Wecare At Monroeville Rehabilitation And Nsg Ctr

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that door alarm systems were regularly tested for full functionality, as required by facility procedures and state regulations. Facility documents showed that the Maintenance Manager’s job description included maintaining competency in fire prevention and safety and facility maintenance requirements, and written alarm testing instructions specified a detailed multi-step process to verify delayed egress operation, alarm activation, automatic door opening, alarm reset, signage, nurse station panel activation, and annual keypad battery replacement. However, during a surveyor interview and observation, the Maintenance Director demonstrated that he did not follow these written procedures. During an observed test of a door alarm, the Maintenance Director was unable to deactivate the alarm and required nursing staff to respond to the alarming door to silence the alarm and reactivate the locking mechanism. When questioned on how he ensured door alarms were functional, he stated that he only attempted to open the door to confirm it was locked, and acknowledged that this action did not verify the alarm’s functionality. In a separate interview, the Nursing Home Administrator confirmed that the facility failed to make certain that door alarm systems were regularly tested for functionality, in violation of 28 Pa. Code 201.14(a) and 201.18(b)(1)(3).

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide prescribed wound treatments, including NPWT/wound vac therapy, and to follow physician orders for wound care for two residents. One resident with heart failure, diabetes, and a diabetic foot ulcer complicated by osteomyelitis was discharged from the hospital with debridement, antibiotic beads, and an order for a wound vac. Despite multiple clinical notes from physicians and wound NPs on several dates referencing that the left foot had antibiotic beads and a wound vac and requesting clarification or confirming that podiatry still recommended a wound vac, there was no active wound vac order in the facility record until nearly two weeks after admission. The resident’s care plan for diabetic ulcers did not include the need for a wound vac, and facility communications showed that a wound vac delivered to a sister facility was malfunctioning, not started, and then misplaced and later located, while the resident never actually received wound vac therapy. For this same resident, the facility substituted wet-to-dry dressings in place of the wound vac but failed to consistently document that ordered wound care was provided. The TAR showed multiple dates and shifts with no documentation of wet-to-dry dressing changes and missing documentation for several other ordered wound treatments, including petrolatum gauze and various wound care orders to the left mid foot, left posterior thigh, right mid foot, right shin, and right medial lower leg. The resident reported never receiving a wound vac, being unhappy with wound care, and stated that he did not always receive wound care as scheduled and often had to request dressing changes. The resident also disputed documentation that he was pleased with wound progress and stated that while the wound did not deteriorate, there was negligible improvement. The second resident had bacteremia, hypertension, and a history of stroke and was admitted with a PICO 14 NPWT dressing to the left femoral region per hospital discharge paperwork and physician orders. The plan of care for actual skin impairment did not include goals or interventions for the use of the PICO dressing. Progress notes and wound NP documentation confirmed that the PICO dressing and battery pack were in place and intact on multiple dates, with instructions that the dressing had a seven-day life and the battery pack a 14-day life, and that the dressing should be replaced at day seven or when saturated, conserving the battery pack until it turned off. However, the clinical record lacked documentation that the dressing portion was changed at the required seven-day intervals or that the battery pack was changed at 14 days, and a later note indicated the PICO battery was dead and the dressing was removed. The Nursing Home Administrator and DON confirmed that the facility failed to provide prescribed treatment and services related to wound care for these two 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 safe and appropriate respiratory care and medication administration for two residents with COPD and other cardiac conditions. Facility policy required medications to be administered safely, timely, as prescribed, and fully documented, including date, time, dosage, route, and results. For one resident with atrial fibrillation and COPD, the MDS showed a BIMS score of 15, indicating cognitive intactness. Physician orders dated 1/20/26 directed that this resident receive Breo Ellipta once daily, with a documented therapeutic interchange to Ipratropium‑Albuterol nebulizer solution every eight hours. Review of the MAR from 2/1/26 through 2/24/26 showed multiple days when Breo Ellipta was marked as received, some days marked as held, and one day undocumented, but there was no documentation of the timing or administration of the substituted Ipratropium‑Albuterol nebulizer treatments. The resident confirmed he had not been receiving his Breo Ellipta inhaler. A second resident, admitted with diagnoses including coronary artery disease and COPD and a BIMS score of 14, had a plan of care for shortness of breath related to Flu A and COPD that did not include the use of respiratory medications or nebulizer treatments. Physician orders dated 1/30/26 directed that this resident receive Trelegy Ellipta once daily and Ipratropium‑Albuterol inhalation aerosol every six hours as needed for COPD, with a pharmacy‑supplied therapeutic interchange to Ipratropium‑Albuterol nebulizer solution every six hours as needed. Review of the MAR from 2/1/26 through 2/24/26 showed Trelegy Ellipta documented as received on most days, with several days marked as held and one day undocumented. Despite these MAR entries, the resident later confirmed he had not been receiving his Trelegy Ellipta inhaler. On observation of the medication cart on the 100‑unit hall, neither resident’s Breo Ellipta nor Trelegy Ellipta inhalers were present. Instead, unopened pharmacy‑supplied boxes of Ipratropium‑Albuterol nebulizer ampules labeled as therapeutic interchange were found, with full supplies and no ampules removed. An LPN confirmed that the inhalers were not in the cart and that no Ipratropium‑Albuterol ampules had been used, yet could not explain why the MAR reflected that both residents had received their inhalers during the morning medication pass. Later observation in the shared room showed both residents receiving nebulizer treatments, and interviews at that time confirmed that neither resident had previously received nebulizer treatments in the facility. The nursing home administrator and DON acknowledged that the facility failed to provide appropriate respiratory care for these two 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 adequate supervision to prevent elopement for a resident who had been identified as at risk for unsafe wandering. The resident had diagnoses including atherosclerotic heart disease, age-related debility, and dementia, with a BIMS score of 8 indicating moderate cognitive impairment. An Elopement Risk Evaluation documented that the resident was at risk for elopement, and the care plan stated the resident would remain safe within the facility unless accompanied by staff or another authorized person. A physician’s order directed staff to monitor the resident’s wandering behavior. Despite these assessments and orders, the resident was able to leave the building unaccompanied. On the day of the incident, the resident exited the facility through a back exit door on one of the units. The resident was last seen inside by a CNA at 5:18 p.m. and was found outside and brought back into the building by an LPN at 5:20 p.m., wearing regular indoor clothing in 50-degree Fahrenheit weather. A progress note documented that the back door opened easily and that only a low alarm sounded while the loud alarm remained silent when the resident exited. An employee statement from a nurse aide described a similar situation in which a male individual, assumed to be a family member, walked toward exit doors and left the building without any alarms sounding, with alarms only activating when he re-entered the facility about ten minutes later. These events demonstrate that the resident, previously identified as an elopement risk, was able to leave the facility due to inadequate supervision and malfunctioning or ineffective door alarm systems.

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 maintain essential emergency and laundry equipment in safe and operable condition. Surveyors observed that the 100-Hall crash cart was missing multiple items listed on the Emergency Cart Daily Checklist, including a blank code book, band-aids, needles with syringes, gowns, masks, goggles or face shield, alcohol-based hand rub, an ambu-bag, 14 French suction kits, Christmas tree adapters, a non-rebreather mask, and a nasal cannula. Review of the 100-Hall Emergency Cart Checklist showed multiple days where the cart contents were not documented, and several days where the checklist was marked complete without a staff signature; there was also no checklist available for a subsequent month. The 200-Hall crash cart was also found missing numerous required items, including a blank code book, blood pressure cuff and stethoscope, glucometer, flashlight or penlight, alcohol pads, band-aids, disposable razors, needles with syringes, gloves, gowns, masks, goggles or face shield, IV start kits, alcohol-based hand rub, an ambu-bag, a full oxygen tank (all three present were empty), a nebulizer kit, and 14 French suction kits. Documentation for the 200-Hall cart similarly showed multiple days without documentation of items present, and on some days the glucometer was noted as missing. The deficiency also includes failure to maintain operable dryers and adequate linen supply. In the laundry room, surveyors observed an uncountable number of bags and carts filled with soiled linen, and a laundry worker reported that the facility’s industrial dryers had been inoperable for several days, requiring use of a smaller, non-commercial resident dryer that could not keep up with laundry volume. Multiple observations of linen carts on both the 100-Hall and 200-Hall revealed repeated shortages or absence of towels and washcloths, with some carts having none and others having only a few. Staff interviews confirmed that residents were not receiving showers due to lack of clean towels, that staff were cutting up bath blankets to make washcloths, and that some staff were using personally purchased baby wipes, dry wipes, or clothing protectors to bathe and dry residents. The Nursing Home Administrator and DON acknowledged that the facility failed to ensure two crash carts and two facility dryers were in safe operating 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 deficiency involves the facility’s failure to notify physicians of significantly elevated capillary blood glucose (CBG) levels for four residents with diabetes, contrary to facility policy and physician expectations. The facility’s Diabetes – Clinical Protocol stated that physicians would order appropriate interventions for diabetes management. The Centers for Disease Control definition of hyperglycemia was cited, and the facility’s care plans for several residents directed staff to monitor, document, and report signs and symptoms of hyperglycemia as needed. Despite these directives, multiple documented CBG readings far above normal ranges were not followed by documented provider notification. One resident with heart failure and diabetes had a care plan to monitor and report signs and symptoms of hyperglycemia and a physician order for Humalog insulin per sliding scale, with instructions to call the physician if blood sugar exceeded 500 mg/dL. The resident’s blood sugar record showed numerous readings at or above 500 mg/dL, including values such as 547, 589, 525, 594, 571, 561, 509, and 570 mg/dL, without documentation that the physician was notified. Another resident with dementia and diabetes had a care plan to monitor and report hyperglycemia and an order for scheduled Humalog insulin three times daily, but no specific notification parameters. This resident’s blood sugar record showed multiple elevated readings, including 410, 404, 539, 412, and 400 mg/dL, again without documentation of provider notification. A third resident with end stage renal disease and diabetes had an order for Humalog insulin per sliding scale with instructions to call the physician if blood sugar exceeded 400 mg/dL. The blood sugar record showed a reading of 489 mg/dL without documentation that the physician was notified. A fourth resident with coronary artery disease and diabetes had a care plan to monitor and report signs and symptoms of hyperglycemia and an order for scheduled Humalog insulin three times daily, but no specific notification parameters. This resident’s blood sugar record contained numerous elevated readings above 400 mg/dL, including values such as 412, 441, 423, 464, 481, 533, 457, 428, 445, 460, 500, 488, and others, with no documentation of provider notification. In interviews, the Medical Director stated that staff were expected to notify providers of out-of-range blood sugars and, in the absence of specific parameters, to notify at levels of 400–450 mg/dL unless otherwise specified. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to notify physicians of increased CBG levels for four of six reviewed 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

Surveyors found that the facility failed to ensure that certain nursing personnel maintained current CPR certification for healthcare providers that included a hands-on session, as required by facility policy and accepted national standards. The facility’s written policy on emergency procedures for cardiopulmonary resuscitation required staff to obtain and maintain American Red Cross or American Heart Association certification in Basic Life Support/CPR. The Nursing Home Administrator provided a list of currently employed LPNs and RNs, and review of CPR certification cards for three of 27 licensed nurses (two LPNs and one RN) showed that their certifications were from online-only CPR classes intended for non-healthcare providers and did not include any hands-on component. In an interview, the Nursing Home Administrator confirmed that the facility had not ensured these nurses held appropriate, hands-on CPR certification for healthcare providers in accordance with accepted national standards. No specific residents, medical histories, or clinical events related to CPR use were described in the report; the deficiency was identified through policy review, staff record review, and staff interviews.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain documentation that nursing personnel had current education and certification in basic life support (BLS), including cardiopulmonary resuscitation (CPR), as required to provide emergency care prior to the arrival of emergency medical personnel and in accordance with physician orders and residents’ advance directives. The facility’s CPR policy stated that personnel must have completed training on initiation of CPR and BLS, including defibrillation, for victims of sudden cardiac arrest. During the survey, the Nursing Home Administrator provided a list of currently employed LPNs and RNs and then supplied available CPR certification cards; however, CPR certification cards were not available for 15 of 27 licensed nurses, including multiple LPNs and RNs. In an interview, the Nursing Home Administrator confirmed that the facility did not maintain documentation showing that these nursing personnel had current CPR/BLS education and certification, in violation of 28 Pa. Code 201.14(a) and 211.12(d)(1)(5). No specific residents, medical histories, or clinical events were described in the report; the deficiency centers on the lack of documented current CPR/BLS certification for a substantial portion of the licensed nursing 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 ensure that nurses and nurse aides had the appropriate competencies to provide emergency services, including use and location of automated external defibrillators (AEDs), despite a resident population with significant cardiac and circulatory conditions. The facility assessment listed common diagnoses such as congestive heart failure, coronary artery disease, angina, dysrhythmia, hypertension, orthostatic hypotension, peripheral vascular disease, risk for bleeding or blood clots, deep venous thrombosis, and pulmonary thrombo-embolism. The facility’s CPR/BLS policy required personnel to be trained in CPR, BLS, and defibrillation for sudden cardiac arrest and directed staff to retrieve an AED and initiate the BLS sequence when an individual was found unresponsive. National Heart, Lung, and Blood Institute information cited in the report identified heart problems, including coronary artery disease, arrhythmias, atrial fibrillation, angina, cardiomyopathy, heart valve disease, and heart failure, as key risk factors for cardiac arrest. During observations, surveyors noted that wall-mounted boxes on two halls were labeled as containing AEDs but were empty. When asked to locate the AED, an RN initially texted an LPN for assistance and the AED was ultimately found stored in an unlabeled lower cabinet in a clean utility room, not in the labeled wall boxes. Multiple nurse aides and an LPN either did not know where the AED was located or incorrectly believed it was in the wall boxes or at the nurses’ stations. Only one nurse aide initially stated she knew the location but was unable to identify it when questioned further. The Nursing Home Administrator and Director of Nursing were informed that staff could not accurately describe the AED locations and confirmed that the facility failed to ensure nursing staff had the competencies and skill sets necessary to provide emergency services, affecting eight of nine sampled staff members.

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency related to the facility’s failure to ensure that drugs and medical supplies on two crash carts were properly stored and disposed of in accordance with facility policy and professional standards. The facility’s “Storage of Medications” policy, dated 1/8/26 (previously 6/1/25), required that discontinued, outdated, or deteriorated drugs be returned to the dispensing pharmacy or destroyed. During an observation of the 100-Hall crash cart, surveyors found multiple items that were either expired or not properly maintained, including a Yankauer catheter with its sterile packaging open, a box of acetaminophen suppositories expiring 12/2024, a bottle of 0.9% sodium chloride solution expiring 5/18/24, IV start kits expiring 4/30/24 and 9/7/25, a concentrator mask with tubing expiring 03/2025, connection tubing expiring 06/2012, a box of glucose gel expiring 02/2025, lubricating jelly packets expiring 06/10/2021, an IV catheter expiring 9/1/22, and normal saline flushes expiring 2/3/25 and 10/31/25. A similar observation of the 200-Hall crash cart revealed additional expired or soon-to-expire medical supplies, including a box of glucose gel expiring 02/2025, a box of acetaminophen suppositories expiring 12/2024, IV start kits expiring 5/16/25 and 8/31/24, normal saline flushes expiring 2/3/25, and an IV catheter expiring 8/31/25. These findings demonstrated that the facility did not consistently remove or properly manage outdated or deteriorated medications and supplies on both crash carts as required by its own policy. In a subsequent interview, the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that medical supplies on the two crash carts were properly stored and/or disposed of, in violation of 28 Pa Code 201.14(a) regarding the responsibility of the licensee.

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 governing body failed to implement and align facility policies with Centers for Medicare & Medicaid Services (CMS) requirements, resulting in deficiencies related to CPR/BLS certification and diabetes management. Review of the facility’s governing body policy showed it was responsible for establishing and implementing policies for management and operation of the facility. However, the facility’s CPR policy only required a designated CPR team per shift (including at least one nurse, one LPN/LVN, and two CNAs with CPR/BLS certification) and did not include the CMS requirement that all clinical staff maintain current CPR certification through a provider with hands-on practice and in-person skills assessment. The facility reported having 47 nurse aides actively employed but was unable to provide evidence that any of them had CPR/BLS certification. The Medical Director confirmed that all healthcare providers employed by the facility were required to have CPR/BLS certification, demonstrating a discrepancy between practice, policy, and federal requirements. The governing body also failed to ensure that the facility’s diabetes clinical protocol provided clear direction to nursing staff on when to notify providers of hyperglycemia in the absence of specific physician orders. The diabetes policy listed possible physician-ordered interventions but did not specify notification parameters for elevated blood glucose levels. One resident with coronary artery disease and diabetes had a care plan instructing staff to monitor, document, and report signs and symptoms of hyperglycemia as needed, and an order for scheduled Humalog insulin with meals, but the physician’s orders did not include specific notification parameters. The resident’s blood sugar records showed multiple significantly elevated readings (ranging from 412 mg/dL to 533 mg/dL) without documentation that a provider was notified. The Medical Director stated his expectation that staff notify providers of out-of-range blood sugars greater than 400–450 mg/dL when parameters are not specified, and acknowledged that, because the facility policy did not define notification requirements and some physician orders lacked parameters, nursing staff would be unaware of general or specific notification requirements. The Nursing Home Administrator and DON acknowledged that the governing body failed to implement policies aligned with CMS requirements.

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 maintain complete and accurate clinical documentation and wound care orders in accordance with its own policies and accepted professional standards. The facility’s Charting and Documentation policy required that all services provided, progress toward care plan goals, and changes in condition be documented in the medical record, and the Wound Care policy required documentation of the date and time wound care was given. The facility assessment indicated it would provide care for skin ulcers and injuries. Despite these requirements, surveyors identified multiple instances where wound care orders were missing or delayed and where ordered treatments were not documented as completed on the treatment administration records (TARs). For one resident with heart failure and chronic kidney disease who had an abscess on the right knee and a new wound on the right medial knee, a wound nurse practitioner ordered gentamicin ointment for both wounds, with the abscess to be changed daily and the medial wound twice daily. However, there was no physician’s order entered for the right medial knee wound until several days after the NP note, and the existing order for the right knee abscess was discontinued with no new order until the same later date. The TAR for the right medial wound also lacked documentation of completed dressing changes on multiple specified dates and times. Another resident, cognitively intact with hypertension and cellulitis and care-planned for potential pressure ulcers, had a physician’s order for twice-daily dressing changes to the left second toe, but the January TAR showed missing documentation of completed dressing changes on several evenings and mornings. This resident stated that he did not know what the staff’s problem was and expressed that it seemed like they did not care. A third cognitively intact resident with diabetes, necrotizing fasciitis, and gangrene, care-planned for actual/potential skin integrity impairment, had an order for twice-daily dressing changes to the left heel. The January TAR lacked documentation of completed dressing changes on multiple specified dates and times. This resident indicated that sometimes she had to remind staff and that if she did not ask or did not get a certain nurse, the dressing changes did not get done. A fourth resident with diabetes and cerebral palsy, care-planned for an actual pressure ulcer and with physician’s orders for daily coccyx dressing changes, also had multiple dates on the January TAR where the dressing changes were not documented as completed. The Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to appropriately document wound care orders and treatments for four of seven reviewed residents, in violation of state clinical records requirements.

Penalty

No penalty information released

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

Summary

The facility failed to accurately complete its facility-wide assessment used to determine necessary resources for competent resident care during routine operations and emergencies. Review of the Facility Assessment Tool dated 1/23/26 showed that in the section titled “Services and Care,” the facility listed ventilator care and hypodermoclysis even though this did not reflect accurate information. In the section titled “List of Key Personnel,” the assessment still identified the previous Nursing Home Administrator and the previous Director of Nursing instead of current leadership. In the section titled “Physical Resources,” the assessment failed to include crash carts and AEDs, which are emergency equipment maintained and used in urgent situations. During an interview, the current Nursing Home Administrator confirmed that the facility failed to accurately complete the Facility Assessment. No specific residents or their medical conditions were identified in the report as being directly involved in this deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement baseline care plans that included necessary instructions to provide effective and person-centered care for all ten residents reviewed. Clinical record reviews and staff interviews revealed that, for each resident, the baseline care plan was either incomplete or contained errors within the required timeframe following admission. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to address residents' physical, psychosocial, and functional needs, but this was not achieved for any of the residents in the sample. The residents affected had a range of complex medical conditions, including Alzheimer's disease, bipolar disorder, dementia, diabetes, spina bifida, bladder cancer, endocarditis, atrial fibrillation, encephalopathy, chronic obstructive pulmonary disease (COPD), wedge fracture, prostate cancer, heart failure, and throat cancer. Despite these significant diagnoses, the baseline care plans were not completed within the required period after admission, with some remaining incomplete for up to 21 days. The Nursing Home Administrator confirmed the failure to develop and implement appropriate baseline care plans for all residents reviewed.

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 accessible grievance boxes for residents in both the front and rear hallways. Observations revealed that the openings for grievance forms in both locations were mounted at 57 inches from the floor, exceeding the ADA Standards for Accessible Design, which recommend operable parts be mounted between 15 and 48 inches above the floor to accommodate individuals using wheelchairs. The Nursing Home Administrator confirmed that the grievance boxes were not accessible to residents in these two locations. This deficiency was identified through review of facility policy, direct observation, and staff interviews.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations and staff interviews. Specific incidents included dried vomit remaining under a resident's bed for four days, food and a urine odor present on another resident's floor, and a room with blood on the restroom light switch, feces and blood on the bathroom floor, and a dirty commode and sink. Additional findings included dirty overbed tables, refuse on the floor, unclean walls, a wall outlet with a loose faceplate and a gouge, and a handwritten sign warning not to use the outlet. The Environmental Services Supervisor confirmed that only three housekeepers were currently employed, which may have contributed to the lack of cleanliness. Further observations revealed a soiled brief on a restroom floor, feces on bed linens, and rooms with overwhelming urine odors, with one staff member stating that the urine was embedded in the mattresses. Other rooms were found to be unclean, with soiled gloves on overbed tables and bags of soiled linen left on the floor. These deficiencies were confirmed by the Nursing Home Administrator, who acknowledged the facility's failure to provide a clean and homelike environment on both nursing units and for seven of twelve residents reviewed.

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 document and/or follow up on grievances and concerns presented by staff and residents for five residents. According to the facility's grievance policy, all grievances should be addressed promptly, with written notice of outcomes provided to the resident or their representative. However, review of grievance forms for five residents revealed that the sections indicating whether the resident or their representative was informed of the resolution, and the name of the person informed, were left blank in each case. These grievances included concerns about not receiving showers, not receiving fresh water, being left in a wheelchair, and not receiving incontinence care. Additionally, during an interview, the Nursing Home Administrator confirmed that the facility did not document or follow up on these grievances as required. The lack of documentation and follow-up was consistent across all five reviewed cases, indicating a failure to comply with both facility policy and regulatory requirements regarding resident rights and grievance 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 protect residents from verbal and emotional abuse and/or neglect, as evidenced by incidents involving three residents. One resident with dementia and a history of stroke, who was cognitively intact but frequently incontinent, was found by staff to be in a heavily soiled brief and bed linen, with visible redness and a scabbed area on the toe. Documentation showed a significant gap in incontinence care, with the resident stating he had not been changed for an extended period and reporting that this neglect was a recurring issue. Staff statements corroborated the resident's account, describing the resident's condition as deplorable and noting that concerns had been reported multiple times without resolution. Another resident with dementia and a history of stroke, who was always incontinent and had moderate cognitive impairment, was also not provided with incontinence care on multiple occasions. Therapy staff reported finding the resident in extremely soiled briefs and bedding, with a strong odor and visible soiling, and documented that these findings were brought to the attention of supervisory staff. Care records indicated several days without documented incontinence care, further supporting the neglect. A third resident with diabetes and heart failure, who had moderate cognitive impairment, was subjected to verbal abuse by a nurse aide. The resident reported being called an offensive name by the staff member while in a public area of the facility, and this was confirmed by statements from other employees. The incident was witnessed by two staff members, and the resident expressed feeling surprised and offended by the verbal abuse.

Penalty

No penalty information released

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

Summary

Surveyors determined that the facility failed to follow physician orders for four out of five residents reviewed. Residents with diagnoses such as heart failure, hemiplegia, multiple sclerosis, and seizure disorder had active physician orders and care plans specifying the use of various splints, protective sleeves, gloves, and orthoses to be worn daily during the day shift as tolerated. However, during observations, these residents were found in their rooms without the prescribed devices in place. Despite this, documentation in the treatment administration records (TARs) by LPNs indicated that the devices had been applied as ordered. Interviews with therapy staff revealed concerns that splints and braces were often not applied unless therapy staff intervened. The Nursing Home Administrator confirmed that the facility did not follow physician orders for these residents. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) for 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

The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in multiple instances where residents did not receive timely or adequate care. Observations and interviews revealed that residents were left in soiled clothing and bed linens, experienced malodorous conditions, and did not receive regular personal hygiene care such as showers, nail care, and grooming. Documentation showed lapses in incontinence care and meal intake recording, with some residents not having their care needs addressed for extended periods. Residents and their families reported significant delays in call light responses, with some call lights going unanswered for up to 50 minutes. Several residents and staff members stated that the facility was understaffed, leading to unmet needs such as assistance with toileting, bathing, and getting out of bed. Therapy staff corroborated these findings, noting that residents often appeared unclean and were not being assisted as required. Resident Council minutes and grievance reviews further supported these findings, documenting ongoing concerns about insufficient staffing, lack of timely care, and unmet basic needs such as fresh water, snacks, and linen changes. The Nursing Home Administrator confirmed that the facility did not have enough nursing staff to provide necessary services to maintain the highest practicable well-being of 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 implement its policies and procedures for reporting possible neglect of a resident. According to facility policy, any suspicion of abuse, neglect, exploitation, or misappropriation must be reported immediately to designated authorities, including the state licensing agency, ombudsman, resident's representative, adult protective services, law enforcement, the resident's attending physician, and the facility medical director. Immediate reporting is defined as within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. In this case, documentation and staff interviews revealed that a resident with dementia, a history of stroke, and moderate cognitive impairment was not provided with incontinence care for multiple days, despite being always incontinent of bowel and bladder as documented in the care plan and MDS assessment. Therapy staff observed the resident to be extremely soiled on consecutive days, with soiled clothing and bedding, and reported these findings to the nurse supervisor, Administrator, Director of Rehabilitation, Social Services, and Human Resources. However, the facility failed to submit a report of possible neglect to the State Survey Agency as required by policy. The Nursing Home Administrator later confirmed that the facility did not implement the required reporting procedures for this incident involving possible neglect.

Penalty

No penalty information released

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

Summary

The facility failed to obtain laboratory services as ordered for one of three residents. According to the facility's policy, laboratory tests are to be obtained, processed, reviewed, and acted upon in a timely manner by qualified staff. A resident with chronic kidney disease, heart failure, high blood pressure, and psoriasis was evaluated by a dermatologist, who determined that systemic medication was needed for uncontrolled psoriasis. The dermatologist ordered blood work to be completed prior to starting the medication. However, review of the clinical record showed no documentation that the required blood tests were completed within the specified timeframe. Progress notes indicated that the resident inquired about the bloodwork, but staff could not locate any related orders initially. Later, the dermatology office confirmed that labs were ordered and needed to be completed before starting the medication. Although a laboratory order was eventually entered, the blood drawn was related to an unrelated order, and there was no documentation that the correct blood tests were completed. Both the Nursing Home Administrator and the resident confirmed that the required blood tests had not been completed 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 assess whether it was safe for a resident to self-administer medications, as required by its own policy. The policy states that if a resident chooses to self-administer medication, an assessment must be conducted to determine the resident's ability to do so safely and accurately. In this case, a resident with diagnoses of diabetes and dementia, and documented moderate cognitive impairment, was not assessed for the ability to self-administer medications. The resident's care plan did not include goals or interventions related to self-administration, and there was no physician order authorizing self-administration of medications. During observations, the resident was found with a medicine cup containing five prescribed medications on her bedside table at two separate times, indicating that medications were left within her reach. The medication administration record showed that an LPN had administered the medications, but the medications remained at the bedside for an extended period. The Nursing Home Administrator confirmed that the facility did not determine if it was safe for the resident to self-administer medications, resulting in noncompliance with regulatory requirements.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents across both nursing units due to a persistent shortage of linens, including bed sheets, bath towels, and washcloths. Residents reported frequent unavailability of clean linens, with one resident stating that after an accident in bed, staff had to search the building for clean sheets, sometimes taking up to an hour. Another resident expressed uncertainty about the availability of clean sheets, and a third resident confirmed a daily shortage of bath towels, washcloths, and sheets. These concerns were also documented in resident council meeting grievance reports, which noted ongoing issues with insufficient linen supplies. During a tour of the units, a linen cart inspection revealed only a minimal supply of linens available. Staff interviews, including those with the Director of Housekeeping and Laundry, as well as nurse aides, confirmed the ongoing linen shortage. The Director of Housekeeping and Laundry attributed the shortage to a delayed linen purchase order due to billing issues. Both the Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to meet the required standards for providing a safe, clean, and homelike environment 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 and readily accessible to residents, resulting in inadequate hydration and failure to meet resident preferences and comfort for three of ten residents. Observations and interviews revealed that residents often had to request water, which was not always provided, and that ice was unavailable due to broken ice machines. Documentation showed low daily fluid intake for the affected residents, with some days lacking any documentation of intake. Water pitchers were not consistently filled or kept within easy reach, as required by the facility's Certified Nursing Assistant job description. Residents involved included individuals with care plans addressing inadequate food and beverage intake, as well as those with a history or risk of dehydration due to conditions such as nausea, vomiting, and diarrhea. During rounds, it was observed that water and ice were not routinely offered, and residents confirmed they had not received water or ice as expected. Facility leadership acknowledged the failure to provide consistent access to fresh drinking water, which was corroborated by both staff and resident interviews.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that essential equipment, specifically the Automatic External Defibrillator (AED) located at the Nursing Station (Side 2), was maintained in safe operating condition. During an observation, it was found that the last documented AED audit was conducted several years prior, and there was no current maintenance log or record of regular checks as required by facility policy. Staff, including an RN and the DON, were unaware of who was responsible for completing the AED audit log, and the facility did not have the manufacturer's guidelines for the AED available. The DON confirmed that there were no other complete AED audit logs and acknowledged the failure to maintain the AED according to 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 meet required nurse aide (NA) staffing ratios on multiple shifts over a six-day period, as evidenced by a review of staffing documents and staff interviews. Specifically, the facility did not provide at least one NA per 10 residents during the day shift on two days, one NA per 11 residents during the evening shift on two days, and one NA per 15 residents during the night shift on one day, as mandated by regulation. The Nursing Home Administrator confirmed these staffing shortfalls during an interview, and the documentation reviewed detailed the census and actual NA hours compared to the required hours for each shift where deficiencies occurred.

Plan Of Correction

The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off-duty staff, calling sister facilities, or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated the NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5 times weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further 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 state-mandated minimum of 3.2 hours of direct nursing care per resident per day on one of six reviewed days. Specifically, staffing documents and nursing schedules showed that on 6/29/25, the provided direct care hours were only 2.90 per patient daily (PPD), which is below the required threshold. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not provide the minimum required hours of direct care on the identified date. No additional details regarding the residents' medical history or condition at the time of the deficiency were provided in the report.

Plan Of Correction

The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off-duty staff, calling sister facilities, or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. The RDO educated NHA/DON on ensuring sufficient nursing staff and ensuring a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly x4, then monthly x2, to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further 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

Surveyors identified that the facility failed to store drugs and biologicals in a safe, secure, and orderly manner on at least one of four medication carts, specifically the 100 Hall cart, which was observed left open and unattended with the computer screen displaying patient information. Additionally, multi-dose vials on both the 100 and 200 Hall carts were not labeled with the date opened, and several medications were found to be expired or had unreadable expiration dates. These findings were confirmed during staff interviews and direct observation. Further inspection of the Medication Room and Central Supply Room revealed multiple expired medical supplies and medications, including blood collection tubes, test slides, disposable thermometers, IV start kits, and various medications such as Dairy Aid, Preservision, Geri-tussin, and IV administration sets. The facility's policies require that medication carts remain locked when unattended and that multi-dose containers be labeled with the date opened, but these procedures were not followed as evidenced by the observations and staff verification.

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 and document required education regarding COVID-19, influenza, and pneumococcal vaccinations for several residents, as outlined in its own policies. Specifically, three residents received the COVID-19 vaccine, two residents received or refused the influenza vaccine, and five residents received the pneumococcal vaccine without documented evidence that education on the benefits, risks, and potential side effects was provided prior to vaccination. These findings were confirmed through clinical record reviews, which showed that the education was not completed or documented for the affected residents. Interviews with the Nursing Home Administrator and Regional Administrator further confirmed that the facility did not provide or document the necessary vaccine education for the identified residents. The deficiency was cited under 28 Pa. code: 211.5(f) Clinical Records, as the facility's failure to follow its own policies resulted in incomplete documentation and lack of education for residents regarding their vaccinations.

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 showers and baths were provided or offered as scheduled for three residents who required extensive assistance with activities of daily living (ADLs). According to facility policy, residents unable to perform ADLs independently should receive appropriate support and assistance with hygiene and bathing. Clinical record reviews showed that one resident with diabetes, a right ankle foot ulcer, and morbid obesity required extensive assistance of two people for ADLs but did not receive scheduled showers on three occasions in April. Another resident with dementia and Down's Syndrome, requiring extensive assistance of one person, missed scheduled showers on six occasions in April. A third resident with diabetes, peripheral vascular disease, and chronic pain, requiring extensive assistance of two people, did not receive scheduled showers on five occasions in April. These findings were confirmed through review of facility shower schedules, ADL-Shower Task documentation, and staff interviews. The Nursing Home Administrator acknowledged that showers and baths were not provided or offered as scheduled for the three residents. The deficiency was cited under 28 Pa. Code: 211.12(1) Nursing services, 211.10(d) Resident care policies, and 211.12 (2)(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

The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple shifts over a seven-day period. Specifically, the facility did not provide the mandated one NA per 10 residents during the day shift on six out of seven days, one NA per 11 residents during the evening shift on three out of seven days, and one NA per 15 residents during the night shift on four out of seven days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfall in staffing on the specified dates.

Plan Of Correction

The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further 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 state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on two specific days, April 12 and April 13, 2025. On these days, the facility provided only 2.44 PPD and 2.81 PPD, respectively. This deficiency was identified through a review of staffing documents and nursing staff schedules covering the period from April 11 to April 17, 2025. The Nursing Home Administrator confirmed during an interview on April 18, 2025, that the facility did not meet the required PPD hours on the specified dates.

Plan Of Correction

The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. The RDO educated NHA/DON on ensuring sufficient nursing staff and ensuring a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly x4 weekly then monthly x2 to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.

Penalty

Fine: $17,220

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

Summary

The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident R1, who had severe cognitive impairment and was at risk for elopement. Resident R1 had a history of Alzheimer's disease, bipolar disorder, schizophrenia, and a seizure disorder, which contributed to her wandering behavior. Despite being identified as an elopement risk and having an electronic monitoring bracelet ordered, Resident R1 managed to leave the facility without staff knowledge on multiple occasions. On the day of the incident, Resident R1 was observed outside the facility on two separate occasions. Initially, she was found outside near another resident's room and was brought back inside by staff. Later, she was seen in the parking lot and was found attempting to get into a vehicle. Staff intervened and managed to bring her back into the facility. The facility's records and staff interviews revealed that there were lapses in monitoring and documentation, including failure to perform risk management, vital checks, and notify the family or physician promptly. The situation was further complicated by a busy evening where multiple incidents occurred simultaneously, including another resident attempting to leave, a choking episode, and a seizure incident. The facility's response was inadequate, as evidenced by the lack of immediate and thorough assessments, failure to update care plans, and insufficient communication among staff. This failure to provide adequate supervision and monitoring created an immediate jeopardy situation for 19 of the 91 residents in the facility.

Removal Plan

• Facility recovered resident and provided safety. RN assessed resident and provided safety.
• Physician and Resident Representative notified of event.
• Wander guard device checked for placement and function.
• All door alarms checked for function and lock mechanism to ensure facility is secure.
• Resident care plan reviewed and updated to ensure accurate and appropriate interventions in place.
• Witness statements obtained, and headcount checks completed.
• Supervisor conducted door securement and alarm audit and initiated a 4 point system to monitor doors to ensure security.
• Supervisor posted staff at each door while audit conducted to ensure doors are shut, locked, and alarms are on and functioning.
• DON directed RN supervisor and assigned nurse to ensure Resident receives an assessment, notify physician and family of incident, and ensure resident is monitored to prevent reoccurrence.
• RN Supervisor performed assessment on the resident for injuries; none noted.
• Door audits completed to ensure doors are secure. Door alarm checks completed to ensure alarms are functioning.
• New alarms ordered to ensure that alarm sounds are loud enough to hear.
• Facility notified the attending physician to report findings and conditions of the resident and the resident's legal representative.
• Documentation of incident in residents record completed.
• Resident's care plan and orders reviewed and updated to ensure Wanderguard and exit seeking behaviors addressed in care plan and orders as appropriate.
• All residents assessed for Elopement Risk.
• Residents newly identified to have potential for elopement had care plans updated with appropriate interventions.
• Facility-initiated house audit for exit/entry points to ensure alarm function and doors lock appropriately.
• Facility conducted whole house resident head count to ensure accountability of residents.
• House audit conducted on resident wanderguard orders to ensure accuracy.
• All Wanderguards placed on residents assessed for function, care plans updated as needed.
• Elopement Books audited to ensure accuracy and placed at each nurses station and reception area.
• RN Supervisor provided a discipline due to not following DON directive to ensure that Resident was assessed and notifications occurred and documented.
• RN terminated due to failing to complete these tasks.
• Nurse assigned to resident on cart also failed to ensure resident was accounted for and skin checks performed following incident. DON provided discipline to this nurse for failure to complete tasks. Termination resulted.
• All residents in house will be assessed for elopement risk by the Director of Nursing or designee.
• All care plans for residents identified with elopement risks will be reviewed and updated with interventions to prevent elopement by the Director of Nursing or designee.
• All residents identified to be elopement risk will have wanderguard placed and added to Elopement Binder per protocol.
• House audit on all doors and exit points will be conducted by Maintenance to ensure that facility is secure and alarms are functional.
• House audit on all wanderguards will be conducted to ensure placement and function.
• Facility Director of Nursing or designee will conduct education to all facility staff regarding dementia/behavior in LTC residents, Elopement risk and mitigation, and Elopement Policy and Procedures to include keeping doors secure.
• Education will be completed for all clinical staff on Elopement Risks, Assessments, Care Plans, and Supervision of Residents by the Director of Nursing or designee.
• Elopement Books with identified resident photos will be placed on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee.
• Audits will be conducted on all doors/exits by Supervisor twice per shift daily and then weekly thereafter.
• Maintenance Director or designee will conduct daily (twice per shift) audit on doors to ensure secure and alarmed. Audit will remain ongoing.
• All new admissions will be reviewed for elopement risks by IDT and ongoing.
• Elopement assessments will be audited for compliance by IDT and will remain ongoing.
• An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee.

Penalty

Fine: $17,220

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

Summary

The facility failed to protect a resident from neglect, resulting in the actual harm of an elopement. The resident, identified as Resident R1, had severe cognitive impairment and was at risk for elopement due to conditions such as Alzheimer's disease, bipolar disorder, schizophrenia, and a seizure disorder. Despite being identified as an elopement risk and having an electronic monitoring bracelet ordered, the resident managed to leave the facility without staff knowledge. On the day of the incident, Resident R1 was observed outside the facility on two separate occasions. Initially, the resident was found outside near another resident's room and was brought back inside by staff. However, later the same day, the resident was seen in the parking lot and was found attempting to get into a vehicle with an unknown community member. The resident was eventually brought back to the facility by a staff member who intervened. The facility's staff, including RN Employee E2 and RNS Employee E4, failed to complete necessary assessments and implement 15-minute checks after the first elopement attempt, which allowed the resident to elope a second time. The Director of Nursing confirmed that these failures in protocol contributed to the resident's ability to leave the facility again, leading to the termination of the involved staff members.

Penalty

Fine: $17,220

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 comply with the requirements for notifying resident representatives and medical providers of changes in medication or condition for three residents. Resident R10, who had a BIMS score indicating severe cognitive impairment, was prescribed Eliquis, an anticoagulant medication, but there was no documentation of communication to the resident's healthcare power of attorney about this new medication order. This lack of communication could have impacted the resident's care and decision-making process. Resident R11, with a BIMS score indicating moderate cognitive impairment, experienced a significant change in condition, including nausea, vomiting, and low food consumption. Despite these changes, there was no documentation of communication to the resident's spouse, who was the healthcare decision maker, about the initiation of intravenous fluids or the resident's refusal of meals. Additionally, there was no evidence of communication with the medical provider regarding the resident's symptoms or the need for treatment for nausea and vomiting. Resident R2, with a BIMS score indicating severe cognitive impairment, experienced a significant change in condition when found unresponsive and later transported to the hospital. The facility failed to document notification to the resident's daughter, who was the responsible party and power of attorney, about the change in condition and the hospital transfer. The lack of documentation and communication in these cases highlights the facility's failure to adhere to the notification requirements, potentially affecting the residents' care and safety.

Plan Of Correction

The responsible parties for Residents R10, R11, and R2 were contacted immediately upon identification of the deficiency to provide retrospective notification and updates on the resident's condition and treatment. The attending physicians and providers were also notified where clinical follow-up was necessary. Progress notes were updated to reflect the communications and any interventions completed post-notification. The DON/designee conducted a house audit for new medication orders, changes in condition, and transfers to the hospital, from 3/31-4/21, and validated documentation of notification to the physician and resident representative. The DON/designee will provide education to licensed nurses to ensure notifications must occur for residents with change in condition, new treatment orders, and transfers out to the hospital by 4/30/25. The Director of Nursing (DON) or designee will perform an audit on the following: new medication orders, changes in condition, transfer to hospital, and documentation of notification to the physician and resident representative; 5 days per week for 4 weeks, then 3 days per week for 2 weeks.

Penalty

Fine: $17,220

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

Summary

The facility failed to notify physicians of abnormal Capillary Blood Glucose (CBG) levels for four residents, as required by their care plans and physician orders. The facility's policy on diabetes management mandates that staff incorporate physician-ordered parameters for blood sugar monitoring into the Medication Administration Record (MAR) and care plan. However, the review of clinical records revealed that staff did not notify physicians of elevated or decreased blood sugar levels for Residents R7, R18, R19, and R20, despite these levels exceeding the thresholds set by their respective physician orders. Resident R7, diagnosed with coronary artery disease and diabetes, had multiple instances of elevated blood sugar levels, some as high as 600 mg/dL, without documentation of physician notification. Similarly, Resident R18, with multiple sclerosis and diabetes, had several elevated blood sugar readings above the physician-ordered threshold of 341 mg/dL, yet there was no evidence of physician notification. Resident R19, diagnosed with COPD and diabetes, also had elevated blood sugar levels exceeding 400 mg/dL without documentation of physician notification. Resident R20, with paraplegia and diabetes, had a significantly low blood sugar level of 38 mg/dL, but there was no documentation of reassessment or treatment for this low blood sugar. The Nursing Home Administrator and the Director of Nursing confirmed during an interview that the facility failed to notify physicians of these abnormal CBG levels for the four residents, indicating a lapse in adherence to the facility's diabetes management protocol.

Plan Of Correction

Facility is unable to retroactively correct identified notification for R7 blood sugar out of range for dates specified. Physician was made aware of trend in glucoses over this period. Medication was reviewed with physician to ensure order is appropriate. Facility is unable to retroactively correct identified notification for R18 blood sugar out of range for dates specified. Physician was made aware of trend in glucoses over this period. Medication was reviewed with physician to ensure order is appropriate. Facility is unable to retroactively correct identified notification for R19 blood sugar out of range for dates specified. Physician was made aware of trend in glucoses over this period. Medication was reviewed with physician to ensure order is appropriate. Facility is unable to retroactively correct identified notification for R20 blood sugar out of range for dates specified. Physician was made aware of trend in glucoses over this period. Medication was reviewed with physician to ensure order is appropriate. DON/designee will conduct a facility-wide audit of residents with sliding scale orders to ensure blood sugar values are reviewed, documentation of physician notification per ordered parameters, evidence of follow-up and resident response to abnormal readings. No negative findings. All licensed nursing staff will receive mandatory in-service training by DON on interpreting provider-specific glucose parameters, timely physician notification procedures, documentation expectations, and diabetes management protocol by 4/30/25. DON/designee will conduct audits 5 times per week for 4 weeks, then 3 times per week for 2 weeks on residents EMR with blood sugar out of range contains documentation of physician notification per ordered parameters, evidence of follow-up and resident response to abnormal readings.

Penalty

Fine: $17,220

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 treatment and services for pressure ulcers for two residents, R4 and R5, consistent with professional standards of practice. Resident R4, who had diagnoses including heart failure, arthritis, and cancer, was admitted to the facility and later developed a new Stage 2 pressure injury on the right buttock. Despite a wound care nurse practitioner's order for specific treatments and protein supplements to promote healing, these orders were not entered into the electronic medical record, and the Treatment Administration Record (TAR) did not document that the resident received the prescribed treatment. Similarly, Resident R5, who had diagnoses of diabetes and osteomyelitis, developed a new Stage 2 pressure injury on the right lower leg. The wound care nurse practitioner ordered specific treatments and protein supplements for this resident as well. However, the physician's orders and the TAR did not reflect these orders, and there was no documentation that the resident received the necessary treatment. Interviews with the Assistant Director of Nursing, the Nursing Home Administrator, and the Director of Nursing confirmed the facility's failure to ensure that residents received the required care for pressure ulcers. The facility's policy required the physician to order pertinent wound treatments, but this was not adhered to, resulting in a lack of appropriate care for the residents' pressure injuries.

Plan Of Correction

Resident 4 was immediately reviewed to ensure physician orders were entered correctly and wound care was immediately initiated, and all missed treatments were assessed and caught up as appropriate. A skin care note and wound progress documentation were entered retrospectively based on the wound nurse's findings. Resident's care plan was reviewed to ensure accuracy. Resident 5 was immediately reviewed to ensure physician orders were entered correctly and wound care was immediately initiated, and all missed treatments were assessed and caught up as appropriate. A skin care note and wound progress documentation were entered retrospectively based on the wound nurse's findings. Resident's care plan was reviewed to ensure accuracy. DON conducted facility-wide skin audit on all wound treatment orders to ensure timeliness of wound identification and documentation, presence of treatment orders in the EMR, accuracy of TARs and completion records. House skin sweep conducted to ensure all residents assessed for wounds and ensure treatments are completed per order. No harm was identified in any of these cases. Mandatory in-service training will be held by DON for all licensed nursing staff and wound care coordinators by 4/30/25 on wound care policies and procedures, proper and timely EMR documentation of new wounds and associated orders, TAR compliance expectations and treatment completion per physician order. DON/designee will audit all new wound treatment orders to ensure that treatments are being delivered and documented 5 days per week for 4 weeks, then 3 times per week for 2 weeks.

Penalty

Fine: $17,220

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 colostomy care and services consistent with professional standards of practice for two residents. Resident R5, who was admitted with diagnoses including diabetes, Ogilvie's syndrome, and pressure ulcers, had a physician order for specific colostomy appliances. However, the care plan did not specify the type and size of the appliance, leading to confusion among staff. A registered nurse admitted to being unaware of the correct appliance size and type, relying instead on available supplies in the resident's room or the supervisor's office. An observation revealed that the ostomy supplies lacked visible type or size information. Resident R6, admitted with ulcerative colitis, malnutrition, and a history of stroke, also had a physician order for specific colostomy appliances. However, the care plan did not include a developed plan for the presence of an ostomy. An observation of Resident R6's room showed a mismatch between the supplies present and the physician's order. The Central Supply employee confirmed that sizes are listed on the shipping receipt, but this information was not effectively communicated to the staff. The Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to provide care consistent with professional standards.

Plan Of Correction

As of 03/28/25, colostomy care orders were reviewed and updated in the EMR per order for R5. Ostomy supplies were labeled and stored properly and care plan reviewed. As of 03/28/25, physician orders were clarified and entered per order for R6. The care plan was created and implemented to address ostomy care needs, risks of leakage, and maintenance of skin integrity. Incorrect supplies were removed from the resident's room, and the correct items were provided in clearly labeled original packaging. Central Supply updated the inventory records and verified product-match to orders. A facility-wide audit was completed for all residents with any type of ostomy (colostomy, ileostomy, or urostomy) to ensure orders were reviewed for completeness and accuracy, care plans were reviewed for alignment with physician orders and ostomy type, and supply availability, labeling, and product-match were verified in resident rooms. No adverse outcomes were identified during the audit. By 4/30/25, DON will conduct education for all licensed nurses, CNAs, and Central Supply staff on: - Ostomy care policy and procedures, to include: - Ostomy care protocols per professional standards - Matching product types and sizes to orders - Updating and referencing care plans before providing care - Labeling and organizing ostomy supplies in resident rooms DON/designee will conduct audits 5 times per week for 8 weeks, then monthly thereafter, of all residents with ostomies to ensure: - Product-match between orders, supplies, and usage - Proper labeling and organization of supplies - Care plan accuracy and staff documentation

Penalty

Fine: $17,220

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 was found to have insufficient nursing staff to provide necessary care and services to ensure the highest practicable physical, mental, and psychosocial well-being of ten out of eighteen residents. Observations and interviews revealed that call lights were not being answered promptly, with some residents experiencing delays of up to an hour. During an observation, six nursing staff members were seen seated at the nursing station without responding to a call light until a surveyor noted the time, prompting a response from a nurse aide. Residents reported long wait times for assistance, with some stating that there were not enough aides available, and those present were often on breaks. Grievances filed on behalf of residents highlighted issues such as inadequate staffing, resulting in residents not being moved, changed, or cared for in a timely manner. One grievance noted that a resident was not put to bed until late at night and had not been attended to since early morning. Another grievance mentioned a resident being told to wait until the next shift for assistance. Resident Council concerns also indicated ongoing issues with call light response times, particularly during the 3-11 shift and on weekends. The Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to maintain sufficient nursing staff to meet residents' needs.

Plan Of Correction

Facility failed to have sufficient nursing staff to provide nursing and related services. Residents voiced concerns during the group interview regarding delayed call bell response times, inconsistent medication administration, and missed care (showers, shaving, etc.) due to insufficient staffing. Immediately following the survey exit on 3/28/25, the facility initiated the following corrective actions: Reassessment of current staffing levels and assignment adjustments were completed to prioritize resident care needs, including call bell responsiveness, medication administration, and resident hygiene. Nursing leadership provided direct support to ensure critical resident care needs were met. Nursing assistants were reallocated to high-acuity areas as needed to ensure residents received care timely. All residents in the facility have the potential to be affected by insufficient staffing. A comprehensive review of staffing levels and resident care delivery for all residents was conducted by the Director of Nursing (DON) and Nursing Home Administrator (NHA) by 4/5/25. Focus areas included: - Timeliness of call bell responses. - Medication administration times. - Resident care delivery (showers, shaving, repositioning, ambulation, etc.). Corrective actions were implemented immediately for any identified concerns, and resident care plans were updated accordingly. All nursing staff received education on 4/7/25 and 4/8/25 regarding: - Prioritizing resident care needs. - Timely response to call bells. - Importance of accurate documentation of care provided. - Facility policies on safe staffing and reporting staffing concerns. Staffing Review Process: The DON or designee will review staffing levels daily during the clinical morning meeting to assess: - Adequacy of staffing for all shifts. - Appropriate staff assignment based on resident needs. - Coverage plans for any call-offs. Weekend staffing coverage will be reviewed and confirmed by the Administrator or DON by the preceding Friday afternoon each week. The DON or designee will conduct random audits on all shifts, observing: - Call bell response times. - Medication administration timeliness. - Completion of showers and daily care tasks. Audits will be conducted 5 times per week for 4 weeks, then weekly for 2 months, and monthly for 3 months thereafter.

Penalty

Fine: $17,220

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 appropriately document physician notifications for three residents, identified as R7, R8, and R9, regarding their blood sugar levels. The facility's policy requires that all services provided to residents, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. However, the review of the residents' records revealed that there were multiple instances where blood sugar levels exceeded the parameters set by physician orders, yet the notifications to physicians were not documented in a timely manner. For Resident R7, there were numerous instances of blood sugar levels exceeding 400 mg/dL, as per the hypoglycemia protocol, which required physician notification. Despite this, the progress notes indicated late entries for these out-of-range levels, created by the Director of Nursing (DON) on a single day, suggesting that the notifications were not made at the time of the incidents. Similarly, Resident R8 had blood sugar levels above 341 mg/dL, and Resident R9 had levels above 400 mg/dL, both requiring physician notification. Again, late entries were made by the DON, indicating that the notifications were not documented contemporaneously. The DON confirmed during an interview that the late entries were based on audits of the charts and that there was a book at the nurses' station for documenting physician notifications. However, the provided documentation showed entries in the same handwriting, raising concerns about the accuracy and authenticity of the records. The Nursing Home Administrator and the DON acknowledged the failure to appropriately document physician notifications for the three residents, which is a violation of the facility's policy and regulatory requirements.

Plan Of Correction

On 03/27/25, the Director of Nursing (DON) reviewed the medical records of Residents R7, R8, and R9. While some late entries existed, it was confirmed that not all physician notifications had been made or documented at the time of abnormal blood glucose results. The physician of record for each resident was contacted and updated on: - Past abnormal blood sugar values - Current status and any necessary follow-up The residents' plans of care were reviewed and updated to emphasize immediate reporting and documentation expectations for critical blood sugar readings. A facility-wide audit of diabetic residents with orders for sliding scale was conducted by DON, specifically reviewing: - Physician orders for blood sugar parameters - Blood glucose logs (CBG) - Progress notes and documentation of provider notification to ensure that orders are followed. By 4/30/25, mandatory in-service training will be conducted by DON/designee for all licensed staff on: - Diabetic Protocol - Proper documentation and notification practices. DON/designee will conduct audits 5 times per week for 4 weeks, then 3 times per week for 3 weeks on verified physician/family notification for out-of-range CBG results and treatments per order.

Penalty

Fine: $17,220

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 and Performance Improvement (QAPI) program failed to address previously cited deficiencies related to the notification of medical providers for out-of-range blood sugar levels. Despite having a plan of correction in place, the facility did not ensure compliance with the established protocols for notifying physicians when residents' blood glucose levels were outside the set parameters. This deficiency was identified during a survey, which revealed that the facility had not effectively implemented its QAPI program to correct these issues. The survey findings highlighted specific instances where residents with elevated blood sugar levels did not have documented notifications to their medical providers. For example, one resident had multiple instances of elevated blood sugar readings, some as high as 600 mg/dL, without any record of provider notification. Similar patterns were observed with other residents, indicating a systemic issue in the facility's process for managing and communicating critical health information. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to maintain an effective Quality Assurance Committee. This failure to address the concerns related to blood sugar management had the potential to affect 18 out of 91 residents, demonstrating a significant gap in the facility's quality assurance processes.

Plan Of Correction

Facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care. The Facility will maintain a Quality Assurance Performance Improvement (QAPI) plan according to regulation in order to ensure that the Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. To identify other areas potentially affected, the Facility will develop and implement appropriate plans of action to correct quality deficiencies and regularly review and analyze data, including data collected under the QAPI program and data specifically related to monitoring residents with sliding scale orders to ensure blood sugar values are reviewed, documentation of physician notification per ordered parameters, and evidence of follow-up and resident response to abnormal readings. To prevent this from happening again, the Nursing Home Administrator or designee will educate the Interdisciplinary Team and Quality Assurance Performance Improvement (QAPI) Committee to ensure the facility's Quality Assurance Performance Improvement program, and its participants, implement effective systems to correct quality deficiencies and ensure that plans effectively address recurring deficiencies. The Quality Assurance Performance Improvement (QAPI) committee will meet weekly for four weeks, then monthly for two months to ensure plans of correction and audit tools are effective. All licensed nursing staff will receive mandatory in-service training by the DON on interpreting provider-specific glucose parameters, timely physician notification procedures, documentation expectations, and diabetes management protocol by 4/30/25. The facility NHA will monitor corrections, education, and ongoing monitoring to ensure that plans are effective to address recurring deficiencies. The DON/designee will conduct audits five times per week for four weeks, then three times per week for two weeks on residents' EMR with blood sugar out of range, which contains documentation of physician notification per ordered parameters, evidence of follow-up, and resident response to abnormal readings. The NHA will submit reports to QAPI on compliance of audits. To monitor and maintain ongoing compliance for action plans related to providing quality care by monitoring resident blood glucose monitoring and ensuring appropriate interventions are implemented, the results from auditing and ongoing monitoring reviewed at the Quality Assurance Performance Improvement meetings will be reviewed by the Regional Clinical Operations Director to ensure adequate implementation of QAPI plans to maintain ongoing compliance. The DON/designee will submit a report to QAPI on the compliance with notification of physicians on high or low blood sugar levels. This will be done for a period of two months.

Penalty

Fine: $17,220

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 resident call system in three of five restrooms accessible to residents. During observations, it was noted that the staff restroom across from the 200-Unit nursing station and two staff restrooms across from the Activities room were unlocked and accessible to residents, yet lacked emergency call lights or call cords. This deficiency was confirmed by the Nursing Home Administrator during an interview, acknowledging that the restrooms were accessible to residents without the necessary emergency call systems in place.

Plan Of Correction

The three restrooms without emergency call systems (across from the 200-Unit nursing station and the Activities Room) were locked and labeled with signage stating "Staff and Visitors Only" to prevent resident access. All remaining resident-accessible restrooms were audited and confirmed to have functioning emergency call cords or buttons. A house audit was completed by the Maintenance Director on all public accessible restrooms to ensure that they are locked or had an accessible call bell. NHA/designee will conduct education for the facility maintenance director and assistants on ensuring all public accessible restrooms are locked or had an accessible call bell. NHA/designee will conduct an audit to ensure all public accessible restrooms are locked or have an accessible call bell, weekly for three weeks.

Penalty

Fine: $17,220

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 licensed nurses demonstrated the necessary competencies and skills to provide appropriate nursing services for a resident with diabetes. The deficiency was identified when a resident, who had a history of coronary artery disease, chronic kidney disease, and diabetes, became unresponsive with a capillary blood glucose level of 59. Despite the resident's condition, a Registered Nurse administered only half a tube of glucose gel because the resident was not swallowing properly and sounded gurgling. The nurse then administered a glucagon injection, which only raised the blood glucose level to 65. Further investigation revealed that a Licensed Practical Nurse initially stated she would administer glucose gel to an unresponsive resident, which is inappropriate. Upon correction, she acknowledged that she would not administer glucose gel but also stated she would not provide any medication, indicating a lack of understanding of the proper protocol for treating severe hypoglycemia. The Director of Nursing confirmed the facility's failure to ensure that licensed nurses had the appropriate competencies and skills to provide necessary nursing services.

Plan Of Correction

Resident 11 was immediately assessed and orders reviewed by to ensure appropriate. The incident was reviewed by nursing administration. Resident R11's care plan and diabetic protocol orders were re-reviewed and confirmed to be accurate and appropriate for future hypoglycemic events. A clinical record audit was completed by DON/designee to identify residents with orders for emergency interventions (e.g., glucagon) to ensure that orders are clear for glucose gel vs. glucagon based on response level. A facility-wide mandatory in-service was conducted on by DON/designee for all licensed nurses, focusing on: - Recognizing signs and symptoms of hypoglycemia - When and how to administer glucagon - Contraindications for glucose gel (i.e., unresponsive residents) - Immediate documentation and provider notification DON/designee will conduct audit on all blood glucose out of range interventions to ensure correct treatment 5 times per week for 4 weeks, then 3 times per week for 2 weeks. All hypoglycemic episodes will be reviewed by the DON to ensure proper treatment selection based on the resident's responsiveness, documentation of actions taken.

Penalty

No penalty information released

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

Summary

The facility failed to comply with the regulation requiring separate soiled and clean workrooms in utility rooms. During an observation, it was noted that the Side One soiled utility room lacked a proper keypad locking mechanism, as a button was missing, and the door was left open approximately two inches. Inside the room, there were red biohazardous waste bags and black waste bags on the floor, a folded mattress on the floor, used oxygen tubing in the sink, and more than thirty vacutainers, along with gastrointestinal, urine, and respiratory collection kits, and blood collection needle sets. This indicates that the facility did not maintain the required separation and organization of soiled and clean materials in the utility room, as stipulated by the regulation.

Plan Of Correction

Facility immediately audited all clean supplies were removed from the soiled utility room. Environmental Services (EVS) deep-cleaned and disinfected the space. Facility evaluated lock on utility room door to ensure function. Currently, lock is functional and door does properly close and lock. Facility conducted a facility-wide audit of all utility rooms to ensure soiled and clean items are separated per requirements. By 4/30/25, all relevant staff (including nursing, maintenance, EVS, therapy, and supply chain) were educated by the Infection Preventionist and DON on: - Environmental separation and cross-contamination risks - Proper storage and handling of clean and soiled supplies - Expectations for utility room use and reporting of noncompliance Facility will install new lock on soiled utility room door. Door closer will be adjusted to ensure positive latching. NHA/designee will perform bi-weekly inspections of all clean and soiled utility rooms for 1 month, then monthly thereafter. Results will be logged and submitted to the 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 comply with regulations by not providing separate soiled and clean workrooms in one of two utility rooms. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed that clean supplies were stored in the soiled utility room. Additionally, the facility did not provide hand-washing capabilities in both soiled utility rooms. Observations revealed that the Side One soiled utility room had used oxygen tubing in the sink, and access to the sink was blocked by two linen hampers. Similarly, the Side Two soiled utility room's sink access was obstructed by six linen hampers. These findings indicate a failure to maintain proper hygiene and separation of clean and soiled areas as required by the regulations.

Plan Of Correction

Facility immediately addressed both soiled utility rooms to ensure that linen hampers blocking sinks in side one and side two rooms were removed and relocated to designated dirty linen holding areas outside of the rooms. The sink in side one was sanitized and cleared of used oxygen tubing, which was disposed of appropriately. Both sinks were disinfected with a facility-approved EPA-registered disinfectant. A facility-wide audit of all clean and soiled utility rooms was conducted by the NHA on ensuring that sinks are accessible and soiled items remain separate as per requirements. By 4/30/25, mandatory clear access to all handwashing sinks in utility rooms and no storage of linen hampers, carts, or other obstructions within 3 feet of a sink, proper placement and handling of soiled linens and equipment. NHA/designee will conduct weekly audits of all utility rooms to verify unobstructed access to all sinks and proper storage and placement of soiled linens and equipment.

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 staffing levels for nurse aides (NAs) on multiple shifts over a five-day period. Specifically, the facility did not provide the mandated one NA per 10 residents during the day shift on four out of five days, one NA per 11 residents during the evening shift on four out of five days, and one NA per 15 residents during the night shift on three out of five days. This deficiency was identified through a review of staffing documents and confirmed by the Nursing Home Administrator during an interview. The specific dates and census numbers for each shift were documented, showing a shortfall in the actual hours provided compared to the required hours.

Plan Of Correction

The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further 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 staffing levels for Licensed Practical Nurses (LPNs) during the night shift on March 15, 2025. Specifically, the facility did not provide the minimum of one LPN per 40 residents, as mandated by the regulation effective July 1, 2023. A review of the nursing time schedules and facility census data from March 11 to March 15, 2025, revealed a staffing shortage on the night of March 15, 2025, when the census was 92 residents, but the actual LPN hours provided were insufficient. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 19, 2025.

Plan Of Correction

The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further 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 state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on four out of five days, from March 12 to March 15, 2025. A review of staffing documents and nursing staff schedules revealed that on March 12, the facility provided 3.17 PPD, on March 13, 2.70 PPD, and on both March 14 and 15, 3.02 PPD. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 19, 2025, who acknowledged the failure to meet the required staffing levels on the specified dates.

Plan Of Correction

The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities, or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. The RDO educated NHA/DON on ensuring sufficient nursing staff and ensuring a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further 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 notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia or hypoglycemia, affecting eight residents. These residents had various diagnoses, including diabetes, high blood pressure, depression, stroke, dementia, anxiety, and repeated falls. Despite having physician orders for insulin administration and care plans that required monitoring and reporting of blood glucose levels, the facility did not follow these protocols. For instance, Resident R3 had CBG levels of 430 and 409 on separate occasions, but there was no assessment for hyperglycemia, and the physician was not notified. Similarly, Resident R9 had multiple instances of high CBG levels, ranging from 410 to 450, without any assessment or physician notification. Resident R54's care plan included a sliding scale for insulin administration, requiring physician notification for CBG levels over 400, yet the resident experienced levels as high as 485 without the required actions being taken. Other residents, such as R55, R59, R61, R66, and R187, also experienced high or low CBG levels without appropriate assessments or notifications, indicating a systemic issue in the facility's management of diabetic care. Interviews with Licensed Practical Nurses (LPNs) revealed inconsistencies in the facility's protocol for notifying physicians of abnormal CBG levels. The Director of Nursing confirmed the facility's failure to provide timely and complete communication to physicians and to recognize, assist, and document the treatment of diabetes-related complications. The facility's documentation did not reflect careful assessment of diabetic residents, including vital signs, skin condition, meal consumption, mood changes, and other relevant factors.