Greenwood Center For Nursing And Rehab

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

Nursing staff failed to administer a prescribed antihypertensive medication, Norvasc (Amlodipine Besylate), in accordance with physician orders and facility policy for a resident with multiple cardiac and respiratory diagnoses, including congestive heart failure, respiratory failure with hypoxia, atherosclerotic heart disease, and hypertension. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 120 mm/Hg. Despite this, clinical record review showed that the medication was administered on at least 30 occasions when the resident's systolic blood pressure was below the ordered threshold. Facility policy required staff to verify medication allergies and obtain vital signs prior to medication administration, and state nursing standards mandate that licensed nurses provide care in accordance with professional standards and maintain accurate records. Documentation revealed that the medication was repeatedly given outside the prescribed parameters, and this was confirmed by the Nursing Home Administrator during an interview. The failure to follow physician orders and professional standards resulted in multiple medication administration errors 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 ensure that a resident's medication regimen was free from significant medication errors. A review of clinical records, facility policy, pharmacy records, and interviews revealed that a resident with documented allergies and intolerances to several medications, including Ondansetron and Gabapentin, was administered these medications despite their allergy status. The resident's medical history included Type 2 Diabetes, congestive heart failure, and nausea and vomiting. The facility's policy required staff to verify medication allergies and obtain vital signs as applicable before administering medications. However, the resident received Ondansetron on ten occasions and Gabapentin daily for over two weeks, even though both were listed as allergies or intolerances in the resident's records. The resident reported being aware of her allergy to Ondansetron and stated that it caused her to vomit, which she had previously communicated to her physician. There was no documentation provided by the facility to show that the physician justified the use of these medications despite the allergy listings. Additionally, the consultant pharmacist's monthly reviews did not identify or recommend discontinuation of the contraindicated medications. The Nursing Home Administrator acknowledged that the medications were administered despite the documented allergies and that no physician justification could be provided.

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 from sexual abuse and harassment by another resident, despite documented evidence of prior sexually inappropriate behaviors. One resident, who was severely cognitively impaired and had a history of sexualized behaviors, including making sexual comments and gestures toward staff, was known to require two-person assistance for care and had been referred to psychiatric services. Despite these interventions, the resident continued to display inappropriate behaviors, including an incident where he attempted to inappropriately grab staff. Another resident, also severely cognitively impaired and lacking the capacity to consent to sexual contact, became the victim of sexual abuse during a scheduled activity, where the first resident was observed touching her breast and genital area. Staff intervened immediately, but the incident was not reported to the Department of Health, as facility leadership did not perceive intent on the part of the perpetrator and only increased supervision as a response. A subsequent incident occurred in the dining room, where the same resident touched the victim's buttocks, which was witnessed and documented by staff. Only after this second incident did the facility report the matter to the appropriate authorities and implement more stringent supervision and separation measures. The facility's documentation and interviews with leadership revealed a lack of sufficient safeguards to prevent recurring sexual harassment or abuse, and there was no evidence that the facility ensured the victim was free from such abuse, as required by policy and regulation.

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 complete and accurate investigation into an alleged incident of sexual abuse involving a resident with severe cognitive impairment. According to the facility's abuse policy, all reports of abuse must be promptly reported to appropriate agencies and thoroughly investigated. However, after an activities aide reported witnessing one resident grab another resident's breast and genital area during an activity, the only written statement obtained was from the reporting staff member. No additional written statements or interviews from other staff or alert and oriented residents present at the time were included in the investigation file. The Director of Nursing (DON) concluded that the incident was not reportable due to both residents being incapable and the absence of injury, despite an eyewitness account describing inappropriate touching. The facility did not document any efforts to interview other potential witnesses or follow up on the eyewitness account, nor did it report the incident to the Department of Health as required by policy and federal regulations. Interviews with the DON and Nursing Home Administrator confirmed that they did not believe the incident was reportable and were unable to provide evidence that the investigation was complete or compliant with facility policy and regulatory requirements. The resident involved had a diagnosis of dementia and was assessed as severely cognitively impaired at the time of the incident.

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 compliance with regulations requiring the protection of residents from sexual abuse. Despite a known history of maladaptive behaviors, including inappropriate sexual comments, touching staff inappropriately, wandering into female residents' rooms, and grabbing residents' wheelchairs, one resident was not adequately monitored or included in ongoing audits intended to prevent abuse. On August 27, 2025, this resident was witnessed by staff sexually abusing another resident by touching her genital area over her clothing without consent. Clinical record reviews confirmed the perpetrator's behavioral history, but there was no evidence that this risk was addressed in the facility's quality assurance or performance improvement activities. The Quality Assurance and Performance Improvement (QAPI) committee did not identify or address the underlying causes of the original deficiency, as their plan focused only on the previously identified incident and did not evaluate or implement targeted prevention strategies for residents with known behavioral risks. Internal audits conducted after the initial survey did not include the resident with a history of maladaptive behaviors, nor did they monitor the effectiveness of corrective actions beyond the initial audits. As a result, the facility's failure to identify and address these risk factors contributed to the recurrence of resident-to-resident sexual 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 provide written notice, including the reason for a room change, to residents and/or their representatives prior to facility-initiated room changes for three of eight residents reviewed. Clinical record reviews showed that residents were moved from their original rooms to different wings within the facility without any documented evidence that written notification or explanation was given in advance. This included one resident who was cognitively intact and another who was moderately cognitively impaired, as indicated by a BIMS score of 12. Both residents and their representatives were not informed in writing about the reason for the move, nor were they given the opportunity to refuse the room change or to be involved in the process as required by federal regulations. Interviews with the affected residents revealed that they were not told why their rooms were being changed and were not made aware of their right to refuse the move. One resident expressed frustration at being moved after over a year in the same room and stated that she would have refused the change if she had been informed of her rights. The Nursing Home Administrator was unable to provide any documentation showing that written explanations were given to the residents or their representatives prior to the room 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 ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with a history of Type 2 diabetes and a recent upper arm fracture, who was cognitively intact, was mistakenly given Hydralazine 75 mg and Clonidine 0.2 mg, both antihypertensive medications, instead of her prescribed pain medication. This error occurred when the resident approached the nurse during medication preparation for another resident, leading the nurse to inadvertently place the wrong medications in the resident's cup. The resident subsequently experienced hypotension, with a blood pressure reading of 80/52, but did not report symptoms such as dizziness or chest pain at the time of assessment. In the second incident, a resident with severe cognitive impairment, Alzheimer's disease, depression, and a history of upper arm fracture was affected by a medication transcription error. Following a provider's recommendation for a gradual dose reduction of Risperidone from 1 mg to 0.75 mg at bedtime, the nurse entered the new order for 0.75 mg but failed to discontinue the existing 1 mg order in the electronic system. As a result, the resident received a combined nightly dose of 1.75 mg of Risperidone for nearly two weeks before the error was discovered. No adverse effects were documented during this period. Both incidents were confirmed by the Nursing Home Administrator and were determined to be the result of failures to follow professional standards of practice, including the Five Rights of Medication Administration and proper transcription of physician orders. These deficiencies were identified through clinical record review, medication error reports, and staff interviews.

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 nursing staff to meet the needs of residents, resulting in delayed care and unmet resident needs. Multiple residents reported waiting 30 minutes or longer for assistance, with some instances of waiting up to two hours, particularly during weekend shifts. Residents with significant medical needs, such as those with multiple sclerosis, dysphagia, cancer with a laryngectomy stoma, PEG tube, cerebral infarction, peripheral vascular disease, depression, and Parkinson's disease, experienced delays in care, including assistance with turning, repositioning, and toileting. One resident reported having to attempt unsafe self-transfers due to long wait times, and another reported holding her bowels as long as possible because of the delays. Observations and interviews confirmed that call bells were not answered in a timely manner, and staff acknowledged being unable to respond promptly due to insufficient staffing. One nurse aide stated that only two staff were assigned to a hallway where many residents required two-person assistance, making it difficult to meet residents' needs. Documentation showed that a resident received fewer showers than desired, with staff citing lack of staffing as the reason for substituting bed baths for showers. Group interviews with residents further corroborated the ongoing issues with delayed responses and inadequate care provision. A review of nurse staffing data revealed that the facility did not meet state minimum requirements for nurse aide and nurse staff direct care hours on at least one shift. The Nursing Home Administrator confirmed the failure to meet these requirements and acknowledged the facility's responsibility to provide sufficient nursing staff. The administrator was unable to explain the ongoing reports of untimely staff responses or the specific observed delay in responding to a resident's call bell.

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 residents' rights to privacy and confidentiality in two separate instances. For one resident with acute respiratory failure and a recent COVID-19 diagnosis, a sign was posted outside the resident's room that specifically identified the resident as having SARS-CoV-2 (COVID-19) or symptoms with positive testing. This sign was visible to anyone passing by, thereby compromising the resident's right to privacy regarding their health status. The Nursing Home Administrator later confirmed that the sign had been redacted to remove identifying information, but at the time of observation, the resident's confidential health information was exposed. In a separate incident, another resident with morbid obesity and major depressive disorder reported not receiving her incoming mail, specifically her monthly social security statements, unopened. The resident stated she had repeatedly asked the business office manager about this issue and only received a copy, not the original statement. The business office manager admitted to opening the resident's social security statements to assist with account balancing and tax purposes, despite the facility not being the resident's representative payee. The Nursing Home Administrator confirmed that residents have the right to receive their mail unopened and was unable to provide documentation that this right was upheld 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 ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, the discharge return-not-anticipated MDS assessment inaccurately indicated that the resident was discharged to a short-term general hospital, when clinical documentation and staff interview confirmed the resident was actually discharged to another long-term care facility. This discrepancy was verified through a review of the progress note and confirmed by the Nursing Home Administrator. For another resident with a diagnosis of stage 4 chronic kidney disease, the admission MDS assessment incorrectly documented that the resident was receiving dialysis both prior to and during their stay at the facility. A review of the clinical record found no evidence of dialysis orders or treatments, and the DON confirmed that the resident had not received dialysis at the hospital prior to admission or while at the facility. These inaccuracies in the MDS assessments were identified through clinical record review and staff interviews.

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 wound care services in accordance with physician orders and professional standards of practice for one resident. The resident, who was admitted with diagnoses including pneumonia and venous insufficiency, had a physician's order for daily wound care to the left calf, specifying the use of oil emulsion dressing, ABD, and Kling, with the dressing to be checked each shift and replaced if missing. Documentation in the Treatment Administration Record showed that wound care was only recorded as completed on select days, with no documentation for at least two days when care was required. Facility policy required that all dressing changes be marked with the date, time, and staff initials, and that wound care be documented at the time of completion. A family member reported concerns after observing that the resident's wound dressing was not changed as ordered, with the dressing dated several days prior to their visit. Staff witness statements confirmed that wound care was not consistently performed as documented, with one LPN acknowledging uncertainty about whether the treatment was completed and another confirming that documentation was signed off without the care being provided. The Nursing Home Administrator confirmed that staff failed to consistently perform and document wound care in accordance with physician orders and facility policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the ready availability of necessary emergency dialysis supplies for a resident receiving hemodialysis. According to the care plan for the resident, who had chronic kidney disease and acute kidney failure and received hemodialysis via a right chest perma-Cath, an emergency kit containing pressure dressing, tape, and a clamp was required to be at the bedside on the wall. This intervention was intended to provide immediate access to supplies in the event of complications such as hemorrhage or catheter dislodgement. However, during an observation, surveyors found that the emergency kit was not present or accessible in the resident's room, and there were no visible emergency clamps or pressure dressings as directed by the care plan. Staff interviews confirmed that the emergency kit should have been present and accessible, in accordance with both the resident's care plan and facility policy. The Nursing Home Administrator also verified that facility policy required emergency kits to be maintained in the rooms of residents receiving hemodialysis. The absence of these critical emergency supplies constituted a failure to follow the individualized care plan and facility policy for a resident with significant renal conditions requiring hemodialysis.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the correct installation of bed rails for one resident. The resident, who had diagnoses including morbid obesity and bradycardia, was assessed as cognitively intact and had a care plan that included the use of a bariatric bed with bilateral bed rails to assist with mobility. The interdisciplinary care team recommended the use of bed rails, and informed consent was obtained from the resident. However, during an interview and observation, the resident reported that the bed rails were loose and shifted when used for support. Direct observation confirmed that the bed rails were visibly unstable and not properly affixed to the bed frame. Further investigation revealed that the bed rails were not secured to the bed frame and moved when the resident attempted to use them. The facility was unable to provide documentation that the bed rails were compatible with the bariatric bed frame or that they had been installed according to the manufacturer's specifications. The facility's policy required adherence to manufacturer instructions for bed rail installation, but this was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the timely acquisition and administration of a prescribed medication for a resident following discharge from a hospital. The resident, who had a diagnosis including cerebral infarction, was recommended by the hospital to begin gabapentin 100 mg three times daily for pain and discomfort. Despite this recommendation being included in the hospital discharge summary, the medication was not entered into the resident's clinical record or administered until six days after the resident's return to the facility. During this period, the resident's medication administration record showed no doses of gabapentin were given, and the physician's order for the medication was not entered until several days after the discharge. The resident's representative expressed concern about the lack of pain management, recalling the hospital's prescription for gabapentin. The Nursing Home Administrator acknowledged that the facility did not ensure the attending physician received and acted upon the hospital's discharge recommendation, resulting in a delay in the resident receiving the prescribed medication.

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 accommodate individual food preferences for residents, as evidenced by multiple observations and interviews. One resident consistently received meals containing eggs and Brussels sprouts, despite documented dislikes for these items on his meal ticket, and was not offered alternative options. During a meal observation, this resident was served Brussels sprouts, and he expressed ongoing dissatisfaction with the lack of alternatives. Another resident reported repeatedly receiving broccoli on his meal tray, even though his meal ticket indicated a dislike for broccoli, and the dietary manager confirmed that no alternate vegetable was provided when broccoli was on the menu. Additionally, during a group interview, a resident stated that only one vegetable option was available per meal, and no alternatives were offered if a resident disliked the provided vegetable. The nursing home administrator was unable to provide documentation showing efforts to accommodate these food preferences. These findings demonstrate that the facility did not make sufficient efforts to honor resident food preferences, as required, to enhance meal satisfaction.

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 multiple sclerosis and dysphagia was admitted to the facility and had a care plan that included aspiration precautions. Following a documented choking episode, the care plan was revised to require staff-assisted feeding using a small maroon dysphagia spoon at all meals, as recommended by the speech-language pathologist. A physician's order also specified that the resident was to receive meals with the maroon spoon due to dysphagia and aspiration risk, along with a prescribed puree diet and honey-thick liquids. During a breakfast observation, the resident was served and fed with a standard silver teaspoon instead of the prescribed maroon spoon. The nurse aide feeding the resident confirmed that the maroon spoon was not present or used. The Nursing Home Administrator acknowledged that the facility failed to provide and use the prescribed adaptive equipment in accordance with the physician's orders.

Penalty

No penalty information released

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

Summary

During an initial kitchen tour with the dietary manager, surveyors observed several unsanitary food storage and service practices. Specifically, two opened bottles of nectar-thick juice were found in the walk-in refrigerator without any date of opening, despite manufacturer instructions to use the product within 10 days after opening. Additionally, a container of nectar-thick orange juice covered with plastic wrap and a pitcher of nectar-thick milk were also present in the refrigerator without any date markings. These items were not stored in accordance with professional standards for food safety and handling. Further observation revealed that the dish dispenser in the tray line area lacked a cover, leaving clean dishes exposed to potential contaminants. The dietary manager confirmed during the tour that the department was expected to maintain sanitary conditions and that all foods should be properly dated and stored to prevent contamination and foodborne illness. These findings indicate a failure to follow established food safety protocols in the dietary services department.

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 meet the required nurse aide to resident ratios as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2023. Specifically, the regulation requires a minimum of 1 nurse aide per 12 residents during the day and evening shifts, and 1 nurse aide per 20 residents overnight. A review of the facility's staffing records revealed that on 12 out of 21 shifts reviewed, the facility did not provide the minimum required number of nurse aides. For instance, on February 4, 2025, the day shift had 6.75 nurse aides instead of the required 8.25 for a census of 99 residents, and the evening shift had 7.53 nurse aides instead of the required 8.42 for a census of 101 residents. The deficiency was confirmed during an interview with the Nursing Home Administrator on February 12, 2025, who acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no excess higher-level staff available to compensate for the staffing shortfall. This failure to comply with staffing regulations was documented across multiple shifts, indicating a pattern of non-compliance with the mandated staffing levels.

Plan Of Correction

1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.

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 meet the required nurse aide to resident ratios as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides per residents on 17 out of 21 shifts reviewed. The required ratios are 1 nurse aide per 10 residents during the day, 1 per 11 residents in the evening, and 1 per 15 residents overnight. The staffing records from February 4 to February 10, 2025, show consistent understaffing across various shifts, with the number of nurse aides falling short of the required numbers based on the facility's census. The deficiency was confirmed during an interview with the Nursing Home Administrator on February 12, 2025, who acknowledged the failure to meet the staffing requirements on the specified dates. The report does not mention any additional higher-level staff being available to compensate for the deficiency, indicating a lack of adequate staffing to meet regulatory requirements. No specific residents or their conditions are mentioned in the report, and the focus remains on the facility's inability to provide the mandated nurse aide coverage.

Plan Of Correction

1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.

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 meet the required licensed practical nurse (LPN) to resident ratios on three occasions during the night shift. Specifically, on February 6, 2025, the facility had 3.09 LPNs on the day shift instead of the required 4.08 for a census of 102 residents. On February 8 and 9, 2025, the facility had 4.13 LPNs on the day shift, falling short of the required 4.16 for a census of 104 residents. No additional higher-level staff were available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios on these dates.

Plan Of Correction

1. Facility cannot retroactively correct past LPN ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit LPN ratios weekly for 4 weeks and then monthly for 2 months to ensure LPN ratios are met. 5. Audits will be submitted to QAPI for review.

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 meet the required minimum of 2.87 hours of direct resident care per resident in a 24-hour period, as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2023. On February 5, 2025, the facility provided only 2.74 hours of direct care nursing per resident, and on February 9, 2025, it provided 2.68 hours per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 12, 2025, who acknowledged the facility's failure to consistently provide the minimum required nursing care hours to each resident daily.

Plan Of Correction

1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA nursing hours are met. 5. Audits will be submitted to QAPI for review.

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 meet the required minimum of 3.2 hours of direct resident care per resident per day, as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, effective July 1, 2024. A review of the facility's staffing levels revealed that on several dates in February 2025, the facility provided less than the required nursing care hours. Specifically, on February 4, 5, 6, 7, 8, 9, and 10, the facility's direct care nursing hours per resident were below the mandated 3.2 hours, with the lowest being 2.68 hours on February 9, 2025. An interview with the Nursing Home Administrator on February 12, 2025, confirmed the facility's failure to consistently provide the minimum required general nursing care hours to each resident daily. This deficiency was identified through a review of nurse staffing records and resident census data, which highlighted the facility's inability to meet the regulatory requirements for nursing care hours on the specified dates.

Plan Of Correction

1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA Nursing hours are met. 5. Audits will be submitted to QAPI for review.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident and their designated representative were involved in the development and implementation of the resident's person-centered plan of care. According to the facility's policy, residents and their representatives should be encouraged to participate in care planning by being given sufficient notice of care plan meetings. However, for one resident, identified as Resident 3, there was no documented evidence that either the resident or their representative were invited to or participated in the November 2024 quarterly interdisciplinary care plan meeting. Resident 3, who was admitted with diagnoses including pneumonia and chronic obstructive pulmonary disease, was noted to be severely cognitively impaired with a BIMS score of 06. Despite the resident's cognitive impairment and the involvement of a family member as the resident's representative, the facility did not document any invitation or participation of the resident or their representative in the care planning process. This was confirmed by the Director of Nursing during an interview, acknowledging the facility's responsibility to involve residents and their representatives in care plan development.

Plan Of Correction

1. Care conference for R3 was scheduled for 1/7/25 and RR is attending with resident. 2. Facility completed 30 day lookback to ensure each applicable MDS has a care conference scheduled with RR or resident invite. 3. Facility implemented new process which includes tracking form to ensure each applicable scheduled MDS has a care plan scheduled with RR and/or resident invite and completion of care plan. NHA educated RNAC and LNAC on this new process. 4. NHA/designee will audit scheduled MDS' weekly for 4 weeks and then monthly for 2 months to ensure the applicable MDS' have a care plan scheduled with RR and resident invite sent and care plan completed. 5. Audits will be submitted to QAPI for review.

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 meet the required nurse aide to resident ratios on several occasions, as evidenced by a review of staffing records and staff interviews. Specifically, the facility did not provide the minimum number of nurse aides required during the day shift on December 21, 24, 25, and 26, 2024, with the number of nurse aides falling short of the required 8.5 for a census of 102 residents. Additionally, on December 24, 2024, the evening shift was understaffed with only 5.09 nurse aides instead of the required 8.42 for a census of 101 residents. Furthermore, the night shift on December 24 and 25, 2024, also failed to meet the minimum staffing requirements, with fewer nurse aides than the required 5.1 and 5.0 for the respective census counts. The Director of Nursing confirmed during an interview that the facility did not meet the required nurse aide to resident ratios on the specified dates. The report indicates that no additional higher-level staff were available to compensate for the staffing deficiencies on these occasions. This lack of adequate staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks that occurred as a result of the staffing shortfalls.

Plan Of Correction

1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.

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 meet the required nurse aide to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum number of nurse aides required for the day, evening, and night shifts on several dates in December 2024. For the day shift, the facility was consistently short of the required 10.20 nurse aides for a census of 102 residents, with staffing levels ranging from 7.28 to 9.66 nurse aides. Similarly, the evening shift was understaffed on several occasions, with the number of nurse aides falling short of the required 9.27 to 9.36 for a census of 102 to 103 residents. The night shift also experienced deficiencies, with staffing levels below the required 6.67 to 6.87 nurse aides for a census of 100 to 103 residents. The Director of Nursing confirmed that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the staffing deficiencies. This lack of adequate staffing was identified during a review of the facility's weekly staffing records and was corroborated by staff interviews, highlighting a systemic issue in maintaining the mandated staffing levels necessary for resident care.

Plan Of Correction

1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.

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 meet the required licensed practical nurse (LPN) to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum LPN staffing levels on 14 out of 21 shifts reviewed. On the day shift, the facility consistently fell short of the required 1 LPN per 25 residents, with staffing levels ranging from 2.91 to 4.06 LPNs for a census of 102 residents, where 4.08 LPNs were required. Similarly, the evening shift did not meet the required 1 LPN per 30 residents, with staffing levels between 2.06 and 3.22 LPNs for a census of 101 to 102 residents, where 3.37 to 3.40 LPNs were needed. The night shift also failed to meet the required 1 LPN per 40 residents, with staffing levels ranging from 1.38 to 2.19 LPNs for a census of 100 to 103 residents, where 2.50 to 2.58 LPNs were necessary. The Director of Nursing confirmed that no additional higher-level staff were available to compensate for these deficiencies. This lack of adequate staffing was confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to meet the required LPN to resident ratios on the specified dates.

Plan Of Correction

1. Facility cannot retroactively correct past LPN ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit LPN ratios weekly for 4 weeks and then monthly for 2 months to ensure LPN ratios are met. 5. Audits will be submitted to QAPI for review.

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 meet the regulatory requirement of providing a minimum of 2.87 hours of direct nursing care per resident per day. This deficiency was identified during a review of the facility's staffing levels, which revealed that on three specific dates, the facility provided only 2.56 and 2.55 hours of direct care nursing per resident. These dates were December 21, 24, and 25, 2024. An interview with the Director of Nursing confirmed the facility's failure to consistently meet the required nursing care hours on these days.

Plan Of Correction

1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA Nursing hours are met. 5. Audits will be submitted to QAPI for review.

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 meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident per day. This deficiency was identified through a review of the facility's staffing levels and confirmed by an interview with the Director of Nursing. On six out of the seven days reviewed, the facility's staffing levels were below the required minimum, with direct care nursing hours per resident ranging from 2.55 to 3.01 hours. Specific dates where the facility fell short include December 20, 21, 23, 24, 25, and 26, 2024. The Director of Nursing confirmed the inconsistency in meeting the required nursing care hours during an interview conducted on January 2, 2025.

Plan Of Correction

1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented a system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA Nursing hours are met. 5. Audits will be submitted to QAPI for review.

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 nursing services consistent with professional standards of quality for Resident CR1, who was admitted with diagnoses including COVID-19, cognitive communication deficit, and acute kidney failure. Upon admission, the resident was placed in the facility's designated COVID-19 isolation hallway. Initial assessments noted stable vital signs and diminished lung sounds without complaints of shortness of breath. However, the resident's condition deteriorated, and the facility staff were unable to obtain an oxygen saturation level despite multiple attempts. The resident exhibited difficulty breathing and was using accessory muscles to assist with breathing. The facility's certified registered nurse practitioner (CRNP) was contacted, and new orders for oxygen and respiratory treatment were given. However, there was no documented evidence that the CRNP or any other medical professional examined or evaluated the resident after the change in condition. The resident's symptoms of shortness of breath began hours before the nebulizer treatment was administered, and there was no follow-up assessment or documentation of the resident's condition after the treatment. This lack of timely assessment and documentation failed to ensure the resident's immediate medical needs were met. The situation escalated when the resident's daughter reported that the resident had stopped breathing. Despite immediate CPR efforts by the facility staff and the arrival of EMS, the resident expired. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the resident was not timely assessed after the change in condition. It was also noted that the CRNP and the Physician could not see the resident in the same 24-hour period due to payment restrictions, which contributed to the delay in treatment.

Penalty

No penalty information released

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

Summary

The facility failed to demonstrate the implementation of an ongoing Quality Assurance and Performance Improvement (QAPI) program, specifically in investigating and analyzing the root cause of adverse events. This deficiency was identified through the case of a resident who sustained a significant injury. The resident, who was cognitively intact, experienced a fracture during a linen change after wound care treatment. Despite the resident's ability to provide a coherent account of the incident, the facility did not obtain a witness statement from her, relying solely on the statements of the staff involved. The incident involved a nurse and a wound care nurse aide who were changing the resident's bed linens. During the process, the resident's knee was reportedly pulled, resulting in a pop sound and subsequent pain. The facility's documentation indicated that proper technique was used, but the resident's account contradicted this, stating that the nurse pulled her knee without supporting her shoulder or hip. The facility did not thoroughly investigate the incident, as evidenced by the lack of a resident statement and the inconsistency between the staff's and the resident's accounts. The facility's failure to conduct a comprehensive investigation and obtain all relevant witness statements hindered their ability to accurately identify the root cause of the incident. This lack of thorough investigation and documentation meant that the facility could not demonstrate an effective QAPI program. Consequently, there was no evidence of corrective actions or performance improvement activities being developed or implemented to prevent similar incidents in the future.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely responses to residents' requests for assistance, negatively impacting their quality of life. Resident 40, who is cognitively intact, reported that staff do not answer call bells promptly, especially during the night shift, with wait times often exceeding 45 minutes. Despite reporting this issue to the facility, no action was taken. Resident 26, also cognitively intact, experienced delays of several hours for call bell responses, resulting in sitting in their own feces for extended periods. This resident expressed feelings of neglect and concern about making staff upset by using the call bell. Resident 79, with moderate cognitive impairment, had a family member lodge a complaint about staff ignoring the call bell, leading to waits of up to two hours. This resident requires assistance to the bathroom and is left in urine and feces when staff do not respond. Resident 3, who is cognitively intact, reported waiting a couple of hours on weekends and 30 minutes to an hour during weekdays for assistance. Additionally, the survey team found that there was no functioning call bell in the activity room, leaving residents without a means to request help. The Nursing Home Administrator confirmed the lack of a call bell in the activity room and was unable to explain the untimely staff responses.

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 clean and orderly environment in resident areas on both the West and East Nursing Units. Observations on the West Nursing Unit revealed multiple deficiencies, including gouges and holes in the walls of resident rooms, bubbling paint, and chipped surfaces. Additionally, there were issues with cleanliness, such as a dinner tray from the previous evening left on a nightstand, dirty used gloves, food particles, and wrappers on the floor. Stains were observed on a resident's pillowcase, and urinals half-filled with urine were found on the floor. The bathroom door lock was broken, and there were spots on the privacy curtains. Other rooms had dirty urinals, dirt and debris on the floor, and chipped wood on doors. On the East Nursing Unit, a missing section of paint was observed beneath a wall-mounted hand sanitizer dispenser, and the protective edge of an over-the-bed table was removed, exposing the cork underneath. These observations were confirmed by the Nursing Home Administrator, who acknowledged that the facility is expected to be maintained daily to ensure a clean and sanitary environment for residents. The report highlights the facility's failure to uphold the residents' right to a safe, clean, comfortable, and homelike environment as required by regulations.

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 supplemental oxygen administration as ordered for a resident diagnosed with shortness of breath and chronic respiratory failure with hypoxia. The resident was admitted with physician's orders for oxygen at 2 liters per minute per nasal cannula, with specific instructions for maintaining the oxygen equipment. However, observations revealed that the resident's oxygen was consistently set at incorrect levels, either at 5 liters per minute or 3 liters per minute, contrary to the physician's orders. Additionally, the humidification water canister was not replaced as needed, remaining empty and dated from May 4, 2024, despite the requirement for regular maintenance. Further observations indicated that the resident's oxygen tank was empty on multiple occasions, and the oxygen tubing was not dated, suggesting a lack of proper equipment management. Interviews with LPNs confirmed these discrepancies, acknowledging the failure to adhere to the physician's orders and maintain the oxygen equipment as required. The Nursing Home Administrator and Director of Nursing also confirmed the facility's failure to provide oxygen administration and care consistent with professional standards of practice.

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 physician orders for pain management regimens for several residents, leading to inappropriate administration of pain medications. Resident 54, diagnosed with chronic pain disorder, rheumatoid arthritis, and progressive neuropathy, received Tramadol for pain levels lower than the prescribed range of 8-10 on multiple occasions in April and May 2024. Similarly, Resident 86, with chronic kidney disease and muscle weakness, was administered Oxycodone for pain levels below the prescribed range of 8-10 during the same period. Resident 17, who had a left ankle fracture and underwent surgery, had conflicting physician orders for pain management. The orders did not specify when to administer Acetaminophen versus Hydrocodone-Acetaminophen, leading to the administration of Hydrocodone-Acetaminophen for varying pain levels from 2 to 9. This lack of clarity in the physician orders was confirmed by the facility's administration. Additionally, Resident 190, who had a cholecystectomy tube, did not have an individualized pain management plan despite experiencing severe pain. The resident consistently reported pain levels of 8 or higher, yet the care plan did not address her pain management needs. This oversight was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.

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 procedures to ensure accurate accounting of controlled medications for three residents. For Resident 64, there were discrepancies in the administration of Oxycodone, a narcotic opioid pain medication, as doses were signed out but not recorded on the Medication Administration Record (MAR) on specific dates. Similarly, for Resident 52, doses of Oxycodone were signed out on multiple occasions, but the administration was not documented on the MAR. These inconsistencies were confirmed by the Nursing Home Administrator. For Resident 54, who had diagnoses including PTSD and anxiety, there was a failure to maintain separate controlled substance records for standing and as-needed orders of Lorazepam (Ativan). Both orders were recorded on the same controlled substance record, and the same blister pack was used, leading to an inaccurate record of medication administration. This issue was also confirmed by the Nursing Home Administrator and an LPN.

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 serve meals that are palatable, attractive, and at a safe and appetizing temperature, as determined by observations, resident and staff interviews, and test tray results. Several residents expressed dissatisfaction with the temperature and taste of the food. Resident 40 mentioned that the food is often not hot enough, while Resident 45 and Resident 79 stated that the food could taste better and is never hot when served. Resident 3 reported that the food is not served hot and does not taste good, leading them to rely on sandwiches due to the low quality of the meals. An observation of Resident 40's lunch revealed that the cream of vegetable soup appeared unappetizing, with a white semi-translucent color and lumpy consistency. A test tray conducted on the B Hall Nursing Unit showed that the hot meal items were served at temperatures below the recommended safe range, with chicken noodle soup at 125 degrees Fahrenheit, chicken parmesan at 116 degrees Fahrenheit, penne pasta at 112 degrees Fahrenheit, and Italian vegetables at 115 degrees Fahrenheit. The food was described as lukewarm and not palatable, with the Italian vegetables being soggy and soft. An interview with the registered dietitian confirmed that the food was expected to be palatable, attractive, and served at safe and appetizing temperatures, which was not achieved in this instance.

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 meals that accommodated residents' dietary preferences and restrictions, leading to dissatisfaction among several residents. Specifically, the facility did not consistently provide food items as selected by residents, nor did it adequately accommodate low-sodium dietary needs. For instance, Resident 3, who required a low-sodium diet, repeatedly received high-sodium meals and was not informed when her selected meal options were unavailable. This resident also reported significant weight gain since admission due to the lack of healthier food options. Additionally, Resident 40 frequently received meals that did not match her selections, such as receiving a ham steak instead of a meatball sandwich. The facility's dietary services were further compromised by a lack of available menu items and substitutions. During a group meeting, several residents expressed that their food preferences were not honored, citing instances where planned alternates like cheesesteak and meatball sandwiches were unavailable due to missing ingredients. The dietary manager confirmed that substitutions were often necessary due to incomplete food orders and acknowledged the absence of a substitution list to track and ensure appropriate replacements. This lack of organization and communication contributed to the residents' dissatisfaction with 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 ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the quarterly MDS Assessment for a resident dated March 12, 2024, inaccurately indicated that the resident did not receive scheduled or as-needed pain medication in the last 5 days. However, a review of the resident's March 2024 Medication Administration Record showed that the resident received physician-prescribed Acetaminophen as needed for pain 5 times in the last 5 days. Additionally, the MDS Assessment inaccurately documented the resident's orthopedic surgery history. It indicated no repair fractures of the pelvis, hip, leg, knee, or ankle, despite a nurse's note from February 14, 2024, stating that the resident had a left ankle fracture following a fall. Another note from March 5, 2024, confirmed the resident was readmitted to the facility after undergoing open reduction and internal fixation (ORIF) surgery for a fracture dislocation of the left ankle on March 1, 2024. An interview with the administrator confirmed the inaccuracies in the MDS Assessment regarding pain medication and orthopedic surgery.

Penalty

No penalty information released

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

Summary

The facility failed to revise and update the comprehensive care plans for two residents following significant changes in their medical conditions. Resident 77, who was admitted with diagnoses including malignant neoplasm of the prostate and obstructive and reflex uropathy, had an indwelling catheter care plan last revised on March 19, 2024. However, after a suprapubic catheter was placed on April 5, 2024, the facility did not update the care plan to reflect this change and the new interventions required for the suprapubic catheter. Similarly, Resident 17, admitted with COPD and diabetes mellitus, experienced a fall resulting in a left ankle fracture. After undergoing surgery for the fracture and being readmitted to the facility, the care plan, last revised on February 23, 2024, was not updated to address the potential for pain and new interventions related to the ankle fracture. Interviews with the Nursing Home Administrator confirmed the facility's failure to revise and update the care plans for both 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 accurately assess and address the bowel and bladder function of Resident 86, who was admitted with diagnoses including chronic kidney disease, unsteadiness on feet, and muscle weakness. A three-day bowel and bladder diary indicated frequent urinary incontinence, contradicting the admission assessment that noted the resident as continent. The Admission Minimum Data Set assessment later confirmed frequent incontinence of both bowel and bladder. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that the initial assessment was incorrect, and a program to manage the resident's mixed incontinence should have been initiated.

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 person-centered care for a resident receiving hemodialysis services. The resident, who was admitted with stage 4 chronic kidney disease and dependence on renal dialysis, had no documented physician's orders for dialysis treatment. The clinical records lacked information on the schedule or frequency of the dialysis treatments, which is crucial for managing the resident's condition. Additionally, the resident's care plan did not include essential details such as the dialysis days, emergency care procedures, necessary supplies for the dialysis access site, and the transportation plan to and from dialysis treatments. This oversight was confirmed during an interview with the Nursing Home Administrator, highlighting a significant gap in the care planning process for the resident's dialysis needs.

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 nursing staff possessed the necessary knowledge, competencies, and skill sets to provide care tailored to a resident's individualized needs as outlined in the resident's care plan. This deficiency was identified for one resident, who was admitted with complex medical conditions including Lennox-Gastaut Syndrome, a severe form of epilepsy. The resident's care plan included specific interventions for managing seizures, such as the use of a vagal nerve stimulator (VNS) and administration of Diazepam via a gastronomy tube, which required precise execution by the nursing staff. The report highlighted that there was no documented evidence of comprehensive staff training on the specific instructions for using the VNS device, as detailed in the resident's care plan. Interviews with various staff members, including LPNs and a Registered Nurse Supervisor, revealed inconsistencies in their understanding and training regarding the use of the VNS device. Some staff members admitted to not recalling any training or being unsure of the proper use of the device, indicating a gap in staff education and competency. Furthermore, the facility was unable to provide documentation proving that nursing staff had the necessary competencies to assess and document seizure activity accurately, as required by the resident's care plan. The lack of proper training and documentation was confirmed during interviews with the Director of Nursing and the Nursing Home Administrator, who acknowledged the deficiency in staff development and orientation to the resident's specific needs.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement an effective individualized person-centered care plan for a resident diagnosed with vascular dementia. The resident, who was admitted with severe cognitive impairment, exhibited behaviors such as exit-seeking, intrusive wandering, and agitation. Despite these behaviors being documented in progress notes from February to May 2024, the resident's care plan did not address their dementia diagnosis or include individualized interventions tailored to their preferences, social history, routines, and interests. The facility did not provide evidence of necessary care and services, including non-pharmacological approaches, meaningful activities, and environmental modifications to manage the resident's dementia-related behaviors. An interview with the Nursing Home Administrator confirmed the absence of an individualized person-centered plan to address these behaviors, indicating a deficiency in providing specialized services and supports for the resident's 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 ensure accurate medication labeling for a resident, identified as Resident 54, who was admitted with diagnoses including post-traumatic stress disorder and anxiety. The resident had two physician orders for Lorazepam (Ativan): a standing order for 0.5 mg every 12 hours and a PRN order for 0.5 mg every 24 hours, not to be given within two hours of the standing order dose. However, the controlled substance record only accounted for the standing order and did not include the PRN order, leading to both orders being recorded on the same controlled substance record. The deficiency was confirmed through a review of the medication administration record and controlled substance record, as well as interviews with a Licensed Practical Nurse and the Nursing Home Administrator. It was observed that the staff used the same blister pack for both orders, failing to maintain an accurate record of the medication administration. Additionally, there were not two separate pharmacy labels attached to the controlled substance records, and there was no blister pack with the correct pharmacy label to reflect the current active physician order.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely laboratory services for a resident, identified as Resident 39, who was admitted with a diagnosis of dementia. On May 10, 2024, a CRNP examined the resident and noted complaints of burning upon urination and increased agitation. The CRNP requested a repeat urinalysis and culture and sensitivity (U/A C&S) before starting the resident on Bactrim, an antibiotic. However, during a survey ending on May 17, 2024, it was found that there was no documented evidence that the requested laboratory tests had been completed. The Director of Nursing confirmed during an interview that the lab studies were not completed in a timely manner as ordered by the CRNP.

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 acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the kitchen, it was observed that there was a build-up of dirt and debris on the perimeter area of the kitchen floor. Additionally, a plastic crate filled with half pint containers of milk was stored directly on the floor of the walk-in freezer, and two bags of frozen vegetables on the shelf of the walk-in freezer were not dated. These unsanitary practices have the potential to introduce contaminants into food. Further observation revealed an accumulation of dust on the fins of the fan located in the dishroom. An interview with the dietary manager confirmed that the dietary department was expected to be maintained in a sanitary manner and that foods should be dated and stored properly to prevent potential contamination and foodborne illness. These findings indicate a failure to adhere to food safety and inspection standards, as outlined by the USDA, which are essential in preventing foodborne illness.