Greenbrier Health Center

Penalty

Inspection fine: $26,685

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 cognitively impaired resident with a history of elopement exited the facility without staff knowledge and was found by local police in the middle of a residential street approximately 1.7 miles from the facility. The resident was confused, speaking in his native language, and seeking a local ethnic meat market. The resident was subsequently transported to a local hospital for evaluation. Prior to this incident, the resident had previously eloped from the facility's smoking area by kicking open a gate and was returned by emergency services. Despite being identified as an elopement risk with documented wandering and exit-seeking behaviors, the resident's care plan and interventions were not consistently updated to reflect the need for increased supervision, such as 1:1 monitoring, and behavior monitoring was not completed on the shift when the elopement occurred. Staff interviews revealed that the resident was known to be restless, had poor safety awareness, and required significant redirection. On the evening of the incident, the staff member assigned to provide 1:1 supervision for the resident called off, and administration was not notified, resulting in the resident not receiving the required supervision. The facility was unable to determine exactly how the resident exited the building, but it was believed the resident left through the front door, which was keypad-secured. The facility's elopement prevention policy included regular rounds, environmental modifications, and protected lists of at-risk residents, but these measures were not sufficient to prevent the incident. Additionally, the facility failed to maintain a safe environment related to resident smoking. Observations showed that smoking materials, including cigarettes and lighters, were not kept in locked areas as required by facility policy. Multiple residents were found with smoking paraphernalia unsecured in their rooms, and some did not have required smoking contracts or access to secure storage. The outdoor smoking area was observed to have cigarette butts and combustible items mixed in ash trays, further contributing to accident hazards.

Removal Plan

• Local police notified facility that Resident #117 was found outside and transported to the hospital.
• A headcount was completed by facility staff to ensure each resident was accounted for.
• Resident #117 returned to the facility and was immediately assessed by the nurse.
• Resident #117 was placed on one on one (1:1) supervision with a plan for 1:1 supervision to remain in place until the resident was no longer identified as high risk for elopement which would be assessed quarterly using the wandering observation tool.
• Maintenance Director completed an audit to validate all windows and doors were secure and functioning properly.
• The DON/designee reported to the facility Quality Assessment and Performance Improvement (QAPI) committee the concerns related to Resident #117's elopement.
• The QAPI committee met to complete a root cause analysis.
• Maintenance Director changed all secure door codes.
• LPN completed a wandering assessment, pain assessment and head to toe assessment on Resident #117.
• The Administrator conducted staff education for all facility staff in person, via Onshift software (e-learning platform) and via phone calls related to Elopement prevention and management overview and Unit Supervision with emphasis on safety and supervision.
• Resident #117's physician and emergency contact was notified.
• The clinical interdisciplinary team which consists of the Director of Nursing, assistant Director of Nursing and Unit Managers completed wandering/elopement assessments on all residents.
• Elopement/wandering care plans were reviewed for all residents at risk by the DON/designee.
• The facility elopement binder was reviewed by the DON/designee.
• Resident #117's care plan was updated by Minimum Data Set Nurse to include 1:1 supervision for an elopement intervention.
• Two residents (Resident #37 and Resident #100) care plans were updated with elopement interventions by Minimum Data Set Nurse.
• The facility implemented a plan to monitor for ongoing compliance, elopement drills would be completed twice weekly for two weeks, then weekly for two weeks. The drills would be conducted by the DON/designee on night shift, day shift, evening shift and day shift.
• The Administrator/DON/Designee began calling the facility at the start of each shift to ensure coverage of one-on-one (1:1) care providers for Resident #117 and others as needed. This would continue every shift indefinitely until the facility Quality Assessment and Performance Improvement (QAPI) committee deemed appropriate changes.
• The facility implemented a plan for the DON/designee to complete observation audits to ensure resident(s) who had one on one supervision were provided five days a week every three months.
• The DON/designee would complete observation audits to ensure interventions were in place for elopement risk residents, five days a week for three months.

Penalty

Inspection fine: $26,685

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 multiple deficiencies related to medication management within the facility. During an observation of the medication storage room, expired stock medications intended for resident use were found, including Tylenol, enteric coated Aspirin, Geri Max antacid, and Docusate Sodium. The Unit Manager and Supply Coordinator confirmed the presence of these expired medications and acknowledged that expired drugs should have been removed and disposed of according to facility policy. Additionally, the medication storage refrigerator was found to be operating at 50°F, above the recommended range for medication storage, with water pooling inside. Several temperature-sensitive medications, such as insulin and Micafungin injection, were stored in this refrigerator, contrary to manufacturer recommendations. Further investigation revealed that a resident with a history of hemiplegia, epilepsy, insomnia, anxiety, and diabetes had medications left unsecured at the bedside by an LPN, without confirmation of administration. The resident reported that this was a recurring practice by the nurse, and interviews with staff and the resident's responsible party corroborated that medications were left at the bedside overnight and not administered as intended. The Medication Administration Record indicated the medications were signed as given, but there was no documentation of the missed doses or notification to the physician or family regarding the incident. The facility's failure to ensure medications were not expired, were stored at appropriate temperatures, and were not left unsecured at the bedside without proper administration or documentation affected at least one resident and had the potential to impact all residents. These findings were confirmed through observation, interviews with staff and residents, and review of facility policies and records.

Penalty

Inspection fine: $26,685

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 clean and sanitary environment, as observed during an environmental tour and confirmed by the Housekeeping Director. Hallway handrails were chipped, scuffed, and rough, while light fixtures throughout the hallways contained dust, dirt, and dead insects. In several resident rooms, issues included missing light bulbs, water-stained ceiling tiles, stained privacy curtains, severely scuffed walls, and damaged or scraped bathroom doors. Wall-unit air conditioners in some rooms displayed a clean filter indicator light, with filters coated in dust. Additional deficiencies included detached protective covers on heat pipes, holes or gouges in wood wall coverings, extremely dirty wheelchairs with accumulations of food and debris, a visible wall crack, and a missing cover on a wall telephone line exposing live wires. These conditions were observed in multiple resident rooms and common areas, affecting the overall cleanliness and safety of the environment for all residents, staff, and the public.

Penalty

Inspection fine: $26,685

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 hire staff free of disqualifying offenses. Review of 3 of 12 personnel files showed that CNA #660 had a hire date of 01/25/22 and a background check dated 12/27/22 that revealed a theft conviction under 2913.02 from March 2004. SC/CNA #604 had a hire date of 06/08/22 and a background check dated 01/08/25 that revealed a conviction for unauthorized use of property under 2913.04 from April 2022. LPN #639 had a hire date of 04/27/21 and a background check dated 05/17/21 that revealed an assault conviction from May 2016. No personal character standards were located in the personnel files or background check envelopes for CNA #660, SC/CNA #604, or LPN #639. During interview, the Human Resource Manager confirmed the facility did not have any personal character standards available for these employees, which should have been included in their personnel files if used in the hiring process. The facility policy stated that it intended to employ only properly screened persons and that pre-hire criminal background checks and licensure/registry checks would be completed after the interview. The cited Ohio rule listed assault, theft, and unauthorized use of property as disqualifying offenses for direct care providers.

Penalty

Inspection fine: $26,685

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

Food and drink were not consistently served palatable, attractive, or at a safe and appetizing temperature. Multiple residents reported receiving cold, overcooked, hard, or otherwise unappetizing meals. Resident #3, who had diagnoses including acute embolism and thrombosis of the right femoral vein, type II diabetes mellitus with neuropathy, and mild protein-calorie malnutrition, was cognitively intact, received a therapeutic diet, and required meal setup; the resident stated they got the same cold and overcooked foods. Resident #27, with diagnoses including orthopedic aftercare for surgical amputation, vascular dementia, type II diabetes mellitus with neuropathy, and stage III kidney disease, was cognitively intact, received a regular diet, and required meal setup; the resident stated lunch was late and frequently cold. Resident #52 reported food was frequently cold, and Resident #54 reported chicken parmesan was grey inside, hard, and cold, and the next day country fried steak was hard, overcooked, tasted awful, and cold. Additional residents described similar concerns. Resident #69, who had diagnoses including spondylosis without myelopathy, hypertensive heart disease, dysphagia oral phase, and peripheral vascular disease, stated food was usually cold and processed and that the alternate option was a peanut butter and jelly sandwich. Resident #99, who had diagnoses including hemiparesis and hemiplegia, type II diabetes mellitus with neuropathy, mild non-proliferative retinopathy with bilateral macular edema, and morbid obesity, stated they had requested no pork but had previously received bacon at breakfast and a bacon, lettuce and tomato sandwich for lunch; the resident also reported an English muffin was rock hard, and the muffin appeared and sounded hard on observation. Resident #128, with diagnoses including malignant neoplasm of the bladder, malignant neoplasm of the liver and intrahepatic bile duct, mild protein-calorie malnutrition, and anxiety disorder, stated meals were frequently cold. Survey observations showed meal service was delayed and food temperatures dropped during tray line and delivery. The facility’s meal cart schedule showed staggered cart arrival times extending from noon to 1:00 P.M. for the floors. On observation, the last resident room tray was being passed at 1:32 P.M. Staff stated dining room trays were usually served around noon to 12:45 P.M. and room trays for the 200 hall were passed after 1:00 P.M. and took about fifteen minutes to pass. During lunch tray line observation, five carts left the kitchen between 12:03 P.M. and 1:03 P.M., the tray line later resumed after asparagus ran out, and the final cart left at 1:22 P.M.; the last tray reached the second-floor nursing station at 1:25 P.M. and the last tray was passed at 1:32 P.M. Test tray temperatures at 1:35 P.M. showed chicken piccata at 137.2 F, asparagus at 126.6 F, and rice pilaf at 114.4 F. The Foodservice Director confirmed the facility had been short staffed due to illness and turnover, which had caused meals to be late at times, and resident council and food committee minutes documented repeated complaints about late meals, cold food, food running out before the end of tray line, and meals not always being served on time.

Penalty

Inspection fine: $26,685

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 appropriate monitoring and safe storage of outside food in unit and resident room refrigerators. During observation with the Registered Dietitian, the unit refrigerator for Unit AR U1 contained an undated dietary plate with a resident’s name on a loose paper towel, three undated Styrofoam containers of restaurant food labeled with another resident’s name, and a tray of six undated kitchen-provided sandwiches on an undated tray. The ARU2 unit refrigerator contained an undated disposable container of what appeared to be spaghetti labeled with a resident’s name, four unlabeled and undated one-half cup containers from the kitchen that appeared to be dessert from a previous meal, and four undated kitchen-provided sandwiches. The unit freezer also contained two undated partially eaten pints of chocolate ice cream without resident names. Observation of resident room refrigerators found multiple concerns, including refrigerators with no thermometer or temperature monitoring logs, one with heavy ice buildup, and another with no thermometer or logs. One refrigerator was full of various lunch meats and snacks and had a strong odor of something rotten. A resident stated that food had previously spoiled and liquid had spilled on the bottom of the refrigerator, but no one had come to assist with cleaning it. The Registered Dietitian confirmed the unit and resident room refrigerator findings and stated staff are supposed to monitor temperatures and contents to ensure food is safe for consumption. The facility policy required foods brought in by visitors to be stored separately or be easily distinguishable, sealed, labeled with the resident name and current date, kept in refrigerators with thermometers and daily temperature monitoring, and discarded after more than seven days; it also stated refrigerator units are to be cleaned weekly.

Penalty

Inspection fine: $26,685

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 who were dependent on staff for activities of daily living (ADL), specifically bathing and showering, received showers as required by their care plans and facility policy. Multiple residents with varying degrees of cognitive and physical impairment, including those with diagnoses such as renal dialysis dependence, hemiplegia, dementia, and chronic obstructive pulmonary disease, were scheduled for regular showers but did not consistently receive them. Documentation revealed missed showers, incomplete records, and instances where showers were marked as 'not applicable' without evidence of refusal or alternative care, such as bed baths. Interviews with residents and staff confirmed that showers were not provided as scheduled, with some residents reporting not having been bathed for weeks and staff acknowledging the lack of proper documentation and completion of scheduled showers. In several cases, the Minimum Data Set (MDS) assessments marked bathing as 'not applicable' because the residents had not been bathed during the look-back period, further confirming the lack of care. Observations also noted poor hygiene, such as oily hair and dirty nails, in residents who had missed scheduled showers. The deficiency was widespread, affecting a significant number of residents reviewed for showers, and was corroborated by both record review and staff interviews. Facility policy required at least two showers per week for dependent residents, but this standard was not met for many individuals. The lack of documentation for missed showers, refusals, or alternative bathing methods indicated a systemic failure to provide and record essential ADL care as required.

Penalty

Inspection fine: $26,685

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 comprehensive wound management system was in place for multiple residents, resulting in deficiencies in wound care and treatment according to physician orders. One resident with a recent surgical amputation and moderate cognitive impairment was observed with a dressing on the left lower leg that was not changed as ordered, with documentation indicating the dressing was not current. Another resident with a central venous catheter and intact cognition was discharged with a central line dressing that was not intact and had not been changed as ordered, despite documentation in the facility records indicating otherwise. The home care nurse reported the dressing had not been changed for several weeks, and photographic evidence supported this finding. A third resident with a nephrostomy tube and intact cognition had physician orders for regular dressing changes, but interviews and observations revealed the dressing was not changed as ordered. Staff interviews confirmed that documentation of dressing changes was inaccurate, with nurses signing off on treatments that were not performed. The facility also lacked a policy for nephrostomy tube care, contributing to the inconsistency in treatment. Additionally, a resident with chronic conditions and limited mobility was not provided with timely incontinence care or wound assessments. Observations showed the resident remained in a soiled brief for extended periods, resulting in redness and open areas on the buttocks. Staff interviews confirmed that the resident was not checked or changed as required, and wound care was not performed according to orders. The wound care nurse had not assessed the resident for several weeks, and inappropriate application of wound care products was observed.

Penalty

Inspection fine: $26,685

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 nursing staff each day to meet the needs of all residents, as required by their own facility assessment and federal regulations. Staffing schedules for the second floor consistently fell below the minimum number of Certified Nursing Assistants (CNAs) needed, with multiple days showing only four to seven CNAs present when at least eight were required. The Human Resource Manager confirmed that the facility did not use agency staff and relied on an outsourced scheduling company, resulting in persistent understaffing. The Administrator acknowledged that staffing levels did not meet the facility's own assessment standards for the entire review period. Direct observations and interviews revealed that residents experienced significant delays in receiving care, including long waits for assistance, missed showers, and inadequate incontinence care. Several residents reported not receiving showers for weeks, waiting up to 1.5 to 2 hours for call lights to be answered, and not having their needs addressed in a timely manner. Staff interviews corroborated these concerns, with CNAs and LPNs stating that there were not enough staff to meet resident needs, leading to missed care and incomplete documentation. Specific resident cases highlighted the impact of insufficient staffing. One resident with chronic conditions and limited mobility developed a sacrococcygeal wound, with observations showing prolonged periods without incontinence care or repositioning, resulting in saturated briefs, foul odor, and open wounds. Another resident with a tracheostomy was observed with thick mucus accumulation and a dusty suction machine, with staff unable to confirm when suctioning last occurred. Multiple records confirmed that scheduled showers were not completed for several residents, and staff consistently reported that the number of CNAs on duty was inadequate to provide necessary care.

Penalty

Inspection fine: $26,685

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 routine notice when resident account balances reached and/or exceeded the resource limit, affecting four of five residents reviewed for resident funds. Review of the facility policy, Resident Trust Fund, revised 10/19/17, showed the facility was to issue a notification letter monthly to any Medicaid resident with a trust fund balance within $200.00 of the resource limit. Record review and interview with the Business Office Manager confirmed that the required spend-down letters were not provided as required for the residents identified in the survey. Resident #26, admitted with COPD, asthma, type two diabetes, vitamin D deficiency, and anxiety, had balances of $29,860.02, $31,005.30, and $32,237.87 across three months, but only one spend-down letter was provided. Resident #46, admitted with Alzheimer's disease, dementia with mood disturbance, depression, vitamin D deficiency, anemia, and chronic kidney disease, had balances of $1,919.64, $1,972.43, and $2,025.23, with no spend-down letters available. Resident #52, admitted with restless legs syndrome, transient ischemic attack, insomnia, shortness of breath, anxiety, and chronic kidney disease, had balances of $4,361.64, $8,194.16, and $14,866.50, but only one spend-down letter was provided. Resident #106, admitted with type two diabetes, paranoid schizophrenia, depression, vitamin D deficiency, and difficulty walking, had balances of $14,893.98 and $15,706.21, with no spend-down letters available.

Penalty

Inspection fine: $26,685

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 dental services for four residents reviewed for dental care. Resident #71 had diagnoses including Alzheimer's disease, dementia, and major depressive disorder, and an annual MDS showed severe cognitive impairment. Review of the care plan did not show a dental care plan, and observation found a partially cracked or decayed tooth on the upper right side of the mouth. Social Service Designee #670 stated the resident had not had a dental visit since admission, and LPN MDS #662 and LPN MDS #679 confirmed there was no dental care plan. Resident #119 had diagnoses including hemiplegia, COPD, and bipolar disorder, and a quarterly MDS showed intact cognition. The resident, who was Medicaid-covered, stated she had not had a dental evaluation since admission about two years earlier. SSD #670 confirmed that Resident #119 had not had a dental visit since admission. Resident #69 was admitted with diagnoses including spondylosis, need for assistance with personal care, and muscle weakness, and an annual MDS showed intact cognition and no abnormal mouth tissue. The resident stated she wanted to see the dentist, had asked several times, and reported missing teeth on the left side made chewing difficult and that her teeth had become discolored. Observation showed three missing teeth in a row on the left upper jaw and discolored teeth. LSW #670 and the Administrator confirmed there was no evidence the resident had ever been offered or seen by dental services while at the facility. Resident #8 had diagnoses including type II diabetes mellitus with stage five chronic kidney dialysis, dependence on renal dialysis, moderate protein-calorie malnutrition, and oropharyngeal dysphagia. An outside dental appointment record showed the resident was not seen because the dentist did not accept Medicaid, and the facility ancillary services list did not show a date of last dental visit. The resident stated he had wanted to see the dentist for quite some time, and staff and the ancillary dental office could not confirm when he was last seen or when he would next be seen.

Penalty

Inspection fine: $26,685

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

Infection prevention and control practices were not maintained during blood glucose monitoring for residents with diabetes. Resident #104, who had diabetes mellitus and was moderately cognitively impaired, had a fingerstick blood sugar checked by an LPN using a shared glucometer taken uncovered from the medication cart. The glucometer was not cleaned before use, and after the blood sugar was obtained, the used strip was removed and the glucometer was returned to the cart without hand hygiene or cleaning. The same LPN later used the same glucometer for Resident #138, who was cognitively intact and received daily insulin injections, again removing the glucometer uncovered from the cart, not cleaning it before use, and placing it on the resident’s bedside table during the procedure. Afterward, the LPN removed the used strip and returned the glucometer to the cart without removing gloves, then briefly wiped the device and left it to air dry. The LPN stated she used the same glucometer for multiple residents and then cleaned it afterward, despite the facility policy stating each medication cart should have at least two glucose meters and that one meter may be used while the other is undergoing disinfection for the required wet-contact time. Similar infection control failures were observed with other residents during fingerstick blood sugar checks. Resident #40, who was cognitively intact and received insulin injections daily, had a blood sugar assessed with a glucometer removed uncovered from the medication cart without being cleaned first. After the assessment, the LPN wiped the glucometer for only a few seconds and placed it on top of the cart to air dry. Resident #87, who was cognitively intact and received daily insulin, also had a blood sugar checked with an uncovered glucometer that was not cleaned before use; afterward, the LPN wiped it for only three to four seconds and left it to air dry. The LPN confirmed she did not clean the glucometer before use and acknowledged the wipe contact time should have been longer, while the wipe container instructions indicated a two-minute contact time. Enhanced Barrier Precautions were not followed during catheter care for two residents with urinary catheters. Resident #25 had an indwelling catheter and orders for EBP during catheter care and other high-contact activities, yet a CNA provided catheter care and emptied the drainage bag without wearing an isolation gown. The CNA confirmed she did not wear a gown and did not know she was supposed to. Resident #38, who had a suprapubic catheter and was dependent for activities of daily living, also had orders for EBP during catheter care and other high-contact care, but a CNA provided suprapubic catheter care and emptied the catheter bag without wearing an isolation gown. The resident stated not all staff wore isolation gowns while providing care, and the CNA confirmed she never wore one during the procedure. The facility policy identified gown and glove use as required PPE for EBP during urinary catheter care.

Penalty

Inspection fine: $26,685

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 revise and update care plans to reflect the current needs of two residents. For one resident with diagnoses including Parkinsonism, a rare brain disease, and dementia, the care plan identified the resident as an elopement risk but was not updated after multiple incidents of elopement. The resident was involved in two separate elopement events: in the first, the resident exited through a gate in the smoking area and was found in the parking lot, and in the second, the resident was found by police approximately 1.7 miles away from the facility after being reported missing. Despite these incidents, the only direct intervention implemented was one-on-one supervision, and the care plan was not revised to include new interventions addressing the repeated elopement attempts. For another resident with cognitive intactness and physical impairments, there was no documentation of any care plan meeting being completed from admission through over a year later. Although the social worker reported that care conferences were scheduled and completed on two occasions, there was no documentation available to confirm these meetings. The lack of documented care plan meetings indicates that the resident's care plan was not reviewed or revised as required, failing to ensure that the care plan reflected the resident's current needs.

Penalty

Inspection fine: $26,685

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 quadriplegia, diabetes, and schizophrenia was admitted and later readmitted to the facility. The resident had multiple stage three pressure wounds, including on the mid-spine, right back, sacrum, and left buttock, all of which were documented as improving. Physician orders required daily wound care, including cleansing with wound cleanser, application of a collagen sheet, and securing with a bordered foam dressing to several wound sites. Survey findings revealed that the wound care dressings for the resident were not completed as ordered. Specifically, the dressings were signed off as completed on the medication and treatment administration records by an LPN, but the actual dressing dates did not match the documentation, confirming that the care was not provided as scheduled. The facility's wound care policy required treatment based on wound characteristics, but the records and staff interview confirmed a failure to follow the prescribed wound care regimen and maintain accurate documentation.

Penalty

Inspection fine: $26,685

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 #119, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, and diabetes, was identified as being frequently incontinent of bowel and bladder and requiring substantial to maximal assistance with toileting hygiene. The resident's care plan reflected these needs. On observation, the resident was found with a saturated incontinence brief and deep red discoloration on both buttocks, with a large dried yellow stain on the bedsheets beneath her. The resident reported that she had not been changed since the previous evening and that staff did not respond to her call light requests. Interviews with staff revealed inconsistencies in the timing and frequency of incontinence care provided to the resident. One CNA stated the resident was last changed at 6:00 A.M. on the day of observation, while the resident herself reported the last change occurred the previous evening. The facility's perineal care policy requires regular care to maintain cleanliness, comfort, and skin integrity, but this was not followed, resulting in prolonged exposure to urine and compromised skin condition for the resident.

Penalty

Inspection fine: $26,685

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 medication error rate of 6.7% was identified during observation of medication administration, record review, and staff interviews. Two residents with diabetes, both cognitively intact and receiving daily insulin injections, were affected. For one resident, an LPN prepared and administered insulin using a pen-injector but failed to prime the pen before administration, contrary to manufacturer instructions. The LPN confirmed she did not prime the pen and stated she believed it was unnecessary. For another resident, a different LPN primed the insulin pen-injector before attaching the needle, then administered the insulin without priming after the needle was attached. The LPN confirmed this sequence and acknowledged not priming the pen after the needle was in place. Manufacturer instructions reviewed by surveyors specified that priming should occur after the needle is attached and before each injection to ensure the correct dose is delivered. These failures to follow proper insulin pen priming procedures resulted in medication administration errors.

Penalty

Inspection fine: $26,685

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 two residents were free from significant medication errors, as evidenced by missed and improperly administered medications. One resident with a history of Crohn's disease, chronic pain, and other related conditions was prescribed Gattex for short bowel syndrome. Despite physician orders and care plan interventions to provide medications as ordered, the resident received the medication inconsistently over several months. Documentation on the Medication Administration Record (MAR) indicated that the medication was often marked as unavailable or not given, with progress notes confirming that Gattex was either on order or not accessible to nursing staff. Interviews revealed that the medication was present in the facility but locked in a provider office, leading to miscommunication and failure to administer the drug as prescribed. Another resident, admitted with diagnoses including altered mental status and infection due to a central venous catheter, was prescribed amoxicillin-potassium clavulanate for a bacterial infection. The resident did not receive all ordered doses of the antibiotic, with the MAR and pharmacy records confirming that several doses were missed due to delays in pharmacy delivery and issues with medication removal from the facility's medication dispensary. Staff and pharmacy interviews corroborated that only a portion of the prescribed antibiotics were administered, and the resident ultimately received fewer doses than ordered. The facility's medication administration policy required medications to be administered within a specific time frame and properly documented. However, in both cases, the facility failed to follow these procedures, resulting in significant medication errors for two residents. These findings were confirmed through record reviews, staff interviews, and pharmacy documentation.

Penalty

Inspection fine: $26,685

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 advance directives were updated in the medical record to reflect a resident's current wishes. For Resident #10, the medical record showed an admission date and diagnoses including Ogilvie syndrome, atrial fibrillation, type II diabetes mellitus, morbid obesity, and schizophrenia. The discharge MDS 3.0 indicated intact cognition. Review of the electronic record showed conflicting code status information. A code status form uploaded under the miscellaneous tab contained a signed advance directive for Do Not Resuscitate Comfort Care Arrest, while the blue banner bar in the EMR listed the resident's code status as CPR. During interview, the Unit Manager confirmed the code status had not been updated, did not match, and there was no code status listed in the paper medical record. The facility policy stated that decisions regarding life-sustaining treatment and advance directives would be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for care.

Penalty

Inspection fine: $26,685

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 #123 received the Notice of Medicare Non-Coverage (NOMNC) timely and in writing, and failed to document that the resident understood the notice and the right to appeal. Resident #123 was admitted on 05/12/25 with diagnoses including cerebral palsy, morbid severe obesity, muscle weakness, and need for assistance with personal care. The admission MDS indicated the resident was cognitively intact, had no impairment to the upper or lower extremities, required supervision or touch assistance with eating, was dependent for toileting and personal hygiene, and needed substantial to maximum assistance with bed mobility and dependent transfers. The record showed PT services were ordered on 06/11/25, and skilled documentation on 06/25/25 noted the resident was alert and oriented to person, place, and time and was receiving OT and PT. Social Services documented that a voicemail was left regarding the NOMNC and last covered day, but there was no resident signature on the notice and no documentation that the Social Worker followed up to ensure the resident received the NOMNC in writing or understood the appeal rights. Therapy confirmed the resident received PT and OT five times a week through the last covered day, and the insurance issued a last covered day of 06/27/25. There was no appeal.

Penalty

Inspection fine: $26,685

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

Summary

The facility failed to develop individualized plans of care for three residents out of 44 records reviewed. Resident #67 was admitted with chronic respiratory failure with hypoxia, epilepsy, hypertension, bipolar disorder, quadriplegia, and contractures to both hands, knees, and hips. His MDS showed severe cognitive impairment, highly impaired vision, adequate hearing, and dependence on staff for ADLs. Review of his care plans showed no plan addressing his sex offender status, and the Administrator confirmed during interview that no such plan was in place. The Administrator stated the resident was identified as a sex offender after police notified the facility and that police returned quarterly thereafter; information provided during interview identified him as a tier one sex offender convicted in Ohio on 04/30/14. Resident #117 was admitted with Parkinsonism, Steele-[NAME]-[NAME] syndrome, and dementia. His MDS showed moderate cognitive impairment, walker use, setup assistance for ADLs, wandering behaviors every one to three days, Russian as his primary language, and that activities were somewhat important to him. Review of the care plan showed no goals or interventions addressing activity preferences or related activity needs, and the Administrator confirmed no activities care plan had been developed. Resident #71 was admitted with Alzheimer's disease, dementia, and major depressive disorder, and her annual MDS showed severe cognitive impairment. Her care plans did not include a dental care plan, although observation found a partially cracked or decayed tooth on the upper right side of her mouth. Social Services Designee #670 stated she had not had a dental visit since admission, and LPN MDS #662 and LPN MDS #679 confirmed there was no dental care plan.

Penalty

Inspection fine: $26,685

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 one resident's enteral feeding was labeled and dated as required. Resident #67 was admitted with diagnoses including chronic respiratory failure with hypoxia, gastrostomy status, traumatic subdural hemorrhage, epilepsy, multiple contractures, bipolar disorder, tracheostomy, and quadriplegia. The resident's MDS indicated severe cognitive impairment and total dependence on staff for all activities of daily living. Physician orders included nothing by mouth and enteral nutrition via pump with Jevity 1.5 calorie formula at 50 mL per hour for 20 hours, and the care plan identified the resident as requiring tube feeding for nutrition and hydration. During observation, the resident's tube feeding was running at 50 mL per hour, and the feeding container was not dated, had no time listed, and did not include the nurse's initials. The RN confirmed the container had been hung by the night shift and should have been labeled with the date, time, and nurse initials before being hung. The facility policy for enteral nutrition guidelines stated that the administration set should be labeled with the date and time of administration and licensed nurse initials.

Penalty

Inspection fine: $26,685

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

Provide safe and appropriate respiratory care for a resident when needed was not maintained for a resident with a tracheostomy. Resident #14 was admitted with diagnoses including cranial cerebrospinal fluid leak, tracheostomy, dysphagia, cognitive communication deficit, muscle weakness, and need for assistance with personal care. The quarterly MDS indicated the resident was severely cognitively impaired, had impairment on one side of the upper extremities, required assistance with ADLs, and received suctioning and trach care. The care plan and physician orders directed trach care every shift and as needed, suctioning every shift and as needed, weekly suction tubing and cannister changes, trach tie changes on Monday, Wednesday, and Friday, and keeping the same-size trach and one size smaller at bedside at all times. During observation, the resident's trach site was red with dry and wet mucus, and the resident stated the trach site was painful. The LPN confirmed the resident had a large amount of brown thick mucus covering the ties on both sides of the trach and dried on the skin and under the trach. The LPN also confirmed that no spare trachs were in the resident's room. The suction machine on the nightstand was covered in thick dust, the cannister was undated and unused, and the machine remained in the same dusty, unused condition on the following day. A second LPN later confirmed the trach ties were still covered in brown dried and wet mucus with a large amount of phlegm, the suction machine appeared unused and very dusty, and no spare trachs were available in the resident's room or central supply.

Penalty

Inspection fine: $26,685

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 #8 was monitored before and after dialysis treatments. Resident #8 was admitted with diagnoses including type II diabetes mellitus with chronic kidney disease, moderate protein-calorie malnutrition, stage five chronic kidney disease, and dependence on renal dialysis. The resident’s record showed an order for dialysis every Monday, Wednesday, and Friday, and another order directing staff to send the medication list, face sheet, and dialysis assessment with the resident on dialysis days. Review of the record showed that, between 06/01/25 and 09/24/25, only 11 pre-dialysis assessments were completed out of 50 scheduled dialysis appointments, and only one post-dialysis assessment was completed during that same period. The dialysis record binder at the nurses’ station contained a most recent printed dialysis assessment dated 09/30/24. The MAR showed that on 11 dialysis days in September, staff signed off that the medication list, face sheet, and pre-dialysis assessment form were sent with the resident, but only two pre-assessments were actually completed and sent. During interviews, the receptionist confirmed paperwork was not usually sent with the resident, an LPN stated she did not complete the dialysis pre-assessment paperwork and was unaware of a pre- or post-dialysis assessment requirement, and the DON stated the facility provided a dialysis communication form and thought it was placed in a folder to send with the resident. The Administrator was unable to provide additional evidence of pre- and post-dialysis assessments beyond what was in the EHR.

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 pain-relieving medications as ordered for a resident with chronic pain conditions, including Crohn's disease and intervertebral disc degeneration. The resident, who had intact cognition, was supposed to receive hydromorphone every four hours as needed for pain. On the day in question, the Assistant Director of Nursing (ADON) was working the floor due to a staff call-off and was unfamiliar with the medication administration on that unit. The ADON did not administer the pain medication in a timely manner, causing the resident to wait at least an hour for relief, despite the resident's request and visible distress. The incident was investigated after concerns were raised by staff, residents, and family members about the delay in medication administration. The Unit Manager took over the medication administration from the ADON and provided the resident with the overdue hydromorphone. The facility's policy on pain management and assessment requires staff to ensure residents receive treatment and care in accordance with professional standards, which was not adhered to in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's pain management protocols.

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 effective discharge planning for two residents, leading to deficiencies in their care transitions. Resident #125, who had intact cognition and required supervision for activities of daily living, was discharged to an assisted living facility without documented changes to the discharge plan or updates to the care plan. The social worker confirmed that no updates were made to the medical record regarding the discharge planning process, indicating a lack of proper documentation and planning. Resident #126, who also had intact cognition but required moderate to maximum assistance for activities of daily living, expressed a desire to move to South Carolina to be closer to family. Despite this, the discharge care plan was not updated to reflect this change, and there was no documentation of the discharge planning process in the medical record. The resident was discharged with arrangements made for a flight and transportation, but the discharge summary lacked details about the hospital or potential facilities for placement in South Carolina. Interviews with facility staff and external parties involved in the discharge process revealed that the facility did not adequately document or update the discharge plans for these residents. The facility's policy required regular re-evaluation and updates to the discharge plan, which were not followed in these cases. This deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with discharge planning requirements.

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 all staff followed the mechanical lift protocol, which resulted in an incident involving Resident #135. The resident, who had diagnoses including diabetes, chronic kidney disease, morbid obesity, spinal stenosis, and osteoarthritis, was dependent on mechanical lift transfers. During a transfer, the Hoyer lift scale detached, causing the resident to drop into her wheelchair, and the scale hit her forehead. Although the resident did not fall, she sustained a cut on her forehead. The incident was reported by the Unit Manager LPN #309, who noted that the transfer was conducted by STNA #312 without the required assistance of a second staff member. Interviews and observations revealed that the mechanical lift malfunction occurred when the weight scale got caught, causing the Hoyer bar to drop suddenly. Maintenance Assistant #311 confirmed that the mechanical lifts were checked monthly, and the issue was reported on the day of the incident. The facility's policy required two employees to assist with mechanical lift transfers, but this protocol was not followed by STNA #312, who received a final written warning for her actions. The incident was self-reported, and a full investigation was conducted.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely incontinence care for several residents, as observed during a survey. Resident #102, who has Alzheimer's disease and dementia, was found in a wheelchair with wet pants and a puddle of urine on the seat. The assigned STNA was unaware of the resident's need for incontinence care and could not confirm when the resident was last checked or changed. This indicates a lack of communication and accountability among staff regarding resident care assignments. Resident #115, with intellectual disabilities and muscle weakness, was reported by a roommate to have not been changed all night. Upon observation, the resident was found saturated with urine and stool, which had soaked through the incontinence brief and bed sheets onto the mattress. The STNAs responsible for the resident's care were unsure when the resident was last attended to, highlighting a failure in maintaining regular incontinence care schedules. Resident #117, who has cognitive deficits and a tracheostomy, was also found with a large amount of urine that had soaked through the bed sheets to the mattress. The STNA on duty had not provided care since the start of her shift and was unable to state when the resident was last checked. Similarly, Resident #120, with morbid obesity, was found with urine and stool soaked through her incontinence brief and sheets. The STNA responsible did not know when the resident was last changed, indicating a systemic issue in providing timely incontinence care across 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 honor the rights of residents to be treated with respect and dignity, as well as their right to self-determination and communication. This deficiency was highlighted by an incident involving a resident who required assistance with activities of daily living and was dependent on staff for transfers. The resident, who had intact cognition, requested assistance to be transferred back to bed in the evening but was not helped. After several hours without assistance, the resident contacted her son, who then called the police. Upon the police's arrival, the resident was finally assisted back into bed. Interviews with staff and other residents revealed a pattern of complaints about staff being rude and unresponsive to resident needs. The incident was further corroborated by a police report, which indicated that the resident had been left in her wheelchair for an extended period and had soiled herself twice. The facility's policy on resident rights, which includes the right to be treated with respect and to decide when to go to bed, was not adhered to in this case. The facility's administration acknowledged the incident and obtained a copy of the police report, confirming the resident's account of events. This deficiency was investigated under a specific complaint number, indicating a formal recognition of the issue by regulatory authorities.

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 clean and sanitary environment, affecting two residents. During an observation, two soiled incontinence briefs were found on a resident's wheelchair, with gnats flying around them. An STNA revealed that she had picked up the briefs from the floor and placed them on the wheelchair. In another instance, a large pile of dirty linens was observed on the floor of a resident's room, emitting a foul odor. The resident confirmed that the linens had been there since the previous night after his bed was changed. This was corroborated by an STNA who acknowledged the situation and indicated she would dispose of the linens.