Parkview Care 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

Surveyors identified a deficiency in the facility’s failure to ensure that comprehensive care plans included a discharge plan of care, as required by facility policy and regulatory standards. Medical record review for four residents admitted and/or readmitted during the review period showed that each had an admission MDS completed and an overall plan of care initiated and revised within the required time frames, but none contained a discharge planning component. These residents had various diagnoses including dementia, hypertension, type 2 diabetes mellitus, Parkinsonism, bipolar disorder, and atrial fibrillation, and some had documented impaired cognition on their admission MDS assessments. Despite these assessments and multiple admissions and readmissions in one case, no discharge care plans were initiated for any of the four residents. For one resident with dementia and multiple readmissions, the plan of care initiated shortly after admission and last revised several months later did not include any discharge planning. For three other residents, each with an admission and subsequent discharge during the review period, their plans of care similarly lacked any discharge planning component, regardless of whether cognition was impaired or intact. In each instance, the MDS RN confirmed during interview that a discharge care plan had not been initiated and acknowledged that it should have been included in the plan of care. Review of the facility’s “Care Plans, Comprehensive Person-Centered” policy, revised 12/2016, showed that comprehensive care plans were required to include the resident’s stated preference and potential for future discharge, which was not reflected in the care plans reviewed. This deficiency was identified incidentally during a complaint investigation.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to implement and monitor pressure-relieving interventions, including a low air loss/alternating air mattress, for a bedbound resident with a pre-existing stage IV pressure ulcer and multiple comorbidities. The resident had diagnoses including multiple sclerosis, sepsis, severe protein-calorie malnutrition, chronic respiratory failure, Crohn’s disease, colostomy, neuromuscular bladder dysfunction, and a long-standing stage IV left buttock pressure ulcer. A care plan and physician orders called for use of a low air loss mattress, turning and repositioning at least every two hours, heel off-loading, and monitoring of wound status and mattress function. However, on readmission from the hospital, the nursing assessment documented only an area of skin breakdown to the buttocks without describing or measuring the wound, and there was no documentation of what pressure-relieving surface was in use or any assessment of the low air loss mattress for proper fit or operation. Between the resident’s readmission and several days afterward, the medical record lacked documentation that the alternating air mattress function was checked each shift, despite a prior order to do so. There were also gaps in documentation of wound treatments: no wound treatment applications, including the hospital-ordered TRIAD barrier/autolytic debridement, were recorded from readmission until a new dressing order was obtained days later. Turning and repositioning documentation showed long intervals without recorded repositioning, particularly from the time of readmission until early the next morning, and then only sporadic repositioning entries over subsequent days. The record did not contain any documentation that the resident refused repositioning during this period, nor any documentation of off-loading or side-to-side positioning consistent with the care plan and wound specialist recommendations. On one date, nursing notes recorded that staff discussed transferring the resident to a wheelchair so the bed mattress could be worked on, and the resident refused transfer by mechanical lift, stating she would remain in bed until family could transfer her. After this refusal, the record contained no further documentation of attempts to replace or repair the faulty mattress, no re-approach to address the refusal, and no additional interventions to reduce pressure. When surveyors observed the resident, she was lying on her back on a low air loss mattress with an active visual alarm indicating alternate failure and a muted audible alarm. Her feet extended beyond the end of the mattress, with pillows filling an 18-inch gap between the mattress and footboard, and she reported sitting on the metal bed frame. An LPN caring for the resident was unaware the mattress was malfunctioning, did not know how to verify proper operation beyond checking the mattress sides, and confirmed the resident was sitting with direct pressure on the metal frame. Subsequent wound evaluation with the wound specialist showed the original stage IV left buttock ulcer had enlarged and three additional unstageable deep tissue injuries on the back and buttock had developed, which the surveyors attributed to the lack of appropriate pressure-relieving interventions and monitoring. Facility leadership later confirmed that wound measurements and descriptions were not obtained at readmission and were not documented until the wound specialist’s evaluation several days later. They also verified that, following the resident’s refusal to be transferred for mattress work, the medical record lacked evidence of re-approach, assessment of the cause of refusal, or implementation of additional measures to promote skin integrity. The facility’s own pressure ulcer/skin breakdown protocol required examination of newly admitted residents’ skin, physician orders for appropriate pressure reduction surfaces, and ongoing review of whether current approaches remained pertinent to the resident’s condition. The survey findings concluded that these required assessments and interventions were not carried out or documented, resulting in deterioration of the existing stage IV ulcer and the development of three in-house acquired unstageable deep tissue injuries.

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 prevent employment of nursing staff with disqualifying legal convictions related to abuse, neglect, exploitation, or theft, affecting all 31 residents in the facility. Personnel file review showed that an LPN was hired on 10/28/25, and the facility’s criminal background log indicated that the LPN’s background check was submitted on 10/27/25 and returned on 11/20/25. Despite the returned background check, the LPN worked a scheduled shift on 01/06/26 from 6:53 A.M. to 7:36 P.M. The Administrator reported that the LPN had been charged and found guilty of domestic violence and had not disclosed this conviction at the time of hire. When the fingerprint/background results were returned, the acting human resources staff and the Business Office Manager/Human Resource designee recorded the Bureau of Criminal Investigation results as acceptable and did not recognize that the code “A” on the report indicated a disqualifying offense. During interview, the Business Office Manager/Human Resource designee stated she was unaware that this code disqualified the LPN from employment and, upon review of the list of employment disqualifying offenses, it was confirmed that the code corresponded to a domestic violence conviction. This was inconsistent with the facility’s written policy titled “Resident Right to Freedom from Abuse, Neglect, and Exploitation,” dated 2025, which states the facility will not employ individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency in the facility’s handling and inventory of controlled substances and narcotic medications for all eight residents who were receiving these drugs. During an early-morning observation, pharmacy delivery staff handed a package of medications, including controlled substances, to an LPN, who did not count the medications or review the contents with the delivery person before the delivery staff left the building. The LPN then placed medication cards, including those containing controlled/narcotic medications, into two medication carts without any second staff member present to monitor or verify the placement. A subsequent reconciliation count of narcotic medications in the front medication cart showed a discrepancy between the documented inventory and the actual number of tablets for an oxycodone 5-325 mg prescription for one resident. The control substance inventory sheet for this resident’s oxycodone listed a total of 23 tablets, while the medication card contained only 22 tablets. In an interview at the time of the observation, the LPN confirmed that the reconciliation count was not accurate and stated that she had previously administered a dose of the medication to the resident but had not recorded the removal on the controlled substance inventory sheet at the time of administration. Review of the facility’s controlled substances policy showed that controlled substances are required to be counted upon delivery by both the receiving nurse and the delivery person, with both signing the controlled substance record, and that controlled medications are to be counted at each shift change by the oncoming and outgoing nurses together. The Regional RN later confirmed that medication delivery requires a joint count by the receiving nurse and delivery personnel, including when narcotics are delivered.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to implement physician-ordered interventions to manage lower extremity edema for two residents. For one resident with diagnoses including lymphedema, chronic venous hypertension with lower extremity ulcer, chronic peripheral venous insufficiency, morbid obesity, cellulitis, and a history of transient ischemic attack, the care plan addressed risk for impaired skin integrity and included interventions such as pressure-relieving/reducing mattress use and skin monitoring. A physician order directed that bilateral lower extremities be washed, patted dry, and wrapped with UNNA boot dressings from toes to below the knee, covered with Coban, to be changed three times weekly and as needed, with triad paste and roll gauze plus Coban as an alternative if UNNA boots were unavailable. On observation, the resident was in bed without any pressure relief boots or wraps in place, and the RN confirmed the absence of ordered treatments and assessed the resident as having +3 edema in both lower extremities. For a second resident with diagnoses including intracerebral hemorrhage, right-sided hemiplegia, seizure disorder, anxiety disorder, deep vein thrombosis and embolism of the right lower extremity, chronic respiratory condition, tracheostomy, gastrostomy, and anemia, the care plan addressed impaired self-care and mobility deficits and included application of ace wraps to the right lower leg from toes to knee. A physician order specified ace wraps to the right lower leg from toes to knee each shift as tolerated for edema. During observation, this resident was seated at the bedside with feet on the floor and no wraps applied to the lower extremities. An LPN verified that the leg wraps were not in place, assessed +3 edema in the right lower extremity, and the resident reported that the wraps had not been applied for the past three days. These findings show that physician-prescribed treatments for edema management were not implemented as ordered for both residents.

Penalty

No penalty information released

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

Summary

The facility failed to notify a resident's representative of significant changes in the resident's condition, specifically regarding weight loss and new dietary interventions. The resident, who had severe cognitive impairment and multiple complex diagnoses including acute respiratory failure, chronic ulcer, dysphagia, and severe protein calorie malnutrition, experienced a notable weight loss during their stay. Despite physician orders for weekly and then monthly weights, the resident's admission weight was not documented, and there were gaps in weight documentation leading up to discharge. The resident's weight dropped from 159 pounds at hospital admission to 145 pounds within two weeks, and the dietician was notified of this loss, recommending additional nutritional supplements and changes to the resident's diet. Physician orders were updated to include nutritional supplements and a change in diet consistency, but there was no documentation that the resident's representative was informed of the weight loss, the recommended interventions, or the new physician orders. Staff interviews and policy review confirmed that the facility's policy required notification of the resident's representative in the event of changes in condition or treatment, but this did not occur. This deficiency was identified during a complaint investigation and affected one resident out of those reviewed for changes 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

The facility failed to obtain and document a resident's weight upon admission as required by physician orders and facility policy. The resident, who had multiple diagnoses including severe protein calorie malnutrition, dysphagia, and acute respiratory failure, had a history of significant weight loss prior to admission. Despite a physician order for weekly weights for four weeks followed by monthly weights, there was no admission weight recorded, and weights were not documented from a certain date through discharge. This lack of documentation prevented proper monitoring of the resident's nutritional status. Additionally, the facility did not ensure that all recommended nutritional interventions were implemented and monitored. Although the dietician recommended a health shake and a frozen nutritional supplement to address the resident's protein and calorie needs, only the health shake and protein supplement were ordered and documented as administered. There was no physician order or documentation for the frozen nutritional supplement, and staff interviews confirmed it was not received. Facility policies required monitoring and documentation of weights and dietary intake, but these were not consistently followed for this resident.

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 that several resident rooms were not maintained in a safe and sanitary condition. Specifically, in three out of six rooms observed, floor ventilation air vents were found to have rust spots, missing paint finish, and in one case, a vent was bent in the middle. Additionally, there was a significant buildup of dust inside the floor vents. In one room, a piece of trim was missing alongside the bed, with a nail protruding from the wall. These conditions were directly observed by surveyors during their inspection. The Director of Maintenance confirmed the degraded condition of the ventilation vents and the missing trim with the exposed nail, stating that facility staff had not reported these issues to him. An interview with the Regional Risk Registered Nurse revealed that the facility did not have a policy regarding the maintenance of resident rooms. Review of the Director of Environmental Services' job description indicated responsibility for periodic inspections and correction of damages in resident rooms, but these duties were not carried out as required.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that physician orders were in place and care was provided for a resident with a peripherally inserted central catheter (PICC line) used for long-term intravenous access. Medical record review showed that after a hospital visit for a urinary tract infection, the resident was discharged with a new PICC line and an order for IV vancomycin. The care plan indicated the need for IV antibiotics and monitoring of the PICC line, including site evaluation, dressing changes, and tubing management. However, there were no physician orders for monitoring, flushing, or dressing changes for the PICC line from the time it was placed until 15 days later. Review of the Treatment Administration Record (TAR) confirmed that during this period, there was no documentation of PICC line flushing, monitoring, or dressing changes. The Director of Nursing verified that there were no orders for these essential care activities during the specified timeframe, despite facility policy requiring regular flushing, monitoring, and documentation for IV catheters. This lapse was identified during a complaint investigation and affected one resident with a PICC line.

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 qualified staff were available to administer intravenous (IV) medication through a Peripherally Inserted Central Catheter (PICC) line for a resident who required this level of care. The resident, who had diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and Crohn's disease, was admitted and later readmitted to the facility. Following a hospital visit for a urinary tract infection, the resident was discharged with a new order for vancomycin IV to be administered every twelve hours via a PICC line. The medication was delivered to the facility, but was not administered as ordered. Documentation and staff interviews revealed that the doses of vancomycin scheduled for administration were missed because there was no Registered Nurse (RN) available to initiate the medication through the PICC line. The Director of Nursing (DON) confirmed that she was the only RN on staff and was not present to administer the medication, and the Assistant Director of Nursing (ADON) was no longer employed at the facility. Facility policy required that medication be administered without unnecessary interruptions and in accordance with prescriber orders, but this was not followed due to the lack of qualified staff.

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 the accuracy of an admission Minimum Data Set (MDS) skin condition assessment for one resident. Upon review, the resident was admitted with diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon. Hospital discharge documentation indicated the presence of a right buttock wound and a left buttock deep tissue injury. However, the facility's admission wound assessment, completed by the Director of Nursing (DON), documented only a surgical incision to the abdomen and a stage two pressure ulcer of the left axilla, with no mention of wounds to the buttocks. The admission MDS assessment, completed by an MDS Registered Nurse who had not personally assessed the resident, recorded a stage two pressure ulcer and a deep tissue injury based solely on hospital documentation. During interviews, the MDS nurse admitted uncertainty about how to proceed when hospital records and clinical assessments did not align, as she was still in training. Subsequent observation and interviews confirmed the absence of pressure ulcers or deep tissue injuries on the buttocks at admission. The facility's policy required interdisciplinary participation in resident assessments, but the discrepancy between hospital and facility findings was not resolved prior to completing the MDS assessment.

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 colostomy drainage bag changes were completed according to physician orders for a resident with a colostomy. The physician's order specified that the ostomy bag should be changed every three days and as needed. However, a review of the treatment administration record over a specified period revealed no documentation that these changes had been performed as ordered. The resident, who had diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon, reported that her colostomy bag had burst a couple of times when she rolled over in bed, and she was unsure how often staff were changing the bag. Further investigation found that the order to change the colostomy bag appeared on the treatment administration record but was not entered correctly, preventing staff from documenting when the changes were completed. Interviews with facility leadership confirmed the lack of documentation for the required colostomy bag changes. Additionally, facility policy required staff to document the date and time of colostomy care, but this was not done in this case.

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 diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon was not administered their prescribed apixaban 5 mg at night on two consecutive days following admission. The resident had intact cognition and was admitted with physician orders for several medications, including apixaban, dronabinol, folic acid, and oxycodone. Although apixaban was available in the facility's automated medication dispensing machine, the medication was not given as ordered on the nights in question. The failure to administer the medication was due to a combination of factors: the admitting LPN did not enter the physician medication orders before the end of her shift, and the night shift LPN did not have authorized access to the automated medication dispensing machine. Additionally, neither nurse notified the physician that the medication would not be administered. The DON confirmed that the nurse could have contacted her to obtain the medication, but this did not occur. Facility policy required medications to be administered per physician orders but did not provide guidelines for physician notification when medications were unavailable.

Penalty

No penalty information released

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

Summary

The facility failed to implement a comprehensive water management program to prevent the growth of Legionella bacteria. The water management plan lacked specific information on how the facility would intervene if control measures were not met, what actions would be taken if contamination was suspected, and how the effectiveness of the plan would be monitored on an ongoing basis. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of these critical components in the plan. The facility's policy on Legionella surveillance and detection stated a commitment to preventing water-borne contaminants, but the plan did not align with the CDC's recommended key elements for a water management program. Additionally, the facility failed to adhere to infection control procedures during medication administration. An LPN administered insulin to a resident with diabetes mellitus without wearing gloves, as observed during a medication pass. The LPN confirmed the oversight in an interview. The facility's policy on administering medications, revised in December 2002, required staff to follow established infection control procedures, including the use of gloves, which was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to provide activities that met the preferences and needs of its residents, particularly in the evenings and on weekends. This deficiency was identified through a review of medical records, resident and staff interviews, and the facility's activities calendar. A resident, who was cognitively intact and independent in mobility and activities of daily living, expressed dissatisfaction with the lack of evening and weekend activities. The resident noted that the facility did not offer a variety of activities that matched their interests, and this was corroborated by the activities calendar, which showed no scheduled activities after 3:00 P.M. on weekdays or weekends, except for a Bible study session once a week. The Activities Director confirmed the absence of organized activities during these times and explained that certified nurse aides were expected to provide activities and stimulation on weekends due to the lack of dedicated activities personnel. The facility's policy on activities emphasized the importance of conducting person-appropriate activities that cater to the specific needs and interests of residents. However, the facility had not yet adapted its activities program to suit the younger resident population, contributing to the deficiency in meeting the psychosocial well-being of the residents.

Penalty

No penalty information released

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

Summary

The facility failed to maintain medical equipment and supplies in a sanitary manner, affecting all 34 residents. During an observation with the Maintenance Director, it was discovered that the medical supply rooms in the facility's basement contained soiled and compromised supplies. Specifically, an open box of 16 indwelling urinary catheter insertion trays was found with a brown substance on them, and a closed case of tracheostomy care kits was discovered with a yellow-brown substance and moisture stain penetrating the box. Additionally, the large medical storage room had a heavy amount of debris on the floor, including incontinence briefs, open COVID-19 test kits, specimen sample containers, and wound treatment dressing packages. The shelving in the large storage room also had 96 boxes of medium latex gloves fused together due to moisture infiltration. Interviews with staff revealed that the nursing staff currently utilizes the medical storage supplies located in the two basement medical storage rooms. The Director of Nursing confirmed the soiled and compromised medical supplies and acknowledged that there was no current procedure or policy in place to ensure medical supplies were maintained and stored in a sanitary manner. The report identified one resident with an indwelling urinary catheter and another with a tracheostomy, indicating the potential impact on residents requiring specific medical supplies. This deficiency was investigated under Complaint Number OH00157897.

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 the heating and air conditioning equipment was operational in a resident's room, affecting one resident out of four reviewed for environmental heating, ventilation, and cooling. The resident, who had diagnoses including Alzheimer's disease, multiple sclerosis, dementia, mood disturbance, anxiety disorder, and hypertension, was placed in a single occupancy room with a non-operational PTAC unit as the sole source of heating and cooling. The resident reported that the heat and cooling had not been operational since being placed in the room and had requested additional blankets. Observations confirmed that the PTAC unit was unplugged, and the room temperature was recorded between 71-81 degrees Fahrenheit. The Maintenance Director confirmed that the PTAC unit had not been operational for an undetermined time and that the facility was attempting to obtain a replacement. The Administrator confirmed that the facility's COVID-19 infection control protocol required room doors to be closed when a resident is in isolation, further impacting the resident's ability to adjust the room temperature.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe and hazard-free physical environment, affecting one resident's room. During an observation, a resident was found in a room with a broken window pane that had three fractures extending across the entire pane, allowing exterior air to enter the room. Additionally, the room had three electrical receptacles with electronic devices plugged in, which were extremely loose in their junction boxes. One of these outlets was dislodged, with a one-foot diameter section of drywall broken away from the wall. The Maintenance Director confirmed these issues during a subsequent observation and stated he was unaware of the environmental concerns in the resident's room.

Penalty

Inspection fine: $91,637

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 protect a cognitively impaired resident from resident-to-resident sexual abuse. Resident #02 exhibited increased sexual behaviors towards other residents, including exposing his genitalia and inappropriate touching. Despite these incidents being reported by staff, the facility did not update Resident #02's care plan to reflect these behaviors or implement effective interventions to prevent further abuse. This led to multiple incidents where Resident #02 exposed himself and inappropriately touched Resident #03 and Resident #21. On one occasion, Resident #02 was found with his pants unfastened in front of Resident #03, and on another, he was caught with his hands down Resident #03's pants. Despite these incidents, the facility only increased monitoring and did not initiate one-on-one supervision until much later. Resident #03 experienced significant psychosocial distress, including self-isolation and fearfulness, as a result of these incidents. The facility's failure to act promptly and effectively allowed the abuse to continue, causing harm to the residents involved. Interviews with staff revealed that the incidents were reported to the nursing staff, but no immediate or effective actions were taken. The Director of Nursing (DON) was not notified promptly, and there were no follow-up assessments or interventions for the affected residents. The facility's lack of timely and appropriate response to the reported sexual behaviors and abuse incidents resulted in ongoing harm and distress for the residents involved.

Removal Plan

• Resident #03 was assessed by the DON for ill effects. Physician #400 was notified with a new order for a psychiatric evaluation. Resident #03's care plan was updated by Regional Minimum Data Set Registered Nurse (RMDSRN) #49 with interventions for maintaining safety, a room change, and psychosocial well-being intervention to allow resident time to answer questions and to verbalize feelings, perceptions, and fears as indicated.
• Resident #02's care plan was updated by RMDSRN #49 for sexually inappropriate behaviors with interventions including intervening as necessary to protect the rights and safety of others, divert attention and remove resident to alternative location as needed, and monitoring behavior episodes, determine cause, and document. Resident #02's intervention of one-to-one supervision was effective pending psychiatric evaluation which is scheduled. Resident #02's interventions include: psychiatric evaluation, one-to-one monitoring, urinalysis STAT (immediately) and urinalysis with culture and sensitivity ordered by Physician #400.
• RMDSRN #49 updated the care plan for Resident #21 identified with sexually inappropriate behavior.
• The DON and QARN #43 completed a facility-wide audit to ensure accuracy of residents at risk for abuse were safe with no issues. The DON to complete audits weekly during clinical rounds and morning clinical meetings.
• The facility immediately implemented the following measures to assure this alleged deficiency does not recur: 1. The Administrator and DON provided the abuse policy education to all staff. 2. QARN #43 reviewed the policies and procedures related to abuse, documentation, and reporting. There was no revision to the policy made. 3. The DON provided an all-staff in-service on the policies and procedures stated above. 4. QARN #43 and RDO #40 provided education to the DON and Administrator on SRI reporting and immediate interventions.
• QARN #43 and Regional Director of Clinical (RDC) #48 with other members of the Quality Assurance Performance Improvement (QAPI) team completed a Root Cause Analysis using a Fishbone diagram to review the alleged deficiency. The Medical Director Physician #400 was made aware by QARN #43 verbally of the Immediate Jeopardy and the systemic actions being implemented.
• The DON will complete a random audit of potential for abuse weekly on three residents per week to ensure compliance and randomly thereafter.
• The first Ad-Hoc QAPI meeting was completed. The facility would discuss the results of the audits during a weekly Ad-Hoc QAPI meeting to ensure compliance.
• The DON completed a Self-Reported Incident (SRI) for the incidents.
• The facility Administrator would be responsible for ensuring the plan was completed.

Penalty

Inspection fine: $91,637

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 quarterly Quality Assessment and Assurance (QAA) meetings were completed as required, which had the potential to affect all residents. Review of the quarterly QAA meeting sign-in sheets revealed no documentation of a quarterly QAA meeting with all required members for the second and third quarters of 2023. The Director of Nursing (DON) confirmed the absence of sign-in sheets for these quarters, attributing the oversight to a former administrator who was responsible for the sign-in sheets. The facility's policy, dated 2024, stated that the QAA committee would meet at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified during a complaint investigation.

Penalty

Inspection fine: $91,637

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 the physician and nurse practitioner (NP) were alternating resident visits as required. This deficiency affected five residents out of six reviewed for physician visits. The medical records revealed that the NP had multiple visits with each resident, while the physician had only one signed progress note within the specified timeframe. For instance, Resident #17 had numerous NP visits from 02/21/23 to 05/01/24, but only one physician visit on 02/08/24. Similar patterns were observed for Residents #19, #03, #02, and #11, where the NP conducted frequent visits, but the physician had only one documented visit during the same period. Interviews and policy reviews confirmed the deficiency. Resident #11 reported seeing the physician only once since admission, and the Director of Nursing (DON) verified that there was only one signed physician History and Physical (H&P) progress note for each of the five residents. The facility's policy, last revised in 04/2013, stated that the physician would visit residents at appropriate intervals and ensure adequate alternative coverage. However, the facility did not adhere to this policy, leading to the identified deficiency.

Penalty

Inspection fine: $91,637

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

Summary

The facility failed to report allegations of sexual abuse involving three residents. Resident #21, who had intact cognition and was admitted with multiple diagnoses including malignant neoplasm of the breast and bipolar disorder, was found in a compromising situation with Resident #02. Resident #02, who had impaired cognition and was admitted with diagnoses including dementia and hypertension, was observed with his pants unfastened near Resident #21. The incident was reported to the assistant director of nursing but not to the state agency as required by policy. Another incident involved Resident #02 exposing himself to Resident #03, who had impaired cognition and was admitted with diagnoses including schizoaffective disorder and chronic kidney disease. Housekeeping staff witnessed the incident and reported it to the nurse. Despite this, the incident was not documented in Resident #03's medical record, and no Self-Reported Incident (SRI) was filed with the state agency. The Director of Nursing (DON) confirmed that SRIs were not filed and that the incidents were not investigated until several days later. Interviews with staff revealed that the DON instructed an LPN to cross out a nurse's note documenting the incident and to gather witness statements, which were then placed in the DON's mailbox. The facility's policy on abuse investigation and reporting, which mandates prompt reporting to local, state, and federal agencies, was not followed. This failure to report and investigate the incidents promptly led to a deficiency in the facility's handling of suspected abuse cases.

Penalty

Inspection fine: $91,637

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 nutritional supplements were provided per physician orders for two residents. Resident #25, who had severe cognitive impairment and significant weight loss, was observed not receiving the prescribed magic cup nutritional supplement during lunch. The resident's medical record indicated orders for a regular diet and nutritional supplements due to protein-calorie malnutrition, but the Medication Administration Record (MAR) showed varied supplement intakes. Dietary staff confirmed the omission and provided the supplement after being notified. Similarly, Resident #19, who had impaired cognition and significant weight loss, was not provided the prescribed nutritional shake supplement during breakfast. The resident's medical record included orders for a regular diet and nutritional supplements for severe protein-calorie malnutrition and cachexia. The care plan highlighted the resident's history of stomach cancer and partial stomach removal. A registered nurse confirmed the omission and notified dietary staff, who then provided the supplement. The facility's policy on food and nutrition services required staff to inspect food trays to ensure correct meals were provided, but this was not adhered to in these instances.