Accel At Crystal Park

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 medications were available for administration per physician orders for 2 of 6 sampled residents reviewed for medication administration. For Resident #11, physician orders dated 04/02/26 included Xalatan 0.005% eye drops, one drop in both eyes nightly at bedtime, and Modafinil 200 mg daily. The MAR for 04/02/26 through 04/12/26 showed Modafinil was held or missed from 04/03/26 through 04/11/26 because the medication was not available, and Xalatan eye drops were held or missed from 04/04/26 through 04/10/26 because the medication was not available. The Record of Admission form showed the resident was admitted with diagnoses including unspecified fracture of the left femur, muscle weakness, chronic pain, and hypersomnia. For Resident #7, physician orders dated 05/17/26 included Cefdinir 300 mg every 12 hours for three days and ipratropium bromide-albuterol inhalation every eight hours. The MAR showed Cefdinir was documented as held on 05/21/26 at 9:00 a.m. because the medication was not available. The TAR showed ipratropium bromide-albuterol was documented as held on 05/18/26 at 5:00 p.m., 05/19/26 at 5:00 p.m., 05/21/26 at 1:00 a.m., and 05/21/26 at 9:00 a.m. because the medication was on order. The Record of Admission form showed the resident was admitted with diagnoses including hypertension, saddle embolus of the pulmonary artery, and mild intermittent asthma. The policy titled Medication Ordering and Receiving from Pharmacy Provider stated timely delivery of new orders is required so medication administration is not delayed. On 05/28/26, the DON stated the medications were ordered for Residents #7 and #11 and were not documented as given per the medical record, and that the medications should have been available and 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 perform hand hygiene and wear a gown during wound care for Resident #1, who had diagnoses including paroxysmal atrial fibrillation, an unstageable sacral pressure ulcer, pain, aphasia following cerebral infarction, and orders for topical wound treatments and enhanced barrier precautions. On 05/26/26 at 11:40 a.m., an LPN was observed providing wound care to the resident’s right calf, including removing the dressing, cleaning the wound, and applying gentamicin, Santyl, and calcium alginate, while wearing gloves but not a gown. The LPN was also observed changing gloves without performing hand hygiene before donning new gloves and did not perform hand hygiene before leaving the room. The facility policy stated hand hygiene should be performed before resident contact, before taking part in a medical or surgical procedure, after contact with contaminated articles, after resident contact, after contact with wounds, and after removal of gloves. The enhanced barrier precautions policy stated gown and gloves were required during high-contact care activities, including wound care. The DON stated residents on enhanced barrier precautions were identified by a colored name badge on the door and that staff should wear a gown and gloves during contact care for residents with wounds, peg tubes, or catheters. The LPN stated they had heard of enhanced barrier precautions but did not know which residents required them and had not received training or education about them.

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 discharge plans were completed, reviewed with the resident, and a copy provided to the resident and/or family for 2 of 3 sampled residents reviewed for discharges. A facility policy titled Discharge Plan stated that, at a minimum, the post-discharge plan would include social services reviewing the plan with the resident and family before discharge and providing a copy to the resident, with another copy filed in the medical record. Resident #5 was admitted with diagnoses including acute systolic and diastolic heart failure, type 2 diabetes mellitus, acute kidney failure, end stage renal disease, and dependence on renal dialysis, and was later discharged from the facility. The discharge planning document for this resident was incomplete for goals, participating members, and discharge planning. Resident #11 was admitted with diagnoses including fracture of the left femur, atherosclerotic heart disease, peripheral vascular disease, and hypersomnia, and was later discharged from the facility. There was no documentation that discharge planning was provided before discharge. The resident stated they received medication instructions but were not clear on the discharge day or time until they were told they were ready to go home and needed someone to pick them up. The social services director stated there was not a care plan meeting or discharge planning meeting for this resident, and notes kept regarding planning and conversations were not in the medical record or provided to the resident or family. The DON stated the discharge planning form should have been completed by the interdisciplinary team and placed in the medical record, and they did not know whether a copy had been given to either resident or family because there was no documentation in the electronic 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 facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for one resident. During an observed medication pass, an LPN prepared crushed medication for the resident’s PEG tube, donned a gown and gloves, stopped the tube feeding, and checked placement and residual. The LPN then poured water and the crushed medication into a 30 ml cup and attempted to pour the diluted medication directly into the PEG tube without using a syringe, causing the medication to spill out over and around the tube. The LPN then obtained another cup with diluted medication and a syringe but did not know how to connect the syringe to the PEG tube, hesitated, activated the call light, and stated they would call for assistance. The DON later entered the room and provided instructional assistance to the LPN on administering medication through the PEG tube. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction. A physician order directed flushing the PEG tube with 30 ml of water before and after medications and 15 ml between each medication. The LPN stated they were unsure how much medication the resident received when the diluted medication spilled during administration. The DON stated the LPN did not correctly administer the medication via the PEG tube, that the medication was spilled and the resident did not receive the full dose, and that the LPN should have notified the physician. The DON also stated the facility used skills competency checklists upon hire and yearly during a skills fair, but the LPN did not have a skills competency checklist completed upon hire and was past the 90-day timeframe for completion.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to ensure that physician orders were followed for medication administration and colostomy care, resulting in a resident not receiving timely intervention for a new stoma that became necrotic. The resident, who had a history of volvulus, heart failure, and chronic kidney disease, was admitted with a pink, patent, and protruding ostomy. Physician orders included medications such as Colace and polyethylene glycol for bowel management, as well as daily colostomy care and assessments. However, documentation revealed that the resident did not receive the ordered Colace, and there was no evidence that daily assessments of the colostomy site, stoma, and bowel sounds were performed as required. The resident experienced ongoing pain, nausea, and changes in condition, including a black, necrotic, and odorous stoma, which was not promptly addressed. Nursing notes indicated that the resident's condition deteriorated, with symptoms such as slurred speech, bleeding from the stoma, and abdominal distention. Despite these changes, there was a lack of comprehensive assessment and documentation, including vital signs, pain assessment, and bowel sound evaluation at critical times. Communication with the physician was delayed, and the facility did not demonstrate a sense of urgency in responding to the resident's declining condition. Further review showed that other residents also experienced lapses in daily skilled assessments, as required by facility policy. For example, another resident with multiple diagnoses did not have daily skilled notes or assessments completed for several days. Interviews with staff confirmed that assessments were expected but not consistently performed or documented. These failures contributed to the deficient practice of not providing appropriate treatment and care according to physician orders and resident needs.

Removal Plan

• Audit of current residents inhouse was performed to ensure stoma is patent and healthy appearing
• Stoma site will be evaluated daily with care on the treatment record
• DON/designee will provide education to all clinical staff on completion of colostomy care, evaluation, and documentation on the treatment record
• The Administrator/designee will be responsible for the implementation of the New Process
• The New Process/system will be started and no licensed staff will be able to return to work until they complete the above stated education

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 baseline care plans were completed for two of nine sampled residents upon admission or re-admission. For one resident who was re-admitted following major orthopedic surgery, there was no documentation of a baseline care plan being completed at the time of re-admission, as confirmed by the Director of Nursing (DON) who was unable to locate the required documentation. Another resident, admitted with diagnoses including diabetes, hypertension, and gait and mobility abnormalities, also did not have a baseline care plan completed upon admission. The DON confirmed that this resident did not have a baseline care plan and stated that nurses were responsible for completing these plans at the time of admission.

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 hospital discharge medication orders were fully transcribed and administered as ordered for one resident, and failed to administer medications as ordered for another resident. In the first case, a resident admitted with diagnoses including volvulus, heart failure, and chronic kidney disease had a hospital discharge summary listing several medications, including Lasix and Colace. Upon review, it was found that while most medications were ordered by the facility, Lasix and Colace were not ordered at admission as required. The Director of Nursing (DON) confirmed that these medications should have been ordered and that the facility's process involves initialing orders and having them checked by the DON or assistant DON. In the second case, a resident with diabetes, hypertension, and mobility issues had a physician's order for Lortab to be given every six hours for pain. The medication administration record (MAR) showed that several doses were held, some without documented reasons, even when the resident reported significant pain. Staff interviews revealed that medications were sometimes held due to unavailability or other undocumented reasons, and there was no evidence of communication with the pharmacy or physician regarding the missed doses. The DON stated that staff should notify the physician if medications are held for reasons not specified in the orders.

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 with a peripherally inserted central catheter (PICC) line had an appropriate care plan in place to address the use and management of the PICC line. Observation on 10/07/25 confirmed the presence of a PICC line in the resident's right arm. The resident's 5-day PPS scheduled assessment documented central IV access and a diagnosis of major orthopedic surgery, but the care plan revised on 09/08/25 did not include any documentation regarding the PICC line. Interviews with the RN and MDS coordinator confirmed that the resident had a PICC line since admission and that all PICC lines should be included in the care plan, but this was not done for this resident.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with a history of atherosclerosis of the right leg with ulceration was ordered to receive intravenous meropenem every eight hours. The physician's order and the medication administration record did not specify the rate of infusion for the antibiotic. During observation, an LPN initiated the infusion at a rate of 125ml/hr, based on routine practice rather than a specific order. The medication bag itself indicated a rate of 100ml/hr, but the LPN did not initially follow this rate and did not contact the physician to clarify the appropriate infusion rate prior to administration. The facility's policy required nurses to verify that the medication label matched the prescriber's order, including the infusion rate, and to contact the physician if the rate was not specified. Both the LPN and the DON acknowledged that the rate should have been confirmed with the physician before administration. The DON also confirmed that the order lacked the required infusion rate and emphasized the importance of this information for safe medication administration.

Penalty

No penalty information released

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

Summary

The facility failed to properly handle intravenous (IV) tubing and follow evidence-based protocols during IV medication administration for a resident with a peripherally inserted central catheter (PICC) line. Observations revealed that the IV tubing was left without an end cap and was hanging 2 to 3 inches above the floor, connected to a new bag of meropenem, with no date labeled on the tubing. Two empty medication bags and a syringe cap were found in the trash, and the tubing was not dated as required by facility policy. During the administration of the IV medication, the LPN did not wear a gown as required under Enhanced Barrier Precautions (EBP) and was unsure about the frequency of IV tubing changes or the meaning of EBP. The LPN also admitted to discarding the original end cap and not replacing it, leaving the tubing uncapped. The resident involved had a diagnosis of major orthopedic surgery and a physician's order for meropenem IV infusions related to atherosclerosis with ulceration. The facility's policies required that intermittent administration sets used more than once in 24 hours be capped with a sterile end cap, labeled with date and time, and changed every 24 hours. The Director of Nursing confirmed that the observed practices did not align with facility policy, as the tubing should have been capped, dated, and the staff should have worn both gown and gloves for EBP. The LPN's lack of knowledge regarding EBP and proper IV tubing handling contributed to the deficiency.

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 its abuse policy and report an incident of alleged abuse in a timely manner, as required by their policy. The incident involved a resident with end-stage renal disease and legal blindness, who reported feeling intimidated and verbally abused by a CNA. The resident's family member also expressed concerns about the staff's behavior, which they perceived as abusive. The facility's policy mandates that any suspected abuse be reported to the Abuse Coordinator within two hours, but this was not done. The incident began when the resident requested pain medication, and there was a delay in receiving it. The resident reported that the CNA became rude and made derogatory comments about their eyes and family. The situation escalated when the resident's family member called the facility, upset about the alleged intimidation and verbal abuse. The family member reported the incident to the charge nurse, who did not immediately report it to the Abuse Coordinator as required by the facility's policy. The administrator was only made aware of the incident the following morning after reading the clinical notes, rather than being informed directly by the staff. The charge nurse involved did not perceive the incident as abuse but rather a misunderstanding, and allowed the CNA to continue working with other residents. This failure to report the incident promptly and follow the facility's abuse policy resulted in a deficiency being cited by the surveyors.

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 administration and supervision of respiratory care for a resident, specifically in the administration of oxygen and nebulizer treatments. The resident, who had a diagnosis of acute respiratory failure, was observed receiving a nebulizer treatment without staff supervision, contrary to the facility's policy which requires staff to remain with the resident unless they are assessed and authorized to self-administer. The resident was unsure of the time the treatment was administered and had to turn off the nebulizer themselves, indicating a lack of supervision. Additionally, the oxygen concentrator was set at 3.5 liters per minute, which was not in accordance with the physician's order of 2 liters per minute. The LPN responsible for the resident's care admitted to administering multiple nebulizer treatments simultaneously and not being able to stay with the resident during the treatment. The LPN also acknowledged that the resident's oxygen was set higher than the ordered amount and could not provide documentation to support any communication with the provider regarding this discrepancy. The DON confirmed that staff were expected to follow physician orders and remain with residents during nebulizer treatments, and that the resident had not been assessed to self-administer the treatment.

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 dialysis communication forms were consistently filled out for a resident with end-stage renal disease who required dialysis services. The facility's Dialysis-Hemodialysis policy required community nurses to complete specific sections of the communication form post-dialysis, including vital signs and an assessment of the resident. However, for two separate dates, the forms for a resident were missing documentation in the post-dialysis section. The resident confirmed that staff did not take their vital signs or assess them before or after returning from dialysis. An LPN acknowledged the absence of documentation, and the DON verified the missing forms and confirmed the resident's statement.

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 medication error rate of less than five percent, resulting in a 7.14% error rate during a medication administration observation. The deficiency involved Resident #142, who had a diagnosis of hypothyroidism and was prescribed levothyroxine 200 mcg and 25 mcg tablets to be taken together at 5:00 a.m. On the date of observation, the medication was administered at 9:10 a.m., which was not in accordance with the physician's orders. The facility's Medication Administration policy requires medications to be administered as prescribed and within 60 minutes of the scheduled time, except for specific meal-related orders. The error occurred when CMA #1 prepared and administered the medication at 9:01 a.m., after being informed by an outgoing agency nurse that all medications due had been given. However, upon observation, the CMA noticed the levothyroxine had not been administered and proceeded to give it to the resident. LPN #2 confirmed that the medication was not administered according to the physician's orders and acknowledged the error. The Director of Nursing (DON) was informed of the incident and notified the resident's physician and nurse practitioner, but no new orders were received.

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 timely toileting assistance to Resident #142, who had a care plan in place to reduce incontinent episodes through a scheduled toileting program. On the morning of January 14, 2025, Resident #142 expressed the need to urinate to CMA #1, who activated the call light and left the room. Despite the call light being on and beeping, it was not addressed promptly by the staff. Observations noted that both CMA #1 and LPN #2 were present in the hallway, and the wellness director passed by the room without responding to the call light. The Director of Nursing (DON) eventually entered the room, turned off the call light, but did not inquire about the resident's needs. The resident later confirmed they were still waiting to use the urinal. The DON acknowledged the oversight and arranged for CNA #4 to assist the resident. The delay in responding to the call light and addressing the resident's toileting needs resulted in the resident's needs not being met in a timely manner, as confirmed by the DON.

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 admission and weekly weights were obtained for a resident on dialysis, identified as Resident #21. The facility's weight monitoring policy, reviewed in May 2023, requires newly admitted residents to be weighed upon admission and weekly for four weeks, then monthly unless otherwise indicated by a physician's order. Resident #21, who was admitted with end-stage renal disease and dependence on dialysis, had a physician order dated December 28, 2024, specifying weekly weights every Wednesday on day shift for 28 days on admission, then weekly for four weeks, and monthly if stable. However, the resident's weight record showed only one weight recorded on January 1, 2025. Interviews with the resident, a CNA, and an LPN revealed that the weekly weights were not conducted as ordered, with the LPN acknowledging that only one weight was documented in the electronic health record (EHR).

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 a discharge hospital order for a fluid restriction for one resident with chronic kidney disease and pulmonary edema. The hospital's After Visit Summary specified a fluid restriction of no more than 2000 milliliters in a 24-hour period, but the resident had no fluid restriction orders upon admission to the facility. The resident reported that staff were unsure about their fluid restriction status, and a water pitcher with 700 ml of clear fluids was observed at the bedside. A CNA stated that they would be informed by nurses if a resident was on a fluid restriction, but there was confusion about the resident's status. An LPN confirmed that there was no order for a fluid restriction in the resident's records. The ADON acknowledged that the resident should have been on a fluid restriction and identified an oversight in entering the hospital orders upon admission.

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 topical pain medication was administered as ordered for a resident diagnosed with pain. The physician's order specified the application of Voltaren arthritis pain 1% topical gel every 12 hours to the resident's right knee. However, the Medication Administration Record (MAR) for January 2025 documented that the medication was not administered on several occasions, marked with an 'x' and noted as 'due to special parameters,' without any explanation provided for these parameters. During interviews, the resident stated they had not received any topical medication for their knee, and a family member confirmed they had never seen staff apply any pain cream. An LPN and the Director of Nursing (DON) reviewed the MAR and confirmed the medication was not administered, with the DON indicating that the 'x' meant the medication was not given and that the 'due to parameters' could be related to vital signs. The LPN also admitted to not administering the topical pain gel during the resident's current stay.

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 its infection prevention and control program effectively, as evidenced by multiple deficiencies observed during wound care and incontinent care. Specifically, the facility did not adhere to its enhanced barrier precautions policy for a resident with a pressure ulcer. The staff did not use gowns and gloves as required for direct patient care, and there was no use of normal saline to clean the resident's wound, contrary to the physician's orders. Additionally, the facility did not ensure proper hand hygiene and glove use during incontinent care for several residents. Staff members were observed not changing gloves or washing/sanitizing their hands when transitioning from dirty to clean tasks. This was noted during the care of multiple residents, where staff continued to perform tasks and handle items without changing gloves or sanitizing hands, leading to potential cross-contamination. The facility's policies on hand hygiene and perineal care were not followed, as staff failed to wash or sanitize their hands after providing care to one resident and before assisting another. This was observed in several instances, including when staff moved between residents and handled personal items and equipment without proper hand hygiene. The Director of Nursing and other staff members acknowledged the expected procedures, but these were not consistently practiced, resulting in the identified deficiencies.

Penalty

No penalty information released

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

Summary

The facility failed to notify the physician when a resident experienced a change in condition, specifically regarding oxygen saturation levels. The resident, who had diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase, was admitted for a skilled stay related to orthopedic aftercare for cervical stenosis. On one occasion, the resident removed their oxygen, leading to a significant drop in oxygen saturation to 76%, prompting a family member to request hospital transfer. The staff responded by increasing the oxygen flow, stabilizing the resident's condition, but did not notify the physician of the incident. Further documentation revealed another instance where the resident's oxygen saturation was recorded at 86%, yet again, there was no evidence of physician notification. Interviews with the family member and the Director of Nursing (DON) confirmed these events, with the DON acknowledging that staff should have contacted the physician when the resident's oxygen levels dropped. The facility's policy required documentation of physician notification in such cases, which was not adhered to, leading to the deficiency.

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 protect residents from the misappropriation of controlled medications, affecting two residents who were reviewed for this issue. Resident #8, with diagnoses including an unspecified fracture of the shaft of the left fibula and low back pain, had a physician's order for hydrocodone 10 mg - acetaminophen 325 mg to be administered every four hours as needed for pain. Resident #9, with diagnoses including low back pain and pain in both hips, had a physician's order for acetaminophen 300 mg - codeine 30 mg to be administered every six hours as needed for low back pain. Both residents were affected by the misappropriation of their prescribed pain medications. The incident was identified when the Director of Nursing (DON) discovered that the pain medications for these residents were not available, despite having been received from the pharmacy. An investigation revealed that the medications were missing, and LPN #1, who was the receiving staff member, was suspended pending further investigation. The facility determined that 60 tablets of hydrocodone 10 mg - acetaminophen 325 mg and 60 tablets of acetaminophen 300 mg - codeine 30 mg were missing. The medications had to be reordered, and the facility conducted a search and staff interviews to address the issue.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that physician-ordered vital signs were obtained for a resident who was being monitored for a change in condition. The resident had diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase. A physician order dated June 24, 2024, required vital signs to be checked every two shifts, including systolic and diastolic blood pressure, pulse, respirations, temperature, and O2 saturation. However, the medication administration record for June 2024 showed blanks for the night shift vital signs on the 26th, 28th, and 30th, indicating that these vital signs were not obtained. The Director of Nursing (DON) confirmed that the absence of recorded vital signs meant they were not taken and noted that the facility had several new nurses and the resident was not at the facility for long.

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 pressure ulcer treatment as ordered for a resident with a sacral pressure ulcer. The resident was admitted with a physician's order to cleanse the wound with normal saline, pat dry, pack with mesalt, cover with a nonbordered dressing, and secure with tape, to be changed daily and as needed. However, during an observation, it was noted that the wound was not cleaned with normal saline, was not packed with mesalt, and a nonbordered dressing was not used. Instead, an LPN applied a xeroform and two foam bordered dressings over the resident's coccyx, which did not align with the physician's orders. The LPN involved admitted to not following the physician's orders, stating they used their own knowledge from nursing school to decide on the wound care. The LPN also mentioned that the resident's dressing had come off earlier in the shift and that they attempted to get an order for wound care. The Director of Nursing (DON) stated that when a resident is admitted with a wound, staff are expected to perform an initial skin assessment and follow any existing wound care orders. If no orders are present, staff should contact the provider to obtain them. The failure to adhere to the prescribed wound care regimen resulted in a deficiency in the care provided to the resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure oxygen therapy was consistent with professional standards of practice for a resident who had diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase. A physician order indicated the resident was to receive three liters per minute (LPM) of oxygen via nasal cannula. However, a nurse note documented an incident where the resident removed their oxygen, leading to a significant drop in oxygen saturation to 76%. In response, staff increased the oxygen flow to 10 LPM without obtaining a physician's order, which was not in accordance with the prescribed treatment plan. Family members reported concerns about the resident's breathing difficulties and the facility's response. They noted instances where the resident's oxygen saturation dropped significantly, and they had to intervene by increasing the oxygen flow themselves. The Director of Nursing (DON) acknowledged the situation and stated that staff should have contacted the physician when the resident's oxygen saturation dropped. The DON also reviewed the nurse note and could not explain the charting of 'hyperventilate,' indicating a lack of clarity and adherence to proper procedures in managing the resident's oxygen therapy.

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 showers in a timely manner and according to the plan of care for a resident with diagnoses including a fracture of the lower end of the left femur and muscle atrophy. The facility's Bathing policy, revised in January 2023, required staff to provide bathing services within standard practice guidelines and document the procedure. A Self-Care Deficit care plan initiated in January 2024 indicated the resident would assist with bathing and hygiene daily over the next 90 days. A physician order from January 2024 specified the resident was to receive baths on Tuesdays and Fridays. However, during a two-week stay, documentation showed that a bath or shower was only offered on two occasions. Interviews with facility staff revealed that showers should be given twice a week, but documentation to support this was missing. The Assistant Director of Nursing (ADON) confirmed the lack of documentation, and the Director of Nursing (DON) stated that shower assignments are listed on daily assignment sheets, which were not located for the relevant time frame. The regional nurse mentioned that orders for baths should be entered at admission and checked the next business day, indicating a lapse in following the established procedures.

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 storage of a dirty bedside commode, leading to a potential risk of cross-contamination among residents. On May 21, 2024, a dirty bedside commode with a yellow-orange substance was observed in the hallway outside a resident's room. This was contrary to the statements of two CNAs who confirmed that bedside commodes should be sterilized between uses and never stored in the hallway. Additionally, other items such as an IV pole with a blue baseball cap, a red cane, and wheelchair footrest attachments were also left unattended in the hallway. The administrator acknowledged that the commode should have been taken to the dirty utility closet for proper handling, indicating a lapse in staff adherence to infection control protocols.

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 allegations of abuse were investigated for two residents. Resident #5, who had severe quadriplegia, reported feeling unsafe and disrespected by night staff. A grievance was filed by the resident's family, stating that staff had moved the call light away from the resident, who had limited use of their extremities. Despite these reports, there was no documentation that the allegations had been investigated. The Social Services Director (SSD) confirmed that the grievance was reported to the Administrator, who acknowledged the issue but had not addressed it in a timely manner. Resident #6, diagnosed with bacterial pneumonia, also reported feeling unsafe depending on the staff. This concern was documented in a Safe Survey, but again, there was no documentation that the allegation had been investigated. The SSD confirmed that the Safe Surveys were given to the Administrator, who admitted to not catching the issues sooner and failing to investigate the allegations promptly. The Administrator acknowledged that the failure to investigate these allegations was a problem and confirmed that the allegations had not been reported and investigated in a timely manner.

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 adequate staff to ensure timely administration of medications for two residents. Resident #2, who had chronic pain, was prescribed oxycodone-acetaminophen to be taken every four hours. However, the medication was administered late multiple times between 12/08/23 and 12/22/23. Similarly, Resident #5, who also had pain, was prescribed gabapentin three times a day and a Lidocaine patch to be applied in the morning and removed in the evening. The resident received both medications late on several occasions between 12/01/23 and 12/27/23. Interviews with staff revealed that medications and treatments were often administered late due to a heavy workload and insufficient staffing.

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 medications were administered timely for two residents reviewed for medications. Resident #2, who had a diagnosis of chronic pain, was prescribed oxycodone-acetaminophen 5 mg every four hours from 12/08/23 to 12/22/23 and 7.5 mg every four hours from 12/14/23 to 12/22/23. The medication administration record (MAR) showed that Resident #2 received the medication late multiple times. Similarly, Resident #5, who had a diagnosis of pain, was prescribed gabapentin three times a day and a Lidocaine patch to be placed in the morning and removed in the evening. The MAR indicated that Resident #5 received gabapentin and the Lidocaine patch late on several occasions. Interviews with staff confirmed that medications and treatments were often administered late, and the Director of Nursing (DON) acknowledged the delays after reviewing the administration times.

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 residents had the right to view or receive copies of their clinical records. This deficiency was identified for one resident out of three reviewed. The resident, who had a diagnosis of depression, requested their entire medical record using the Oklahoma Standard Authorization To Use Or Share Protected Health Information form. Despite completing the necessary paperwork on 12/11/23, the resident did not receive their records in a timely manner. The Social Note dated 12/13/23 documented that the resident was informed they had to fill out the paperwork, which would then be submitted to corporate for processing before the records could be released. On 12/28/23, the medical records personnel confirmed that the resident's request was submitted on 12/11/23, but approval to release the records was not received until 12/26/23. The records had not been released because the resident was no longer in the facility, and there was uncertainty about the payment for the records. The medical records personnel stated that the timeframe for releasing records varied based on the size of the file and corporate processing times, typically taking three to four days. However, the resident's request took significantly longer, indicating a failure to comply with the policy and ensure timely access to medical records.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the resolution of grievances for one of three sampled residents reviewed for grievances. The facility's grievance policy, dated 01/12/20, stated that residents would be informed of the findings of the investigation and the actions taken to correct any identified problems within three working days of filing the grievance. However, a grievance dated 12/21/23 documented that a resident reported not receiving pain medication during the night when requested and that the night shift ignored them. There was no documentation that the grievance had been resolved. The resident confirmed on 12/27/23 that they did not receive pain medication timely and had informed staff about their complaints. The Administrator stated that any staff could input a grievance in the EHR and that there was no official timeframe for resolving grievances, indicating a lack of adherence to the facility's grievance 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 ensure care plan fall interventions were in place for one of three sampled residents reviewed for falls. Resident #3, who had a diagnosis including a fracture of an unspecified part of the right femur, was observed with the call light out of reach on multiple occasions. On one occasion, the resident was observed looking for the call light and stated they did not know where it was. When asked, RN #3 also could not initially locate the call light and confirmed it was not within the resident's reach. The DON and other staff members acknowledged that ensuring call lights are within reach is a key measure to prevent falls, but this was not adhered to in the case of Resident #3.