Park Health Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff-to-resident sexual abuse and to protect residents after the allegation. A cognitively impaired resident with severe dementia, depression, and a history of occasional delusional thinking reported that a male staff member attempted to put his "thing" in her mouth, gesturing toward her own and the nurse’s private areas. The resident identified the alleged perpetrator by name and described his clothing, which matched that of a male CNA on duty. The resident appeared upset and was yelling when initially interviewed by the social worker designee and human resources director, and later became guarded and defensive when asked by surveyors about the incident, stating she had been told she was safe and that the man would no longer care for her, and that she was told not to discuss the incident. Staff actions and documentation on the date of the allegation were incomplete and did not meet the facility’s own abuse policy. The LPN caring for the resident was informed by the CNA that the resident was combative during care and, upon assessing the resident, heard the resident’s statements about the attempted sexual act. The LPN reported the concern to the social worker designee because administration was not yet on site. The social worker designee and human resources director interviewed the resident, confirmed the description of the CNA’s clothing, and notified the Administrator by phone. The Administrator, via speaker phone, directed that the CNA leave the facility pending investigation, and the CNA clocked out that morning. However, the facility’s internal investigation file for that date contained only brief, non-witness statements from other staff attesting that they had never seen the CNA be abusive, and lacked detailed statements from the social worker designee, human resources director, the LPN who received the allegation, or the CNA accused. There was no documentation in the medical record regarding the resident’s allegation or the events of that day. The facility’s investigation summary for the date of the allegation concluded that the resident was confused and combative during personal care and that no abuse occurred, relying in part on the resident’s son’s statement that the resident behaves that way when she has a UTI and that he did not think an investigation was warranted. The assistant DON confirmed that no deeper investigation was conducted and that the incident was not reported to the state agency, despite facility policy requiring reporting of any allegations or suspicions of abuse prior to investigation. Furthermore, after being sent home the day of the allegation, the CNA was allowed to return to work on the next scheduled shift and was assigned as a shower aide on a different unit, providing care to eight other residents while the initial allegation had not been fully investigated or reported. The DON and ADON verified that the CNA worked that full shift with resident care responsibilities before being placed on leave when a formal allegation was later made by the resident’s son.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to timely report an allegation of staff-to-resident sexual abuse to the state agency as required by policy. A resident with severe cognitive impairment, dementia, depression, and multiple medical conditions, who required extensive assistance of two staff for mobility and transfers, alleged that a male CNA attempted to put his genitalia in her mouth. The resident identified the alleged perpetrator by name and physical description, which matched a male CNA on duty. The social worker designee and the human resources director interviewed the resident the same morning, confirmed the description, and contacted the Administrator by phone while in the resident’s room, placing the Administrator on speaker so she could hear the interview and reported events. Despite the Administrator being made aware of the allegation on the same morning it occurred, the facility did not document the incident in the resident’s medical record and did not report the allegation of sexual abuse to the state agency at that time. The internal investigation file for that date contained only brief, non-witness statements from staff attesting generally to the CNA’s behavior, with no detailed statements from the social worker designee, the human resources director, the LPN caring for the resident, or the CNA accused. The investigation summary concluded that the resident was confused and combative during personal care and that no abuse occurred, and the facility relied in part on the resident’s son’s opinion that an investigation was not needed and that the resident might have a urinary tract infection. Subsequently, when an SRI was entered into the state’s reporting system, it was categorized as physical abuse rather than sexual abuse, and there was no SRI entered for the original date of the allegation. A police report later documented that the Administrator reported the incident as sexual in nature and stated that the facility was not made aware of the allegation until the resident’s son reported concerns, which conflicted with staff interviews confirming the Administrator’s awareness on the date of the incident. The facility’s own abuse policy required that any allegation or suspicion of all types of abuse be reported to the state agency prior to investigation, but the allegation of staff-to-resident sexual abuse was not reported as such when initially known, and the investigation was incomplete and poorly documented.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide and document medically related social services for a resident who experienced a significant psychosocial event related to an allegation of staff-to-resident sexual abuse. The resident, admitted with multiple diagnoses including stroke, depression, dementia, and severe cognitive impairment, required extensive assistance with mobility and had a care plan for mood and behavioral alterations, including delusional thinking and yelling out. Despite this, there was no documentation in the medical record of the alleged sexual abuse incident, no social services notes, and no psychosocial assessments entered between 03/10/26 and 03/19/26. The quarterly MDS showed severe depression with no documented change since the prior assessment, and the behavior and mood assessments reflected no behaviors since the prior annual assessment, despite the reported allegation. During an interview, the resident became guarded and defensive when asked about the alleged abuse, reported being told by the Administrator and police officers that she was safe and that the male staff member would no longer care for her, and refused to elaborate further. The social worker designee reported being informed of the allegation by an LPN, interviewing the resident when she was upset and yelling about a man trying to put his “thing” in her mouth, and confirming the description of the alleged perpetrator matched a CNA on duty. The social worker designee stated she met with the resident several times after the alleged incident to follow up on her emotional and cognitive status and to check in with her, but acknowledged she did not document the resident’s behaviors or allegations on the date of the incident, nor any follow-up visits or updated psychosocial assessments. This lack of documentation and failure to accurately record psychosocial needs and interactions conflicted with the written job responsibilities for the social worker designee.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility Administrator’s failure to effectively administer the facility by not properly reporting and characterizing an allegation of staff-to-resident sexual abuse and by providing false information to police. The resident involved had multiple medical conditions including stroke, dementia with severe cognitive impairment, depression, and functional dependence requiring extensive assistance of two staff for bed mobility, transfers, and ambulation. Her care plan noted alterations in mood and behaviors, including occasional delusional thinking and yelling out. On the morning in question, the resident reported that a male staff member tried to put his “thing” in her mouth, gesturing toward her own and the nurse’s private areas, and identified the alleged perpetrator by name and description, which matched a CNA on duty. Staff interviews showed that the allegation was promptly brought to facility leadership on the same morning it occurred. An LPN, after hearing the resident’s statements, reported the concern to the social worker designee because administration was not yet on site. The social worker designee and the Human Resources Director jointly interviewed the resident, who remained upset and repeated the allegation, and they confirmed that the CNA she identified matched the description she gave. The Human Resources Director called the Administrator on speaker phone during this interview so he could hear the resident’s statements and the reported events. The Administrator then spoke with the CNA by phone, in the presence of the social worker designee and Human Resources Director, and directed the CNA to leave the facility pending investigation. Despite being made aware of the allegation on the day it occurred, the Administrator did not report the allegation of sexual abuse to the state agency as required by the facility’s abuse policy, which mandates reporting all allegations or suspicions of abuse prior to investigation. Review of the state reporting system showed no self-reported incident for sexual abuse on the date of the allegation, and when an incident was later entered, it was reported as physical abuse rather than sexual abuse. Additionally, in a subsequent police report for a sex offense, the Administrator told law enforcement that the facility was not made aware of the allegation until the resident’s son reported concerns two days after the incident, which conflicted with consistent staff statements that the Administrator had been immediately informed on the day of the alleged abuse. These actions and omissions constituted a failure of effective facility administration.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with severe cognitive impairment and multiple medical diagnoses, including stroke, dementia, depression, lung disease, and hypertension. The resident required extensive assistance of two staff for bed mobility, transfers, and ambulation, and had documented severe depression and a history of altered mood/behaviors with delusional thinking and yelling out. Despite this, the medical record contained no documentation of events related to an allegation of staff-to-resident sexual abuse that occurred on a specific date. On the morning of the alleged incident, a CNA reported to an LPN that the resident was combative when being assisted off a bedpan. When the LPN assessed the resident, the resident was very agitated and reported that a man tried to put his “thing” in her mouth, gesturing toward her own and the nurse’s private areas. The LPN acknowledged that not everything the resident said made sense but recognized the need to report the concern and informed the social worker designee. The LPN later entered a note in the medical record describing the resident as having increased delusions and false beliefs, with discomfort to the left wrist after becoming combative, and that the son stated the resident behaves this way with a UTI. However, the LPN did not document the resident’s specific statements, gestures, or emotional status from that assessment. The social worker designee reported being notified of the allegation that morning and, along with the human resources director, interviewed the resident, who was upset and yelling about a man trying to put his “thing” in her mouth, and identified a man by name and clothing description that matched the CNA. The social worker designee also noted the resident complained of right wrist pain and stated she had multiple follow-up contacts with the resident to assess emotional and cognitive status and to check in. Despite these interactions, the social worker designee confirmed that she did not document the resident’s behaviors, allegations, or any follow-up visits or psychosocial assessments in the medical record. The ADON verified that there was no documentation in the medical record of the incident, the nature of the delusions, or what led to the resident becoming combative, and that social services had made no entries for the resident during the period in question, resulting in an incomplete and inaccurate medical record related to the abuse allegation.

Penalty

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 deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.

Penalty

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 impaired cognition, muscle wasting, and a recent right femur fracture was re-admitted to the facility and required assistance with personal care. The resident's power of attorney had authorized and installed a fixed-position, motion-activated video camera in the resident's room for electronic monitoring. On the date in question, video footage showed a registered nurse exiting the resident's bathroom, raising her hand to block her face from the camera, and then standing in front of the camera, which obscured the view of the resident as she was brought out of the bathroom. The camera, being motion-activated, stopped recording due to the obstruction. Facility policy on electronic monitoring explicitly prohibits intentional obstruction, tampering, or destruction of any electronic monitoring device or its recordings. The registered nurse later stated that her action was a reaction to the camera's recording light, as she disliked cameras. The Director of Nursing confirmed the incident after reviewing the video. This event demonstrated a failure to treat the resident with respect and dignity, as required by facility policy and resident rights.

Penalty

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 right femur fracture, muscle wasting, atrophy, and cognitive impairment was re-admitted to the facility and required moderate assistance for transfers. The resident was frequently incontinent of bladder and bowel and had a care plan in place that included a toileting program and interventions to maintain cleanliness and monitor elimination. On the evening in question, video footage showed the resident requesting to use the bathroom, but the assigned CNA did not assist her to the toilet. Instead, the CNA instructed the resident to urinate in her incontinence brief, stating it was difficult for her to use the toilet due to her leg injury and that she would be cleaned up afterward. The CNA later confirmed in an interview that he did not redirect the resident appropriately and opted to have her use the brief because he was about to change her. The care plan interventions, which included providing opportunities for toileting, were not followed, and the resident was not given the chance to maintain her ability to perform activities of daily living related to toileting. This incident was identified through record review, policy review, video evidence, and staff interviews, and it affected one resident out of four reviewed for change in condition.

Penalty

No penalty information released

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

Summary

Surveyors observed multiple failures in food storage and preparation practices within the facility's kitchen. During an initial tour, it was found that a bag of mixed vegetables and Charbroil burgers in the walk-in freezer had been opened and not resealed, leaving the contents exposed. In the walk-in refrigerator, 58 individual cartons of whole milk were present with a sell-by date that had already passed. Additionally, leftover chili was found without any date, and a five-pound carton of sour cream was discovered to be expired. A scoop was observed resting on the lid of a thickener container, not stored in a sanitary manner. Dust was noted on all four pipes over the stove cooktop on the ansel system, and the shelf above the cooktop was both dusty and greasy. An interview with the cook confirmed the presence of outdated, unsealed, and undated food items, as well as the unsanitary storage of the scoop and the dusty kitchen surfaces. Review of the facility's Food Storage-Labeling and Dating policy indicated that all food must be dated upon entry and after opening, with leftovers to be held for no more than seven days unless the manufacturer's expiration date is sooner. These observations and confirmations demonstrate that the facility failed to store and prepare food under sanitary conditions, affecting all residents who receive nutrition from the kitchen.

Plan Of Correction

The facility will continue to ensure food is stored properly and prepared under sanitary conditions. Dietary Manager immediately threw away a bag of mixed vegetables, charbroil burgers, 58 cartons of Bordon whole milk, leftover chili, and a five-pound carton of Gordon Choice sour cream noted in the facility's initial tour on 3/24/2025. The Dietary Manager immediately cleaned the scoop on the lid of the thickener container, dust on all four pipes over the stove cooktop on the Ansul system, and dust/grease on the shelf over the cookout noted on the initial tour on 3/24/2025. An initial walk-through of the kitchen and storage areas was conducted by the Administrator on 3/28/2025, to ensure proper storage, labeling, and cleanliness of the kitchen. No negative findings were noted. The Administrator reeducated all dietary staff on the facility's food storage-labeling and dating policy, as well as the cleaning schedule, on 3/24/2025. Weekly, for two weeks, the Dietary Manager and/or designee will conduct an audit three times per week to ensure dietary staff is following facility policy regarding proper food storage and the cleaning schedule. Negative findings will be corrected immediately by reeducating dietary staff and reported to QA for review and recommendation. The Administrator will ensure the completion of weekly audits. The Administrator is responsible for ongoing compliance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that advance directives were accurate and consistent for one resident. Upon review, the resident's electronic medical record indicated a change in code status from Do Not Resuscitate Comfort Care Arrest (DNRCCA) to Do Not Resuscitate Comfort Care (DNRCC) as ordered by the physician. However, the paper chart for the same resident still contained a signed DNRCCA form, which did not reflect the updated code status. This discrepancy was confirmed during an interview with a registered nurse, who acknowledged that the advance directives in the electronic and paper records did not match. The facility's policy required that copies of advance directives be placed on the chart, but the records were not updated to reflect the most current physician orders. The resident involved had multiple diagnoses, including epilepsy, atherosclerotic heart disease, cerebrovascular disease, hyperlipidemia, COPD, schizoaffective disorder, angina, Parkinson's disease, and adult failure to thrive.

Plan Of Correction

This plan of correction does not constitute an admission to any of the allegations contained within the State of Deficiency. Rather, this plan of corrections has been prepared and executed because state and federal law require it, and not because Park Health Nursing Home and Rehabilitation Center agrees with the citation. The facility maintains that the alleged deficiency does not individually or collectively jeopardize the health and safety of the residents. This plan of correction is not meant to establish any standard of care contract, obligation or position, and Park Health Nursing Home and Rehabilitation Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. This plan of correction shall also operate as the facility's credible allegation of compliance. Please accept 4/22/2025 as our date of compliance. The facility will continue to ensure accurate advanced directives are maintained. On 3/25/2025, the unit nurse verified with resident #2 she wanted his advanced directives to remain a DNRCC. Order verified in her electronic medical record and the current DNRCCA form was replaced with signed DNRCC in her hard chart. An initial audit was conducted on 3/31/2025, by the facility DON with no negative findings noted on current residents' charts. The Regional clinical manager reviewed current facility process with Medical Records clerk, DON and ADON on 4/14/2025. By 4/17/2025, the DON and or designee will reeducate licensed nursing staff on facility process for obtaining advanced directives, maintaining advanced directives records, and managing changes to desired code status/advance directives. Weekly for 2 weeks, the DON and or designee will audit 5 random residents ensuring proper documentation and record keeping for current desired advanced directives. Negative findings will be corrected by ensuring proper records/orders, and reeducating staff. Negative findings will also be reported to the QA committee for review and recommendations. The DON is responsible for the ongoing compliance and the Administrator will review the weekly audits ensuring completion.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with chronic atrial fibrillation, congestive heart failure, and peripheral vascular disease, who was cognitively intact, reported approximately $500 in cash missing from her purse, which she kept in her room. The resident's representative had recently cashed a check for $545, of which $500 remained in a banker's envelope. The resident stated she did not leave her purse unattended and always took it with her when leaving the room. The missing money was reported to facility staff, and a police report was filed at the resident's request. Staff interviews and a facility investigation did not reveal evidence of staff involvement or additional missing items among other residents or staff. Despite the investigation being unsubstantiated for staff misappropriation, the facility did not reimburse the resident for the missing $500. Interviews with the resident, the Ombudsman, and staff confirmed that the money was not returned or reimbursed. The facility administrator verified that no reimbursement was provided, as the investigation did not find evidence implicating staff in the misappropriation.

Plan Of Correction

The facility will continue to ensure residents are free of misappropriation. On 3/27/2025, the facility Administrator reimbursed resident #10 $500.00. The Regional Administrator reviewed and educated the Abuse/Misappropriation policy with the Administrator on 3/28/2025. An initial audit was conducted on 3/28/2025 by the facility Administrator to ensure no other misappropriation of residents' funds, with no negative findings noted. By 4/17/2025, the Administrator and/or designee will reeducate all staff on the facility's abuse/misappropriation policy. Weekly for 2 weeks, the Administrator and/or designee will review the missing item log, ensuring no additional misappropriation was reported. Negative findings will be corrected by ensuring missing items are investigated with resolution and staff reeducated. Negative findings will also be reported to the QA committee for review and recommendations. The Administrator is responsible for the ongoing compliance, and the Regional Administrator will review the weekly audits ensuring completion.

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 develop and implement a comprehensive, person-centered care plan for a resident who was receiving psychotropic medications. The resident, admitted with diagnoses including epilepsy, anxiety disorder, Parkinson's disease, and adult failure to thrive, was assessed as moderately impaired for daily decision making and was prescribed both antipsychotic and antianxiety medications. Despite these factors, the care plan did not include a measurable or comprehensive approach to the use of psychotropic medications, nor did it identify specific behaviors to be monitored in relation to the administration of antipsychotic drugs. A review of the resident's medical record and care plans confirmed the absence of targeted behaviors or monitoring parameters for the effectiveness of the antipsychotic medications. An interview with a registered nurse further verified that no care plan had been developed for the use of psychotropic medications and that there were no identified behaviors being tracked. Additionally, the facility did not have a policy in place regarding the use of psychotropic medications.

Plan Of Correction

The facility will continue to develop and implement comprehensive care plans. Resident #2 continues to reside in the facility. No negative effects noted. The comprehensive care plan was constructed by the MDS nurse for alteration in mood and behavior on 3/25/2025. Resident #2's current psychoactive care plan was reviewed and modified on 3/25/2025 by the facility MDS nurse. An initial audit of psychoactive care plans was completed by the MDS nurse on 4/15/2025, ensuring facility monitoring of the effectiveness of psychoactive drugs for targeted behaviors identified. Negative findings were corrected by updating care plans. The Interdisciplinary team, responsible for creating and revising a comprehensive care plan, was reeducated by the Regional Clinical Manager on 4/14/2025 to ensure the care plans meet the current needs of the resident. Weekly, for 2 weeks, the DON or designee will conduct a random audit of 5 residents who are taking psychoactive medications, ensuring monitoring for medication effectiveness for targeted behaviors is reflected on the care plan. Negative findings will be corrected immediately by updating the current care plan and reeducating staff. Negative findings will also be reported to the QA committee for review. The Administrator will ensure the completion of the weekly audits. The DON is responsible for ongoing compliance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that care plans were updated to reflect residents' current medical needs and preferences, as required by regulation. For one resident with multiple complex diagnoses, including morbid obesity, chronic kidney disease, and dependence on dialysis, the care plan for dialysis was not individualized and did not specify the presence of a fistula used for hemodialysis access. This omission was confirmed by both the resident and a registered nurse, who acknowledged that the care plan lacked details about the specific type of dialysis access and the services required. Another resident, with a history of metabolic encephalopathy, diabetes, and rheumatoid arthritis, had care plans that were not revised to reflect significant changes in condition or preferences over an extended period. Despite a significant change assessment indicating moderate cognitive impairment, increased behavioral symptoms, and new medical interventions such as continuous tube feeding, the care plan was not updated to address these changes. Observations and staff interviews revealed ongoing refusals of care, changes in activity participation, and the importance of religious activities, none of which were reflected in the care plan until after the surveyor's inquiry. The deficiency was identified through record review, observation, and staff interviews, which demonstrated that the interdisciplinary team did not consistently review and revise care plans after assessments or significant changes in residents' conditions. The lack of timely and individualized updates to care plans affected the delivery of person-centered care for at least two residents reviewed during the survey.

Plan Of Correction

The Facility will continue to implement and revise care plans to meet the needs of each resident. Resident #26 and #133 continue to reside at the facility. Resident #26 Care plan for dialysis was revised by the MDS nurse on 3/26/2025 to ensure proper care for dialysis treatments. Resident #133 was reassessed by the Activities Director on 3/26/2025 and revised activities care plan on 3/26/2025. An initial audit was conducted by the MDS Nurse to ensure accuracy of current activity care plans for residents who are bed bound and did not participate in many activities. 9 residents were identified and reviewed. No negative findings were noted. Resident #26 is the facility's only dialysis patient at this time. No initial audit was needed to be completed at this time. The Interdisciplinary team, who are responsible for creating a comprehensive care plan, and revising care plans were reeducated by the Regional Clinical Manager on 4/14/25, to ensure the care plans meet the current needs of the resident. Weekly for 2 weeks, or as directed by the QA committee, the MDS nurse will audit care plans for residents on dialysis and 5 random residents for activities, ensuring care plans are meeting the needs of the residents. Negative findings will be reported to the QA committee. Negative findings will be corrected by updating the care plans and reeducating staff. The Administrator will ensure weekly completion of audits and the DON is responsible for the ongoing compliance.

Penalty

No penalty information released

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

Summary

Surveyors found that the facility failed to provide necessary assistance with activities of daily living (ADLs), specifically routine nail care and showers, for two residents who were dependent on staff for these services. One resident, with chronic obstructive pulmonary disease, hypertension, and diabetes, was documented as dependent for bathing and required assistance with personal hygiene. Despite records indicating that showers and nail care were provided on specific dates, observations revealed the resident had long, dirty, and untrimmed fingernails on multiple occasions. The resident reported that staff did not cut or clean her fingernails, and a CNA confirmed the nails were untrimmed and unclean, stating that nail care should be completed with each shower. Another resident, diagnosed with Parkinson's disease, psychotic disorder, diabetes, and other conditions, was also dependent for bathing and had a documented preference for three to four showers per week. Interviews with the resident's wife indicated that the resident was not consistently receiving showers or oral care as preferred, sometimes receiving fewer than two showers per week. Review of records showed missed showers on several scheduled days, and on one occasion, a bed bath was provided instead of a shower without explanation. Staff interviews confirmed that the resident did not receive showers as scheduled and that decisions about showering were sometimes left to the resident's wife.

Plan Of Correction

The facility will continue to offer showers and nail care to dependent residents. Resident #9 and #70 continue to reside at the facility. On 3/25/2025, direct care staff offered nail care to resident #9 and resident #70, and both residents accepted. CNA #80 was reeducated on offering nail care if nails appear soiled or jagged in between shower frequency. Resident #2's care plan for ADLs was reviewed by the IDT. Resident #70 was offered a shower on 3/26/2025 and accepted. STNA #80 was reeducated by the Nurse Manager on 3/25/2025 to ensure offering showers per the resident's preference and proper documentation of showers and refusals of showers. An initial audit of residents' shower preferences was conducted on 4/10/2025 by the DON. Shower schedules were reviewed and updated as needed. An initial observation audit of residents' fingernails was conducted on 4/9/2025 by the DON. Negative findings were corrected by offering/performing nail care. By 4/17/2025, facility direct care staff and licensed nurses will be reeducated by the DON and nurse management team. Reeducation will consist of expectations of staff offering/providing daily grooming and hygiene care, such as but not limited to; showers per preference, hair care, oral care, dressing, shaving, and nail care. Weekly, for 2 weeks, or as directed by the QA committee, the DON and/or designee will audit 5 random residents, ensuring showers and nail care are provided. Negative findings will be corrected by offering the resident a shower and/or nail care and reeducating the staff. Negative findings will be reported to the QA committee for review. The Administrator will ensure the completion of the audits. The DON is responsible for the ongoing compliance.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with a history of chronic atrial fibrillation, heart failure, cerebrovascular disease, and chronic obstructive pulmonary disease was not administered an ordered anticoagulant medication (Eliquis) following a new diagnosis of pulmonary embolism. The resident had recently returned from the hospital, where conservative management with Eliquis was recommended due to a history of hematuria with the medication. Upon return to the facility, an order for Eliquis 5 mg twice daily was placed. Despite the order, the bedtime dose of Eliquis was not administered on the day of the resident's return because the medication was reportedly not available and was being delivered from the pharmacy. However, the Director of Nursing later confirmed that Eliquis was available in the facility's contingency medication box, but the nurse did not retrieve it. This failure to administer the medication as ordered was confirmed through medical record review and staff interview.

Plan Of Correction

The Facility will continue to ensure anticoagulants are administered as ordered. Resident #76 continues to reside at the facility. The DON reported missing doses to PCP, with no further recommendations needed. Nurse identified as marking medication as unavailable and not given was reeducated regarding the pharmacy contingency box that allows nurses to pull medications without waiting on pharmacy to deliver. An initial audit of residents on anticoagulant medication was conducted by the DON on 4/1/2025, ensuring medication was given timely and as ordered. No negative findings were noted. By 4/17/2025, licensed nurses will be reeducated by the DON on the pharmacy contingency box, ensuring medications such as anticoagulants are given timely and as ordered. Weekly for 2 weeks or as directed by the QA committee, the DON will randomly review 5 residents who are on an anticoagulant, ensuring they are receiving their medications as prescribed. Negative findings will be corrected immediately by reporting findings to the PCP for recommendations and reeducating the licensed nurse. Negative findings will be reported to the QA committee for review. The Administrator will ensure the completion of the weekly audits. The DON is responsible for the ongoing compliance.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with multiple risk factors for pressure ulcers, including peripheral vascular disease, anemia, edema, and limited mobility, was not provided with a properly functioning low air loss mattress as ordered. The resident's care plan and physician orders specified the use of a low air loss mattress with perimeters, set according to weight and alternating pressure, with functionality checks required every shift. Despite these orders, observations on two consecutive days revealed that the mattress panel was blinking red, indicating low pressure, and the alarm had been muted. Staff had documented on the treatment administration record that the mattress was functioning, but direct observation contradicted this documentation. Multiple staff, including a registered nurse, wound nurse, and wound nurse practitioner, were either unaware of the malfunction or did not notice the low-pressure indicator and muted alarm during their assessments and rounds. The mattress remained in use while malfunctioning, and the issue was not identified or addressed until it was brought to the attention of staff during the survey. The resident was observed lying in bed on the malfunctioning mattress, and staff were unable to confirm whether all air cells were properly inflated due to the mattress cover and the resident being in bed. The facility's operational manual for the mattress clearly states that a low-pressure indicator and alarm are designed to alert staff to malfunctions, and the facility's policy requires monitoring and revising interventions as appropriate. However, the required checks and responses to the alarm were not performed, resulting in the resident not receiving care consistent with professional standards of practice to prevent pressure ulcers.

Plan Of Correction

The facility will continue to ensure low air loss mattresses are functioning properly. Resident #240 continues to reside at the facility. On 3/25/2025, the Administrator removed the mattress and pump and replaced it with a functioning mattress and pump. Resident #240's skin was assessed and noted with no new identified areas. RN #60 was reeducated by the facility wound nurse on properly monitoring the low air loss mattresses for proper functioning. An initial audit of current residents with low air loss mattresses was conducted for function on 3/27/2025 by the DON. No negative findings were noted at the time of the audit. By 4/17/2025, the DON and/or designee will reeducate the licensed nurses and direct care staff on ensuring proper function of low air loss mattresses and how to troubleshoot alarms to pumps per manufacturer guidelines. Weekly, for 2 weeks, or as directed by the QA committee, the facility wound nurse and/or designee will randomly audit 5 residents, ensuring the low air loss mattress is set properly, functioning, and not alarming. Negative findings will be immediately corrected by assessing the mattress and resident and replacing the mattress as appropriate. Negative findings will also be reported to the QA committee for review. The facility Administrator will ensure the completion of the weekly audits. The DON is responsible for the ongoing compliance. F 0686

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident admitted with a urinary tract infection (UTI) did not receive prescribed antibiotic treatment as ordered. The resident, who had diagnoses including UTI, low back pain, muscle weakness, dementia, and depression, was ordered Cefpodoxime 200 mg, two tablets by mouth twice daily for three days. Medical record review showed that the medication was not administered as scheduled on multiple occasions due to its unavailability. Specifically, doses were missed on the evening of admission and on both scheduled times the following two days. The first dose was not given until three days after admission, and the antibiotic course was completed late. Documentation revealed that while the physician was notified on the day of admission that the medication was not available and had been ordered from the pharmacy, there was no evidence that the physician was notified on subsequent days when the medication continued to be unavailable and not administered. The DON confirmed the medication was not in the facility's contingency medication box and that pharmacy delivery was delayed. The resident experienced an episode of unresponsiveness during this period, and the physician was updated about the resident's condition, but not specifically about the ongoing lack of antibiotic administration.

Plan Of Correction

The facility will continue to ensure antibiotics are administered as ordered to treat urinary tract infections. Resident #236 continues to reside at the facility and has completed her round of ATB for UTI. Resident assessed by 4/10/2025 and was noted to be free of s/s of UTI. Immediate reeducation on transcribing orders was conducted by the DON with licensed nurse who readmitted resident #236 for hospital. An initial audit of antibiotic use in the last 30 days was conducted by DON on 4/17/2025. The DON reviewed ATB for proper administration and timely administration of antibiotics. No negative findings were noted. By 4/17/2025, the DON and or designee will reeducate licensed nurses on proper transcription of antibiotic orders, ensuring timely administration, and notifying PCP when medications are not available to be given. Weekly for 2 weeks, or as directed by the QA committee, the DON or designee will audit antibiotic orders ensuring proper transcription of orders and that they were administered timely and as prescribed. Negative findings will be corrected by notifying the practitioner and reeducating staff. Negative findings will be reported to the QA committee for review. The Administrator will ensure completion of the weekly audits. The DON is responsible for the ongoing compliance.

Penalty

No penalty information released

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

Summary

A deficiency was identified in the care of a resident requiring dialysis services. The resident, who had multiple complex diagnoses including chronic kidney disease stage 4, dependence on renal dialysis, and a right arm fistula for dialysis access, did not have an individualized dialysis care plan. The care plan was generic and failed to specify the presence of a fistula or the specific care required for it. Physician orders did not include instructions to check for bruit and thrill in the fistula or to avoid taking blood pressure in the affected arm. Additionally, orders referenced a vascath, which the resident did not have, and included instructions for dressing care that were not consistent with the resident's actual needs. Staff interviews and record reviews revealed that nurses were signing off on dressing changes for the fistula site even though the resident reported and was observed not to have a dressing in place after dialysis. Nurses also confirmed that the care plan and orders were not updated to reflect the resident's current dialysis access and required monitoring. The lack of specific orders and individualized care planning resulted in the resident not receiving appropriate monitoring and care for the dialysis fistula, as required by professional standards and the resident's care needs.

Plan Of Correction

The facility will continue to ensure appropriate care is provided for residents receiving dialysis. Resident #26 continues to reside at the facility and receive dialysis services. On 3/26/2025, the licensed nurse reviewed orders with the PCP and updated orders to reflect current care needs and emergency care needs for his fistula. Resident #26's care plan was reviewed by the MDS nurse on 3/26/2025, to ensure we are addressing care needs for the fistula. Resident #26 is the facility's only dialysis patient at this time. No initial audit was needed to be completed at this time. On 4/14/2025, the Regional clinician reviewed facility practices for ensuring proper treatment for dialysis patients with the nursing IDT. This review included comprehensive care planning and revision, order sets to ensure the facility is meeting the needs of current dialysis patients, and reviewing dialysis notes to ensure awareness of treatment changes and orders. By 4/17/2025, licensed nurses will be reeducated regarding transcribing and monitoring for different types of dialysis access such as a fistula and/or vascath to ensure proper monitoring and proper documentation of a medical record to meet the needs of the patient. Weekly, for 2 weeks, or as directed by the QA committee, the DON or designee will audit residents receiving dialysis, ensuring proper orders are in place and care plans are updated to manage care needs. Findings will be corrected by reporting to the PCP and obtaining orders. Reeducation will be provided to licensed nursing staff. Negative findings will also be reported to the QA committee for review. The Administrator will ensure weekly completion of the audits. The DON is responsible for the ongoing compliance.

Penalty

No penalty information released

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

Summary

The pharmacy failed to ensure timely availability of medications for multiple residents, resulting in missed or delayed administration of prescribed drugs and vaccines. One resident with type 2 diabetes and chronic kidney disease did not receive their scheduled Ozempic injection because the medication was not available at the time of administration. The registered nurse confirmed that the medication should have been reordered and available, but a pharmacy error led to the delay. Another resident, admitted with obesity, diabetes, heart disease, and overactive bladder, consented to receive the Prevnar 20 pneumococcal vaccine. Despite multiple orders and documentation attempts, the vaccine was not received from the pharmacy and was not administered as scheduled. The directors of nursing were unaware of the reason for the delay and had to follow up with the pharmacy, which repeatedly failed to deliver the vaccine as expected. A third resident, admitted with a urinary tract infection and other conditions, was prescribed Cefpodoxime, an antibiotic, to be administered twice daily for three days. The medication was not available in the facility's contingency box, and the pharmacy did not deliver it until several days after the initial order. As a result, the resident missed multiple doses, and there was no documented evidence that the physician was notified of the missed doses on two of the days.

Plan Of Correction

The facility will continue to ensure medications are available timely for administration. Resident #64 continues to reside at the facility and received his Ozempic on 3/26/2025. Resident #236 continues to reside at the facility and has completed her round of ATB for UTI without negative effects. Resident #238 continues to reside at the facility and received her Prevar 20 vaccine on 3/27/2025. Resident #236 was assessed by facility nurse on 4/10/2025 and was noted to be free of s/s of UTI. An initial audit of all medications to ensure timely availability for administration was conducted by DON 4/10/2025. No negative findings were noted. The DON and Administrator reviewed survey findings with facility pharmacist on 4/18/2025. The Administrator, DON and IDT reviewed facility processes for pharmacy orders and deliveries on 4/17/2025. Infection preventionist will monitor deliveries and administration of vaccinations and antibiotics ensuring they are provided timely. Admission orders will be reviewed in clinical meetings ensuring medications are available and given timely. By 4/17/2025, the DON and or designee will reeducate licensed nurses on proper transcription of pharmacy orders, ensuring timely administration, and notifying PCP when medications are not available to be given. Weekly for 2 weeks, or as directed by the QA committee, the DON or designee will audit medication orders ensuring proper transcription of orders and that they were administered timely and as prescribed. Negative findings will be corrected by notifying practitioner and reeducating staff. Negative findings will be reported to the QA committee for review. The Administrator will ensure completion of the weekly audits. The DON is responsible for the ongoing compliance.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with multiple diagnoses, including chronic atrial fibrillation, heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, and pulmonary embolism, was administered Midodrine outside of the prescribed parameters. The physician's order specified that Midodrine 10 mg should be given three times daily for hypotension, but only if the resident's systolic blood pressure was 110 or less. Despite this, the medication was administered on several occasions when the resident's systolic blood pressure was above 110, as documented in the Medication Administration Record. Specifically, the medication was given on multiple dates when the resident's systolic blood pressure readings ranged from 112 to 120, contrary to the order. The Director of Nursing confirmed that the medication was administered outside the specified parameters on several occasions, based on both the MAR and staff interviews. The nurse responsible acknowledged that if the medication was signed off as administered, it was indeed given, despite the blood pressure readings being above the ordered threshold.

Plan Of Correction

The facility will continue to ensure medications are administered per physician order. Resident #76 continues to reside at the facility. On 4/1/2025, the DON reviewed the current medication order for midodrine and parameters with resident’s Dr. Chiu. Dr. Chiu reviewed current blood pressures and ordered midodrine to be given daily and to discontinue blood pressure parameters to hold medication. An initial audit was conducted by the DON reviewing medications to treat hypertension and hypotension to ensure current medications with parameters are being followed. Negative findings were reported to the PCP for review and further recommendations. By 4/17/2025, the DON and/or designee will reeducate licensed nursing staff on ensuring they are following the direction in the electronic MAR when completing a medication administration. Ensuring notifications are conducted timely when blood pressure results are outside the parameters given by the prescriber, following those parameters, and properly documenting in the medical record. Weekly for 2 weeks or as directed by the QA committee, the DON will randomly audit residents on hypertensive or hypotensive medications ensuring parameters are being followed, prescribers are notified as directed, and proper documentation is recorded in the medical record. Negative findings will be reported to the QA committee for review. Negative findings will be corrected by notifying the prescriber and reeducating staff. The Administrator will ensure completion of weekly audits. The DON is responsible for the ongoing compliance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident met the appropriate criteria for antibiotic treatment as part of its antibiotic stewardship program. A resident with a history of obesity, diabetes, heart disease, and overactive bladder was admitted and later developed respiratory symptoms, including cough and slight dizziness. Diagnostic studies were ordered, and the resident tested positive for Influenza A. Despite this, the resident was prescribed doxycycline, an antibiotic, and prednisone, a steroid, for treatment of Influenza A, and received these medications for several days. Medical record review showed that the resident did not meet the McGeer criteria for antibiotic treatment of influenza, as the required combination of symptoms was not documented. The resident had a fever and cough, but there was no evidence of at least three additional symptoms such as chills, headache, myalgias, malaise, or sore throat, as required by the criteria. Additionally, although a chest x-ray was ordered to rule out pneumonia, there was no evidence in the records that this diagnostic test was completed. The infection control log indicated that the resident met criteria for antibiotic treatment, but this was not supported by the documented clinical findings or by CDC guidelines, which state that influenza should not be treated with antibiotics. The facility's own policy required the use of McGeer and Loeb criteria to determine the necessity of antibiotics, and prescriptions were to be reassessed for appropriateness based on diagnostic results and clinical status. These protocols were not followed in this case, resulting in the inappropriate use of antibiotics.

Plan Of Correction

The facility will continue to ensure criteria for antibiotic use is being met. Resident #238 continues to reside at the facility. The resident has completed antibiotic treatment with no adverse effects. An initial audit of the last 30 days of antibiotic (ATB) use was conducted by the DON and infection preventionist on 4/17/2025. No negative findings were noted. On 4/14/2025, the Regional Clinician met with the Senior DON, Facility DON (infection preventionist), and Nurse Managers to review current policies and procedures for ATB stewardship. By 4/17/2025, the licensed nursing staff will be reeducated on ATB stewardship, criteria for antibiotic use, and clarifying antibiotic orders when they don't meet criteria, ensuring the rationale is documented in the medical record. Weekly, for 2 weeks or as directed by the QA committee, the DON and/or designee will audit 3 residents on ATB to ensure symptom criteria are met to treat with antibiotics. Negative findings will be reported to the QA committee, and the prescriber will be notified for clarification and rationale for treatment if continuing ATB. The Administrator will ensure the completion of the weekly audits. The DON is responsible for ongoing compliance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure Resident #1 was provided adequate and proper assistance, following manufacturer's guidelines to reposition in a geriatric (geri) chair, which led to an accident with injury. Resident #1, who had severe cognitive impairment and required physical assistance with activities of daily living, suffered a deep laceration on the right inner leg while being repositioned in a geri chair by an STNA. The incident occurred when the STNA attempted to change the resident's position from reclining to sitting, and the chair malfunctioned, causing the resident's leg to get caught and injured. The facility's investigation did not provide conclusive evidence on the cause of the chair malfunction or whether the STNA had ensured proper positioning of the resident before attempting to change the chair's position. The resident's medical record indicated multiple diagnoses, including heart failure, diabetes mellitus, chronic kidney disease, and osteoarthritis. The care plan required staff assistance with activities of daily living and interventions to maintain proper body alignment and reposition the resident for comfort. On the day of the incident, the STNA transported the resident in a reclined position to the dining room and attempted to place the resident in an upright position. The chair malfunctioned, causing the resident's leg to get caught between the leg rest and the frame of the chair, resulting in a severe laceration that required emergency medical attention and 28 sutures. Interviews with staff and family members revealed that the chair used during the incident had not been approved by facility therapy staff for the resident prior to use. Additionally, the STNA did not reposition or check the resident's positioning before transporting or attempting to change the chair's position. The facility's investigation lacked evidence of proper assessment and training for staff on the use of geri chairs, and there was no documented evidence of employee training related to resident safety and positioning. The facility's policy on resident handling and transfers was not adequately followed, leading to the incident and injury of Resident #1.