The Enclave At Barnesville

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive, individualized pressure injury prevention interventions for a resident who was dependent on staff for bed mobility, transfers, dressing, bathing, hygiene, and personal care, and who had multiple chronic conditions including chronic respiratory failure, oxygen dependence, lung disease, diabetes, chronic kidney disease stage 4, cirrhosis, depression, anxiety, fibromyalgia, and high blood pressure. The resident’s MDS and Braden Scale reflected pressure injury risk and need for staff assistance with positioning, and the care plan included barrier cream, frequent repositioning, keeping skin clean and dry, and education about position changes. However, task documentation from January through May showed no evidence that staff assisted with turning and repositioning, offloaded pressure, or provided documented encouragement or education for frequent position changes. After the resident returned from a hospitalization, the facility documented moisture associated skin damage to both buttocks on re-entry, but there was no evidence of wound measurements, pressure injury treatment, or pressure relief interventions at that time. The resident also left the facility in a wheelchair for a physician appointment without any documented pressure reduction measures in the wheelchair. The record showed no physician orders for pressure relieving devices for the chair or bed, despite MDS documentation indicating use of pressure relieving devices and ointments/creams for prevention. The NP who assessed the resident noted intact skin earlier in the month and later identified the resident as high risk for skin breakdown due to mobility limitations and chronic conditions. On 03/26/26, the NP identified an unstageable pressure injury to the right buttock gluteal fold measuring 5.0 cm by 3.0 cm by 0.3 cm with 100% slough and recommended wound care. However, the TAR showed no wound care or treatment to the right buttock from the time the facility first identified MASD until 03/29/26, and nursing notes did not document the pressure injury during that period. A later nursing note documented the resident reporting soreness and an open area on the right gluteal fold, and subsequent orders were entered for wound cleansing and dressings. The wound was later staged as unstageable and then as a Stage III pressure ulcer. During observation, the resident was seen sitting in bed and in a wheelchair without a pressure relieving device, and during wound care she winced and pulled her buttocks away, indicating discomfort. Interviews confirmed the resident had been assessed as high risk, that no pressure injury prevention care plan had been in place before the wound developed, and that the facility record did not show documentation of the pressure injury or prevention measures when the wound was first identified.

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 food in a sanitary manner and failed to maintain drainpipes to prevent sewage odor in the kitchen. During the initial kitchen tour, the dry storage pantry had a strong sewage smell coming from an open drainpipe in the floor. The Dietary Manager verified the odor and stated it had been present for several months, with both administration and maintenance aware of the concern. Later, the odor was no longer present, and the Dietary Manager stated the drain had been snaked and vinegar and baking soda were poured down it, but also reported that monthly water flow through the drain was needed to prevent odors and that this had not been known to staff. The facility also failed to keep refrigerated foods at proper temperatures and to maintain adequate air circulation in the walk-in cooler. The walk-in cooler was observed at 42 degrees Fahrenheit and had only one fan working, which the Dietary Manager verified and stated had been broken for two weeks or longer, with administration and maintenance aware of the issue. During dinner meal service, canned beets held in the cooler for about three hours were 53.2 degrees Fahrenheit, and canned fruit cocktail held for about three hours was 49.0 degrees Fahrenheit. The CEO stated he knew the fan was not working and believed a part had been ordered or that a vendor may have looked at the unit, and an online receipt later showed a new fan was ordered the following day.

Penalty

No penalty information released

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

Summary

The facility failed to ensure resident assessment data accurately reflected residents’ status for four residents. For one resident admitted with diagnoses including urinary tract infection, Parkinson’s disease, spinal stenosis, major depression, and high blood pressure, the most recent MDS 3.0 comprehensive initial assessment incorrectly indicated that insulin injections were received even though there were no insulin orders and no insulin administration documented in the physician orders or MAR. The MDS coordinator later confirmed the item was coded incorrectly and that the resident did not receive insulin injections. For another resident admitted with acute respiratory failure, depression, hyponatremia, gastrointestinal bleed, anemia, high blood pressure, and hepatic encephalopathy, the MDS 3.0 comprehensive initial assessment also incorrectly indicated insulin injections were received. The physician orders showed no insulin, the MAR showed no insulin administration, and RN #215 confirmed the resident did not have diabetes, was not ordered insulin, and did not receive insulin injections. The MDS was acknowledged as needing correction to reflect no insulin injections. A third resident admitted with chronic respiratory failure, oxygen dependence, lung disease, fibromyalgia, diabetes, depression, anxiety, high blood pressure, chronic kidney disease stage 4, gastric reflux, cirrhosis, and a new pressure ulcer injury of the right buttock had an MDS quarterly assessment that coded a stage three pressure ulcer present upon reentry to the facility. However, the discharge assessment from the hospital showed no current pressure injuries, the nursing assessment on return documented MASD to the bilateral buttocks without measurements or wounds, and the NP history and physical later documented an unstageable pressure injury to the right buttock gluteal fold. RN #215 later verified the resident did not have an unstageable pressure injury upon return and that the MDS and matrix were not coded accurately. For a fourth resident with unspecified dementia, hypertension, and chronic kidney disease, the quarterly MDS did not identify hyperlipidemia as an active diagnosis even though the resident had a standing order for Simvastatin 10 mg at bedtime for hypercholesterolemia and the MAR documented administration during the assessment period. The DON confirmed the MDS was not coded accurately because the resident was receiving Simvastatin for hypercholesterolemia during the seven-day assessment period.

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 pureed foods were prepared to an appropriate puree consistency for residents receiving a puree diet. During observation of pureed dinner preparation, a dietary cook prepared beets, fruit cocktail, and grilled chicken in a robot coup for the puree process. After the cook pureed nine premeasured servings of beets and visually checked the consistency, the surveyor requested a taste test. The cook stated she had never tasted pureed foods for consistency or taste, and tasting of the beets revealed a crunchy texture in a semi-thin liquid that had separated from the beets. The dietary cook and the Dietary Manager verified that the beets had a crunchy texture rather than the smooth texture expected of pureed food. The cook then returned the beets to the robot coup and pureed them for several more minutes before retesting and spooning them into serving bowls. The facility dietary manual stated that puree diets consist of foods that are smooth, cohesive, and require no chewing, and that pureed foods should have no lumps, should not be sticky, and should not have liquid separating from the solid food. The deficiency had the potential to affect nine residents identified as receiving a puree diet in a census of 52.

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 reasonably accommodate Resident #26’s personal preferences by removing her nightstand and toiletry items from her bathroom and not providing an alternative in the bathroom for those items. Resident #26 was admitted on 12/03/22 with diagnoses including chronic kidney disease stage 4, hypertension, bilateral hearing loss, and arthropathy. Her quarterly MDS showed she was cognitively intact and independent with toileting hygiene, showering/bathing, and personal hygiene. Her ADL care plan, revised 06/17/25, noted she required assistance for ADLs related to advanced age, active wounds, and use of an assistive device, with interventions to encourage and allow self-care as able. During interview, Resident #26 stated she preferred to bathe herself and had previously kept a stand in her bathroom with her toiletries, but staff removed it. She stated she wanted it returned because she had to carry everything back and forth to the bathroom. Observation showed her nightstand outside the bathroom and her toiletry items in her closet, with nothing in the bathroom to replace the stand for her use. The DON verified that the nightstand and toiletry items were taken out of the bathroom and that the resident preferred them there, and stated the stand was removed because staff were told during a corporate survey that it could not be in the resident’s bathroom. The facility policy on Quality of Life-Homelike Environment stated staff shall provide person-centered care emphasizing residents’ comfort, independence, and personal needs and preferences.

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 Resident #17’s care plan to reflect the family’s preference that he not wear any splints, braces, or other orthotics as part of his contracture management. Resident #17 was admitted with diagnoses including hemiplegia and hemiparesis affecting his left non-dominant side, muscle weakness, cognitive communication deficit, unspecified dementia, and mood disorder with depressive features. His quarterly MDS showed severely impaired cognition, unclear speech, and a functional limitation in range of motion on one side of his upper extremities. His active care plan addressed alteration in musculoskeletal status related to a left hand contracture and left hemiplegia, with interventions to encourage and assist with supportive devices as ordered, but it was not revised to reflect the family’s decision not to use splints, braces, or other orthotics. Review of physician orders showed no active orders for splints, braces, or other orthotic devices for contracture management, although there was an order for active range of motion as part of a restorative program. Progress notes for the prior four months contained no documentation of refusals related to splints, braces, or orthotics. During observation, the resident was seen in a tilt-in-space wheelchair with his left arm drawn up against his chest and no splints, braces, or orthotic devices in place. Rehab staff stated the facility had previously obtained splints for the resident’s left hand and left knee, but the family did not want him to use them because they caused discomfort, and the DON confirmed the care plan did not reflect the family’s wishes.

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 a timely implemented Functional Maintenance Program (FMP) for Resident #29, who was admitted with diagnoses including acute respiratory failure, depression, hyponatremia, gastrointestinal bleed, anemia, high blood pressure, and hepatic encephalopathy. The resident’s MDS showed no hearing, visual, or cognitive impairments, but he required a mechanical lift for transfers and was dependent on staff for toileting, bathing, and dressing. Physical therapy services were ordered and provided, and the PT discharge summary stated the resident was discharged from therapy services and recommended an FMP. The PT communication form for the resident indicated the FMP was to begin after discharge from therapy, but the program did not start until 05/07/26, with no explanation documented for the delay. The functional maintenance care plan was then initiated with active ROM to all extremities for 10 reps for 3-5 sets daily, 6-7 times per week. During interview, the PT stated he recommended the FMP at discharge and gave the communication form to the LPN responsible for setting it up, while the LPN confirmed the resident did not receive the FMP from 04/27/26 through 05/07/26 because the form was misplaced on her desk and not reviewed until 05/07/26.

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 residents identified as at risk for elopement and residing on a secured memory care unit did not exit the building without staff knowledge. Resident #39 had diagnoses including Alzheimer's disease, dementia, epilepsy, Parkinsonism, intermittent explosive disorder, frontotemporal neurocognitive disorder, and muscle weakness, and was documented as severely cognitively impaired and able to ambulate independently. Her record showed a history of wandering and exit-seeking, and her care plan called for supervision at all times while off the unit and in the secured courtyard, along with redirection if she attempted to elope or wander. On 03/25/26, Resident #39 was last seen by an RN during medication administration and was then found outside in the parking lot by the therapy director about 10 minutes later. The resident had wandered outside the building without staff knowledge. The elopement timeline documented that staff completed a head count and accounted for all residents, notified the DON, administrator, physician, family, and risk group, and completed assessments after the event. The RN stated the CNA was off the unit assisting another resident with a shower, and the therapy director stated he found the resident outside and assisted her back inside. The report also noted the door system was not closing correctly because of a magnetized lock concern. The facility also failed to ensure interventions for another resident at risk for elopement were timely implemented. Resident #54 had vascular dementia with mood disturbance, unspecified mood disorder, and violent behavior, and his wandering risk assessment documented that he had wandered before, was cognitively impaired, ambulated independently, and had increasing wandering behavior. His care plan included use of a wander guard on the right lower leg and other safety interventions. However, the spouse stated the wander guard was not implemented until 05/04/26, and the elopement binder had no information for this resident when reviewed with the DON. On observation, the resident exited through the front door and the alarm sounded, with the DON and respiratory therapy director responding within one minute. The facility further failed to ensure fall prevention interventions were in place for Resident #17. He had diagnoses including unspecified dementia, hemiplegia and hemiparesis following stroke, osteoporosis, cognitive communication deficit, and muscle weakness. His care plan and physician orders included a low bed and fall mats on both sides of the bed. On two separate observations, he was found lying in bed with the bed raised and not in its lowest position. An LPN confirmed the bed was not in the low position and was able to lower it further, and the DON acknowledged the resident was supposed to be in a low bed per the care plan.

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 comprehensive, resident-centered dementia care to prevent resident-to-resident physical abuse involving two residents on the locked memory care unit. One resident had diagnoses including Alzheimer’s disease, dementia with moderate behavior disturbances, PTSD, depression, and spinal stenosis, and the most recent MDS showed severe cognitive impairment with a brief interview for mental status score of 5/15. That resident was independent with walking without a device but required supervision for safety concerns, and nursing notes documented behaviors such as inserting herself into other residents’ conversations, blocking staff movement, becoming angry when redirected, attempting to go out a back door with another resident, and later escalating to grabbing another resident’s hair and trying to pull her out of bed. The other resident also resided on the locked memory care unit and had a diagnosis of unspecified dementia without behavioral disturbances, severe cognitive impairment on the MDS, and dependence on staff for bathing, dressing, toileting, and personal care. The resident’s care plan addressed wandering and attempted elopement, with interventions including redirection, diversional activities, medication administration as ordered, and supervision while off the secured unit or courtyard. During the incident, the first resident entered the second resident’s room while a CNA was assisting the second resident into bed, reached around the CNA, pulled the second resident’s hair, and tried to pull the resident out of bed. The nurse assessed the second resident and noted no injuries. Staff statements and interviews showed the first resident had ongoing behavioral issues and was difficult to redirect, with staff reporting that the two residents often had to be separated because the first resident would pick at the second resident. The CNA who witnessed the event stated she was the only staff member present on the memory care unit at the time. The LPN stated she did not witness the event and learned of it from the CNA, and also stated that staffing on the night shift typically consisted of one nurse covering both the north hall and memory care unit and one CNA on the memory care unit, making supervision difficult when residents had behaviors. Another CNA confirmed there was generally only one CNA on the unit at night and that this made it difficult to supervise residents and provide dementia care when behaviors were occurring or could occur.

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 physician-ordered medication parameters were followed for a narcotic pain medication for one resident with diagnoses including repeated falls, low back pain, spinal stenosis, lumbar disc degeneration, and arthritis. The resident had intact cognition on the most recent BIMS and was assessed to frequently have pain. Her orders included Tylenol 500 mg every six hours as needed for pain and Percocet 5/325 mg every eight hours as needed for severe pain rated 6-10, but the MAR showed Percocet was administered outside of the ordered parameters on multiple dates from January through May 2026. The resident stated she requested a pain pill when having pain, and an RN confirmed the medication had been given outside the ordered parameters and not per the physician's order. The facility also failed to monitor a resident's heart rate as ordered before administering Toprol XL 50 mg each morning for hypertension. The resident had diagnoses including hypertension and atrial fibrillation, and the order included a hold parameter if the heart rate was less than 60 bpm. The MAR had a place for initials but no place to document heart rate, and the record did not show consistent evidence that the resident's heart rate was checked daily at the time the medication was given. The DON confirmed there was no evidence that nurses were monitoring the resident's heart rate prior to administration of the medication to follow the ordered parameters.

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 its medication error rate did not exceed 5%, with three errors identified out of 33 opportunities for a 9% error rate. The deficiency involved two residents during medication administration observations and was based on observation, record review, staff interview, and policy review. For one resident, an RN administered morning medications and signed the MAR to show Ferrous Sulfate 325 mg had been given, but observation and later interview confirmed the medication was not actually administered. For another resident, the RN gave only one 81 mg ASA tablet instead of the ordered two tablets for a total of 162 mg, and gave 10 mcg of Vitamin D instead of the ordered 50 mcg. The RN acknowledged she had assumed one ASA tablet was correct and confirmed the Vitamin D dose given was less than ordered. The facility policy required medications to be administered as prescribed and the nurse to verify the right resident, medication, dosage, time, and route.

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 appropriate hand hygiene during medication administration when a nurse administered eye drops to Resident #31 and then returned to prepare medications for Resident #11 without washing her hands or using hand sanitizer. During observation on 05/06/26 at 8:15 A.M., Registered Nurse #227 prepared and administered medications to Resident #31, including Artificial Tears Ophthalmic solution 0.2-0.2-1%. She gave the resident pills first and then instilled one drop into both eyes before leaving the room, but she was not observed performing hand hygiene after leaving the room or before returning to the medication cart to prepare medications for the next resident. During interview on 05/06/26 at 8:24 A.M., RN #227 confirmed she did not perform hand hygiene after administering the eye drops to Resident #31 or before preparing medications for Resident #11. She stated she should have performed hand hygiene between the two residents' medication administrations and reported there was no hand sanitizer on the medication cart that morning. Review of the facility's medication administration policy required staff to follow established infection control procedures, including handwashing, and the eye drop policy required hands to be washed and dried thoroughly before treatment and again after the eye drops were administered.

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 appropriate transfer notices to residents and/or their representatives when residents were transferred to the hospital, and it failed to notify the State's local Ombudsman of all transfers and discharges as required. This affected three residents reviewed for hospitalizations and/or planned discharges. Facility policy titled Transfer or Discharge Notices, revised 07/30/25, stated residents and/or representatives were to be notified in writing of an impending transfer or discharge and the reasons for the move, and a copy of the notice was to be sent to the Office of the State Long-Term Care Ombudsman. For one resident, the record showed three separate hospital transfers during the stay. The resident was sent out after being found with his tracheostomy tube out, later transferred again for altered mental status and hyperglycemia, and then transferred a third time when he was not responding verbally and was tachycardic. The record contained no documented evidence that the resident or his representative received transfer notices for any of the three hospital transfers. The record also showed no evidence that the Ombudsman was notified of the first transfer, and the March 2026 transfer list sent to the Ombudsman did not include that resident's name despite the transfer occurring during that month. For another resident, the record showed a hospital transfer for vomiting and abdominal pain, but there was no evidence of a transfer notice or bed hold notice provided to the resident or family at or around the time of transfer. For a third resident, the record showed discharge home with the son, but the DON confirmed there was no evidence the Ombudsman was notified of the discharge. Interviews with the DON, Regional Nurse, Administrator, and the Office of the Long-Term Care Ombudsman verified the missing transfer/discharge notices and missing Ombudsman notification.

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 submit the required staffing information for the fourth quarter of 2024 to the Payroll Based Journal (PBJ) data, which had the potential to affect all residents, with a census of 46. A review of the PBJ staffing report for the period from July 1st, 2024, through September 30th, 2024, revealed that the facility did not submit the necessary data. This resulted in a one-star staffing rating, excessively low weekend staffing, no registered nurse (RN) hours, and a lack of licensed nursing coverage 24 hours per day. During an interview, the Administrator stated that the corporate office is responsible for submitting the staffing data. Despite reaching out to corporate multiple times for proof of submission, the Administrator had not received any evidence. A subsequent interview confirmed that corporate was unable to provide evidence that the facility had submitted the required staffing information for the specified quarter.

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 proper infection control practices, which had the potential to affect 26 out of 46 residents. During an observation, a male resident was seen helping himself to ice from the ice chest located next to the nurses' station without practicing hand hygiene. The ice scoop was left inside the ice chest, which is against standard infection control practices. Two aides were present at the nurses' station during this observation. In an interview, a Certified Nursing Assistant (CNA) confirmed the observation and stated that residents typically do not and should not help themselves to ice, but should ask for assistance.

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 completion of Preadmission Screening and Resident Review (PASARR) for three residents, leading to deficiencies in identifying mental health conditions. Resident #40 was admitted with diagnoses including Alzheimer's disease, major depressive disorder, PTSD, and dementia with behavioral disturbances. Despite these conditions, the PASARR dated 02/23/24 inaccurately indicated no mental illness, which was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident #43's PASARR failed to reflect their mental health diagnoses, including bipolar disorder, and the use of medications such as Zoloft and Depakote, as confirmed by the DON. Resident #3's PASARR was also inaccurate, as it did not list anxiety disorder and misclassified alcohol dependence as a psychotic disorder. The Social Service Director (SSD) acknowledged the inaccuracies and the lack of a PASARR review upon the resident's admission. The facility's policy requires screening for serious mental illness or developmental disabilities prior to admission and within 14 days of a new diagnosis or significant change in status, but these procedures were not followed, leading to the deficiencies noted in the report.

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 individualize the care plans for two residents, leading to deficiencies in their treatment management. Resident #7, who was admitted with multiple diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and acute respiratory distress syndrome, had a physician's order for continuous oxygen therapy at four liters per minute via nasal cannula. However, the resident's care plan was not updated to reflect this treatment order. This oversight was confirmed by a Registered Nurse during an interview, who acknowledged that the care plan did not indicate the resident was receiving oxygen therapy. Similarly, Resident #46, admitted with diagnoses such as gastrostomy, anemia, and malignant neoplasm of the colon, was receiving Zyprexa, an antipsychotic medication, as per the Medication Administration Record. Despite this, the resident's care plan was not individualized to include the treatment order for Zyprexa. The Director of Nursing confirmed during an interview that the care plan did not reflect the administration of the antipsychotic medication. These failures to update and individualize care plans for the residents' specific treatments were identified as deficiencies during the survey.

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 blood glucose level was obtained prior to administering insulin, as per physician orders. Resident #33, who has a history of Alzheimer's disease, dementia, and diabetes mellitus, did not have their blood glucose level checked on two consecutive days, and insulin was administered without this critical check on one of those days. The resident had previously refused care, becoming aggressive, which was documented in the nursing progress notes. The Director of Nursing confirmed the oversight in obtaining the blood glucose levels as per the physician's orders. Additionally, the facility did not timely identify and document edema in another resident. Resident #26, who has hemiplegia and diabetes, reported right foot pain and swelling, which had been present for three to four weeks. Despite the resident and a CNA acknowledging the edema, it was not documented or assessed by nursing staff until it was brought to the attention of an LPN during the survey. The Director of Nursing confirmed the lack of documentation regarding the resident's condition, and the facility's policy requires prompt notification of changes in a resident's condition.

Penalty

No penalty information released

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

Summary

The facility failed to follow an order for an alternating air mattress for a resident at risk for developing pressure ulcers. Resident #32, who was admitted with diagnoses including stage three chronic kidney disease, hyperlipidemia, anxiety disorder, dementia, and osteoarthritis, was identified as having the potential for skin integrity impairment. The care plan included interventions such as a pressure-reducing mattress. However, observations on multiple occasions revealed that the resident did not have the prescribed low air-loss mattress with side bolsters. This was confirmed by an LPN during an interview, indicating non-compliance with the care plan designed to prevent pressure ulcers.

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 an order for non-skid strips was followed for a resident at risk for falls. Resident #32, who was admitted with diagnoses including stage three chronic kidney disease, hyperlipidemia, anxiety disorder, dementia, and osteoarthritis, was identified as being at risk for falls due to confusion, gait/balance issues, and other factors. The resident's fall care plan included interventions such as ensuring non-skid footwear and placing non-skid strips to the right of the bed. However, observations on multiple occasions revealed that there were no non-skid strips in front of the resident's bed, as required by an order dated 03/22/23. This was confirmed by an interview with an LPN, who acknowledged the absence of the non-skid strips.

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 necessary interventions for a resident who experienced a significant weight loss of 5.45% within one month. The resident, who was admitted with diagnoses including dementia, urinary tract infection, and type II diabetes, was on a consistent carbohydrate diet. Despite the care plan indicating the need to monitor diet tolerance, meal/fluid intakes, and notify the physician of significant weight loss, no additional nutritional interventions were ordered following the weight loss. The resident's meal intake records showed that 70% of meals were consumed at 0-50%, with 11 meals completely refused, indicating inadequate nutritional intake. Interviews with facility staff revealed that the resident's eating habits fluctuated, and although alternatives were offered, the resident was not receiving any medications or supplements to assist in maintaining weight. The Registered Dietician acknowledged the weight loss but did not implement any interventions, as the resident's weight was considered to be at baseline from a previous stay. This lack of action contributed to the deficiency in providing adequate nutrition to maintain the resident's health.

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 replacement of a resident's oxygen humidifier bottle, affecting a resident who was receiving oxygen therapy. The resident, who had a history of chronic obstructive pulmonary disease, asthma, dementia, diabetes mellitus, congestive heart failure, and atrial fibrillation, was admitted with an order for continuous oxygen administration at four liters per minute via nasal cannula due to low oxygen saturation. During an observation, it was noted that the resident's oxygen humidifier bottle was dated over a month prior, indicating it had not been changed weekly as required by the facility's policy. Interviews with the LPN and the DON confirmed that the humidifier bottle should have been replaced weekly, as per the facility's policy on infection control and oxygen therapy. The policy specified that humidifier bottles are to be replaced weekly on the Sunday night shift. The failure to adhere to this policy resulted in the deficiency noted during the survey, as the humidifier bottle had not been changed in accordance with the established schedule.

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 a comprehensive assessment and individualized plan of care for a resident with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with diagnoses including Alzheimer's disease, major depressive disorder, PTSD, and dementia with behavioral disturbances, did not have PTSD documented in the admission assessment. The assessment also failed to identify any history of trauma or triggers, and the 48-hour care plan included generic interventions without individualization. The comprehensive plan of care lacked evidence of an individualized approach to managing the resident's PTSD. Interviews with facility staff revealed a lack of awareness regarding the cause of the resident's PTSD and the absence of a comprehensive assessment or care plan. The Director of Nursing was unaware of the PTSD triggers, and an LPN had to reach out to the resident's family to gather information. The family indicated that the resident might have been physically or sexually abused as a child, with men being a trigger for her agitation and aggression. The facility's policy on Trauma Informed Care was not followed, as it required social services to interview new residents for trauma history and initiate a comprehensive care plan with individualized goals and interventions.

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 antibiotics, specifically affecting a resident with a history of recurrent urinary tract infections (UTIs). The resident, who was admitted with diagnoses including atherosclerotic heart disease, chronic kidney disease, urinary incontinence, and mild cognitive impairment, had multiple urine cultures showing resistance to the antibiotic Cipro. Despite this resistance, the resident was prescribed Cipro prophylactically by a urologist in January 2025, even though there was no new UTI at that time to justify starting another antibiotic. Interviews with a Licensed Practical Nurse (LPN) revealed uncertainty about why Cipro was chosen for prophylaxis when the resident's cultures consistently showed resistance to it. The LPN also noted that the resident was allergic to Macrobid, the urologist's usual choice for prophylaxis, leading to the decision to use Cipro. However, there was no documentation from the urology department to support this prophylactic treatment, and the resident's representative was unaware of the resistance issue. The facility's policy on antibiotic stewardship emphasized the importance of appropriate antibiotic use and communication of lab results to prescribers, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure appropriate diagnoses for psychotropic medication and did not have supporting evidence for declining gradual dose reduction (GDR) recommendations and increasing doses of psychotropic medication for two residents. Resident #43 was admitted with diagnoses including dementia with psychotic disturbance, anxiety, major depressive disorder, and unspecified psychosis. Despite pharmacy recommendations for GDRs on medications such as Abilify, Zoloft, and Depakote, the physician disagreed, citing persistent target symptoms, although there was no documented evidence of behaviors. The Director of Nursing (DON) confirmed the lack of documentation and justification for increasing Abilify and the absence of attempts for GDRs in the past eight months. Resident #46 was admitted with diagnoses including gastrostomy, anemia, malignant neoplasm of the colon, acute post-thoracotomy pain, depression, and anxiety. The resident's Minimum Data Set (MDS) assessment indicated intact cognition with no hallucinations, delusions, or behavioral issues. However, the resident was receiving Zyprexa, an antipsychotic, without a supporting diagnosis. The pharmacist informed the physician of this discrepancy, and the DON verified the inappropriate prescription. The facility's policy on tapering medication and GDRs requires attempts to reduce antipsychotic drugs unless clinically contraindicated. Despite this policy, the facility did not adhere to the guidelines, as evidenced by the lack of documented behaviors and the absence of attempts to reduce medication dosages. The deficiencies highlight the facility's failure to follow its own policies and ensure appropriate medication management for residents.

Penalty

Inspection fine: $121,951

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 meet its financial obligations, which led to a deficiency in the delivery of care and maintenance. This deficiency was identified when it was discovered that the facility did not have sufficient funds to make payroll on the scheduled date, resulting in 39 staff members not receiving their paychecks on time. This included various staff members such as the Administrator, Director of Nursing, Registered Nurses, Licensed Practical Nurses, and other essential personnel. The delay in payroll was due to insufficient funds in the facility's bank account, which was confirmed by the Bank of Oklahoma Treasury Client Services Representative. Additionally, the facility neglected to pay its therapy provider, Broad River Rehabilitation, leading to a significant outstanding balance for services rendered from December 2023 through May 2024. The therapy provider had notified the facility that services would be terminated if a substantial payment was not received, which placed residents receiving therapy services at risk of having their care interrupted. The facility's financial instability also affected its ability to pay other vendors, such as Medline Medical Supplies, which had an outstanding balance and a past due amount. The investigation revealed that the facility did not have a comprehensive and effective system in place to monitor its financial solvency and ensure that all bills were paid timely. This lack of financial oversight and management led to the potential interruption of essential services and care for all residents, as the facility was unable to meet its financial obligations to staff and service providers.

Removal Plan

• The facility implemented corrective actions to remove Immediate Jeopardy.
• The Administrator identified payroll issues and verified payroll was met.
• All staff received education on the facility abuse/neglect policy.
• All residents and/or resident representatives were interviewed by the interdisciplinary team to ensure care needs were being met.
• Daily audits were implemented to ensure medical supplies, food, medications, and staff continue to be provided.
• R&R Management was appointed as the new management company to fund payroll.
• Payroll ACHs would be deposited, with audits completed to ensure all funds were received.
• Letters to notify vendors of the new receiver were sent.
• A Broad River payment plan was initiated to pay 25% of outstanding balances each month.
• Staffing contracts were verified, and incentives were offered for immediate/same-day shift pickups.
• Managers were educated on shift pickup via in-service.
• A plan for ancillary staffing was implemented, including sharing staff between facilities managed by the company.
• Weekly audits of financial obligations were implemented to ensure delivery of care continues as required.
• Results of audits and interventions would be brought to the QAPI meeting monthly and as needed.

Penalty

Inspection fine: $121,951

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 establish an effective governing body responsible for implementing policies regarding management and operation, including financial obligations. This deficiency was identified through multiple complaint surveys, revealing ongoing issues with financial solvency, particularly concerning employee payroll. On several occasions, employees did not receive their paychecks due to insufficient funds, and the facility was unable to provide adequate explanations for these financial shortcomings. Additionally, the facility had outstanding balances with vendors and suppliers, leading to shut-off notices and threats of service termination. Interviews with facility staff, including the Administrator and Director of Nursing, highlighted the lack of a comprehensive system to monitor financial solvency. The Administrator was unable to clarify the facility's financial processes, and it was unclear whether Epic Healthcare Solutions was responsible for payments. The facility's owner attempted to address payroll issues by offering bonuses to affected staff, but the underlying financial management problems persisted. The facility was placed under court-ordered receivership, indicating severe financial mismanagement. Vendor interviews further exposed the facility's financial instability. The therapy provider reported an outstanding balance of over $84,000, threatening to cease services without a substantial payment. Similarly, a medical supplies vendor noted a past due balance, though the facility failed to provide explanations or evidence of good standing. The facility's governing body policy outlined fiduciary duties and responsibilities, but the lack of active engagement and effective financial oversight contributed to the ongoing deficiencies.

Penalty

Inspection fine: $121,951

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 continuous evaluations were in place to verify financial obligations were met as planned, which could potentially disrupt resident care and services. This deficiency was identified through multiple complaint surveys, revealing ongoing issues with financial solvency, particularly concerning employee payroll and vendor payments. On several occasions, employees did not receive their paychecks due to insufficient funds, and the facility had outstanding balances with various vendors, leading to shut-off notices and threats of service termination. During interviews, the facility's Administrator and Owner were unable to provide satisfactory explanations for the financial issues. The Administrator was unsure of the payment processes and whether Epic Healthcare Solutions was responsible for all payments. The Owner admitted to issues with payroll processing due to bank policies and attempted to compensate employees with bonuses for delayed payments. Despite these efforts, the facility continued to struggle with meeting its financial obligations, as evidenced by the ongoing issues with payroll and vendor payments. The facility's Quality Assurance and Performance Improvement (QAPI) program was found to be ineffective in addressing these financial deficiencies. The program was supposed to track and measure performance, identify and prioritize quality deficiencies, and implement corrective actions. However, the lack of a comprehensive system to monitor financial solvency and ensure timely payments to employees and vendors indicated a failure in the QAPI program's implementation. This deficiency was investigated under Complaint Number OH00154712.