Avir At Luling

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 store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen. Surveyor observations showed that the handwashing sink in the kitchen had a brown stain around the drain and faucet, and the step-on trash can next to the sink was covered with a brown sticky substance on the lid and was non-functional, requiring staff to touch the lid to open it. The Dietary Manager and Dietary Aide both stated that all dietary staff were responsible for cleaning the sink and trash, and the Administrator stated the step-on trash was intended to prevent staff from touching the trash after handwashing. Additional observations revealed multiple bread products on the kitchen bread rack that were past their best by dates, including several packs of sliced bread and hotdog buns. During lunch service, the Dietary Manager was about to serve a slice of bread from a package with a best by date that had already passed and then removed it from the serving line after checking the date. The Dietary Manager stated that all staff, especially the cook, were responsible for checking expiration dates, that the bread had been expired for almost a week, and that residents were at risk for illness when they ate bread past the best by date. The Administrator stated that if food was not used by the best by date, it should be discarded and that serving food a week after the best by date could have a negative impact on a resident, depending on the product. Further observations in the kitchen showed that the AC unit was covered with dust, the silver cart used to distribute residents’ food down the hall was stained with brownish substances on both sides, and the blue crate used to store dishes was also stained with a brownish substance. The Dietary Manager acknowledged that the AC had dust that could cause cross contamination to food, that the silver cart needed to be power washed and the kitchen deep cleaned, and that the blue crate was not cleaned as it should be and was used to store dirty dishes. The Dietary Aide confirmed that the AC unit looked dusty, the silver cart had a lot of dirt and did not look good, and the blue crate used for dishes did not look clean. Facility policies on Food Receiving and Storage and Sanitation required safe food handling practices, proper dating and rotation of foods, and that kitchen areas, equipment, and waste containers be kept clean, in good repair, and sanitary.

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 a safe, clean, comfortable, and homelike environment by not maintaining functioning toilets and sinks in multiple resident rooms. Four residents were identified as being affected by non-functioning or inconsistently functioning bathroom fixtures. Surveyors’ observations confirmed that toilets did not flush and sinks produced no water or only low-pressure water in these residents’ rooms. Residents reported that these problems had been ongoing for weeks to months, and that they frequently had to rely on alternative locations, such as shower rooms or communal bathrooms, to perform basic hygiene tasks like handwashing, showering, and toothbrushing. One resident with paraplegia, depression, and generalized anxiety disorder, and with a BIMS score indicating no cognitive impairment, reported having no water in his sink or a working toilet for six weeks. He stated that he had to remove the toilet tank lid and pour a gallon of water into the tank to flush, despite his paraplegia, and expressed unhappiness about the lack of working bathroom fixtures in his room. Observation confirmed that his toilet did not flush and no water came from his sink. Another resident with a history of atherosclerotic heart disease, difficulty walking, anxiety, major depressive disorder, dementia, and PTSD reported that his water sometimes worked and sometimes did not, and that this had been occurring for a few months. He stated that the toilet took a long time to fill and could not always be flushed, that he considered the situation unsanitary and a health hazard, and that he had to go to another hall to shower, wash his hands, and could not brush his teeth in his own bathroom. Observation confirmed his toilet did not flush and his sink produced no water. A third resident with cerebral infarction, need for assistance with personal care, unsteadiness on feet, and generalized anxiety disorder, and with a BIMS score indicating no cognitive impairment, stated that his only issue at the facility was his bathroom. He reported that his toilet did not flush, his sink produced no water or only non-hot water, and that he had to use the shower room to brush his teeth, wash his hands, or use the bathroom. He stated that his bathroom often smelled foul because urine or feces remained in the unflushed toilet, and that staff only flushed the toilet once a day, with gallons of water kept in the room for flushing by pouring into the tank. Observation confirmed that his sink did not work and his toilet did not flush. A fourth resident with Alzheimer’s disease, Parkinson’s disease, muscle weakness, difficulty walking, and major depressive disorder, and with a BIMS score indicating moderate cognitive impairment, reported having no hot water in the sink and a full toilet. Observation revealed a toilet full of fecal matter and urine with a foul odor, and a later observation the same day showed the toilet still unflushed and the odor persisting. Interviews with staff and administration showed inconsistent awareness, training, and practices regarding the plumbing issues and interim measures. The maintenance director stated that the facility needed replumbing, that only certain rooms were affected, and that water bottles were being used to flush toilets by pouring water into the tank when residents requested assistance or when staff rounded. Some CNAs and nurses reported that they were told to use water jugs to flush toilets and to check toilets during rounds, and that the problem had been ongoing from about a week to up to two months, depending on the staff member’s account. However, an agency CNA and an agency LVN reported they had not been trained or specifically informed about flushing toilets with water bottles or performing toilet-flushing rounds. The administrator acknowledged that water pressure on the affected hall was inconsistent, that water bottles were placed in rooms for flushing, and that staff were told to check toilets during rounds, but also stated he was unsure whether in-services had been completed on offering alternatives for toothbrushing and handwashing. Record review showed no in-services on rounding to ensure toilets were flushed or on offering alternatives for hygiene, and no grievances related to bathroom concerns, despite multiple resident reports of ongoing problems. Facility policies on environmental services and resident rights indicated expectations for maintaining a standard of excellence in housekeeping and for treating residents with dignity and respect, including a dignified existence. Nonetheless, the documented observations and interviews demonstrated that several residents lived with non-functioning toilets and sinks for extended periods, relied on staff or themselves to manually flush toilets with water jugs, and experienced foul odors and lack of in-room access to running water for basic hygiene. These conditions and the inconsistent staff training and response led to the cited deficiency for failing to maintain sanitary, orderly, and comfortable interior conditions and to honor residents’ rights to a safe, clean, comfortable, and homelike environment.

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 refrigerator #2 and the inside kitchen freezer in safe operating condition. On 9/23/2025, refrigerator #2 was observed at 52 degrees. On 9/24/2025, refrigerator #2 was again observed out of range at 58 degrees, and the second freezer in the dry pantry room was observed at 30 degrees. During interview, the DM stated the breaker box may have triggered off and that maintenance had been made aware of the freezer issue. The DM also stated the thermometer inside the silver refrigerator might not be working and placed another thermometer, but the temperature remained out of compliance at 58 degrees. On 9/25/2025, refrigerator #2 was observed at 60 degrees on the outside thermometer and 58 degrees on the inside thermometer. The DM stated the refrigerator had read 39 degrees earlier that morning and that maintenance had adjusted the seal. The DM also stated the repair company had not come out the prior day and that items would be removed from the refrigerator until it was repaired. The ADM stated the maintenance director cleaned the refrigerator coils and that the service man was scheduled to come later that afternoon. Facility policy stated refrigerators are to be maintained at or below 41 degrees and freezers are to keep frozen foods frozen solid.

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 four residents had functioning toilets in their rooms, and it also had a shower room restroom on the 100 hall with a toilet seat that was not attached on one side. Resident #14, who had Alzheimer’s disease, diabetes, bipolar disorder, and a BIMS score of 7, was observed with a toilet that would not flush and had urine visible in the bowl with an odor of urine in the bathroom. He stated the toilet in his room had been broken since 09/18/2025 and that he had been using the public restroom in the hallway. Resident #6, Resident #31, and Resident #42 shared another bathroom, and observation showed that their toilet would not flush and had no water in the tank. Resident #6 had diagnoses including cerebral infarction, type 2 diabetes, and bipolar disorder, with a BIMS score of 13. Resident #31 had type 2 diabetes, need for assistance with personal care, and difficulty walking, with a BIMS score of 10. Resident #42 had type 2 diabetes, dementia, and constipation, with a BIMS score of 10. Interviews with these residents showed that they were using the hallway shower room restroom or, in some cases, relying on staff to fill the toilet tank with water jugs so the toilet could be flushed. The MD stated that the facility had called a service to review the water pressure and toilet issue and that the town had known water pressure problems. He explained that some toilets on the right side of the 100 hall were having trouble flushing because of water pressure, sediment buildup, hard water, and years of use, and that the facility was waiting for an invoice from the plumbing company before replacing pipes. The DON stated that residents could tell staff when they used the restroom so staff could refill the tank to flush it, and that CNAs had been inserviced to monitor the affected rooms. The ADON and ADM stated that residents have the right to a private working bathroom, while also noting that the shower room restroom was more public and did not lock from the inside for safety reasons.

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 comprehensive person-centered care plans with measurable objectives and time frames for 3 residents whose assessments and records showed identified needs that were not reflected in the care plans. The deficiency involved Resident #51, Resident #38, and Resident #26, and surveyors reviewed observations, interviews, and records showing that each resident had a condition or device that was not addressed in the comprehensive care plan. Resident #51 had diagnoses including end stage renal disease and cognitive communication deficit, and the quarterly MDS indicated he required hemodialysis. Physician orders documented care for a central venous catheter used for dialysis access, including dressing instructions and a dialysis schedule of Monday, Wednesday, and Friday. The resident’s progress notes documented that he returned from the hospital with a perma catheter to the left chest wall, and survey observation showed the catheter dressing was clean, dry, and intact. However, the care plan contained no focus areas, goals, or interventions related to the central venous catheter for dialysis access. Staff interviews reflected that medical devices should be included in the care plan, and the ADON stated Resident #51 should have care plan areas and interventions related to the dialysis access device. Resident #38 had diagnoses including anxiety disorder, unspecified mood disorder, and PTSD, and the discharge MDS reflected active psychiatric and mood disorder diagnoses. The care plan did not include a focus area for PTSD, related person-centered goals, interventions, or possible triggers. The facility’s trauma-informed care policy stated that individualized care plans should address past trauma, identify and decrease exposure to triggers, and be developed in collaboration with the resident and family as appropriate. In interview, the DON stated that new diagnoses such as PTSD should be included in care plans, and the ADM stated that care plans should be updated with new diagnoses and treatments. Resident #26 had severe cognitive impairment and was admitted with a parole-issued ankle monitor. Records showed the resident removed the monitor at one point because it hurt his leg, and an observation later showed the resident wearing the ankle monitor. The comprehensive care plan did not document the monitor, its impact on skin integrity, safety, or daily care, or staff interventions to monitor and report concerns. A CNA stated she checked the resident’s skin under the monitor but had not been given written instructions or guidance in the care plan. The ADON acknowledged the ankle monitor should have been included in the care plan, and the ADM stated the facility did not have a policy in place for residents with parole-issued ankle monitors.

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 use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 36 of 90 days reviewed in the third quarter of 2025. Review of the facility’s RN staffing hours showed no RN hours on multiple days in April, May, and June 2025, including weekends and several weekdays. During an interview on 09/24/2025 at 11:24 AM, the Administrator stated the RN days listed on the PBJ staffing did not have RN coverage, that he was unable to get an RN for those days, and that he had tried to recruit one with aids. He also stated the facility was not using agency staff for RN coverage, was working on getting a waiver, and did not have a policy for RN coverage, using the TAC instead. The Administrator stated the facility should have an RN on duty 8 hours a day 7 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 prepare pureed foods by methods that conserve nutritive value and flavor for 5 residents on pureed diets. During lunch service, a cook poured unmeasured amounts of milk into spaghetti and meatballs and into green beans, then added torn bread and hamburger bun pieces to the pureed mixtures. The food became loose or too thick during preparation, and additional unmeasured milk was added without using the recipe. The cook stated she had been employed since November 2024 and that it was her last day at the facility. She reported that she had been shown the puree process by a temporary dietary manager who was not certified and that she had no support in the dietary department. She also stated she estimated she was preparing enough food for five puree diet residents but did not consult the recipe, and that she had been instructed to use bread even though she knew it was not according to the recipe. A test tray later showed that the pureed meal had a sticky texture and bland taste and did not replicate the regular texture meal. The DON stated she was unsure of the puree process details and that the dietary department should follow recipes. The ADM stated the pureed diet should be pudding or mashed potato consistency and that staff should follow recipes as written. The DM stated she did not know whether cooks were trained properly on diet textures and confirmed that staff were expected to follow recipes.

Penalty

No penalty information released

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

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen and related storage areas. During observations of the kitchen, refrigerators, freezers, the dry pantry, and outside freezer storage, surveyors found multiple food items that were unlabeled, undated, or both, including bowls of pudding and applesauce, tuna, ham salad, salad dressing, sour cream, a ham sandwich, chicken alfredo, eggs, peas, fish, waffles, meatballs, cake mix, spam meat, meat strips, hamburger patties, zucchini, bread, and hamburger buns. Several items had dates that were past the discard date or had dates that did not clarify whether they were received, opened, or discard dates. Staff also had food items stored in the kitchen refrigerator that appeared to belong to staff. Surveyors observed expired food items in the refrigerator and dry pantry area, including tuna, ham salad, a ham sandwich, and hamburger buns with a best-buy date that had passed. In the silver refrigerator, the temperature was repeatedly observed above the required range, with readings of 52 degrees, 58 degrees, and 52 degrees on different checks. Food in that refrigerator included cooked meatballs, opened fruit cocktail, uncovered pureed fruit, breakfast sausage patties, dairy products, and other items without proper labeling or dating. In the dry pantry freezer, food was observed thawing while the freezer temperature was 30 degrees and out of compliance. The trash containers in the kitchen were observed without lids, and the outside freezer storage room was observed with dirty residue inside the freezers, including dark brown residue and dead bugs in one freezer. Interviews with the Dietary Manager, DON, and Administrator showed that staff were aware of expectations for labeling, dating, discarding expired food, maintaining temperatures, and keeping trash containers covered, but the DON stated she had not reviewed the policy and the Dietary Manager stated she was not familiar with this facility's labeling, dating, and storage policy. The facility policy required food storage areas to be kept clean and sanitary, dry foods to be labeled and dated, and refrigerated or frozen foods to be covered, labeled, dated, and stored at proper temperatures.

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 Resident #25’s right to dignity and privacy during personal care when CNA C provided care with the resident’s door open. Resident #25 was admitted on 05/12/2025 with diagnoses including type II diabetes mellitus with diabetic chronic kidney disease, Alzheimer’s disease with early onset, and unspecified dementia. The resident’s MDS assessment dated 08/18/2025 showed a BIMS score of 2 out of 15, indicating severe cognitive impairment, and the care plan stated that the resident’s ADL care would be met by staff. During observation on 9/23/2025 at 9:21 AM, CNA C was seen providing personal care to Resident #25 with the door open. The surveyor later described that the care included opening the resident’s brief on both sides, adjusting it, rolling the resident over with the brief exposed, and placing a pad under him while the door remained open. During interview, CNA C stated staff should knock before entering, inform the resident of the care to be provided, and close the door to ensure privacy, and acknowledged that not closing the door could affect dignity and be embarrassing. The DON stated staff are expected to knock and close doors during care and acknowledged that failing to close a resident’s door during care could constitute a dignity infraction.

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 coordinate assessments with the PASRR program for one resident who had a history of mental health diagnoses and a new diagnosis of PTSD. Record review showed the resident’s diagnoses included atherosclerotic heart disease, auditory hallucinations, major depressive disorder, anxiety disorder, unspecified mood disorder, and PTSD, with PTSD listed as an active diagnosis during the stay. The resident’s discharge MDS also reflected active anxiety disorder and PTSD under the psychiatric/mood disorder category. The resident’s only PASRR Level I, dated 11/08/2018, reflected that he did not have any mental illness. The record review also showed no care plan focus area for PTSD with related person-centered goals and interventions. During interview, the ADON stated that the resident did not have PTSD when admitted in 2018, that she was responsible for PASRR duties, and that she was still learning after completing a self-study. She stated she was not aware that the resident had not had an evaluation since 2018 until asked by the survey team. The DON stated that a PASRR evaluation should be completed with a new diagnosis of PTSD, and the ADM stated that a PASRR evaluation should be done for a new diagnosis of PTSD. The facility policy stated that PASRR is intended to ensure individuals with mental illness or intellectual disabilities receive appropriate care and services, and that a Level II evaluation is conducted if the Level I screening indicates potential mental illness or intellectual disability. The report also noted the facility policy for trauma-informed care, which calls for individualized care plans that address past trauma and recognize the relationship between past trauma and current health concerns.

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 review and revise the person-centered, comprehensive care plan for one resident to reflect his current need for staff assistance with placement of his indwelling catheter bag after he self-transferred back to bed. The resident had diagnoses including cerebral infarction, encephalopathy, and urinary retention, and his quarterly MDS reflected a BIMS score of 12, partial to moderate assistance with transfers, and an indwelling urinary catheter. His comprehensive care plan dated 07/09/2025 included interventions for catheter and drainage bag care, keeping the tubing and bag below the bladder, and ensuring staff were aware of correct placement of the catheter gravity drainage bag and tubing. Observations on multiple occasions showed the resident in bed with the indwelling catheter bag lying on the floor next to his bed. During interview, the resident stated he put himself in bed and did not know what to do with the catheter bag. A CNA stated the bag should not be on the floor and that the resident transfers himself most of the time after smoke breaks, but staff did not check on him to ensure the bag was positioned properly. The DON and ADON both stated the catheter bag should not be on the floor and that the resident’s need for staff to check and position the bag after self-transfers should have been reflected in the care plan, but it was not.

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 appropriate care for a resident with an indwelling urinary catheter to prevent urinary tract infections when the catheter drainage bag was observed lying on the floor next to the bed. Resident #43 was admitted and readmitted with diagnoses including cerebral infarction, encephalopathy, and urinary retention, and the quarterly MDS reflected moderate cognitive impairment, partial to moderate assistance with transfers, and an indwelling urinary catheter. The care plan included interventions to keep the catheter drainage bag and tubing below the bladder and to ensure staff were aware of correct placement of the gravity drainage bag and tubing. During observations on multiple occasions, Resident #43 was found in bed with the catheter bag on the floor. When asked, the resident stated he did not know what to do with it. A CNA stated the bag should not be on the floor and that staff should check after smoke breaks to make sure it was positioned properly by hanging from the bed, but she had not thought about it. The DON stated the catheter bag should not be on the floor and that staff were expected to check frequently to ensure proper placement. The facility policy stated catheter tubing and drainage bags are to be kept off the floor.

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 care or services that was trauma informed and/or culturally competent was not ensured for Resident #38, who had diagnoses including PTSD, anxiety disorder, major depressive disorder, unspecified mood disorder, auditory hallucinations, and atherosclerotic heart disease. Record review showed the resident’s MDS reflected active PTSD and anxiety disorder, but the care plan printed on 09/24/2025 had no focus area for PTSD, no person-centered goals or interventions related to PTSD, and no possible triggers identified for the condition. During interview, the resident stated he had no concerns with nursing care and that staff treated him well. The ADON stated the resident should have PTSD included in the care plan and said she was responsible for all aspects of resident care plans, while also stating the DON and nurses were not updating care plans at that time. The DON stated the ADON was responsible for care plans, but also said she had not been trained on how to use the care plan system yet; she agreed PTSD should be included with individualized goals and interventions. The ADMIN also stated the care plan should be updated with PTSD and that missing appropriate updates and interventions could result in potential harm to residents. The facility policy for Trauma Informed Care and Culturally Competent Care required individualized care plans that address past trauma, identify and decrease exposure to triggers, and incorporate resident preferences and cultural needs.

Penalty

No penalty information released

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

Summary

The facility failed to establish and maintain an infection prevention and control program for 2 of 4 residents reviewed for infection control. During wound care for a resident with diabetes, severe dementia, and pressure ulcers of the left heel and right heel, TN used a clean pair of scissors to cut the gauze dressing off the resident’s left foot, then used the same scissors to cut the Manuka honey impregnated dressing that was applied directly to the exposed wound bed. TN stated she did not clean the scissors between cutting the soiled dressing and the clean dressing, and said she should have cleaned them before using them on the wound bed. During medication administration for another resident with type 2 diabetes, dementia, and hypertension, LVN D returned to the medication cart after checking the resident’s blood sugar, removed the gloves worn for the blood sugar check, cleaned the glucose monitor with a sanitary wipe, and then prepared a subcutaneous Novolin R insulin injection from a sterilely packaged syringe and a reusable multidose vial. The observation showed that hand hygiene was not performed before preparing the injection, and LVN D was not wearing gloves while administering the injection. The resident had an order for sliding-scale insulin three times daily. Interviews confirmed the observed practices. LVN E stated hand hygiene should be performed before and after care and before and after removing gloves, and that gloves should be worn during blood sugar checks and while giving injections. The DON stated scissors used during dressing changes should be cleaned between dirty and clean portions of the procedure, and that nurses should perform hand hygiene before preparing injectable medications and wear gloves while administering injections. Facility policies also reflected hand hygiene expectations and use of gloves for aseptic procedures, while the wound care policy did not address cleaning scissors between uses and the insulin administration policy did not address PPE required for subcutaneous injections.

Penalty

Inspection fine: $4,648

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

Summary

A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

Inspection fine: $24,752

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 and implement necessary interventions to prevent accidents for three residents. One resident, with moderate cognitive impairment and mobility issues, was able to leave the facility unsupervised and was returned by a community member after being found at a gas station over a mile away. Staff interviews revealed that the resident was last seen during a smoke break, and there was a lack of awareness among staff regarding the resident's whereabouts until he was brought back. Documentation showed that the resident was assessed as high risk for elopement, but interventions were limited to routine monitoring, and staff did not consistently monitor or supervise the resident as required. Another resident, with severe cognitive impairment and a history of stroke, was identified as high risk for elopement based on assessments and physician notes. However, the care plan did not include information or interventions related to this risk, and multiple staff members were unaware of any residents being high elopement risks. This lack of communication and failure to update care plans and inform staff resulted in inadequate supervision and increased the risk of elopement for this resident. A third resident, with a history of falls and moderate cognitive impairment, was not provided with required fall prevention interventions. Despite physician orders for a low bed and fall mat, the resident's bed was not in the lowest position and the fall mat was not in place at the time of a fall that resulted in a left hip fracture. Staff interviews confirmed that the interventions were not implemented, and the care plan did not specify these requirements. The incident report and staff statements indicated a lack of consistent implementation and monitoring of fall prevention measures for this resident.

Removal Plan

• Resident was discharged to a secured facility.
• All entrances to the facility have been key-pad locked and residents are not allowed out of the facility without an assigned staff member being with them.
• One resident who is high risk for elopement was placed on 1:1 monitoring until secure placement is located.
• All resident elopement assessments were completed, and high risk residents were identified.
• High risk resident's care plan was formulated and any resident care plans requiring updates were done.
• Administrator in-serviced department heads and facility staff on interventions for the identified high risk resident, including 1:1 monitoring, updated care plan, and Kardex update.
• Staff not available in person were contacted by phone and verbally in-serviced.
• Staff are informed that the administrator/designee will notify staff through the above measures and through an in-service if any other resident is deemed high risk for elopement.
• PRN, agency staff, and new hires will be educated on this process as they are assigned to work.
• Administrator will interview staff on their understanding and retention of education given to them on elopement and where to find information on residents at high risk for elopement.
• Regional Nurse will monitor new admission elopement assessments for high risk residents to validate that interventions are in place and communication is in the EMR system.
• Administrator will document this on an audit form.
• Regional nurse in-serviced the administrator and the director of nursing on reviewing any new admission elopement assessments to identify a resident scoring ten or more.
• Ensuring that any new staff are educated to the interventions of a resident deemed high-risk for elopement.
• Initial comprehension of education with the administrator and the DON was completed by questioning on understanding of the training by the regional nurse consultant.
• Regional nurse will document compliance using an audit form.
• Ad.Hoc QAPI meeting was completed with the IDT and the medical director to discuss this plan of removal.
• Resident's fall care plan interventions and Point of Care Kardex were reviewed and updated to reflect the resident's current condition.
• Regional Nurse Consultant/ADON reviewed the facility fall assessment report to identify residents at risk of falls and to validate that current interventions are in place on the resident care plan and Point of Care Kardex.
• RNC and the ADON reviewed all facility residents to validate that their fall interventions were care planned and that the Point of Care Kardex was updated to list the fall interventions.
• Audit was documented utilizing the PCC Fall Assessment score report.
• Additional residents were identified as at risk for falls. Each had a care plan developed with interventions added to their POC Kardex.
• RNC/administrator educated facility staff regarding where to find the information for fall interventions.
• Staff not receiving the initial education will receive it before starting their next assigned shift.
• Nurses were instructed to review the care plan, and CNAs were instructed to review the Point of Care Kardex.
• Interdisciplinary team were given a list of resident fall interventions by the RNC, to refer to while making rounds on their regularly assigned residents before the morning stand-up meeting and reporting any concerns during that meeting.
• IDT manager on duty will make rounds on the weekend to identify and immediately resolve concerns with fall interventions.
• Administrator verified the initial comprehension of staff training by questioning staff and documenting it on an audit form.
• Administrator and the RNC will document these tasks on a facility created audit form for record keeping purposes.
• RNC will review falls to ensure that the care plan is updated with a new intervention and that those interventions, if applicable, are carried over to the Point of Care Kardex.
• Any concerns will be corrected immediately and re-education given to the management team.
• Education understanding will be completed by the administrator by questioning the facility staff about where they can find the fall intervention information.
• RNC will complete education understanding with the management IDT by questioning them regarding IDT rounds and identifying problems with fall interventions specifically.
• Ad.Hoc QAPI meeting was held with the medical director and the IDT to discuss this plan of removal.

Penalty

Inspection fine: $24,752

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 comprehensive, person-centered care plans for two residents, as required. For one resident with a history of cerebral infarction, severe cognitive impairment, and high risk for elopement, the care plan did not include any information or interventions addressing the elopement risk, despite assessments and physician notes identifying this risk. Multiple staff interviews revealed a lack of awareness regarding residents at high risk for elopement, even though facility leadership confirmed that this resident was considered high risk. For another resident with a history of falls, moderate cognitive impairment, and significant dependence for activities of daily living, the care plan did not include specific fall prevention interventions such as keeping the bed in a low position or ensuring a fall mat was at the bedside. These interventions were present in the physician's orders but were not reflected in the care plan. Staff interviews indicated an expectation that such interventions would be documented in the care plan, and facility policy required individualized fall prevention plans based on resident risk factors. The deficiencies were identified through record reviews, staff interviews, and policy reviews, which showed that the care plans did not reflect all identified risks and physician-ordered interventions for the residents. This lack of comprehensive care planning could result in staff not being aware of or implementing necessary interventions to address the residents' medical, nursing, and psychosocial needs.

Penalty

Inspection fine: $24,752

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

Summary

The facility failed to provide the required registered nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week, as evidenced by a review of daily sign-in schedules showing no RN charge nurse present on eight specific days within the review period. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator (ADM), confirmed that there was no RN coverage on weekends during this time frame. The ADON and DON both stated that if RN services were needed, they would reach out to the regional nurse or DON, but there was no established protocol for when an RN was unavailable. The facility had ongoing difficulties hiring an RN, particularly for weekend shifts, and had an open job posting for this position. The absence of an RN on duty was not due to a lack of need for RN-level care, but rather due to staffing challenges and the facility's belief that their resident population did not require high-acuity nursing services. The DON reported being present during weekdays, and the facility occasionally used agency RNs, but consistent weekend coverage was not maintained. There was no specific policy in place regarding RN coverage, and the facility relied on state guidelines and ad hoc arrangements when RN-level care was required.

Penalty

Inspection fine: $24,752

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

Summary

The facility failed to develop a baseline care plan that included necessary instructions for effective and person-centered care for a resident within 48 hours of admission. Specifically, the baseline care plan did not address the resident's identified risk for elopement, despite an admission elopement risk assessment indicating the resident was at risk and required routine monitoring. The baseline care plan incorrectly stated that the resident did not have a history of wandering or elopement and omitted interventions related to elopement risk, even though the assessment and provider investigation report confirmed the risk and subsequent elopement event. Interviews with nursing staff, the ADON, DON, and administrator revealed that care plans are expected to include critical information such as fall and elopement risks, along with appropriate interventions. Staff relied on care plans and 24-hour reports for guidance on resident care, and it was confirmed that the ADON was responsible for updating care plans with new interventions. The facility's policy required comprehensive, person-centered care plans reflecting current assessments and interventions, but this was not followed in the case of the resident who later eloped from the facility.

Penalty

No penalty information released

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

Summary

The facility failed to report an alleged violation involving misappropriation of property within the required 24-hour timeframe to the State Survey Agency. This incident involved a resident who was observed giving money to a CNA, who was an employee of the facility at the time. The resident, who had a history of moderately impaired cognition and various medical conditions, including hypertension, diabetes, and borderline personality disorder, was not in the facility when the incident occurred but had planned to return. The CNA was reported to have requested and accepted money from the resident, which was observed by a staff member from a hospital where the resident was receiving care. The facility's administrator was informed of the incident by the hospital's CEO but did not report it to the state agency, as the resident was not physically present in the facility at the time. The facility's policies on preventing resident abuse and resident rights did not specifically address the reporting of abuse, neglect, or exploitation. Interviews with the facility's administrator and regional director of operations revealed that the CNA was suspended and later terminated following the investigation. However, there was uncertainty about whether the incident was reported to the state, as the resident was not at the facility when it occurred. The resident expressed a desire for privacy regarding the money and mentioned feeling bad about the CNA losing her job. The facility's failure to report the incident in a timely manner could place residents at risk for further misappropriation.

Penalty

Inspection fine: $6,159

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 environment for its residents, resulting in a significant incident involving a resident who left the facility unsupervised. The resident, a male with a history of type II diabetes, Parkinson's disease, and moderate cognitive impairment, was found approximately 0.9 miles away from the facility on railroad tracks after falling. The resident's quarterly care plan indicated a risk for falls due to poor safety awareness and mobility issues, and his most recent fall risk assessment showed a high risk for falls. Despite these indicators, the resident was able to leave the facility without signing out or notifying staff, leading to an immediate jeopardy situation. Interviews with facility staff revealed a lack of awareness and supervision regarding the resident's departure. The resident's cognitive abilities were inconsistent, with staff noting that he was sometimes alert and oriented but often confused and unable to remember the facility's sign-out procedures. On the day of the incident, the facility was understaffed, with only one nurse on duty who was unfamiliar with the resident's cognitive status. This lack of supervision and understanding of the resident's needs contributed to the resident's ability to leave the facility unsupervised. The facility's policies required residents to sign out and notify staff when leaving, but these procedures were not effectively communicated or enforced. Interviews with staff indicated that there was confusion about which residents could leave the facility independently and a lack of consistent monitoring to ensure all residents were accounted for. The facility's failure to adhere to its own policies and provide adequate supervision placed the resident at risk of harm, leading to the identification of an immediate jeopardy situation.

Penalty

Inspection fine: $6,159

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 incident involving a resident who eloped from the facility without staff knowledge and was found approximately an hour later after falling on railroad tracks about a mile from the facility. The resident, a male with a history of type II diabetes, Parkinson's disease, and moderate cognitive impairment, was admitted to the facility with a high risk for falls and a low initial risk for elopement. However, after the incident, his elopement risk assessment score increased significantly. The facility did not report this incident to the State Agency within the required 24-hour timeframe, as the administrator believed the resident was his own responsible party, was not injured, and had not missed medication doses. The facility's Preventing Resident Abuse Policy did not specify when abuse or neglect should be reported to the Health and Human Services Commission (HHSC). The administrator and the charge registered nurse (CRN) believed that elopement involved residents who were in harm's way due to cognitive issues or dementia. The administrator assumed the resident had signed out and was unaware of the fall on the railroad tracks, which would have prompted a report. The Long-Term Care Regulation Provider Letter required reporting of incidents involving neglect or a missing resident within 24 hours, which the facility failed to do.

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 several areas, as observed during a survey. Clean plastic cups were improperly stored on wet trays without air-drying nets, which could prevent proper air circulation and promote microorganism growth. Additionally, the tabletop can opener was found to be covered in sticky grime, including the blade and base, which could lead to food contamination. An opened bag of pancake mix was not stored in a sealed container, risking contamination and deterioration of food quality. The reach-in refrigerator was observed to have dirty racks and a buildup of stains from spilled liquids, indicating a lack of cleanliness and maintenance. This could potentially lead to contamination of stored food. Furthermore, the low-temperature dishwasher failed to reach the required 120 degrees Fahrenheit during the wash cycle, with temperatures recorded as low as 92 degrees Fahrenheit. This failure could result in dishes not being properly sanitized, increasing the risk of foodborne illness. The facility's policies on sanitization and food storage were not followed, as evidenced by the observations. The sanitization policy requires that all equipment and utensils be kept clean and sanitized, and the dishwasher operated according to manufacturer's instructions. The food storage policy mandates that dry foods be stored in a manner that maintains packaging integrity. These deficiencies in food storage, preparation, and sanitation could place residents at risk for foodborne illnesses.

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 requirement of having a registered nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week, and did not employ a full-time Director of Nursing (DON) for 74 out of 184 days reviewed. Specifically, the facility did not have an RN scheduled on numerous dates from March through August 2024. Additionally, the facility has been without a full-time DON since July 31, 2024. This lack of RN coverage and absence of a full-time DON could potentially compromise the supervision of nursing services provided to residents. During an interview on September 5, 2024, the Administrator and Regional Nurse confirmed the absence of an RN on the specified dates and acknowledged the lack of a full-time DON since the end of July. They admitted that they were unable to schedule an RN for the selected dates, which would have ensured better clinical oversight of the nursing services. The facility's job description for the DON emphasizes the role's responsibility in planning, organizing, and directing the Nursing Services Department to maintain compliance with regulations and ensure high-quality care.

Penalty

No penalty information released

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

Summary

The facility failed to assist a resident in obtaining necessary dental services following a referral to an oral surgeon for a tooth extraction. The resident, who had a history of cerebral infarction, Type 2 diabetes mellitus with kidney complications, and a periapical abscess, was initially treated with antibiotics for a tooth infection in February. Despite being referred to an oral surgeon for extraction after a dental visit in March, the resident did not attend the appointment. The facility's records did not provide documentation of the dental visit or reasons for the missed oral surgeon appointment. In July, the resident experienced another tooth infection and was again referred to an oral surgeon. An appointment was scheduled for early August, but the resident did not attend. Interviews with the Regional RN confirmed the resident's treatment history and the missed appointments, but no explanation was provided for the failure to follow through with the oral surgeon visits. The facility's policy on dental services, which includes assistance with appointments and transportation, was not adhered to, potentially leading to increased pain and infection for the 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 that food was prepared in a form designed to meet the individual needs of residents on a pureed diet. Specifically, the dietary manager (DM) did not puree the peach cobbler to the required pudding or mashed potato consistency for four residents who were ordered a pureed diet. During observations, the pureed peach cobbler was found to have the consistency of a nectar-thick liquid, which was inappropriate for residents requiring a pureed diet. Interviews with certified nursing assistants (CNAs) confirmed that the dessert was thin and runny, and not suitable for the residents' dietary needs. The DM admitted to not following the recipe, which led to the incorrect texture of the peach cobbler. The recipe required the cobbler to be blended until smooth, with the consistency of moist mashed potatoes or pudding, but the DM only pureed the peaches with some liquid. This oversight could contribute to choking, poor intake, and weight loss among residents who received pureed meals. The facility's records and guidelines for a Dysphagia Puree (Level 1) Diet emphasized the importance of achieving the correct consistency to accommodate residents with severe chewing and swallowing problems.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. During a wound dressing change for a resident with a venous wound and peripheral vascular disease, an LVN did not sanitize hands or change gloves between the removal of the old dressing and the application of the new dressing. The LVN admitted to not being aware of the need for such precautions, indicating a lack of proper training or adherence to infection control protocols. In another instance, a CNA providing incontinent care to a resident with moderate cognitive impairment and total dependence on others for toileting did not sanitize her hands between glove changes. The CNA also touched a wipes dispenser with dirty gloves and stored clean gloves in her scrub pocket alongside her cell phone. The CNA acknowledged these lapses, citing a lack of available hand sanitizers and being in a hurry as reasons for her actions. The Regional RN confirmed that these practices were against the facility's infection control procedures, which require hand hygiene and proper glove use to prevent cross-contamination. Additionally, the shared shower and toilet area on the South Hall was found to be in an unsanitary condition, with feces and urine on the floor, used gloves, and razors improperly disposed of. Housekeeping staff and supervisors acknowledged the state of the area, attributing it to staffing shortages and turnover. The facility's policy requires that environmental surfaces be cleaned appropriately, but the observed conditions indicated a failure to adhere to these standards, potentially leading to the spread of infection.

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 safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation conducted with the Maintenance Director, several environmental concerns were identified. These included mold inside the overhead light cover in a resident's room, rust on a ceiling pipe above a bed, a dirty chair cushion, a stripped window sill, and mold on the hallway ceiling. Additionally, there was dust and dirt in two hallway air conditioning vents, unsecured overhead lights, missing ceiling tiles, and mold on a wall area above a door entrance. A broken ceiling tile was also noted in the hallway, along with a wall penetration and a broken cabinet hinge in the ice machine room. Interviews with the Maintenance Director and the Administrator revealed that the Maintenance Director was not previously aware of these issues, and both acknowledged that addressing these concerns would promote resident safety and a more homelike environment. The facility's policy on Maintenance Service, dated December 2009, states that the Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, ensuring the building is in good repair and free of hazards.

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 resident environment free of pests and rodents, as evidenced by the presence of live roaches in resident rooms and the kitchen. During an observation on September 3, 2024, a live roach was seen on the wall of a resident room, and a CNA confirmed the sighting. Two residents reported seeing live roaches on their bedroom floor approximately two weeks prior. Additionally, on September 5, 2024, several live roaches were observed on the kitchen floor in front of the stove. The Dietary Manager acknowledged periodic sightings of roaches in the kitchen, despite the facility's monthly pest control service. The facility's policy, dated May 2008, states that an ongoing pest control program is maintained to keep the building free of insects and rodents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was fully informed and understood their health status, care, and treatments, specifically regarding the administration of psychotropic and antidepressant medications. The resident, who had multiple diagnoses including Alzheimer's disease, Parkinsonism, bipolar disorder, anxiety disorder, schizoaffective disorder, and major depressive disorder, was not provided with the necessary information to make informed decisions about their treatment. The facility did not obtain signed consent forms for the administration of antipsychotic medication Ziprasidone and antidepressant medications Zoloft and Trazodone prior to their administration. The resident's electronic health record contained three unsigned consent forms for Ziprasidone, and there were no consent forms for Trazodone or Zoloft. The facility's policy required that consents be obtained for any psychotropic medication, but this was not adhered to. The Regional Nurse confirmed the absence of signed consent forms and could not explain why they were missing. This oversight placed the resident at risk of receiving medications without their knowledge or consent, potentially affecting their ability to make informed decisions about their care.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans for two residents, which resulted in deficiencies in addressing their medication needs. Resident #3, a [AGE] year-old with severe cognitive impairment and a history of traumatic brain injury, was prescribed Xarelto, an anti-coagulant, but this was not included in their care plan. The omission of this critical medication in the care plan could lead to missed or inaccurate care, as the care plan did not reflect the resident's current medical needs. Similarly, Resident #33, a [AGE] year-old with moderate cognitive impairment and a history of behavioral issues, was prescribed Sertraline, an anti-depressant, which was also not included in their care plan. The absence of this medication in the care plan indicates a failure to address the resident's mental health needs adequately. The Regional MDS Nurse confirmed these omissions and acknowledged that the care plans should have included these medications to ensure the residents' care needs were met.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, the nursing staff did not provide a shower or change the stained shirt of a resident on his scheduled shower day. The resident, who has moderate cognitive impairment and requires assistance for showering and dressing, was observed wearing the same stained T-shirt over several days. The resident expressed dissatisfaction with the situation, stating that he had not showered in two weeks and that staff often attempted to assist him during his smoke break, leading to missed opportunities for care. Interviews with staff revealed that the resident's shower was not documented on the scheduled day due to a CNA being called away for another task, and no other staff were available to assist. The facility's policy requires documentation of showers and any refusals, along with notifying a supervisor if a resident refuses care. However, the documentation was incomplete, and the resident did not receive the necessary hygiene care, which could lead to issues such as body odor or skin problems.

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 environment for a resident by allowing a small refrigerator to be placed on top of a clothes dresser near the head of the resident's bed. This setup posed a potential accident hazard. The refrigerator measured approximately 19x32 inches and was placed on a dresser measuring 30x30 inches. This arrangement was observed during a survey, and the resident expressed concern about the refrigerator potentially falling over. The resident involved had a medical history that included type 2 diabetes, schizophrenia, and major depressive disorder, with a BIMS score indicating intact cognition. The resident's care plan noted concerns such as decreased vision, fall risk, and the need for assistance with activities of daily living (ADLs). The facility's maintenance policy requires the environment to be free of hazards, yet this policy was not adhered to in this instance, leading to the identified 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 ensure that the pharmacist's medication regimen review recommendations were reviewed by the attending physician and documented for two residents. For one resident, the pharmacist recommended monitoring for side effects of Xarelto, an anticoagulant prescribed for traumatic brain injury. However, there were no physician orders to monitor for these side effects, and the medication administration records did not show any documentation of monitoring. The resident's care plan also lacked a focus area addressing the use of the anticoagulant. For another resident, the pharmacist recommended clarifying the diagnosis for the use of Sertraline, an antidepressant, and considering a dose reduction. Despite these recommendations, there was no documented response from the physician, and the resident continued to be prescribed the same dosage. The facility's policy required that the pharmacist's recommendations be sent to the attending physicians within 24 hours, but due to the absence of a Director of Nursing, there was no documentation showing that the recommendations were reviewed by the physicians.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was not given a psychotropic drug unless necessary to treat a specific condition as diagnosed and documented in the clinical record. A resident was prescribed Sertraline, an antidepressant, for depression without a documented diagnosis of depression in their clinical record. The resident's care plan did not address the use of an antidepressant, and the medication regimen review (MRR) recommended clarifying the diagnosis for Sertraline. However, there was no documented response from the physician to this recommendation. The facility's process for handling MRR recommendations was compromised due to the absence of a Director of Nursing (DON). The Regional RN confirmed that the facility had been without a DON for periods of time, which resulted in a lack of documentation showing that the pharmacy recommendations had been sent to or reviewed by the physicians. This deficiency could lead to physicians not being aware of or acting upon pharmacist recommendations, potentially placing residents at risk of receiving unnecessary psychotropic medications.