Smithville Western 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

The facility failed to ensure and maintain accurate and complete drug records for multiple residents, as evidenced by discrepancies between controlled drug records, medication administration records (MAR), and physician orders. For one resident with Alzheimer's dementia and anxiety, Ativan was removed from secured storage and signed out by a nurse after the order had been discontinued, with no documentation in the MAR or medical record indicating administration or a valid order. Additionally, for the same resident, Norco was documented as administered in the MAR, but the controlled drug record indicated it was not given, as the count remained accurate. Another resident with paraplegia and chronic pain had Oxycodone signed out from secured storage after the order had expired, with no documentation in the MAR or medical record to support administration or a valid order. For a resident admitted to hospice with a history of cerebral infarction, the controlled drug record for morphine sulfate did not include the drug name or directions for use, and there were inconsistencies between the controlled drug record and the MAR regarding the times and documentation of administration. A further resident with toxic encephalopathy had Hydrocodone-Acetaminophen signed out twice on the same day, with a handwritten note indicating the medication was wasted, but without the required second nurse signature to verify the waste. The MAR indicated the medication was administered, but the documentation did not meet policy requirements. The facility's policy requires immediate and complete documentation of controlled substance administration and proper witnessing and documentation of wasted doses, which was not followed in these cases.

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 was admitted to a room that did not maintain a comfortable temperature, as required by facility policy. The resident, who had diagnoses including diabetes mellitus, depression, and anxiety disorder and was cognitively intact, reported that the room was cold and lacked heat. Despite informing staff of the issue, the only immediate action taken was to provide an extra blanket. The resident's family also experienced the cold during visits, and maintenance staff confirmed that the baseboard heater in the room was not functioning due to a failed thermocouple. Maintenance was not available over the weekend, and the resident was not offered a room change during this period, despite ongoing complaints about the cold temperature. Staff interviews confirmed that nursing staff submitted maintenance tickets regarding the room temperature, but no further action was taken to address the resident's comfort until after the weekend, when maintenance returned and the resident was moved to a different room. The facility's policy requires maintaining room temperatures between 71 and 81 degrees Fahrenheit, but this standard was not met for the resident during their stay in the affected room. The deficiency was identified through interviews, record reviews, and weather history, and it was determined that the resident's right to a safe, clean, comfortable, and homelike environment was not honored.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident, who was cognitively intact, was fully informed and able to direct his own medical care. The resident, who had a history of pneumonia, acute respiratory failure, and other serious health conditions, expressed concerns about his respiratory status and requested a chest x-ray to confirm his condition. Despite his requests and the presence of symptoms such as a cough and fluctuating oxygen saturation levels, the facility did not facilitate a chest x-ray due to the resident's body habitus and did not send him to the hospital for further evaluation. The resident's progress notes indicated that he repeatedly expressed concerns about having pneumonia and requested medical interventions similar to those he received in a hospital setting. However, the facility's physician did not examine or communicate with the resident from the time of his admission until he was eventually sent to the hospital. The Director of Nursing confirmed that the physician did not order a chest x-ray and instructed the nurses not to send the resident to the hospital, despite the resident's persistent requests and concerns. Interviews with the resident and a family member revealed dissatisfaction with the facility's handling of the situation, particularly regarding the lack of a chest x-ray and the perceived lack of responsiveness to the resident's health concerns. The facility's policy on resident rights emphasizes the importance of supporting resident self-determination and choice in their healthcare, which was not upheld in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with resident rights.

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 privacy of a resident, identified as Resident #88, during an incident involving a Licensed Practical Nurse (LPN) and other staff members. Resident #88, who had a history of paraplegia, type two diabetes mellitus with diabetic neuropathy, morbid obesity, bipolar disorder, and anxiety disorder, was involved in a heated verbal exchange with LPN #204. During this altercation, it was alleged that LPN #204 recorded the conversation with Resident #88 without proper consent, although LPN #204 claimed that Resident #88 had given permission. The incident was reported by a Certified Nursing Assistant (CNA) who witnessed the altercation and alleged that another CNA was also recording the incident. The altercation occurred in Resident #88's room, where the resident was reportedly yelling at LPN #204 and using racial slurs. The LPN allegedly recorded the conversation on her cell phone, which was left on the treatment cart. Witnesses reported that the recording was played at the nurses' station, although it did not contain any identifying information. The incident was reported to the Unit Manager, who intervened to calm the situation but did not witness any abuse. The Director of Nursing (DON) confirmed that the LPN was reprimanded for recording the resident, and staff were educated on the facility's cell phone use policy. Resident #88 expressed dissatisfaction with the facility, citing multiple arguments with LPN #204 and feeling overwhelmed and stressed by the situation. The resident claimed that the recording was made without consent and that the incident caused significant distress, leading to a transfer to another facility. The facility's policy on the use of personal handheld devices prohibits their use during working time unless authorized for business purposes, and the incident was investigated as a potential violation of this policy.

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 adhere to physician's orders for the management of diabetes in Resident #81, leading to improper insulin administration. Resident #81, who has a history of type one diabetes mellitus with hyperglycemia and type two diabetes mellitus with hypoglycemia, was supposed to have blood sugar levels checked before insulin administration. However, on 10/03/24, insulin was administered without checking blood sugar levels, and both scheduled and sliding scale insulin doses were given simultaneously, contrary to the physician's orders. This mismanagement was confirmed by the Director of Nursing and the Licensed Practical Nurse involved, who acknowledged the deviation from the prescribed insulin administration schedule. Additionally, the facility failed to evaluate and treat an open area on Resident #86's abdominal fold. Resident #86, who was admitted with conditions including pneumonia and type two diabetes mellitus with hyperglycemia, had an open, reddened area on the right lower abdominal fold that was not properly assessed or treated from 12/11/24 to 12/15/24. Despite the presence of a chronic skin condition noted in a weekly skin check, there were no treatment orders or documentation of care for this area. Interviews with Resident #86 and nursing staff revealed that the area was not consistently monitored or treated, and the facility's policy for wound management was not followed. These deficiencies highlight the facility's failure to provide appropriate treatment and care according to physician's orders and resident needs. The lack of adherence to insulin administration protocols and inadequate wound care management for the residents involved demonstrates a significant lapse in the facility's quality of care practices.

Penalty

Inspection fine: $42,777

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

Summary

The facility failed to provide timely and adequate care for Resident #78, who was admitted following a hospitalization for acute ischemia of the small intestine, septic shock, and gastroenteritis. Despite exhibiting symptoms such as increased nausea, vomiting, diarrhea, and abdominal pain between 09/05/24 and 09/18/24, the facility did not update the physician on the resident's change in condition, including abnormal laboratory values and meal refusals. The resident's thyroid stimulating hormone (TSH) level was significantly elevated, and the physician, unaware of the resident's current levothyroxine treatment, ordered a lower dose, exacerbating the resident's condition. From 09/24/24 to 10/09/24, Resident #78 continued to experience severe symptoms, including nausea, vomiting, diarrhea, abdominal pain, decreased appetite, and weight loss, without adequate intervention or physician notification. The resident's laboratory results on 09/24/24 showed abnormal sodium, potassium, and creatinine levels, yet there was no evidence of physician notification. The resident's condition deteriorated, leading to a transfer to the emergency room on 10/09/24, where she was diagnosed with severe dehydration, malnutrition, and an abnormal TSH level, requiring hospitalization. Additionally, the facility failed to ensure continuity of care for Resident #25, who missed scheduled appointments, and did not assess Resident #71 in a timely manner for elevated blood sugar. These failures affected three residents out of the twelve reviewed for changes in condition and continuity of care, indicating systemic issues in the facility's management of resident care and communication with healthcare providers.

Removal Plan

• Resident #78 was transferred to the emergency room and did not return to the facility.
• The DON conducted a whole house audit to ensure all resident labs in the last 30 days had documented evidence of physician notification.
• The DON conducted a whole house audit to ensure any resident who refused meals in the last 72 hours had physician and registered dietitian (RD) notification and documentation.
• The DON educated Registered Dietitian (RD) #613 on communicating meal refusals with the facility nursing management.
• Licensed Practical Nurse (LPN) #578/Unit Manager conducted a whole house audit for all resident's nursing progress notes from the previous 72 hours to ensure any change in condition had proper notification and documentation.
• The DON educated all nurses on the proper process for reporting labs, observing new orders and ensuring appropriate documentation of all notifications and new orders. The education also included current medications related to lab values should be relayed to the physician at the time of notification.
• The DON completed verbal education to all facility physicians and nurse practitioners regarding verifying the current dose of any medication related to a lab value before changing the dose.
• The DON completed education for all nurses on notification of change in condition policy and recognizing signs and symptoms of a change in condition.
• Registered Nurse (RN) #583/Unit Manager conducted a whole house audit for all residents ordered levothyroxine to ensure labs within the last 30 days were managed appropriately. All orders were verified for accuracy. Any concerns were addressed and documented.
• Physician #600, who was the Medical Director, was notified of the concern related to Resident #78 and notified of the facility current corrective action plan.
• An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, RDO #606, VPO #612, RCRN #605, LPN #593/Minimum Data Set Nurse, RN #583/Unit Manager, LPN #578/Unit Manager, and with Physician #600 via telephone. Discussion included requirements of visits, labs, notifications, communication, current orders, and resident conditions.
• The DON/designee would audit all labs for results, notifications and documentation every business day for four weeks then randomly thereafter for a total of two months. Quality Assurance (QA) would review the results of the audits weekly.
• The DON/designee would audit all nurses' notes for a change in condition and proper notification and documentation each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results of the audits weekly.
• The DON/designee would audit meal intakes on five residents each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly.
• The DON/designee would audit four residents on Levothyroxine each week to check for notification of physician as warranted, if new orders were reviewed and were appropriate, documentation of labs, new order notification to family, and if any needed follow up was completed immediately for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly.

Penalty

Inspection fine: $42,777

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

Summary

The facility failed to ensure that residents were seen by their physician at least once every 30 days for the first 90 days following admission, affecting four out of seven residents reviewed. Resident #9, admitted with serious conditions such as necrotizing fasciitis and sepsis, was not seen by his physician during his stay, although he was seen by a nurse practitioner and external specialists. Interviews confirmed that the resident had not met with his assigned physician at the facility. Similarly, Resident #10, with diagnoses including diabetes mellitus and chronic kidney disease, was not seen by her physician during her stay, only by a nurse practitioner. Resident #78, who had acute ischemia and other serious health issues, was also not seen by her physician before being discharged to the hospital. Resident #84, with chronic obstructive pulmonary disease and lung cancer, was only seen by her physician once, just before being discharged to the hospital, and not within the required 30 days of admission. Interviews with facility staff verified these deficiencies in physician visits.

Penalty

Inspection fine: $42,777

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 the physician and/or nurse practitioner of abnormal lab results for a resident, which was a deficiency identified during a survey. The resident, who had a history of acute ischemia of the small intestine, infectious gastroenteritis, and other conditions, was admitted to the facility from the hospital. The resident's lab results on multiple occasions showed abnormal sodium and creatinine levels, indicating potential health concerns that required medical attention. Despite the abnormal lab results, there was no evidence that the resident's physician or nurse practitioner was notified of these results, particularly the lab results from September 24, 2024, which showed low sodium and potassium levels and high creatinine levels. Interviews with the Director of Nursing and the physician confirmed that the physician was not aware of these abnormal results, and if notified, would have taken corrective actions such as ordering oral potassium and additional IV fluids. The facility's policy on Notification of Change in Resident Condition required that significant changes in a resident's status be communicated to the physician and other relevant parties. However, this policy was not followed in the case of the resident's abnormal lab results, leading to a deficiency being cited during the survey. This deficiency was investigated under a specific complaint number.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean and sanitary kitchen area and ensure proper food storage, which had the potential to affect all 90 residents receiving meals. During an observation, a plastic storage container with oats was found with a scoop resting on top inside the container. In the walk-in refrigerator, a box of cucumbers contained two molded cucumbers touching non-molded ones, and there were several unlabeled and undated items, including a quarter-full pan of tomato soup and a pitcher of red juice. Additionally, pitchers of grape juice and sweet tea were dated beyond the facility's seven-day storage policy. The deep fryer had dark oil with food debris, and the surrounding area was unclean, with oil build-up and food debris on the floor and equipment. Further observations revealed significant cleanliness issues in the kitchen, including food build-up on ovens, dark grease on the flat top grill, and food debris on the clean side of the dish machine. The dish machine area had greasy and slippery floors, dust-covered fans, and dirty trash cans. The ceilings in the kitchen and dish machine areas had dust build-up around lights and air vents. A hand sink next to the coffee machine was found with significant food debris. The facility's policies on sanitation and food handling, as well as food stock rotation, were not adhered to, as confirmed by the Dining Services Director.

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 disposal of garbage and refuse, which had the potential to affect all 90 residents. During an observation of the outside trash area, it was noted that there were various plastic wrappers, gloves, plastic spoons, and cigarette butts on the ground surrounding the dumpsters. This observation was confirmed through an interview with the Dining Services Director. The facility's policy, dated January 2022, stated that the area around the dumpsters should be free from debris and that each employee was responsible for maintaining cleanliness in this area.

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 employ a full-time, qualified social worker, which had the potential to affect all 90 residents. The facility, with 127 certified and licensed beds, had a Social Services Designee (SSD) who did not meet the qualifications outlined in the job description. SSD #611, hired on 03/28/21, had attended college but did not earn a degree and had no documented history of long-term care experience. The job description required two years of experience in long-term care and preferred a Licensed Social Worker (LSW). Additionally, the Activities Director (AD) #502, who was identified as handling social services, had a degree in healthcare administration but no social services experience. Interviews with the Administrator revealed that SSD #611 had moved to a corporate position, and AD #502 was training to fill the social services role. SSD #611 continued to assist the facility twice weekly, with Corporate Social Services Designee (CSSD) #902 providing oversight and assistance once every week or every other week. LSW #900 from a sister facility initially assisted once a week but now only helped as needed. The Administrator confirmed that neither AD #502 nor SSD #611 were LSWs or held a related degree, and CSSD #902, who oversaw the Social Services Department, was also not an LSW.

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 kitchen area free of pests, specifically drain flies, which had the potential to affect all 90 residents who received meals from the kitchen. During an observation of the kitchen with the Dining Services Director (DSD), large amounts of drain flies were noted in the dish machine area, seen on the walls and equipment, and flying around. The DSD confirmed the presence of the drain flies and indicated that maintenance was supposed to address the issue, but no action had been taken for two weeks. The Maintenance Director (MD) later revealed he was unaware of the issue until after the observation. A review of pest control service inspection reports from January to June showed that the kitchen had not been treated for drain flies. The facility's pest control policy stated that the pest control company would be contacted and appropriate services provided when an issue arises.

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 store medications in a safe manner, as observed during a medication administration on the secured memory care unit. A registered nurse (RN) placed medications for another resident in a medication cup and left it unsupervised on the medication cart. This occurred while Resident #79, who was severely cognitively impaired and used a walker/wheelchair for mobility, was standing near the cart. The RN left the medications unattended while entering another resident's room to assess their blood sugar, leaving the medication cart out of view and without any staff present to monitor Resident #79. The facility's policy, revised in August 2021, requires that medications be stored in a locked medication cart or locked overflow area until ready for use. However, the RN confirmed during an interview that she left the medication cup unsupervised, acknowledging that Resident #79 could have taken the medications. This incident affected Resident #79 and had the potential to affect nine additional residents who were independently mobile and cognitively impaired, residing on the memory care unit.

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 residents' rooms in a clean and sanitary manner, affecting ten residents. Observations revealed several issues, including closet doors hanging off the track, black markings and gashes on walls, exposed wiring on bed remotes, and missing covers on heating units. Additionally, light fixtures were covered with heavy dust and dead bugs, and call light panels were not affixed to the wall. These deficiencies were observed in multiple rooms, indicating a widespread issue with the physical environment. Interviews with the Director of Maintenance (DOM) confirmed these findings. The DOM verified that some repairs were made, such as covering exposed wiring with tape and placing a cover on a heating unit, but acknowledged that further cleaning and repairs were needed. Additional observations with the DOM revealed unsanitary conditions in residents' bathrooms, including cracked floor tiles, missing light covers, and dirty walls and baseboards. The DOM confirmed these issues and stated that further cleaning and repairs were necessary.

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 authorizations for managing resident funds were attested to by a witness not affiliated with the facility, affecting three residents out of five reviewed. Specifically, the authorizations for Residents #10, #34, and #57 lacked the required non-facility affiliated witness signatures. These authorizations were dated 02/15/24, 07/17/23, and 08/30/22, respectively. This deficiency was confirmed during an interview with the Business Office Manager, who verified the absence of the necessary witness signatures for all three 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 ensure timely conveyance of resident funds upon discharge, affecting one resident. The resident was admitted and later readmitted to the facility before being discharged to a hospital, where they subsequently expired. A review of the resident's fund records showed that checks were dispersed to the state and a funeral home, but not within the required 30-day timeframe post-discharge. This was confirmed during an interview with the Business Office Manager, who acknowledged the delay in conveying the funds.

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 written transfer notices to residents and/or their representatives when transferring residents to the hospital. This deficiency affected two residents, one with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic diastolic heart failure, and muscle weakness, and another with diabetes mellitus, end-stage renal disease, atrial fibrillation, hypoxemia, metabolic encephalopathy, and lobar pneumonia. The medical records for these residents showed multiple hospital transfers, but there was no evidence of written transfer notices being provided. Interviews with the facility's Administrator and Social Services Designee confirmed that transfer notices were communicated over the phone but not provided in writing. The Administrator acknowledged that social services were responsible for the transfer and discharge notices, but there was uncertainty about whether written notices were given. The Social Services Designee admitted to not providing written transfer/discharge notices to the residents or their responsible parties.

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 necessary toenail care for a resident who was severely cognitively impaired and required substantial assistance with personal hygiene. The resident, who had been admitted with diagnoses including unspecified dementia and muscle weakness, was observed with very long, thick, and curling toenails. Despite the evident need for toenail care, there was no documentation in the resident's medical record indicating an assessment or referral for podiatry services. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) confirmed the lack of action regarding the resident's toenail care. The DON acknowledged that the toenails were too thick and long for staff to manage and that there was no record of the resident being assessed for podiatry needs or referred for such services. It was only after the surveyor's observation that podiatry was notified of the resident's need for toenail care, indicating a delay in addressing the resident's personal care needs.

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 all fall interventions for two residents, leading to deficiencies in accident prevention and supervision. Resident #41, who was at high risk for falls due to conditions such as hemiplegia and vascular dementia, experienced a fall in the dining room, resulting in a fracture of the right humerus. Despite being identified as requiring two-person assistance for transfers, Resident #41 was observed independently ambulating without staff intervention, indicating a lack of adherence to the prescribed fall prevention measures. Additionally, the facility did not follow proper procedures after Resident #41's fall, as staff moved the resident despite complaints of pain, contrary to the facility's policy of not moving residents after a fall until assessed to prevent further injury. The Director of Nursing confirmed that the resident should not have been moved and that the physician should have been notified immediately. Resident #45, who required maximal assistance with ADLs, experienced two falls within a short period. The first fall occurred while being assisted to bed, and the second fall happened during a transfer to bed, despite a new intervention requiring two-person assistance with a front-wheeled walker. The facility's fall investigation did not confirm whether this intervention was in place during the second fall, and there was no statement from the aide involved, indicating a lack of thorough investigation and communication of new interventions to 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 that a resident's drug regimen was free from unnecessary medication increases. Resident #74, who had diagnoses including end-stage renal disease, depression, insomnia, and anxiety disorder, experienced an increase in Trazodone dosage from 50 mg to 100 mg over a period of time. This increase was ordered by a Psychiatric Nurse Practitioner (PNP) in response to the resident's complaints of sleep disturbances, which were attributed to noise and disturbances caused by a roommate. Despite the resident's reports and a nurse's note indicating the issue, there was no evidence of follow-up action to address the environmental factors affecting the resident's sleep. Interviews with staff revealed a lack of communication and awareness regarding the resident's situation. The Registered Nurse (RN) was aware of the resident's dissatisfaction with the roommate and noted that a room change could be easily arranged. However, the Administrator was unaware of the issue, and the Unit Manager believed the situation had been resolved. The Director of Nursing (DON) and the Unit Manager were unaware of the reasons for the medication increases, despite the DON being aware of the increase itself. This lack of coordination and follow-up contributed to the unnecessary medication increase for Resident #74.

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 documentation on the Treatment Administration Record (TAR) for a resident with quadriplegia, polyneuropathy, and morbid obesity. The resident was dependent on staff for mobility and had orders for a low air loss (LAL) mattress, which were signed off as completed from early June to late June. However, there was no evidence of when the resident was switched from a LAL mattress to a bariatric mattress, and interviews with staff revealed uncertainty about the exact timing of the switch. The Director of Nursing confirmed the orders were inaccurately signed off as completed. Additionally, the facility failed to ensure accurate care conference documentation for two residents. One resident with severe cognitive impairment had care conference documentation indicating meetings were held on two separate dates, but both were documented as occurring at the same time, which was verified as incorrect by the Director of Nursing. Another resident's care plan meeting was documented as having occurred with specific attendees, but interviews revealed that the meeting did not take place as documented, and the resident's daughter, who was supposed to be involved, denied any participation. The inaccuracies in documentation affected three residents in total, highlighting a failure in maintaining accurate medical records and care conference documentation. The discrepancies were confirmed through interviews with staff, including the Director of Nursing, who acknowledged the errors in documentation and the lack of proper record-keeping for the residents involved.

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 liability notices were received timely for Resident #104. The resident, who had diagnoses including Alzheimer's disease, dementia, and COVID-19, was discharged on [DATE]. The Notice of Medicare Non-Coverage (NOMNC) indicated that skilled services would end on 02/19/24, with the option to appeal no later than noon of the day before the effective date. However, the NOMNC was signed and dated by the resident on 02/19/24, not providing the required 48-hour notice for an appeal. This was confirmed by the Admissions Director, who acknowledged the late issuance of the NOMNC. This deficiency was investigated under Complaint Number OH00152123.