Rae Ann Geneva

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 honor a resident’s right to a dignified existence and to follow his established end-of-life and funeral arrangements. The resident was a long-term placement with diagnoses including dementia, type 2 diabetes, and aftercare following joint replacement surgery, and had a DNR-CCA order. His care plan and medical record documented that he was on hospice, had a guardian, and had pre-arranged, fully paid funeral and burial arrangements with a specific funeral home, including a designated burial plot. Hospice admission documentation and a hospice client coordination note indicated that a funeral provider was on record, and an LPN documented confirming with the guardian that the funeral home on file was correct. On the day of death, an LPN documented the resident’s time of death and notified the MD and hospice, with hospice to notify the guardian and the funeral home. Later, another LPN documented that the resident’s body was released to a crematorium. Subsequent email correspondence showed that social services questioned hospice about why the crematorium had been called when prior arrangements with the funeral home were in place, and the funeral home contacted the facility requesting the resident’s body. The funeral home’s office manager stated the resident was supposed to be released to that funeral home, had long-standing pre-arrangements since 1987, was not to be cremated, and that there was no documentation in the medical record, hospice agreement, or any crematorium agreement indicating the crematorium should receive the body. Interviews revealed conflicting accounts between hospice staff and facility staff regarding which entity was designated to receive the body. A hospice RN and hospice LSW each stated they had confirmed with the guardian that the crematorium was the correct provider, but neither could produce documentation of any agreement with the crematorium. The guardian reported she had never heard of the crematorium until contacted by them and stated the resident was to be transferred to the funeral home and should never have been released to the crematorium. The crematorium coordinator confirmed there were no pre-arrangements, paperwork, or burial plans for the resident and that the body was picked up after the facility contacted them and remained there for about three days before being released to the correct funeral home. The funeral home office manager further reported being told by social services that the nurse at the time of death could not locate the funeral home paperwork and therefore contacted the nearest funeral home. The Administrator and DON acknowledged that the resident had pre-arrangements with the funeral home, that this was well documented in the record, and that the facility released the body to the wrong funeral home.

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 injury of unknown origin for one resident. The resident was a long‑term resident with heart failure, pulmonary fibrosis, dysphagia, memory problems, and dependence on staff for ADLs. Her care plan identified her as at risk for falls due to a history of falls, with interventions including family involvement and assistance with ADLs. Physician orders required use of a two‑person mechanical lift for transfers and turning/repositioning every two hours as tolerated. On the evening in question, after routine night care in which a CNA rolled the resident for check and change, the resident began complaining of left knee pain approximately 20 minutes later and contacted her POA, who requested transfer to the ER. The roommate reported that during the check and change the resident was yelling out, and CNA #902 reported that the resident resisted, pushed back, and screamed while being rolled, after which she was placed on her back and later complained of knee pain. The resident was sent to the hospital and diagnosed with a distal fracture of the femur and a UTI. The facility’s SRI documented this as an injury of unknown origin and concluded the fracture was most likely secondary to underlying chronic disease processes rather than acute trauma, with no reported history of falls or physical injury, even though the resident reported that her leg had been pulled back and she believed it was broken. Despite these differing accounts and clinical information, the facility’s investigation, as reflected in the SRI and email correspondence, concluded that no incident or trauma occurred and that the fracture was pathological in nature. A hospital note described the fracture as an acute, impacted distal femoral metaphyseal fracture indicating a recently broken bone due to a specific trauma or injury, and a follow‑up note by the medical director referenced a recent fall with a distal left femur fracture. The DON stated she was unaware how the fracture occurred, acknowledged there was no known fall before the resident was sent out, and attributed the event in part to the resident pushing against the bed during care. When questioned about the discrepancy between the hospital documentation of an acute fracture and the facility’s conclusion of a pathological fracture, as well as the medical director’s note referencing a fall, the DON was unable to provide additional documentation to clarify the SRI findings, the documented fall, or the ambiguity between an acute versus pathological fracture, despite a facility policy requiring all allegations to be thoroughly investigated.

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 required bed-hold notifications to residents and/or their representatives upon transfer to the hospital. One resident was a long-term male resident with atherosclerotic heart disease, post-laminectomy syndrome, hypertension, impaired upper extremities, and dependence on staff for ADLs. His MDS showed a BIMS score of seven, indicating he was alert and oriented with cognitive impairment, and he had a designated representative and care conference contact. He was sent to the hospital via emergency services after a change in condition, but his medical record did not contain any documentation that bed-hold notifications of days remaining were provided to him or his representative at the time of this discharge/transfer. Another long-term female resident with heart failure, pulmonary fibrosis, dysphagia, memory problems, and dependence on staff for ADLs was also affected. She had a designated POA, representative, and care conference contact, and was ultimately discharged from the facility. Progress notes documented that she was sent to the hospital via emergency services on two separate occasions after changes in condition. However, her medical record lacked bed-hold notifications of remaining days for both hospital transfers. During an interview, the Admissions Director stated that residents on Medicaid who were sent to the hospital and expected to return should receive a bed-hold notice and that all such notices and policies were kept in the medical record. The Admissions Director reported that this resident and later her POA were informed of remaining bed-hold days for all transfers, but upon review of the record, confirmed there were no bed-hold notifications for the two identified hospitalizations, despite a facility policy requiring provision of a bed-hold letter and policy upon admission and any subsequent discharge or transfer.

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 ensure that the physician accurately documented and provided services as recorded in the medical record, resulting in false documentation and billing for services not rendered. A long-term resident with multiple diagnoses, including heart failure, pulmonary fibrosis, dysphagia, memory problems, and dependence on staff for ADLs, was admitted to the facility and later transferred to the hospital for a change in condition, without returning to the facility. The resident’s actual date of leaving the facility was documented as mid-month, and the facility stopped billing at the end of that month. A progress note later documented that the resident was not returning to the facility following the hospital transfer. Despite the resident’s non-return and discharge status, an after-visit summary dated approximately two weeks after the hospital transfer documented that the medical director examined the resident in the facility, including a detailed discussion of multiple medical conditions and specific vital signs. An insurance statement showed that the physician billed for doctor and nursing home care on that date, and payment was processed. The AD confirmed the resident should not have been billed after the end of the month, and the DON acknowledged that the physician’s documentation was sometimes inaccurate and verified that the resident was not in the facility when the after-visit was completed. Email correspondence from the physician confirmed he had documented seeing the resident at the facility on that date even though she had transferred to the hospital with no return, contrary to the facility’s policy requiring objective, complete, and accurate documentation in the medical record.

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 medical record for a resident in accordance with its documentation policy. The resident was admitted with multiple diagnoses including heart failure, pulmonary fibrosis, and dysphagia, and was care planned as a long-term resident not expected to return to the community. She transferred to the hospital for a change in condition and did not return to the facility, with her actual date of leaving identified as mid-January and her discharge date documented as later that month. A progress note indicated she was not returning to the facility following her hospital transfer. Despite the resident no longer being in the facility and having been discharged, an after-visit summary was entered in her medical record with a date after her discharge, documenting that the medical director examined her in the facility. This after-visit note included a detailed discussion of multiple medical conditions and specific vital signs, implying an in-person examination that did not occur at the facility because the resident was no longer present. The DON acknowledged that the physician’s documentation was sometimes inaccurate with dates and confirmed the resident was not in the facility when the after-visit was completed, and the Administrator also confirmed the after-visit summary was incorrect. This conflicted with the facility’s “Charting and Documentation” policy, which required objective, complete, and accurate information in the resident’s medical record.

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 develop and implement a comprehensive, individualized pressure ulcer prevention and treatment program for a resident with multiple comorbidities and severe functional dependence. The resident was legally blind, had osteoarthritis, dysphagia, heart disease with heart failure, COPD, chronic kidney disease, anemia, depression, anxiety, and a history of repeated falls and acute respiratory failure. She was severely cognitively impaired, dependent on staff for toileting, bathing, bed mobility, and transfers, had an indwelling urinary catheter, and was frequently incontinent of bowel. Despite these risk factors, the care plan for impaired skin integrity did not translate into consistent, accurate assessment and documentation of her coccyx pressure ulcer, and the 5‑Day MDS inaccurately documented that she had no pressure ulcers and no nutritional or hydration interventions for skin problems, even though she had a Stage II coccyx ulcer on readmission. The resident returned from the hospital on one occasion with a Stage II coccyx pressure ulcer that was not measured or described, and early treatment orders (e.g., zinc and foam dressing) were not documented as completed on multiple days. On a subsequent readmission, the coccyx wound was documented as Stage I with minimal description, and treatment orders again were not documented as completed on specified dates. By 10/13, the wound had progressed to a Stage III ulcer with 100% slough, and although wound care orders and nutritional supplements were initiated, the Prostat supplement was discontinued due to refusals. After another hospitalization, the resident returned with a Stage II coccyx ulcer and a suspected deep tissue injury to the buttock; wound care orders were in place and documented through the end of October, but the weekly wound summary on 10/31 showed the coccyx ulcer worsening in size and appearance and the buttock injury enlarging. In November, there were significant lapses in wound assessment and treatment implementation. From 11/08 through 11/21, there were no treatment orders or documented treatments for the coccyx wound, and there were no wound assessments between 10/31 and 11/13, and then no documented coccyx treatments from 11/13 through 11/20, despite a 11/13 note describing the coccyx as a Stage III ulcer with 90% slough. On 11/21, the coccyx wound was found to have deteriorated to an unstageable ulcer with 100% slough, erythema, and warmth, requiring sharp debridement and extensive diagnostic workup. The DON later confirmed that there was no in‑house wound care team for several months, that an LPN who could not stage wounds was performing wound assessments with RN assistance, and that orders were not transcribed, resulting in a lapse of treatment during the transition between wound care providers. The CNP acknowledged awareness of the gap in wound care from late October to late November and noted the resident’s poor intake and refusals to get out of bed, while the dietitian described ongoing weight loss, fluctuating supplement acceptance, and concerns about the resident’s nutrition and wound status since October. These combined assessment, documentation, and treatment failures led to the worsening of the resident’s coccyx pressure ulcer from Stage II to Stage IV.

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 staff member working as a CNA met state and federal requirements before providing direct resident care. Human Resources records and interviews showed that this individual was hired as a CNA and provided care to residents for approximately 17 months without ever obtaining CNA certification or being listed on the Nurse Aide Registry. The HR Director reported that the staff member completed an initial Nurse Aide Training class and repeatedly attempted the CNA test but failed the written portion multiple times, then missed a subsequent test and was required to retake the entire training. After completing a second Nurse Aide Training class, the staff member again failed the written test and never achieved certification. Despite this, the facility allowed the individual to continue performing CNA duties and providing care to residents throughout the facility. Review of the personnel file confirmed only certificates of completion for two Nurse Aide Training classes and no documentation of a Nurse Aide Registry check or active certification. This deficiency was identified through personnel record review and staff interviews and was associated with complaint investigations, with the facility census noted as 60 residents at the time of the survey. The report states that this failure had the potential to affect all residents residing in the facility.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to report an injury of unknown origin to the State Survey Agency as required by its own policy and regulations. A resident with multiple complex medical conditions, including local skin infection, congestive heart failure, pulmonary fibrosis, dysphagia, hypoxemia, hypertensive heart disease with heart failure, gout, anemia, osteoporosis, major depressive disorder, generalized anxiety disorder, hypothyroidism, chronic pain syndrome, chronic kidney disease, acute respiratory failure with hypoxia, myocardial infarction, osteoarthritis of the knee, cognitive communication deficit, COPD, repeated falls, and legal blindness, was admitted on 01/07/22. The resident’s MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and documented that the resident was dependent on staff for all ADLs and mobility. On 06/05/25, the resident complained of right knee pain, and an x-ray was ordered and performed on 06/06/25. The x-ray results showed a broken osteophyte at the superior margin of the patella, likely chronic, and moderate osteoarthritis of the right knee joint. During an interview on 01/08/25, the DON stated that staff were unaware of how the resident’s knee injury occurred and confirmed that an investigation was conducted. However, no self-reported incident related to this injury of unknown origin was submitted to the State Survey Agency, despite the facility’s written policy requiring immediate reporting of suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source to the administrator and appropriate officials within specified time frames. This failure to report was identified as an incidental finding 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 ensure staff followed appropriate infection prevention and control practices during incontinence care for one resident and wound care for another. For the first resident, who had multiple medical conditions including vascular dementia, orthopedic aftercare needs, and complete dependence on staff for ADLs and continence care, surveyors observed incontinence care being performed by an LPN and a CNA. After removing the resident’s soiled brief and performing perineal care, the CNA removed her soiled gloves and immediately donned clean gloves without performing hand hygiene before obtaining and applying clean clothing. The LPN also did not change gloves or perform proper hand hygiene between handling the soiled brief and proceeding with the clean brief. Both staff members later confirmed they had not applied clean gloves or used proper hand hygiene between the soiled and clean portions of the care. The second deficiency involved wound care for another resident who was cognitively intact, independent with ADLs, and had a Stage III pressure ulcer on the right lateral ankle with care orders that included cleansing with normal saline, applying Skin-Prep, and covering with a bordered foam dressing. This resident had an active order for enhanced barrier precautions (EBP), and signage indicating EBP was posted on the door. During observed wound care, the LPN sanitized the bedside table, placed a barrier, gathered supplies, performed hand hygiene, and donned clean gloves, but did not don any additional PPE required under EBP before starting the procedure. The LPN removed the soiled dressing, discarded it, changed gloves with hand hygiene in between, cleansed the wound, applied Skin-Prep and a new foam dressing, and completed the task without ever using the additional PPE indicated by the EBP signage and facility policy. The facility’s own undated standard precautions policy required hand hygiene before and after direct contact with a resident’s skin, after contact with body fluids or excretions, and after glove removal. CDC guidance on hand hygiene and glove use, cited in the report, states that gloves are not a substitute for hand hygiene and that staff should change gloves and perform hand hygiene when moving from a soiled body site to a clean body site on the same patient. The DON confirmed that the facility had a policy requiring PPE use for wound care. The observed failures in hand hygiene and PPE use for these two residents were identified as deficiencies 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 facility failed to ensure that the medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings as required. Review of QAPI meeting attendance sign-in sheets over a period of more than a year showed that the medical director did not attend any of the meetings. This was confirmed during an interview with the administrator, who verified that there was no evidence of the medical director's attendance at any QAPI meeting during the specified timeframe. Additionally, the facility's QAPI policy did not specify the required members, including the medical director, nor did it outline the frequency of attendance for required members.

Plan Of Correction

All residents were immediately assessed and found to have no adverse effects. All QAPI reviewed and ensured that physician was in attendance Quarterly. Education immediately provided by admin to all staff required to be in attendance at QAPI regarding attendance requirements. Admin/Designee to review next 3 QAPI meetings to ensure all necessary attendees are present. Results to be reviewed in QAPI.

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 the building floors in a safe and clean condition, as evidenced by multiple observations of soiled, stained, cracked, and sunken flooring throughout various areas, including the front foyer, hallways, nurses' stations, and resident rooms. Specific issues included dark soiled areas, worn and scratched surfaces, scuff marks, cracked and sunken tiles, and sloping floors that posed a fall hazard. The carpeted areas near the dining room and nurses' station were also noted to have permanent stains, and the floor bordering the nurses' station was observed to slope downward, increasing the risk of falls for residents who ambulate in that area. These conditions were confirmed by both staff interviews and direct observation. Interviews with staff, including an LPN and the Housekeeping Director, verified awareness of the floor hazards, including the sloping floor and the presence of permanent stains. The Housekeeping Director reported that floors were scrubbed monthly and mopped daily, with carpets cleaned weekly, but acknowledged that some stains were permanent and deep cleaning may not occur routinely each month. The Administrator confirmed knowledge of the floor conditions and ongoing discussions with ownership about floor replacement, but was unaware of any formal plan or scheduled dates for repairs. The deficiency had the potential to affect all 66 residents residing in the facility.

Plan Of Correction

All residents were immediately reviewed and found to have no adverse effects. All residents have the ability to be affected. Flooring was immediately reviewed by the Administrator, Housekeeping Supervisor, and Maintenance Department to ensure floors were safe and clean. Housekeeping Supervisor immediately buffed all tile flooring. Maintenance Department replaced all cracked and chipped tiles by 5/30/25. Housekeeping Supervisor deep cleaned all carpeting on 5/22/25. Maintenance/Designee to monitor flooring weekly for 4 weeks to ensure compliance. Results to be reviewed in QAPI.

Penalty

No penalty information released

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

Summary

The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframe of 92 days for nine out of eleven residents reviewed. Record reviews showed that for each of these residents, the last quarterly or annual MDS assessment was not followed by a subsequent quarterly assessment as mandated. The residents affected had various diagnoses, including Parkinsonism, dementia, diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, hypertensive heart disease, hemiplegia, hemiparesis, chronic pain syndrome, Alzheimer's disease, degeneration of the nervous system due to alcohol, epilepsy, congestive heart failure, and asthma. Interviews with the MDS Coordinator confirmed that the required quarterly assessments were not completed for these residents within the specified timeframe. The deficiency was identified through both record review and staff interviews, with the facility census at 66 residents at the time of the survey. No evidence was found in the records to indicate that the quarterly MDS assessments were completed as required for the identified residents.

Plan Of Correction

Residents #11, 20, 21, 22, 26, 29, 41, 42, and 60 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #11, 20, 21, 22, 26, 29, 41, 42, and 60 quarterly MDS assessments were immediately reviewed by MDS. Residents #11, 22, 26, 29 quarterly assessments were completed immediately, and residents #20, 21, 41, 42, and 60 quarterly assessments were completed on 5/29/25 by MDS. MDS reviewed all quarterly MDS assessments on 5/21/25. Admin provided the MDS Coordinator education on quarterly MDS assessment policy and timely submission. The DON/designee will audit 3 residents' charts weekly to ensure quarterly MDS assessments are submitted timely for 4 weeks. Results will be reviewed in QAPI.

Penalty

No penalty information released

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

Summary

The facility failed to complete and submit Minimum Data Set (MDS) assessments within the required timeframes for all 11 residents reviewed. According to the findings, MDS assessments, including quarterly, annual, significant change, admission, and discharge assessments, were not completed or submitted within the 14-day period mandated after the assessment reference date (ARD) or relevant event, such as admission or discharge. In several cases, the Care Area Assessments (CAAs) associated with the MDS were also not completed within the required timeframe. Record reviews for each resident showed that the assessments were delayed, sometimes by several weeks beyond the required period. For example, one resident's quarterly MDS with an ARD of 12/31/24 was not completed until 02/13/25, and another resident's annual MDS with an ARD of 01/30/25 was not completed until 03/06/25. These delays were consistently verified through interviews with the MDS Coordinator, who acknowledged that the assessments and CAAs were not completed or submitted on time. The residents affected had a range of medical conditions, including Parkinsonism, dementia, diabetes mellitus, COPD, chronic pain syndrome, hypertensive heart disease, epilepsy, and metabolic encephalopathy. The facility's policy, revised in March 2022, required comprehensive assessments to be conducted in accordance with the Resident Assessment Instrument (RAI) User Manual, including completion by day 14 for admission assessments. Despite this policy, the facility did not adhere to the required assessment and submission timeframes for the residents reviewed.

Plan Of Correction

Residents #11, 20, 21, 22, 26, 29, 41, 42, 62, 70, and 60 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #11, 20, 21, 22, 26, 29, 41, 42, and 60 assessments were immediately reviewed by MDS. Residents #11, 22, 26, 29, 62, and 70 assessments were completed immediately, and residents #20, 21, 41, 42, and 60 quarterly assessments were completed on 5/29/25 by MDS. All resident MDS assessments were reviewed by MDS on 5/22/25. Admin provided MDS Coordinator education on MDS Assessment policy and timely submission on 5/21/25. Random weekly audits of comprehensive care plans are to be completed by the DON/Designee within 4 weeks. Results are to be reviewed in QAPI.

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 revise and complete comprehensive care plans for four residents as required. For two residents with cognitive impairment and significant medical conditions, the care plans did not include the use and monitoring of seat belts and alarms as restrictive devices. Specifically, one resident with hemiplegia, hemiparesis, and vascular dementia had a physician order for a Velcro seat belt for positioning and safety, but the care plan only referenced the seat belt as a fall intervention and did not address monitoring or assessment of the device as necessary, appropriate, or least restrictive. Another resident with dementia and multiple comorbidities had orders for an alarming Velcro seat belt and a pressure alarm, but the care plan did not address these devices or include any plan for monitoring or assessment. Observations and interviews confirmed the devices were either in use without proper care plan documentation or had been removed without documentation or care plan revision. Additionally, the facility failed to complete comprehensive care plans within the required timeframe for two other residents. For both, the care area assessment and care plan were completed after the 21-day post-admission requirement. Interviews with the MDS Coordinator confirmed the late completion of these care plans. Record reviews, staff interviews, and facility policy review all supported these findings. The facility's policy indicated that care plans should be used in developing daily care routines and be available to staff responsible for resident care, but this was not consistently followed for the residents reviewed.

Plan Of Correction

Resident #3 and #25 were immediately assessed and found to have no adverse effects. All residents with restrictive devices and alarms have the ability to be affected. Seatbelt for resident #25 was DCed immediately by DON on 5/21/25. Seatbelt for resident #3 was requested to stay in place by resident. Chart was reviewed by DON immediately on 5/21/25 to insure proper documentation was in place. Resident #3 and #25 comprehensive care plan immediately reviewed and updated by MDS on 5/21/25. Admin immediately provided MDS Coordinator education on comprehensive care plan policy and timely submission. Education on appropriate alarm and restrictive device usage and documentation provided by DON to all staff on 5/22/25. All residents alarms/restrictive devices were reviewed by IDT on 5/28/25 to ensure appropriateness and supporting documentation in place. Weekly audits of three alarms/restrictive devices to be complete by DON/designee to ensure the care plan is accurate and the device in place is appropriate as the least restrictive option with proper monitoring for 4 weeks. Results to be reviewed in QAPI.

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 insulin pens for multiple residents were properly dated upon opening and disposed of according to manufacturer guidelines. During observations of the East and North medication carts, opened insulin pens for several residents were found without dates indicating when they were first used. In one instance, an insulin pen was dated but had not been discarded after the recommended period. Interviews with nursing staff confirmed that insulin should be dated when opened, but there was uncertainty regarding the correct duration for use and disposal timelines. The facility's policies required dating multi-dose containers upon opening, but did not specify the required duration for insulin use after opening. Medical records showed that the affected residents had diagnoses including diabetes, hypertension, congestive heart failure, and other conditions requiring insulin therapy. Manufacturer guidelines for the insulins in use specified strict timeframes for discarding opened pens, ranging from 28 days to eight weeks, which were not consistently followed. The facility's failure to date and dispose of insulin as required had the potential to affect all residents with insulin orders, as staff could not determine when the insulin should be discarded.

Plan Of Correction

Resident #8, 11, 63, and 131 were immediately assessed and found to have no adverse effects. All residents with insulin orders have the ability to be affected. Resident #8, 11, 63, and 131 insulin pens were immediately dated by nursing. All insulin pens were audited immediately to ensure proper storage and labeling. Education was provided to all nursing staff by the DON on 5/22/25 regarding proper medication storage. The DON/Designee will audit 3 insulin pens per week for 4 weeks to ensure they are appropriately dated. Results will be reviewed in QAPI.

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 the facility failed to notify a resident's primary care physician (PCP) of an unknown injury involving significant bruising. The resident, who had a history of congestive heart failure, muscle weakness, cirrhosis of the liver, diabetes, and hypertension, was found during a shower to have large areas of discoloration on her right forearm, right arm, right inner thigh, right breast, and the inside of her left arm. The resident was on Plavix, an antiplatelet medication, and her care plan included monitoring for signs of bleeding or bruising and reporting these to the physician. Documentation showed that administration was notified of the bruising, but there was no evidence that the PCP was informed as required by facility policy. The incident was also reported as a self-reported incident (SRI) and an incident report was completed, both noting the extensive bruising and the resident's lack of awareness of how the injuries occurred. Interviews with the resident and the Director of Nursing (DON) confirmed that the PCP was not notified of the unknown injury. Facility policies required prompt physician notification for changes in condition, including injuries of unknown source, especially for residents on anticoagulation therapy. Despite these requirements, there was no documentation or evidence that the physician was contacted regarding the resident's condition.

Plan Of Correction

Resident #9 was immediately assessed and found to have no adverse effects. Open Risk assessments audited by DON to ensure all physicians were notified on 5/22/25. All residents have the ability to be affected. Education on appropriate physician notification for resident change in condition was provided by DON to all staff on 5/22/25. DON/designee to audit 2 charts a week for 4 weeks to ensure PCP was notified of change in condition. Results to be reviewed in QAPI.

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 routinely assess the necessity, appropriateness, and least restrictive use of seat belts and alarms for residents, as required by policy. For one resident with hemiplegia, hemiparesis, and moderate cognitive impairment, a Velcro seat belt was ordered and applied for positioning and safety, but there was no assessment at the time of application or thereafter to determine if the device was necessary, appropriate, or the least restrictive option. The care plan referenced the seat belt as a fall intervention but did not include any plan for monitoring or reassessment, and there was no documentation justifying its use or monitoring its continued need. Staff confirmed the seat belt was used to prevent unassisted rising, and the resident was able to self-release the belt with the unaffected hand, but this was not routinely assessed or documented. Another resident with multiple diagnoses, including dementia and moderate cognitive impairment, had both an alarming Velcro seat belt and a pressure alarm ordered for safety. There were no assessments completed upon application of these devices or subsequently to determine their necessity or appropriateness. The care plan addressed the pressure alarm but not the seat belt, and neither device was monitored or reassessed for continued need or least restrictiveness. Documentation did not justify the use of these devices, and there was no record of their removal, despite staff indicating the devices were no longer in use. Facility policy required a pre-restraining assessment and ongoing re-evaluation for any restrictive device, as well as documentation of the resident's response to interventions. The facility identified 13 residents with seat belts or alarms as restrictive devices, but failed to ensure assessments and documentation were completed as required. Observations and interviews confirmed that devices were used or removed without proper assessment, monitoring, or documentation, resulting in a deficiency related to the use of physical restraints and restrictive devices.

Plan Of Correction

Resident #3 and #25 were immediately assessed and found to have no adverse effects. All residents who utilize alarms or seatbelts have the ability to be affected. Seatbelt order for resident #25 was DCed immediately by DON on 5/21/25. Alarm for resident #3 was requested to stay in place by resident. Chart was reviewed by DON immediately on 5/21/25 to ensure proper documentation was in place. All residents with alarms/restrictive devices were reviewed by IDT on 5/28/25 to ensure the least restrictive device was in place and that remaining devices were appropriate. Education on appropriate alarm and restrictive device usage and ongoing assessment was provided by DON to all staff on 5/22/25. DON/designee to review 3 residents with an alarm or restrictive device in place weekly for 4 weeks to ensure they are necessary, being routinely reviewed, and least restrictive. Results of audit to be reviewed in QAPI.

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 PRN psychotropic medication prescribed to a resident was reviewed by a practitioner for necessity and appropriateness within 14 days, as required. The resident, who had diagnoses including hemiplegia, major depressive disorder, adjustment disorder with anxiety, and vascular dementia, was admitted with severe cognitive impairment. The care plan identified the potential for adverse effects from antianxiety medications and included interventions for administering and monitoring these medications. A PRN order for Vistaril 25 mg every six hours for anxiety or agitation was initiated without a specified duration. Despite a pharmacy recommendation to review the PRN psychotropic order after 14 days, the physician did not review or address the order until over a month later. During this period, the medication was administered on two occasions. The facility's policy required practitioner review and documentation of rationale for continuing PRN psychotropic medications beyond 14 days, but this was not followed. The DON confirmed that the required review was not completed within the specified timeframe.

Plan Of Correction

Resident #33 was immediately assessed and found to have no adverse effects. All residents on a PRN antipsychotic medication have the ability to be affected. All residents on PRN antipsychotic orders were immediately audited by DON/designee to ensure all had stop dates in place. Education on antipsychotic usage, GDR process, and appropriate orders was provided by the DON to all nursing staff on 5/22/25. DON/designee to audit all PRN antipsychotic orders for stop date weekly for 4 weeks. Results to be reviewed in QAPI. Resident #22 was immediately assessed and found to have no adverse effects. All residents have the ability to be affected. MDS reviewed all residents for open annual MDS assessments on 5/22/25 to ensure they were complete. Resident #22’s annual MDS assessments were immediately reviewed and completed on 5/29/25 by MDS. Admin immediately provided MDS Coordinator education on MDS assessments policy and timely submission. DON/designee to audit 2 residents with annual MDS assessments due weekly for 4 weeks. Results to be reviewed in QAPI.

Penalty

No penalty information released

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

Summary

The facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for one resident within the required timeframe of 366 days from the previous assessment. Record review showed that the resident, who had diagnoses including chronic obstructive pulmonary disease and type 2 diabetes mellitus, was admitted on a specified date and did not have a comprehensive MDS assessment completed after the last one documented. This was confirmed during an interview with the MDS Coordinator, who acknowledged that the required assessment had not been completed within the mandated period. Facility policy requires that comprehensive assessments be conducted according to the Resident Assessment Instrument (RAI) User Manual, with annual assessments completed at least every 366 days.

Plan Of Correction

Resident #22 was immediately assessed and found to have no adverse effects. All residents have the ability to be affected. MDS reviewed all residents for open annual MDS Assessments on 5/22/25 to ensure they were complete. Resident #22 annual MDS Assessments were immediately reviewed and completed on 5/29/25 by MDS. Admin immediately provided MDS Coordinator education on MDS Assessments policy and timely submission. DON/designee to audit 2 residents with annual MDS assessments due weekly for 4 weeks. Results to be reviewed in QAPI.

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 residents and their representatives with a written summary of the baseline care plan within 48 hours of admission, as required by facility policy. For two residents reviewed, both with complex medical conditions and cognitive impairments, there was documentation of baseline care plans being developed and family conferences being held to discuss care. However, there was no evidence in the medical records, family conference forms, or nursing progress notes that the residents or their representatives received a written summary of these baseline care plans. Interviews with the MDS Coordinator confirmed that neither resident nor their representatives were given the required written summaries. The facility's policy, revised in March 2022, specifies that such summaries must be provided in a language understandable to the resident or representative. Despite this policy, the documentation and staff interviews verified that this step was not completed for the two residents reviewed.

Plan Of Correction

All residents have the ability to be affected. All baseline care plans reviewed by DON, MDS/designee to ensure they are in place on 5/22/25 and residents received a copy. Admin provided MDS Coordinator education on baseline care plan policy and importance of timely patient review and acknowledgment immediately on 5/21/25. DON provided all nursing staff education on baseline care plan policy and importance of timely patient review and acknowledgment on 5/22/25. DON/designee to audit 3 new admissions baseline care weekly to ensure timely receipt of baseline care plans for 4 weeks. Results to be reviewed in QAPI.

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 care plan that addressed trauma-informed care for two residents with trauma-related diagnoses. For one resident with dementia, major depressive disorder, generalized anxiety disorder, and PTSD, there were no trauma screenings or assessments completed since admission, and no documentation in the care plan, nursing notes, or physician notes regarding trauma, triggers, or trauma-informed interventions. The resident's care plan only referenced cognitive impairment, depression, anxiety, and a history of alcohol abuse, without any mention of trauma-informed care. The nursing assistant Kardex also lacked any information related to trauma-informed care for this resident. Interviews with facility staff confirmed that no trauma assessments were completed and that trauma-related needs were not included in the care plan or daily care routines. Similarly, another resident with PTSD, major depressive disorder, generalized anxiety disorder, and other medical conditions did not have trauma-informed care addressed in the baseline care plan. The baseline care plan included information on adjustment issues, risk factors, and therapy needs, but omitted any reference to PTSD or trauma-informed interventions. Staff interviews revealed that a trauma assessment was not completed within the required timeframe after admission, and as a result, trauma care was not included in the resident's baseline care plan. The facility's own policies required trauma-informed, person-centered care planning, but these were not followed for the residents reviewed.

Plan Of Correction

All residents have the ability to be affected. Social Services and all staff educated by DON on Trauma-Informed Care 5/22/25. PCC Trauma-Informed Care assessment put in place and completed by social services on 5/22/25 for #25, #140, and on all appropriate residents. DON/designee to audit trauma-informed assessments on new admissions weekly for 4 weeks. Results to be reviewed in QAPI.

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 properly monitor and maintain safety interventions for a resident with multiple diagnoses, including dementia, impaired cognition, and a history of falls. Physician orders were in place for an alarming Velcro seat belt and a pressure alarm to the resident's wheelchair for safety and positioning. However, there were no assessments completed to determine the necessity or appropriateness of these devices, and the care plan did not address the seat belt or provide a plan for monitoring or assessment of either device. Documentation in the progress notes did not justify the use of the devices or monitor their continued need, and the seat belt order was not included in the nursing assistant Kardex. Observations revealed that neither the seat belt nor the pressure alarm was in place as ordered, despite being signed off as checked and in place on the Treatment Administration Record. Staff interviews confirmed the devices had been removed at some point without documentation of the removal or rationale, and staff could not specify when or why the devices were discontinued. Facility policy required monitoring and documentation of the efficacy of such interventions, but this was not followed, resulting in a lack of oversight and failure to ensure the resident's safety interventions were properly managed.

Plan Of Correction

Resident #25 was immediately assessed and found to have no adverse effects. All residents with safety interventions have the ability to be effected. Resident #25 seatbelt immediately DCed by DON. Education provided to all staff by DON on 5/22/25 regarding alarm/ restrictive device policy. All residents with orders for restrictive devices/alarms were audited by IDT team on 5/22/25 to ensure they are appropriate, in place, and have required documentation. Don/Designee to audit 2 residents weekly ensuring that proper documentation is in place for their safety interventions for 4 weeks to ensure compliance. Results to be reviewed in QAPI.

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 trauma-informed care and culturally competent services to two residents with trauma-related diagnoses. Both residents had documented histories of PTSD and other mental health conditions, yet their care plans, assessments, and daily care documentation lacked any reference to trauma, triggers, or specific interventions related to their trauma histories. There was no evidence that trauma assessments or screenings were completed upon admission or thereafter for either resident, and their care plans did not address trauma-informed approaches as required by facility policy. Staff interviews revealed a lack of awareness and training regarding trauma-informed care. The Director of Nursing (DON), Certified Nursing Assistant (CNA), Registered Nurse (RN), and Social Services Director (SSD) all confirmed that no trauma assessments had been completed for the residents in question, and that staff had not received training on trauma-informed care, screening tools, or strategies to address trauma-related triggers. The SSD acknowledged that trauma assessments should have been completed within 48 hours of admission to inform the baseline and comprehensive care plans, but this was not done for either resident. Review of the facility's policy on trauma-informed care indicated that all staff were to be trained on trauma, its impact, and the use of screening tools, with universal screening of residents for trauma. However, there was no evidence that these policy requirements were met. The lack of trauma assessments, absence of trauma-related care planning, and insufficient staff training directly contributed to the facility's failure to provide trauma-informed care to residents with known trauma histories.

Plan Of Correction

Resident #25 and #140 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #25 and #140 chart immediately reviewed, trauma-informed assessment was added by Social Services. All residents were reviewed to ensure they had trauma-informed care plans in place. Education was provided to all staff by the DON on 5/22/25 regarding trauma-informed care importance and policy. The DON/Designee will complete weekly audits of new hire paperwork to ensure review of trauma-informed care for 4 weeks to ensure compliance. Results will be reviewed in QAPI plans.

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 accurate and complete documentation on the medication administration record (MAR) and treatment administration record (TAR) for two residents. For one resident with chronic obstructive pulmonary disease, congestive heart failure, an indwelling urethral catheter, and neuromuscular dysfunction of the bladder, the MAR was left blank for scheduled doses of intravenous meropenem, an antibiotic ordered for a urinary tract infection. Interviews with nursing staff and the Director of Nursing confirmed that the MAR was not signed for these doses, and staff could not verify whether the medication was administered, despite facility policy requiring complete and accurate documentation. For another resident with multiple diagnoses including COPD, diabetes, dementia, and psychiatric disorders, the TAR was not signed to indicate that required safety devices—a seat belt and pressure alarm—were checked as ordered. Observations and interviews revealed that these devices were not in place as ordered, and staff could not specify when or why they were removed. Additionally, there was no documentation in the progress notes regarding the removal of these devices, despite ongoing documentation on the TAR indicating they were checked and in place.

Plan Of Correction

Resident #43 and #25 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #43 MAR was immediately updated. Resident #25 seat belt and chair alarm was immediately DCed by DON. Education provided to all staff by DON on 5/22/25 regarding appropriate and timely documentation. MAR and TAR reviewed on randomly selected residents 5/28/25 by IDT during Risk to ensure timely and accurate documentation. DON/Designee to audit 2 MAR and 2 TAR weekly for 4 weeks to ensure accurate documentation. Results to be reviewed in QAPI.

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 proper cleaning of a resident's CPAP equipment and mask as recommended by facility policy. The resident, who had diagnoses including COPD, obstructive sleep apnea, diabetes, and hypertension, used a BiPap with oxygen every night. The care plan did not include interventions related to cleaning respiratory equipment, and there were no physician orders or documentation in the Treatment Administration Record regarding cleaning of the CPAP equipment or mask. Nursing notes also lacked any mention of cleaning, and multiple observations confirmed that the equipment and mask were not cleaned. Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for cleaning the CPAP equipment, with no official cleaning schedule or documentation in place. The Director of Nursing confirmed that the facility did not have a system for cleaning or documenting the cleaning of CPAP equipment and masks. The facility's policy required weekly cleaning of the equipment, but this was not followed, and the resident expressed concern about the cleanliness of her equipment and the risk of infection.

Plan Of Correction

Resident #10 was immediately assessed and found to have no adverse effects. All residents with orders for a CPAP have the ability to be effected. Resident #10 CPAP was immediately cleaned by respiratory nurse. All CPAPs were immediately audited by respiratory nurse to ensure proper cleaning. Education was provided to respiratory nursing by DON on 5/22/25 regarding CPAP cleaning policy. DON/Designee to complete weekly audits to ensure all CPAPs are cleaned per policy for 4 weeks to ensure compliance. Results to be reviewed in QAPI.

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 that the facility failed to implement Enhanced Barrier Precautions (EBP) as required for residents with wounds or indwelling medical devices. Specifically, two residents were observed during care activities where staff did not don gowns, despite clear signage and availability of personal protective equipment (PPE) at the room entrances. In both cases, staff only wore gloves and omitted the gown, resulting in direct contact between their uniforms and the residents during high-contact care activities. One resident with osteomyelitis, a chronic foot ulcer, diabetes, and a Med Port for intravenous antibiotics was observed receiving IV medication from an LPN who wore gloves but not a gown. The LPN's uniform came into direct contact with the resident during the procedure. The resident's care plan did not include EBP interventions, although physician orders specified EBP use. The LPN later confirmed awareness of the EBP requirement but admitted to not following it during the observed care. Another resident with an indwelling urinary catheter due to neurogenic bladder, as well as other chronic conditions, was assisted by a CNA with toileting and catheter care. The CNA wore gloves but not a gown, resulting in direct contact with the resident. The CNA was unsure of the EBP requirements despite prior training and signage. The resident's care plan also lacked EBP interventions, though physician orders required EBP. The DON confirmed that staff had ongoing issues remembering to use EBP, despite reminders and available PPE.

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 serve food at appropriate temperatures, affecting 61 residents who consume meals prepared by the facility. An interview with a resident revealed that food was often served cold. During an observation of a test tray for breakfast, the scrambled eggs were found to be lukewarm at 123 degrees Fahrenheit, and the toast was unpalatably cool, while the canned pears were not noted to have any temperature concerns. The food was served on a room temperature plate and covered with a clear plastic lid. The Dietary Director confirmed these findings and acknowledged past resident concerns about food temperature. The facility lacked a plate warmer and had only five rubber dish containers to maintain heat. The facility's food and nutrition services policy, dated October 2017, stated that food should be served at a safe and appetizing temperature but did not specify an exact range for warm foods.