Avamere Rehabilitation Of Lebanon

Penalty

No penalty information released

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

Summary

The facility failed to provide sufficient staffing to meet resident needs in a timely manner, as shown by repeated long call light wait times for 3 of 4 sampled residents. The facility’s 4/29/26 Quality Assurance Resident Council meeting minutes documented that call lights were not answered timely, and the resident council questions recorded “no” when asked whether staff responded within 10 minutes and whether there were enough staff to meet residents’ needs. The administrator stated the expectation for call light response time was 10 minutes or less. Resident 1 was admitted in 3/2026 with diagnoses including diabetes and chronic pain and was identified as high risk for falls. The call data report showed call light wait times of 20, 25, and 23 minutes on separate occasions in early 4/2026. Resident 1 stated call light wait times were long and there were not enough staff to assist residents timely. A CNA stated residents complained of long wait times and that the facility did not have enough CNAs for resident acuity; another CNA stated the facility was most likely short-staffed during busy times such as when residents were assisted up for dinner and to bed. Resident 2, who had diagnoses including diabetes, anxiety, and chronic pain and was cognitively intact, had multiple call light waits ranging from 23 to 64 minutes, including several waits over 30 minutes. A grievance documented that Resident 2 pushed the call light for two hours and no one came to assist. Resident 2 stated that when staff did not answer the call light timely, he/she would go out to get them. Staff reported residents had incontinent episodes while waiting and that Resident 2 sometimes required two staff to assist, making it difficult to find help. Resident 5, who had diabetes and anxiety, was moderately cognitively impaired and dependent on staff for transfers. A grievance stated Resident 5 pushed the call light for two hours and no one came to assist, and the call data report showed waits of 27 to 40 minutes. Resident 5 stated call light wait times continued to be a problem, while CNAs reported evening staffing concerns, busy mealtimes, difficulty finding another staff member for two-person assists, and that call lights were sometimes not answered because staff were busy with showers or other 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 reduce the risk of a potential accident hazard for 1 of 3 sampled residents reviewed for accidents. Resident 1 was admitted with diagnoses including diabetes, a foot ulcer, and chronic pain, and the 4/4/26 MDS indicated the resident was cognitively intact. A 4/23/26 After Visit Summary included post-anesthesia/sedation instructions stating the resident should not stay alone and should have a responsible person present because of possible lightheadedness, dizziness, and sleepiness. On 5/1/26, the State Survey agency received a public complaint alleging Resident 1 did not have a staff member accompany the resident to the medical appointment. Resident 1 stated that Staff 16 accompanied the resident to the surgery appointment, but the facility later picked up Staff 16 and no one waited to assist the resident back to the facility after surgery. Staff 16 stated she accompanied Resident 1 to the surgery appointment but was not with the resident to assist with transport back to the facility. Staff 8 stated Staff 16 was picked up from the appointment and Resident 1 did not have a staff member to accompany the resident back after surgery. Staff 1 stated she expected staff to escort Resident 1 while transporting back from surgery to the facility.

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 obtain lab samples for 1 of 3 sampled residents reviewed for change of condition. Resident 10 was admitted with diagnoses including kidney disease. A physician called the facility and gave STAT orders for a CBC and leukocytosis lab test, and an RN attempted twice to obtain the STAT CBC sample but was unable to do so. Staff stated that if a lab sample could not be obtained, a note was normally written and passed to the next shift, and that physician-ordered lab tests should be completed the same day as the order. Another RN stated the facility received numerous STAT laboratory orders and that she may not have completed the order because she was often switched from one side of the facility to the other. There was no documented evidence in the resident’s clinical record that the STAT laboratory order was completed, and the DNS stated physician orders were expected to be followed in a timely manner, with STAT laboratory orders expected to be completed within two to four hours.

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 that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to 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 deficiency involves the facility’s failure to obtain physician orders and provide treatment for a non-pressure skin wound on a resident’s left foot following admission. The resident was admitted in 10/2025 with diagnoses including diabetes and a non-pressure chronic ulcer on the left foot, and hospital admission orders documented an ulcer of the left second toe with skin breakdown and toe pain. On the admission Nursing Database assessment the day after admission, nursing staff recorded scabs on the resident’s second and fourth toes and the top of the left foot, and an admission MDS completed the following week indicated a non-pressure chronic ulcer on the left foot. Despite these documented findings, there were no physician orders or wound treatments in the clinical record for the left foot ulcer from admission through mid-November. A nursing note later documented that staff sent a message to the physician about the left second toe scab and that treatment was initiated at that time. In interviews, an agency LPN who completed the admission assessment could not recall whether she confirmed physician orders for the wound and stated that normal practice would be to contact the physician if there were no orders, and a regional nurse stated that staff should ensure physician orders exist for residents with skin wounds. This failure to obtain and implement physician-directed wound care for the resident’s documented non-pressure ulcer and toe scabs during the identified period constituted the cited deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to demonstrate active involvement of staff and residents in determining staffing needs during its facility-wide assessment. The assessment identified insufficiencies in staffing, training, services, and personnel. Interviews revealed that CNAs and Resident Care Managers were not asked to provide input regarding staffing needs based on resident acuity, and there was no formal process for staff to give feedback to management about staffing. Members of the Resident Council reported that concerns about staffing had been discussed in meetings without resolution, and noted that agency staff required additional training. Documentation was not available to show how staffing hours or feedback from residents and staff were incorporated into the facility assessment.

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 multiple failures in infection prevention and control practices during a COVID-19 outbreak affecting two halls. Used COVID-19 rapid tests were observed left on a bedside table near a facility exit and on top of the North Nurses Station, accessible to staff and residents passing by. Staff interviews confirmed that testing was supposed to occur in locked medication rooms, with used tests to be discarded immediately by a nurse, but this protocol was not followed. The Infection Preventionist acknowledged that the tests should not have been left in open areas and that the night nurse had left them out for an extended period. Additionally, signage for droplet precautions was found to be incorrect, with staff unable to see all necessary instructions, and the Infection Preventionist confirmed the signage did not meet expectations. Further observations revealed lapses in personal protective equipment (PPE) use and hand hygiene. A CNA was seen entering and exiting a room on droplet precautions without wearing a required face shield and failed to remove her N95 respirator before leaving the room. Another CNA was observed disposing of a used respirator and donning a new one without performing hand hygiene. The Infection Preventionist and other facility leaders stated that staff were expected to follow posted PPE guidelines and perform hand hygiene before donning clean masks, but these practices were not consistently followed. One resident involved had chronic obstructive pulmonary disease and was on special droplet precautions for COVID-19 at the time of the observed deficiencies.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents were informed of their rights both orally and in writing on an ongoing basis. A review of Resident Council meeting minutes from three separate dates showed that resident rights were not reviewed during any of the meetings. During interviews, the Activity Director confirmed that resident rights were not discussed at Resident Council meetings, and members of the Resident Council also stated that these rights were not reviewed. The Administrator acknowledged that the expectation was for resident rights to be reviewed with residents during these meetings, but this did not occur.

Penalty

No penalty information released

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

Summary

The facility failed to provide required written bed-hold notifications and did not notify the LTC Ombudsman during resident transfers to hospitals and discharges home. Specifically, for four residents with various diagnoses including heart failure, kidney disease, weakness, stroke, and alcohol abuse, there was no evidence in the clinical records that written notice of the facility's bed-hold policy was given to the residents or their representatives at the time of transfer or hospitalization. Additionally, there was no documentation that the LTC Ombudsman was notified of these transfers or discharges, as required by facility policy. Interviews with facility staff, including the Administrator and Social Services Director, confirmed that written bed-hold notifications were not provided and that the Ombudsman was not notified for the affected residents. The lack of documentation and staff acknowledgment of these omissions demonstrate that the facility did not follow its own policies regarding resident notification and communication with the Ombudsman during transfers and discharges.

Penalty

No penalty information released

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

Summary

The facility failed to provide covered exterior refuse containers for three out of four observed locations. On multiple occasions, surveyors observed uncovered refuse containers outside various exits, each containing food debris and other trash. Staff, including the Maintenance Lead, confirmed that there were no lids available for these containers. Both the Administrator and the Regional Director of Quality Assurance acknowledged the presence of uncovered refuse containers at three exterior doors.

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 complete a comprehensive assessment for one resident who had a history of chronic kidney disease and multiple recent hospitalizations. Upon review, it was found that the resident's annual Minimum Data Set (MDS) assessment, which was due, remained incomplete beyond the required timeframe. Additionally, there was no evidence in the clinical record that a significant change assessment or an admissions assessment had been completed following the resident's multiple hospitalizations and subsequent return to the facility. Both the Regional Reimbursement Analyst and the Administrator acknowledged that the comprehensive assessment was not completed in a timely manner, despite the expectation for timely and accurate MDS assessments for each resident.

Penalty

No penalty information released

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

Summary

The facility failed to coordinate appropriate services to address the communication needs of a resident with a persistent vegetative state and traumatic brain injury. Upon admission, the resident's ability to understand others was not assessed, and although a physician order was made for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) at the family's request, there was no evidence that these referrals were promptly initiated. During a care conference, the family specifically requested referrals for OT, PT, SLP, and a neurologist, but staff were unclear about whether the SLP referral had been made. The resident's care plan was updated to reflect non-verbal communication needs, but staff interviews revealed uncertainty about how SLP could assist and a lack of timely follow-through on the requested services. Observations and interviews indicated that the resident attempted to communicate through non-verbal means such as eye movements, grunting, and swatting at staff. Staff members, including a CNA and the Activities Director, described the resident's responses to stimuli and attempts to make needs known, but there was no evidence of assessment for improved communication technology as requested by the family. The Regional Director of Quality Assurance confirmed that referrals for communication services were expected to be initiated as soon as requested, but acknowledged that there was a delay in providing these services for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to follow physician orders for wound care for one resident who was admitted with a leg fracture. The orthopedic physician had ordered that the resident's dressing be removed one week after admission, the incision cleansed with warm water and soap, dried, covered with a nonadhesive pad or gauze, and the dressing changed every one to two days until a follow-up appointment. Staff were also instructed to monitor for signs of infection and contact Trauma/Orthopedics if any were observed. However, the physician's wound care order was not entered into the Treatment Administration Record (TAR), and there was no evidence that the wound care was completed as ordered. As a result, the resident's incision became red, swollen, and warm to the touch, with the resident reporting burning and tenderness. The resident stated that the dressing was not removed for nearly two weeks after admission and that staff did not check the incision until it became infected and painful, despite multiple reports of pain. Staff interviews confirmed that the physician's order was not placed on the TAR, dressing changes were not initiated, and the resident developed an incision infection. The process for entering and verifying new orders was reviewed, and it was acknowledged by multiple staff members that the order was missed.

Penalty

No penalty information released

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

Summary

The facility failed to implement care plan interventions related to smoking safety for a resident with a history of inhalant dependence and inhalant-induced dementia, who was assessed as cognitively intact. The resident's care plan required smoking only in designated areas, adherence to a smoking schedule, and storage of tobacco and fire materials in a lock box at the nurse's station. However, observations showed the resident repeatedly accessed smoking materials from the nurse's station counter, exited through the North exit door, and smoked or vaped outside of the designated smoking area, contrary to the care plan. Staff interviews confirmed that the resident was allowed to smoke independently, outside of scheduled times and designated areas, and that smoking materials were not consistently secured in the lock box as required. Additionally, staff were unclear about the frequency of required checks for burns on the resident, and the resident was observed leaving smoking materials unattended on the nurse's station counter. The Director of Nursing Services acknowledged that the only designated smoking area was the courtyard and that staff were expected to secure smoking materials immediately, but this was not consistently done. These actions and inactions resulted in the facility failing to ensure a safe environment free from accident hazards related to smoking, as outlined in the resident's care plan.

Penalty

No penalty information released

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

Summary

The facility failed to complete annual performance reviews for two of five sampled CNA staff. Personnel records showed that one CNA, hired in May 2020, had their last performance review in June 2024, and another CNA, hired in August 2018, had their last performance review in August 2024. The administrator confirmed that annual staff evaluations were expected to be completed in a timely manner.

Penalty

No penalty information released

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

Summary

The facility failed to timely address a newly identified behavior in a resident with a history of anxiety and heart failure. The resident, who was cognitively intact and had documented episodes of depression, exhibited inappropriate behaviors such as refusal of care, confabulation, and verbal aggression on multiple days, as recorded in the behavior monitoring record. Despite these behaviors, interventions were largely ineffective, and there was no documentation of additional behaviors in the progress notes for over a month. Staff interviews revealed that the resident had recently displayed physical aggression by banging a walker against the wall, but this incident was not reported or documented by staff who witnessed it, as they assumed others were aware. Further interviews indicated that key staff, including the Social Services Director and the Director of Nursing Services, were unaware of the resident's physical aggression and expected such incidents to be documented to facilitate timely intervention. The Social Services Director acknowledged the need for a new behavioral assessment and consideration of additional behavioral services due to the change in the resident's behavior. The facility assessment also indicated insufficient behavioral health staffing, which may have contributed to the lack of timely response and documentation regarding the resident's behavioral changes.

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 observed that treatment carts containing medications and medical supplies, including insulin, needles, glucometers, IV supplies, syringes, anticoagulant, and antibiotic medications, were left unlocked and unattended in two separate hallways. On one occasion, a staff member noticed the unlocked cart and secured it, although she was not responsible for it. The charge nurse responsible for the cart stated she typically locked it but was unsure why it was left unlocked in this instance. In both cases, staff confirmed that the expectation was for treatment carts to be locked at all times when unattended. These observations were made during random checks, and in both instances, staff and residents were seen walking by the unsecured carts. The unlocked carts contained medications and supplies that should have been secured according to facility policy and professional standards. No specific residents were identified as being directly involved or affected at the time of the observations.

Penalty

No penalty information released

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

Summary

The facility failed to follow up on dental services for one resident who was admitted with chronic kidney disease. According to the facility's policies, social services are responsible for assisting with dental appointments, transportation, and documenting all dental services in the resident's medical record. The resident's care plan required staff to coordinate dental care and transportation as needed. A review of the clinical record showed no evidence of dental services being referred or provided for the resident over a three-month period. Documentation indicated that a dental referral was made when the provider was at the facility, but there was no follow-up or documentation of a scheduled dental appointment, and the Social Services Director was unable to account for any further action taken.

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 chronic obstructive pulmonary disease and metabolic encephalopathy, who was dependent on staff for bathing and required two-person assistance, did not consistently receive scheduled bathing or shower care. The resident's care plan and admission assessments indicated the need for staff assistance with bathing. Bath/Shower task logs showed that showers were only documented as provided on three occasions, while scheduled shower days on three other dates were left blank with no documentation of care provided or refusals. Progress notes did not indicate that the resident was offered additional opportunities for bathing when a shower was missed or refused. Staff interviews revealed that sometimes tasks were not documented due to staff being too busy, and a resident care manager confirmed that blank logs indicated the task was not completed, with at least one missed shower attributed to short staffing.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate nursing staff to meet the needs of all residents on multiple occasions, as evidenced by direct care staff daily reports, resident and staff interviews, and documentation reviews. On several dates, the number of Certified Nursing Assistants (CNAs) scheduled for both day and evening shifts was below the minimum required by Oregon state staffing ratios for the facility's census. This resulted in residents not receiving scheduled showers, delays in being put to bed, and missed oral care. Staff and residents consistently reported that management did not assist on the floor during shortages, and CNAs often skipped breaks or stayed late to complete tasks. Specific residents with diagnoses such as dementia, stroke, and cancer, who required assistance with activities of daily living (ADLs) like bathing, did not receive scheduled showers on the days when staffing was insufficient. Documentation was either missing or inaccurately indicated that residents refused care when, in fact, staff did not have time to provide it. Multiple staff members, including CNAs, LPNs, and the social service director, confirmed that showers and other care tasks were missed due to inadequate staffing, and that efforts to obtain agency staff were unsuccessful. The administrator and other management staff acknowledged ongoing staffing issues, confirming that resident needs were not met on the identified dates due to being short-staffed. The facility continued to admit new residents despite not having enough CNAs to provide required care, and staff reported that shortages were a frequent and unresolved problem. Residents expressed dissatisfaction with missed care, and staff described having to prioritize basic needs over other required tasks when working short.

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 respond in a timely manner to a resident's grievance regarding missing property. According to the facility's grievance policy, grievances are to be addressed within five days of receipt, and the concerned party is to be informed of the resolution. A cognitively intact resident with a diagnosis of diabetes reported missing money from their wallet, specifying the denominations and amount believed to be missing. Staff, with the resident's permission, inspected the wallet and confirmed the discrepancy in the amount present. During the investigation, staff determined that theft was ruled out due to inconsistent statements from the resident, and the resident was offered the option to secure their remaining money. Despite this, the resident was not informed in a timely manner about whether the missing money would be reimbursed. Staff communication regarding the resolution was lacking, as one staff member was unsure about reimbursement and another did not communicate findings to the resident, assuming reimbursement would occur. The administrator acknowledged that the grievance policy was not followed, as the resident was not notified of the resolution within the required timeframe.

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 a history of stroke and documented as cognitively intact reported that their cell phone went missing after being placed on their bedside table following a call to their spouse. The resident stated that no one entered the room except staff and, occasionally, their roommate's visitors. Staff interviews confirmed that the resident had possession of the phone the evening before it was reported missing, and the phone was not found during a facility-wide search. The resident's spouse was able to use a phone locator to determine that the phone was located several blocks away from the facility the following day. The incident was reported to the police, and the resident's spouse subsequently requested reimbursement for the lost phone and the purchase of a new one. The report documents that the facility failed to protect the resident from the wrongful use or theft of their personal belongings, specifically the cell phone, as required. This deficiency was identified through interviews, record reviews, and the facility's own investigation into the missing property.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a staff member failed to honor a resident's right to dignity and self-determination. The resident, who was moderately cognitively impaired and diagnosed with dementia, was admitted to the facility in July 2024. On the date of the incident, a CNA attempted to change the resident's soiled shirt despite the resident's explicit refusal and requests to be left alone. The CNA proceeded to remove the shirt, which led to the resident becoming upset, fighting, and using strong language. The CNA later reported the resident's distress to an LPN, who confirmed the resident was angry about being made to change the shirt. Other staff members recalled the incident, with one CNA remembering the resident crying and reporting the situation to a nurse, and another LPN noting the resident appeared in distress and was forced to do something against their wishes. The resident did not use the word "abuse" but repeated the details of the incident, and two days later, no longer remembered it. The administrator and director of nursing services confirmed the accuracy of the incident and acknowledged the failure to maintain resident rights.

Penalty

No penalty information released

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

Summary

The facility failed to provide physician-ordered diets as prescribed for three residents, leading to significant health risks. Resident 57, who had a history of pneumonitis due to inhalation of food and severe dysphagia, was given food that did not meet the required minced and moist texture. This resulted in a severe coughing episode, indicating a risk of choking or aspiration. Staff were aware of the diet texture error but did not correct it due to a busy kitchen environment. Resident 3, diagnosed with difficulty swallowing, experienced a choking incident after being served inadequately prepared food. Despite a care plan that required supervision during meals and an easy-to-chew diet, Resident 3 choked on a piece of pork, leading to an emergency department visit. Documentation revealed multiple instances where Resident 3 refused to eat in the dining room, and there was insufficient staff to supervise meals in the resident's room. Resident 39, who had a stroke and dysphagia, was observed coughing while eating a tortilla, which was not appropriate for their easy chew 7 diet texture. The Certified Dietary Manager confirmed that the resident should have received bread instead. These incidents highlight the facility's failure to adhere to prescribed diet textures, posing significant health risks to the residents involved.

Removal Plan

• Resident 57 was assessed for signs and symptoms of aspiration, her/his physician was notified, and the resident was placed on alert charting.
• Staff 4 was suspended and slated for 1:1 inservice training related to food textures, ensuring food textures served matched the meal ticket, and the process for what to do if there was a discrepancy.
• Kitchen staff currently working were trained regarding proper diet textures. Other kitchen staff were slated to be educated until 100% were inserviced. Inserving was scheduled to be provided by a Certified Dietary Manager independent of the facility.
• Nursing staff were slated to be inserviced regarding appropriate food textures and ensuring residents received the correct texture.
• All residents with mechanically altered diets would have their meal tickets audited for correct texture prior to leaving the kitchen by the Certified Dietary Manager or designee, and a second check would occur by IDT team members in collaboration with CNAs prior to meals being served to residents.
• Audits would be conducted of each meal. All findings were to be reported to the QAPI committee. Audits were to be conducted by the Certified Dietary Manager or designee.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that meals were served at appropriate temperatures and with proper flavor, affecting the palatability and safety of the food. On July 18, 2024, during a lunch service, sample plates were observed to contain cold and underdone au gratin potatoes, cold and firm broccoli, melted ice cream, and warm milk served at 64 degrees. The Certified Dietary Manager acknowledged these issues, confirming that the meal temperatures, flavors, and palatability were not appropriate. Additionally, a resident with diagnoses including malnutrition and diabetes reported consistent issues with the food quality. The resident stated that the food was bland, over-ripe, dry, tough, and always cold. Observations on July 18, 2024, during breakfast and lunch confirmed the resident's complaints, with meals appearing unappetizing and lacking flavor. A staff member, an RCM-LPN, also observed the resident's lunch and agreed that it did not appear appetizing or appealing.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to established recipes to meet menu and therapeutic standards, as observed in the kitchen. On the specified date, the posted lunch menu included breaded pork cutlet, au gratin potatoes, and cauliflower, with an alternative menu of sloppy joes, cheddar mash potatoes, and broccoli. However, the cook, who had been employed for three weeks, reported that no recipes were provided during his training, and none were followed in preparing the lunch meal. The Certified Dietary Manager confirmed that a new menu system with recipes was introduced in June 2024, and recipes should have been printed and followed for all therapeutic diets. This failure placed residents at risk for lack of meal satisfaction and compromised nutrition.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper sanitation processes in the kitchen, specifically regarding the monitoring of chemical concentration levels in the low-temperature dishwasher. From July 1 to July 14, 2024, there was no documentation of chemical concentration levels, which are crucial for ensuring dishes are properly sanitized. On July 15, 2024, a Dietary Aide was observed using the dishwasher without monitoring the chemical concentration, as she had not been instructed to do so. The Dietary Services Manager acknowledged the oversight and admitted reliance on monthly inspections by the chemical supplier instead of daily monitoring. Additionally, the Certified Dietary Manager confirmed that the form used for monitoring the dishwasher was inadequate, as it did not include a section for documenting chemical sanitizer concentration, which should be logged daily.

Penalty

No penalty information released

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

Summary

The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by multiple observations and interviews. Residents and staff reported long wait times for call lights to be answered, with some residents waiting up to 45 minutes for assistance with toileting and other needs. This issue was prevalent across different shifts, particularly during the night shift, and was corroborated by council meeting minutes and staff interviews. Residents expressed dissatisfaction with the delays, and staff acknowledged being overworked and unable to complete their tasks due to understaffing. Specific incidents highlighted the impact of insufficient staffing on resident care. For instance, a resident with a fractured pelvis and bladder incontinence waited 45 minutes for toileting assistance during dinner time, leading to episodes of incontinence. The resident's care plan required substantial assistance with transfers, but the staffing shortages hindered timely care. Staff confirmed the complaint and noted that call wait times often exceeded the facility's expectation of 15 to 20 minutes. Staff interviews revealed that the facility frequently experienced CNA shortages, with staff calling off work shortly before shifts. This led to incomplete care tasks, such as showers and incontinent care, resulting in skin issues for residents. Staff reported burnout and high turnover due to the ongoing understaffing, which further exacerbated the problem. The facility's administration acknowledged the staffing issues, confirming the challenges in meeting residents' needs effectively.

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 staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for 34 out of 126 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Report sheets covering several periods from January to July 2024. Specific dates were noted where RN coverage was lacking, including multiple days in January, February, March, June, and July. This lack of consistent RN coverage placed residents at risk for unmet assessment needs. During an interview on July 19, 2024, the facility's administrator, director of nursing services (DNS), regional support lead, and regional nurse consultant acknowledged the issue, noting that they believed RN coverage was better than documented and reported that two RNs had their employment terminated.

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 post accurate and complete staffing information, as observed on multiple occasions. On several dates, the Direct Care Staff Daily Report (DCSDR) was posted without documenting staff hours for Licensed Practical Nurses (LPNs) or Certified Nursing Assistants (CNAs). Witness 1, a staff member, revealed that nurses were instructed to fill in staff numbers without hours, with the expectation that administration would complete the form the following day. This practice was confirmed by multiple staff members, including the Administrator and Regional Support Lead, who acknowledged ongoing issues with staff not adding up the hours on the DCSDR.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by a review of training records for five randomly selected staff members. Staff members hired between 2019 and 2022 had significantly less documented training than required, with one staff member having only 15 minutes of training over a year. During an interview, the facility's administrator, Director of Nursing Services (DNS), Regional Support Lead, and Regional Nurse Consultant acknowledged that staff were not obtaining sign-up sheets for trainings, which hindered the tracking of training hours. This deficiency placed residents at risk due to the lack of competent staff.

Penalty

No penalty information released

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

Summary

The facility failed to provide a clean and homelike environment for several residents, as observed during a survey. Multiple residents, including those with reduced mobility, end-of-life care, heart disease, stroke, and anxiety disorder, were found to be living in rooms with significant flooring damage. Observations included dents with black marks on the floors, gray substance lines, and aged, dingy flooring. In some cases, the flooring was chipped, missing pieces, or had been patched with putty. Additionally, there were issues with the cleanliness of the bathrooms, with gray and black substances observed around toilets and on the floors. The survey also noted environmental deficiencies in the facility's hallways, where large dark stains and black coloration were observed on the carpet. Ceiling damage was also noted in one resident's room, with leakage damage and dark brown dried debris on the wall. These conditions were confirmed by the Maintenance Lead, who acknowledged the need for repairs. The report highlights the facility's failure to maintain a clean and homelike environment, impacting the quality of life for the residents involved.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a pest-free environment, as evidenced by the presence of flies and maggots in resident areas. A work order was submitted on July 6, 2024, indicating an excessive amount of flies in the main area and resident rooms in the south part of the building. Despite this, the issue was not addressed until July 8, 2024, when the Maintenance Lead walked around the building but did not observe any issues. Pest control did not arrive until July 10, 2024. On July 13, 2024, a resident was found with maggots on their bed, which were traced back to their wound dressing, leading to their transport to the hospital. The resident had previously complained about flies landing on their food and foot, but no action was taken. The situation was further exacerbated when the resident returned from the hospital to find flies still present in their room. Staff were directed to deep clean the room, but the resident remained in the room during the process, necessitating a second cleaning. The facility administration was informed of the maggot issue early in the morning, but did not arrive until after noon. An investigation was conducted by the Director of Nursing Services and the Regional Nurse Consultant, who acknowledged the facility's lack of awareness regarding the initial work order related to flies. This oversight placed residents at risk for pest infestation, as flies were also observed in the dining room, where residents had to swat them away from their meals.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident, who was cognitively intact and had a history of PTSD and anxiety, from harassment and intimidation by another resident. The issue began when the resident politely asked the other resident not to be disruptive in the dining room, which led to the other resident becoming angry and subsequently engaging in behavior that made the resident feel harassed and anxious. Despite the resident's complaints to management and staff observations of the intimidating behavior, the facility did not take effective action to prevent the harassment. Staff members reported that the resident felt scared, intimidated, and uncomfortable due to the other resident's behavior, which included staring and following the resident to their room. Although staff were instructed to redirect the harassing resident, this approach was ineffective and often resulted in the resident becoming angry. The facility's management was aware of the situation but failed to implement measures to protect the resident, leading to a deficiency in ensuring residents were free from abuse.

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 investigate allegations of abuse involving a resident with PTSD and anxiety disorder, who felt harassed and intimidated by another resident. The incident began when the resident asked the other resident not to be disruptive in the dining room, leading to ongoing harassment. Despite multiple observations and staff reports of the harassing behavior, management did not take adequate steps to protect the resident or investigate the allegations. Staff members reported that the harassing resident frequently visited the resident's hall and room, causing the resident to feel scared and anxious. Although staff were instructed to redirect the harassing resident, this approach was ineffective and further angered the resident. The facility's management was aware of the situation but failed to take appropriate action to ensure the resident's safety and well-being.

Penalty

No penalty information released

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

Summary

The facility failed to revise care plan interventions for three residents, leading to unmet needs. Resident 10, admitted with a broken arm, was at risk for contracture to the left fingers. Despite instructions on the Treatment Administration Record (TAR) to soak and wash the hand and apply a hand brace, the care plan lacked documentation regarding the hand contracture. Staff confirmed that the hand contracture should have been included in the care plan. Resident 24, admitted with aphasia and stroke, had a care plan indicating deficits in ADL performance and nutritional issues but lacked documentation on whether supervision or assistance with eating was required. Staff acknowledged that supervision and cueing for eating assistance should have been specified. Resident 17, admitted with alcohol dependency and narcissistic personality disorder, had a behavior care plan but was not care planned for alcohol dependency or worsening behaviors with alcohol consumption. Staff confirmed that alcohol consumption worsened Resident 17's behaviors, yet the care plan did not address this issue. The lack of appropriate care plan revisions for these residents placed them at risk for unmet needs, as confirmed by facility staff.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to unmet needs. Resident 16, who was cognitively intact and required assistance with toileting due to bladder incontinence, experienced a delay in receiving help. Despite activating the call light, the resident waited 45 minutes for assistance, resulting in an incontinent episode. Staff confirmed the delay and acknowledged that the expected response time for call lights was 15 to 20 minutes. Resident 24, who had deficits in ADL performance due to stroke and dementia, was dependent on staff for bathing. Documentation revealed that the resident missed several showers, leading to body odor. Staff admitted that time constraints prevented completion of all tasks, and showers were sometimes falsely documented as refused. Similarly, Resident 40, who required assistance for personal hygiene, received fewer showers than scheduled due to staffing shortages. Observations noted poor hygiene, and staff acknowledged the need for improved training to ensure compliance with bathing schedules.

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 replace hearing aids in a timely manner for a resident with dementia and depression, leading to a deficiency in addressing sensory needs. The resident was admitted in 2022 and was assessed to have adequate hearing with the use of hearing aids. A care plan revised in June 2024 indicated the resident was to wear hearing aids in both ears to address a mild hearing deficit. However, observations in July 2024 revealed the resident was not wearing hearing aids, and staff confirmed the aids had been broken for three to four months. The resident was on a list for repair, but no action had been taken. Staff members, including a CNA and an LPN, acknowledged the absence of hearing aids since the resident moved to a new hall in April 2024. The Social Service Director was unaware of the issue, mistakenly believing the resident chose not to wear the aids.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident's environment was free from accident hazards and did not respond to changes in condition in a timely manner. Resident 65, who was admitted with a leg fracture, experienced a fall resulting in a swollen, bruised, and painful right lower extremity. An x-ray confirmed a right ankle fracture, but there was a delay in notifying the on-call physician and sending the resident to the emergency room. Staff 42 acknowledged not calling the on-call physician and only sending a message through the hospital messaging system, which delayed the necessary care for Resident 65. Additionally, the facility did not adhere to the care plan for Resident 66, who required two staff members for mechanical lift transfers due to diagnoses including COPD, generalized muscle weakness, and a transient ischemic attack. An incident occurred when a CNA attempted to transfer Resident 66 alone, resulting in the resident falling out of the lift sling and hitting her head on the floor. The care plan was not followed, as the transfer was conducted by one staff member instead of two, leading to the resident being sent to the hospital. Staff 43 admitted to not following the care plan due to being rushed.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate catheter care for a resident with a nephrostomy tube, which placed the resident at risk for urinary infections. The resident was admitted with chronic kidney disease and had a nephrostomy tube placed. There was a physician order to cover the nephrostomy tube site and change the bandage daily, but there were no orders for nephrostomy care from March to May. The care plan was revised in July to include monitoring for complications, but it lacked specific interventions related to the nephrostomy. The resident expressed concerns about the placement and staff knowledge regarding the nephrostomy bag, reporting incidents of the bag bursting or leaking due to improper handling. Staff interviews revealed confusion about responsibility for the nephrostomy bag care, unclear instructions on bag placement, and issues with supply availability. Staff acknowledged the need for a systematic method to maintain supplies, additional CNA training, and a detailed care plan for the nephrostomy bag care and placement.

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 obtain necessary orders for oxygen use for two residents with chronic obstructive pulmonary disease (COPD), leading to unmet respiratory needs. Resident 30, admitted in April 2022, had a care plan for oxygen use as needed but lacked a current order for oxygen use in their medical record. Staff confirmed that Resident 30 used oxygen almost daily when experiencing shortness of breath, yet no formal order was documented. Similarly, Resident 63, admitted in 2024, had a physician order for oxygen at three liters per minute (LPM) as needed. However, the medical record showed continuous oxygen use without documentation of adherence to the prescribed LPM or the frequency of oxygen tubing changes. Staff confirmed the continuous use of oxygen, acknowledging the absence of a formal order for such use and the lack of documentation regarding tubing changes.

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 complete annual performance reviews for a Certified Nursing Assistant (CNA), identified as Staff 9, who was hired on March 23, 2021. The only performance review provided for this staff member was dated April 30, 2022. This oversight was identified during an interview conducted on July 19, 2024, with the facility's Administrator, Director of Nursing Services (DNS), Regional Support Lead, and Regional Nurse Consultant. They acknowledged that the missed review occurred during a staffing transition, which placed residents at risk due to the potential lack of competent staff.

Penalty

No penalty information released

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

Summary

The facility failed to provide risk and benefit information related to the use of antipsychotic medications to residents or their responsible parties prior to administration. This deficiency was identified for one of the five sampled residents, who was admitted with a diagnosis including dementia. The resident, who had a BIMS score indicating moderate cognitive impairment, was prescribed Haloperidol for anxiety and agitation. The medication was administered starting on 5/9/24, but the consent form for the use of psychotropic medication therapy was not signed until 5/16/24. This indicates that the responsible party was not informed about the risks and benefits of the medication before it was administered. During an interview, facility staff confirmed that medication consent forms were expected to be signed before administration, highlighting a lapse in protocol adherence.

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 conduct a care conference for a resident with dementia, admitted in November 2021, as scheduled. On July 18, 2024, a family member, Witness 6, reported that a care conference was scheduled for May 27, 2024, but it did not occur, and no rescheduling was communicated. Staff 15, an LPN Assistant RCM, confirmed the scheduled conference and noted that Witness 6 had no concerns when she inquired about it on the scheduled date, but also confirmed that the resident was not present. Similarly, Staff 33, the Social Service Coordinator, confirmed the absence of the resident and the lack of concerns from Witness 6. On July 19, 2024, Staff 32, an LPN RCM, and Staff 31, an SSD, both stated that care conferences should include the resident, family, and the interdisciplinary team (IDT), which comprises nursing, social services, therapy, dietary, and activities. Staff 31 acknowledged that the care conference did not occur and mentioned efforts to reschedule it.

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 include a resident in decisions regarding their shower schedule, which is a violation of the resident's right to self-determination and choice. The resident, who was admitted in 2024 with diagnoses including diabetes and a foot ulcer, required assistance with transfers and dressing. A revised care plan indicated these needs. The resident's shower schedule was changed automatically following a room move, without prior discussion or consent from the resident. This change conflicted with the resident's weekly medical appointments, causing inconvenience. Staff acknowledged that the shower schedule should have been discussed with the resident before any changes were made.

Penalty

No penalty information released

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

Summary

The facility failed to notify the provider of a resident's refusals for critical health checks, specifically capillary blood glucose (CBG) checks and orthostatic blood pressure measurements. The resident, admitted in September 2019 with a diagnosis of diabetes, had physician orders for weekly CBG checks and monthly orthostatic blood pressure assessments. However, the resident refused CBG checks on multiple occasions in May, June, and July 2024, and also refused orthostatic blood pressure checks in May and June 2024. Despite these refusals, there was no evidence in the medical record that the provider was informed of these refusals, as confirmed by a regional nurse consultant on July 19, 2024.

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 assess and provide meaningful activities for two residents, leading to a lack of social interaction. Resident 36, who was cognitively intact and expressed a desire for group activities, particularly exercise, was not engaged in any activities for 30 days. Despite being aware of Resident 36's interest in exercise, the Activities Director acknowledged that current activities did not include exercise programming. Resident 42, diagnosed with an anxiety disorder, had no activity care plan, and did not participate in any activities for 30 days. The Activities Director admitted that an activity preference sheet was not completed for Resident 42.

Penalty

No penalty information released

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

Summary

The facility failed to implement proper medication management and bowel care for two residents, leading to unmet needs. Resident 17, who was admitted with a diagnosis of diabetes, had a physician's order to increase their Lisinopril dosage from 5 mg to 7.5 mg on 5/7/24. However, this change was not entered into the resident's chart until 6/15/24. During this period, the pharmacy sent the correct dosage, but staff continued to administer the incorrect 5 mg dose as per the outdated chart. Staff members, including an LPN and CMA, confirmed the discrepancy, and the DNS acknowledged the failure to update the chart promptly, leaving uncertainty about the duration the resident received the incorrect dosage. Resident 33, admitted with arthritis, experienced a lapse in bowel care. From 6/7/24 to 6/13/24, the resident did not have a bowel movement, and although the MAR indicated that milk of magnesia should be administered every 24 hours as needed for constipation, the resident only received the medication on 6/12/24, five days after the last recorded bowel movement. The facility's administrator, DNS, regional support lead, and regional nurse consultant confirmed that bowel care should have been provided sooner, indicating a failure to adhere to the prescribed bowel management protocol.

Penalty

No penalty information released

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

Summary

The facility failed to implement appropriate pressure ulcer treatments and care plans for two residents, leading to deficiencies in care. Resident 3, admitted with a diagnosis of stroke, developed new skin irregularities with significant redness in the peri and sacral areas, as noted in a weekly skin audit. However, there was no documentation that the physician was informed of these changes. The Treatment Administration Record (TAR) indicated that bi-weekly skin checks were to be conducted, but there were inconsistencies in the documentation, with missing assessments for several dates. An external physician visit later identified an unstageable pressure injury on Resident 3's buttocks, and the physician requested an off-loading mattress and a facility skin assessment, which was not documented in the clinical records. Resident 1, admitted with an anoxic brain injury, developed an in-house acquired Stage 4 pressure ulcer on the left upper abdomen. Despite the severity of the ulcer, there was no investigation conducted to determine its cause. Staff interviews revealed that the ulcer was caused by the resident's contracted left arm pressing against the abdomen, but no further action was taken to investigate or address the issue. This lack of investigation and documentation highlights the facility's failure to provide adequate pressure ulcer care and prevention.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate dialysis care and services for a resident with end-stage kidney disease, who was admitted in 2024. The resident, who underwent dialysis three times a week, reported that upon returning from dialysis, staff did not check the access site for thrill and bruit, which are essential to ensure good blood flow in a dialysis fistula. The care plan dated 2/7/24 required staff to monitor the access site for infection and bleeding and to document weights. However, the resident's clinical record showed only six weights documented from 2/7/24 through 6/29/24, with no evidence of access site monitoring. Staff acknowledged the absence of documentation regarding the type of dialysis access site and the necessary care needs for the resident, as well as the lack of daily weight documentation.