Avir At Arlington

Penalty

No penalty information released

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

Summary

The facility failed to ensure a Registered Nurse was on duty for a minimum of eight consecutive hours a day, seven days a week. Record review of the CMS PBJ Staffing Data Report showed no RN hours on multiple dates in January, February, and March 2025, and an undated excel file for RN time stamp hours from 01/01/25 through 03/31/25 also showed no RN coverage on numerous dates, with additional dates showing less than 8 hours of RN coverage, including 6.83 hours, 7.43 hours, 2.50 hours, 7.67 hours, 3.57 hours, 2.35 hours, 7.74 hours, 4.00 hours, and 7.37 hours on various days reviewed. During interviews, the HR Director stated the staffing coordinator was responsible for scheduling and that payroll and a contracted company reviewed RN hours for CMS submission. The Staffing Coordinator stated she was responsible for the schedule and knew of the 8 consecutive hour RN requirement, but said there was no RN scheduled during the identified gaps and that the facility had other licensed nurses. The DON, who had worked at the facility since January 2026, stated she would fill gaps herself or contact a PRN RN, but did not know why there was no RN coverage during the reviewed periods. The Interim Administrator stated there should be an RN scheduled for 8 consecutive hours and identified the staffing coordinator and HR as responsible for scheduling and review. The facility policy titled, Staffing, Sufficient and Competent Nursing, revised August 2022, stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents were informed, before or at admission and periodically during their stay, of services available in the facility and of charges for those services, including charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. The deficiency involved the failure to provide Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) forms and Notice of Medicare Non-Coverage (NOMNC) forms to 3 of 3 residents reviewed for Medicare/Medicaid coverage: Resident #26, Resident #62, and Resident #63. Record review of the facility’s Beneficiary Notice list showed these residents had discharged from a Medicare Part A stay with benefit days remaining. For Resident #26, the record showed a stroke diagnosis, a skilled service episode beginning 01/02/26, and a last covered day of 02/13/26; the SNF ABN and NOMNC were marked as not provided. For Resident #62, the record showed a diagnosis of metabolic encephalopathy, an original admission on 11/05/25 with readmission on 11/13/25, and a last covered day of 11/21/25; the SNF ABN and NOMNC were also marked as not provided. For Resident #63, the record showed a stroke diagnosis, a discharge on 12/27/25, and a last covered day of 12/22/25; the SNF ABN and NOMNC were marked as not provided. The Director of Social Services stated she was responsible for issuing SNF ABN and NOMNC forms and said she had been issuing them for managed care, but did not realize they were needed for traditional Medicare. She stated she had just been educated on the facility policy and when to issue the forms. The Interim Administrator stated the Director of Social Services was responsible for issuing the forms. The facility policy titled Medicare Advance Beneficiary and Medicare Non-coverage Notices stated that if Medicare would not pay for otherwise covered skilled services, the resident or representative is to be notified in writing, and that a NOMNC is issued at least two calendar days before benefits end and informs the resident of the pending termination of coverage and the right to an expedited review.

Penalty

No penalty information released

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

Summary

The facility failed to ensure care plans were developed in consultation with the resident and resident representative for two residents. For Resident #10, the record showed an [AGE]-year-old male admitted on 05/12/20 and readmitted on [DATE] with diagnoses including Type 2 diabetes mellitus with ketoacidosis without coma, Parkinsonism, and dementia. His MDS noted a BIMS score of 15 with memory intact and that he was able to make decisions related to care and required set-up to supervision with ADL care. The clinical record contained no documentation of quarterly care plan meetings with the resident or resident representative since admission, and the resident stated on interview that he had not been involved in care plan meetings and had not been given information about his medications. His family member stated she had not been involved in his care plan meetings since he had been at the facility. For Resident #11, the record showed an [AGE]-year-old female admitted on 01/04/2026 with diagnoses including unspecified fracture of the right femur, essential hypertension, and trigeminal neuralgia. Her MDS noted a BIMS score of 15 with memory intact and that she was able to make independent decisions related to care and required set-up to supervision with ADL care. The clinical record contained no documentation of an initial care plan meeting with the resident or resident representative. The resident stated she had not met with the SW or team members to discuss her plan of care, and the SW stated that care plan meetings are to be set up with the resident and family members or RP, with calls made to invite them, but no documentation was found in the clinical record of calls, invitations, or care plan meetings for either resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a safe, clean, comfortable, and homelike environment for 3 of 17 residents reviewed for environmental conditions. In Resident #14's room, observation showed flooring missing underneath one leg of one bed and two legs of another bed, with the flooring peeled back and rolling up at the edge of the bathroom entrance; black nonskid tape appeared to have been used over the missing and peeled areas. Resident #14's quarterly MDS identified him as a male with unspecified dementia and cerebral infarction, and his BIMS score was 5, indicating severe cognitive impairment. In the bathroom shared by Resident #2 and Resident #60, observation and interview showed the right sink knob was missing. Resident #2's quarterly MDS identified him as a male with cerebral infarction and a BIMS score of 14, indicating intact cognition. Resident #60's face sheet identified him as a male with hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and he stated the knob had been broken since he arrived and that it bothered him. Staff interviews confirmed maintenance requests were expected to be entered into the work order system, and the Maintenance Director stated he was aware of the flooring issue and that the sink knob had already been replaced.

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 each resident's environment remained free from accident hazards for 1 of 8 residents reviewed, involving a resident admitted with an unspecified fracture of the right femur, essential hypertension, and trigeminal neuralgia. The resident's MDS showed a BIMS score of 15 with intact memory, and she was able to make decisions related to her care but needed max to substantial assistance with ADLs. Her care plan contained no documentation related to self-administration of medication, and her physician orders contained no orders for self-administration of medication. Observation revealed a bottle of Gelatide Dietary Supplement on the resident's bedside table with a warning label stating to keep it out of the reach of children. When the LVN was asked about the supplement, she removed it from the room. The resident stated she had bought the supplement over the weekend and did not realize she could not have it with her, while the LVN stated the facility policy was that there were to be no medications of any kind at a resident's bedside and that if medications were found in a room, the physician was to be notified and an order obtained. The DON stated the resident had the supplement on her bedside table and reported that residents should have an assessment to determine if they can self-administer meds at the bedside, with a lockbox provided if they pass the assessment.

Penalty

No penalty information released

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

Summary

The facility failed to provide pharmaceutical services to meet the needs of each resident when station one’s nurses’ medication cart did not have an accurate narcotic log for Resident #21. Resident #21 was a female resident admitted and readmitted to the facility with diagnoses including pain and a BIMS score of 11, indicating moderately impaired cognition. Her physician’s order included Acetaminophen-Codeine 300-30 mg, one tablet by mouth as needed every six hours, and her February 2026 MAR showed the medication was last administered on 02/22/26 at 02:59. During observation and record review of the medication cart and Narcotic Administration Record, the narcotic log for Acetaminophen-Codeine showed 4 pills remaining while the blister pack count showed 5 pills. The log also reflected the medication was last administered on 02/24/26 at 8:00 PM. The LVN stated she did not realize the narcotic count and narcotic log did not match and said the count had been done with outgoing staff that morning, but the discrepancy was not noticed during shift change. The DON stated staff were expected to document narcotics when given and sign the narcotic log to prevent discrepancies, and that the narcotic administration record should match the count.

Penalty

Inspection fine: $121,953

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 develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents with wounds, and failure to follow an existing wound care plan. For one resident, a female with moderately impaired cognition and diagnoses including cancer, heart failure, and sepsis risk, the care plan identified her as at risk for skin alterations and documented an unstageable wound to the buttock. The care plan interventions included monitoring the site for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. Physician orders dated mid-month directed specific wound care to the coccyx, but the treatment administration record showed at least one missed treatment. Progress notes documented a reopened wound to the sacrum and buttocks and a weekly skin/wound note indicated an unstageable coccyx pressure injury with malodor, necrotic tissue, and detailed wound characteristics. Despite these findings, there was no evidence that the wound was consistently monitored for infection or that the physician was notified of changes in the wound’s condition. On the day of a family outing, nursing documentation reflected that the resident was described as stable and left with her responsible party for holiday celebrations with portable oxygen. The facility had previously informed the responsible party only that the resident had a “hot spot” on her bottom and was receiving treatment, without disclosing the severity of the wound. That same evening, the responsible party observed the wound at home, described it as large, dark, and unstageable with necrotic tissue and surrounding deep red tissue, and took the resident to the hospital. Emergency department documentation noted an unstageable decubitus ulcer to the coccyx with foul odor and necrotic tissue. Interviews revealed that the CNA who first saw the open wound on the resident’s buttocks notified an LVN, who estimated the wound as dime-sized but did not measure it and did not continue to visualize it after the initial date. Another CNA later reported noticing the wound appearing more open and notified a nurse. The wound care nurse practitioner evaluated the wound several days before the outing, documented an unstageable coccyx pressure ulcer with significant slough and eschar, ordered Dakin’s solution and iodoform packing, and requested a wound culture, but stated she was not notified about the wound until she arrived at the facility and that the facility should have notified her or the physician before the wound worsened. The facility physician confirmed he was only notified once about the wound and did not assess it between its identification and the resident’s transfer out. A second resident, a male with intact cognition and diagnoses including heart failure, wound infection, paraplegia, malnutrition, and chronic bone infection, had documented wounds including a Stage III pressure ulcer and chronic leg ulcers. His care plan addressed only a non-pressure chronic ulcer to the right leg, with interventions to monitor and document the wound’s location, size, and treatment, and to report abnormalities and signs of infection to the physician. There was no care plan in place for his chronic ulcer on the left leg or for the pressure ulcer on the sacrum, despite physician orders for wound care to both lower legs and the coccyx. Additionally, this resident was not listed on the facility’s wound report, even though the wound care nurse and DON acknowledged he had a pressure ulcer and two leg wounds and that the wound care nurse had already been providing wound care. The wound care nurse stated she was responsible for ensuring wound care plans were written and used them to educate staff, but could not explain why the care plan for the first resident was not followed or why the second resident lacked care plans for all of his wounds. The facility’s own policy required comprehensive, person-centered care plans with measurable objectives and timeframes that describe services to meet residents’ physical, mental, and psychosocial needs, but the documented practices for these two residents did not meet those requirements. The situation for the first resident escalated to an Immediate Jeopardy determination after it was identified that the resident’s wound site was not monitored for signs and symptoms of infection, the effectiveness of treatment was not evaluated, and the physician was not notified of wound changes, despite the presence of an unstageable coccyx pressure ulcer with necrotic tissue and malodor. The resident was taken out of the facility by her responsible party, who then sought emergency care after observing the wound. Hospital records documented an unstageable decubitus ulcer with foul odor and necrotic tissue, and the responsible party reported being told the resident had sepsis possibly due to the wound and that the resident later died. For the second resident, the absence of care plans for all documented wounds and the omission from the wound report represented additional failures to ensure that comprehensive, person-centered care plans were developed and implemented for residents with wounds, as required by facility policy and regulatory standards.

Removal Plan

• Resident #3's care plan was updated to reflect the current state of their wound and interventions per the interdisciplinary team's discussion.
• All residents with wounds were reviewed to ensure the care plans are reflecting the residents' current wound status.
• Regional Nurse Consultant will educate Director of Nursing, Assistant Director of Nursing, Treatment Nurse, and MDSC Nurse over the care plan policy with emphasis on care planning wounds (wound location, type, stage), following physician orders, and ensuring care plans are comprehensive person-centered, consistent with resident rights, and include measurable objectives and time frames to meet medical, nursing, mental and psychosocial needs.
• All licensed nurses will be educated over the care plan policy with emphasis on care planning wounds (wound location, type, stage), following physician orders, and ensuring care plans are comprehensive person-centered, consistent with resident rights, and include measurable objectives and time frames to meet medical, nursing, mental and psychosocial needs.
• The Treatment Nurse and/or Designee will complete and update the care plans with any changes for wounds.
• The Director of Nursing or Designee will review the wound care plans to ensure they are present, accurate, and being followed.
• In Quality of Care meeting, the Director of Nursing, Assistant Director of Nursing, Treatment Nurse, and/or Designee will review residents with wounds, weekly wound report from wound care nurse practitioner, facility wound report, wound care orders, and wound care plans to ensure accurate information is present and documented.
• Ad hoc QAPI performed with Medical Director to inform them of the Immediate Jeopardy and the facility's plan to remove the immediacy.

Penalty

Inspection fine: $121,953

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 necessary pressure ulcer treatment and services, consistent with professional standards of practice, for two residents with pressure ulcers. One resident, an older female with cancer, heart failure, and sepsis, was admitted without pressure ulcers but was identified on 12/09/25 as being at risk for skin alterations with an unstageable wound to the buttock. Her care plan interventions included monitoring for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. A physician order dated 12/18/25 directed staff to cleanse the coccyx with wound cleanser or normal saline, apply collagen, and cover with a dry dressing once daily. The Treatment Administration Record showed the ordered wound treatment was not completed on 12/19/25, and although LVN C documented treatment on 12/20–12/21, the Wound Care Nurse’s (WCN) initials appeared for 12/22–12/25 without the WCN recognizing or confirming those entries. Progress notes documented that on 12/18/25 a skin check identified a reopened wound to the sacrum and open areas to the left and right buttocks, with education provided on treatment and turning every two hours. On 12/22/25, a weekly skin/wound note by the WCN stated the sacral pressure injury was assessed and treated per order, with the wound cleansed and dressing changed, but no measurements or detailed wound characteristics were documented. On 12/24/25, the Wound Care Nurse Practitioner performed a first evaluation of the coccyx pressure ulcer, describing it as an unstageable pressure ulcer measuring 4.5 cm x 4.5 cm x 3.5 cm with 40% granulation, 40% slough, and 20% eschar, malodorous drainage, fragile and ecchymotic peri-wound tissue, and non-blanchable maroon discoloration. The Nurse Practitioner ordered Dakin’s solution for cleansing, iodoform packing, and a superabsorbent dressing to be changed every other day, and noted that a sharp debridement was not performed at that time. The Nurse Practitioner reported she was not notified about the wound until she arrived on 12/24/25 and that the facility had no wound culture supplies when she requested a culture. Interviews revealed multiple failures in assessment, treatment, and communication for this resident’s wound. CNA B reported first seeing the open wound on 12/18/25 and notifying LVN A, who estimated the wound to be about the size of a dime, obtained an order from the WCN, but did not personally treat or subsequently visualize the wound, assuming the WCN would do so. CNA C, who bathed the resident, noticed the wound looked more open on 12/21/25 and notified a nurse, stating that each time he saw the wound it had cream on it. LVN D, who performed wound care on 12/20–12/21, described the wound as about the size of a quarter, not very deep, and without drainage, and reported using calcium alginate and a dry dressing. The WCN stated she saw the wound on 12/22/25 and 12/24/25, described it on 12/22/25 as about the size of a tangerine and curved in but did not measure or document its size, and acknowledged she did not notify the facility physician of the wound and did not document her phone contact with the Nurse Practitioner on 12/22/25. The DON stated she never looked at the wound, and the facility physician confirmed he was only notified about the wound on 12/18/25 and was not informed of any subsequent changes or suspected infection. The resident’s responsible party reported the facility had described the area only as a “hot spot,” did not disclose the severity, and that when the resident was taken home for a holiday dinner on 12/25/25, the responsible party observed a large, dark, unstageable coccyx ulcer with necrotic tissue and a separate Stage II ulcer on the right lower buttock, then took the resident to the hospital, where the emergency department physician documented an unstageable decubitus ulcer with foul odor and necrotic tissue. The deficiency also includes improper wound care technique for a second resident with a Stage III sacral pressure ulcer and diabetes. This resident’s care plan required assessment and documentation of wound appearance, including size, depth, exudate, tissue type, odor, and location during dressing changes, and a physician order directed daily cleansing with wound cleanser, application of medical grade honey, and a bordered dressing. During an observed wound care procedure, the WCN sprayed wound cleanser on and around the ulcer, then used gauze to clean only the skin around the wound, leaving wound cleanser in the ulcer itself. After measuring the wound length, the WCN changed gloves while the DON held the resident’s left buttock away from the ulcer; when the DON briefly released the buttock, it fell onto the ulcer. The WCN then resumed care without re-cleansing the wound until prompted by a question about whether she would clean the wound, at which point she sprayed cleanser again but initially still did not remove it from the ulcer bed. Only after further questioning did the WCN use gauze to clean the wound cleanser off the ulcer and surrounding skin before applying the ordered treatment and dressing. Both the DON and the WCN later acknowledged in interviews that it was important to cleanse the ulcer and surrounding skin, and to re-clean the wound if the buttock touched it, and to remove wound cleanser from the ulcer to avoid transferring bacteria into the wound.

Removal Plan

• Assess all residents with wounds and communicate the current condition of each wound with the resident's physician and the wound care nurse practitioner to ensure proper treatments are in place to treat and heal the wounds.
• Provide education to the Director of Nursing, Treatment Nurse, and Assistant Director of Nursing on the Change in Condition policy as it relates to physician notification, following orders that promote healing and prevention of pressure ulcers, and documenting all characteristics of wounds, including measurements.
• Provide education to all nurses on the Change in Condition policy as it relates to physician notification.
• Provide education to all nurses, including the treatment nurse, on documenting all characteristics of wounds, including measurements, and following physician orders related to healing and preventing pressure ulcers.
• Complete a competency test with nurses related to physician notification, following orders that promote healing and prevention of pressure ulcers, and changes in skin.
• Designate the Treatment Nurse to complete wound care and assign coverage by the Assistant Director of Nursing, Director of Nursing, or a designated nurse when the Treatment Nurse is unavailable, with weekend wound care completed by the weekend supervisor or assigned charge nurse.
• Have the Director of Nursing and/or designee observe wounds to ensure documentation and proper notification are charted, immediately address discrepancies or concerns with the resident's physician and wound care practitioner, provide reeducation as needed, and review the wound care nurse practitioner's notes to ensure no additional concerns are noted.
• Perform an ad hoc QAPI with the Medical Director to review the IJ template, identify the root cause of the deficient practice, and discuss the facility's plan to remove the immediacy.

Penalty

Inspection fine: $121,953

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 immediately consult with a resident’s physician when there was a significant change in the resident’s condition, specifically a deterioration in wound status. The resident was an older female with a history of cancer, heart failure, and prior sepsis, cognitively moderately impaired, and at risk for pressure ulcers but initially documented as not having one. On 12/09/25, her care plan identified an unstageable wound to the buttock with interventions including monitoring for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. On 12/18/25, a skin check note documented a reopened wound to the sacrum and open areas to the left and right buttocks, and a wound care order was initiated to cleanse and dress the coccyx wound daily. Over the following days, multiple staff observed and treated the wound, but there were gaps and inconsistencies in assessment, documentation, and physician notification. The Treatment Administration Record showed the ordered wound treatment was not completed on 12/19/25, and different nurses, including the wound care nurse (WCN) and LVNs, provided care from 12/20/25 through 12/25/25. CNA staff reported first seeing the open wound on 12/18/25 and notifying nursing, describing it initially as about the size of a dime, and later noticing it appeared more open on 12/21/25 and again notifying a nurse. LVN D, who performed wound care on 12/20/25–12/21/25, described the wound as about the size of a quarter, not very deep, and without drainage. The WCN stated that when she saw the wound on 12/22/25 it was about the size of a tangerine, curved in, without drainage or odor, and that she contacted the wound care nurse practitioner by phone but did not document this contact or notify the facility physician. On 12/24/25, the wound care nurse practitioner conducted a first evaluation of the existing coccyx pressure ulcer, documenting it as an unstageable pressure ulcer/injury with malodor after cleansing, measuring 4.5 cm x 4.5 cm x 3.5 cm, with 40% granulation, 40% slough, and 20% eschar, exposed dermis and subcutaneous tissue, fragile and ecchymotic peri-wound with non-blanchable maroon discoloration, and moderate serosanguineous drainage. She ordered Dakin’s solution, iodoform packing, and superabsorbent dressings and requested a wound culture but was told the facility did not have supplies. The facility physician reported he was only notified about the wound on 12/18/25 and was not informed of any subsequent changes or suspected infection and did not assess the wound between 12/18/25 and 12/25/25. On 12/25/25, nursing documented the resident as stable when she left with her responsible party for a holiday outing. That same evening, the responsible party saw the wound at home, described having previously been told only that there was a “hot spot,” and took the resident to the hospital, where the emergency department physician documented an unstageable decubitus ulcer to the coccyx with foul odor and necrotic tissue. The facility’s failure centered on not immediately consulting the resident’s physician when the wound significantly changed and showed concerning characteristics, despite policy requiring physician notification for significant changes in condition, including changes in skin. The surveyors determined that this failure to notify the physician of the significant change in wound status constituted a deficiency and identified it as Immediate Jeopardy on 01/08/26. Interviews with the WCN, DON, facility physician, CNAs, and other nursing staff confirmed that the physician was not kept informed of the wound’s progression or potential infection after the initial notification on 12/18/25, even as the wound increased in size, became unstageable, and developed malodor and necrotic tissue. The facility’s policy on change in condition required physician notification for significant changes in physical condition, including skin changes, but this was not followed in this case, leading to the cited deficiency.

Removal Plan

• Assess all residents with wounds; communicate the current condition of each wound with the resident's physician and the wound care nurse practitioner.
• Regional Nurse Consultant will provide education to the Director of Nursing, Treatment Nurse, and Assistant Director of Nursing on the Change in Condition policy as it relates to physician notification and documenting all wound characteristics, including measurements.
• Provide education to all nurses on the Change in Condition policy as it relates to physician notification, including changes in skin.
• Provide education to all nurses, including the treatment nurse, on documenting all wound characteristics, including measurements.
• Complete a competency test with nurses on physician notification related to changes in skin.
• Designate the Treatment Nurse to complete wound care; assign the Assistant Director of Nursing, Director of Nursing, or a designated nurse to complete wound care when the Treatment Nurse is unavailable; assign weekend wound care to the weekend supervisor or assigned charge nurse.
• Director of Nursing and/or designee will observe wounds to ensure documentation and proper notification are charted; immediately discuss discrepancies or concerns with the resident's physician and wound care practitioner and provide reeducation as needed.
• Director of Nursing and/or designee will review the wound care nurse practitioner's notes to ensure no additional concerns are noted.
• Conduct a QAPI meeting with the Medical Director to review the IJ template, identify root causes of the deficient practice, and implement the facility's plan to remove the immediacy.

Penalty

Inspection fine: $121,953

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 a resident’s MDS assessment accurately reflected his clinical status, specifically his skin conditions and wounds. The admission MDS for a male resident with diagnoses including heart failure, wound infection, paraplegia, malnutrition, chronic bone infection, and a Stage III pressure ulcer documented only the Stage III pressure ulcer and did not indicate any other wounds. However, the resident’s care plan identified an actual impairment to skin integrity related to a non-pressure chronic ulcer on the right leg, with interventions to monitor and document the wound and report abnormalities to the physician. Additionally, the facility’s wound care report showed that the resident had an atypical lesion on the right leg, an atypical lesion on the left leg, and a Stage III pressure ulcer on the coccyx, all present on admission. Surveyors were unable to interview the MDS Coordinator, who did not return calls. The DON stated she did not sign the MDS assessment for this resident and did not know who was responsible for ensuring MDS assessments were correct, though she acknowledged their importance for ensuring appropriate care interventions. The Corporate Nurse reported that she signed the MDS assessment to show it was completed, while the MDS Coordinator actually filled it out. Facility policy on resident assessments indicated that a comprehensive assessment includes completion of the MDS and that the interdisciplinary team uses the MDS form mandated by federal and state regulations to conduct the resident assessment. Despite this policy, the resident’s MDS did not accurately capture all existing wounds documented elsewhere in the record.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with significant physical and cognitive impairments did not receive adequate supervision and assistance during transfers. The resident, diagnosed with Alzheimer's disease, hemiplegia, generalized muscle weakness, unsteadiness, and other mobility issues, was care planned and assessed as requiring extensive assistance for bed mobility with one person and total dependence with two-person physical assist for transfers. However, interviews and record reviews revealed that staff routinely transferred the resident alone, using a 'bear hug' technique, despite documentation indicating a two-person assist was required for transfers. Multiple staff members, including CNAs, reported transferring the resident by themselves, stating that the resident was now a one-person assist. Family observations corroborated that the resident was transferred by a single staff member, contrary to the care plan and MDS documentation. There was also inconsistency among staff and administration regarding the use of a gait belt, with conflicting statements about whether it was necessary or appropriate for the resident. The facility's policy required ongoing assessment and documentation of residents' transfer needs, including input from nursing and rehabilitation staff. Despite this, the care plan and MDS were not updated consistently to reflect the resident's actual transfer status, and staff did not follow the documented requirements for assistance. This failure to provide the required level of supervision and assistance during transfers constituted a deficiency in ensuring the area was free from accident hazards and that adequate supervision was provided to prevent accidents.

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 for food service safety in their kitchen, as observed during a survey. Cook G was found prepping food without a beard guard properly in place, leaving his beard exposed. This was confirmed during an interview with Cook G, who acknowledged the risk of bacterial contamination due to the lack of a beard guard. Additionally, the facility's refrigerator contained improperly stored food items, including a block of Swiss cheese that was partially wrapped and exposed to air, and a plastic container of green beans that was neither labeled nor dated. Cook G confirmed these observations and acknowledged the importance of proper labeling and sealing to prevent food contamination. The facility's Food Storage policy from 2018 requires all refrigerated foods to be dated, labeled, and tightly sealed. The FDA Food Code of 2017 also mandates that food storage containers be identified with the common name of the food and that refrigerated, ready-to-eat foods be clearly marked with the date by which they should be consumed or discarded. The failure to comply with these standards could place residents at risk for foodborne illness, as the food was not adequately protected from contamination.

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 confidentiality of residents' personal and medical information when a medication aide, MA E, left a laptop on a medication cart unlocked and unattended in the hallway of Station 3. This incident was observed by a surveyor, who noted that the laptop screen displayed resident information such as names, dates of birth, and photos. At the time of the observation, there were no staff present in the hallway, and a resident was seen walking past the unsecured medication cart. MA E admitted to being responsible for securing the laptop and acknowledged the risk of unauthorized access to residents' confidential information. Interviews with other staff members, including an LVN and the DON, revealed that they were unaware of the incident but confirmed that staff were trained to keep medication carts locked and secured when unattended. The facility's policy on medication storage did not address securing clinical records, and the Administrator confirmed the absence of a specific HIPAA policy. Despite regular in-service training on HIPAA compliance, the failure to secure the laptop posed a risk of unauthorized access to sensitive resident information.

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 properly secure medications in locked compartments on Station 3, as observed by a surveyor. A medication cart was found unlocked and unattended in the hallway, with a resident walking past it. The Medication Aide (MA E) responsible for the cart was inside a resident's room at the time. MA E acknowledged her responsibility to ensure the cart was locked and secure, admitting she thought she had locked it before entering the room. She recognized the risk of unauthorized access to medications, which could lead to ingestion and potential harm. Interviews with staff, including an LVN and the Director of Nursing (DON), revealed that they were unaware of the unlocked cart. Both confirmed that staff were trained to keep medication carts locked when unattended. The DON expressed her expectation that carts should always be locked and acknowledged the potential harm if medications were accessed by unauthorized individuals. The facility's policy mandates that medication carts be locked or attended by authorized personnel, highlighting a lapse in adherence to this 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 accommodate a resident's food preferences, specifically the request for daily oatmeal, which was not consistently provided. The resident, who had moderately impaired cognition and medical conditions including gastroesophageal reflux disease, diabetes, and end-stage renal disease, expressed dissatisfaction with the breakfast options, preferring oatmeal over the bacon and eggs provided. Despite communicating this preference to multiple staff members, including a nurse and a medication aide, the resident continued to receive meals that did not align with her request. Interviews with staff revealed a lack of clear communication and understanding regarding the resident's ongoing preference for oatmeal. LVN C and other staff members misunderstood the request as a one-time preference rather than a standing order. The Dietary Manager, who had recently started in her position, noted that menus were posted outside the dining room, and dietary staff followed diet orders on tickets. However, there was no established process for ensuring that resident preferences were consistently communicated and honored. The Director of Nursing (DON) and other staff acknowledged the potential risks of not honoring resident food preferences, including malnutrition and weight loss. The facility did not have a policy related to dietary services and resident preferences, which contributed to the communication breakdown and failure to meet the resident's dietary needs. The Administrator noted recent staff turnover in dietary services, which may have further impacted communication and service delivery.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the call system in a resident's room was functioning properly, which could place residents at risk of not receiving necessary care and services. The resident, an elderly female with moderately impaired cognition and a diagnosis of unspecified dementia, required supervision with dressing and partial assistance with transfers. During an observation, it was noted that when the call light button was pressed, the light above the door did not function, no sound was heard at the nurses' station, and the panel near the nurses' station did not indicate the call was placed. The call light was plugged into the wall using a cord that was split with another cord for the unoccupied half of the room, and the second call light was found to be functioning appropriately. Interviews with staff revealed that the resident's call light malfunction was not previously reported or logged in the maintenance records. The Maintenance Supervisor, who was responsible for testing call lights daily, was unaware of the issue and stated that call light malfunctions could place residents at risk. The Charge Nurse was also unaware of the malfunction and emphasized the importance of checking call lights periodically. The facility's policy required that defective call lights be reported immediately and logged in the maintenance log, but there were no entries related to call light malfunctions in the log book for the relevant period.