Pavilion At St Luke Village, The

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 was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.

Penalty

No penalty information released

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

Summary

The facility failed to adequately address and resolve ongoing resident complaints and grievances raised during Resident Council meetings, specifically regarding long wait times for care and delayed meal distribution. Despite multiple residents consistently voicing these concerns over several months, meeting minutes indicated that grievances were to be filed on their behalf, but a review of facility records revealed no documentation of such grievances being filed for the relevant periods. Residents reported that their requests for assistance were not responded to in a timely manner and that meal trays, although arriving on time, were left sitting for extended periods before being distributed, resulting in cold food. These issues were repeatedly marked as unresolved in the Resident Council meeting minutes. Interviews with residents confirmed that these problems persisted despite being brought up multiple times, and the Nursing Home Administrator was unable to provide evidence of any effective actions taken to resolve the concerns. The administrator also could not explain the lack of grievance documentation or demonstrate any follow-up or communication with residents regarding the status of their complaints. The facility's own policy requires prompt efforts to resolve grievances and to keep residents informed of progress, but these procedures were not followed, resulting in continued dissatisfaction and unresolved issues 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 Minimum Data Set (MDS) assessments accurately reflected the clinical status of three residents. For one resident with respiratory failure, tracheostomy, and continuous oxygen needs, the quarterly MDS assessment did not indicate that the resident was receiving continuous oxygen therapy, as-needed suctioning, or tracheostomy care, despite physician orders and treatment records confirming these interventions were provided. Another resident with schizophrenia had an annual MDS assessment that inaccurately documented the resident's PASARR status, indicating no need for a Level II PASARR, even though clinical records and a determination letter confirmed the requirement for specialized services due to a mental condition. A third resident, admitted with quadriplegia, was assessed on the admission MDS as having an indwelling urinary catheter, but direct observation revealed no catheter was present. In each case, the inaccuracies were confirmed by the Nursing Home Administrator during interviews. These findings demonstrate that the facility did not follow the required procedures for accurate MDS completion, including direct observation and proper documentation, as outlined in the RAI User's Manual and state 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

A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical 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 maintain accurate and complete clinical records for one resident who was admitted with chronic obstructive pulmonary disease and chronic kidney disease. The resident had a physician's order to receive Cefazolin, an antibiotic, intravenously every eight hours for 15 days to treat MRSA. Upon review of the medication administration record for the specified month, it was found that documentation was missing for seven scheduled administrations of the antibiotic on several dates and times. During an interview, the Nursing Home Administrator confirmed that nursing staff omitted the required documentation from the clinical record. An attestation from a registered nurse indicated that the medication was administered as ordered, but the nurse forgot to document these administrations in the electronic health record. The administrator acknowledged that it is the facility's responsibility to ensure that medical records are accurate and complete.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect the resident's current needs and services. Clinical record review showed that the resident, who had diagnoses including schizophrenia, depression, and anxiety, was transferred to a hospital for involuntary psychiatric commitment due to verbal and physical aggression. Upon readmission from a behavioral hospital, documentation from the hospital included specific red flags, warning signs, and internal coping strategies relevant to the resident's mental health status. However, the facility's care plan did not incorporate these updated findings, nor did it reflect the resident's recent psychiatric hospitalization or the escalation of behaviors that led to the hospital stay. The care plan, initially created years prior, was not updated to include the resident's current diagnosis of schizophrenia, recent behavioral episodes, or the interventions and strategies identified by the behavioral hospital. Interventions and goals in the care plan were outdated and did not address the resident's present mental health risks or needs. An interview with the director of nursing confirmed there was no documented evidence that the care plan had been reviewed or revised to reflect the resident's current condition and required interventions.

Penalty

No penalty information released

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

Summary

A resident with a history of dysphagia and Alzheimer's disease was admitted with a physician's order for continuous enteral feeding via a PEG tube. During observation, the enteral feeding container in use for this resident was found to be lacking a label indicating the date and time it was opened and hung, which is required to ensure safe administration within the recommended 48-hour timeframe as per facility policy. This omission was directly observed while the tube feeding and pump were running and delivering nutrition to the resident. Additionally, the resident's wheelchair and the attached feeding pole were observed to be coated with a dried tan residue, which was present on multiple surfaces including the seat cushion, seat support, back support, armrests, and wheels. The Nursing Home Administrator confirmed that housekeeping is responsible for scheduled cleaning of all wheelchairs and that all staff are expected to clean wheelchairs immediately when soiled. The facility failed to ensure proper labeling of enteral feeding containers and did not maintain the resident's equipment in a sanitary condition.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement an individualized, person-centered plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). A review of the facility's policy on trauma-informed care indicated that care and services should be culturally competent, account for resident experiences and preferences, and address the needs of trauma survivors by minimizing triggers and re-traumatization. However, the clinical record for the resident, who was admitted with diagnoses including PTSD and anxiety, did not include identification of PTSD symptoms, triggers, or resident-specific interventions to address these needs. Additionally, an outside psychiatry consultation for the resident did not mention a history of PTSD, and the current care plan in effect at the time of review failed to address the resident's PTSD diagnosis or provide interventions to minimize triggers and re-traumatization. Interviews with the Nursing Home Administrator and Social Services Director confirmed that the facility could not demonstrate the provision of culturally competent, trauma-informed care in accordance with professional standards and the resident's preferences.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer for a resident, resulting in actual harm. The resident was admitted with diagnoses including muscle weakness, dysphagia, and urinary retention, and was identified as being at moderate risk for pressure injury development. The care plan included interventions such as a pressure-reducing mattress, wheelchair cushion, encouragement of nutrition and hydration, weekly skin assessments, and repositioning every two hours. However, documentation and staff interviews revealed that these interventions, particularly scheduled turning and repositioning, were not consistently implemented or documented as ordered by the physician. Clinical records and task summary reports from the period in question failed to show evidence that staff performed the required pressure ulcer prevention tasks, specifically scheduled turning and repositioning. Additionally, licensed nursing staff did not develop or implement timely interventions to address the resident's decreased mobility and risk for pressure injuries. The facility was also unable to provide evidence of weight loss or treatment refusals by the resident, and there were inconsistencies in the administration of prescribed nutritional supplements. Over the course of several weeks, the resident developed new pressure ulcers on the buttocks and sacrum, which progressed from Stage II to unstageable ulcers with slough and eschar, eventually merging into a large ulceration. Despite updates to the care plan and new treatment orders, the lack of consistent implementation of preventive measures and documentation contributed to the worsening of the resident's condition, ultimately resulting in the resident being sent to the emergency room for evaluation due to the deterioration of the sacral wound.

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 effectively implement and enforce its compliance and ethics program, as evidenced by the actions of two employees in the activity department and business office. The Code of Ethics manual required all employees to undergo compliance training and to report any unethical, illegal, or unprofessional behavior. Despite this, Employee 1, the Activities Director, accepted monetary payments from an insurance vendor in exchange for introducing the vendor to residents and/or their responsible parties, resulting in several residents being signed up for the vendor's insurance plan. Employee 1 admitted to accepting payments on multiple occasions, motivated by financial need and persistent encouragement from the vendor. Employee 2, the Business Office Manager, was aware of the vendor's offers to compensate staff for facilitating insurance enrollments, having witnessed such discussions at a staff party and being directly offered payment to intervene with a resident's family regarding insurance enrollment. Despite completing annual training on the Code of Ethics and Corporate Compliance, Employee 2 did not report these unethical solicitations to facility leadership or the compliance hotline, as required by facility policy. Other employees who witnessed the vendor's discussions also failed to report the behavior. The Nursing Home Administrator confirmed that she was unaware of the vendor's actions and the employees' involvement until the investigation was initiated. The lack of reporting by both Employee 1 and Employee 2, despite their training and the facility's mandatory reporting policy, demonstrated a failure in the facility's internal controls to monitor adherence to statutes, regulations, and program requirements. This deficiency resulted in the facility's inability to prevent and detect criminal, civil, and administrative violations related to the Anti-Kickback statute and the facility's own Code of Ethics.

Penalty

No penalty information released

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

Summary

The facility failed to meet the required nurse aide to resident ratios as stipulated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides per resident on six out of twenty-one reviewed shifts. The regulation mandates a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. However, on several dates in January 2025, the facility's staffing records showed a shortfall in the required number of nurse aides for the night and evening shifts, based on the facility's census. For instance, on January 5, 2025, the night shift had 6.30 nurse aides instead of the required 7.07 for a census of 106 residents. Similarly, on January 6, 2025, the evening shift had 9.07 nurse aides instead of the required 9.73 for a census of 107 residents. These deficiencies were confirmed during an interview with the Nursing Home Administrator on January 28, 2025. The report also noted that no additional higher-level staff were available to compensate for the staffing shortfall on the mentioned dates.

Plan Of Correction

The facility cannot retroactively correct the Nurse Aide Staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum nurse aide to resident ratios on all shifts, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient ratios 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor Nurse Aide to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Nurse Aide to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

Penalty

No penalty information released

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

Summary

The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) during the day shift on one occasion. Specifically, on January 11, 2025, the facility did not provide the mandated ratio of one LPN per 25 residents, as evidenced by staffing records showing only 3.40 LPNs available for a resident census of 108, where 4.32 LPNs were required. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 28, 2025.

Plan Of Correction

The facility cannot retroactively correct the Licensed Practical Nurse staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum Licensed Practical Nurse staff to resident ratios on all shifts, ensuring continued proactive planning and follow-up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and a comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules for current staff, focuses on recruitment of direct hire staff for continuity of care, as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with the IDT during staffing meetings. The NHA/Designee will quality monitor Licensed Practical Nurse staff to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Licensed Practical Nurse to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

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 required minimum of 3.2 hours of direct resident care per resident per day, as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, effective July 1, 2024. A review of the facility's staffing levels revealed deficiencies on specific dates in January 2025, where the facility provided only 3.13, 3.00, and 3.06 direct care nursing hours per resident, respectively. This shortfall in nursing care hours was confirmed during an interview with the Nursing Home Administrator on January 28, 2025.

Plan Of Correction

The facility cannot retroactively correct the per patient hours on previous days. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum 3.20 per patient hours per day, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor per patient hours 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum 2.87 per patient hours are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

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 18 out of 48 shifts reviewed. The regulation, effective July 1, 2024, mandates a minimum of 1 nurse aide per 10 residents during the day, 1 per 11 residents in the evening, and 1 per 15 residents overnight. However, the facility's staffing records revealed multiple instances where the number of nurse aides fell short of these requirements. For example, on December 17, 2024, the night shift had 5.5 nurse aides instead of the required 6.73 for a census of 101 residents. Similar deficiencies were noted on various dates, including December 22, 24, 25, 26, 27, 28, 29, 30, 31, 2024, and January 1, 2025, across different shifts. The Nursing Home Administrator confirmed during an interview on January 3, 2025, that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the staffing deficiencies. This lack of adequate staffing was consistent across several shifts, indicating a systemic issue in maintaining the mandated staffing levels.

Plan Of Correction

The facility cannot retroactively correct the Nurse Aide Staff to resident ratios on past shifts identified. The facility cannot retroactively correct the Nurse Aide Staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum nurse aide to resident ratios on all shifts, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient ratios 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor Nurse Aide to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Nurse Aide to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

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 LPN-to-resident ratios on six shifts out of 48 reviewed, as evidenced by a review of nurse staffing records and staff interviews. Specifically, on December 21, 2024, the evening shift had 2.88 LPNs instead of the required 3.37 for a census of 101 residents. On December 22, 2024, the night shift had 2.38 LPNs instead of the required 2.53 for the same census. On December 25, 2024, the day shift had 3.19 LPNs instead of the required 4.16 for a census of 104, and the evening shift had 3.19 LPNs instead of the required 3.47. On December 30, 2024, the evening shift had 3.5 LPNs instead of the required 3.57 for a census of 107. Finally, on December 31, 2024, the night shift had 2.13 LPNs instead of the required 2.73 for a census of 109. The Nursing Home Administrator confirmed these deficiencies during an interview on January 3, 2025.

Plan Of Correction

The facility cannot retroactively correct the Licensed Practical Nurse Staff to resident ratios on past shifts identified. The facility cannot retroactively correct the Licensed Practical Nurse Staff to resident ratios on previous shifts. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum Licensed Practical Nurse staff to resident ratios on all shifts, ensuring continued proactive planning and follow-up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules, etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor Licensed Practical Nurse Staff to resident ratios 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum Licensed Practical Nurse to resident ratios are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

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 regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of the facility's staffing levels revealed that on several dates, including December 22, 25, 27, 29, 30, 2024, and January 1, 2025, the facility provided less than the required nursing care hours, with figures ranging from 2.88 to 3.19 hours per resident. An interview with the Nursing Home Administrator confirmed the facility's inability to meet the mandated staffing levels on these dates.

Plan Of Correction

The facility cannot retroactively correct the per patient hours on past days identified. The facility cannot retroactively correct the per patient hours on previous days. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum 3.20 per patient hours per day, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. Facility utilizes contracted nursing staff, incentives, and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. Call in list used to attempt fill unexpected absences. Resident occupancy reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor per patient hours 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum 2.87 per patient hours are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive infection control program, which led to the spread of infectious diseases, including scabies, among residents and staff. The infection control tracking logs lacked detailed data collection necessary for monitoring and investigating infections, such as resident room location, infectious organism, treatment, infection start and resolution dates, symptoms, and culture information. This lack of documentation prevented the facility from identifying potential trends and implementing specific interventions to prevent the spread of infections. Resident 7, who was admitted with heart disease and chronic kidney disease, developed an itchy rash that persisted despite treatment with Triamcinolone cream and Cetirizine. The resident was placed on contact precautions, but the rash continued to spread, leading to a dermatology consult that confirmed scabies. The facility's infection control documentation revealed that 12 additional residents and several staff members also developed itchy rashes, indicating a scabies outbreak. However, there was no evidence of consistent nursing assessments or documentation regarding staff rashes and treatments. The facility's central supply room was found to be in poor condition, with visible dirt, debris, and unclean equipment, further indicating a failure to maintain an environment conducive to infection prevention. The Director of Nursing confirmed that infection control practices were not maintained, and the facility failed to implement proper infection control practices, including their established policy and procedures, to prevent and mitigate the spread of scabies.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely responses to residents' requests for assistance, impacting their quality of life and dignity. This deficiency was identified through a review of clinical records, resident council meeting minutes, grievances, and interviews with residents and staff. Specifically, two residents out of 21 sampled, and five out of nine residents during a group interview, reported experiencing long wait times for staff to respond to call bells. Resident 25, who is moderately cognitively impaired, reported waiting 20 minutes or longer for assistance. Resident 74, who is cognitively intact, described waiting from 15 minutes to two hours for care, including a two-hour wait for pain medication. During a resident council group interview, several residents expressed distress over the long wait times. Resident 24 reported waiting 20 to 30 minutes for assistance, while Resident 28 noted that the wait time is particularly long in the evening. Resident 31 mentioned that staff sometimes turn off the call bell without returning promptly. Resident 55 shared an experience of being left on the toilet for 30 minutes, and Resident 57 indicated that she often waits 30 minutes for assistance, leading her to transfer herself to the bathroom unsafely. The Nursing Home Administrator and Director of Nursing acknowledged the importance of treating residents with dignity and respect but could not explain the untimely responses to residents' requests.

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 care and services to prevent the development of pressure sores for two residents. Resident 19, who was admitted with chronic obstructive pulmonary disease and was cognitively intact, developed a Stage II pressure injury on her left ear due to oxygen tubing. Despite having a care plan in place to prevent skin breakdown, the facility did not consistently implement effective interventions, such as padding the oxygen tubing, leading to the development of the pressure injury. Resident 26, who was readmitted with a left hip fracture, reduced mobility, and Alzheimer's disease, developed pressure areas on her left buttock and sacrum. The facility's records did not show that staff performed necessary pressure ulcer prevention tasks, such as scheduled turning and repositioning or frequent incontinence care. Additionally, there was no documentation of interventions being developed and implemented to prevent pressure areas related to the resident's declined mobility. The facility's failure to implement consistent and appropriate measures resulted in the worsening of Resident 26's sacral wound, which progressed from a Stage II to an unstageable pressure area. The Director of Nursing confirmed that the facility did not take consistent actions to prevent the development and worsening of pressure sores for the residents involved.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received appropriate services and assistance to maintain or improve mobility, as required by their restorative nursing program. Resident 74, who was admitted with chronic kidney disease and pulmonary embolism, was cognitively intact and had been placed on a restorative nursing program for ambulation and active range of motion. This program was initiated in April 2024 and discontinued in November 2024. However, documentation revealed that the resident did not receive or was not offered the scheduled restorative nursing program on 18 occasions between October and November 2024. Despite a physical therapy discharge summary indicating that the resident's prognosis to maintain their current level of function was excellent with participation in the restorative nursing program, the resident reported not receiving the necessary therapy or services. The Nursing Home Administrator confirmed the facility's responsibility to provide these services but could not provide documented evidence that the resident received the planned restorative nursing services. This lack of service delivery was confirmed through interviews and a review of the facility's policy and clinical records.

Penalty

No penalty information released

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

Summary

The facility failed to assess and implement individualized measures to meet the toileting needs of a resident, identified as Resident 26, who was part of a sample of 21 residents. The facility's policy required residents to be evaluated for continence upon admission, quarterly, and with significant changes in status. However, despite Resident 26's documented incontinence and cognitive impairment, the facility did not provide evidence of a tailored continence management program or frequent incontinence checks and care. This lack of individualized care was evident in the resident's care plan, which did not reflect necessary interventions to prevent skin breakdown due to incontinence. Resident 26, who had Alzheimer's disease and was severely cognitively impaired, was always incontinent of bowel and bladder and required substantial assistance with personal care. After being readmitted to the facility with additional diagnoses, including a hip fracture and reduced mobility, the resident developed a Stage II pressure ulcer on the sacrum. The facility's investigation revealed that staff did not perform more frequent incontinence checks and care, which contributed to the development of the pressure ulcer. The Nursing Home Administrator confirmed the facility's inability to provide evidence of consistent and timely incontinence management for Resident 26.

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 pharmaceutical services to meet the needs of a resident, identified as Resident 9, who was prescribed Pregabalin Oral Capsule 25 mg for neuropathic pain management. The deficiency occurred when the resident did not receive six doses of the medication from November 8, 2024, through November 10, 2024, due to the pharmacy not delivering the medication to the facility. Despite a physician order initiated on November 8, 2024, and communication between the facility and pharmacy services, the medication was not administered as required. The facility's policy requires that all controlled substance orders be communicated to the pharmacy, with specific instructions for timely delivery if needed before the next scheduled delivery. However, despite a STAT delivery request and confirmation of the prescription receipt by the pharmacy, the medication was not provided until November 10, 2024, at 9:00 PM. The Director of Nursing confirmed the failure to provide the medication as prescribed, acknowledging the facility's responsibility to ensure pharmacy services meet each resident's needs.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper documentation and justification for the continued use of an antipsychotic medication, quetiapine fumarate, for a resident diagnosed with Alzheimer's disease and generalized anxiety disorder. The resident, who was severely cognitively impaired, was prescribed quetiapine to manage anxiety. However, the clinical records lacked evidence of the physician's documentation of the clinical rationale for the continued administration of this medication. Despite behavior tracking indicating no maladaptive behaviors related to anxiety, the resident's quetiapine dosage was increased without adequate documentation of the necessity for such an increase. The facility's records did not show any individualized non-pharmacological interventions being developed or implemented to address the resident's anxiety-related behaviors. Furthermore, the resident's care plan did not identify anxiety or related behavioral symptoms as a problem, nor did it include any non-pharmacological strategies. Interviews with the Nursing Home Administrator and Director of Nursing revealed that they could not provide documented evidence justifying the use of the antipsychotic medication for the resident's anxiety. Additionally, they were unable to demonstrate that the facility had attempted to develop and implement non-pharmacological interventions to manage the resident's anxiety. This lack of documentation and failure to explore alternative interventions contributed to the deficiency identified in the report.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean and homelike environment for Resident 76, as observed and reported during a survey. On October 16, 2024, Resident 76 reported that her soiled clothing was not being taken to the laundry, resulting in dirty clothes accumulating at the bottom of her closet. This was confirmed during an observation at the same time, where several dirty clothing articles were found crumpled on the bottom shelf of her closet. Employee 1, an LPN, acknowledged that the facility is responsible for washing Resident 76's clothing and confirmed that soiled clothing should be placed in a laundry receptacle for cleaning. The LPN also confirmed the presence of dirty clothing in the closet and removed them. The Nursing Home Administrator later confirmed the facility's responsibility to maintain a clean and homelike environment for all 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 provide nursing services consistent with professional standards of practice by not ensuring that a physician-ordered antibiotic was timely obtained and administered to a resident diagnosed with cellulitis. The resident, who was admitted with a diagnosis including chronic atrial fibrillation, was noted to have a slight pink discoloration on her right lower extremity, leading to a physician's order for Doxycycline 100 mg twice a day. However, the pharmacy did not send the medication due to the resident's known allergy to tetracycline, which is contraindicated with Doxycycline. Despite this, the facility did not take timely action to address the issue. The nursing staff failed to implement the facility's policy for notification of change in condition, which required contacting the medical director if the attending physician did not respond in a reasonable time. The physician did not respond to the facility's attempts to clarify and confirm the order, resulting in the resident not receiving any doses of the prescribed medication or an alternative treatment for her cellulitis. Interviews with the resident and the Nursing Home Administrator confirmed the delay in treatment and the failure to contact the medical director to change the medication order.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics, as required by their antibiotic stewardship policy. The policy emphasizes the importance of prescribing antibiotics only when necessary to prevent issues such as gastrointestinal disease and drug-resistant pathogens. Despite this, a resident was prescribed and administered Macrodantin for a urinary tract infection without meeting the criteria for antibiotic therapy. The resident's clinical records showed no symptoms of a urinary tract infection, yet the medication was administered following the insistence of the resident's family. The resident, who was cognitively intact with a BIMS score of 14, had a urine culture showing E. coli growth, but no symptoms were documented to justify the antibiotic treatment. The facility's Nursing Home Administrator confirmed that the criteria for antibiotic therapy were not met, acknowledging the facility's responsibility to prevent unnecessary antibiotic use. This incident highlights a lapse in adhering to the facility's antibiotic stewardship program, as the decision to administer antibiotics was influenced by external pressure rather than clinical necessity.

Penalty

Fine: $55,419

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

Summary

The facility failed to provide necessary care to promote healing and prevent the worsening of a pressure sore for a resident, leading to deterioration and clinical complications. The resident, who was admitted with a pressure ulcer on the right heel, was at risk for developing pressure ulcers and had unhealed pressure ulcers. Upon admission, the resident's pressure wound was noted as unstageable and necrotic, but no further assessment details were documented. The care plan did not include measures to reduce pressure on the unstageable pressure ulcer, such as offloading pressure, turning, and repositioning. Subsequent assessments failed to document thorough details of the pressure wound, and the wound increased in size over time. A wound consult later revealed the pressure sore had worsened, with recommendations for a repositioning schedule and the use of Prevalon boots, which were not implemented by the facility. The resident's condition deteriorated further, with an x-ray revealing calcaneus erosion consistent with osteomyelitis, a bone infection. The facility did not timely notify the physician of the x-ray results, delaying prompt treatment. The resident was eventually sent to the hospital with worsening symptoms, including a non-healing wound and osteomyelitis. Hospital records indicated that the resident's wounds were extensive, and without debridement of dead bone, the chances of curing the osteomyelitis were minimal. The facility's failure to implement recommended measures and document thorough assessments contributed to the resident's declining condition.

Penalty

Fine: $55,419

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

Summary

The facility failed to provide nursing services consistent with professional standards of quality, as evidenced by the inadequate evaluation and documentation of a resident's wounds. The resident, who was admitted with multiple wounds including venous ulcers and a necrotic pressure ulcer, did not have a complete assessment documented by the nursing staff. The assessments lacked critical details such as drainage, wound description, and the condition of surrounding tissue, which are essential for monitoring and treatment. The nursing staff also failed to differentiate between pressure and non-pressure wounds in their documentation, leading to incomplete and inaccurate records. This oversight was evident in multiple assessments where the type of wound was not identified, and the specific locations of wounds on the resident's body were not clearly documented. This lack of thorough documentation hindered the ability to monitor the resident's condition effectively and identify any deterioration in a timely manner. The deficiency was further highlighted when a wound consultant noted significant deterioration in the resident's right heel, recommending an X-ray that revealed osteomyelitis. Despite receiving the X-ray results, there was no documentation of the attending physician being notified until several days later, delaying necessary treatment. This delay in communication and action contributed to the resident's condition worsening, as confirmed by hospital records indicating a severe infection requiring intravenous antibiotics.

Penalty

Fine: $55,419

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 safe and appropriate administration of physician-ordered intravenous (IV) medications for a resident. Specifically, Resident 148, who was admitted with a peripherally inserted central catheter (PICC line) and diagnosed with a septic left knee and diabetes, did not receive the prescribed IV antibiotic, Daptomycin, on three consecutive days. The facility's policy on administering medications, which requires medications to be administered within one hour of their prescribed time, was not followed. Interviews with the Director of Nursing and the nursing home administrator confirmed the failure to administer the IV antibiotic therapy as prescribed and the failure to notify the attending physician of the missed doses. This deficiency was identified during a review of the resident's Medication Administration Record and was corroborated by staff interviews, highlighting a lapse in the facility's adherence to its medication administration policy.

Penalty

Fine: $55,419

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 safe and appropriate pain management for two residents by not attempting non-pharmacological interventions before administering opioid pain medication and not adhering to physician orders. Resident 8, diagnosed with fibromyalgia, had a physician order for oxycodone to be administered as needed for pain levels between 4 and 10. However, the facility's records showed that on multiple occasions in May, June, and July 2024, the medication was given without first attempting non-pharmacological interventions. This lack of adherence to protocol was confirmed during an interview with the Nursing Home Administrator. Similarly, Resident 20, diagnosed with Multiple Sclerosis, had a physician order for oxycodone to be administered for pain levels between 7 and 10. Despite this, the facility's records indicated that the medication was administered for pain levels below the prescribed threshold on several occasions in May, June, and July 2024. The Nursing Home Administrator confirmed that there was no documented evidence of non-pharmacological interventions being attempted prior to administering the medication, and the facility did not follow the physician's orders for pain management.

Penalty

Fine: $55,419

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

Summary

The facility failed to provide timely pharmacy services for Resident 148, who was admitted with a septic left knee and diabetes. A physician's order was in place for the administration of Daptomycin, an intravenous antibiotic, to be given daily in the morning until August 12, 2024. However, a review of the Medication Administration Record revealed that the antibiotic was not administered on July 12, 13, and 14, 2024. This lapse occurred because the facility's pharmacy did not deliver the medication on time, as confirmed by the Nursing Home Administrator during an interview on July 19, 2024.

Penalty

Fine: $55,419

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

Summary

The facility failed to ensure that a licensed pharmacist performed a comprehensive monthly drug regimen review for residents, as required by their policies and procedures. Specifically, the pharmacist did not identify and report irregularities in the drug regimens of four residents, nor was there evidence that physicians acted upon any identified irregularities. The residents involved had various diagnoses, including type 2 diabetes, depression, anxiety, generalized anxiety disorder, major depressive disorder, viral hepatitis, and chronic obstructive pulmonary disease (COPD). Despite the pharmacist completing medication regimen reviews on multiple occasions, the facility could not provide documentation of the results, any noted irregularities, recommendations made, or physician responses. During the survey, it was confirmed through a staff interview that the facility lacked documented evidence of the pharmacist's recommendations or identification of irregularities in the drug regimens of the residents. The Nursing Home Administrator verified the absence of documentation, which is a violation of the facility's regulatory requirements under 28 Pa. Code 211.9 (k) Pharmacy services, 28 Pa. Code 211.12 (c) Nursing services, and 28 Pa. Code 211.2 (d)(3) Medical Director. This deficiency was identified for four out of the 24 residents sampled during the survey.

Penalty

Fine: $55,419

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 and implement a comprehensive infection prevention and control program for two months, specifically June and July 2024. The facility's policy on infection control, last reviewed on May 9, 2024, outlines objectives to prevent, detect, investigate, and control infections, as well as maintain records of incidents and corrective actions. However, a review of the facility's infection control data revealed that the last recorded data for monitoring and managing healthcare-associated infections was completed on May 27, 2024. There was no documented evidence of infection control surveillance and data analysis activities from May 27, 2024, through July 19, 2024. During this period, the facility lacked a functional system to analyze infection clusters, changes in prevalent organisms, or increases in infection rates. Employee 6, the Infection Preventionist, indicated that she coordinated and implemented the infection control program until June 5, 2024, when she transitioned to a different role. She was unable to provide evidence of surveillance activities after May 27, 2024. The Nursing Home Administrator confirmed that the Infection Preventionist was not performing the required duties to implement an effective infection control program, resulting in the facility's failure to fully implement a comprehensive program during the specified months.

Penalty

Fine: $55,419

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

Summary

The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple grievances and interviews with residents and staff. Residents reported long wait times for call bell responses, with some waiting over 20 minutes for assistance. This issue was particularly prevalent during the evening shift and meal times when staff were occupied with other duties. Residents expressed feelings of frustration and anger due to the delays in receiving care, which sometimes resulted in accidents or unmet care needs. Clinical record reviews revealed that several residents, including those with chronic conditions such as COPD, heart failure, and coronary artery disease, were cognitively intact and aware of the staffing deficiencies. These residents reported that the facility was often short-staffed, especially on weekends, and that the number of new admissions had increased without a corresponding increase in nursing staff. This led to residents feeling rushed and dependent on staff for assistance with activities of daily living. Observations and interviews with staff confirmed the staffing shortages, with reports of nurse aides and LPNs calling off and not being replaced. The facility's staffing records showed that they failed to meet the required minimum state ratios for nurse aides and LPNs on numerous occasions. The Nursing Home Administrator acknowledged the staffing issues and confirmed that the facility did not provide additional direct care staff to accommodate the increased resident census.

Penalty

Fine: $55,419

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 uphold the residents' right to self-determination by not providing an accessible smoking area for residents who smoked prior to the implementation of a new non-smoking policy. Two residents, identified as Resident 21 and Resident 72, were affected by this change. Resident 21, who is cognitively intact and uses a wheelchair for mobility, expressed frustration as she could no longer smoke on facility grounds and required assistance to reach the designated smoking area across the street. Similarly, Resident 72, who has moderate cognitive impairment and requires substantial help for mobility, was unable to access the smoking area without assistance. The facility's new smoking policy, effective May 10, 2024, prohibited smoking on facility grounds and required residents to sign out and smoke offsite. This policy change was discussed in a Resident Council meeting, and residents were informed that staff would no longer assist with smoking. The designated smoking area was located across the street, which presented mobility challenges due to uneven terrain and potential hazards, making it difficult for residents in wheelchairs to access safely. During interviews, both residents expressed dissatisfaction with the lack of assistance and the inability to smoke as they had before. The Nursing Home Administrator confirmed the policy change and acknowledged the difficulties residents faced in reaching the smoking area. The facility offered smoking cessation programs and assistance with transferring to another facility for residents who wished to continue smoking, but failed to provide a safe and accessible smoking area for current residents who smoked.

Penalty

Fine: $55,419

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 notify the resident representative of an allegation of physical abuse involving Resident 35. Resident 35, who was admitted with diagnoses including spinal stenosis and hypertension, reported an incident where another resident, Resident 87, entered her room uninvited and slapped her in the face. This incident occurred when Resident 35 asked Resident 87 to put down an orange. Despite the seriousness of the incident, there was no documented evidence that the facility informed Resident 35's representative, who holds medical and financial Power of Attorney, about the reported abuse. The incident was documented in a facility incident report dated July 9, 2024, and a grievance report dated July 11, 2024, highlighted the representative's dissatisfaction with not being informed. An interview with the Nursing Home Administrator confirmed the failure to notify the resident's representative in a timely manner. This deficiency is a violation of the Pennsylvania Code, specifically 28 Pa. Code 211.12 (d)(3)(5) regarding nursing services and 28 Pa. Code 201.29 (b) concerning resident rights.

Penalty

Fine: $55,419

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

Summary

The facility failed to provide a comfortable environment for Resident 89, who was admitted with a diagnosis of spinal stenosis and is cognitively intact with a BIMS score of 15. The resident reported that the temperature in his room was too warm and uncomfortable due to a non-functioning cooling unit, which had been an issue since his admission over a month ago. Despite the facility offering a room change, the resident preferred to stay in his current room with a functioning cooling unit. Observations and interviews revealed that the air cooling unit in the resident's room had not been functioning for over a month, with the room temperature recorded at 75.1 F. A maintenance request order dated May 24, 2024, indicated the issue, but no repairs had been made by the time of the survey ending July 19, 2024. The Nursing Home Administrator was unable to provide evidence of scheduled or in-progress repairs, confirming the facility's responsibility to ensure a comfortable environment for residents.

Penalty

Fine: $55,419

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

Summary

The facility failed to protect a resident from physical abuse and mental anguish, as evidenced by an incident involving two residents. Resident 35, who was cognitively intact, reported that Resident 87, who was severely cognitively impaired, entered her room uninvited and slapped her in the face after being told to return an orange she had taken. The incident report indicated that Resident 35 was assessed with no injuries noted, but she expressed upset over the incident and concern about Resident 87's potential for further aggression. The facility's policy on abuse prevention and investigation was not effectively implemented, as Resident 87 had a known history of entering other residents' rooms uninvited and becoming agitated. Despite this, adequate measures were not in place to prevent the incident. The RN Supervisor acknowledged being aware of Resident 87's behavior and potential for aggression, yet the facility did not ensure sufficient supervision or intervention to prevent the altercation. The nursing home administrator confirmed the facility's failure to protect Resident 35 from abuse.

Penalty

Fine: $55,419

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

Summary

The facility failed to investigate an injury of unknown source for Resident 24, who was severely cognitively impaired and receiving anticoagulant therapy. Despite multiple instances of unexplained vaginal bleeding documented in nursing progress notes, there was no evidence that the facility conducted an investigation to rule out abuse, neglect, or mistreatment. The Nursing Home Administrator and Director of Nursing confirmed that no investigation or physical examination was conducted to determine the cause of the bleeding, which was a violation of the facility's abuse prohibition policy. Additionally, the facility did not thoroughly investigate an allegation of physical abuse involving Resident 35, who reported being slapped by another resident, Resident 87. The incident report noted that Resident 35 was assessed with no injuries, but the investigation lacked a statement from the staff member who initially reported the incident. Interviews revealed that Resident 87 had a history of entering other residents' rooms uninvited and becoming agitated, yet the facility did not substantiate the abuse allegation due to a lack of corroborating evidence. The facility's failure to conduct thorough investigations in both cases highlights a deficiency in adhering to their abuse prohibition policy. The policy mandates immediate reporting and investigation of any injury of unknown source or abuse allegation, which was not followed in these instances. This oversight potentially compromised the safety and well-being of the residents involved.

Penalty

Fine: $55,419

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

Summary

The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the MDS assessment for a resident who was discharged from the facility was found to be inaccurate. The resident's Discharge MDS assessment indicated that they were discharged to a short-term general hospital, whereas the Discharge Plan and Instructions showed that the resident was actually discharged home. This discrepancy was confirmed during an interview with the Nursing Home Administrator.

Penalty

Fine: $55,419

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

Summary

The facility failed to develop and implement individualized plans to manage dementia-related behavioral symptoms for a resident, identified as Resident 87, who was diagnosed with Alzheimer's disease and was severely cognitively impaired. The deficiency was identified following an incident where Resident 87 entered another resident's room uninvited and slapped the resident when confronted. The care plan for Resident 87, initially dated April 10, 2024, did not adequately address the resident's behaviors of intrusive wandering, taking items that did not belong to her, and potential for agitation when confronted. Interviews with staff and residents revealed that Resident 87 had been exhibiting behaviors such as entering other residents' rooms uninvited and becoming agitated when told no. Despite these behaviors, the facility did not have a comprehensive, individualized person-centered plan to address and manage these dementia-related behaviors. The facility's failure to document and implement specific interventions to manage Resident 87's behaviors was confirmed by the Nursing Home Administrator, who acknowledged the lack of a comprehensive care plan to address these issues.

Penalty

Fine: $55,419

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 promptly notify the attending physician of abnormal x-ray results for a resident, leading to a delay in treatment. The resident, who was admitted with diagnoses including Type 2 diabetes and multiple ulcers, had a wound consult on July 10, 2024, which recommended an x-ray due to the deterioration of a pressure ulcer on the right heel. The x-ray, completed on July 11, 2024, revealed calcaneus erosion consistent with osteomyelitis. However, there was no documentation indicating that the physician was informed of these results on the same day. The deficiency was further highlighted when a change in condition assessment five days later noted increased pain and confirmed osteomyelitis, prompting the physician to be notified and the resident to be sent to the hospital. The Nursing Home Administrator confirmed the failure to notify the physician promptly, which was a breach of the facility's responsibility to ensure timely communication of critical health information.

Penalty

Fine: $55,419

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 accurate and complete clinical records for two residents, as required by professional standards of practice. Resident 35, who was admitted with spinal stenosis and hypertension, reported an incident where Resident 87, diagnosed with Alzheimer's disease, entered her room uninvited and slapped her. Despite this report, there was no documentation in the clinical records of either resident regarding the incident of intrusive wandering and physical abuse. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of documented evidence in the clinical records for both residents. This lack of documentation contravenes the American Nurses Association Principles for Nursing Documentation and the Title 49 Professional and Vocational Standards, which mandate timely and accurate record-keeping to ensure informed decisions and high-quality care.

Penalty

Fine: $55,419

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

Summary

The facility failed to ensure proper coordination of care and services between the facility and the hospice agency for a resident diagnosed with malignant neoplasm of the liver and bile duct. The resident was admitted to the facility and had a physician order for hospice services to be provided at the facility. However, during a survey, it was found that the resident's care plan did not reflect the necessary coordination of services between the facility and the hospice agency to meet the resident's daily care needs and specific needs related to their terminal diagnosis. This lack of coordination was confirmed during an interview with the Nursing Home Administrator.

Penalty

Fine: $55,419

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 thoroughly assess and evaluate bowel and bladder function for a resident, leading to a deficiency in providing appropriate care. The facility's policy requires residents to be evaluated for continence upon admission, quarterly, and with significant changes in status. However, for one resident, there was no documented evidence of a Bowel and Bladder evaluation or Bowel and Bladder Elimination Pattern evaluation being completed upon admission or quarterly, despite the resident's frequent incontinence of bladder and bowel. The resident's condition declined, as noted in the Minimum Data Set (MDS) assessments, which showed an increase in bowel incontinence over time. The resident reported that nursing staff often took a long time to respond to call bells, resulting in delayed assistance with toileting. On one occasion, the resident waited over 15 minutes for help, leading to an accident due to bowel incontinence. The nursing home administrator confirmed that there was no documented evidence of the facility acting upon the resident's increased bowel incontinence or implementing any scheduled toileting programs in response to the decline in bowel function. This lack of timely evaluation and intervention contributed to the deficiency 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

The facility failed to implement a system to ensure the timely disposition of resident medications, leading to the improper storage of discontinued and unused medications. During an observation of the second-floor medication room, various medications, including antibiotics, pain medications, and diuretics, were found stored in drawers below the counter. These medications were in blister cards with preprinted pharmacy labels, some of which had the resident's name scratched off. Employee 2, a Registered Nurse, confirmed that these medications were not in a designated location for discontinued medications and should have been returned to the pharmacy for disposition. The RN was unable to explain the handwritten note found on top of the discontinued medications, which stated, 'all need to take turns.' Further observations in the third-floor medication room revealed similar issues, with medications stored in drawers and cupboards among resident care equipment. Medications such as heparin vials, Paxlovid, and Ipratropium-Albuterol solution were found improperly stored. Employee 1, an LPN, confirmed that these medications were not in a designated location for discontinued medications and should have been returned to the pharmacy. Both employees stated that pharmacy deliveries occur daily, and discontinued medications should be inventoried and placed in a pharmacy bag for return. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that discontinued medications should be picked up by the pharmacy or destroyed by nursing staff and not stockpiled in medication rooms. The NHA stated that the facility is to return discontinued medications to the pharmacy at least quarterly but was unable to explain why medications belonging to a resident discharged months earlier were still in the facility. The facility failed to implement procedures to ensure the timely disposition and secure storage of discontinued medications.

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 consistent implementation of infection control procedures in the third-floor medication room. During an observation on April 9, 2024, at approximately 9:28 AM, it was found that a small, dormitory-size medication refrigerator was located on the floor. Inside the refrigerator, resident medications were stored alongside two plastic, one-gallon containers of iced tea and six 16 fluid oz. bottles of salad dressings on the door. An interview with an LPN confirmed that the food and beverages stored in the medication refrigerator belonged to staff. The Director of Nursing also confirmed that the facility failed to store medications under sanitary conditions, which could potentially spread infection.