Meadowbrook Nursing Center

Penalty

No penalty information released

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

Summary

The facility failed to ensure adequate supervision to prevent an elopement for one resident. The resident had diagnoses including congestive heart failure and hypertension, was assessed on 02/12/26 as not at risk for elopement, and a significant change assessment on 02/13/26 documented a BIMS score of 13, indicating cognitive intactness for daily decision making, and that the resident was ambulatory with a walker. On multiple observations in mid-April, the resident was seen in their room, either resting in bed or sitting on the side of the bed, appearing clean and appropriately dressed. The facility’s undated Missing Resident policy stated the intent to be aware of residents’ usual habits and locations as reasonably practicable to identify a possible missing resident. On 04/04/26, while a nurse was at the nurse’s station charting, staff informed the nurse that the resident was out of the building and walking toward the highway. The resident walked onto the highway, stood in front of a stopped semi-truck, and asked the driver to take them home before staff were able to return the resident safely to the facility without injury. In a typed statement dated 04/06/26, the resident reported being angry after a family member hung up on them, then walking slowly down the hallway while waiting for the nurse to leave the desk, observing that the nurse was no longer at the desk, hurrying to the door, entering the code, exiting the building, and continuing down the road toward the highway until a passing truck stopped. The resident confirmed they did not walk in front of the truck until it had stopped. The corporate nurse consultant later stated the resident should never have been able to leave the building unattended.

Penalty

Inspection fine: $21,6456 days payment denial

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

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent accident hazards related to smoking, resulting in a resident smoking in their room while wearing oxygen and sustaining facial burns. The facility had a written smoking policy stating that residents would not be allowed to have cigarettes, matches, or lighters in their possession or in their rooms, and that no smoking was permitted in resident rooms or hallways. Despite this, the resident was able to obtain and use smoking materials in their room. Staff, including the administrator and DON, acknowledged that housekeeping had previously found ashes on the resident’s toilet seat and that the resident had been reported to have smoked in their room multiple times over a two‑month period. The resident involved had diagnoses including COPD, lung cancer of the right lower lobe, respiratory failure, anxiety, depression, and paranoid schizophrenia, and used oxygen. Assessments showed the resident was cognitively intact with a BIMS score of 15 and was identified as a smoker. A smoking assessment documented on 11/12/25 indicated the resident could safely smoke with minimal supervision, and a subsequent assessment on 02/12/26 noted the resident had been observed hiding a cigarette in their pocket to smoke later, yet still concluded they could safely smoke with minimal supervision. A nurse progress note on 02/12/26 recorded that staff had observed the resident placing a cigarette in their jacket pocket and had educated the resident on the dangers of smoking while wearing oxygen. Despite these documented concerns and prior observations of unsafe smoking behavior, the resident continued to access smoking materials and smoke in their room. A nurse progress note dated 03/03/26 recorded that the resident had smoked in their room the night before while wearing oxygen, resulting in burns to the resident’s face. On observation, the resident was noted to have singed mustache hair and a wound near the upper lip. The administrator reported that the maintenance director later found a lighter under the resident’s bed and that it had been reported the resident had smoked in their room six times between early January and early March. Staff interviews confirmed that residents were not supposed to have smoking materials in their possession and were to be supervised while smoking, but also revealed that there was no guarantee that all lighters and cigarettes had been removed from the resident’s room.

Removal Plan

• Notify Medical Director
• Notify resident #26 hospice provider of IJ and coordinate care
• Complete a new Smoking Assessment for all smokers
• Review and revise the smoking policy with the resident and resident council (with agreement/approval) to include checking for any smoking material at the end of each smoke break; update the policy to include observation of smoking residents to ensure smoking material (e.g., cigarette butts) is distinguished and disposed of and the lighter is returned at the end of smoking times; implement a checklist to ensure each resident has complied; staff supervising smoke breaks will keep the smoking materials container in their possession with only one lighter available and will give each resident only one cigarette at a time; all smoking materials brought in by friends/family will be checked in at the nurse's station
• Post the reviewed/revised smoking policy with resident council approval at the nurses' station and by the exit leading to the smoking area
• Have smoking residents sign the revised smoking policy acknowledging the policy
• Administrator to in-service staff on the revised smoking policy
• Regional supervisor to in-service Administrator/DON on ODHS Form 283 and completing it with adequate supervision of residents and follow-up for accidents/incidents related to smoking and charting interventions and follow-up care
• Update the care plan for resident #26
• Review all smoking residents' care plans and revise as needed for adequate supervision/intervention to prevent accidents/injury and ensure follow-up if an occurrence happens
• Move resident #26 to a room closer to the nurse's station
• Educate resident #26 on hazards of smoking in the room and potential harm due to combustion with oxygen; have resident sign education sheet and upload to the resident EHR under resident documents
• Send all ODHS Form 283 reports to a Regional Supervisor for review for completeness and adequate intervention to prevent reoccurrence and ensure follow-up
• Initiate QAPI for the IJ and monitor implementation of the above interventions for removal of IJ

Penalty

Inspection fine: $21,6456 days payment denial

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 required daily nurse staffing information was posted for residents and visitors. Surveyors observed on 03/12/26 at 1:30 p.m. that nurse staffing information was not posted anywhere in the facility, despite the administrator identifying that 34 residents resided there. On 03/13/26 at 9:28 a.m., a dry erase board by the nurse’s station was observed that listed the date, staff names with titles, census, and the number of residents in the hospital. The facility’s undated “Staffing Requirement Policy” stated that daily staffing reports would be posted for residents and visitors to view. During interviews, an LPN stated that nurse staffing information was posted on the dry erase board by the nurse’s station, and the DON stated that nurse staffing information was documented on that board for visitors and residents, while also noting that a separate book at the nurse’s station contained daily staff assignments but was not available to residents and visitors. The administrator acknowledged that nurse staffing information had been posted in the past but stated that “the ball has been dropped on that,” confirming the lapse in maintaining required staffing postings. No specific resident medical histories or conditions were described in relation to this deficiency, only that 34 residents were residing in the facility at the time of the survey.

Penalty

Inspection fine: $21,6456 days payment denial

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

Facility administration failed to use its resources effectively and efficiently to ensure residents attained or maintained their highest practicable well-being. The administrator did not report allegations of abuse involving one resident to the state survey agency (OSDH). The administrator acknowledged that allegations made on two separate dates were not reported because a skin assessment did not show bruising, a police investigation did not substantiate the allegation, and the resident later denied being abused. The administrator questioned the need for further action and did not document the conversation with the resident. The facility also failed to investigate the same resident’s abuse allegations. The administrator stated that the DON, MDS coordinator, or the administrator would normally investigate abuse allegations, but no internal investigation was conducted for either allegation. For one allegation, the administrator relied on the police determination that the allegation was unsubstantiated, and for the other, they relied on a shower aide’s observation that no bruising was present and the resident’s denial of abuse. The administrator stated they had never conducted an abuse investigation and did not initiate or document an internal inquiry. In addition, the facility did not develop or maintain comprehensive and current care plans for multiple residents and did not provide adequate supervision related to smoking. Two residents who smoked did not have appropriate smoking care plans developed initially, and several residents’ care plans were not reviewed or revised quarterly or as needed to reflect current conditions, including hospice services, nutrition/weight loss, and removal of outdated fluid restrictions. One resident with a history of smoking in their room had been reported multiple times for doing so, had smoking materials confiscated, and was later found to have a lighter under the bed, while the administrator acknowledged there was no guarantee residents did not have lighters or cigarettes in their rooms. Regional nursing staff reported that systemic failures existed and that offers of support to facility administration were often refused.

Penalty

Inspection fine: $21,6456 days payment denial

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

Summary

The deficiency involves the facility’s failure to maintain an effective Quality Assessment and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) program. Surveyors found the facility did not demonstrate systematic identification, reporting, investigation, analysis, and prevention of adverse events, nor did it show documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility had a written Quality Assessment and Assurance Program policy dated 06/27/13 that required each department or service to submit quarterly monitoring reports to the QAA committee, and for those reports to be evaluated to determine problems, plan solutions, implement actions, and ensure follow-up and consistent monitoring over a specified time frame. However, the survey findings, as referenced in CMS Form 2567 (F609, F610, F656, F657, and F689), showed that these processes were not effectively carried out. Surveyors identified systematic problems in several areas affecting the 34 residents in the facility, including failure to identify abuse allegations, failure to report abuse allegations to the state survey agency (OSDH), failure to develop and revise comprehensive care plans, and inadequate supervision to prevent accident hazards related to smoking. During interviews, the administrator stated that the QAPI committee met at least quarterly and that they completed an annual process improvement project, most recently focused on urinary catheters. The administrator also stated that during QAPI meetings they reviewed facility concerns and the relevant department head monitored whether goals were met. Nonetheless, the administrator acknowledged that the system failures related to smoking hazards, abuse reporting and investigation, and care plan development/revision had not been identified by the QAPI committee, explaining that this was because “things had been hectic.”

Penalty

Inspection fine: $21,6456 days payment denial

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

Summary

The deficiency involves the facility’s failure to review and revise resident care plans at least quarterly and as needed, as required by its own Care Planning-Interdisciplinary Team policy and federal regulations. The policy, revised in 09/2013, states that assessments are ongoing and care plans must be updated with significant changes, unmet outcomes, readmissions, and at least quarterly with the MDS. Surveyors found multiple examples where this did not occur. One resident with schizophrenia, cognitively intact per a recent quarterly assessment, had a care plan last revised more than a year earlier. Another resident, severely cognitively impaired and admitted to hospice for senile degeneration of the brain, had a care plan last revised over a year prior and with no hospice-related concern documented. The DON, who oversees the MDS coordinator, repeatedly stated they did not know why these care plans had not been updated. Additional residents also had outdated or incomplete care plans despite significant changes in condition or services. One resident with documented poor intake, significant weight loss over several months, dietician interventions including supplements, high-calorie snacks, and an appetite stimulant, and a quarterly assessment noting weight loss, had a care plan last revised months earlier that did not address nutrition or weight loss and still reflected an outdated fluid restriction. Another cognitively intact resident with emphysema and COPD was newly admitted to hospice, but the care plan, last reviewed over a year earlier, did not include hospice services. A further resident on hospice with a prognosis of less than six months had a care plan last revised more than a year earlier and lacking documentation of hospice services or repeated unsafe smoking behaviors, including placing a cigarette in a pocket and later igniting a cigarette while on oxygen, which resulted in a burn treated with Silvadene. The DON acknowledged that care plans were supposed to be updated quarterly and that this had not been done for these residents.

Penalty

Inspection fine: $21,6456 days payment denial

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 and/or their representatives were informed of changes to medication regimens and the associated risks and benefits, contrary to its Notification of Changes Policy requiring immediate sharing of such information. For one cognitively intact resident with schizophrenia who received antipsychotic medications, physician orders initiated clozapine 50 mg at bedtime and later haloperidol 5 mg twice daily, but nursing progress notes over the relevant periods contained no documentation that the resident had been informed of these new medications or their risks and benefits. The resident reported receiving mental health medications that were adjusted at times and was unsure whether they had been notified of the clozapine or haloperidol orders. An LPN stated that the charge nurse receiving a new medication order was responsible for notifying the resident or representative and documenting this in progress notes, but also stated they discussed only possible side effects, not risks and benefits. The DON acknowledged that charge nurses were supposed to document such notifications but that it was not common practice and confirmed that risks and benefits had not been discussed with this resident or their representative. Another cognitively intact resident with depression and schizoaffective disorder was receiving multiple psychotropic and opioid medications, including Rexulti, tramadol, trazodone, and buspirone, with care plan approaches to administer medications as ordered and monitor for side effects and effectiveness. Review of progress notes over several months did not show that the resident or representative had been notified of the risks and benefits of these medications. The DON stated that information on risks and benefits was provided by the physician before medications were given and documented in physician progress notes, but no such documentation was identified in the nursing progress notes reviewed. A third resident with moderate cognitive impairment and diagnoses including emphysema, heart failure, hypertension, and depression had new orders for Lantus insulin and levofloxacin for bacterial pneumonia, yet progress notes did not show that the resident or representative had been informed of the benefits and side effects of these medications. The DON again stated that charge nurses were to document notification of medication changes but that this was not common practice and confirmed that risks and benefits had not been discussed with this resident or their representatives.

Penalty

Inspection fine: $21,6456 days payment denial

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 assistance to develop an advance directive for one resident reviewed for advance directives. Record review showed an Advance Directive Policy and Record form for Resident #15 dated 09/21/25 that indicated documents were not received and the facility was informed of the document, and that a POA was in place with initials from the resident’s responsible party. An admission assessment dated 09/28/25 documented that the resident had a BIMS score of 15, indicating they were cognitively intact for daily decision-making, and listed diagnoses including dementia. During an interview on 03/13/26 at 3:30 p.m., the DON stated that the business office manager typically reviewed the admission packet with all new admissions and acknowledged that this resident was not offered, did not decline, and did not accept assistance to formulate an advance directive.

Penalty

Inspection fine: $21,6456 days payment denial

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

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing residents’ smoking needs and behaviors. For one resident, the admission assessment dated 12/08/25 documented that the resident was a smoker, and the resident later stated they required someone to stay with them when they smoked because they could not push their own transport wheelchair. However, a care plan dated 12/13/25 contained no smoking concern, and the smoking care plan with interventions was not reflected until a version revised 12/15/25, which was only saved by the surveyor on 03/12/26. Quarterly Smoking Assessments dated 03/10/26 and 03/11/26 indicated the resident was safe to smoke with minimal supervision, but no other smoking assessments were found in the record. The DON stated the smoking care plan was implemented and added on 03/12/26 and acknowledged that care plans were to be reviewed and updated quarterly. For another resident, surveyors observed the resident smoking outside with other residents and staff. The resident had signed the facility’s Smoking and Vaping Policy on 10/24/24, and a Quarterly Smoking Assessment showed the resident was able to smoke with minimal supervision. Despite this, the care plan revised 01/31/25 did not document that the resident smoked, and no smoking care plan had been developed. The DON, who was responsible for overseeing the MDS coordinator to ensure comprehensive care plans were developed, reviewed this resident’s care plan and confirmed the resident had smoked since admission but did not know why a smoking care plan was not in place.

Penalty

Inspection fine: $21,6456 days payment denial

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 nurses and nurse aides had documented competencies to care for residents in a manner that maximizes each resident’s well-being, as evidenced by missing competency documentation in the files of four certified nurse aides (CNAs) hired within the past four months. Record review showed that CNA #3, hired on 11/22/25, CNA #4, hired on 01/28/26, CNA #5, hired on 01/08/26, and CNA #2, hired on 02/05/26, all lacked completed staff competency forms in their employee files. The facility’s undated “New Hire Process” policy stated that new employees are subject to TB testing, an employee physical, competencies, and three days of training on the floor at the DON’s discretion and schedule. During an interview, the DON reported that newly hired CNAs were trained by another CNA and that their competencies were to be documented on a check-off form, but acknowledged that these competency documents had not been completed due to recent staff turnover and stated that this requirement had “slipped through the cracks.” No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.

Penalty

Inspection fine: $21,6456 days payment denial

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 annual performance reviews were completed for a certified medication aide (CMA) who had been employed for more than 12 months, resulting in a deficiency related to staff performance oversight. Surveyors observed CMA #1 administering 50 mg of zinc by mouth to Resident #1, while the physician’s order dated 03/03/26 specified zinc 30 mg daily. Review of CMA #1’s employee file showed a hire date of 11/19/24 and no documentation of any performance review since hire. During interview on 03/13/26 at 9:39 a.m., the DON stated there was no system in place to ensure CNAs/CMAs had performance reviews completed at least every 12 months and confirmed they could not locate documentation showing CMA #1 had received a performance review.

Penalty

Inspection fine: $21,6456 days payment denial

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

Summary

Surveyors identified multiple failures related to medication security and storage. On two separate dates, the nurse treatment cart was observed unlocked and unattended at the nurse's station, despite containing medications. During one of these observations, both the administrator and a visitor walked past the unattended, unlocked cart before an LPN returned and opened the top drawer. RN #1 and the DON both stated that medication/treatment carts were to be kept locked when unattended, and the LPN stated they thought they had locked the cart before leaving it. Further inspection of the nurse treatment cart revealed several medication storage issues. One bottle of glucometer check strips was opened and not dated, and multiple insulin pens (Lantus, Novolog, and Lispro) for several residents were opened and not dated, preventing staff from knowing how long they had been in use. The cart also contained an albuterol inhaler and two bottles of nystatin powder with listed expiration dates in 2025. RN #1 stated they did not know how often the cart was monitored for expired medications or how long the undated insulin pens had been opened, while LPN #2 stated the pharmacist monitored the cart monthly for expired medications. The DON stated nurses were to date insulin pens when opened and that one LPN was responsible for monitoring the cart, but the DON did not verify that these audits were completed. Additionally, discontinued narcotics were stored in a drawer of a locked medication/treatment cart in the DON's office; the DON reported the narcotics were behind two locks (the office door and the cart lock), but the internal separately locked compartment could not be used because there was no key, and the cart itself was not permanently affixed.

Penalty

Inspection fine: $21,6456 days payment denial

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 procure and handle food in accordance with professional standards when surveyors observed improper storage and use of food items in the kitchen and dining areas. During inspection of the cold storage refrigerator, surveyors found sliced cheese in an unsealed zip-close bag labeled with a prior date, as well as an unlabeled, undated clear plastic container holding an unknown liquid. Two flats of unpasteurized eggs were also observed in the refrigerator, with no other eggs available. At a subsequent breakfast meal observation, three residents were served and ate eggs cooked over easy. The Dietary Manager reported that the unpasteurized eggs were routinely used every morning for scrambled, over easy, and fried eggs, including that morning’s service, and acknowledged not knowing whether the eggs were pasteurized. The Dietary Manager also stated that the unlabeled container belonged to an employee despite staff having a separate refrigerator for personal food. No facility policy regarding food storage or the use of pasteurized versus unpasteurized eggs was provided to surveyors. The administrator later stated they were unaware that the eggs ordered from the supplier were not pasteurized and had assumed the supplier would provide products appropriate for a nursing facility. In total, the Dietary Manager identified eight residents who ate eggs over easy and 34 residents who consumed food prepared in the kitchen during the relevant meal service. These observations and interviews demonstrate that the facility did not ensure eggs served over easy were pasteurized and did not ensure all leftover foods in the refrigerator were properly labeled and dated, affecting multiple residents who consumed meals from the kitchen.

Penalty

Inspection fine: $21,6456 days payment denial

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

Summary

The deficiency involves the facility’s failure to report allegations of abuse to the Oklahoma State Department of Health (OSDH) as required by its own Abuse Prohibition Procedure. The policy stated that any suspected abuse or unexplained injury must be reported immediately to the charge nurse, DON, or administrator, and that the administrator or designee would immediately initiate an investigation and notify OSDH. Resident #4, who had a BIMS score of 15 indicating intact cognition and a diagnosis of schizophrenia, told other residents during a smoke break that they had been beaten and had bruises on their arms and back. This allegation was documented in a progress note by LPN #3, who later stated they had notified the administrator and DON of the allegation. Several days later, Resident #4 called 911 from a resident phone, reporting to police that staff were beating them with whips and chains. A police officer responded, and together with LPN #4 performed a full body assessment, with no bruising noted. LPN #4 stated they notified the DON of this allegation after the police officer left. The DON stated that allegations of abuse were immediately investigated by the MDS coordinator, the administrator, or themself, and that they were unsure if they had been notified of the first allegation but were aware of the second. The DON acknowledged that they investigated the allegation but did not report it to OSDH because the police had looked into it and had not substantiated the allegation. The administrator also stated they had not reported either of the resident’s abuse allegations to OSDH, relying on the lack of physical findings and the police officer’s investigation instead of following the requirement to report all allegations.

Penalty

Inspection fine: $21,6456 days payment denial

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 investigate allegations of abuse made by a cognitively intact resident. Facility policy stated that any suspected abuse would be reported, investigated, and that the administrator or designee would immediately initiate an investigation and notify the state agency. Resident #4 had a BIMS score of 15, indicating intact cognition, and a diagnosis of schizophrenia. On 02/22/26, a progress note documented that the resident told other residents during a smoke break that they had been getting beaten and had bruises on their arms and back; this note was signed by an LPN. On 02/28/26, another progress note documented that the resident called 911 from a resident phone, reporting to police that staff were beating them with whips and chains. A full body assessment was completed by an LPN and a police officer, with no bruising noted, and this was documented in the record. Interviews confirmed that these allegations were reported to facility leadership but not investigated in accordance with policy. One LPN stated they notified the administrator and DON after the 02/22/26 allegation, and another LPN stated they notified the DON after the 02/28/26 allegation. The DON stated that allegations of abuse were to be immediately investigated by the MDS coordinator, the administrator, or the DON, but acknowledged having no evidence that the allegations from 02/22/26 or 02/28/26 had been investigated. The administrator stated that they did not investigate the 02/28/26 allegation because the police had unsubstantiated it, and did not investigate the 02/22/26 allegation because a shower aide reported no bruising and the resident later denied being abused. The administrator also stated they had never conducted an abuse investigation and had not documented their conversation with the resident, resulting in no formal investigation of the abuse allegations.

Penalty

Inspection fine: $21,6456 days payment denial

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

Summary

The deficiency involves the facility’s failure to ensure that the clinical record contained complete and required documentation for a resident’s discharge. A discharge return-not anticipated assessment showed that Resident #36 was admitted and then discharged home with hospice services, but review of the clinical record for the days leading up to and including the discharge did not show the reason for the discharge, the resident’s status upon discharge, a physician order for discharge, or what resources were required or provided upon discharge. The record from 12/23/25 through 12/29/25 lacked documentation of these key elements. During interviews, an LPN stated that the resident returned to their apartment with hospice services and left with medications and personal belongings. The DON stated that the physician had provided an order allowing the resident to be discharged home, but acknowledged that the clinical record did not contain a physician discharge order, documentation of the resident’s status at discharge, or documentation of the resources required or provided. The administrator reported that the discharge was planned, that the resident had improved, and that the resident left with personal belongings and medications with instructions, but did not know why this information was not documented. A family member confirmed that the resident chose to return to their apartment and left with medications and hospice services.

Penalty

Inspection fine: $21,6456 days payment denial

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

Summary

The facility failed to complete a discharge summary and notify the State Ombudsman office for a resident who was discharged home with hospice services. A discharge return-not anticipated assessment dated 12/29/25 showed that Resident #36 was admitted and then discharged to home, but review of the clinical record from 12/23/25 through 12/29/25 did not show any completed discharge summary or documentation that the State Ombudsman office had been notified of the discharge. LPN #2 reported that the resident returned to their apartment with hospice services and left the facility with medications and personal belongings. The DON stated that discharge summaries were to be completed by the MDS coordinator and filed under the "observations" section of the clinical record, but confirmed that no discharge summary was present for this resident after reviewing the record. The administrator stated they were responsible for notifying the State Ombudsman of discharges and acknowledged that they had not notified the Ombudsman office for this resident, explaining that they only notified the office in cases of involuntary discharge. Regional nurse #2 identified 13 residents who had been discharged in the past three months, but the cited deficiency specifically involved Resident #36, for whom the required discharge summary and Ombudsman notification were not completed or documented.

Penalty

Inspection fine: $21,6456 days payment denial

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 required pre- and post-dialysis assessments were completed and documented for a resident receiving dialysis. Resident #10, who had a BIMS score of 11 indicating moderately impaired cognition and a diagnosis of end stage renal disease, had physician orders for dialysis three times weekly on Monday, Wednesday, and Friday and a care plan reflecting the need for dialysis. Review of Dialysis Communication forms and progress notes from 03/02/26 through 03/13/26 showed no documentation that nurses conducted pre- or post-dialysis assessments on 03/02/26 or 03/09/26. An LPN stated that such assessments should be documented on Dialysis Communication forms or in progress notes, but the DON confirmed they could not locate any documentation of these assessments for the two identified dates and did not know why they had not been completed or what monitoring was in place to ensure they were done. This deficiency centers on the absence of documented pre- and post-dialysis assessments for Resident #10 on specific dialysis treatment days despite existing orders and care plan directives, and the lack of an identified monitoring process by facility leadership to ensure these assessments were consistently completed.

Penalty

Inspection fine: $21,6456 days payment denial

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

Summary

The deficiency involves the facility’s failure to conduct and document required safety assessments for the use of a bedrail for one resident. Surveyors observed the resident in bed with an enabler-style bedrail in the up position on the right side of the bed, and the resident reported using the bedrail to assist with getting out of bed. A physician order dated 12/22/25 authorized use of an enabler-style bedrail for positioning, and the care plan revised 12/27/25 referenced a transfer bar evaluation with demonstration for safe repositioning and transfers in and out of bed. However, review of the observation section and progress notes from 12/25/25 through 03/13/26 showed no evidence that the resident had been assessed for safety with the use of the bedrail, despite facility expectations that residents with bedrails be assessed when bedrails are ordered and then quarterly. The DON stated they were not aware the resident had a bedrail and confirmed there was no documentation of a safety assessment for the bedrail’s use. The facility’s policy requires that before using a bedrail, staff must assess the resident for safety risk, review risks and benefits with the resident or representative, obtain informed consent, and correctly install and maintain the bedrail. In this case, although the bedrail was in use and ordered by a physician, the required safety assessment and related documentation were not completed or available for review.

Penalty

Inspection fine: $21,6456 days payment denial

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 required TB testing and annual flu and pneumonia immunizations were completed and documented for two of five sampled residents reviewed for immunizations. One resident, admitted on 09/21/25 with an admission assessment dated 09/28/25 showing a BIMS score of 15 (cognitively intact) and diagnoses including dementia, had no documentation of a TB test on admission or of annual flu and pneumonia vaccinations in their immunization record. Another resident, with a quarterly assessment dated 02/12/26 showing a BIMS score of 15 and diagnoses including right lower lobe lung cancer, and who had been re-admitted to the facility, had no documentation of a TB test upon admission in their immunization record. During the survey, the DON initially indicated that TB test and vaccination information should be in the electronic health record, then later stated that the documentation was in the administration office, and confirmed that TB tests were to be completed on admission; however, immunization and TB test documentation for these two residents was not provided by the end of the survey. The administrator identified that 34 residents resided at the facility, and the deficiency was identified through record review and staff interview when surveyors requested and did not receive the required TB and immunization documentation for the sampled residents.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective pest control program in the kitchen, as evidenced by the presence of roaches and various environmental deficiencies. During an initial tour of the kitchen, surveyors observed roaches in and around the low temperature dish machine, missing baseboards, standing water under the dish machine, missing floor tiles, buckled flooring, peeling wallpaper, and a 50-gallon trash can without a lid. Additionally, the rear kitchen door could not be easily secured, allowing light to be visible around the door frame, and a mop bucket with standing liquid and dead bugs was found outside the rear kitchen door. The outside commercial trash container was also not covered with lids. The pest control service notification indicated that roaches had been reported in the break room and dining room, but the technician did not observe any live activity at the time of service. The technician treated various areas with liquids and inspected exterior bait stations. However, the maintenance supervisor acknowledged that staff had reported seeing roaches in the dining room and that the pest control company had been out to spray, but they had not noticed the roaches in the dish machine. The maintenance supervisor stated they would collaborate with the dish machine technician and pest control company to address the issue.