Gardens Of Euclid Beach

Penalty

Inspection fine: $200,605

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 facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) or promptly call Emergency Medical Services (EMS) for a resident who had advance directives indicating Full Code status. The resident, who had multiple significant medical diagnoses including chronic obstructive pulmonary disease, diabetes, heart failure, and was receiving hospice services, was found unresponsive. Despite the resident's documented wishes to receive all life-saving measures, no CPR was started by staff, and EMS was not called until nearly an hour after the resident was pronounced deceased. At the time of the incident, the resident was under hospice care but had explicitly chosen to remain a Full Code, as documented in both the physician's orders and the care plan. Staff present at the scene, including an LPN and other aides, failed to recognize or act upon the resident's code status. The hospice nurse who arrived at the scene found the resident with no vital signs and confirmed death after auscultating for a heart rate for three minutes. The crash cart was not brought to the room until much later, and there was confusion among staff regarding the resident's code status and the appropriate emergency response. Interviews and record reviews revealed that the LPN on duty did not know the resident's code status and did not initiate CPR. Other staff members, including another LPN and CNAs, were either unsure of the actions taken or did not participate in resuscitative efforts. Documentation was inconsistent, and there was evidence that staff attempted to retroactively document or misrepresent the provision of CPR. The facility's failure to follow established emergency procedures and to verify and act on the resident's code status resulted in the resident not receiving the life-saving interventions to which they were entitled.

Removal Plan

• Managerial staff, Regional Director of Clinical Services (RDCS) #601, the Administrator, and the DON reviewed data collaboratively, conducted a root cause analysis, and identified that LPN #521 did not know Resident #13's code status and did not initiate CPR.
• The Administrator and DON received education from President of Clinical Services (VPCS) #618 and President of Operations (VPO) #617 on where to locate advanced directives, CPR policy, Code Blue Flow Sheet, that hospice was not a code status and that advanced directives still need checked.
• Staff were educated to check the bed board, with a new process to add code status for staff and contracted service providers.
• Staff were educated to check the bed board, change of condition, communication during a code, the crash cart, and staffing assignments.
• An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with management to review education on advanced directives, CPR policy, Code Blue Flow Sheet, hospice not being a code status, and the new bed board process.
• Contracted service providers would be educated to check the bed board, change of condition, communication during a code, crash cart, and staffing assignments.
• Each service provider would receive a memo upon entering the building stating the facility's new process, sign off on receipt and understanding, and memos would also be emailed to appropriate service providers.
• 32 Certified Nurse Aides (CNAs), 19 LPNs, four Registered Nurses (RN), seven housekeepers, six receptionists, 16 therapists, and 2 activity employees were educated on where to locate advanced directives, CPR policy, Code Blue Flow Sheet, hospice not being a code status, and the new bed board process.
• Contracted service providers will be educated to check the bed board, change of condition, communication during a code and crash cart, and staffing assignments by ADON #615 and the DON.
• A whole house audit for 58 residents' code status orders was reviewed for accuracy by ADON #615. This would be reviewed during clinical meetings, and the DON/designee would update and check the code status for new admissions.
• 58 resident care plans were reviewed for accuracy by MDS Coordinator #613.
• ADON #615 audited all current nurse's CPR certification records to ensure nursing staff had current CPR certification. No nurses were permitted to work until their active CPR certification was verified by Administration.
• Former Director of Nursing (FDON) #604 ran the audit report on 58 residents to assess for change of condition that was not addressed. No issues were identified. The DON/designee would audit the report.
• The DON and ADON #615 audited the three LPNs and four CNAs on duty and had them locate in the electronic medical record where the resident's code status was located.
• The DON/designee completed a mock code blue drill to identify areas of struggle.
• The Administrator, RDCS #601, and Regional Director of Operations (RDO) #599, administered a hands-on and written post-test for all nurses working.
• RDCS #601 and RDO #599 went to the units and demonstrated how to use the overhead page, how and where to look in the electronic medical record for code status, and how to use the walkie talkies. Staff performed a return demonstration of locating code status in the electronic medical record.
• An audit of the bed board code status would be reviewed and updated by the DON. Results of the audit would be reviewed through the facility's QAPI process.
• Mock code blue drills would be conducted on alternating shifts. Staff participating in the mock codes would document on the code blue documentation nurses note form. The mock codes would be overseen by the DON or designee. Results would be reviewed through the facility's QAPI process.
• A code blue drill would be conducted on alternating shifts. These audits would be completed by the DON or designee using the code response form.
• The DON or designee would begin auditing reports from the electronic medical record system to audit for any resident changes in condition, to ensure changes in condition were appropriately addressed. Results would be reviewed through the facility's QAPI process.
• Interview questionnaires would be conducted with first floor staff on how to obtain help during emergency situations on alternating shifts. These interviews would be conducted by the DON or designee. Results would be reviewed through the facility's QAPI process.
• The crash cart would be audited by the DON or designee to ensure all needed supplies are contained in the crash cart. The audits would take place on alternating shifts. Results would be reviewed through the facility's QAPI process.
• The DON or designee would audit the first-floor staffing, to ensure scheduled staff members are present as scheduled, on random shifts. Results would be reviewed through the facility's QAPI process.
• RDCS #601 provided additional one-on-one education to LPN #521 regarding what the Code Blue form is and when to utilize it. LPN #521 verbalized understanding.

Penalty

Inspection fine: $200,605

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 accurately assess and provide timely and necessary medical intervention for residents experiencing acute changes in condition. In multiple instances, staff did not notify physicians or provide adequate interventions when residents exhibited significant symptoms such as low oxygen saturation, shortness of breath, hypotension, and altered mental status. For example, one resident with a history of diabetes, COPD, heart disease, and dependence on supplemental oxygen was found with an oxygen saturation as low as 71%, but the nurse on duty did not notify the physician or escalate care. The resident's condition did not improve after initial interventions, and there was no evidence of further medical action before the resident was later found unresponsive. The facility also failed to provide basic life support (BLS) and cardiopulmonary resuscitation (CPR) in accordance with standards of practice. In several cases, staff initiated CPR without first checking for a pulse, did not use a backboard to ensure effective compressions, and delayed calling emergency medical services (EMS). In one incident, a nurse took over 30 minutes to call 911 after a resident was found unresponsive, and in another, a nurse left an unresponsive resident alone to seek help from another floor, further delaying emergency response. Staff interviews revealed a lack of knowledge regarding code team assignments, CPR protocols, and the use of emergency equipment such as crash carts and AEDs. Additionally, the facility did not maintain adequate staffing or effective systems for emergency response. There was no staffing plan for a newly opened unit, and staff had to physically leave the unit to obtain assistance during emergencies due to the absence of a communication system. Observations confirmed that at times, no staff were present on certain units, and some staff were not CPR certified. These failures resulted in actual harm and subsequent deaths for multiple residents who experienced acute changes in condition.

Removal Plan

• Educated the Administrator, DON, RDCS, and RDO on the facility CPR policy, emergency response processes, and code blue flow sheets related to how to respond to emergency situations and to notify others for help by use of walkie-talkie or overhead paging system.
• Provided education to department heads (Activities Director, Housekeeping Services Director, Assistant Director of Nursing, Medical Records Director, Maintenance Director, Director of Social Services, Minimum Data Set Director, Dietary Manager, Human Resources Director, Wound Care Nurse) on the CPR policy, emergency response processes, and code blue flow sheets.
• Educated all staff (CNAs, LPNs, RNs, housekeeping, receptionists, therapists, activities staff) on the facility CPR policy, emergency response processes, and code blue flow sheets.
• Assessed all residents for any acute changes in condition.
• Provided CPR recertification to nurses; removed nurses from the schedule until they received updated CPR recertification.
• Audited crash carts to ensure they were stocked and readily available for an emergency situation.
• Educated all clinical staff and validated that code statuses were updated; updated code status orders for three residents.
• Met to discuss future staffing for when closed units opened.
• Initiated education to all clinical staff, scheduler/HR, DON, and Administrator to ensure there was always a minimum of one staff member on the first floor.
• Implemented mock code blues on alternating shifts; audits to be documented on the code blue flow sheet and reviewed during QAPI.
• Added CPR policy training to new hire orientation and with staff; DON responsible for ensuring all new hires received the information and monitoring education.
• Added education topics to all new hire orientation training; ensured employees oriented at sister facilities completed all education topics prior to starting on the floor.
• Reviewed all resident care plans for accuracy.
• Ran audit report on all residents to assess for change of condition that was not addressed; DON/designee to audit reports.
• Completed a mock code blue drill to identify areas of struggle.
• Administered a hands-on and written post-test for all nurses working; demonstrated use of overhead page, locating code status in the electronic medical record, and use of walkie talkies; staff performed return demonstration.
• Initiated audit of the bed board code status to be reviewed and updated by the DON; results reviewed through QAPI.
• DON or designee to audit reports from the electronic medical record system to audit for any resident changes in condition; results reviewed through QAPI.
• Conducted interview questionnaires with first floor staff on how to obtain help during emergency situations; results reviewed through QAPI.
• Audited crash cart by the DON or designee to ensure all needed supplies are contained; results reviewed through QAPI.
• Audited first-floor staffing to ensure scheduled staff members are present as scheduled; results reviewed through QAPI.
• Provided additional one-on-one education to LPN #521 regarding what the Code Blue form was and when to utilize it.

Penalty

Inspection fine: $200,605

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 operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable well-being of each resident. There was significant turnover in key administrative positions, with seven administrators, four Directors of Nursing (DON), and three Maintenance Directors within a year. This instability contributed to a lack of consistent oversight and failure to establish and maintain effective systems for compliance with federal, state, and local requirements. The facility did not provide evidence that administrative staff, including the Administrator and DON, had effective systems in place to timely identify and correct quality, care, and environmental concerns. Survey findings included multiple deficiencies across various domains of care and facility operations. These included failures in care planning for oxygen use, maintaining a clean and sanitary environment, proper garbage disposal, timely initiation of CPR or calling EMS, completion and documentation of showers and bathing, timely completion of physician-ordered labs, and accurate medical record documentation. There were also failures in ensuring an updated facility assessment for sufficient staffing, provision of corrective lens and vision care, complete orientation for new staff, sufficient competent staffing, and proper functioning of the quality assurance committee. Additional deficiencies were noted in monitoring resident food storage, supervision during smoking times, dating of oxygen tubing, completion of pharmacy reviews, physician notification of changes in condition, covering catheter drainage bags, and securing medications. Several of these deficiencies directly affected residents, including failure to initiate CPR or call EMS resulting in immediate jeopardy and death, lack of weekly skin assessments and documentation of change of condition and death, and failure to provide appropriate quality of care resulting in immediate jeopardy and death. The report documents that these failures had the potential to affect all residents in the facility, with specific residents identified as being directly impacted by the deficiencies.

Penalty

Inspection fine: $200,605

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 that the facility failed to provide a clean, sanitary, and homelike environment for its residents, as evidenced by multiple observations of unaddressed maintenance and housekeeping issues throughout the building. During several tours, surveyors noted peeling wallpaper, missing or damaged baseboards, exposed and damaged walls, stained and wet ceiling tiles, chipped and peeling paint, rust around sinks, and heating units with built-up dirt or missing covers. Bathrooms were found with dirty toilets, built-up dirt rings, and peeling wallpaper, while several rooms had visible dirt and debris behind doors, soiled privacy curtains, and improperly hung window or privacy curtains. Gnats were observed in one room, and there were reports of full urinals left hanging off garbage cans. These findings were verified by facility staff, including the Housekeeping and Laundry Supervisor, President of Plant Operations, and Maintenance Director. Interviews with facility staff revealed gaps in routine maintenance and cleaning practices. The President of Plant Operations admitted to not conducting regular site visits for general upkeep and cleanliness, and the Maintenance Director was new to the role. Housekeeping staff reported being short-staffed, which resulted in deep cleaning of resident rooms not being performed as scheduled. Documentation review showed that room rounds and inspections were inconsistently conducted, with no room checks recorded after mid-July, and the Regional Director of Operations was unable to confirm the frequency of these rounds due to being new in the position. Additionally, the deep cleaning schedule did not include the first-floor units, and daily cleaning checklists, while present, were undated and not consistently followed. Further review of facility records and communications indicated ongoing issues with the building's overall appearance and maintenance, including unaddressed cosmetic repairs, poor landscaping, and exterior disrepair. An email to facility leadership highlighted a backlog of cosmetic repairs that could be addressed with basic maintenance, and the TELS system for logging building repairs was not being addressed daily. The facility's policy on providing a homelike environment emphasized the importance of cleanliness and order, but the observed conditions and lack of consistent oversight and staffing led to non-compliance with this standard, potentially affecting all residents in the facility.

Penalty

Inspection fine: $200,605

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 dispose of garbage in a clean and sanitary manner. During observation with the Regional Dietary Manager, the outside dumpster area had three dumpsters with lids closed, but the surrounding ground contained loose debris including incontinence care items, used gloves, and various loose trash scattered around the dumpsters. The Regional Dietary Manager confirmed the trash observed on the ground. Review of pest control invoices dated 07/10/25 and 08/04/25 documented sanitation issues in the exterior garbage area, including loose food debris and spilled food materials on the ground that could cause pest problems. The facility policy, Sanitization, revised October 2008, stated that kitchen and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects, and that kitchen waste not disposed of mechanically shall be kept in clean, leakproof, nonabsorbent tightly closed containers and disposed of daily.

Penalty

Inspection fine: $200,605

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 its Quality Assurance and Performance Improvement (QAPI) committee consisted of the required members. A review of the undated document titled "Euclid Beach QAPI Members" showed the committee was intended to include the Committee Chairperson, Administrator, DON, Medical Director, Dietary Representative, Pharmacy Representative, Social Service Representative, Activities Representative, Environmental Service Representative, Infection Control Representative, Rehabilitative/Restorative Services Representative, Staff Development Representative, Safety Representative, and Medical Records Representative. Review of the QAPI meeting records showed the required members were not consistently present. The QAPI Plan dated 01/30/25 showed the meeting was attended by LNHA #629 and DON #623, with no indication or sign-in sheet verifying attendance by the Medical Director or Infection Control Representative. The Quality Assurance and Performance Improvement Meeting dated 03/25/25 had no representative for infection control, the sign-in sheet was void of an infection control signature, and the infection control portion of the document was blank. The Ad-Hoc QAPI Committee Meeting dated 05/29/25 had no signature for the Medical Director and no representative for infection control noted on the sign-in sheet. On 09/02/25 at 12:29 P.M., the RDO #599 verified the lack of an Infection Control Preventionist at the QAPI meetings dated 01/30/25, 03/25/25, and 05/29/25, and verified the absence of the Medical Director at the QAPI meetings dated 01/30/25 and 05/29/25.

Penalty

Inspection fine: $200,605

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 complete orientation, including applicable training and facility-specific policies, was provided to newly hired CNAs and licensed nurses. During personnel file review with the HRD, CNA files for three employees showed dates of hire of 07/01/24 and 05/24/25, but there were no completed clinical nursing assistant orientation forms in the files. The HRD verified the missing orientation forms and stated the forms do not get turned in. Further personnel file review showed that five nurses, including LPNs and one RN, had dates of hire between 12/06/24 and 04/22/25, but none of their files contained completed charge nurse orientation documentation. The HRD verified the missing charge nurse orientation forms and stated the charge nurse job description was used for RNs, and that the charge nurse orientation form was used as guidance for all nurses in the facility. Facility documents reviewed included job descriptions for LPNs, charge nurses, and CNAs, as well as undated orientation forms for clinical nursing assistants and charge nurses that included signature lines for DON completion.

Penalty

Inspection fine: $200,605

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 assistance with activities of daily living (ADLs), specifically showering and bathing, to multiple residents who were dependent on staff for these tasks. Record reviews, staff and resident interviews, and direct observations revealed that 12 residents did not consistently receive scheduled showers or appropriate documentation of bathing over a period of several months. In many cases, residents were scheduled for showers two times per week, but records showed only sporadic or single instances of showers or bed baths, with some residents going weeks without documented bathing. For example, one resident was scheduled for showers on specific days but only received one shower in a 30-day period, while another resident had no showers documented for two consecutive months. The affected residents had significant medical conditions and functional limitations, including end stage renal disease, hemiplegia, morbid obesity, chronic obstructive pulmonary disease (COPD), dementia, and quadriplegia, which made them dependent on staff for personal hygiene. Several residents were cognitively intact and able to report that they were not receiving showers as scheduled, while others were severely cognitively impaired and unable to advocate for themselves. Observations included residents appearing unkempt, with oily hair and signs of not having been bathed for an extended period. Documentation in both the facility's shower book and electronic medical record (EMR) was incomplete or missing for many scheduled showers, and staff interviews confirmed that showers were not always provided as required. Staff interviews revealed systemic issues contributing to the deficiency, such as inadequate staffing, lack of a dedicated shower aide on certain days, and unclear delegation of shower responsibilities when the assigned aide was unavailable. Staff reported being pulled to cover other duties, resulting in missed showers for residents. The facility's own policy required documentation of all showers, refusals, and interventions, but this was not consistently followed. The Director of Nursing confirmed that the available documentation accurately reflected the showers that were actually provided, indicating that the lack of care was not simply a documentation error but a failure to deliver the required assistance with ADLs.

Penalty

Inspection fine: $200,605

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 sufficient levels of competent staff to ensure residents received the care needed to maintain the highest quality of life. Two residents were directly affected, with six others at risk, due to inadequate staffing and lack of proper emergency response procedures. In one case, a resident with multiple complex medical conditions, including diabetes, COPD, schizophrenia, and dependence on supplemental oxygen, experienced a significant drop in oxygen saturation. The nurse on duty administered inhalers and BiPAP, but the resident's oxygen levels remained below normal. There was no evidence that the physician was notified or that adequate interventions were taken. When the resident was later found unresponsive, CPR was initiated, but there was a delay in calling 911 due to staff confusion and lack of familiarity with the facility's emergency procedures and equipment. The resident was ultimately pronounced dead at the hospital. In another incident, a resident with a history of pneumonia, COPD, diabetes, CHF, and severe cognitive impairment became short of breath and requested assistance. The nurse provided inhalers and attempted to obtain oxygen equipment from another floor, leaving the resident unattended. Upon return, the resident was found unresponsive. The nurse had to leave the floor again to seek help, as there was no immediate way to call for assistance. CPR was started without checking for a pulse, and the facility lacked an AED. The resident was transported to the hospital and later pronounced deceased. Staff interviews revealed that nurses and aides were often responsible for residents on multiple floors, and there was confusion about emergency protocols, including the existence of a code team and the use of code blue documentation. Observations and interviews further indicated that staff were not consistently present on the first-floor unit, and some staff were not CPR certified or aware of emergency response roles. The facility's assessment stated that staff training and competencies were to be maintained, but interviews with staff and review of records showed gaps in training, orientation, and emergency preparedness. The lack of clear procedures, insufficient staffing, and inadequate training contributed to delays and errors in emergency response, directly impacting resident care and outcomes.

Penalty

Inspection fine: $200,605

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

Summary

Surveyors observed that multiple medication carts contained loose, unlabeled pills of various shapes and colors in their bottoms. Specifically, 15 loose pills were found in the Sycamore Hall cart, 20 in the Crystal Hall cart, and 5 in the Carousel Hall cart. Nursing staff, including RNs and LPNs, confirmed the presence of these loose pills and stated they were unable to identify the medications or determine to whom they were prescribed. These findings were corroborated through direct observation and staff interviews. A review of the facility's policy on medication storage indicated that drugs and biologicals should be kept in their original packaging, and nursing staff are responsible for maintaining proper storage. The failure to store medications in their original containers and the inability to identify the loose pills had the potential to affect 30 residents who received medications from the reviewed carts. The facility census at the time was 53.

Penalty

Inspection fine: $200,605

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 and enforce its policy regarding the use and storage of food in resident room refrigerators, specifically in relation to temperature monitoring for food safety. Observations and interviews revealed that several residents had personal refrigerators in their rooms, but there was inconsistency and confusion among staff regarding who was responsible for monitoring refrigerator temperatures. Some staff believed it was the responsibility of maintenance, others thought it was the CNAs, and some stated it was the nurses' responsibility. Multiple residents reported that their refrigerators were either not checked regularly or they were unaware of any monitoring taking place. Direct observations of the refrigerators in the rooms of four residents found that temperature monitoring logs were either missing, incomplete, or outdated. In one instance, a refrigerator contained expired food items, including a container of beef stew past its expiration date and a container of parmesan cheese that had expired over a year prior. The facility's policy required that food items be labeled, dated, and discarded after three days, and that unsafe or expired foods be removed by staff, but did not specify procedures for maintaining or monitoring refrigerator temperatures. The lack of clear procedures and consistent monitoring led to a situation where food safety could not be assured for residents storing personal food in their room refrigerators. The facility identified seven residents with personal refrigerators, but there was no systematic approach to ensure compliance with the policy or to safeguard against the storage of expired or unsafe food items.

Penalty

Inspection fine: $200,605

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 have an updated and accurate facility assessment that addressed staffing needs by resident unit, including the first floor. The assessment dated 02/24/25 stated that the facility would consider specific staffing needs for each resident unit, but the subsection titled "Staffing Needs as per Resident Unit" on page 19 was blank and did not identify staffing needs for any unit. The assessment was reviewed by the LNHA and later by the Quality Assurance Committee, and it stated its purpose was to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies. An undated facility floor plan showed the first floor had a capacity of 15 resident beds, and the facility census dated 08/18/25 showed six residents (#22, #26, #31, #35, #46, and #61) living on the first floor. During an interview on 08/26/25, the Regional Director of Operations confirmed the facility assessment did not address staffing by unit. On 08/27/25, the LNHA stated he was not aware the facility assessment did not address staffing by unit.

Penalty

Inspection fine: $200,605

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 weekly skin assessments were documented as ordered and care planned for multiple residents, including residents with diagnoses such as diabetes, hemiplegia, dementia, chronic kidney disease, COPD, malnutrition, and impaired mobility. Physician orders for weekly skin assessments were identified for residents #1, #3, #7, #9, #29, #44, #45, #49, #53, #63, and #69, and care plans for these residents also identified skin breakdown risk with weekly skin assessments as an intervention. Review of the medical records showed repeated gaps in the required weekly documentation, including missing assessments over multiple weeks or months for several residents, and in some cases only one assessment or no assessments were found during the reviewed periods. Specific record review showed that resident #3 had weekly skin assessments completed on some dates, but several weekly assessments were missing. Resident #29 had only one completed skin assessment during the reviewed period. Resident #45 had missing weekly skin assessments on multiple weeks despite an order for body audits and weekly skin assessment. Resident #49 had no weekly skin assessments documented since the referenced date. Resident #53 had only one weekly skin assessment documented during the reviewed period, and resident #63 had assessments completed on only two dates with no additional assessments recorded. Resident #7, resident #44, resident #1, resident #9, and resident #69 also had missing weekly skin assessments during the periods reviewed, despite orders and care plan interventions requiring them. The DON confirmed that weekly skin assessments were supposed to be completed in the EMR under the assessment tab and verified that the weekly skin assessments had not been completed as ordered for the identified residents. The facility policy on prevention of pressure ulcers/injuries required a comprehensive skin assessment upon admission and weekly skin assessments by a licensed nurse, and the charting policy required documentation of services provided and changes in condition in the medical record. In addition, the facility failed to document the change in condition and subsequent death of resident #76. The record showed a change of condition assessment, hospice referral, hospice admission, and a death date, but nursing progress notes did not include documentation of changes in condition, physician or family notification, hospice notification, death in the facility, or release of the body to the funeral home. DON interviews confirmed that these events should have been documented in the EMR.

Penalty

Inspection fine: $200,605

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 physician notification of significant changes in condition for two residents. For one resident with multiple complex diagnoses, including COPD, diabetes, heart failure, and cancer, there was an order for full code status and hospice admission. The resident experienced coffee ground emesis, hypotension, and tachycardia, and while hospice was notified, there was no documentation that the physician was informed of these acute changes. The medical director later confirmed he was not made aware of the resident's deteriorating condition and stated that, had he been notified, he would have recommended transfer to the emergency room for evaluation. In a separate incident, another resident with a history of diabetes, COPD, heart disease, and stroke reported chest pain and constipation to an LPN during morning medication administration. The LPN checked vital signs and advised the resident to go to the ER, but the resident refused. Later, the resident was found unresponsive on the bathroom floor, and CPR was initiated before EMS arrived. There was no documentation that the physician was notified of the resident's chest pain prior to the unresponsive event. The medical director confirmed he was not informed of the chest pain, despite the resident's history of noncompliance with care. Facility policy required nursing staff to notify the physician of significant changes in a resident's condition, including accidents, injuries, adverse reactions, and major declines in health status. In both cases, the required physician notification did not occur as outlined in policy, resulting in a deficiency related to communication of changes in resident condition.

Penalty

Inspection fine: $200,605

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

Resident #29, who has a history of diabetes mellitus with proliferative diabetic retinopathy and severe cognitive impairment, was not provided with corrective lenses or vision care appointments as ordered by physicians. The resident's care plan included interventions to arrange consultations with an eye care practitioner as required, and there were physician orders for both glasses and scheduled eye appointments. However, medical record review showed no documentation that the resident attended the scheduled optometrist or ophthalmologist appointments, nor was there evidence that these appointments were rescheduled or reasons documented for the missed visits. Additionally, the resident's prescription for glasses had expired, and there was no follow-up to obtain a new prescription or replacement glasses after the resident's glasses were reported missing. Interviews with facility staff, including the DON and regional directors, confirmed a lack of documentation regarding the missed appointments and the absence of a facility policy related to vision appointments or following physician orders for ancillary services. The resident's POA reported the missing glasses and noted that the resident did not have them during a leave of absence or recent visits. Observations confirmed the resident was not wearing glasses, and staff were unaware of their absence. The facility was unable to provide evidence of compliance with physician orders for vision care or corrective lenses for this resident.

Penalty

Inspection fine: $200,605

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 supervision for residents who required monitoring while smoking and did not ensure that residents did not possess smoking items in their personal belongings. Observations revealed that three residents were smoking outside without staff supervision during designated smoking times, despite facility policy requiring direct supervision for residents with restricted smoking privileges. The Administrator confirmed that staff supervision was absent and was unsure if the residents required supervision, but acknowledged that staff should have been present if supervision was needed. Medical record reviews for two residents showed that both had been assessed as requiring supervision for safe smoking and had signed contracts indicating that they were not permitted to keep cigarettes or smoking articles in their possession. Despite these requirements, one resident was found with an empty cigarette pack and a lighter in his room, and another resident was found with a pack of cigarettes hidden in his wheelchair cushion. Both instances were confirmed by the Director of Nursing, who acknowledged that these residents were not supposed to have smoking items in their possession. The facility's policy and staff orientation materials clearly outlined the need for supervision and restrictions on possession of smoking materials for certain residents. However, the facility did not enforce these policies, as evidenced by unsupervised smoking and residents retaining smoking items. The deficiency was identified during a complaint investigation and affected multiple residents who had been assessed as requiring supervision while smoking.

Penalty

Inspection fine: $200,605

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 physician order was placed for a resident to receive a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) every three months. Review of the resident's medical record showed that these laboratory tests were not completed as ordered on the specified date, with the last documented completion occurring several months prior. The care plan for the resident, who had multiple diagnoses including hemiplegia, type II diabetes, depression, and a history of substance abuse, included interventions to obtain lab results as ordered and notify the physician of abnormal values. However, there was no evidence that the required labs were performed as scheduled. Further review revealed that the resident had moderate cognitive impairment and was receiving several medications, including antidepressants, antiplatelets, and anticonvulsants. During interviews, facility leadership confirmed the lapse in completing the ordered labs and were unable to provide a facility policy regarding adherence to physician orders. This deficiency was identified during a complaint investigation and affected one resident among those reviewed for physician orders.

Penalty

Inspection fine: $200,605

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 catheter drainage bag was placed in a privacy bag to maintain dignity for Resident #27, who was cognitively intact and had an indwelling Foley catheter. Resident #27 was admitted with diagnoses including other mechanical complication of other urinary catheter, obstructive and reflux uropathy, and neuromuscular dysfunction of the bladder. His orders included an indwelling Foley catheter, catheter changes every 28 days and as needed, emptying every shift, monitoring urine for color, clarity, and odor, and urology consultation for catheter change every 28 days. During observation on 08/18/25 at 1:21 P.M., Resident #27 was seen sitting in a wheelchair with the urinary catheter drainage bag hanging below the level of the bladder and not placed in a privacy bag. The observation was verified by an LPN, who stated the drainage bag should have been placed in a privacy bag. The facility policy on dignity stated that residents shall be cared for in a manner that promotes dignity, respect, and individuality, and that staff shall help residents keep urinary catheter bags covered.

Penalty

Inspection fine: $200,605

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

Summary

The facility did not ensure Resident #55’s care plan was revised to include physician-ordered oxygen therapy. Resident #55 was admitted on 04/25/25 with diagnoses including emphysema and asthma. The physician ordered oxygen at 2 liters per minute via nasal cannula on 05/23/25, and the quarterly MDS assessment indicated the resident was cognitively intact and had oxygen therapy in use. The care plan, initiated on 04/29/25, addressed emphysema and COPD with interventions for shortness of breath, exertional difficulty breathing, and signs and symptoms of acute respiratory insufficiency, but it did not include any interventions for the ordered oxygen therapy. On 08/21/25, RN #604 confirmed that Resident #55 did not have a care plan in place for oxygen therapy. The facility policy stated that the comprehensive, person-centered care plan should include measurable objectives and timetables and be based on the comprehensive assessment.

Penalty

Inspection fine: $200,605

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 oxygen tubing was dated as changed weekly for equipment management and infection control for two residents who were receiving oxygen therapy. Resident #39 had diagnoses including acute respiratory failure with hypercapnia and had an order for oxygen at four liters per minute at bedtime and as needed to keep oxygen saturation above 92 percent, with tubing to be changed every Tuesday. On observation, Resident #39 was lying in bed with oxygen via nasal cannula, and the oxygen tubing was undated on two separate observations. LPN #506 verified the tubing was undated at the time of observation. Resident #55 had diagnoses including emphysema and asthma and an order for oxygen at two liters per minute via nasal cannula, but there was no order to change oxygen tubing weekly. The care plan addressed breathing-related interventions but did not include oxygen use interventions. On observation, Resident #55 was sitting in a wheelchair with oxygen applied, and the tubing from the oxygen concentrator was undated on multiple observations. A plastic bag hanging on the concentrator was dated 08/08/25, and LPN #559 verified the tubing lacked a date and stated that the date on the bag was the date the oxygen tubing was changed. The facility policy stated oxygen tubing would be changed every seven days and dated and initialed with changing.

Penalty

Inspection fine: $200,605

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 licensed pharmacist completed monthly drug regimen reviews for two residents, Resident #4 and Resident #53, as required by facility policy. The policy titled Medication Regimen Review, dated 04/2007, stated that the consultant pharmacist shall review each resident’s medication regimen at least monthly, document findings and recommendations on the monthly review report, and provide written reports for identified irregularities. The policy also required copies of the reports, including physician responses, to be maintained in the permanent medical record. Resident #53 was admitted on 09/08/23 and had diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side, type II diabetes mellitus, history of suicidal behavior, alcohol abuse, and cocaine abuse. Physician orders included sertraline 75 mg daily for depression, Depakote sprinkles 125 mg twice daily for mood stabilization, and aspirin 81 mg daily. The care plan identified risk for adverse effects related to psychoactive medications, and the annual MDS showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Review of the medical record from 08/2024 to 08/2025 showed only two monthly pharmacist medication reviews, dated 07/24/25 and 08/24/25, with no additional monthly pharmacy reviews found. Resident #4 was admitted on 11/23/21 and had diagnoses including multiple sclerosis, type II diabetes mellitus, unspecified vascular dementia, unspecified depression, cognitive communication deficit, neuromuscular dysfunction of the bladder, and long-term insulin use. Orders included glargine insulin 10 units at bedtime, lispro insulin per sliding scale with meals, and Zoloft 125 mg daily for depression. The care plan identified risk for adverse effects related to psychoactive medications and complications related to diabetes and insulin use. The quarterly MDS showed a BIMS score of 15 out of 15, and the progress notes showed pharmacy reviews on 07/24/25 and 08/24/25, but there was no documentation of recommendations for those dates and no earlier pharmacy reviews in the record; the last one documented was 12/17/21. The Director of Clinical Services stated that the only pharmacy reviews he could locate for the facility were from April 2025 through July 2025 and that he could not locate medication regimen reviews prior to April 2025.