Ridgeway Manor Healthcare Center

Penalty

No penalty information released

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

Summary

The facility failed to ensure the low-temperature dishwasher maintained the required final rinse temperature of at least 120 degrees Fahrenheit for proper sanitization of dishware and utensils. During observation, the dishwasher was found operating at 90 degrees Fahrenheit after wash and rinse, and the sanitizer test strip measured 100 ppm. Facility policy required low-temperature dishwashers to have a wash temperature of 120 degrees Fahrenheit and a final rinse sanitizer level of 50 ppm hypochlorite. Record review showed the dishwasher temperatures were repeatedly below the required level over approximately one month, with daily logs documenting readings ranging from 90 to 116 degrees Fahrenheit. The Certified Dietary Manager stated staff had continued documenting the temperatures and had notified management, maintenance, and the Ecolab manufacturer, and that Ecolab had previously replaced the thermostat but the dishwasher still registered low temperatures. The Maintenance Director stated he knew the dishwasher was not reaching temperature and that it had been that way for about one month. An Ecolab representative stated the facility's water heater was unable to keep up with demand and recommended installation of an additional water heater. The Administrator stated she was only made aware of the issue on 04/29/26.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that one CNA received a performance evaluation in 2025 for 1 of 5 direct-care staff records reviewed. Record review showed that CNA1 was hired in February 2023 and that the last performance evaluation in the staff file was completed on 01/15/25. The Staffing Coordinator stated that the facility did not have a policy on performance evaluation expectations. During interview, the DON stated she was new to the position, that her expectation was for CNA performance evaluations to be completed within 90 days of hire and annually thereafter, and that no CNA evaluations had been completed even though she had recently completed evaluations for nurses. The DON acknowledged that CNA1 should already have had a performance evaluation for the 2025-2026 evaluation period. The Administrator stated that HR typically generates notifications when annual CNA evaluations are due, that this may have been overlooked during a period without a DON, and confirmed that CNA1 should have had a performance evaluation completed for the 2025-2026 evaluation period.

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

Provide and implement an infection prevention and control program was cited after surveyors found that the facility did not ensure excessive lint was removed from the lint screens for 2 of 2 commercial clothes dryers in the main laundry room. Facility documentation stated that lint catchers should be cleaned after each load, and the laundry policy required equipment to be used and maintained according to the manufacturer's instructions. The dryer manufacturer's instructions also directed that the lint filter be cleaned at the end of the day to maintain proper airflow and avoid overheating. During observations on 04/29/26, surveyors noted excessive lint on the two lint screens below the dryers. The Laundry Assistant was present during the first observation. Later that day, the lint screens were again observed with excessive lint, while the walls and floor below the dryers had no lint present. During interviews, the Housekeeping Director and Laundry Assistant stated they were unaware the lint screens existed. The Housekeeping Director said he had been cleaning the walls, floors, and behind the dryers with a wet/dry vac but had never cleaned the lint screens, and he reported that a new lint log would include cleaning the lint screens.

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 one CNA received the required 12 hours of annual in-service training. Record review showed that CNA1 was hired in February 2023 and had completed only 8.5 hours of annual training through Relias in 2025, which was less than the minimum annual training expectation for direct-care staff. This was identified during review of 5 direct-care staff records. During interviews, the Staffing Coordinator stated the facility did not currently have a policy on annual training expectations. The DON stated she was not aware of the 12-hour minimum annual training requirement because she was new to the position, and said she had previously provided an in-service for direct-care staff covering dignity, respect, and resident rights. The Administrator stated that each CNA is expected to complete a minimum of 12 hours of training annually, that HR assigns 12 hours in Relias, and that staff completion had not been consistent without constant prompting.

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 administer operations in a way that ensured effective and efficient use of resources, resulting in interruptions to food service, oxygen supply arrangements, linen availability, and an incomplete facility assessment. Surveyors reviewed the facility’s undated and unsigned Business Continuity policy, which stated that critical resources would be identified, contracts with two or more vendors would be maintained, and emergency supplies would be stored at established par levels. The policy also called for ongoing evaluation of communication, resources, utilities, staff, food and water, and safety and security when sheltering in place. A separate undated and unsigned Compliance and Ethics Program policy stated that the facility would assign high-level personnel to oversee compliance, ensure sufficient resources and authority to assure compliance, and review the program annually to promote quality care. During the kitchen tour, surveyors observed that more than 90% of products in the freezer, cold, and dry storage areas bore a food delivery date corresponding to the day of survey, while photos taken earlier that morning by the Dietary Manager showed those same storage areas empty or nearly empty, with between zero and four items. The Administrator and ADON acknowledged that the survey was likely related to food delivery issues and stated this was the second time food delivery had been cut off for nonpayment, with the facility’s U.S. Foods account suspended and two scheduled deliveries missed. The Dietary Manager reported that this was actually the third such occurrence, that food deliveries normally occurred twice weekly, and that the last delivery before the suspension had been on a date when the account was subsequently cut off, causing missed orders. Receipts showed that menu items had to be purchased from local vendors, and payment records from U.S. Foods documented repeated large lump-sum payments made after multiple past-due charges had accumulated, with the account being suspended for nonpayment on multiple occasions. In the laundry area, surveyors observed covered racks of clothing awaiting distribution and bins of personal clothing to be folded, but no linens awaiting distribution and no emergency linen supply. Dirty linens were present in bins awaiting laundering. Invoices from a linen and medical supply vendor showed multiple orders for towels, washcloths, and sheets with 30‑day payment terms over several months, with unclear payment status. The Medical Supplies Clerk stated that ordered items frequently did not arrive because invoices had not been paid, that she would be told by vendors that payment was needed before further orders could be filled, and that this occurred several times per year. She reported that when supplies could not be ordered, items were sometimes obtained from local stores or online, and that the facility had gone through several vendors because bills were not paid. Surveyors also reviewed communications with the oxygen supplier, which showed the facility’s account placed on hold for being over the credit limit on multiple dates, with attached accounting statements. The Medical Supplies Clerk indicated she was responsible for central supply, including linen inventory and ordering medical supplies, and that outstanding invoices were reported to the Accounts Payable person. The Regional Director of Operations stated that the facility did not have a governing board, that the owner was the 100% owner, and that the corporate entity was considered the governing body. He described the owner as difficult to reach and personally signing checks, and he acknowledged that staff should not have had to worry about feeding residents or having enough supplies, and that lack of necessary supplies could affect morale and patient care. The Administrator reported that corporate cards used to purchase food and supplies were sometimes maxed out, that she did not know how much would be placed on the cards, and that although the owner “pulled them out at the last minute,” she was not confident they could get through an emergency. Review of the facility assessment showed it was undated, unsigned, and had been reviewed with the QAA Committee on a prior date, but several sections were blank or incomplete and lacked supporting documentation. A Profit & Loss Budget Overview for a recent month showed a negative net income. When asked about corporate compliance documents, bylaws, or operating policies, the RDO stated there were no bylaws or operating policy, that continuity of business was based on disaster preparedness, and that policies came from an external compliance store. Despite the posted corporate sign in the foyer emphasizing stewardship and improving quality of life, interviews and document reviews demonstrated repeated interruptions in critical vendor services for food, linens, and oxygen due to nonpayment or credit issues, and an incomplete facility assessment, all reflecting failures in the administration of the facility’s resources and compliance structures as observed by surveyors.

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 establish and demonstrate an active governing body that is legally responsible for setting and implementing policies for managing and operating the facility, including appointing a properly licensed administrator and ensuring an effective compliance and ethics program. Surveyors found no evidence of a governing board; the Regional Director of Operations (RDO) stated that there was no governing board, no names to provide, and that the owner was the 100% owner with no operating policy, and that “Mainstay” was described as the governing body without further clarification. The facility’s Compliance and Ethics Program policy was undated and unsigned, and although it stated the facility was committed to compliance and had designed, implemented, and enforced a compliance and ethics program with sufficient resources and authority, there was no evidence that this program was actually implemented. The RDO reported that policies came from a “compliance store” and confirmed there were no bylaws or operating policy, and continuity of business was described as being based on disaster preparedness. Surveyors also identified failures in facility assessment and financial/operational management. The facility assessment was incomplete, unsigned, and contained several blank or incomplete sections with many areas lacking supporting documentation, despite being reviewed with the QAA Committee. A Profit & Loss Budget Overview for a recent month showed a negative net income. Review of a U.S. Foods Customer Account Application showed that payment terms required timely payment of all charges, and the report notes that vendors were not getting paid, resulting in disruption in delivery of food and supplies to residents. Attempts to contact the owner and the accounts payable clerk by telephone and electronic communication were unsuccessful. The RDO indicated that the owner’s sister-in-law handled accounts payable and described reliance on corporate credit cards and a regional maintenance person with access to funds for emergency needs, but no formal governing structure, bylaws, or operating policies were provided to surveyors.

Penalty

No penalty information released

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

Summary

The facility failed to conduct and document a complete facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. The facility assessment on file was undated in the report, not signed, and lacked evidence of review and active involvement by all required participants, with no signature page or other documentation identifying who participated in its development. Surveyors’ review of the assessment showed several sections were blank or incomplete and many sections lacked supporting documentation. During an interview, the Administrator and Regional Director of Operations confirmed that this incomplete and unsigned assessment was the only facility assessment available for review, and this inaction in administering the facility had the potential to affect all residents living in the facility. No specific residents, medical histories, or clinical conditions were described in the report.

Penalty

No penalty information released

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

Summary

Surveyors found that the facility failed to maintain an adequate supply of clean, good‑condition linens in The Home building, affecting all 58 residents there. During multiple tours of the 100 and 200 hallways, both linen closets consistently contained fewer than 10 towels, washcloths, fitted sheets, flat sheets, and pillowcases. A randomly selected washcloth was thin and torn at the seam, and sheets in the closets were worn and thin. In the laundry building, there were no clean linens awaiting distribution and no emergency supply of linens; only bins of dirty linens awaiting laundering were observed. Invoices from the linen supplier showed multiple orders for towels, washcloths, and sheets over several months, but it was unclear if or when these invoices were paid, and another order had only recently been placed. Staff interviews confirmed ongoing linen shortages and poor linen condition. The Administrator acknowledged that the linen closets were low and agreed that torn washcloths should not be used or present in the closets, further stating there was no emergency linen supply and that corporate delays in paying bills resulted in vendors refusing to send orders. The Housekeeping Supervisor reported frequent shortages, difficulty obtaining orders because bills were not paid, and reliance on local suppliers for last‑minute needs, also confirming there was no emergency linen stock. CNAs reported that there were not enough linens, especially washcloths and towels in the mornings, that this had been an issue for up to two years, and that it slowed or delayed resident care, sometimes resulting in residents not receiving baths when desired. A resident reported having to wait several times to be bathed because CNAs did not have enough supplies.

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 completely and accurately document the suspected cause of a resident’s finger fracture, contrary to its policy requiring that each medical record contain an accurate representation of the resident’s actual experiences. The resident had severe cognitive impairment, with BIMS scores indicating inability to complete interviews and impaired decision-making, and relied on staff to anticipate needs. Facility policy required documentation to be accurate, relevant, complete, and detailed enough to depict the resident’s care and responses. In the days surrounding the fracture, multiple progress notes documented significant behavioral disturbances, including the resident fighting staff during care, yelling, climbing and standing on the bed, striking at staff, appearing to experience visual hallucinations, and being very unsteady and weak. On one day, nursing staff documented that the resident was combative and required redirection and one-to-one care, and that bruising and swelling of the right ring finger were noted, prompting orders for Ativan, Tylenol, and an x-ray. Subsequent notes documented that x-rays were obtained, that there were conflicting radiology reports regarding the presence and location of a fracture, and that the resident continued to use his hand and fingers without signs of pain while buddy taping was ordered and implemented for several weeks. During interviews, the ADON, RN, MS clerk/CNA, and former DON all recalled that the resident had been standing on the bed, flailing his arms and legs, hitting or punching the walls, and being combative while staff attempted to provide care and obtain a urine sample. They indicated that the MS clerk had witnessed the resident punching the wall and that this behavior was believed to be the likely cause of the finger fracture. However, none of the contemporaneous progress notes documented that the resident was hitting or punching the wall, nor did they record this as a suspected cause of the fracture. The lack of specific documentation of the wall-punching behavior and its relationship to the injury resulted in an incomplete and inaccurate medical record regarding the cause of the resident’s fracture.

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 its Heating, Ventilation, and Air Conditioning (HVAC) systems in safe operating condition, resulting in inoperable or inadequate heating in the 200 and 300 halls and the lobby. On the date of observation, temperatures in the lobby were recorded below 71 degrees Fahrenheit, and multiple rooms on the 200 hall were without a functioning HVAC system. Residents were moved from the 300 hall due to the HVAC system being out of service. The facility's policy requires HVAC systems to be maintained according to manufacturer specifications and the Life Safety Code, with documentation of all inspections, tests, and maintenance to be kept by the Maintenance Director. Interviews revealed that the HVAC system had been out since earlier in the week, and the facility had contacted an outside company for repairs. The Regional Maintenance Director stated that filters are changed monthly but admitted to not maintaining documentation for the HVAC system as required by policy. The Facility Administrator was unable to specify the frequency of HVAC maintenance and deferred to the Maintenance Director. These actions and inactions resulted in the facility's inability to maintain required ambient temperatures for residents in affected areas.

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 monitor and prevent the misappropriation of narcotic medication for a resident, identified as R8, which led to a potential risk of serious harm due to drug diversion. R8, who was admitted with diagnoses including breast cancer and chronic pain, was prescribed oxycodone for pain management. However, discrepancies were found in the administration and documentation of the medication. The facility's records indicated that R8 received a total of 133 oxycodone tablets, but there was no documentation for 45 tablets, raising concerns about their whereabouts. The issue came to light when a registered nurse (RN1) and a licensed practical nurse (LPN1) discovered discrepancies in R8's medication orders and administration records. It was found that the unit manager (UM) had altered R8's oxycodone regimen without proper documentation, leading to confusion and mismanagement of the medication. The UM was found to have taken a blister pack of oxycodone pills, which she later returned with only two pills remaining. This incident prompted an investigation by the facility and involvement of local law enforcement. Interviews with staff revealed that there were inconsistencies in the handling and documentation of narcotic medications. The Director of Nursing (DON) and other staff members were unable to account for the missing narcotic sheets and blister packs, leading to further confusion about the administration of R8's medication. The facility's failure to maintain accurate records and secure narcotic medications resulted in a deficiency related to the misappropriation of resident property, specifically narcotic drug diversion.

Removal Plan

• The resident's medications were replaced and the MAR shows no doses of the medication were missed.
• An audit of all narcotic medications and controlled substance count forms was conducted. No other issues were identified.
• Policies and procedures were reviewed to identify any necessary revisions to aid in control of narcotic diversion.
• The facility reported the nurse to LLR.
• Education for all staff was initiated on resident abuse, neglect, and misappropriation of property, including the need for immediate reporting of suspicious behavior in relation to narcotic medications.
• Education is being provided to staff from all shifts and PRN and agency staff as well and will be conducted prior to their next shift. This education will be completed.
• All new hires will receive this education during their orientation, prior to resident contact.
• Policies and procedures were reviewed by the Admin, DON, RDO, and RNC to identify any necessary revisions to aid in control of narcotic diversion.
• Updates on the narcotic count sheet process and accounting were revised on the policy titled Controlled Substance Administration and Accountability.
• Changes included updating how the total number of meds is noted on the sheets and it now requires two nurses' signatures to add or remove medications.
• The diverted medications were identified as actually missing and the 2-hour report was sent to the state agency which was within the 2-hour window.
• All reportable events will be reviewed by the QAPI Committee to ensure timely reporting is accomplished.
• The controlled substance card count sheet was updated to include a full count of on-hand medications, with two nurses' signatures required to add or remove medications from the cart.
• The DON and/or Admin will audit narcotic counts and medications three times weekly until no further instances of non-compliance are found to exist.
• Once compliance is achieved, the audits will be conducted weekly going forward.
• All audit results will be provided to the facility QAPI committee for review.
• The facility QAPI committee will review the narcotic count audits for three months of audits showing no issues.

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 maintain pharmaceutical services for the receipt, disposition, reconciliation, and control of narcotic medication for one resident, identified as R8, who was receiving narcotic pain medication. This deficiency was identified during a survey and had the potential to place all residents receiving narcotic pain medication at risk of serious harm due to drug diversion. The issue was discovered when discrepancies were found in the narcotic count sheets and the administration records for R8's oxycodone medication. R8 was admitted to the facility with diagnoses including breast cancer, chronic pain, major depressive disorder, affective mood disorder, and anxiety disorder. The resident was prescribed oxycodone, a narcotic pain medication, to be taken every four hours while awake. However, a review of the medication administration records and narcotic count sheets revealed inconsistencies in the number of tablets administered and the number of tablets documented as received and destroyed. Specifically, there was a lack of documentation for 45 tablets, and the narcotic count sheets for several blister packs were missing. Interviews with facility staff, including the Director of Nursing (DON) and Registered Nurse (RN), revealed that the Unit Manager (UM) had taken possession of some of the narcotic medication and later returned a blister pack with two pills remaining. The UM left the facility grounds and quit when questioned about the missing medications. The facility's policies did not require two nurses to sign off on the receipt or removal of narcotic medications, which contributed to the lack of accountability and control over the narcotic medications.

Removal Plan

• The resident's medications were replaced and the MAR shows no doses of the medication were missed.
• An audit of all narcotic medications and controlled substance count forms was conducted. No other issues were identified.
• Policies and procedures were reviewed to identify any necessary revisions to aid in control of narcotic diversion.
• The facility reported the nurse to LLR.
• Education for all staff was initiated on resident abuse, neglect, and misappropriation of property.
• Education includes the need for immediate reporting of suspicious behavior in relation to narcotic medications and is being provided to staff from all shifts and PRN and agency staff as well and will be conducted prior to their next shift.
• Education will be completed.
• All new hires will receive this education during their orientation, prior to resident contact.
• Policies and procedures were reviewed by the Admin, DON, RDO, and RNC to identify any necessary revisions to aid in control of narcotic diversion.
• Updates on the narcotic count sheet process and accounting were revised on the policy titled Controlled Substance Administration and Accountability.
• Changes included updating of how the total number of meds is noted on the sheets and it now requires two nurses' signatures to add or remove medications.
• The diverted medications were identified as actually missing and the 2-hour report was sent to the state agency which was within the 2-hour window.
• All reportable events will be reviewed by the QAPI Committee to ensure timely reporting is accomplished.
• The controlled substance card count sheet was updated to include a full count of on-hand medications with two nurses' signatures required to add or remove medications from the cart.
• The DON and/or Admin will audit narcotic counts and medications three times weekly until no further instances of non-compliance are found to exist.
• Once compliance is achieved, the audits will be conducted weekly going forward.
• All audit results will be provided to the facility QAPI committee for review.
• The facility QAPI committee will review the narcotic count audits for audits showing no issues.

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 an effective Quality Assurance and Performance Improvement (QAPI) program, which resulted in inadequate identification, analysis, and addressing of issues impacting resident care, particularly in pharmaceutical services. This deficiency had the potential to affect all 85 residents in the facility. The facility's QAPI plan, revised in 2019, was designed to monitor and evaluate the quality and safety of resident care, but it was not effectively executed. The facility did not adequately collect, monitor, or improve initiatives related to pharmaceutical services, leading to potential serious harm to residents. One specific incident involved the misappropriation of narcotic medication for a resident, which was part of a sample of 21 residents reviewed for misappropriation. This failure to monitor, protect, and prevent drug diversion placed all residents receiving narcotic pain medication at risk of serious harm due to uncontrolled pain. The facility's lack of accountability and proper documentation for narcotic medications was highlighted by discrepancies noted in the Medication Administration Record (MAR) and narcotic sheets during pharmacy audits. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, revealed that excess narcotics were improperly stored in the DON's office without proper accountability or double verification. The facility had not addressed pharmacy reports in their QAPI meetings, and there was a lack of documentation on discussions regarding pharmacy quality assurance reports. These lapses in procedure and oversight contributed to the facility's failure to provide and maintain adequate pharmaceutical services, which had the potential to cause serious harm to residents.

Removal Plan

• The resident's medications were replaced and the MAR shows no doses of the medication were missed.
• The facility system for monitoring, identifying, reporting, tracking, and investigating adverse events related to pharmacy services after noted discrepancies in narcotic medication reconciliation were reviewed and updated as necessary to ensure the safety and wellbeing of the facility residents receiving narcotic medications.
• Education for all staff was initiated on resident abuse, neglect, and misappropriation of property. This education includes the need for immediate reporting of suspicious behavior in relation to narcotic medications and is being provided to staff from all shifts and PRN and agency staff as well and will be conducted prior to their next shift. All new hires will receive this education during their orientation, prior to resident contact.
• Policies and procedures were reviewed by the Admin, DON, RDO, and RNC to identify any necessary revisions to aid in control of narcotic diversion. As a result of the review, updates on the narcotic count sheet process and accounting were revised on the policy titled Controlled Substance Administration and Accountability. These changes included updating how the total number of meds is noted on the sheets and it now requires two nurses' signatures to add or remove medications and for receiving medications from the pharmacy.
• The controlled substance card count sheet was updated to include a full count of on-hand medications, with two nurses' signatures required to add or remove medications from the cart.
• The DON and/or Admin will audit narcotic counts and medications three times weekly until no further instances of non-compliance are found to exist. Once compliance is achieved, the audits will be conducted weekly going forward.
• All audit results will be provided to the facility QAPI committee for review.
• The pharmacy report will also be reviewed by the committee.
• The facility QAPI committee will review the narcotic count audits with no issues noted. Pharmacy reports will also be reviewed by the QAPI Committee to ensure timely reporting is accomplished.

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 food stored in the main kitchen was properly labeled and dated, which could potentially increase the risk of foodborne illness and infection for 79 residents who receive food from the kitchen. During an observation, it was noted that an opened bag of chicken tenders, a bag of fish fillets, and a bag of frozen French fries were not labeled with the date they were received or opened. The chicken tenders had a use-by date, but the fish fillets and French fries did not. Ice crystals were observed on the fish fillets, indicating possible freezer burn or spoilage. Interviews with the dietary staff revealed a lack of adherence to the facility's policy on food labeling and dating. The Dietary [NAME] (DC) was unsure of when the food items were received or opened and stated that staff would consult the Dietary Manager (DM) if they had questions about the usability of an item. The DM confirmed that it was the facility's expectation for all food items to be labeled with the date received and the date opened, but this was not being consistently followed. This lack of compliance with food safety standards was identified as a deficiency during the survey.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a Registered Nurse (RN) was on duty for eight hours a day, seven days a week, as required. This deficiency was identified for a total of seven days across July, August, and September 2024. The absence of RN coverage on these specific dates was confirmed through a review of the facility's Payroll Based Journal (PBJ) and Daily Census Reports, which showed that the facility had no RN coverage on 07/06/24, 07/17/24, 07/20/24, 07/21/24, 08/18/24, 08/22/24, and 09/01/24. The facility was licensed for 112 beds, and the census on these dates ranged from 93 to 101 residents. Interviews conducted with the Staffing/Medical Supplies (SMS), Human Resources Director (HRD), Administrator, Director of Nurses, and Regional Director of Operations (RDO) confirmed the lack of RN coverage on the identified dates. The facility's job description for a Registered Nurse outlines essential duties such as assessing and evaluating residents' health status, administering medications and treatments, and supervising other nursing staff. The absence of RN coverage on the specified dates created the potential for the clinical needs of all residents not to be met, as there was no RN available to perform these critical duties.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of misappropriation of narcotic medication to the state survey agency within the required two-hour timeframe. The incident involved a resident who was admitted with diagnoses including left breast cancer, chronic pain, major depressive disorder, affective mood disorder, and anxiety disorder. The issue was identified when the narcotic count for the resident was found to be incorrect, and the Director of Nursing (DON) was informed by an LPN about the missing oxycodone. The DON then informed the Administrator, and an investigation was initiated. During the investigation, the Unit Manager (UM), who was initially involved in care plan meetings, left the facility without notice and later returned to provide a statement. The UM handed over a blister pack of the resident's oxycodone with only two pills remaining, which she had in her possession. The local law enforcement was notified around 11:30 AM, but the state agency was not informed until 3:00 PM, after the facility had validated that drugs were missing. The delay in reporting was due to the facility's policy of confirming the validity of the incident before making a report. Interviews with the DON and Administrator revealed that they believed there was nothing to report until the situation was confirmed at 3:00 PM. The facility's policy requires immediate reporting of such incidents, but the staff waited until they had confirmed the details of the missing narcotics. This delay in reporting the misappropriation of medication had the potential to allow continued misappropriation, as the state agency was not informed within the required timeframe.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to professional standards of medication administration for one resident, identified as R8, which led to a discrepancy in the administration of oxycodone. R8, who was admitted with diagnoses including left breast cancer, chronic pain, and anxiety disorder, had a physician's order for oxycodone 5 mg to be administered twice daily for pain. However, a discrepancy was noted when the medication order was altered in the electronic medical record but not accurately reflected in the hard-copy narcotics book. This resulted in a situation where the medication administration record (MAR) did not match the actual medication orders, leading to potential medication errors. The issue was identified when LPN1 noticed a discrepancy in the narcotic box and informed RN1. Despite the availability of a drug reference library in the electronic medical record, LPN1 did not verify the medication before administration. The Director of Nursing (DON) and the Administrator both stated that nurses should not administer medication they did not personally prepare, highlighting a breach in protocol. This failure to follow proper medication administration procedures had the potential to expose residents to adverse effects due to incorrect medication administration.

Penalty

No penalty information released

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

Summary

The facility failed to update the care plans of two residents, R1 and R2, following an incident involving a potential sexual advance. R1, who has a diagnosis of HIV and is cognitively intact, allegedly approached R2, who has mild cognitive impairment, with a sexual advance in exchange for money. Despite the incident being reported and discussed among staff, the care plans for both residents were not updated to reflect the change in status or the potential for sexual contact. Interviews with staff and residents revealed discrepancies in the accounts of the incident. R1 denied any sexual contact with R2, while R2 initially admitted to receiving a sexual advance and giving money to R1, but later denied any contact after learning of R1's HIV status. The facility's policy requires care plans to be reviewed and revised upon a change in status, but this was not done for either resident, despite the incident being reported to the Minimum Data Set (MDS) Coordinator and the Interdisciplinary Team (IDT). The failure to update the care plans was attributed to the residents' denials of the incident and the Resident Representative's lack of concern regarding R2's potential sexual relationship with female residents. However, staff were aware that R2 no longer desired contact with R1 after learning of her HIV status. The Administrator acknowledged that the care plans should have been updated to reflect the change in condition, but this was not completed in a timely manner.