Embassy Of Woodview

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe, sanitary, and comfortable environment for residents, staff, and the public. During an observation of the Short Coral/West Wing, an infection control bin was seen outside a doorway with a bunched up pile of medical gloves on the floor beside it, and employees were observed walking past the area. On the Long Coral/West Wing, two pairs of medical gloves were observed on the floor between two resident rooms. In the Long Green/East Wing, there was a trail of spilled coffee in the hallway in front of two resident rooms. In Resident #200's room, the resident was sitting in a chair eating breakfast while a 10 inch by 10 inch round dried orange-brown substance was observed on the floor under her feet; the resident stated it was betadine solution spilled from a foot treatment the day before and that no one cleaned the floor. Resident #205 was observed in bed with a dirty white blanket, white sheet, and incontinence pad lying on the floor at the end of the bed. The Administrator verified the observations during the tour, and the Housekeeping Director stated housekeeping had a daily schedule for cleaning common areas, resident rooms, and hallways, and that staff were responsible for informing the department when immediate assistance was 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 staff a Registered Nurse (RN) for at least 8 hours a day and 7 days a week. Review of the staffing schedule for 06/27/26 showed RN #110 was scheduled to work from 7:00 A.M. to 7:00 P.M., but review of the Payroll Based Journal (PBJ) data showed no evidence that RN #110 or any other RN was scheduled to work that day. During an interview on 07/20/26 at 3:32 P.M., the Human Resources Regional Manager verified there was no evidence of RN #110 or any other RN working on 06/27/26. The facility assessment approved by the Administrator on 03/04/26 stated that one to six RNs were necessary to care for residents per day. The deficiency was identified under Complaint Numbers 2982837, 2806222, and 2800143 and had the potential to affect all 68 residents in the facility.

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

Sanitary food service practices were not maintained in the kitchen and resident refrigerator areas. During observation of the kitchen walk-in refrigerator, multiple opened food items were found without required open or use-by dates, including cheese sauce, mashed potatoes, beef Stroganov, diced onions, shredded cheddar cheese, and sliced tomatoes. An interview with the food service staff member confirmed these items were open and undated and stated open items in the refrigerator should have a 7-day expiration. Three bins of cereal were also observed on a stainless steel countertop, and two bins of cereal were labeled with a use-by date of 04/19/26; the staff member confirmed the date and stated cereal should be dated for 30 days after opening. The facility policy required foods needing temperature control to be labeled with the food name, date opened, and use-by date. Additional observations showed visible caked-on dirt on the floor of the kitchen dry storage room and in the hallway leading to that room in front of the chemical storage door. The same staff member confirmed the dirt and stated a new floor was needed. Two chemical containers, Sanitize RTU food contact sanitizer and SparClean high temp rinse aid, were also stored among food items in the dry storage room, and the staff member stated they should have been stored in the chemical closet. In the central lounge refrigerator, expired milk labeled for a resident and an expired red velvet cake were present, along with unlabeled Burger King and Kentucky Fried Chicken bags. An LPN confirmed the expired and unlabeled items, and the facility policy required resident and family foods to be labeled with the resident's name, item, and date.

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 water heater serving the coral side of the building, which affected all residents residing in that area, including Residents #3, #4, #5, #6, #8, #12, #13, #14, #15, #17, #18, #20, #23, #26, #27, #28, #29, #30, #31, #35, #36, #38, #40, #43, #47, #48, #51, #52, #54, #60, #64, #65, #81, and #82. Resident #31 stated during interview that the bathroom did not have hot water. During observation with the Director of Maintenance, hot water temperature readings in two resident room bathroom faucets on the coral side registered 84 degrees Fahrenheit, and the Director of Maintenance confirmed the hot water outage in those rooms. The Regional Director provided a handwritten timeline showing that a problem with the hot water heater was identified on 03/09/26. The Regional Director confirmed there was no evidence of action from the procurement team on a new water heater between 03/09/26 and 06/06/26, although a new tank had been ordered. The Director of Maintenance stated the hot water heater servicing the coral side had been out since starting the job about 4 weeks earlier. An email from Plumbing Company #1 stated installation of the new water heater was slated for 07/15/26, and observation on that date confirmed work to install the new water heater. The facility policy stated that the facility would be equipped and maintained to provide a safe, functional, and comfortable environment and that all essential mechanical and patient care equipment would be maintained in safe operating condition.

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 #31's bathroom was clean. During an interview, Resident #31 stated the bathroom was dirty and said it was bothersome. Observation of the bathroom showed multiple reddish-brown stains and visible dirt on the bathroom floor. The Director of Maintenance later observed the bathroom floor and confirmed the reddish-brown staining and visible dirt. The facility also failed to ensure a PTAC unit in Resident #2's room was functional and that the hallway floor between rooms 200 and 222 was clean. Resident #2 reported water on the floor from the PTAC unit, and several blankets were observed under the unit soaking up dripping water. The Maintenance Director verified the blankets were soaking up water and also noted a cable outlet hanging off the wall by the resident's television. Later observations showed the blankets remained saturated with water under the PTAC unit, and a CNA confirmed the blanket was still on the floor soaked in water. In the hallway, surveyors observed over 20 dried spill marks spread across the floor, and staff stated the spills were coffee that had been left there for too long.

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 thorough investigations following allegations of abuse and neglect/mistreatment involving four residents. For one resident, the investigation of an allegation of neglect/mistreatment did not include interviews with interviewable residents in the facility or skin checks for residents who could not be interviewed, and the Regional Administrator confirmed these steps were not completed. For another resident, the investigation of an allegation of neglect/mistreatment also lacked interviews with interviewable residents and skin checks for residents unable to be interviewed, and the Regional Administrator again confirmed the absence of these actions. For a third resident, the investigation of an allegation of physical abuse did not include staff education on physical abuse, and the Regional Administrator confirmed no such education occurred after the allegation. For a fourth resident, the investigation of an allegation of physical abuse did not include skin assessments for residents in the facility who were unable to be interviewed, and the Regional Administrator confirmed no skin checks were completed for other residents. The facility policy required identifying and interviewing all involved persons, completing thorough documentation, and providing staff education as needed, but the investigations reviewed did not reflect those steps.

Penalty

No penalty information released

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

Summary

The facility failed to ensure staff practiced hand hygiene during resident care. On 07/15/26, CNA #112 entered Resident #7’s room and practiced hand hygiene before assisting with repositioning. CNA #128 then entered the room without performing hand hygiene or applying gloves, repositioned Resident #7 in bed, touched the resident’s linens, and left without performing hand hygiene. CNA #128 then took a meal tray from a metal food bin with bare hands, entered Resident #62’s room without hand hygiene, moved personal items on the bedside table, and set up the meal tray before leaving the room without performing hand hygiene. CNA #128 later confirmed she did not perform hand hygiene before or after Resident #7’s room and that she touched the linens and handled Resident #62’s meal tray. The facility also failed to post enhanced barrier precautions signage for two residents. Resident #04 was admitted with diagnoses including injury of unspecified body region, type 2 diabetes, and spinal stenosis, and had wound care and IV solution orders. The resident’s care plan included an intervention to maintain EBP per facility protocol, but observations on 07/13/26 showed protective equipment outside the room and no EBP sign on the door. Resident #11 was admitted with diagnoses including anoxic brain damage, chronic respiratory failure, and dysphagia, had an enteral tube feeding order and an order for cleaning the gastric tube site, and the care plan included EBP as indicated. Observations on 07/14/26 and 07/15/26 showed no EBP signage on the door, and CNAs confirmed the resident had a gastric tube and no sign was posted. The facility further failed to ensure EBP was followed during wound care for Resident #67 and failed to keep a urinary catheter drainage bag off the floor for Resident #12. Resident #67 had diagnoses including major depressive disorder, type 2 diabetes, and COPD, with a BIMS score of 6, and had an order for EBP due to wound care; during wound dressing changes on 07/16/26, LPN #153 did not wear a gown. Resident #12 had diagnoses including BPH, obstructive and reflux uropathy, and chronic kidney disease, with a care plan noting risk for catheter-related trauma and UTI related to a Foley catheter; on 07/14/26, the catheter bag was uncovered on the floor under a walker, and the RN who responded confirmed it should be affixed to an unmovable part of the bed.

Penalty

No penalty information released

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

Summary

The facility failed to provide a fitted sheet for Resident #30’s bariatric bed mattress, affecting the resident’s right to a safe, clean, comfortable, and homelike environment. Resident #30 was admitted with diagnoses including COPD, urinary or dual incontinence, and Type 2 diabetes mellitus, and the resident’s MDS assessment indicated cognitive intactness. During an interview, Resident #30 stated the facility did not provide a fitted sheet for the bariatric bed mattress. At the time of observation, Resident #30 was lying in bed and the bariatric mattress did not have a fitted sheet. A later interview with a CNA confirmed the mattress still did not have a fitted sheet, and the CNA retrieved one at that time. When the resident was observed again later, the mattress had a fitted sheet, and Resident #30 stated that a fitted sheet is preferred. The facility policy on Resident Rights states that residents have the right to a comfortable and homelike environment, including support for daily living.

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 allegation of neglect to the State Agency when Resident #85 eloped from the facility. Resident #85 was admitted with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, absence of limb, depression, and a history of homelessness. On 06/07/26, a nurse went to administer medications and found the resident was not in the room. Staff checked the facility grounds, the resident could not be located, administration was notified, and a police report was made. The progress notes indicated the resident did not return to the facility, but the facility had no SRI for the elopement and the Regional Administrator could not locate an investigation related to the incident. The facility also failed to report an allegation of resident-to-resident physical abuse involving Resident #35 and Resident #59. Resident #35 had diagnoses including type 2 diabetes mellitus, alcohol dependence, and dementia, and Resident #59 had diagnoses including alcohol dependence, chronic obstructive pulmonary disease, and depression; both were assessed as cognitively intact. Resident #59 and another resident described an incident in which Resident #35, allegedly drunk, shoved Resident #59 into a chair, and police were called to the facility. A police report dated 05/26/26 documented that officers spoke with Resident #59, who reported that Resident #35 pushed her into a chair and waved his cane in an intimidating manner. The facility's SRI records contained no report of the altercation, and the Business Office Manager verified there was no 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 complete quarterly care conferences and failed to ensure a resident’s care plan reflected current status. Resident #05 was admitted with diagnoses including acute cerebrovascular insufficiency, PTSD, and depression, and the Quarterly MDS assessment showed a BIMS score of 11, indicating moderate cognitive impairment. Review of the care conference record showed conferences on 10/13/25, 02/05/26, and 07/02/26, with four months between the first and second conference and five months between the second and third conference. Social Services confirmed that care conferences were not being completed every three months/quarterly. The record also showed that Resident #05 smoked and required supervision for smoking, based on the facility document titled Smoking Evaluation dated 06/22/26. However, the care plan dated 02/13/26 contained no goals or interventions for smoking. On 07/13/26, the resident was observed outside smoking with another resident and no staff present. The MDON confirmed the resident did not have a smoking care plan and was an active smoker at the facility.

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 weekly skin assessments as ordered for Resident #48. The resident was admitted with diagnoses including anxiety disorder, morbid obesity, and COPD, and the MDS 3.0 assessment indicated the resident was cognitively intact. A medical record review showed an order written on 02/09/26 for weekly skin observation every Wednesday, but the assessments record contained no skin assessments between 04/15/26 and 06/18/26. During interview, an LPN confirmed that no skin assessments were recorded on the assessments tab of the electronic medical record during that period.

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

Weekly skin assessments were not completed as ordered for Resident #57, a cognitively intact resident admitted with diagnoses including acute respiratory failure with hypoxia, obesity, and acute kidney failure with acute cortical necrosis. Physician orders included skin observations every night shift every Monday and Triad Paste to the buttocks every shift as a preventative skin measure. Review of the skin assessment record showed no skin assessments were completed between 03/06/26 and 03/31/26, and the skin assessment dated [DATE] documented a stage three pressure ulcer on the left buttock. Progress notes showed that on 03/31/2026, during wound rounds, the CNP discovered a new pressure injury to the resident’s left buttock, which was treated and new orders were implemented. The resident stated that staff were not completing skin checks as ordered, and the Wound Nurse verified that the pressure ulcer was not reported until 03/31/26 and was stage three on the initial assessment. The facility policy required licensed nurses to conduct and document full body skin assessments on all residents upon admission/readmission and weekly.

Penalty

No penalty information released

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

Summary

The facility failed to ensure staff accompanied residents to smoking, affecting two residents observed for smoking. Resident #35 was admitted with diagnoses including type 2 diabetes mellitus, alcohol dependence, and dementia, and an MDS assessment indicated the resident was cognitively intact. The care plan identified the resident as non-compliant with the smoking policy and stated the resident was a potential hazard related to smoking and required supervision by staff or a family member while smoking. On two separate observations, Resident #35 was seen smoking in the courtyard by the central lounge sliding glass door without supervision, and both a CNA and an LPN confirmed the resident was smoking unsupervised. Resident #32 was admitted with diagnoses including schizophrenia, altered mental status, and nicotine dependence with cigarettes. The record showed the resident was noncompliant in care, hid used cigarette butts to smoke later, and required supervision when smoking due to cognitive impairment. The care plan stated the resident had potential for safety hazards or injury related to smoking and could smoke only with supervision by staff or family. During observation, Resident #32 was seen smoking unsupervised in the garden area with two enclosed patios, and a CNA verified there was no supervision. The MDON stated some residents were noncompliant and smoked without staff, and that all residents were supposed to be supervised by staff while smoking. The facility policy stated safe smoking measures were to be documented in the care plan and communicated to those responsible for supervising residents while smoking.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely incontinence care for Resident #21, who was admitted with diagnoses including type 2 diabetes, dementia, heart failure, and adult failure to thrive. The resident’s MDS showed a BIMS score of 11, indicating cognitive impairment, and the resident was dependent on staff for toileting, personal hygiene, and bathing. The care plan dated 03/17/26 identified the resident as incontinent of bowel and bladder and directed incontinence care every two hours and as needed. On 07/14/26, Resident #21 was observed sitting in a specialized wheelchair at the nurses’ station at 11:14 A.M. and was later taken to the dining room for lunch at 11:25 A.M. The resident returned to the 200-hall nurses’ station at 1:12 P.M., and no incontinence care was provided during that time. At 2:57 P.M., CNA #112 provided incontinence care and found the resident’s brief to be heavily saturated with urine and to have a strong urine odor. CNA #112 verified that the resident required 2-hour incontinence checks and had not been checked since 11:00 A.M.

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 administer oxygen as ordered for two residents receiving respiratory care. Resident #48, who had diagnoses including anxiety disorder, morbid obesity, and COPD, was admitted with an order for oxygen via nasal cannula at 3 L every shift related to chronic respiratory failure with hypoxia and unspecified asthma. During observation, the resident’s oxygen concentrator was found set at 1.5 L, and the LPN confirmed the flow rate was below 2 L before later confirming the ordered rate was 3 L. Resident #23, who had diagnoses including diabetic neuropathy, morbid obesity, and COPD, had a care plan directing oxygen administration as prescribed due to impaired gas exchange respiratory failure and an order for oxygen via nasal cannula at 2 L every shift related to COPD. During observation, the resident’s oxygen concentrator was found set at 3 L, and the LPN confirmed the flow rate was above 3 L before confirming the ordered rate was 2 L. The facility policy stated oxygen is administered under physician orders and consistent with professional standards of practice.

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

Facility staff failed to monitor and document a resident's blood glucose levels and oxygen saturations as ordered by the physician. The resident, who had diagnoses including ischemic cardiomyopathy, type 2 diabetes mellitus, and heart disease, was admitted and discharged within a short period. Physician orders specified the administration of insulin and Trulicity for diabetes management, as well as blood glucose monitoring four times daily with instructions to notify the physician if readings were below 60 mg/dL or above 400 mg/dL. However, review of the medication and treatment administration records for the relevant month showed no documentation that blood glucose monitoring was performed as ordered during the resident's stay. During an interview, the regional nurse confirmed that the resident was using a Free Style blood glucose monitoring system, which recorded readings on the resident's personal phone. Despite this, the readings were not recorded in the resident's medical record by facility staff. The lack of documentation and monitoring as per physician orders was confirmed by the regional nurse, constituting a failure to provide appropriate treatment and care according to orders and the resident's needs.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate pressure ulcer care and prevention for three residents, resulting in actual harm to one resident and placing two others at risk for more than minimal harm. For one resident with a history of acute embolism, muscle weakness, and diabetes, the facility did not initiate treatment or complete an accurate assessment for a suspected deep tissue injury (SDTI) to the bilateral buttocks upon admission, despite clear hospital discharge instructions and recommendations from a Wound Certified Nurse Practitioner (CNP). The SDTI was not measured or documented by facility staff, and the prescribed triad cream treatment was not ordered or administered. The resident, who was cognitively intact, reported that no cream had been applied since admission and only refused care due to pain, which could have been managed with pre-medication. The lack of assessment and treatment led to the SDTI worsening into four stage III pressure ulcers. Another resident with dementia, cerebral infarction, and chronic kidney disease was admitted with an unstageable pressure ulcer on the left elbow, but no treatment order was in place until the day after admission. Additionally, a stage II pressure ulcer to the scrotum was identified, but treatment was delayed for two days after documentation. The care plan for this resident did not include interventions for wound treatments as ordered, contrary to facility policy requiring timely and evidence-based treatment for pressure injuries. A third resident with pressure ulcers on both heels had an order for pressure relief boots that was discontinued by staff without a physician's order. Furthermore, there was no documentation that prescribed wound treatments for both heels were completed on several dates. The DON confirmed that treatments were not completed as ordered. Facility policies required full body skin assessments upon admission, weekly assessments, and adherence to physician orders for wound care, but these were not followed 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

The facility failed to implement enhanced barrier precautions for a resident who had an actual area of skin impairment, specifically a suspected deep tissue injury (SDTI) on the bilateral buttocks. The resident's medical record indicated multiple diagnoses, including acute embolism, thrombosis, muscle weakness, and Type II Diabetes Mellitus, and the resident was assessed as cognitively intact. Despite the facility's policy requiring an order for enhanced barrier precautions for residents with wounds, there was no such order in the physician's orders, and the resident's care plan did not include interventions for enhanced barrier precautions. During observation, there was no signage or enhanced barrier precautions cart with gowns and gloves outside the resident's room, and no trash can was positioned inside the room near the exit for discarding personal protective equipment, as required by facility policy. The Assistant Director of Nursing confirmed that the resident should have been on enhanced barrier precautions but was not. This deficiency affected one resident and had the potential to impact all residents on the hall.

Penalty

No penalty information released

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

Summary

The facility failed to provide a sufficient supply of washcloths, hand towels, and bath towels necessary for resident care, affecting at least two residents and potentially all 70 residents in the facility. Observations revealed that multiple resident rooms lacked any bath linens, and the linen closet and laundry room were nearly empty of these items. One resident with Parkinson's Disease and other comorbidities reported frequent delays in receiving showers due to the shortage, with her preferred shower times not being met. Another resident with respiratory failure and other diagnoses stated that towels were removed from her room to be used for others, leaving her unable to wash her face when desired. Staff interviews confirmed that shortages were ongoing, with CNAs prioritizing towel distribution based on which residents woke up first and sometimes resorting to using pillowcases in place of towels. Environmental Services staff confirmed that one of the facility's dryers had been out of order for at least six days, exacerbating the linen shortage. Staff reported that requests for additional linens had been made to management, but the problem persisted. The lack of linens extended to other essential items such as sheets and Hoyer pads, and staff described the linen carts as usually empty. Documentation and interviews indicated that the shortage led to missed or delayed showers and alternative bathing methods, directly impacting residents' ability to receive timely and appropriate 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

A resident with a history of bilateral below-knee amputations, congestive heart failure, chronic obstructive pulmonary disease, osteoarthritis, pain, and peripheral vascular disease was admitted to the facility with an electric wheelchair. Upon admission, there was no assessment completed for the safe use of the electric wheelchair, despite documentation that the resident's mobility was severely limited and required the use of a wheelchair. An incident occurred in which the resident collided with another resident while operating the electric wheelchair, prompting a referral to occupational therapy (OT) for evaluation of safe operation. Subsequent OT evaluation noted the resident had poor depth perception and recommended an optometrist evaluation, which had not yet occurred. The resident was later discharged from OT and deemed incapable of safely operating the power wheelchair. As a result, the facility removed the control panel from the resident's wheelchair, preventing her from independently operating it. There was no physician order, assessment, or care plan in place for this restriction. Both the DON and OT confirmed that restricting the resident's ability to operate her wheelchair limited her mobility.

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 monitor and provide timely and adequate treatments for non-pressure skin issues for two residents. For one resident with multiple diagnoses including dementia and chronic kidney disease, there were documented delays in initiating physician-ordered treatments for peri-area moisture-associated skin damage (MASD), a left hip skin tear, and a right inner thigh abrasion. In each case, there was a gap of several days between the identification of the skin issue and the implementation of the corresponding treatment orders, as confirmed by medical record review and interview with the Director of Nursing. Another resident with MASD of the buttocks and venous ulcers of the left shin and ankle also experienced delays in the initiation of ordered wound care treatments. Additionally, a physician's order for pressure relief boots was discontinued by facility staff without a corresponding physician order. The facility's own policy required that wound treatments be provided in accordance with physician orders, but the treatments for this resident's wounds were not started until several days after the orders were written, as confirmed by both record review and staff interview.

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 residents' drug regimens were free from unnecessary drugs by not providing proper parameters for as-needed (PRN) pain medications and by not following established parameters prior to medication administration. For two residents, physician orders for PRN pain medications such as ibuprofen and acetaminophen did not specify the pain levels or conditions under which each medication should be administered. Additionally, for another resident, there were gaps in the pain scale coverage for PRN opioid orders, and at times, no parameters were in place for certain pain levels. The Assistant Director of Nursing confirmed that pain parameters should have been established for these medications. The facility also failed to follow medication administration parameters for several residents. One resident received PRN pain medications outside of the prescribed pain level ranges on multiple occasions, as documented in the medication administration records over several months. This included administration of oxycodone for pain ratings that did not match the specified parameters in the physician's orders. Additionally, blood pressure medications with specific hold parameters were administered when the resident's systolic blood pressure was below the threshold, contrary to the physician's instructions. Another resident with a history of hypertension and other chronic conditions had a physician order for hydralazine to be administered when systolic blood pressure exceeded a certain value. However, review of the medication administration records revealed multiple instances over several months where the medication was not given despite blood pressure readings above the ordered threshold. The Director of Nursing verified that these doses were missed, and facility policy required medications to be administered as ordered by the physician.

Penalty

Inspection fine: $59,94816 days payment denial

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

Summary

The facility failed to ensure that medications were administered as ordered for four out of seven residents reviewed, resulting in significant medication errors. In multiple instances, residents did not receive critical medications such as anticoagulants, anticonvulsants, antidiabetics, antibiotics, and pain medications due to the medications not being available at the facility. Documentation showed that doses of Lovenox and levetiracetam were missed for a resident with acute respiratory failure and seizures, with progress notes indicating the medications were not available and the pharmacy had not delivered them. The DON confirmed these omissions were due to unavailability of the medications. Another resident with acute osteomyelitis, sepsis, and diabetes mellitus did not receive several scheduled doses of Rybelsus and Bactrim, as these medications were also not available and not kept in the emergency drug kit. Progress notes repeatedly documented that the facility was awaiting delivery from the pharmacy, and the DON confirmed the medications were not available for administration for an extended period after admission. Additional missed doses occurred even after the medication was reportedly delivered, with no clear explanation provided. Further review revealed that two residents prescribed Methadone for chronic pain experienced both missed doses and administration errors. One resident received Oxycodone instead of Methadone, and another received an incorrect dosage of Methadone, both errors confirmed by the DON. These events were documented on Medication Error forms and verified through staff interviews and record reviews, demonstrating a failure to administer medications as ordered and to prevent significant medication errors.

Penalty

Inspection fine: $59,94816 days payment denial

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

Summary

The facility failed to maintain accurate and complete documentation in the medical records of three residents. For one resident with acute osteomyelitis, sepsis, and diabetes mellitus, the Medication Administration Record (MAR) inaccurately documented administration of Rybelsus 3 mg on several dates, despite progress notes and pharmacy records confirming the medication was not available and had not been delivered to the facility during that period. The Director of Nursing (DON) confirmed that the MAR entries were completed in error and did not reflect actual administration of the medication. For two other residents with complex medical histories including chronic pain, osteomyelitis, and opioid dependence, medication errors occurred but were not documented in their permanent medical records. One resident received Oxycodone instead of Methadone, and another received an incorrect dosage of Methadone. Although Medication Error forms were completed for both incidents, these forms were not included in the official medical records, contrary to facility policy. The DON verified that these errors should have been documented in the residents' permanent records.

Penalty

Inspection fine: $91,408

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, timely, and necessary care and services for Resident #100, who had vascular wounds and required follow-up with a vascular surgeon. The deficiency began when a scheduled follow-up appointment with a vascular surgeon was canceled on 07/16/24, and there was no evidence of attempts by facility staff to reschedule or schedule a new consult until 08/14/24. This delay in care resulted in Resident #100 experiencing a significant change in condition, including increased lower extremity pain and bleeding from wounds, leading to a hospital transfer on 08/18/24. The resident was admitted to the hospital with sepsis and infected vascular wounds, requiring extensive treatment and ultimately leading to a decision for end-of-life care. Resident #100 had a history of peripheral vascular disease and chronic vascular wounds, which had previously required hospitalization. Despite having a care plan that included interventions for wound care and follow-up with a vascular surgeon, the facility failed to ensure these were carried out. The resident's condition deteriorated significantly due to the lack of timely medical intervention, as evidenced by the hospital's findings of severe infection and limited options for revascularization. Additionally, the facility failed to transcribe and schedule follow-up appointments for two other residents, placing them at risk for harm. The facility's inadequate appointment scheduling and follow-up processes contributed to the deficiencies identified during the survey, affecting the care and outcomes for multiple residents.

Removal Plan

• Resident #100 was transferred to the hospital and admitted for treatment. The resident did not return to the facility.
• The Administrator, RDCS #490 and Regional Director of Operations (RDO) #485 educated DON, Licensed Practical Nurse (LPN)/ Assistant Director of Nursing (ADON) #238 and Scheduler #376 on proper documentation, uploading of new orders, and setting up transportation for new appointments.
• All staff education was completed on the facility abuse policy. This was completed by the Administrator.
• An initial audit of all outside resident appointments for all current residents was completed by the DON and Scheduler #376. Any discrepancies were fixed immediately.
• All current residents received a head-to-toe assessment completed with no change in conditions or negative outcomes noted. This was completed by LPN #392, Agency Registered Nurse (RN) #645 and Agency RN #678.
• The DON notified facility Medical Director (MD) #900 of the concerns involving Resident #100 identified by the State agency.
• An ad hoc Quality Assurance Performance Improvement (QAPI) committee met to review the facility appointment scheduling process. The Administrator, DON, RDCS #490 and RDO #485 attended.
• A new tracking log was implemented to track additional details of residents outside appointments. The log included the resident's name, the appointment date and time, transportation arrangements, the need for staff assistance, whether the appointment was completed, whether the appointment needed re-scheduled, and if there was any follow up needed. Scheduler #376 is responsible for maintaining and updating the log with oversight from the Administrator. Pertinent information regarding appointments will be shared with the interdisciplinary team weekly on an ongoing basis.
• The DON or designee will monitor 24-hour report and all new orders on an ongoing basis.
• An ongoing audit of post-admission chart reviews will be completed to ensure the admitting nurse accurately transcribed physician's orders. This will be completed by LPN/ADON #238 with the DON as a back-up reviewer.
• An ongoing audit of appointments and transportation will be conducted to ensure appointments are accurately transcribed into the resident's record and are added to the appointment tracking log for verification of appointment attendance. This will be completed by the DON or designee on an ongoing basis and communicated to the interdisciplinary team during morning meetings.
• An ongoing audit of outside resident appointments and transportations as listed on the appointment tracking log will be conducted on random days of the week by the Administrator.
• A staffing huddle was implemented with direct care staff to communicate upcoming scheduled appointments, needs for the appointment, and transportation arrangements. This huddle will occur weekly, Monday through Friday, following the conclusion of morning meeting. Any potential weekend appointments will be communicated on Fridays. The staffing huddle will be coordinated by the Administrator and/or DON or designee.
• The Administrator will send the appointment tracking log to RDO #485 and RDCS #490 for four weeks.
• A random audit of outside resident appointments and transportations will be conducted weekly by RDO #485 or RDCS #490 for additional oversight for a duration of 4 weeks.
• Staff nurses were educated on scheduling appointments, transcribing appointment orders, and monitoring appointment attendance. This was completed by the Administrator.
• Two communication binders were implemented and contained pertinent policies, including written appointment scheduling expectations for communication for both agency and staff nurses. Pertinent policies and updates will be placed in the communication book on an ongoing basis by the DON or designee.
• Results of ongoing audits will be reported and reviewed through the facility QAPI committee for 6 months and randomly thereafter.

Penalty

Inspection fine: $91,408

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 honor a resident's preference for shower times, which is a violation of the resident's right to self-determination. The resident, who had intact cognition and a medical history including COPD, acute respiratory failure, osteoarthritis, anxiety, and depression, expressed a preference for nighttime showers. Despite this, the facility's shower schedule was not adjusted to accommodate this preference, leading to multiple recorded refusals of showers by the resident. The resident's care plan did not reflect her preference for nighttime showers, and the facility's policy on Activities of Daily Living (ADLs) and Resident Rights emphasized the importance of accommodating resident choices. Interviews with the Director of Nursing (DON) and Scheduler revealed that although the scheduler verbally instructed staff to offer nighttime showers, the written schedule was never updated to reflect this change. This oversight resulted in the resident not receiving showers according to her preference, as confirmed by the resident during a telephone interview. The facility's failure to adjust the shower schedule and document the resident's preferences in her care plan led to the deficiency, as it did not align with the facility's policies on promoting resident choice and self-determination.

Penalty

Inspection fine: $91,408

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

Summary

The facility failed to timely notify a resident's family of a change in condition, specifically a positive COVID-19 test result. Resident #58, who had vascular dementia, congestive heart failure, and acute COVID-19, was found to have tested positive for COVID-19 on 09/10/24. Despite being asymptomatic, the resident's family was not informed of this significant change in health status. The resident had a BIMS score indicating intact cognition, and the facility's policy required notification of family members in such cases. The deficiency was identified when a family member, listed as an emergency contact, visited the resident and was informed by the resident himself about the positive COVID-19 test. The family member expressed concern about not being notified, which was confirmed by the Director of Nursing. The facility was using multiple agency nurses at the time, who were not familiar with the notification policy, leading to the oversight. The facility's policy mandates informing the resident's family or legal representative of significant health changes, which was not adhered to in this instance.

Penalty

Inspection fine: $91,408

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

Summary

The facility failed to ensure timely notification to the family of Resident #110 and the Office of the State Long-Term Care Ombudsman regarding the resident's 30-day discharge notice, emergency transfer, and subsequent emergency discharge. Resident #110, who had diagnoses including bipolar disorder, anxiety, and depression, was involved in multiple incidents of verbal and physical aggression towards staff and other residents. Despite these behaviors, the facility did not properly notify the resident's family or the Ombudsman of the discharge and transfer actions taken. Resident #110 was emergently transferred to a hospital on multiple occasions due to escalating behaviors, including an inpatient psychiatric hospitalization and emergency department visits. The facility issued a 30-day discharge notice citing safety concerns but failed to provide this notice to the resident's family or the Ombudsman. Additionally, the resident was transferred to a local hospital with an emergency transfer notice, which also lacked proper notification to the family and the Ombudsman. Interviews with the resident, family members, and the facility's Administrator confirmed the lack of communication and notification regarding the resident's transfers and discharge. The Administrator admitted to not notifying the family or the Ombudsman and misunderstood the requirements for submitting transfer/discharge logs. The facility's policy required timely notification, but this was not adhered to, resulting in a deficiency under Complaint Number OH00157521.

Penalty

Inspection fine: $91,408

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 safe and sanitary infection control practices during a dressing change for a resident with vascular wounds. The resident, who was cognitively intact and required assistance with activities of daily living, had orders for enhanced barrier precautions and specific wound care treatments. During an observation, a Certified Nurse Practitioner (CNP) was seen performing a dressing change without adhering to proper infection control protocols. The CNP, who was usually assisted by a Licensed Practical Nurse (LPN) who was absent, did not change gloves after removing soiled dressings and touched various surfaces and supplies with contaminated gloves. The CNP exited the resident's room while still wearing the soiled gown and gloves, searched for supplies in another treatment cart, and returned to the resident's room without performing hand hygiene before applying new personal protective equipment (PPE). Interviews with the CNP and the Director of Nursing (DON) confirmed the breach in infection control practices. The facility's policies on enhanced barrier precautions and clean dressing changes were not followed, as the CNP did not remove gloves and gown before leaving the resident's room, nor did he perform hand hygiene between PPE changes. This deficiency was identified during a complaint investigation.