Lakewood Rehabilitation & Healthcare Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure timely acquisition and administration of a prescribed IV antibiotic and to follow its own policy for unavailable medications. Facility policy on unavailable medications, last reviewed December 8, 2025, requires nursing staff, in conjunction with the contracted pharmacy, to make every effort to ensure ordered medications are available, and upon learning a medication is unavailable, to notify the physician, obtain a new order and discontinue the prior order, or obtain a hold order. For one resident, a physician’s order for Vancomycin IV 1000 mg/200 ml every 12 hours for MRSA was initiated on March 20, 2026. An admission progress note that day documented the resident’s admission with a right foot abscess and MRSA and indicated that the physician’s orders were reviewed with no clinically significant order issues identified. A review of the medication administration record for March 2026 showed that the resident did not receive the ordered Vancomycin IV doses scheduled for 9:00 PM on March 20 and 9:00 AM on March 21. The clinical record contained no documentation that staff notified the physician that the Vancomycin IV was not available for administration. During interviews, the NHA and DON confirmed that the resident did not receive the Vancomycin IV as ordered because the medication was not available at those scheduled times and that they were unable to provide documentation of physician notification regarding the unavailability of the antibiotic. This resulted in two missed administrations of the prescribed antibiotic medication for this resident.

Penalty

Fine: $30,257

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 protect a cognitively impaired resident from sexual abuse by another resident and to follow its own abuse and sexual abuse investigation policies. Resident 1, who had dementia and a BIMS score of 7 indicating severe cognitive impairment and impaired judgment and decision-making capacity, shared a bathroom with Resident 2, who had intact cognition with a BIMS score of 14. On one evening, a nurse aide (Employee 1) observed Resident 1 in the shared bathroom unlocking and slightly opening the door to Resident 2’s room, which was described as a habitual signal that she was finished using the bathroom. Resident 2 opened his door, leaned toward Resident 1, and kissed her on the lips. Employee 1 immediately removed Resident 1 from the bathroom and notified the RN Supervisor. The facility’s investigation documented this event and noted that Resident 2 later stated, “She is my friend. Who cares if we kissed.” Following this initial incident, staff reported ongoing concerning behaviors by Resident 2 toward Resident 1. Employee 1 stated that she and another nurse aide frequently remained in Resident 1’s room to ensure her safety because Resident 2 continued to sit outside Resident 1’s room and stare at her in common areas. Facility documentation showed that the inside door to Resident 2’s side of the shared bathroom was locked and a bedside commode was provided to limit his access to the shared bathroom, and that the facility attempted to relocate Resident 2 but he declined. The Nursing Home Administrator acknowledged that Resident 1 was not relocated after the first incident due to concern that a move would increase her confusion, and Resident 1 was not offered a room change despite her cognitive impairment. Progress notes documented that Resident 2 exited Resident 1’s room after a visit with her and her family and that he later argued with staff, felt he was being watched, and could not be redirected. Social Services met with Resident 2 and documented that he reflected on past interactions with Resident 1 and was instructed not to enter her room or allow her into his room. A subsequent, more serious incident occurred when Employee 3 and Employee 4, both nurse aides, were conducting rounds after midnight and found Resident 1 missing from her bed, with her wheelchair empty and next to the bed. They found the shared bathroom door locked from the inside and, due to the known prior history between the residents, proceeded to Resident 2’s room. There, they observed Resident 1 lying naked in Resident 2’s bed while Resident 2 was touching her vaginal area, with her legs open. Employee 3 later clarified in interview that she observed Resident 2’s fingers inside Resident 1’s vagina and that she yelled for the supervisor, at which point Resident 1 went to the bathroom, dressed, and wiped herself. Both aides documented that Resident 1 complained of vaginal pain and was observed checking herself in the bathroom. The facility’s investigative documentation recorded that both residents stated they had been talking, that the facility determined there was no evidence of penetration, and that no further assessment was completed at that time. The Nursing Home Administrator stated Resident 1 was not sent to the emergency department for evaluation despite facility policy indicating the need for evaluation following suspected sexual abuse. Despite these events and the facility’s own policy defining sexual abuse as non-consensual sexual conduct and requiring investigation and protection when a resident may lack capacity to consent, the facility did not fully investigate or rule out sexual abuse and did not implement timely and effective interventions to prevent further contact between the two residents. Employee 3 reported that staff were aware of multiple prior incidents, including Resident 2 being found in the bathroom with Resident 1 on multiple occasions and an additional incident where Resident 2 was found caressing Resident 1’s breast. Employee 1 reported that even after the January 11 incident, the two residents were still found unattended together multiple times, and at the time of her interview, they were alone together in the chapel, which the surveyor confirmed. Resident 2 acknowledged spending time alone with Resident 1 and described her as infatuated, while recognizing her dementia diagnosis. Resident 1’s care plan did not include 15-minute safety checks until days after the sexual abuse incident, and the safety check documentation for both residents was incomplete or delayed, with later-added entries and signatures that conflicted with the original records. The Director of Nursing could not explain why incomplete safety check records were later supplemented. Staff reported observable changes in Resident 1’s behavior after the incident, including staying awake later than usual and appearing fearful when using the bathroom, frequently looking toward the doorway previously used by Resident 2. These failures led surveyors to determine that the facility did not ensure Resident 1 was free from sexual abuse by Resident 2 and did not follow its abuse policies, resulting in Immediate Jeopardy to residents’ health and safety.

Removal Plan

• Provide staff education on facility abuse policies, including allegations of sexual abuse.
• Provide education to nurse aides and licensed nurses on documenting resident behaviors.
• Monitor documentation of resident behaviors and update resident care plans as needed.
• Continue education prior to each licensed staff member’s next shift.
• Immediately place the perpetrator and victim on 1:1 supervision in the event of sexual abuse.

Penalty

Fine: $30,257

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 accurately and completely report and document an alleged incident of sexual abuse to the State Survey Agency and the Area Agency on Aging, as required by its own abuse policies. The facility’s Abuse Protection policy required reporting occurrences of abuse, neglect, misappropriation, and suspicions of a crime to the State Survey Agency, Department of Aging, and local law enforcement, and specified that events involving serious bodily injury, including sexual abuse, must be reported within two hours of forming the suspicion. A related policy on Identifying Sexual Abuse and Capacity to Consent required immediate protective measures, immediate reporting to appropriate authorities, a thorough investigation including assessment of capacity to consent, and thorough documentation and reporting of the investigation results. These policies formed the basis for the expectations the facility did not meet. Resident 1, who had dementia and a BIMS score of 7 indicating severe cognitive impairment, and Resident 2, who had a cerebral infarction and a BIMS score of 14 indicating intact cognition, were involved in the incident. According to the facility’s abuse investigation report, a nurse aide (Employee 3) observed Resident 1 on Resident 2’s bed at approximately 1:15 AM, with Resident 2 seated in his wheelchair at the bedside and Resident 1 unclothed. The facility’s report stated that both residents indicated they were talking and concluded there was no evidence of penetration. However, written witness statements from Employee 3 and Employee 4 documented additional details that were not reflected in the facility’s report, including that Resident 1 had been last seen in her own chair around 12:50 AM, was later found unclothed in Resident 2’s bed, and that Resident 2 was observed touching Resident 1’s vaginal area while her legs were open. The witness statements further documented that after the incident Resident 1 complained of vaginal pain or discomfort and was observed checking herself in the bathroom. Despite these eyewitness accounts, the information submitted by the facility to the State Survey Agency and the Area Agency on Aging did not identify that staff directly observed Resident 2 touching Resident 1’s vaginal area and did not report Resident 1’s complaint of vaginal pain immediately following the incident. Instead, the facility reported that Resident 1 exhibited no signs or symptoms of distress, which was inconsistent with the written statements of Employees 3 and 4. During interviews, the Nursing Home Administrator acknowledged that the facility did not report all observed findings because both residents stated they were just talking, and it was confirmed that the facility did not follow its established abuse policy and procedures for reporting abuse or factually report all relevant information obtained during the investigation.

Penalty

Fine: $30,257

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

Summary

Facility administration failed to effectively use its resources to promote resident safety and maintain residents’ highest practicable physical and mental well-being, resulting in a resident being subjected to sexual abuse by another resident. The Nursing Home Administrator’s job description required fostering a safe environment, providing emotional and psychological support, overseeing day-to-day operations to ensure quality care in accordance with state and federal standards, and implementing and enforcing company policies and procedures. The DON’s job description required assuring resident safety through nursing staff, evaluating the effects of care delivered, assigning special treatments when indicated, and reviewing and revising care plans and assessments as necessary. However, review of facility documentation and staff interviews showed that administrative oversight did not ensure effective coordination, monitoring, and implementation of systems designed to protect residents from abuse. The facility did not identify, mitigate, or manage known and foreseeable risks associated with resident interactions, particularly among residents with cognitive impairment, which limited their ability to understand, process, or make safe decisions. This failure in administrative oversight, including failure to ensure appropriate supervision, consistent implementation of resident safety and abuse prevention policies, and timely administrative intervention when safety risks were present, allowed one resident to sexually abuse another. The deficient practice was directly related to an Immediate Jeopardy citation under F600 (Freedom from Abuse, 42 CFR §483.12), with leadership’s lack of effective oversight, monitoring, and enforcement of policies contributing to the Immediate Jeopardy situation.

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

Facility staff failed to protect and maintain personal privacy and dignity when a nurse aide used a personal cell phone to record video footage of a resident receiving incontinence care without consent. The recording was made through a window where the blinds had not been lowered, and neither the resident nor the staff member providing care were aware of the recording. Facility policies reviewed indicated that staff are prohibited from taking or releasing images or recordings of any resident without explicit written consent, and that resident privacy must be maintained during personal care. The resident involved had diagnoses including dementia and cerebral infarction, with severe cognitive impairment documented on a recent assessment. The resident required assistance with toileting and incontinence care due to impaired mobility and physical limitations. The incident occurred when two nurse aides positioned themselves across the facility courtyard and recorded the resident during care, in violation of facility policies and without any form of consent.

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 two corridor doors, specifically those to Resident Room 217 and Resident Room 223, were not functioning as required. During an inspection, it was found that these doors were getting stuck in their frames, which prevented them from fully latching. This issue was directly observed between 10:56 am and 10:57 am on June 30, 2025. At the exit conference, both the Administrator and the Director of Maintenance confirmed that the doors failed to positively latch into their frames. The deficiency was limited to these two doors within one of six smoke compartments in the facility. No additional information about the residents in these rooms or their medical conditions was provided in the report.

Plan Of Correction

Maintenance has repaired the doors to rooms 217 and 223 to ensure that they latch appropriately. NHA to re-educate facility Maintenance Director on proper latching of corridor doors. A full house audit completed by maintenance to ensure that corridor doors were not getting stuck in their corresponding frames to prevent them from fully latching. Maintenance will conduct weekly audits x 4 weeks and monthly audits x 2 months to ensure doors latch appropriately. Audits to be submitted to QAPI for review and recommendations.

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 four out of twelve required fire drills on a random basis, as evidenced by documentation review and staff interviews. Specifically, observations showed that all first shift fire drills over the past twelve months were performed within the same hour each time (between 9:08 am and 10:03 am), rather than at varying times as required. During the exit conference, both the Administrator and Director of Maintenance confirmed that the fire drills were not performed randomly.

Plan Of Correction

A fire drill has been conducted for the first shift at 11:15 AM. Administrator to re-educate Maintenance Director on fire drills being held at random. Maintenance Director will continue to perform monthly fire drills on a random basis. NHA/designee will conduct audits weekly for 4 weeks and monthly for 2 months to ensure fire drills are being held randomly each month. Audits to be submitted to QAPI for review and recommendations.

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 invited to participate in the development and implementation of their person-centered care plans, as required by both facility policy and regulatory standards. Specifically, for three residents reviewed, there was no documented evidence that care plan conferences were conducted with the required interdisciplinary team (IDT) members, nor that the residents or their representatives were invited to participate in the care planning process. The facility's policy mandates that the IDT, including nursing, social services, activities, and other relevant staff, involve the resident and/or their representative in care plan meetings, and document if participation is not practicable. For one resident with a history of respiratory failure and Parkinson's disease, who was cognitively intact, there was no documentation of a care plan meeting or invitation to participate following both admission and quarterly MDS assessments. Although a meeting was documented between the resident and the social worker, there was no evidence that other required IDT members were present, nor that the comprehensive care plan was reviewed by the full team. The resident confirmed not being invited to participate in any care plan meetings and expressed interest in doing so. Two additional residents, one with spinal cord compression and another with hereditary ataxia, were also found to be cognitively intact or only moderately impaired, yet neither had documentation of care plan conferences or invitations to participate in the care planning process. Both residents confirmed in interviews that they had not been invited to participate in care plan meetings since admission. The Nursing Home Administrator was unable to provide documentation to show that care plan conferences had been held or that the residents or their responsible parties had been invited to participate, as required.

Penalty

No penalty information released

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

Summary

The facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for three residents. For one resident with dementia, Xanax was not administered as ordered on multiple occasions due to the medication being unavailable; documentation showed delays in obtaining a new prescription and in communication with the pharmacy and physician. Another resident with atrial fibrillation and diabetes did not receive a prescribed dose of Macrobid because the medication was unavailable from the pharmacy, and the facility could not provide a reason for the unavailability. A third resident with unspecified dementia did not receive a scheduled dose of Oxycodone due to the need for a new prescription and unsuccessful attempts to obtain a release code from the pharmacy. Facility policy required nurses to check the Med Cubex inventory, contact the pharmacy for medication status, and notify the physician if a new order was needed. However, interviews with the DON and clinical nurse consultant confirmed that procedures were not adequately followed to ensure timely medication acquisition and administration. Documentation in the medication administration records and nursing notes consistently indicated medication unavailability and delays in obtaining necessary prescriptions or pharmacy codes, resulting in missed doses for the affected 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 ensure that fresh drinking water was consistently accessible to residents in accordance with their needs and preferences. According to facility policy, residents are to receive a fresh supply of drinking water, with new cups provided daily and refills occurring each shift and as needed. However, interviews with five alert and oriented residents revealed that fresh ice water was only reliably provided during the overnight shift, and not during the day or evening shifts unless specifically requested by the resident. Residents reported that water provided overnight would become room temperature by the time they awoke, and that staff did not routinely refill water during the day unless asked. The Nursing Home Administrator confirmed that the facility's protocol was not being followed, as fresh ice water was not consistently made available to residents during all shifts. This deficiency was identified for five residents, all of whom expressed a preference for cold, fresh water and reported discomfort or dissatisfaction with the current water service practices. The findings were based on resident and staff interviews, as well as a review of 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 a resident's right to communication with and access to persons and services outside the facility. The resident, who was moderately cognitively impaired with a diagnosis of hereditary ataxia and muscle weakness, had a scheduled telephone hearing with an Administrative Law Judge regarding a fair hearing appeal. Documentation showed that the resident's attendance at the hearing was confirmed by a staff member, who signed and returned the required acknowledgement card. However, the staff member responsible for this process resigned abruptly prior to the hearing and did not inform other facility staff about the scheduled event. As a result, the resident was not made available for the hearing, and no valid reason for the absence was provided. Consequently, the resident's appeal was dismissed due to non-attendance. The Nursing Home Administrator confirmed that the facility did not ensure the resident had access to the scheduled external service.

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 the Minimum Data Set (MDS) assessment for one resident. A review of the resident's clinical record showed an admission with a diagnosis of dementia. The quarterly MDS assessment indicated that a limb restraint was used less than daily, as documented in Section P0100. However, a review of the physician's orders did not reveal any orders for a physical restraint for this resident. Furthermore, the Regional Nurse Consultant confirmed in an interview that the resident had never had any type of physical restraint while residing in 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

Facility staff failed to consistently implement fall prevention interventions as outlined in the comprehensive care plan for one resident. The resident, who was admitted with diagnoses including liver cancer and major depressive disorder, was identified as being at high risk for falls following a documented fall and a subsequent fall risk evaluation. The care plan specified the use of a bolster on the right side of the bed and a beveled fall mat on the left side of the bed as preventative measures. During an observation, it was noted that neither the bolster nor the fall mat were in place as required by the care plan. This absence was confirmed by an LPN and acknowledged by the Nursing Home Administrator, who confirmed that staff had not consistently followed the care plan interventions for fall safety for this resident. The deficiency was cited under 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

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 nursing staff failed to ensure that medication orders were accurately transcribed and administered according to professional standards. A resident with a history of rectal and lung cancer and atrial fibrillation was admitted and later readmitted to the facility. Upon the resident's discharge to the hospital, an order for apixaban 5 mg twice daily was not discontinued, and the medication remained accessible in the medication cart. When the resident was readmitted, new orders for apixaban 2.5 mg twice daily were transcribed, but the previous 5 mg order was still active on the medication administration record (MAR). On the day of readmission, an agency LPN administered both the 5 mg and 2.5 mg doses of apixaban, resulting in a total dose of 7.5 mg, which exceeded the prescribed amount and constituted a medication error. The facility's medication error report confirmed that the previous order had not been discontinued and that the medication was still available in the cart. Additionally, the report noted that no employee witness statements were obtained at the time of the incident. The Director of Nursing acknowledged that professional nursing standards were not followed, leading to the medication error.

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 consistently provide restorative nursing services as planned for a resident with Alzheimer's disease and generalized muscle weakness. The resident, who was severely cognitively impaired and required substantial to maximal assistance for ambulation, had completed a course of physical therapy. At discharge, physical therapy recommended a Restorative Nursing Program (RNP) to maintain the resident's current level of mobility, specifically ambulation of 150 feet with a front-wheeled walker and the assistance of one person. These recommendations were intended to prevent decline and maintain functional abilities. Despite these recommendations, there was no documented evidence that the RNP for ambulation was incorporated into the resident's care plan or implemented. Reviews of the electronic task report and documentation for the relevant months showed no record of the restorative ambulation program being carried out. Additionally, there was no indication that licensed staff were aware that the program was not being implemented as planned. The Assistant Director of Nursing confirmed that the facility did not consistently implement the restorative nursing program as recommended by physical therapy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that oxygen therapy was administered according to the physician's orders for one resident. The facility's Oxygen Administration Policy requires verification of a physician's order and documentation of the oxygen flow rate, route, and rationale. A review of the clinical record showed that the resident was admitted with respiratory failure and had a physician's order for oxygen at 4 liters per minute via nasal cannula for COPD. However, observations on two separate days revealed that the resident was receiving oxygen at 3 liters per minute instead of the prescribed 4 liters per minute. An LPN confirmed during observation that the oxygen flow was set at 3 liters per minute, not the ordered 4 liters. The Corporate Regional Nurse also confirmed that it is the facility's responsibility to ensure oxygen therapy is administered as prescribed.

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 pneumococcal and influenza immunizations were properly offered and/or provided to a resident, as required by facility policy and state regulations. Specifically, for one resident with a diagnosis including multiple sclerosis, the clinical record contained informed consent forms for both pneumococcal and influenza vaccines that did not indicate whether the resident accepted or declined the vaccines. There was no documentation to show that the facility identified these incomplete forms or made further attempts to determine the resident's immunization preferences. Additionally, there was no evidence in the clinical record that the vaccines were administered, declined, previously received, or medically contraindicated for this resident. The regional nurse consultant confirmed that the facility did not offer or provide the required vaccinations in accordance with established policies. This deficiency was identified through a review of facility policies, clinical records, 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

A resident with paraplegia was discharged from the facility to home, with the discharge plan indicating that written prescriptions for physician-ordered medications would be provided to the resident or their representative. The Discharge Summary and Plan Policy required that a discharge summary and post-discharge plan be developed, including a complete list of medications and arrangements for follow-up care. Documentation in the clinical record stated that discharge instructions were reviewed and medications were sent with the resident at the time of discharge. However, a follow-up discharge call revealed that the resident did not receive the necessary prescriptions for their medications. Further, an email from the home health agency confirmed that the resident was not discharged with an adequate supply of medication to last until the scheduled follow-up appointment. There was no documented evidence that the facility addressed the issue after being made aware that the resident had not received prescriptions at discharge. Facility leadership confirmed that the Discharge Summary incorrectly indicated prescriptions were provided and acknowledged that 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

A resident with spinal cord compression, muscle weakness, and a need for assistance with personal care was admitted to the facility and required substantial to maximal staff assistance for showering and bathing, as documented in the Minimum Data Set Assessment. The resident was cognitively intact and had scheduled shower days on Tuesdays and Saturdays, as indicated in the electronic Kardex. Despite this, the resident reported that staff were not consistent in providing showers on the scheduled days, citing instances where she missed showers due to being gotten up late by staff or because staff did not return to offer a shower after her therapy or family visit. The resident also stated that staff marked her as refusing showers when she had not refused, but rather was unable to receive them due to scheduling conflicts caused by staff actions. A review of the resident's shower logs for April and May revealed that she did not receive any showers during April and missed several scheduled showers in May, with bed baths documented instead. There was no documentation indicating that the resident refused showers or requested bed baths in lieu of showers. Additionally, there was no explanation documented for the omission of scheduled showers. The Nursing Home Administrator confirmed the resident's shower schedule and acknowledged that showers should have been provided as planned but could not explain the inconsistency in care.

Penalty

No penalty information released

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

Summary

Lakewood Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations due to its failure to conduct a thorough investigation into allegations of potential resident-to-resident abuse. The incident involved Resident CR1, who was observed masturbating in the doorway of his room, which was directly across from Resident 2's room. Despite being redirected by staff, Resident CR1 continued the behavior for a few minutes, visible to staff and other residents. The facility's policy mandates a comprehensive investigation into such incidents, but there was no documented evidence that this was done. Resident 2, who was potentially affected by the incident, was admitted to the facility with severe cognitive impairment, as indicated by a BIMS score of 00. This score reflects significant cognitive challenges, making it difficult for Resident 2 to describe or react to the incident. Resident CR1, on the other hand, was cognitively intact with a BIMS score of 13 and had a history of inappropriate sexual behavior, including a past conviction for a sexual offense. Despite these factors, the facility did not conduct a thorough investigation into the incident involving Resident CR1's behavior. Interviews with facility staff revealed that the social services director was unaware of any other residents involved in the incident, and the LPN who witnessed the event was not asked for further information. The Nursing Home Administrator confirmed the lack of a documented investigation, acknowledging the facility's responsibility to protect residents from abuse. The failure to investigate the incident thoroughly was a significant oversight, given the nature of the behavior and the potential impact on Resident 2.

Plan Of Correction

1. Resident CR1 has discharged from the facility. 2. Current residents have been interviewed. No residents report any knowledge of Resident CR1 behavior, sexual gratification, on the identified date. No residents or staff report an allegation of abuse related to resident R #1 behavior, on the identified date. 3. Facility staff will be re-educated by the NHA and or designee to the facility policy for abuse reporting and investigation to rule out potential resident abuse. 4. The Inter Disciplinary Team will audit resident progress notes, daily as part of the facility Clinical meeting process, to identify any instances of resident behavior requiring initiation of abuse reporting and investigation. If an allegation of abuse is identified, NHA and DON will follow abuse investigation policy. All abuse investigations will be submitted to and reviewed by the facility QAPI Committee.

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 staffing ratios on three out of 21 shifts reviewed. Specifically, on March 27, 29, and 30, 2025, the night shift staffing levels were below the mandated minimum of 1 nurse aide per 15 residents. On March 27, there were 5.63 nurse aides instead of the required 6.47 for a census of 97 residents. On March 29, there were 5.00 nurse aides instead of the required 6.20 for a census of 93 residents. On March 30, there were 3.63 nurse aides instead of the required 6.13 for a census of 92 residents. No additional higher-level staff were available to compensate for this deficiency. An interview with the Nursing Home Administrator on April 2, 2025, confirmed the facility's failure to consistently provide the minimum nurse aide staffing hours required for each resident during the specified shifts.

Plan Of Correction

1. The facility cannot retroactively correct nurse aide staffing ratio. 2. NHA/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. NHA/designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. NHA/designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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 nursing care per resident per day. This deficiency was identified during a review of the facility's weekly staffing records, which showed that on two specific days, March 28 and March 30, 2025, the facility provided only 3.14 and 3.02 hours of direct care nursing per resident, respectively. This shortfall in nursing hours was confirmed during an interview with the Nursing Home Administrator on April 2, 2025, indicating a failure to consistently meet the mandated staffing levels for resident care.

Plan Of Correction

1. The facility cannot retroactively correct staffing PPD. 2. NHA/designee will conduct an initial audit of the past two weeks scheduled to determine if PPD are in compliance. 3. NHA/designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. NHA/designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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

Lakewood Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding pharmacy services. The facility failed to provide timely pharmaceutical services to meet the needs of two residents. Resident 1, who was admitted with a prescription for oxycodone-acetaminophen for severe pain, experienced delays in receiving the medication upon admission. The facility cited pharmacy delivery issues as the reason for the delay, and there was no documented evidence explaining why the medication was not administered despite the availability of an emergency supply. Additionally, there were discrepancies in the accounting of narcotic medications for Resident 1, with tablets signed out by nursing staff but not documented as administered. Resident 2, admitted with prescriptions for Effexor and other medications, also faced delays in receiving prescribed medications. Effexor was not ordered until several days after admission, and there was no documentation explaining the delay. Furthermore, Resident 2's nighttime medications were not administered as scheduled on the day of admission, with no explanation provided for the omission. Both residents reported experiencing delays in receiving their medications, which the facility confirmed during interviews. The facility's failure to ensure timely acquisition and administration of medications, as well as proper accounting of controlled substances, resulted in non-compliance with pharmacy service regulations. The Nursing Home Administrator and Corporate Nurse Consultant acknowledged the deficiencies, confirming the facility's responsibility to meet residents' pharmaceutical needs.

Plan Of Correction

1. Resident R 1 discharged from the facility to home on 2/08/25. Resident R 2 discharged from the facility to home on 2/08/25. 2. Current residents admitted to the facility in the past 7 days have been reviewed to ensure that hospital discharge medications are transcribed as ordered and available for administration. Current residents with physician orders for narcotic medications have been reviewed to ensure narcotic count sheets are in place and accurate for medication administration. 3. Licensed nurses will be reeducated by the DON and or designee to correct transcription of admission medications and scheduling to ensure medication availability. Licensed nurses will be reeducated by the DON and or designee to the facility process for narcotic administration including the documentation for accounting of narcotic medications. 4. Audits will be completed twice weekly by the Clinical administrative team, x 2 weeks, then monthly x 2 months, to ensure new resident medications are available for administration, per physician orders. Audits will be completed twice weekly by the Clinical administrative team, x 2 weeks, then monthly x 2 months, to ensure narcotic medications administered are being accurately documented per the facility process for narcotic medication administration records. Trends will be reviewed by the QAPI committee for further follow-up as needed.

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

Lakewood Rehabilitation and Healthcare Center failed to ensure adequate supervision and safety measures for a resident identified as a wandering risk, leading to the resident's elopement. The resident, who had been admitted with Parkinson's disease and schizoaffective disorder, was known to exhibit exit-seeking behaviors and had a severe cognitive impairment with a BIMS score of 6. Despite these known risks, the facility did not effectively monitor or prevent the resident from leaving the premises unsupervised. On the night of the incident, the resident was last seen by staff at 9 P.M. and was reported missing at 1:45 A.M. The RN supervisor on duty, who was unfamiliar with the residents and the facility's wandering identification process, mistakenly allowed the resident to exit the building, believing the resident was a visitor. This lack of awareness and failure to confirm the resident's identity contributed to the resident's unsupervised departure. The resident was found 0.5 miles away at a car wash, exhibiting signs of hypothermia and injuries consistent with a fall. The facility's failure to promptly identify the resident's absence and implement effective supervisory measures placed the resident in immediate jeopardy, resulting in potential harm and necessitating emergency medical intervention.

Plan Of Correction

1. Resident # 1 no longer resides in the facility. 2. Current residents have been evaluated for exit seeking/elopement risk. Those residents identified as at risk for exit seeking and or elopement have had safety measures/interventions updated in their plan of care. 3. Facility staff have been re-educated by the NHA and or Designee to the facility processes for Elopement management and Prevention and the Visitation- Visitor Badge Process. Random audits will be completed by the NHA and or designee, weekly x 2 then monthly x 2, on residents at risk for exit seeking and or elopement. Random audits will be completed by the NHA and or designee, weekly x 2 weeks then monthly x 2, to ensure staff knowledge is maintained on the facility processes for Elopement management and Prevention and the Visitor Badge Process. Trends will be reviewed by the QAPI Committee for further follow-up as needed.

Removal Plan

• The resident was discharged from the facility from the hospital emergency room and admitted to a facility with a locked dementia unit.
• All residents were assessed for elopement/wandering.
• Staff education was completed regarding elopement/wandering/resident safety.
• The facility visitation policy reviewed and revised.
• Audits were completed to ensure that no other residents in the facility are affected.
• Implemented a process of the RN supervisor will verify that all residents are accounted for at the beginning of each shift by physically performing walking rounds in the facility each shift.
• RN Supervisor will validate that nurse aides understand assignments/assigned residents. Education to Nursing staff regarding staff assignments was completed.
• Facility completed staff education regarding elopement/wandering and visitation. Education regarding staffing, staff assignments and staffing responsibility was initiated for the 7 A.M. to 3 P.M. and 3 P.M. to 11 P.M. shifts. The 11pm-7am shift will be educated when they arrive before their scheduled shift. All nonscheduled staff will be educated prior to their next scheduled shift, and no staff will be permitted to work until they have received the education.
• Facility QAPI committee convened to review the initial interventions and start this plan. The QAPI committee to meet to complete the 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's administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental functioning of its residents. This was evidenced by the elopement of one resident, which placed eight residents identified as at risk for elopement in immediate jeopardy. The administration did not provide necessary supervision and effective safety measures to monitor the resident's whereabouts, leading to the elopement incident. The review of the administrator's job description highlighted a lack of effective oversight and failure to address identified elopement risks for at-risk residents. The Director of Nursing Services (DON) also failed to provide adequate monitoring or implement effective interventions to prevent the resident's elopement. There was insufficient coordination of staff to ensure the safety of other residents at risk for elopement. The facility's inability to implement and enforce policies to monitor the resident and address elopement risks resulted in immediate jeopardy to the health and safety of the residents. This demonstrated a systemic failure in the administration's oversight and resource allocation to ensure a safe environment for residents.

Plan Of Correction

1. Resident #1 no longer resides in the facility. 2. Current residents have been evaluated for exit seeking/elopement risk. Those residents identified as at risk for exit seeking and or elopement have had safety measures/interventions updated in their plan of care, per IDT review of the resident's individual behaviors, patterns, and routines. Residents who have been identified as at risk for exit seeking and or elopement have been entered into the facility resident exit seeking/elopement identification binder; present at the front desk, nurses stations, and dietary department; with current photo and profile, updated. 3. The NHA and DON have been reeducated by the Regional Director of Clinical Services, RN, to the facility processes for resident safety monitoring; elopement management; includes the exit seeking/elopement identification binder and Prevention and Visitation-Visitor Badge Process. Facility staff have been reeducated by the NHA and or designee to the facility processes for Elopement management; includes the exit seeking/elopement identification binder and Prevention and Visitation-Visitor Badge Process. New staff hired will be educated to the facility processes for resident safety monitoring; elopement management and Prevention and Visitation-Visitor Badge process by the NHA and or Designee prior to working in the facility as well as directed in-service for staff. 4. The NHA and or DON has audited the facilities compliance with resident safety monitoring; elopement management and Visitation Process-Visitor Identification Badge system with no further incidence of resident incident; occurring. The NHA and or DON will review new hired staff education, prior to working in the facility, to ensure resident safety monitoring; elopement management and Prevention and Visitation-Visitor Badge process has been completed. The NHA and or DON will monitor that the Exit Seeking/elopement binder has been updated, daily, for any residents identified as exit seeking/elopement risk. Trends will be reviewed by the QAPI Committee for further follow-up as needed.

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

Lakewood Rehabilitation and Healthcare Center failed to provide timely and appropriate care to a resident who experienced a significant change in condition. The resident, admitted with diagnoses including muscle weakness and hypertension, showed signs of acute kidney injury and metabolic abnormalities, as evidenced by laboratory results and vital signs. Despite these indicators, the facility did not conduct timely monitoring or escalate care appropriately. The resident's condition deteriorated, with symptoms such as lethargy, diaphoresis, and poor oral intake, yet there was no documented escalation of care or transfer to a hospital. On January 5, 2025, the resident's vital signs indicated a concerning change, including low blood pressure and elevated heart rate, but no interventions were documented at that time. The following day, intravenous fluids were initiated, but the resident's condition continued to decline. By January 7, 2025, the resident was found unresponsive and later pronounced deceased after CPR was attempted. Interviews confirmed the facility was aware of the resident's condition change but failed to provide necessary interventions or hospital transfer, resulting in a missed opportunity to address the resident's acute medical needs.

Plan Of Correction

1. Resident R1 no longer resides in the facility. 2. Current residents identified as having a change in condition in the past 7 days have had their records reviewed to ensure timely interventions have been initiated as applicable. 3. The DON/Designee will reeducate licensed nurses to the facility Change in Resident Condition or Status policy. 4. The DON/Designee will audit random audit progress notes weekly x 4 weeks, then monthly x 2 months to ensure resident changes in condition have applicable interventions or transfer to higher level of care. Audits will be presented to the QA Committee for review and follow-up as needed.

Penalty

Fine: $59,400

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

Lakewood Rehabilitation and Healthcare Center was found to be non-compliant with the requirements of 42 CFR Part 483 Subpart B, specifically regarding notice requirements before transfer or discharge. The facility failed to provide a written notice for a facility-initiated transfer to the hospital for one resident. This notice should have included the reason for the transfer in a language and manner easily understood by the resident and their representative. The deficiency was identified during a survey conducted on December 30, 2024, which reviewed clinical records and included staff interviews. The specific incident involved a resident who was transferred to the hospital on December 29, 2024, due to a change in mental status. The clinical record indicated that the transfer was initiated by the facility, but there was no evidence of a written notice being provided to the resident or their representative. This lack of documentation and communication was a key factor in the facility's failure to meet the regulatory requirements for notice before transfer or discharge.

Plan Of Correction

1. The facility has provided Resident 2/resident representative with the facility transfer notice via certified mail. 2. The facility has reviewed resident's transfers and discharges for the past 14 days to ensure the notice of transfer has been provided. 3. DON/designee will re-educate licensed nursing staff to the facility process of notifying residents/resident representatives on facility transfers. 4. DON/designee will audit random resident transfers and discharges to ensure a written notice and the reason for transfer has been provided. Audits to be completed weekly for four weeks and monthly for two months. Audits to be submitted to QAPI for review and recommendations.

Penalty

Fine: $59,400

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 the required written notice of the bed-hold policy to a resident or their representative upon the resident's transfer to the hospital. This deficiency was identified during an interview with the Nursing Home Administrator (NHA) and a review of clinical records, the facility's bed-hold policy, and interviews with staff and family. The resident, who was cognitively intact with a BIMS score of 15 and had a diagnosed intellectual disability, was transferred to the hospital. Despite the facility's standard practice of sending a copy of the bed-hold policy with the resident during transfers, there was no documented evidence that this was done in this instance. The Business Office Manager (BOM) stated that she provides written bed-hold notifications during business hours, and nursing staff is responsible for this task when she is unavailable. However, no documentation confirmed that this process was completed for the resident in question. The NHA confirmed the failure to provide the required written notice, which deprived the resident and their representative of critical information regarding the bed-hold policy, including the duration and reserve bed payment policy. This oversight potentially compromised the resident's rights and ability to plan for continuity of care.

Plan Of Correction

1. The facility has provided Resident 2/resident representative with the facility bed hold policy via certified mail. 2. The facility has reviewed resident's transfers and discharges for the past 14 days to ensure the bed hold policy has been provided. 3. DON/designee will re-educate licensed nursing staff to the facility process of notifying residents/resident representatives on facility bed hold policy. 4. DON/designee will audit random resident transfers and discharges to ensure the bed hold policy was provided. Audits to be completed weekly for four weeks and monthly for two months. Audits to be submitted to QAPI for review and recommendations.

Penalty

Fine: $59,400

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 completion of prescribed laboratory services for a resident, which resulted in a delay in monitoring and managing the resident's elevated potassium levels. The resident, who was admitted with diagnoses including diabetes, heart failure, and morbid obesity, had consistently elevated potassium levels documented over several days. Despite new orders being written for medication to treat hyperkalemia and a repeat Basic Metabolic Panel (BMP) to be conducted, the facility did not collect the BMP as prescribed. During an interview, the corporate nurse confirmed that the BMP lab test was not drawn and could not explain why the nursing staff did not follow up or notify the prescribing practitioner about the missed test. There was no documented evidence of attempts to reobtain the BMP or notify the practitioner of the failure to complete the ordered diagnostic testing. This inaction posed significant risks to the resident's health, as timely monitoring and addressing of elevated potassium levels are crucial.

Plan Of Correction

1. Physician was immediately notified on 12/30/24 of the ordered lab not being drawn as ordered on 11/22/24. NOR for CMP to be drawn on 12/31/24. Same completed. 2. Current residents with ordered labs have been reviewed to ensure labs have been obtained per physician order and completed. 3. DON/designee will re-educate licensed nursing staff were immediately to facility process for requisitioning of physician ordered labs. 4. DON/designee will perform random audits to ensure lab protocols are being followed and reviewed in a timely matter. Audits to be conducted weekly for four weeks and monthly for two months. Audits to be completed and submitted to QAPI for review and recommendations.

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 eight out of 21 shifts reviewed. Specifically, on December 23, 24, 25, 26, and 27, 2024, the facility did not provide the minimum number of nurse aides needed for the evening and night shifts based on the census. For instance, on December 23, 2024, there were only 8.33 nurse aides on the evening shift when 9 were required for a census of 99. Similarly, on December 24, 2024, the night shift had only 5.03 nurse aides instead of the required 6.67 for a census of 100. The deficiency was confirmed during an interview with the Nursing Home Administrator on December 30, 2024, who acknowledged the shortfall in meeting the required staffing ratios. No additional higher-level staff were available to compensate for this deficiency on the mentioned dates.

Plan Of Correction

1. The facility cannot retroactively correct nurse aide staffing ratio. 2. DON/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. DON/designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. DON/designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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 six out of 21 shifts reviewed. Specifically, on December 22, 2024, the day shift had 3.22 LPNs instead of the required 4 for a census of 100 residents, the evening shift had 2.72 LPNs instead of 3.33, and the night shift had 2.03 LPNs instead of 2.5. On December 25, 2024, the day shift had 3.66 LPNs instead of 4 for a census of 100. On December 27, 2024, the night shift had 2.19 LPNs instead of 2.45 for a census of 98. On December 28, 2024, the evening shift had 2.97 LPNs instead of 3.20 for a census of 96. No additional higher-level staff were available to compensate for this deficiency. The Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.

Plan Of Correction

1. The facility cannot retroactively correct LPN staffing ratio. 2. DON/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. DON/designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. DON/designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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 consistently meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. On December 22, 2024, the facility provided 3.07 hours, on December 24, 2024, 3.13 hours, and on December 25, 2024, only 2.69 hours of direct care per resident. These staffing levels were below the mandated minimum requirement. An interview with the Nursing Home Administrator on December 30, 2024, confirmed the facility's failure to provide the required minimum general nursing care hours to each resident daily.

Plan Of Correction

1. The facility cannot retroactively correct staffing PPD. 2. DON/designee will conduct an initial audit of the past two weeks scheduled to determine if PPD are in compliance. 3. DON/designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. DON/designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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 timely and effective safety interventions and necessary staff supervision for a resident with known unsafe behaviors, resulting in multiple falls and a major injury. Resident 91, who was admitted with dementia and mobility issues, was identified as being at high risk for falls. Despite being severely cognitively impaired and requiring substantial assistance, the facility did not consistently provide the ordered 1:1 supervision. This lack of supervision led to several incidents where the resident attempted to self-transfer and fell, ultimately resulting in a hip fracture. The facility's documentation revealed that Resident 91 exhibited exit-seeking behaviors and was difficult to redirect, necessitating close supervision. However, the facility failed to maintain the required level of supervision, as evidenced by multiple falls, including a significant fall that resulted in a hip fracture. The facility did not provide documented evidence that the physician-ordered 1:1 supervision was consistently implemented, contributing to the resident's repeated falls and eventual major injury. Similarly, Resident 33, also severely cognitively impaired and at risk for falls, experienced multiple unwitnessed falls. The facility's interventions, such as bed and chair alarms, were ineffective in preventing these falls. The facility did not adjust its interventions to address the root causes of the falls or increase staff supervision, leading to repeated incidents. The Director of Nursing confirmed the inadequacy of the facility's interventions and supervision in preventing falls for Resident 33.

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 pain management interventions for a resident, identified as Resident 260, who was admitted with significant medical conditions including aftercare following digestive tract surgery and pressure injuries. The facility's policy on pain management emphasizes a multidisciplinary approach, including regular assessment and treatment of pain. However, the facility did not adhere to this policy, as evidenced by multiple instances where Resident 260's pain was not adequately assessed or managed. Resident 260 experienced various levels of pain, ranging from mild to severe, due to pressure ulcers and other conditions. Despite having physician orders for pain medications such as Ultram and Norco, there were several documented instances where the resident did not receive any pharmacological or non-pharmacological interventions to manage her pain. For example, on August 22, 2024, the resident was noted to be very agitated and yelling, yet there was no documentation linking this behavior to pain or any subsequent intervention. Similarly, on August 26 and 27, 2024, the resident's pain was not managed effectively, with reports of severe pain and family complaints about the lack of pain relief. Interviews with staff and family members further highlighted the facility's failure to provide timely pain management. The resident's husband expressed frustration over the lack of pain relief, and staff interviews revealed issues with obtaining prescribed medications from the pharmacy. The Corporate Nurse Consultant and Corporate Administrator were unable to provide explanations or documentation for the lack of interventions during critical periods when the resident was in severe pain. This deficiency in pain management was a clear violation of the facility's own policies and professional standards of care.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by inadequate tracking and analysis of infections, particularly urinary tract infections (UTIs) occurring on the same hallways from January to May 2024. The infection control data was incomplete for June and July 2024, and there was no evidence of a functional system to analyze clusters or increases in infection rates. Although staff education on infection control practices was provided in January and February, there was no investigation into the causes of the UTIs or implementation of interventions to prevent their recurrence. Additionally, during a medication pass observation, an agency LPN failed to follow proper infection control procedures. The LPN did not change gloves or sanitize hands between tasks and residents, potentially spreading infection. The LPN also did not clean a blood glucose monitor between uses. Furthermore, the facility did not maintain ice storage in a sanitary manner, as an ice scoop was found resting directly on the ice in a portable ice chest, with the handle in contact with the ice. These deficiencies indicate a lack of consistent implementation of infection control procedures.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective pest control program, as evidenced by observations and interviews conducted during the survey. The pest management report from August 16, 2024, highlighted several recommendations that were not addressed, including replacing damaged exterior grates, repairing door gaps, and filling gaps between pipes and walls. Observations on August 27, 2024, revealed brown/black feces-like pellets in multiple resident rooms, indicating rodent activity. Interviews with two residents confirmed sightings of mice in their rooms, further supporting the presence of a pest issue. During a facility tour, several structural deficiencies were noted, such as an ajar main entry door, loose exterior vent screens, holes in window screens, and gaps around air conditioning units and garage doors, all of which provide entry points for pests. The Nursing Home Administrator and Director of Nursing were unable to provide evidence that the facility had addressed the pest management company's recommendations, confirming the inadequacy of the current pest control program.

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 the privacy and confidentiality of residents during a physician visit, affecting seven residents. During an observation, it was noted that a contracted eye doctor was examining a resident in a room with glass walls and open doors, allowing other residents, staff, and visitors to view the examination. The residents waiting for their eye examinations were seated in wheelchairs in the lounge and hallway, with no screen or partition to ensure privacy. The Nursing Home Administrator confirmed that the residents' dignity was compromised as their examinations were visible to others. Additionally, the facility did not ensure personal privacy for one resident by posting therapy instructions on the wall of the resident's room, visible from the bed. The interim Director of Nursing confirmed that these instructions should not have been displayed in such a manner. The Nursing Home Administrator acknowledged that the facility staff is responsible for addressing residents' needs in a way that promotes their quality of life and protects their privacy, and confirmed that physician examinations should be conducted in private.

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 a comprehensive person-centered plan of care for a resident with specific medical needs. The resident, who was admitted with an automatic implantable cardiac defibrillator (AICD) and a complete traumatic amputation at the knee level of the left lower leg, did not have their care needs related to the AICD adequately addressed in their care plan. The survey conducted revealed that there was no documented evidence of interventions for AICD checks or monitoring for signs and symptoms of AICD complications. Additionally, the facility did not address the emergency care procedures for the AICD device, such as consulting a physician, obtaining vital signs, and ensuring the safety of the resident and staff during an AICD activation. The Director of Nursing confirmed that the facility failed to fully address the care and management of the resident's AICD in the person-centered plan of care.

Penalty

No penalty information released

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

Summary

The facility failed to conduct timely bladder assessments and develop individualized toileting plans for two residents, leading to deficiencies in their care. Resident 91, who was admitted with a Foley catheter and diagnosed with dementia, urinary tract infection, and mobility issues, removed her catheter on her own. Despite this, the facility did not perform a bladder assessment until nine days later, and no scheduled toileting program was implemented to manage her incontinence. This lack of timely intervention contributed to repeated falls as the resident attempted to use the bathroom independently. Resident 32, admitted for post-surgical care with an indwelling Foley catheter, also experienced deficiencies in care. The facility did not provide justification for the use of the catheter upon admission, nor did it document a timely urinary assessment or develop a toileting plan. Although a voiding trial was initiated, there was no follow-up documentation or assessment to determine the resident's incontinence type or the need for continued catheter use. The Nursing Home Administrator confirmed the lack of timely bladder assessments and the absence of documented justification for the use and delayed removal of Foley catheters for both residents. These deficiencies highlight the facility's failure to adhere to its own policies and regulatory requirements for managing urinary incontinence and catheter use.

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 adequately monitor the weight of two residents, leading to significant weight loss that was not addressed in a timely manner. Resident 27 experienced an 8% weight loss over 26 days, and a total of 13.7% over 90 days. Despite a recommendation for weekly weight checks, only two of the four recommended checks were completed. The resident was admitted to hospice care, and the facility decided to discontinue weight monitoring for comfort measures. The registered dietitian confirmed that the facility did not complete the recommended weekly weights, which contributed to the oversight in monitoring the resident's weight. Resident 78 also experienced a significant weight loss of 21.3 pounds, or 15.66%, over 32 days. The facility's staff failed to inform the registered dietitian or the physician of this significant weight loss at the time it was recorded. The dietitian was unaware of the weight loss and questioned the accuracy of the weight, but no reweights were conducted by the nursing staff to verify the measurement. This lack of communication and follow-up contributed to the deficiency in monitoring the resident's nutritional status. Additionally, the facility did not adhere to a physician-ordered fluid restriction for Resident 25, who had a diagnosis of diabetes and chronic kidney disease requiring dialysis. The resident's fluid intake exceeded the prescribed 1000 cc limit on multiple occasions, and there was no evidence that the registered dietitian or physician was notified of these excesses. The registered dietitian confirmed that the fluid restriction was not calculated, and she was unsure if the resident's daily fluid intake was monitored, indicating a failure in maintaining the resident's health as per 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

The facility failed to ensure that physician services met the immediate care needs of two residents, leading to deficiencies in their care. Resident 260 was admitted with diagnoses including aftercare following digestive tract surgery and pressure injuries. The resident experienced untreated pain due to the facility's failure to obtain a prescription from the physician for pain medication. Despite the family's repeated requests for pain relief, the facility did not provide any pharmacological or non-pharmacological interventions from the evening of August 26, 2024, until the afternoon of August 27, 2024. Interviews with staff confirmed the lack of action and inability to provide necessary pain management due to the missing prescription. Resident 77, who was admitted with diabetes mellitus and an indwelling urinary catheter, was prescribed Keflex for dysuria and penile pain following a hospital discharge. However, a laboratory report indicated that the resident's urine culture did not require antibiotic treatment. Despite this, Resident 77 received five doses of Keflex after the report was available. The facility's Infection Preventionist and Director of Nursing were unable to explain the delay in communication with the physician regarding the unnecessary antibiotic treatment. The facility's failure to ensure timely and appropriate physician services resulted in Resident 260 experiencing prolonged pain and Resident 77 receiving unnecessary medication. The Corporate Administrator and Director of Nursing acknowledged the facility's responsibility to meet residents' immediate needs but could not provide explanations for the lapses in care. These deficiencies were noted under F697 and F757, highlighting the facility's non-compliance with medical director and nursing services 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 sufficient nursing staff to consistently meet the needs of residents, resulting in delayed care and supervision. On one occasion, a cognitively intact resident reported waiting approximately two hours for assistance with a bedpan during the third shift. Another resident, who had returned from a community hospital, did not receive his morning insulin medication on time due to an overwhelmed LPN who was unable to manage her workload effectively. This delay in medication administration was confirmed by a review of the resident's Medication Administration Record, which showed insulin was administered significantly later than the physician's orders. Observations on the East Nursing Unit Long Hall revealed inadequate staffing, with only one agency LPN present and no nurse aides available at certain times. A resident was found calling for help with breakfast, unable to eat without assistance, and requiring repositioning by two staff members. Interviews with staff confirmed that call-offs and insufficient staffing prolonged resident wait times and made it difficult to meet residents' needs. The facility's administrator was unable to provide evidence of adequate staffing, and the regional staffing coordinator noted that the director of nursing was filling in due to a lack of available 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 store drugs and pharmacy supplies safely in one of its medication storage rooms and did not remove medications awaiting final disposition in a timely manner. During an observation, a large paper bag containing discontinued resident medications was found unsecured in the East Wing medication storage room. Employee 8, a Registered Nurse Supervisor, confirmed that these medications were supposed to be returned to the pharmacy but were left unsecured, which could lead to unauthorized access and potential drug diversion. Employee 6, the Chief Nursing Officer, stated that discontinued medications should be destroyed at the facility, but this was not done in a timely manner. Additionally, the facility did not document the accounting and disposition of medications for two residents upon their discharge. Resident 108 was discharged without any documented evidence of medication accounting, and Resident 107, who expired at the facility, also lacked such documentation. Furthermore, the facility failed to ensure accurate narcotic accountability for Resident 84, who was prescribed Klonopin for anxiety. Discrepancies were found in the narcotic administration records, including incorrect dosages and inconsistent entries, which were not explained by the nursing administration.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate of less than 5%, as evidenced by the administration errors observed with Resident 6. The resident, who was admitted with diagnoses including psychosis and diabetes, was cognitively intact and required limited assistance for daily activities. The resident had specific physician orders for medication, including a lactase tablet to be taken before breakfast and a fiber powder to be mixed with a specific amount of liquid and taken once daily. On the day of observation, an LPN administered the lactase tablet after the resident had already consumed breakfast, contrary to the physician's order. Additionally, the LPN incorrectly administered only 2 teaspoons of fiber powder instead of the ordered 2 tablespoons, and mixed it with an incorrect amount of liquid. These errors contributed to a medication error rate of 6.67%, exceeding the acceptable threshold. The Director of Nursing confirmed these errors during an interview, acknowledging the failure to administer medications as ordered.

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 two residents were free from significant medication errors. Resident 5, who was admitted with diagnoses including congestive heart failure and atrial fibrillation, had a physician's order for Warfarin to be administered on specific days. On August 12, 2024, the medication was not administered as scheduled due to a delay in delivery from the pharmacy. The omission was documented, and the physician was informed, but the resident missed a dose of the anticoagulant. Resident 77, diagnosed with diabetes mellitus, had multiple insulin orders, including a sliding scale for blood sugar management. On August 27, 2024, the resident expressed concern about elevated blood sugar levels after returning from a hospital visit. The LPN administered the insulin doses late, including the Toujeo Solostar and Novolog, which were given over an hour past the scheduled time. The LPN acknowledged the delay, attributing it to being overwhelmed with workload. The following day, another LPN performed a blood glucose check while the resident was eating breakfast, contrary to the physician's order to check before meals. The Director of Nursing confirmed the failure to administer medication timely, impacting the management of Resident 77's diabetes. These incidents highlight the facility's inability to ensure timely and accurate medication administration for these 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's Quality Assurance Performance Improvement (QAPI) committee failed to effectively monitor and respond to adverse events, specifically repeated falls among residents. The facility's policy for QAPI, reviewed in July 2024, outlined objectives to measure care outcomes, establish performance improvement projects, and monitor corrective actions. However, the facility did not demonstrate the use of monitoring data to prevent similar adverse events, as evidenced by the increasing number of falls from January to August 2024, totaling 127 falls in eight months. There was no evidence that the facility identified the increased falls as a systemic issue or analyzed underlying causes to develop corrective actions. Resident 91, admitted with dementia and mobility issues, experienced multiple falls despite being identified as at risk for falls. The care plan included interventions such as alarms and one-to-one supervision, but these measures were not effectively implemented. Documentation revealed several incidents where Resident 91 fell, including a significant fall resulting in a hip fracture. The facility failed to provide documented evidence of the ordered one-to-one supervision during the required timeframe, leading to repeated falls and a major injury. Similarly, Resident 33, also with severe cognitive impairment and a history of falls, experienced nine unwitnessed falls over two months. The care plan included alarms and other preventive measures, but the facility did not increase supervision to prevent further falls. An interview with the Nursing Home Administrator confirmed the facility's failure to provide evidence of an effective QAPI program regarding falls and the lack of internal action to prevent resident falls.

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 offer and/or provide the pneumococcal immunization to three residents, as required by their policy. The policy, last reviewed on July 1, 2024, mandates that residents be assessed for eligibility to receive the pneumococcal vaccine prior to or upon admission, and if indicated, the vaccine should be administered within 30 days of admission. However, the facility did not adhere to this policy for Residents 31, 27, and 91. Resident 31, who was admitted with diagnoses including cerebral infarction and COPD, had a signed consent for the vaccine dated July 12, 2024, but there was no documented evidence that the vaccine was administered. Similarly, Resident 27, admitted with dementia and diabetes, had no documented evidence of receiving the pneumococcal vaccine prior to or upon admission, nor was there evidence that the vaccine was offered or that it was clinically contraindicated. Resident 91, admitted with dementia and gait abnormalities, also lacked documentation of receiving the vaccine or being offered it upon admission. The facility was unable to provide evidence that these residents had previously received the vaccine or that it was contraindicated, as confirmed by the regional nurse consultant during an interview on August 30, 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 provide abuse prevention training to two employees, an agency LPN and an agency RN supervisor, as required by their policies. Employee 7, an agency LPN, stated during an interview that she had worked several shifts at the facility since July 2024 but had not received training on the facility's abuse prohibition policy before starting her duties. Similarly, Employee 15, an agency RN supervisor, confirmed on her first day at the facility that she had not been trained on the facility's abuse prohibition policy. The interim Director of Nursing confirmed that there were no written records to show that these employees were trained on the facility's policies and procedures regarding the prohibition of abuse, neglect, and exploitation before they assumed their job duties.

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 reasonably accommodate the needs of a resident with sensitive skin, identified as Resident 94, who was admitted with a diagnosis of Crohn's disease. This condition can lead to diarrhea and bloody stool, resulting in episodes of fecal incontinence. Resident 94, who is cognitively intact, reported experiencing discomfort and irritation when staff used washcloths to clean her after bowel movements, describing the sensation as if her skin was ripping. She expressed a preference for disposable hygiene wipes, which she found to be more comfortable and effective, but the facility did not provide them. An observation of the linen closet revealed that the washcloths available were stiff and not soft to the touch. The Nursing Home Administrator confirmed that the facility had discontinued the use of disposable hygiene wipes over a year ago due to issues with the septic system becoming clogged. Despite Resident 94's willingness to purchase the wipes herself, the facility did not allow their use and failed to provide an alternative solution, such as softer washcloths, to prevent discomfort during perineal care.

Penalty

No penalty information released

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

Summary

The facility failed to timely consult with a resident's physician regarding the need to initiate a new treatment. Resident 72, who was admitted with a complete traumatic amputation at the knee level of the left lower leg, had a physician order for specific wound care. On August 12, 2024, a CRNP from the Vascular Surgeon's office noted the resident's wound was improving and recommended a referral to a prosthetic company for a stump shrinker. On August 21, 2024, a CPO from the Prosthetic Clinic fitted the resident with a stump shrinker and recommended wearing it for 23 hours per day. However, the facility did not obtain a physician's order for the resident to wear the stump shrinker as recommended. An interview with a Physician Assistant revealed no recollection of being notified about the prosthetist's recommendations, and there was no documented evidence that the physician was informed. The Director of Nursing confirmed the failure to notify the physician about the prosthetist's recommendation, leading to a deficiency in nursing services as per 28 Pa Code 211.12 (d)(3)(5).