents near the nurse’s station were visibly soiled, and a ceiling tile near the nurse’s station was missing. A licensed practical nurse confirmed the peeling and unsightly wall carpet and wallpaper, and a registered nurse confirmed the dirty air vents and missing ceiling tile, stating the tile had not been replaced following recent remodeling on the unit. On a subsequent observation, paint at the nurse’s station on the MC unit was noted to be peeling, which was confirmed by another LPN. On another day, three lights in the MC dining/common area were observed to be flickering and only partially illuminated, and an LPN and a receptionist confirmed the lights were flickering and not fully functioning. Review of the facility’s “Quality of Life - Homelike Environment” policy, dated May 2017, showed the facility is to provide a clean, orderly, and well-maintained environment with adequate lighting and homelike characteristics, which was not met in these observed conditions.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to notify the physician in a timely manner when a resident experienced a change in condition. The resident, who had diagnoses including Parkinson’s disease and essential hypertension, was admitted and later discharged on the dates noted in the record. An Occupational Therapy (OT) treatment note documented that the resident had decreased alertness and lethargy during an evaluation, was constantly falling asleep, and required verbal cues to stay awake. There was no evidence in the medical record that the physician was notified of this change in condition. The facility’s policy on charting and documentation required that changes in the resident’s condition and any unusual findings be documented in the medical record. A nursing progress note recorded that an LPN held the resident’s cyclobenzaprine 10 mg tablet because the resident was lethargic and unable to stay awake for conversation, with the resident stating, “I’m just tired.” There was no documentation that the physician was notified of this change in condition or of the held medication. Later, another nursing note indicated that CNAs alerted an LPN that the resident was breathing differently; when the LPN returned to the room, the resident was unresponsive, and full code procedures were initiated, with EMS later calling time of death. The DON confirmed there was no documentation of physician notification on the dates when OT identified a change in condition and when the LPN held the medication, and stated the physician should have been notified on those dates. The Medical Director also stated that staff should notify the physician or on-call NP any time there is a change in condition and confirmed that if the resident was presenting with lethargy and hypotension, the on-call physician should have been called immediately.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect a resident from misappropriation of narcotic medication and to ensure accurate documentation of controlled substances. A cognitively intact resident with diagnoses including congestive heart failure, end-stage heart failure, Type II diabetes, and COPD had a physician’s PRN order for Oxycodone 5 mg, two tablets every six hours for pain rated six to ten. The resident’s care plan noted a potential for altered comfort and directed that she be educated to request pain medication before pain became severe. Medication Administration Records showed only three documented administrations of Oxycodone over two months, all noted as effective, while the resident reported using Tylenol for phantom limb pain and stated she had not taken Oxycodone in quite some time. In contrast, the Controlled Drug Administration Record showed multiple removals of Oxycodone doses from the secured narcotic lock box for this resident on several dates and times that were not reflected as administered on the MAR. The facility’s review identified unaccounted doses of Oxycodone that had been signed out but not documented as given. An internal investigation and self-reported incident determined that, of 41 PRN Oxycodone sign-outs for this resident, one nurse signed for 35 of the removals, often twice during a shift, while the resident’s drug test was negative for opiates and Oxycodone. The resident, who was confirmed cognitively intact via a BIMs score of 15, stated she had not needed stronger pain medication in a long time. Staff interviews further described documentation and handling issues with controlled substances. One LPN reported that another LPN was not signing narcotics out properly, had forgotten to sign out two narcotic pills, and that they failed to count narcotics together before a cart handoff. The nurse in question stated that each time she signed the medication out, it was requested by the resident and administered, despite the lack of corresponding MAR entries and the resident’s statements and negative drug test. The facility’s abuse, neglect, exploitation, and misappropriation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent, and the facility concluded that the available evidence regarding the suspected misappropriation of the resident’s Oxycodone was inconclusive but suspected.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide required Activities of Daily Living (ADL) care, including personal hygiene, to dependent residents as outlined in their MDS assessments and care plans. One resident with hypertensive chronic kidney disease, hypertension, dementia without behavioral disturbance, muscle weakness, and aortic ectasia required supervision or touching assistance for personal hygiene and partial or moderate assistance for showering and bathing per a quarterly MDS. The resident’s care plan documented a self-care deficit related to weakness and cognitive impairment, with interventions for staff to assist with ADLs as needed and to report changes in participation. On the morning of the survey, the resident’s POA reported that the resident’s hair and teeth had not been brushed before breakfast, and observation confirmed the resident’s hair was disheveled while seated in the dining room. The CNA assigned to the resident verified she had not brushed the resident’s hair or teeth during morning personal hygiene care. Another resident, admitted with unspecified dementia, major depressive disorder, and chronic kidney disease, was documented on a quarterly MDS as cognitively impaired and requiring supervision or touching assistance with ADLs. The resident’s care plan identified an ADL self-care deficit related to disease process, with interventions to assist with ADLs as needed and to report improvement or decline in participation. On two separate observations, the resident was seen sitting at the dining room table with hair sticking out on one side, appearing unkempt, indicating morning care was incomplete. During an interview, a CNA initially stated uncertainty about who was responsible for the resident’s care, then acknowledged the resident was on her assignment, confirmed the resident’s hair was unbrushed, and that the resident required assistance with ADLs. The facility’s ADL policy stated that appropriate care and services would be provided for residents unable to carry out ADLs independently, 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

The deficiency involves the facility’s failure to provide appropriate treatment and care according to orders, resident preferences, and goals, including failure to follow up on skin breakdown, document skilled assessments and vital signs, notify the physician of changes in condition, and implement physician orders after an office visit. For one resident, admitted with diagnoses including Parkinson’s disease, essential hypertension, dorsalgia, and a history of thoracic spine fracture, the record showed that vital signs were obtained on admission and once later that evening, but no further vital signs were documented during the remainder of the stay despite the resident being a skilled resident who, per the DON, should have had skilled assessments with vitals twice daily. Skilled documentation entries were missing on multiple days, and when present, did not include vital signs. The physician progress note relied on outdated vital signs, and the resident was documented as receiving oxygen via nasal cannula without any corresponding physician order for oxygen. Further review showed that the physician had ordered monitoring of lung sounds, pulse rate, and pulse oximetry before and after nebulizer and incentive spirometry treatments, with documentation of setup and monitoring time each shift. The Treatment Administration Record reflected only the setup time and lacked any documentation of lung sounds, pulse, or pulse oximetry as ordered. A nurse’s note documented that a urine specimen was obtained by straight catheterization and that an open area was observed on the right abdominal fold and groin extending to the outer right hip, as well as a raised area on the left outer labia. The areas were cleansed and treated with a barrier product, and the nurse stated the nurse practitioner was notified; however, there was no documentation on the Treatment Administration Record of ongoing monitoring of these open or raised areas. Later, the same nurse documented holding a dose of Cyclobenzaprine because the resident was lethargic and difficult to arouse, but there was no documented notification to the physician or NP regarding this change in condition. On the morning of the resident’s death, staff administered morning medications without documenting vital signs, and EMS records indicated the nurse reported the resident had presented with lethargy and hypotension that morning and that medications were withheld due to this, which was not reflected in the facility’s documentation. The deficiency also includes failure to implement physician orders following an office visit for another resident with multiple diagnoses including diverticulosis, anemia, obstructive sleep apnea, atrial fibrillation, sick sinus syndrome, and unspecified hemorrhoids. Gynecology visit notes documented a diagnosis of a labial cyst and orders for sitz bath treatments. A subsequent facility physician progress note referenced that the labial cyst was being managed by gynecology with recommendations to continue sitz baths. However, there were no corresponding physician orders or care plan interventions in the facility record for sitz bath treatments. The resident reported that the facility did not have the necessary equipment and that sitz baths did not begin until her representative provided a sitz bath basin and Epsom salt, at which point she reported improved comfort. Staff interviews confirmed that sitz baths were not initiated until weeks after the order and that the treatments ordered by gynecology were not implemented in a timely manner. Facility policies on charting, documentation, and medication and treatment orders stated that records should facilitate communication about resident condition and that treatment orders should be implemented consistent with safe and effective order writing, but the documented practices for these two residents did not align with those policies. Family and staff interviews further described events surrounding the first resident’s decline. The resident’s family reported difficulty reaching the resident by phone and stated that when they did speak with her, she said something was not right and that she was going to be sent to the emergency room, but the family did not hear from the facility until after the resident was pronounced dead. The family also reported that during a prior visit the resident had been hallucinating, which they reported to nursing staff, but they were never informed of any physician response. A CNA reported that on the morning of the resident’s death the resident refused to get out of bed, which was not normal for her, and that this was reported to the LPN. The DON confirmed that vital signs were not obtained for several days, that staff were not monitoring the documented open abdominal and groin areas or the raised labial area, that oxygen was used without an order, and that ordered monitoring for incentive spirometry was not documented. The medical director confirmed that staff should notify the physician or on-call NP for any change in condition. These documented omissions and failures in assessment, monitoring, documentation, and implementation of orders for both residents formed the basis of the cited quality of care deficiency.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure accurate documentation of controlled medication administration for a resident receiving PRN opioid therapy. The resident, admitted with diagnoses including congestive heart failure, end-stage heart failure, Type II diabetes mellitus, and COPD, had intact cognition per a quarterly MDS and a care plan identifying potential for altered comfort with an intervention to request pain medication before pain became severe. A physician’s order directed Oxycodone HCl 5 mg, two tablets every six hours PRN for pain levels of 6–10. However, review of the MAR showed that Oxycodone was documented as administered on specific dates and times, including for pain levels of 4 and 8, and noted as effective, which did not consistently align with the ordered pain parameters. Further review of the controlled drug administration record showed multiple instances where Oxycodone 5 mg, two tablets, were signed out of the secured narcotic lock box for the resident on various dates and times that were not reflected on the electronic MAR. A facility self-reported incident identified that an LPN had signed for narcotics on the controlled drug administration record but failed to document administration in the electronic MAR. The facility’s review determined that this nurse failed to properly document the administration of controlled substances on multiple occasions and shifts, affecting the accuracy of medication documentation for this resident and potentially for other residents receiving opioid medications.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's care plan accurately reflected their documented code status. Medical record review for a resident with multiple complex diagnoses, including chronic kidney disease, heart disease, and dependence on renal dialysis, showed that the resident had a signed Advanced Directives form indicating a Do Not Resuscitate Comfort Care-Arrest (DNR CC-A) status. This directive was also supported by a physician's order. However, the resident's care plan listed interventions for full resuscitative measures, including CPR and calling 911, which contradicted the resident's documented wishes and physician order. During an interview, the DON confirmed that the resident's care plan did not match the signed Advanced Directives form or the physician's order, and that the resident was care planned as a full-code instead of DNR CC-A. Facility policy requires that care plans be consistent with residents' documented treatment preferences and advance directives. This discrepancy was identified during a review of care planning for three residents, affecting one resident, and was investigated under a specific complaint number.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's code status orders accurately reflected their wishes as documented in their Advance Directives Form. Specifically, a cognitively intact resident with multiple complex medical diagnoses, including chronic kidney disease, heart disease, and diabetes, had a signed Advance Directives Form indicating a preference for Do Not Resuscitate Comfort Care-Arrest (DNR CC-A). Despite this, the physician order in the medical record listed the resident as full code from the time of admission until two months later, at which point the order was changed to DNR CC-A. This discrepancy was confirmed through medical record review and interview with the Director of Nursing, who acknowledged that the resident's code status order did not match the documented advance directive for a significant period. The facility's policy requires that advance directives be respected and that the plan of care be consistent with the resident's documented treatment preferences, but this was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that routine medications were supplied and administered as ordered for a resident. Specifically, a resident with multiple complex medical diagnoses, including chronic kidney disease, diabetes, sepsis, and other serious conditions, had a physician's order for daily Magnesium Gluconate 250 mg due to hypomagnesemia. Review of the electronic medication administration record (MAR) showed that the resident did not receive several doses of this medication on multiple dates because it was not available in the facility. This was confirmed by both the MAR and the Director of Nursing (DON), who verified the missed doses. Facility policy requires that medications and related products are received from the pharmacy on a timely basis and that accurate records of medication orders and receipt are maintained. Despite this policy, the resident experienced repeated missed doses of the ordered medication over a period of weeks, as documented in the MAR and verified by staff interview. The deficiency was identified during a review of pharmacy services and was investigated under two complaint numbers.

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 ensure proper labeling and dating of injectable medications for two residents who were prescribed injectable medications and resided on the 100-hall. During an inspection of the medication storage cart with an LPN, a Lantus SoloStar Pen containing insulin glargine was found with approximately 60 units remaining, but it was not labeled with the date it was opened or its expiration date. The LPN confirmed at the time of observation that the pen was missing these required labels. According to the medication supplier guidelines, Lantus insulin pens expire 28 days after first use or removal from refrigeration. Additionally, two Ozempic (semaglutide) pens were found in the same medication cart, both lacking labels indicating the resident's name, the date opened, or the expiration date, despite being labeled by the manufacturer for single patient use only. The LPN confirmed that neither pen was labeled appropriately. Facility policy and supplier guidelines require that medications with shortened expiration dates, such as these injectables, be labeled with the date opened and the new expiration date to ensure medication purity and potency. The failure to follow these procedures resulted in the cited deficiency.

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 when a registered nurse (RN) failed to follow enhanced barrier precautions (EBP) during wound care for a resident. The resident, who had multiple complex medical diagnoses including cerebral infarction, BPH, Barrett's esophagus, GI hemorrhage, atrial fibrillation, dementia, and was dependent on a wheelchair, had a physician order for EBP due to wounds. The resident's cognition was severely impaired, as indicated by a BIMS score of 05. A CDC-published sign was posted at the resident's doorway, instructing all staff to clean their hands and wear gloves and a gown for high-contact care activities, including wound care. Despite these clear instructions, observation revealed that the RN entered the resident's room and began a dressing change without donning a gown. The RN confirmed during an interview that she had not put on a gown prior to starting the procedure. Review of the facility's policy on transmission-based precautions indicated that staff are to follow CDC recommendations and posted signage regarding the use of personal protective equipment (PPE). This failure to adhere to established infection prevention protocols resulted in non-compliance with the facility's infection prevention and control program.

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 #40’s code status order accurately reflected the resident’s documented wishes in the Advance Directives Form. Resident #40 was admitted on 07/23/25 with multiple diagnoses including sepsis, bloodstream infection due to a central venous catheter, cellulitis of the left lower limb, morbid obesity, type 2 diabetes mellitus, hypertension, chronic kidney disease stage 3, dependence on renal dialysis, peripheral vascular disease, chronic lymphocytic leukemia, and other significant medical conditions. The most recent MDS assessment dated 08/28/25 showed a BIMS score of 15, indicating the resident was cognitively intact, and the resident required at least some assistance for all functional abilities. The medical record contained a signed Advance Directives Form dated 06/20/25 indicating the resident wished to be DNR CC-A. However, the physician order dated 07/23/25 listed the resident as full code, and that order remained in place until 09/23/25, when it was changed to DNR CC-A. The DON verified the signed Advance Directives Form and confirmed the resident had a full code order from 07/23/25 through 09/23/25 before it was changed. The facility policy stated advance directives would be respected in accordance with state law and that each resident’s plan of care would be consistent with documented treatment preferences and/or advance directives.

Penalty

Inspection fine: $64,604

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 with epilepsy received their prescribed seizure medications, leading to a serious incident. The resident, who had a history of epilepsy and other medical conditions, was admitted to the facility but did not receive their prescribed medications, including Lyrica, lacosamide, and Risperdal. This oversight resulted in the resident experiencing continual tonic-clonic seizures, which required emergency medical intervention and transfer to a hospital's neurological ICU. The deficiency was further compounded by the facility's failure to notify the physician about the resident not receiving their medications and the subsequent seizure activity. The resident's mother, who was the primary caregiver, was assured by the facility that all necessary medications were available, but this was not the case. The resident's condition deteriorated, and despite the mother's efforts to provide medication from home, the facility did not have the necessary medications on hand, nor did they promptly address the situation with the physician. The facility's documentation and communication failures were evident in the lack of recorded doses of critical medications and the absence of timely physician notification. The resident's medical records showed discrepancies in medication orders and administration, contributing to the resident's severe condition. The facility's policies on medication administration and change in resident condition were not followed, leading to the resident's critical health episode.

Removal Plan

• Resident #76 was transferred to the hospital for seizure like activity.
• Upon review of the medical record, the DON identified that Resident #76 did not receive his scheduled Lyrica, lacosamide and Risperdal. A self-imposed plan of correction (SIPOC) was completed.
• SIPOC included review of resident charts who had been admitted within the last 30 days by the DON/Designee, to ensure all physician's orders were transcribed correctly and are administered per order, and all resident medications are available to be administered at the facility.
• Facility nurses were educated by the DON/designee regarding medication order transcription as well as documentation of medication administration, including medications not available and on order from pharmacy, physician notification, and alternate medication administration and representative (RP) notifications.
• The Medical Director was notified via AD Hoc Quality Assurance Review. Review of processes for medication transcription, medication administration and notification of medications not available to physicians and RP.
• The DON completed education to all licensed nurses regarding admission order transcription and obtaining medications from the pharmacy.
• All residents admitted within the last 30 days were reviewed by the DON and/or the Assistant Director of Nursing (ADON), to ensure all orders were transcribed accurately and all medications were available for administration and no discrepancies were identified.
• The DON/Designee will complete a comprehensive medication order review of all admissions/readmissions within 24 hours to verify accuracy of order transcription and availability of medication for administration.
• The facility has had three admissions (Resident #40, Resident #72, and Resident #75), and all medication orders were audited to be accurate and ensure medication availability.
• New admissions and readmissions will continue to be reviewed for transcription accuracy and availability of medications for 4 weeks and reviewed with Quality Assurance and Performance Improvement (QAPI) for compliance.
• Education was initiated by Staff Development Coordinator (SDC) #158 with licensed nurses on Seizures: Clinical Protocol, Assessment and Recognition.
• An Ad hoc Policy Review was held with the Administrator, DON, Regional Director of Clinical Services (RDCS) #103, and the Medical Director to confirm the systems implemented and reviewed to ensure that residents receive medications as ordered by the physician and to meet their total care needs.
• The DON and the ADON verified all prescribed medications for current residents have been transcribed accurately. Current orders were verified for all residents with no discrepancies identified.
• All residents were assessed by the DON, the ADON, and/or Infection Preventionist (IP) Registered Nurse (RN) #176. Four residents were noted to have a change in condition and physicians/physician assistants were notified per policy and orders received as indicated.
• All licensed nurses were re-educated by the DON and/or SDC #158 on the policies and procedures for Admission Assessment and Follow Up: Role of the Nurse, Reconciliation of Medications on Admission, Administering Medications, Change in Resident's Condition or Status, and the procedure for obtaining medications from pharmacy if not available.
• Previously initiated seizure education was also completed at this time. Education to include 13 licensed nurses. Agency staff will be educated upon arrival for and prior to their scheduled shift. All newly hired licensed nurses will be educated at the time of orientation.
• An Ad hoc Resident Council meeting was held with Activities Director #115 and the DON to review the process for obtaining medications and change in resident condition notification.
• The DON/Designee will complete a comprehensive medication order review of admission/readmission charts within 24 hours of admission/readmission.
• Medication orders will be verified for accurate transcription and implementation of medications, and proper medication administration of ordered medications.
• The DON/Designee will complete ongoing auditing of medical records to ensure changes in condition are reported per policy. Ad hoc education will be completed as indicated.
• Admission and readmission orders will be reviewed for transcription and receipt of medications from pharmacy for 4 weeks and reviewed by QAPI for continued compliance.
• Review of all resident medication availability and administration will continue 5 times/week for 4 weeks with QAPI review for compliance.

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 State tested Nursing Assistants (STNAs) had evaluations completed as required. Specifically, the employee file for STNA #555, who was hired on 11/11/22, did not contain an annual performance evaluation. Additionally, the employee file for STNA #557, who was hired on 12/18/23, lacked a 90-day performance evaluation. The Administrator confirmed that these evaluations were not completed, and the Director of Nursing (DON) verified the absence of these evaluations. The facility policy, revised on 07/01/12, mandates that employee performance evaluations for all non-exempt staff be reviewed prior to the 90th day of employment and annually.

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 the flooring was maintained in a clean and appropriate condition, affecting fifteen residents in the memory care unit. Observations revealed irregular areas of sticky yellowish residue on the linoleum floor near the nurses' station and dining room, which were sticky and covered with dust and debris. Staff, residents, and visitors were observed walking through these affected areas. An LPN confirmed that the floor was always sticky and that dirt from the carpet or shoes gets stuck to these areas despite daily mopping. A housekeeping staff member indicated that the sticky areas might be from old wax residue and that the flooring needs to be treated with an auto-scrubber, which is not used in this hallway. The facility's policy states that all residents have a right to a safe, clean, comfortable, and homelike environment, and that housekeeping and maintenance services should maintain a sanitary, orderly, and comfortable interior.

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 preferences for room temperatures were honored, affecting two residents. Resident #39, who is cognitively intact and has multiple diagnoses including type II diabetes and chronic obstructive pulmonary disease, reported that her room was too hot and humid. Despite her request to lower the temperature to 68 degrees Fahrenheit, she was informed that the law required room temperatures to be maintained between 71 and 81 degrees Fahrenheit. Maintenance staff confirmed that residents could not control the cooling in their rooms, and the temperature in Resident #39's room was verified to be 74 degrees Fahrenheit using a portable temperature gun. Similarly, Resident #40, who is also cognitively intact and has multiple diagnoses including chronic diastolic heart failure and major depressive disorder, reported that her room was too hot and that her oscillating fan was broken. Despite her hospice staff's efforts to get her a new fan, the room temperature remained uncomfortable. Maintenance staff confirmed that the thermostat in Resident #40's room read 77 degrees Fahrenheit, but a portable thermometer gun showed it was actually 79 degrees. The resident's oxygen concentrator and the inability to open the window contributed to the increased room temperature. The facility's policy on resident rights and dignity was reviewed, revealing that the facility must promote an environment that enhances the quality of life for each resident, recognizing their individuality.

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 neurology checks on a resident with an unwitnessed fall, as per facility policy. Resident #29, who was cognitively intact and had a diagnosis of a right femur fracture, experienced an unwitnessed fall. The medical record review revealed that no neurology checks were completed following the fall, despite the facility's policy indicating that a focused neurological assessment is necessary after a fall if the resident may have sustained a head injury. The Director of Nursing confirmed that the neurology checks were not completed and that the facility policies did not specify when these checks should be conducted.

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 portable oxygen tanks were sufficiently supplied with available oxygen for resident use. This deficiency affected one resident who was reviewed for oxygen use. Resident #267, who was admitted with chronic respiratory failure and COPD, was observed sitting in the common area with an empty portable oxygen tank. The oxygen tank gauge was on the red refill line, indicating no oxygen remained. The Director of Nursing verified that the portable oxygen tank was empty at the time of observation. The resident's medical record indicated that they required oxygen therapy to maintain an oxygen reading of 90% or above, and the care plan included the use of oxygen as ordered. An interview with an LPN revealed that Resident #267 preferred to be in the common area and that all staff were responsible for monitoring the portable oxygen tank when they passed by. The LPN stated that there were no alarms for portable oxygen tanks, and staff had to check them frequently. The facility's policy on oxygen administration indicated that oxygen tanks might need frequent replacement. Despite this policy, the portable oxygen tank for Resident #267 was found empty, indicating a failure to monitor and replace the oxygen tank as needed.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate physician orders and accurately assess a dialysis access site for Resident #30, who required dialysis. The resident had a history of end-stage renal disease, type II diabetes mellitus, major depressive disorder, primary glaucoma, legal blindness, hyperparathyroidism, and peripheral vascular disease. Despite having a permacatheter in the left upper chest for dialysis since at least August 2023, the medical record lacked documentation of the permacatheter and its care. The facility's records incorrectly indicated that the resident's left arm fistula was being used and monitored, even though it was non-functional and not in use. The resident confirmed that dialysis was being performed through the chest catheter, and the Director of Nursing (DON) verified the absence of relevant documentation and physician orders for the permacatheter care. Additionally, the facility's Treatment Administration Record (TAR) showed inconsistent and inaccurate documentation regarding the assessment of the resident's fistula. The records indicated that the thrill and bruit were checked each shift, but there were multiple instances where the assessment was either marked as non-applicable or not completed. The Licensed Practical Nurse (LPN) responsible for the resident's care was unaware of the chest catheter and continued to check the non-functional left arm fistula. The facility's policy on dialysis care required a care plan to address the access site, including monitoring for infection and bleeding, which was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely psychiatric follow-up for a resident experiencing an exacerbation of mood symptoms. Resident #33, who had a history of multiple mental health diagnoses including Parkinson's disease, dementia, major depressive disorder, and bipolar disorder, exhibited significant behavioral changes and expressed suicidal ideation. Despite these alarming symptoms and a request to see a counselor, the resident did not receive timely psychiatric intervention. The resident was admitted to acute inpatient psychiatry for stabilization from 01/30/24 to 02/16/24, but after discharge, there were no documented behaviors until 04/23/24 when the resident again expressed suicidal thoughts and requested to see a counselor. However, the resident did not receive a psychiatric follow-up until 05/15/24, 22 days after the initial request. Observations of Resident #33 on multiple occasions revealed the resident sitting alone, physically distant from others, and displaying a flat, emotionless affect. The resident's care plan included interventions for socially inappropriate behaviors and the use of psychotropic medications, but there was no evidence of additional assessments, ongoing behavior monitoring, or interventions to address the resident's feelings of not being welcome at the facility and feeling the world would be better off without him. The Social Services Assistant confirmed that no updated care plan interventions, increased monitoring, or assessments were completed until the psychiatric services visit on 05/15/24. The facility's policy on Behavioral Health and Mental Health Services, dated December 2016, mandates that residents displaying or diagnosed with a mental disorder receive appropriate treatment and services to correct the assessed problem or attain the highest practicable mental and psychosocial well-being. However, the facility failed to adhere to this policy, resulting in a significant delay in psychiatric follow-up for Resident #33, who was experiencing severe mood symptoms and suicidal ideation.

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 insulins were dated when opened and that expired insulins were discarded. This deficiency was observed in the medication storage for three residents. Specifically, an insulin pen labeled for one resident and a multi-dose vial labeled for another resident were found opened and undated. Additionally, an insulin pen for a third resident was found opened and dated beyond its expiration date. These observations were verified by Licensed Practical Nurses (LPNs) during the survey. The medical records for the three residents involved revealed that they all required the use of insulin for diabetes management. The facility's policies on medication storage and expiration dating were reviewed and indicated that opened multi-dose vials should be dated and discarded within 18 days unless otherwise specified by the manufacturer. The manufacturer's recommendations for the Lispro insulin pen stated that it should not be used beyond 28 days after opening. The facility failed to adhere to these guidelines, leading to the observed deficiencies.

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 used soiled bed pans were stored appropriately in a shared bathroom, affecting one resident. Resident #38, who has diagnoses including COPD, diabetes mellitus type II, high blood pressure, dependence on oxygen, anxiety, schizoaffective disorder, and bipolar disorder, reported that her roommate's bed pans were often left inappropriately in the shared bathroom. The resident mentioned that the bed pans were sometimes left on the floor, on the back of the toilet, upside down draining into the toilet, or in the sink, causing her to use the community bathroom for personal hygiene tasks like brushing her teeth. An observation confirmed the presence of two soiled bed pans on the floor, stacked on top of each other, with visible fecal matter stains and no labeling or plastic bags for containment. Interviews with staff members corroborated the resident's complaints. A State tested Nursing Assistant (STNA) verified the presence of the used bed pans on the floor and confirmed that the facility's policy requires bed pans to be cleaned and stored in a bag. A Licensed Practical Nurse (LPN) stated that there had been no prior complaints from Resident #38 about the issue but acknowledged having seen uncovered bed pans in the past when she worked as an STNA. The facility's policy, as reviewed, mandates that all resident personal items be appropriately labeled and stored in designated areas, and cleaned and disinfected as necessary.