Buckeye Care And Rehabilitation

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 timely wound treatment according to physician orders and the resident’s care plan. A resident with Parkinson’s disease with dyskinesia, dementia, CHF, dysphagia, and adult failure to thrive was care planned as being at risk for pressure ulcer development, with interventions including turning/repositioning, incontinence care, and weekly skin assessments. The quarterly MDS documented severe cognitive impairment and total dependence on staff for toileting, hygiene, bathing, rolling, and bed mobility, with the resident always incontinent of bowel and bladder and no skin concerns noted at that time. A skin tear/laceration form later documented a skin tear on the resident’s right hip, believed to be caused by the resident scratching, which was cleansed and dressed per physician order, with a note to trim the resident’s nails. However, review of the TAR for that month showed no wound treatments in place or completed for the right hip/trochanter. A subsequent skin issues evaluation showed the right trochanter/hip abrasion had deteriorated in size, though the dressing was intact. Wound treatment with Dakins wound cleanser, Mesalt, and a dry dressing was not initiated until several days after the wound was first discovered, and was then documented as completed daily. A later skin issues evaluation showed further deterioration of the wound with increased size and signs of infection, including erythema/edema and warmth. The treatment was then changed to cleansing with Dakins, followed by Santyl on moistened gauze and a dry dressing. The wound nurse confirmed that the wound was discovered days before any treatment orders were put in place and that neither an outside wound physician nor hospice assessed the wound.

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 in the facility’s failure to provide timely hygiene care, specifically shaving and removal of facial hair, for residents who required assistance with activities of daily living (ADLs). One resident with Parkinson’s disease, right shoulder pain, impaired mobility, COPD, bipolar disorder, obesity, osteoarthritis, heart failure, seizures, and other conditions was cognitively intact and required touching assistance for personal grooming, including shaving, per the MDS and care plan. The care plan documented an actual risk for ADL decline and the need for staff assistance with hygiene. During observation, this resident was seen in a common area with multiple long, white chin hairs that were noticeable. The resident reported being unable to find tweezers and stated that staff usually shaved the chin whiskers but had not done so that day. An LPN confirmed the presence of multiple long white chin hairs and that the resident had requested their removal, which had not been done. Another resident with atrial fibrillation, hypertension, osteoarthritis, anxiety disorder, hypothyroidism, major depressive disorder, ischemic heart disease, anemia, and electrolyte imbalance had moderate cognitive impairment and required moderate assistance for showering and personal hygiene, including shaving, as documented on the MDS and care plan. The care plan indicated an ADL self-care performance deficit related to impaired mobility and required staff assistance for showering and personal hygiene, including shaving. Review of a shower sheet for this resident showed a blank space where shower documentation should have been. Observation revealed multiple black hairs on the resident’s upper and lower lips with the appearance of a mustache, and the resident stated the facial hair bothered her because it did not look good. An LPN stated that female residents’ facial hair is to be shaved on shower days and when noticeable, and that CNAs are expected to shave female residents with facial hair even if it is not their shower day. The LPN confirmed the facial hair on this resident and that the resident had asked for it to be shaved but it remained. Facility policy required that residents unable to carry out ADLs independently receive services necessary to maintain grooming and personal hygiene, including support and assistance with hygiene in accordance with the plan of care.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to timely obtain an ordered urinalysis (UA) with culture and sensitivity and to appropriately document and address a suspected urinary tract infection (UTI) for one resident. The resident was admitted with multiple diagnoses including Parkinson’s disease, Type II diabetes mellitus, progressive multiple sclerosis, malnutrition, dysphagia, legal blindness, and dementia, and had intact cognition per a recent MDS assessment. On 11/10/25, the physician documented the resident’s complaint of lower abdominal pain and ordered a UA with culture and sensitivity, along with encouragement of fluids while results were pending. A physician order for the UA with culture and sensitivity was entered on 11/11/25, but a progress note on 11/12/25 documented that the UA was not collected. On 11/18/25, another physician order was entered for a UA with culture and sensitivity, along with an order for Ciprofloxacin 250 mg by mouth every 12 hours for three days for infection, without documentation explaining the resident’s ongoing symptoms or the rationale for starting the antibiotic at that time. A progress note on 11/19/25 again documented that the UA was not collected. On 11/20/25, documentation showed the resident appeared in the lab system for a UA, but she had already been on antibiotics for two days; the physician was then asked if the UA was still needed, and on 11/21/25 the physician reported the order could be discontinued. Review of the medical record from 11/10/25 to 11/20/25 revealed no further documentation related to the UTI, and the DON confirmed the UA was not completed timely as ordered, that there was no documentation on 11/18/25 to indicate why the antibiotic was ordered or what symptoms persisted, and that the antibiotic was ordered without a UA. The facility’s Antibiotic Stewardship policy required that culture and sensitivity results and the current clinical situation be communicated to the prescriber to determine if antibiotic therapy should be continued or modified, but the UA was never obtained.

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 occurred when the facility failed to maintain a resident’s wheelchair in a clean and sanitary condition, as required to keep the environment safe, easy to use, clean, and comfortable for residents, staff, and the public. The resident, identified as Resident #52, had been admitted on 05/28/21 with multiple diagnoses including Parkinson’s disease, Type II DM, progressive multiple sclerosis, mild cognitive impairment, unspecified protein-calorie malnutrition, legal blindness, dementia, and major depressive disorder. A quarterly MDS assessment dated 10/16/25 documented that the resident had intact cognition. On 01/06/26 at 2:50 p.m. and again on 01/08/26 at 10:05 a.m., surveyor observations showed that the resident’s wheelchair had a large buildup of dirt, food, stains, and splatters along the sides and edges. During an interview on 01/08/26 at 10:05 a.m., the DON confirmed that the wheelchair needed to be cleaned and stated it was on the schedule for the night shift. This deficiency affected one resident out of three reviewed for environment and was investigated under Complaint Number 2706168, with a total facility census of 88.

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 allegations of potential resident-to-resident physical abuse were reported to the State survey agency. Resident #1 was admitted with diagnoses including unspecified psychosis, dementia, generalized anxiety disorder, major depressive disorder, Parkinson’s disease, and a history of a fractured upper end of the right humerus. Her MDS indicated she was cognitively intact, usually able to make herself understood and understand others, and used a wheelchair for mobility. Nursing notes documented that she reported another resident had hit her on the arm on one occasion, and later that the same resident hit her left arm three times with a carrying bag; in both instances, staff separated the residents and assessed Resident #1, who was able to provide credible information about the incidents. An interview with Resident #1 confirmed that another resident hit her with a bag and that she continued to have issues with that resident, who still lived in the facility. Review of the Ohio Department of Health CAL application showed no self-reporting incidents were submitted for either event. The DON acknowledged the facility did not submit a SRI for either incident and agreed both should have been reported as possible physical abuse, but stated the facility did not believe the other resident had malicious intent because of a known developmental disability. The facility policy stated residents had the right to be free from abuse, including physical abuse, and that allegations were to be investigated and reported within required timeframes.

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-centered care plans were individualized and comprehensively addressed residents’ care needs for two residents. Resident #17 was admitted with diagnoses including Ogilvie syndrome, schizoaffective disorder, major depressive disorder, suicidal ideations, insomnia, hypertensive heart disease, and anxiety disorder. The record showed he began exhibiting depression and suicidal ideations, was evaluated at the hospital and returned the same day, received community counseling, had psychoactive medications adjusted with instructions for daily monitoring of tolerance, and then returned to the hospital after symptoms associated with serotonin syndrome and continued suicidal ideations before a later hospitalization. Although his care plan was revised to address risk for decreased psychosocial well-being, emotional distress, ineffective coping, poor impulse control, and adverse effects related to mood and psychiatric diagnoses, it did not specifically address suicidal ideation, behaviors, triggers, or detailed interventions to manage his depression and suicidal thoughts. Resident #65 was admitted with diagnoses including bipolar disorder, moderate protein-calorie malnutrition, major depressive disorder, anxiety disorder, orthostatic hypotension, and other seizures. Observation showed very poor dentition, with missing teeth and visible decay in the teeth present. His care plan identified him as at risk for oral issues and noted he needed assistance with oral care, with interventions for dental consultation, oral exam and intervention as indicated, and physician notification for dental infection or complications. The DON confirmed that his dental condition was not included in his care plan with goals to manage his individualized needs. The facility policy stated comprehensive person-centered care plans should include measurable objectives to meet residents’ physical, psychosocial, and functional needs and be revised as resident conditions change.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a wound was properly identified as a pressure ulcer for one resident with a history that included inflammatory disorders of the scrotum, gangrene Fournier, dementia, and cerebral infarction. The resident’s quarterly MDS indicated risk for pressure ulcers and that the resident had one or more pressure ulcers. The care plan identified multiple skin concerns, including a resolved stage II pressure ulcer to the sacrum, a stage II pressure ulcer to the left gluteus, a surgical wound to the scrotum, an intact blister to the left heel, and a blister to the rear left knee. A skin and wound evaluation identified the left heel wound as a blister measuring 4.6 cm by 3.5 cm, and a later progress note from the wound nurse practitioner identified the left heel wound as an unstageable pressure ulcer covered with 100% eschar. Further review of wound evaluations showed an assessment that still identified the left heel wound as a blister and did not identify any unstageable pressure ulcers. During observation of wound care, the left heel wound was seen as an unstageable pressure ulcer covered with eschar. The RN stated the wound started as an intact fluid-filled blister and was now an unstageable pressure ulcer, and confirmed that an intact fluid-filled blister can be identified as a stage II pressure ulcer according to the facility’s pressure ulcer policy citing the National Pressure Injury Advisory Panel Classification System, and that the wound was not documented properly.

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 residents did not smoke in an area where residents with portable oxygen were present. Resident #23 had diagnoses including dementia, schizo-affective disorder, multiple rib fractures, sacral fracture, COPD, difficulty walking, and muscle weakness. Her smoking assessment identified her as a smoker who could light her own cigarette but required supervision, and her care plan directed staff to educate her on smoking and oxygen safety, remove oxygen before taking her out to smoke, keep residents on oxygen at a safe distance from smoking areas, and supervise her at all times in the courtyard. She also had a physician order for continuous oxygen at 3 LPM by nasal cannula and an order to be supervised in the courtyard at all times. During observation, Resident #23 was brought to the enclosed courtyard/designated smoking area while her oxygen tank remained on the back of her wheelchair and was still turned on. Staff removed the nasal cannula from her nares, but the oxygen tubing remained draped over the wheelchair and air could still be felt coming from the tubing. Housekeeper #425 passed out smoking materials to residents and then attempted to light Resident #23's cigarette while the oxygen tank was still on and connected. The surveyor intervened and stopped the housekeeper from lighting the cigarette. LPN #145 was present in the smoking area but did not recognize that Resident #23 still had her oxygen tank on her wheelchair. The facility also failed to implement fall prevention interventions as ordered for Resident #35, who had diagnoses including dementia, anxiety disorder, major depressive disorder, insomnia, and hypotension. His MDS showed moderate cognitive impairment and dependence on staff for transfers, and his care plan and physician orders included keeping his bed in the lowest position due to fall risk and prior falls, including an incident where he rolled out of bed while sleeping. During observation, he was found in bed with a perimeter mattress, but the bed was not in its lowest position and was raised approximately 24 inches from the floor. On follow-up, the bed remained elevated until staff lowered it. An LPN stated she did not consider him a fall risk and did not know what fall prevention interventions were in place without checking his orders.

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 adequately monitor the nutritional status of a resident with a history of significant weight loss. The resident had multiple diagnoses including progressive multiple sclerosis, mild dementia, schizo-affective disorder, major depressive disorder, diabetes mellitus, dysphagia, vitamin deficiencies, anemia, hyperlipidemia, hypokalemia, moderate protein calorie malnutrition, and constipation. Her care plan identified her as being at nutritional risk due to her diagnoses, medication use, and history of significant weight loss, with goals to consume at least 75% of most meals and interventions to monitor, record, and report signs or symptoms of malnutrition, offer substitute meals if intake was less than 50%, provide the ordered diet, and administer a house nutritional supplement twice daily. Record review showed the resident’s weight declined from 145 pounds to 129.6 pounds and then to 126 pounds, reflecting significant weight loss over 1, 3, and 6 months. Meal intake documentation for the prior 30 days was incomplete, with no meal intake recorded for all three meals on three days, only one meal recorded on one day, and only two meals recorded on two other days. The MAR also showed inconsistent documentation of supplement acceptance, with five entries marked only with a Y instead of the percentage consumed. The DON confirmed that the percentage of supplement consumed was expected to be documented, that the Y only indicated the supplement was given, and that the resident’s meal intakes were not consistently recorded under the EMR task tab.

Penalty

No penalty information released

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

Summary

The facility failed to provide safe, appropriate pain management for two residents who were receiving PRN opioid medications. Resident #2 was admitted with multiple diagnoses including paranoid personality disorder, PTSD, mood disorder, Parkinson’s disease, epilepsy, bipolar disorder, dementia, psychosis, mild cognitive impairment, depressive disorder, Type II diabetes mellitus, and chronic kidney disease. Her care plan identified her as at risk for pain or discomfort and included pain assessment every shift, assessment for non-verbal indicators of pain, and administration of medications and treatments as ordered. Her record showed two active Dilaudid orders in use, both for 4 mg by mouth every four hours as needed for pain, and the MAR showed repeated administration of Dilaudid during December and early January. Review of Resident #2’s progress notes showed that on 12 occasions she received PRN pain medication without documented attempts at nonpharmacological interventions and without a description of her pain, and on two occasions the pain was not described. Resident #5 was admitted with diagnoses including cerebral palsy, cerebral infarction, dementia, osteoarthritis, neoplasm of unspecified behavior of brain, major depressive disorder, abnormal posture, and spinal stenosis. His care plan included evaluating pain characteristics, using a pain scale, completing pain assessments per protocol, medications as ordered, and nonmedication interventions such as relaxation, repositioning, and redirection. His record showed an order for oxycodone-acetaminophen 5-325 mg by mouth every six hours as needed for pain, frequent PRN administration throughout December and early January, and progress notes documenting 35 occasions when PRN pain medication was given without attempted nonpharmacological methods and without a description of his pain. The DON verified nursing was supposed to attempt and document nonpharmacological interventions before giving PRN pain medication and confirmed the duplicate Dilaudid orders for Resident #2.

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

Medication error rates were not kept below 5 percent. Based on observation, medical record review, staff interview, manufacturer guide review, and facility policy review, the facility had two observed medication errors out of 28 opportunities, resulting in a 7.14 percent medication error rate. This involved one resident reviewed for medication administration and had the potential to affect 15 residents who received insulin at the facility, with a census of 88. Resident #103 was admitted with diagnoses including alcoholic hepatitis without ascites, Type II Diabetes Mellitus, and heart failure. Physician orders included Insulin Glargine 20 units subcutaneously twice a day and Insulin Aspart per sliding scale before meals and at bedtime. During observation of medication administration, the RN prepared both insulin pens and did not prime them before giving the injections. In interview, the RN confirmed the pens were not primed before the dose was administered and stated he thought insulin pens only needed to be primed after first opening. Manufacturer instructions for both Insulin Aspart and Insulin Glargine stated that a safety test must be performed before each injection by dialing a test dose of two units and checking that insulin comes out of the needle. The facility policy on administering medications stated medications are administered in accordance with prescriber orders, including any required time frame.

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 enhanced barrier precautions for a resident with an indwelling Foley catheter. The resident had diagnoses including inflammatory disorders of the scrotum, gangrene Fournier, dementia, and cerebral infarction. A physician’s order dated 10/04/25 directed enhanced barrier precautions during high-contact resident care twice a day for the Foley catheter. During an observation on 01/08/26, a CNA was performing a bed bath for the resident while the signage for enhanced barrier precautions was posted on the door, and the CNA verified she was not following the required enhanced barrier precautions as guided by CDC guidance. The facility also failed to ensure hand hygiene was performed during catheter care for another resident. That resident had diagnoses including acute and chronic respiratory failure, kidney and ureter disorders, type II diabetes mellitus, obstructive and reflux uropathy, acute kidney failure, encephalopathy, dementia, sepsis, urinary tract infection, hydronephrosis, urinary retention, atrial fibrillation, anxiety disorder, and overactive bladder. Orders dated 11/11/25 directed enhanced barrier precautions during high-contact resident care every day and night shift and catheter care every shift. The MDS indicated the resident was dependent on staff for toileting hygiene and showering, and the care plan included catheter care and enhanced barrier precautions related to the indwelling Foley catheter. During an observation of catheter care, the CNA did not perform hand hygiene before donning gown and gloves, left the room twice and returned without performing hand hygiene before putting gloves back on, moved the trash can with a gloved hand, reached into her pocket for a trash bag, placed the bag on the floor, and then continued catheter care without doffing gloves, performing hand hygiene, or donning new gloves. At the end of the observation, the CNA confirmed she had not washed her hands before starting catheter care or after leaving the room on the two occasions. Facility policies on catheter care, hand hygiene, and enhanced barrier precautions stated hand hygiene is required before touching a resident and before aseptic tasks, and that gowns and gloves are to be used for high-contact resident care activities such as device care involving a urinary catheter.

Penalty

No penalty information released

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

Summary

The facility failed to report an alleged violation involving a resident's injury to the state department of health in a timely manner. A resident with multiple complex medical diagnoses, including Parkinson's disease, dementia, and muscle weakness, experienced an incident during a transfer using a sit-to-stand machine. Initial nurse's notes indicated the resident felt weakness in her legs and was unable to hold on to the machine, leading staff to return her to bed. At the time, no injuries were noted, and the incident was not documented until approximately nine hours later. Later that evening, the resident reported pain and swelling in her right shoulder and arm, prompting the nurse to contact the physician, who ordered a stat X-ray. The following day, the X-ray revealed a fractured neck of the humerus, and the resident was sent to the emergency room for further evaluation. Despite being made aware of the fracture, facility leadership did not file a Facility Reported Incident (FRI) as required by policy, which mandates immediate reporting to the state agency within two hours for serious bodily injury. Interviews with the DON confirmed awareness of the injury and the connection to the previous day's incident with the sit-to-stand machine. However, the DON had not yet interviewed the two aides involved in the transfer, and the nurse's notes and incident report were not completed by those present at the time of the event. Facility records showed no FRI was filed for the incident, and the internal investigation was incomplete at the time of the survey.

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 wound care treatment and assessments were appropriately implemented and completed for a resident with a history of Parkinsonism, dementia, and dysphagia, who was assessed to have impaired cognition. Despite the identification of a new blister with green and yellow drainage on the resident's right thigh, and subsequent notification of the physician with orders for laboratory testing and antibiotic therapy, no wound care treatment orders were implemented, and no wound assessments were documented from the time the blister was identified through several months. The care plan indicated the resident was at risk for impaired skin integrity, but there was no evidence of wound care or assessment for the blister during the specified period. Observations revealed the presence of a bandage on the resident's right thigh, and interviews with nursing staff confirmed that although the wound was known and bandages were being changed, formal wound care orders were not followed, and required assessments were not completed or documented. The facility's own policy required physician orders for wound care and thorough documentation of wound care and assessments, but these procedures were not adhered to in this case. The Assistant Director of Nursing confirmed that wound care treatment orders and assessments were not implemented or documented as required.

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 resident with diagnoses including Parkinsonism, dementia, and dysphagia, and assessed to have impaired cognition, sustained a burn after spilling hot coffee on himself during lunch. At the time of the incident, the resident was using a two-handled cup with a spouted lid as recommended by Occupational Therapy to prevent spillage and burns. Despite these interventions, the resident spilled coffee, resulting in a blister and redness on the right outer leg, later assessed as a second-degree burn measuring 10.5 cm by 6.6 cm. Record review and staff interview confirmed that all safety interventions and the plan of care were in place and functional at the time of the occurrence. The incident was documented in nursing progress notes, and the burn was assessed and measured by the facility. The event affected one resident out of three reviewed for accidents, and the facility census was 93 at the time.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that blood draw orders for Vancomycin peak and trough levels were obtained and completed for a resident who was receiving intravenous Vancomycin for osteomyelitis. The resident, who had multiple diagnoses including acute osteomyelitis, peripheral vascular disease, diabetes mellitus type two, and abscess of the right ankle and foot, was admitted and received Vancomycin without any corresponding lab orders for monitoring drug levels. Review of the medical record and nursing notes confirmed that no Vancomycin peak or trough levels were ordered or documented during a three-week period of administration. Interviews with facility staff, including an LPN, a physician assistant, the consulting pharmacist, and the Director of Nursing, confirmed that the standard of care for Vancomycin administration was not followed, as regular lab monitoring was expected but not performed. The pharmacist noted that hospital discharge instructions included weekly trough levels, but these were not implemented upon admission. The facility also lacked a policy regarding lab draws and monitoring for antibiotics, contributing to the oversight.

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 residents were treated with dignity and respect during personal care activities, as evidenced by multiple observations involving incontinence care and post-shower assistance. In several instances, residents with cognitive intactness and various medical conditions, including multiple sclerosis, Parkinson's disease, dementia, and heart failure, were exposed during care. One resident was observed receiving incontinence care with the room door open and privacy curtain not drawn, resulting in exposure of the resident's buttocks and legs. Another resident was seen sitting naked on the toilet with her head lowered, and staff confirmed that dignity was not maintained during these activities. Additionally, an incontinence product containing stool was left on the floor without a barrier during care. In a separate incident, a resident was observed self-propelling in a wheelchair in the hallway after a shower, covered only by a towel that left her shoulders, upper thighs, and feet exposed. Staff accompanying the resident acknowledged that the resident was not fully covered. Another resident received incontinence care next to a large window with open blinds, exposing her to view from an adjacent parking lot and sidewalk. The staff member providing care confirmed that the blinds were not closed during the procedure. Facility policy required staff to promote and maintain resident privacy and dignity during personal care, 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 facility failed to maintain a comprehensive pharmaceutical program to safeguard controlled substances and ensure medications were administered as ordered. During a reconciliation of controlled drugs, surveyors observed that controlled medications were not properly labeled or stored. Specifically, two pill-crusher pouches containing an unknown quantity of blue, round, scored tablets were found in a disposable cup labeled only with a resident's name and drug name, but without a pharmacy label or other required identification. The Director of Nursing (DON) was unable to confirm the contents or how long the pouches had been present, and the count of oxycodone tablets did not match the controlled drug record, with missing documentation and discrepancies in the number of tablets available versus what was recorded. Further observations revealed that staff failed to accurately document the administration of controlled medications. In two instances, a registered nurse admitted to administering opioid medications to residents but forgot to sign out the doses on the controlled drug record. Additionally, the number of controlled medication count sheets did not match the number of medication cards, and this discrepancy was not identified during shift change reconciliations. Review of medication administration records and controlled drug records for several residents showed inconsistencies, with some doses recorded as administered on one record but not the other, and in one case, a nurse withheld scheduled pain medication based on personal judgment rather than physician orders. The facility also failed to ensure that antibiotics were administered as ordered. One resident, who had been prescribed a course of Augmentin for pneumonia, did not receive the full number of ordered doses, as confirmed by both the medication administration record and staff interview. Review of facility policies indicated that medications were to be administered as prescribed and that controlled substances were to be properly documented and reconciled, but these procedures were not consistently followed, resulting in multiple deficiencies affecting several residents.

Penalty

No penalty information released

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

Summary

The facility failed to safeguard controlled substances, resulting in the misappropriation of a resident's medication. A resident with multiple medical conditions, including diabetes, fractures, heart failure, and a urinary tract infection, was prescribed oxycodone. When staff attempted to reorder the medication, the pharmacy reported it was too soon for a refill, revealing that 60 tablets had already been delivered and registered in the facility's narcotic count. Despite a comprehensive search, the medication and its control sheet could not be located, and the facility was unable to determine who or when the medication was misappropriated. The incident was identified when the pharmacy denied the refill request, and the attending physician was notified immediately. Further observations during the survey revealed ongoing issues with the documentation and reconciliation of controlled substances. During medication reconciliation, discrepancies were found between the number of tablets recorded on the Controlled Drug Administration Record (CDR) and the actual number of tablets present for two residents. In both cases, a nurse admitted to administering the medication but forgetting to sign it out on the CDR. Additionally, inconsistencies were found between the number of controlled medication cards and the corresponding count sheets, which were not identified during shift change reconciliations. Interviews with nursing staff confirmed a lack of awareness regarding unidentified controlled drugs being stored in the medication lock box and acknowledged continued concerns with documentation and reconciliation of controlled substances. The facility's policy prohibits misappropriation of resident property, but the failure to maintain accurate records and perform thorough shift change counts contributed to the 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 facility failed to provide timely and appropriate care for residents with indwelling catheters, urinary tract infections (UTIs), and incontinence. One resident was admitted with multiple diagnoses, including a fracture, heart failure, chronic kidney disease, benign prostatic hyperplasia, and a UTI. The resident had an indwelling catheter for pain control and mobility, which required comprehensive evaluation upon admission, weekly for four weeks, and then quarterly. However, there was no evidence of ongoing comprehensive evaluation of the catheter between late February and the end of April. The resident's catheter was eventually discontinued at his request, but the urinalysis sample obtained at that time was not sent to the lab promptly, resulting in delayed diagnosis and treatment. The resident was started on antibiotics before urine test results were available, and ultimately required two different antibiotics due to resistance patterns identified later. Additionally, the facility failed to provide adequate incontinence care for another resident who was frequently incontinent of bowel and bladder. During observed care, a CNA performed incontinence care with the blinds open, exposing the resident to potential lack of privacy. The CNA did not fully clean the resident, leaving stool on the resident's skin and on the clean incontinence product that was applied. The CNA acknowledged that the resident was not fully cleaned and stated that staff would check and clean the resident again in about 20 minutes. The Assistant Director of Nursing confirmed that the care provided was not appropriate and that the resident should not have been left soiled. Policy review indicated that indwelling catheters should be used sparingly and only for appropriate indications, with ongoing evaluation and documentation of need. The policy also required prompt identification and management of UTIs and appropriate incontinence care. The facility's failure to follow these policies resulted in delayed assessment and treatment of a UTI, inadequate catheter care, and insufficient incontinence care for the residents involved.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a resident with a gastrostomy tube did not receive proper care during medication administration. The resident, who had diagnoses including dysphagia, intracranial hemorrhage, congestive heart failure, gastrostomy, and dementia, was observed receiving multiple crushed medications mixed in water through the g-tube. The LPN administering the medications failed to check the tube for placement and did not flush the tube prior to medication administration, contrary to facility policy. Additionally, the LPN did not provide the ordered 200 mL of water bolus as prescribed, instead flushing the tube with only 60 mL of water after medication administration. Medical record review confirmed the resident was ordered a regular diet with pureed texture, thin liquids, and a specific water bolus twice daily. Facility policy required verification of tube placement, flushing before and between medications, and use of the prescribed amount of water. The LPN acknowledged during interview that these steps were omitted due to forgetting the cup and not wanting to set it down, resulting in failure to follow both physician orders and facility policy for enteral tube medication administration.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate care and services for a resident with a gastrostomy tube, resulting in a medication error rate of 48% (12 errors out of 25 opportunities) during medication administration. The resident, who had diagnoses including dysphagia, nontraumatic intracranial hemorrhage, congestive heart failure, gastrostomy, and dementia, was observed receiving multiple medications crushed and administered via a gastrostomy tube by an LPN. There was no physician order to administer these medications through the enteral tube, and the medications were ordered to be given orally, with instructions that they could be crushed and given with food if appropriate. During the observed medication pass, the LPN did not check the gastrostomy tube for placement or flush it prior to administration, and only flushed the tube after administering the medications. The LPN confirmed that all medications, including those not intended for enteral administration, were crushed and given via the tube without a proper order. Facility policy required verification of a physician's order for enteral tube medication administration and adherence to the prescribed route, 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 facility failed to ensure that medications were properly labeled in accordance with professional standards and facility policy. During a reconciliation of controlled substances, surveyors observed that a resident's oxycodone tablets were stored in pill-crusher pouches inside a disposable water cup, with the cup labeled only with the resident's name and medication name written in marker. The pouches themselves lacked any pharmacy label or proper identification, containing only handwritten initials and the number '30'. The staff were unable to verify the exact contents or quantity of the medication in the pouches, and the Director of Nursing confirmed that there was no way to know what the tablets actually were or how many were present, aside from the five tablets remaining in the original prescription bottle. The resident involved had a history of osteoporosis, spinal stenosis, chronic pain, osteoarthritis, and joint pain, and had been prescribed oxycodone 5 mg as needed for pain. The medication policy required that drugs be stored in their original packaging with complete pharmacy labeling, and only the dispensing pharmacy was authorized to transfer or relabel medications. The observed practice of storing and labeling the medication did not comply with these requirements, as the medication was not in its original container and lacked the necessary identifying information.

Penalty

No penalty information released

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

Summary

The facility failed to properly monitor and log infections, as well as identify possible infection trends, as evidenced by the omission of a resident's sepsis and urinary tract infection (UTI) from the Infection Control Log. Medical record review showed that a resident with multiple diagnoses, including respiratory failure and heart failure, was admitted and later diagnosed and treated for sepsis and UTI in the hospital. However, the infection preventionist confirmed that these infections were not recorded in the facility's infection control log, and no trends or patterns were identified, despite multiple residents being diagnosed with UTIs caused by E. coli. Additionally, the facility failed to ensure proper hand hygiene practices during incontinence care. Observation revealed that a certified nurse assistant (CNA) provided incontinence care to a resident, disposed of soiled materials, and changed gloves without performing hand hygiene before or after glove changes, contrary to facility policy. The CNA also handled personal items and applied ChapStick to the resident without washing hands. Policy review confirmed that hand hygiene is required after glove removal and after contact with body fluids or contaminated surfaces, but these procedures were not followed during the observed care.

Penalty

No penalty information released

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

Summary

The facility failed to implement appropriate antibiotic stewardship for one resident who was admitted with multiple diagnoses, including a urinary tract infection (UTI). Medical record review showed that the resident was cognitively intact, frequently incontinent of urine, and had a recent history of UTI. The resident had an indwelling urinary catheter for a period prior to the incident. On a specific date, the resident complained of back pain and dysuria, and cloudy urine was observed. A urinalysis was sent for analysis, but a prophylactic antibiotic (Bactrim) was started before the urinalysis and urine culture results were available. The resident continued to receive Bactrim pending the results, and fluids were encouraged. The urine culture later revealed the presence of Escherichia coli (sensitive to Bactrim) and enterococcus faecalis (not sensitive to Bactrim). The resident was then started on a different antibiotic (Cipro) after the culture results were received. An interview with an LPN confirmed that antibiotics were started prior to receiving test results, and that the physician assistant routinely orders antibiotics prophylactically without confirming appropriateness. Facility policy required assessment and diagnostic testing to guide antibiotic use, but this protocol was not followed in this case. 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 a safe outdoor smoking area for residents, particularly for a resident with significant physical impairments. This resident, who had hemiplegia and hemiparalysis affecting her left side, was assessed to smoke independently without supervision. However, she was not accurately assessed for her ability to extinguish herself in the event of a fire, nor was she provided with reasonable access to fire safety equipment or a means to obtain assistance in case of an emergency. On the day of the incident, the resident was smoking in the designated smoking area when an ash from her cigarette ignited her clothing, resulting in severe third-degree burns to her upper body and face. A visitor observed the resident on fire and attempted to extinguish the flames using her own clothing, as there was no fire blanket readily accessible in the smoking area. The resident was subsequently hospitalized and required surgical intervention for her injuries. The facility's smoking policy at the time did not ensure that fire safety equipment was adequately accessible to residents in the smoking area. The resident's care plan and smoking assessment failed to account for her physical limitations and the need for supervision or assistance in the event of a fire, contributing to the severity of the incident.

Removal Plan

• Licensed Practical Nurse (LPN) #242 responded to Resident #100 after being notified the resident had caught fire. LPN #242 assessed Resident #100 for pain which the resident initially denied and refused a transfer to the emergency room. Later Resident #100 agreed to the hospital transfer, the transfer was facilitated, and the resident's representative was notified of the incident.
• The Administrator called Resident #100's representative and discussed the incident.
• The Administrator visited Resident #100 in the hospital. The Administrator stated the resident voiced concerns about losing her smoking privileges and also stated the wind blew amber out of her cigarette and caught her clothes on fire.
• Licensed Practical Nurse (LPN) #242 reviewed the current smoking residents in the facility with no injuries noted. All smoking evaluations were reviewed for accuracy and the plans of care was updated if needed for the residents reviewed. LPN #242 also instructed the residents on the location of the fire safety equipment, fire blanket, and ensured they understood how to use it.
• The Director of Nursing (DON) reviewed skin evaluations on all current residents and there were no signs of any injuries of unknown origin or injuries consistent with a smoking injury.
• LPN #242 observed independent smokers' clothing and no signs of damaged clothing consistent with a smoking incident were noted.
• LPN #242 re-educated current smoking residents on the importance of informing staff of any potential fire hazards immediately to prevent similar incidents from occurring.
• LPN #242 re-educated the current staff on the updated facility smoking policy.
• The Administrator met with the resident council to review the smoking policy, and to receive feedback from the residents related to the possibility of transitioning the facility to supervised smoking in the future.
• Regional Nurse Consultant (RNC) #800 incorporated fire safety equipment checks immediately, daily for four days, then monthly and as needed thereafter to ensure appropriate fire safety equipment was present and in functional order.
• Activities Director (AD)#294 started random audits on a minimum of five residents per week for four weeks then as needed to ensure residents were appropriately assessed and were smoking safely independently, avoiding loose and flammable clothing, and were taking appropriate precautions related to weather conditions. Any issues identified within the audits were to be forwarded to the Quality Assurance (QA) committee for immediate follow-up.
• Registered Nurse (RN) #319 provided staff, residents, and visitors with education regarding placement of the fire extinguisher and fire blanket.
• The Administrator obtained a quote for a gazebo to be placed in the smoking courtyard.
• Regional Nurse Consultant (RNC) #800 updated the smoking policy to include additional fire safety measures, such as having fire extinguisher in the smoking area, training residents on basic fire safety, and inspection and maintenance of fire safety equipment.
• AD#294 educated current smokers on the updated smoking policy, the current smokers were provided with a copy of the policy and signed an attestation of understanding.
• AD#294 placed signage on the facility doors informing and reminding residents and staff of the smoking rules and fire safety practices.
• The Administrator held a meeting with the Ombudsman and all independent smoking residents regarding the smoking policy, placement of the fire extinguisher, placement of the fire blanket, and the importance of verbalizing the need for assistance.
• A gazebo was placed within the courtyard by Maintenance Director (MD) #281.
• MD #281 placed a fire blanket on the gazebo.
• MD #281 moved the fire extinguisher to the designated smoking area.
• Occupational Therapist (OT) #318 assessed all independent smokers to ensure they were able to follow safety precautions related to fire safety and ensured residents were able to remove the fire blanket and understood how to use a fire extinguisher.
• The facility implemented a plan that the DON would educate all licensed nurses on how to complete a smoking assessment to ensure consistency. Licensed nurses would be responsible for completing smoking assessments moving forward. The education would include the new location of the smoking blanket in the designated smoking area. No agency staff were being utilized and no licensed nurses were on leave at the time of the training.
• AD #294 hung signs on the two handicapped accessible doors leading to the smoking area to ensure staff, residents, and visitors had knowledge of where the smoking blanket and fire extinguisher were located.
• The Administrator fastened a walkie talkie to the smoking gazebo for communication in the event of an emergency. The walkie talkie would be changed out daily to ensure it was charged.
• The DON or designee would complete weekly audits for four weeks and as needed to ensure the completed smoking observation/assessments were accurate and reflected the medical record.
• The DON or designee would complete weekly audits for four weeks and as needed to ensure the fire blanket, fire extinguisher, and walkie talkie were in place.
• Results of the audits would be reviewed during monthly Quality Assurance (QA) meetings to determine if the current action plan was effective or if additional interventions would need to be added. Any issues identified within the audit would be forwarded to the QA committee for immediate follow-up.

Penalty

Inspection fine: $20,678

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 multi-use vials of tuberculin purified protein derivative (PPD) were dated when opened. This deficiency was observed during an inspection of the medication room refrigerator, where an opened vial of tuberculin PPD was found without a date indicating when it was opened. An LPN confirmed that the vial was opened the previous day for a new admission but acknowledged that it was not dated as required. The facility's policy, dated April 2019, mandates that the date of opening must be recorded on multi-dose containers, which was not adhered to in this instance.

Penalty

Inspection fine: $20,678

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 not expired and was stored appropriately, as well as failed to ensure staff practiced proper hand hygiene when handling food. During an initial tour of the kitchen, several food items were found to be expired or improperly stored, including a half-used container of salsa, a bag of brown, soggy shredded lettuce, an opened and undated bag of fresh grapes, an unopened bag of pre-sliced potatoes, and a partially used bottle of hot sauce. Additionally, a large bag of premade peanut butter cookie dough cookies was found opened and undated in the freezer. The Dietary Manager confirmed these findings and discarded the items. The facility's policy on food receiving and storage was not adhered to, as it requires foods to be received and stored in a manner that complies with safe food handling practices. Furthermore, Cook #211 was observed not practicing proper hand hygiene while handling food. Cook #211 donned clean gloves without washing hands, handled food items, and then removed the gloves without performing hand hygiene. This process was repeated multiple times during the lunch meal service, including handling French fries, slices of cheese, hamburger buns, and other food items. The cook continued to handle food with the same gloves on, even after touching various surfaces and items. The facility's policy on food preparation and service, which requires proper hygiene and sanitary practices to prevent cross-contamination, was not followed. The Administrator, Dietary Manager, and Cook #211 confirmed these observations during an interview.

Penalty

Inspection fine: $20,678

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 menu was followed for residents on dysphagia advanced, mechanical soft, or pureed diets. On the specified date, the lunch menu was supposed to include a cheeseburger on a bun, lettuce and tomato, French fries, creamy coleslaw, and a cookie. However, Cook #211 prepared and served sloppy joes instead of cheeseburgers, and did not include buns in the pureed version of the meal. Additionally, Cook #211 used gloved hands to scoop shredded lettuce onto plates instead of using a portion control utensil to ensure the correct amount was served, as indicated on the dietary spreadsheet. This affected 23 residents who required specific dietary modifications. Interviews with Cook #211, the Dietary Manager, and the Administrator confirmed that the dietary spreadsheet was not followed for the lunch meal. Cook #211 admitted to using a homemade recipe for sloppy joes and acknowledged the omission of buns in the pureed version, as well as the failure to use portion control utensils for the shredded lettuce. The facility's policy on food preparation and service, which mandates adherence to dietary spreadsheets and portion sizes, was not followed, leading to this deficiency.

Penalty

Inspection fine: $20,678

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

Summary

The facility failed to ensure that a resident was free from physical restraints, which affected one resident. The incident involved a resident who was cognitively intact and had multiple diagnoses, including epilepsy, schizophrenia, and dementia. The resident alleged that an LPN sat on her in the smoking area after she went outside during non-smoking hours. The LPN was trying to get the resident back inside, and the resident became combative, resulting in a bruise on her shoulder from hitting a bench outside. The facility's Self-Reported Incident revealed that the LPN grabbed the resident's wrist, leading to a physical altercation. The LPN then restrained the resident by sitting on her while they were both on a bench outside. Witnesses confirmed that the LPN initiated the physical contact and restrained the resident, which was unnecessary as the resident did not physically engage with the LPN until he grabbed her wrist. The facility's abuse prevention policy prohibits any physical restraint not required to treat the patient's medical symptoms. Interviews with the resident and staff confirmed the details of the incident. The resident expressed frustration about not being allowed to smoke when she wanted, and the LPN's actions were deemed inappropriate and unnecessary. The facility's policy review and interviews indicated that the LPN's actions violated the facility's abuse prevention policy, leading to the deficiency being cited by the surveyors.