Avamere Rehabilitation Of Eugene

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.

Removal Plan

• Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
• Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
• DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
• DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
• DNS or designee would complete a mock code.
• DNS or designee would complete mock codes.

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 timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by 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 deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.

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 laundry was cleaned and sorted in a safe manner when surveyors observed a hole in the wall next to the washing machine and a large pool of brown, dirty standing water behind two washing machines and a clean linen cart in the laundry room. Along the baseboard of the wall behind the machines, a black substance extended about an inch up the wall and an inch onto the floor. The Housekeeping Director stated the hole in the wall had been present for some time, that maintenance had been notified of the standing water a few weeks earlier but it had not yet been repaired, and did not know what the black substance was. Later observation showed a cart of clean linen and laundry near the standing water, with a blanket from the cart partially in the water, which the Laundry Aide confirmed had touched the water. The Administrator subsequently confirmed the presence of standing water and the black substance on the wall and floor and learned from the Laundry Aide that the water on the floor had been occurring for the last three weeks when the washing machines were in use, and that the water and some of the black substance had just been cleaned up. No specific residents or their medical conditions were mentioned 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 report an allegation of abuse and neglect to the State Survey Agency for one cognitively intact resident. The resident, admitted with diagnoses including heart failure and kidney disease, had a care plan dated 12/24/25 indicating that if the resident made accusatory comments about family or staff not treating them well or denying medications, staff were to alert the nurse to assess for signs and symptoms of a urinary tract infection. On 1/12/26 at 2:13 PM, the resident reported that a CNA/CMA had abused them, stating the staff member spoke meanly, was rough, and treated them like a “bad dog.” The resident also expressed fear of retaliation from the staff member and fear of being discharged from the facility. At 2:16 PM the same day, an LPN stated that the staff member identified by the resident was a CNA/CMA and acknowledged hearing this staff member be rude to the resident. The LPN further reported that this staff member’s demeanor changed when rushed or having a bad day and that she had heard the staff member be rude to other residents, with other staff also observing this behavior, but she did not report it to management. At 2:42 PM, the Administrator and DNS were notified that the resident felt abused by this staff member, and the Administrator indicated this was the first time he had heard of the allegation. At 2:52 PM, the Administrator and DNS stated their expectation that when a resident feels abused by a staff member, staff must notify them immediately, notify the provider and family, and ensure resident safety; however, the allegation had not been reported to the State Survey Agency as required.

Penalty

No penalty information released

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

Summary

Surveyors identified that the facility did not consistently follow an established fall-prevention care plan for a resident with dementia and a history of rolling out of bed. The resident’s care plan, initiated in early December, required padded fall mats on both sides of the bed whenever the resident was in bed. On multiple observations over several days in January, the resident was seen in bed without a fall mat on the left side, or with the left fall mat placed away from the bedside or folded and leaning against the foot of the bed. A CNA confirmed the resident was at risk for falls and should have fall mats on the floor next to the bed while in bed, and a LPN Resident Care Manager stated the resident had previously rolled out of bed and was care planned for fall mats on both sides, with the expectation that staff follow the care plan. Surveyors also found that staff failed to follow a care plan requiring two-person assistance for transfers for a resident with a history of stroke and weakness. The resident’s care plan documented a need for two-person assistance with transfers using a front-wheeled walker. A fall investigation from July showed that a CNA, after providing a shower, assisted the resident to stand and transfer using the walker without a second staff member, during which the resident’s legs weakened, balance was lost, and the resident slid or fell to the floor. The CNA stated she did not review the care plan before performing the transfer, and the investigation and root cause analysis identified that the resident was a two-person assist and the CNA did not check the care plan. The LPN notified of the incident and facility leadership later acknowledged that the resident was care planned as a two-person transfer and that staff were expected to review the care plan before providing care.

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 resident with an open fracture of the left lower leg and diabetes was admitted to the facility with specific hospital discharge instructions for surgical wound care, including the use of a honeycomb dressing, monitoring for excessive drainage, removal of staples after two weeks, and scheduled follow-up with the surgeon. Upon review, it was found that the resident's admission nursing database did not include information about the surgical site or wound care, and the medication and treatment administration records lacked any wound care or monitoring orders for the first two weeks after admission. The resident missed the required follow-up appointment, and the prescribed dressing protocol was not implemented or documented during the initial seven days post-admission. Subsequently, the resident developed new slough, increased redness, and drainage at the surgical site, leading to a diagnosis of cellulitis and the initiation of antibiotics. Further review showed that even after wound care orders were eventually entered, there were missed wound care treatments on specific days. Staff interviews confirmed that the wound was not checked or monitored upon admission, the dressing orders were not transcribed, the follow-up appointment was missed, and the sutures were not removed as ordered by the physician.

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 interventions to prevent a resident's elopement were in place, which placed residents at risk for a lack of a safe environment. Resident 315, who was admitted with diagnoses including Parkinson's disease and a history of repeat falls, was identified as an elopement risk with impaired safety awareness. Despite a care plan indicating the resident should not leave the facility unattended, the resident was observed exiting the facility on two occasions. On the first occasion, the resident was seen exiting through the back door and was brought back inside with assistance. On the second occasion, the resident was found outside the facility near a stop sign after hiding their wheelchair in the courtyard and exiting through a different back door. The facility did not conduct an investigation following the first incident on 9/16/24, as the resident did not leave the facility grounds. Staff were aware of the resident's exit-seeking behavior, but no investigation was initiated until after the second incident on 9/28/24. The lack of timely investigation and implementation of appropriate interventions contributed to the resident's ability to leave the building unattended. Staff acknowledged that interventions related to the resident's ability to elope were not discovered and implemented due to the absence of investigations after the initial incidents.

Penalty

Fine: $36,47214 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 adhere to appropriate infection control procedures, resulting in the spread of COVID-19 among residents and staff. Upon entrance, surveyors were informed of a COVID outbreak involving four staff and five residents, yet there was no signage indicating the outbreak. Observations revealed multiple instances of staff failing to use proper personal protective equipment (PPE) and neglecting hand hygiene protocols. For example, a CNA entered a COVID-19 precaution room without eye protection, and another staff member failed to wash hands with soap and water after exiting a room on enteric contact precautions. The facility also demonstrated inappropriate cohorting of residents, as evidenced by the placement of a resident suspected of having clostridium difficile with another resident before confirmation of the infection. This action increased the risk of spreading the infection. Additionally, the facility was out of hand sanitizer for a week, further compromising infection control efforts. Staff were observed not following proper procedures for donning and doffing PPE, and there was a lack of communication to family members about the outbreak. The infection preventionist acknowledged the deficiencies in infection control practices, including improper PPE usage and inadequate hand hygiene. Staff training on infection control procedures was insufficient, as demonstrated by a staff member who was not aware of the need to change masks after exiting a COVID-19 precaution room. The facility's failure to implement timely and effective infection control measures placed residents at risk for the continued spread of infectious diseases.

Removal Plan

• The DNS and Administrators were educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual.
• The Infection Preventionist was placed on suspension due to the enormity of the deficiencies.
• The new Infection Preventionist was educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual and skills demonstrated.
• New Infection Preventionist will be educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual upon hire.
• All staff were educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual for continued compliance of these policies, with emphasis on proper PPE usage and hand hygiene for each type of infection.
• All staff will wear N95 masks while in resident care areas, and in COVID positive rooms will wear a N95 mask, gown, sanitized or disposable goggles and gloves when providing direct patient care and remove all these items before they leave COVID positive room and a new N95 mask will be placed.
• DNS will put face shields on all the COVID 19 isolation carts to replace the need to use goggles exclusively. Staff were educated regarding the face shields usage and disposal. A few clean goggles were left in the isolation carts in case of need.
• Wide base resident testing will be completed every 2-3 days and as symptoms are present until the facility goes two weeks without any positive tests.
• Wide base staff testing will happen before staff members start their shift and as symptoms present until the facility goes two weeks without any positive test.
• The SSD called the first emergency contact for each resident and informed them of the current COVID outbreak.
• All new residents will be informed of the current COVID outbreak before admission to the facility.
• A sign was placed on all entrance doors to inform visitors about the COVID 19 outbreak and was placed next to the sign in sheet in the lobby.
• Facility acquired hand sanitizer to fill all dispensers and extra to make sure it is accessible to staff for proper hand hygiene.
• The DNS and designees will conduct spot checks of proper hand hygiene, donning and doffing PPE, signage and equipment cleansing. Any discrepancies will be brought to the QAPI team for further review.
• The DNS or designee will review the 24-hour report and bowel care list for any symptoms of clostridium difficile, and to ensure policies had been followed correctly. Any discrepancies will be brought to the QAPI team for further review.

Penalty

Fine: $36,47214 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 update care plans for four residents, leading to potential unmet care needs. Resident 4, diagnosed with multiple sclerosis, had a care plan that required urinary catheter flushes three times a week. However, new physician orders indicated the need for flushes one to two times daily, which was not updated in the care plan. Resident 15, with heart disease, was at risk for falls and required non-slip material on walker handles. Despite the resident not using the non-slip material due to it coming off, the care plan was not updated to reflect this change. Resident 18, with atrial fibrillation, was prescribed apixaban, an anticoagulant, but the care plan did not include this medication. Lastly, Resident 48, who was bedbound and at moderate risk for falls, had bilateral fall mats in place, but the care plan was not revised to include this intervention. These oversights were acknowledged by the LPN Resident Care Manager, indicating a lapse in updating care plans to reflect current care needs and interventions.

Penalty

Fine: $36,47214 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 follow up on several critical care aspects for multiple residents, leading to unmet care needs. For Resident 4, who was admitted with multiple sclerosis, the facility did not obtain a new urine sample after the initial sample was improperly handled, resulting in a failure to diagnose a potential urinary tract infection. Staff did not communicate with the physician to obtain orders for a recollection, leaving the resident's condition unaddressed. Resident 15, admitted with heart disease, experienced a fall that was not observed by staff. The required neurological assessments were incomplete on multiple occasions, with staff incorrectly noting that the resident refused or was asleep. The resident later confirmed that they did not refuse the assessments, which were crucial for monitoring potential head injuries after the fall. Resident 163, who had undergone cervical spine surgery, did not receive proper wound assessments for their neck incision during their stay. The dressing was not removed until discharge, and no assessments were documented. Additionally, Resident 42, with spinal stenosis, did not receive a CT scan as ordered due to a lack of follow-up on the MRI alternative. Lastly, Resident 165, under hospice care, reported inadequate pain management, with staff failing to secure necessary medication adjustments despite repeated notifications to hospice.

Penalty

Fine: $36,47214 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 Certified Nursing Assistants (CNAs) received the required 12 hours of training annually. This deficiency was identified for three out of five sampled staff members. Specifically, one staff member hired in July 2016, another hired in July 2022, and a third hired in September 2021 did not complete the mandated training hours in the past year. This was confirmed by Staff 2, the Director of Nursing Services (DNS), during an interview and record review.

Penalty

Fine: $36,47214 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 inform a resident of the risks and benefits associated with the use of psychotropic medication. A resident, admitted in 2024 with diagnoses of anxiety disorder and depression, was prescribed Lexapro, an antidepressant, as per a physician's order dated 7/18/24. However, a review of the medical record showed no documentation of risk and benefit information for Lexapro being provided to the resident. This was confirmed by Staff 2 (DNS) on 8/5/24, indicating that the necessary information was not reviewed with the resident.

Penalty

Fine: $36,47214 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 assess a resident's ability to self-administer medications, which is a requirement for ensuring safe medication practices. Resident 11, who was admitted in August 2014 with a diagnosis of COPD, was observed on July 31, 2024, with two inhaler medications on the bedside table. The resident explained that these medications were used to aid in breathing. However, there was no assessment found in the medical record to determine the resident's capability to self-administer these medications. Staff 26, an LPN, confirmed that Resident 11 had not been assessed for self-administration of medications, acknowledging that such an assessment should have been conducted prior to allowing the resident to self-administer their medications. This oversight placed the resident at risk for improper medication administration.

Penalty

Fine: $36,47214 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 rules and regulations governing resident conduct and responsibilities, specifically regarding the use of compact refrigerators in resident rooms. This deficiency was identified for one resident who was admitted in June 2024 with diagnoses including stroke and anxiety. The facility's Resident Handbook from January 2024 indicated that compact refrigerators might be approved for patient use. However, the resident, who was cognitively intact as per a July 2024 MDS, reported confusion after being denied a request for a personal refrigerator, as they had not received a copy of the Resident Handbook upon admission. The Administrator in Training acknowledged that since March 2024, residents had not been provided with the Resident Handbook as expected.

Penalty

Fine: $36,47214 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 obtain and document advance directives for two residents, which placed them at risk of not having their healthcare decisions honored. Resident 12, admitted with a hip fracture, was noted to have an advance directive during a 72-hour admission huddle, but it was not included in their electronic record. This was confirmed by the Social Services Director. Resident 18, with a diagnosis of congestive heart failure, expressed a desire to formulate an advance directive during a care conference. However, a subsequent review of their medical record showed no evidence of an advance directive, and the resident reiterated their wish to complete one. The Social Services Director confirmed the absence of an advance directive for Resident 18 as well.

Penalty

Fine: $36,47214 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 notify family members of significant changes in the condition and circumstances of two residents. Resident 4, who was admitted with multiple sclerosis and a history of decreased kidney function, experienced a change in mentation, loose stools, and dark orange urine, prompting a transfer to the hospital for evaluation. Despite the severity of the situation, the resident's emergency contact, identified as Witness 6, was not informed of the hospitalization, as confirmed by both Witness 6 and the facility's administrator. Similarly, Resident 266, who was admitted with dementia and a history of UTIs, was moved to a different room without prior notification to the family. Witness 3, a family member, was unaware of the room change until arriving for a visit. The facility's admission coordinator admitted to not considering the impact of the room move on the resident with dementia and acknowledged the lack of communication with the family regarding the change.

Penalty

Fine: $36,47214 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 a comfortable and homelike environment for a resident admitted in March 2024 with diagnoses including palliative care and schizophrenia. Observations made over several days revealed persistent cleanliness issues in the resident's room. On multiple occasions, fall mats were observed with dried debris, dirt, and personal items such as a blanket and towels. Additionally, washcloths with a dark brown substance were found in the resident's sink. Despite staff entering and exiting the room, these cleanliness issues were not addressed. A Regional Nurse Consultant acknowledged the unhomelike environment during an observation.

Penalty

Fine: $36,47214 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 adequate care and services to maintain good grooming and hygiene for two residents, both of whom were receiving hospice services. Resident 48, who was totally dependent on staff for personal hygiene care and dressing, was observed with greasy, uncombed hair, long jagged fingernails with brown debris, food on their face and in their mouth, facial hair, and a shirt with dried dark brown debris. A caregiver visiting Resident 48 reported that the resident did not receive the necessary ADLs care from the staff, which included washing hair, trimming and cleaning nails, shaving, applying lotion to dry feet, and changing into a clean shirt daily. The LPN-Resident Care Manager acknowledged that Resident 48 should be cleaned up daily, including being shaved per their request, and that all ADLs should be completed by staff. Resident 164, who required constant or intermittent supervision with physical assistance for grooming tasks, was observed with long fingernails with brown debris underneath. The LPN-Resident Care Manager confirmed that Resident 164's nails were long and needed cleaning. The care plan for Resident 164 directed staff to assist with combing hair, brushing teeth, shaving, and washing and drying the face and hands, but these tasks were not adequately performed, leading to the observed deficiency.

Penalty

Fine: $36,47214 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 a new facility-acquired pressure ulcer for one of the two sampled residents reviewed for pressure ulcers. The resident was admitted in February 2020 with a diagnosis of hemiplegia on the left nondominant side. On February 9, 2024, the resident developed a stage 3 pressure ulcer on the sacrococcygeal area, which was documented in a wound evaluation on July 29, 2024, measuring 0.76 cm by 0.5 cm. Despite the presence of this ulcer, the facility did not conduct an investigation into its development. On August 2, 2024, the resident was observed to have an open stage 3 wound on the right upper buttock near the sacrococcygeal area, with surrounding red moisture-associated damaged skin. This lack of investigation placed residents at risk for worsening pressure ulcers.

Penalty

Fine: $36,47214 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 adequate care for two residents, leading to an increased risk of urinary tract infections (UTIs). Resident 4, who was admitted with multiple sclerosis and had a urinary catheter, required regular catheter flushes to prevent UTIs. However, from July 1 to July 19, 2024, the staff missed five out of eight scheduled flushes due to a lack of sterile solution. Despite a nationwide recall of sterile water, the facility did not notify the physician to seek an alternative solution, and no documentation was provided to confirm that the flushes were completed as ordered. Resident 266, admitted with dementia and a history of UTIs, experienced repeat UTIs likely due to poor perineum hygiene. The resident's care plan indicated a need for supervision in personal hygiene, but staff were not adequately informed or trained on the resident's unique needs. A CNA stated she was not aware of any specific instructions for Resident 266, and the LPN-Resident Care Manager admitted to not reviewing hospital notes or updating the care plan with personalized details. This lack of communication and documentation contributed to the resident's ongoing UTI issues.

Penalty

Fine: $36,47214 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 maintain respiratory equipment for three residents, leading to potential respiratory issues. Resident 11, diagnosed with COPD, had nebulizer equipment improperly stored among unsanitary items such as an emesis bag, urinal, and dirty clothing. There was no documentation in the resident's medical record regarding the care and services of the nebulizer. Staff confirmed the equipment was not cleaned or stored properly. Similarly, Resident 164, with pneumonia and hypoxia, had nebulizer equipment stored unsanitarily with a bag of incontinent briefs and bedding on top. Again, there was no documentation of care and services for the nebulizer, and staff confirmed the improper storage and lack of record-keeping. Resident 267, diagnosed with kidney failure and sleep apnea, had a CPAP machine with a mask exposed on the bedside table, with bowel movement wipes placed on top. Flecks were observed inside the tubing, indicating it was dirty. There were no care plan interventions or treatments documented for the CPAP machine. Staff confirmed the improper storage and lack of follow-up to obtain orders or care plans for the CPAP machine. These deficiencies in maintaining respiratory equipment placed residents at risk for respiratory issues.

Penalty

Fine: $36,47214 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 evaluate and provide person-centered interventions for a resident with PTSD and anxiety, placing the resident at risk for re-traumatization. The resident was admitted in May 2024, and the care plan for trauma included interventions that were not personalized to the resident's specific triggers. The resident reported having disturbing nightmares related to combat and expressed that staff were not aware of how to assist with their PTSD. Despite requesting counseling, there was no follow-up to the request. Staff interviews revealed that the resident experienced one to three disruptive nightmares weekly, but these were not documented, and thus, the issue was not addressed. The Social Services Director confirmed that no PTSD assessment was completed upon the resident's admission, leaving details about the resident's PTSD unknown. Additionally, there was no formal training for PTSD when a new PTSD form was introduced, and the Director of Nursing Services acknowledged the need for improved evaluation and documentation of the resident's condition.

Penalty

Fine: $36,47214 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 conduct annual performance reviews for three of the five sampled Certified Nursing Assistants (CNAs). Specifically, CNA #3 and CNA #7 had not received performance reviews since 2022, and CNA #4 did not have any performance review documented in her record despite being hired on July 18, 2022. This deficiency was confirmed by Staff 2, the Director of Nursing Services (DNS), on August 1, 2024, at 8:30 AM.

Penalty

Fine: $36,47214 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 monitor a resident's anticoagulant medication regimen, specifically apixaban, for adverse side effects. The resident, who was admitted in May 2016 with a diagnosis of atrial fibrillation, had a physician's order for apixaban dated July 11, 2022. However, a review of the resident's care plan on July 31, 2024, showed no evidence of a care plan for anticoagulant medication. Furthermore, a review of the medical record on August 2, 2024, revealed no monitoring for adverse side effects such as bleeding and bruising. Staff 23, an LPN Resident Care Manager, confirmed that the resident was not monitored for these potential side effects.

Penalty

Fine: $36,47214 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 implement gradual dose reductions (GDR) and adequately monitor psychotropic medications for two residents, placing them at risk for adverse medication reactions. Resident 12, admitted with anxiety disorder and depression, was administered multiple psychotropic medications, including Lexapro, Trazodone, Xanax, and Buspirone. Despite having known triggers that exacerbated anxiety, such as unexpected therapy visits and loneliness, these were not documented, and staff were unaware of them. The resident was not appropriately monitored for the effects of the medications, as acknowledged by the staff. Resident 15, admitted with heart disease, had their Wellbutrin dosage increased from 300 mg to 450 mg daily without documented justification or a recent GDR attempt. Progress notes indicated no exhibited behaviors or mood changes, and the last GDR was recorded in December 2022. Despite a psychotropic medication review in June 2024, no rationale was provided for the dosage increase or the absence of a GDR in December 2023, as confirmed by the LPN Resident Care Manager.

Penalty

Fine: $36,47214 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 a treatment cart was locked on the Shasta Unit, which placed residents at risk for injury. During an observation on July 30, 2024, between 2:23 PM and 2:43 PM, the treatment cart was found to be unlocked in an alcove, with one wall blocking the view from the nurse's station. Nursing and therapy staff passed by the cart multiple times without securing it. At 2:43 PM, a Licensed Practical Nurse (LPN) who had just started her shift acknowledged that she was unaware the cart was unlocked and confirmed that it should have been locked.

Penalty

Fine: $36,47214 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 prepare and serve therapeutic diets for residents requiring dietary restrictions, specifically for a resident with kidney failure and a hip fracture who was admitted in July 2024. The resident was prescribed a diet limited in salt, potassium, and phosphate, but on July 31, 2024, the resident was served sausage, which is high in salt and phosphates, instead of the prescribed alternative of roasted pork. The resident consumed the sausage, trusting the facility to provide the correct diet, which was crucial due to their dialysis treatments. The deficiency was further compounded by the lack of training for the cook, Staff 13, who was unaware of the need to provide alternative options for restricted diets and did not prepare the necessary pork roast. Additionally, the Dietary Manager, Staff 21, acknowledged that since the implementation of a new menu system in April 2024, no alternative menu items were purchased to accommodate therapeutic diets. This oversight led to the failure to follow the therapeutic diet requirements, as observed during the lunch service on July 31, 2024, where no pork roast was available, and sausage was served instead.

Penalty

Fine: $36,47214 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 meals according to residents' preferences, as evidenced by multiple instances where residents did not receive the food they ordered. Resident 1, who has anemia and acute kidney failure, reported frequently not receiving the meals she ordered, which is critical due to her self-limiting special diet. On one occasion, her lunch tray was missing potatoes, which she had selected. The Dietary Manager acknowledged awareness of these issues, indicating that such errors should not occur. Resident 214, with a history of stroke and anxiety, expressed dissatisfaction with receiving disliked foods such as beets, peas, and carrots, despite these preferences being documented in her care plan. The Dietary Manager confirmed ongoing issues with the new menu system and tray ticket accuracy, which began in April 2024. Additionally, a meal tray for another resident included an unrequested item, and there was a shortage of sausage, leading to a resident not receiving it despite their request.

Penalty

Fine: $36,47214 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 residents understood the meaning of an arbitration agreement, which is a legal document stating that disputes will be resolved with a neutral party rather than in court. This deficiency was identified in three residents who were cognitively intact at the time of signing the agreement. Resident 9, admitted with Parkinson's disease, signed the arbitration agreement but later stated they did not recall anything about it. Staff 9, responsible for admissions, confirmed that she reviewed the arbitration agreement with residents or their representatives but did not follow up to ensure understanding. Witness 2, a family member of Resident 9, also did not understand the arbitration agreement and was only involved in discussions about financial eligibility. Similarly, Resident 53, admitted with heart disease, signed the arbitration agreement but later expressed no knowledge of what it entailed. Staff 9 again stated that she reviewed the agreement with the resident but did not ensure comprehension post-signing. Resident 165, also with Parkinson's disease, did not recall signing the arbitration agreement and misunderstood its purpose. Staff 9's consistent approach of not verifying residents' understanding after signing the agreement contributed to the deficiency, leaving residents uninformed of their legal rights.

Penalty

Fine: $36,47214 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 antibiotics were appropriately indicated for a resident diagnosed with multiple sclerosis, who was admitted in January 2024. The resident was administered antibiotics for a possible urinary tract infection (UTI) from late March to early April 2024. However, lab results from March 31, 2024, indicated that a urine culture was not required, suggesting no UTI was present. Despite this, the antibiotics were continued without documented rationale in the resident's clinical record. On August 2, 2024, a Licensed Practical Nurse (LPN) verified the absence of documentation justifying the continuation of antibiotics, which placed residents at risk for developing drug-resistant organisms.

Penalty

Fine: $36,47214 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 proper documentation and administration of immunizations, consents, and declinations for three residents, placing them at risk for infections. Resident 3, admitted with congestive heart failure, received COVID-19 vaccinations on three occasions but lacked signed consents for these vaccinations. Additionally, there was no evidence that COVID-19 booster vaccinations were offered, administered, or declined after the last recorded vaccination. Staff 1, the Administrator in Training, was unable to locate the necessary consents or evidence of booster offerings in the facility's records. Resident 20, who has chronic obstructive pulmonary disease, had no evidence in their medical record of being offered a pneumonia vaccination. Similarly, Resident 22, also with chronic obstructive pulmonary disease, received a COVID-19 booster but lacked a consent form for this administration. Staff 1 confirmed that the records for vaccination offerings, consents, and declinations were kept in a binder but was unable to locate the necessary documentation for these residents, indicating a lapse in the facility's record-keeping and vaccination protocol.

Penalty

Fine: $36,47214 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 call lights were accessible for two residents, leading to unmet needs. Resident 20, who was admitted with hemiplegia on the left nondominant side, was observed multiple times with the call light hanging off the side of the bed, out of reach. Despite the resident softly calling for help, staff members walked past without assisting. It was only after a surveyor's intervention that a CNA confirmed the call light was not within reach and adjusted it accordingly. The LPN Resident Care Manager later confirmed that call lights are required to be within reach at all times. Resident 48, admitted with diagnoses including paranoid schizophrenia and chronic bed confinement, was also found with the call light inaccessible. Observations over several days revealed the call light was placed in a dresser drawer, out of the resident's reach. Staff members verified the call light's inaccessibility, despite the care plan indicating it should be within reach due to the resident's moderate fall risk and impaired mobility. The LPN Resident Care Manager acknowledged that the call light should have been accessible at all times.

Penalty

Fine: $36,47214 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 residents were treated with dignity, as evidenced by an incident involving a resident who felt their privacy was violated. The resident, who was cognitively intact and had a diagnosis of depression, reported a HIPAA violation by a staff member. During a bus trip, the staff member engaged the resident in a conversation about their preferred name and financial situation, including a statement about the resident's house being in foreclosure. This conversation was overheard by another resident, causing the resident in question to feel upset and violated. The resident expressed their distress to another staff member, who confirmed hearing the conversation and noted the resident's upset state. The staff member involved in the incident claimed to be trying to connect with the resident and denied any issues during a subsequent visit. However, an investigation confirmed the violation of the resident's HIPAA rights, leading to increased anxiety and distress for the resident. The incident was reported to the facility's administration, but no further information was provided regarding any additional actions taken.

Penalty

Fine: $36,47214 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 maintain resident privacy for two residents, leading to potential psychosocial harm. Resident 263, who was cognitively impaired and discharged to a memory care facility, had her discharge location disclosed to unwanted family members by a former Social Service Director, despite only two family members being authorized to access her medical information. This breach of confidentiality was acknowledged by the facility's Administrator in Training. Resident 265, who was cognitively intact and admitted with depression, experienced a violation of privacy when a former Social Service Director discussed personal and financial matters inappropriately during a bus ride. The staff member admitted to asking probing questions about the resident's preferred name and finances, which upset the resident. The incident was witnessed by another staff member, who confirmed the resident's distress and assisted in filing a grievance. An investigation concluded that the resident's HIPAA rights were violated, causing increased anxiety and distress.

Penalty

Fine: $36,47214 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 protect a resident from neglect, resulting in an injury. The incident involved a resident who was admitted with diagnoses including leg surgery and chronic pain. The resident, who was cognitively intact, requested tea from a staff member. The staff member, a former CNA, served the tea in a hydration mug with a straw without checking the temperature. The resident took a drink and suffered burns to the tongue and roof of the mouth due to the extremely hot temperature of the tea. The resident experienced significant pain, with skin peeling from the roof of the mouth, and the discomfort lasted for approximately two days. The facility's investigation confirmed that neglect occurred as the resident was injured by the hot tea. Interviews with staff revealed that training had been provided on serving beverages at safe temperatures, but the staff member involved failed to adhere to this protocol. The LPN-Resident Care Manager acknowledged the tea was hot enough to cause burns and confirmed that staff had been trained to ensure beverages were not too hot before serving them to residents.

Penalty

Fine: $36,47214 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 report an allegation of neglect to the appropriate State Agency within the required two-hour timeframe. This deficiency involved a resident who was admitted to the facility with diagnoses including leg surgery and chronic pain. The resident, who was cognitively intact, requested tea from a staff member, which was served in a hydration mug with a straw. Upon drinking, the resident suffered burns to the tongue and roof of the mouth due to the hot temperature of the tea. The incident occurred in the evening, and the facility's administrator was notified the following morning. However, the facility did not report the incident to the State Agency until later that day, exceeding the two-hour reporting requirement. The facility's investigation concluded that neglect was substantiated as the resident was injured from the hot tea.

Penalty

Fine: $36,47214 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 implement comprehensive care plans for three residents, leading to unmet care needs. Resident 2, admitted with diabetes and dementia, did not have an initial care plan addressing diabetic goals and interventions, despite having multiple orders for diabetic care since admission. The resident received insulin regularly, but the lack of a diabetic care plan was acknowledged by the LPN-Resident Care Manager. Resident 266, with dementia and a history of UTIs, was identified as high risk for wandering, yet their care plan lacked goals or interventions for this risk. The resident was observed wandering in a wheelchair, attempting to leave the building. The LPN-Resident Care Manager confirmed the care plan was incomplete regarding elopement risk. Additionally, Resident 165, under hospice care, had no comprehensive care plan for hospice services or scheduled visits, as acknowledged by the DNS.

Penalty

Fine: $36,47214 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 windows on the first floor were properly secured, posing a risk of an unsecured environment for residents. Resident 163, who was admitted in May 2024 following spinal surgery, was placed in rooms where the windows had broken locking devices. Despite the use of locking devices, the windows could still be opened. This issue was confirmed by a complainant and later verified by a maintenance staff member, who admitted to being unaware of the problem. The deficiency was identified through observation, interview, and record review, highlighting a lapse in maintaining a safe environment for residents.