Buena Vida Nursing And Rehab-san Antonio

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency in the facility’s pharmaceutical services related to the accounting and documentation of controlled medications for three residents. The facility failed to ensure that narcotic sheets were labeled in a way that accounted for all medications dispensed by the pharmacy, as required for accurate acquiring, receiving, dispensing, and administering of drugs and biologicals. This issue was found during review of the narcotic book on the 2200/2500 hallway medication cart and through interviews with nursing staff. For one male resident with dementia, muscle weakness, spinal stenosis, impaired mobility, gait and balance problems, and potential for uncontrolled pain, the narcotic sheet for APAP/Codeine 300-30 mg was not labeled to accurately reflect all medications dispensed. During observation, an LVN changed the narcotic sheet notation from “card 1 of 2” to “card 2 of 2” to match the numbering on the blister pack, indicating that the original documentation did not correspond to the actual medication card count. The LVN stated that the numbers on the narcotic sheet did not match what was written on the blister pack and acknowledged that this discrepancy affected the ability to accurately track narcotics and determine when to reorder. For a female resident with muscle weakness and wasting, polyneuropathy, cognitive communication deficit, hip fracture, and potential for uncontrolled pain, the narcotic sheet for Tramadol 50 mg lacked any labeling for card count, with no documentation indicating how many cards had been dispensed. Similarly, for another male resident with cognitive communication deficit, pain, muscle weakness and wasting, lack of coordination, hemiplegia/hemiparesis, ADL self-care deficit, limited physical mobility, and potential for uncontrolled pain, the narcotic sheet for APAP/Codeine 300-30 mg also had no labeling for card count. In both cases, the LVN reported that without proper labeling and documentation, staff could not accurately keep track of the narcotics or know when to reorder because the numbers were wrong or missing. The report states that this failure could affect residents who take narcotics for pain and could result in misappropriation of medications or drug diversion.

Penalty

Fine: $22,320

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

Summary

The deficiency involves the facility’s failure to maintain a resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents for one resident with depression, anxiety disorder, and mild to moderate cognitive impairment. The resident was admitted with diagnoses including mild cognitive impairment, depression, and anxiety disorder, and her admission MDS showed a BIMS score of 8/15, indicating moderate cognitive impairment. She was ambulatory and required partial/moderate assistance for personal hygiene, including shaving. Her medication regimen included Buspirone for anxiety and Sertraline for depression, and her mood assessment reflected minimal depression. The care plan dated 2/6/2026 identified that the resident wanted to end her life and included interventions such as notifying the physician, counseling by social work and staff, refocusing to positive topics, psychological consult, and emergency room evaluation and treatment, but it did not mention a history of suicidal ideation. On 2/4/2026, during the dinner period, the resident told a CNA that she wanted to kill herself and did not want to be there anymore. CNA C reported this statement to LVN B, and CNA A stayed with the resident while this was reported. Despite the resident’s suicidal statement, CNA A had previously provided the resident with two shaving razors so she could shave her legs and did not supervise her use of the razors, contrary to facility policy that residents are not supposed to have sharp objects and that staff must stay with residents who use shavers and dispose of them in sharps containers after use. Staff interviews later confirmed that residents were not to be left alone with razors and that razors were to be supervised and then discarded by staff. The facility’s suicide-threat policy required that suicide threats be taken seriously, immediately reported to the nurse supervisor or charge nurse, the physician be notified, and that a staff member remain 1:1 with the resident until the immediate danger had changed. On 2/5/2026, the resident was discovered with a razor in her hand and a superficial scratch on her left wrist after having expressed multiple times that she wanted to harm herself. Documentation indicated that she had suicidal ideation, had voiced wanting to kill herself in the dining room, and then gone to her room. The transfer form and SBAR documented suicidal ideation and a superficial scrape to the left wrist, and that she was sent out for evaluation of suicidal thoughts. The resident later stated in an interview that she had asked a CNA for a razor to shave her legs and received two shavers with no supervision, that she was upset because a male resident had broken her heart, and that she did scratch herself due to a broken heart. The administrator and ADON reported that the resident had been provided two razor blades by CNA A and that staff were supposed to stay with residents using shavers and ensure no sharp objects were left with residents. The surveyors determined that the facility failed to ensure the resident’s environment was free of hazards and that she was adequately monitored, resulting in an Immediate Jeopardy situation beginning on 2/4/2026 and ending on 2/8/2026. The noncompliance was identified as Past Noncompliance (PNC) at the Immediate Jeopardy level. The report states that this failure could result in residents experiencing suicidal ideations being at risk for harm, injuries, and death.

Removal Plan

• Revised Resident #1's comprehensive care plan to address statements and actions indicating she wanted to end her life
• Placed Resident #1 on 1:1 supervision until EMS arrived
• Notified the physician and Resident #1's responsible party/family
• Social worker met with Resident #1
• Referred Resident #1 to psychological services
• Ordered a urine test for Resident #1
• Sent Resident #1 to the emergency room for evaluation and treatment
• Suspended CNA A pending investigation and disciplined the employee
• Submitted a self-report of the incident to HHSC
• Assessed other residents in the facility for suicidal ideations
• Removed sharp objects/razors from resident rooms and bathrooms
• Conducted a facility-wide sweep to ensure no razors or sharp objects were present to ensure resident safety
• In-serviced all staff on Abuse/Neglect and Exploitation
• In-serviced all direct care staff on Razors
• In-serviced all staff on Suicidal Ideation
• Ensured staff who had not received the required education were not allowed to work until in-services were provided
• Discussed the incident involving Resident #1 with QAPI and during Adhoc meetings

Penalty

Fine: $14,020

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 adequate supervision and prevent elopement for a cognitively impaired resident who was known to be at risk for wandering and exit-seeking. The resident was an adult male with dementia, adjustment disorder, alcohol abuse, and psychosis, with a BIMS score of 06 indicating severely impaired cognition. Prior assessments identified him as an elopement risk, with multiple Elopement Risk Assessments scoring in the elopement risk range. His prior MDS indicated daily wandering behavior, and progress notes documented repeated expressions of wanting to leave the facility to visit a former resident friend, including a statement that he wanted to walk to another city to see this friend. Staff notes also described the resident pacing in front of the exit door, focusing on the door instructions, and stating he "just want[ed] out" to see his friend. Despite these indicators, the resident’s care plan did not include comprehensive interventions addressing his ongoing elopement risk. The care plan documented that the resident wanted to go across the street to visit his friend and that he had previously left the facility without notifying staff to go to a corner store, but there was no detailed care planning related to continued elopement risk. Progress notes showed that the resident had been placed on 1:1 monitoring after a resident-to-resident altercation and was later placed on every 15-minute monitoring due to anxiety, agitation, and exit-seeking behaviors. However, during the period leading up to the elopement, staff documentation reflected that the resident continued to pace, use the elevator between floors, and focus on the exit door, indicating ongoing exit-seeking behavior. On the day of the elopement, the resident was identified as high risk for elopement and was to be monitored every 15 minutes. RN B documented that the resident was in the hallway on the second floor prior to dinner and that the CNA invited him to join other residents in the dining room while the nurse was watching the dining room and feeding residents. During this time, the resident went downstairs unobserved and exited through the front door. Staff were not aware that he had left the facility because he did not sign himself out. The resident remained out of the facility for approximately 30 minutes and was later found at a nearby convenience store and returned by a former employee. The RCN reported that the elopement occurred after a staff member failed to ensure the front door was fully closed upon entering for a scheduled shift, and that the resident should have been visually checked every 15 minutes as ordered, but RN B failed to ensure those observations were conducted. These actions and inactions resulted in the resident eloping from the facility without staff knowledge or supervision.

Penalty

Fine: $14,020

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 addressing elopement risk for four residents identified as being at risk. For one male resident with dementia, adjustment disorder, alcohol abuse, and psychosis, the care plan noted that he wanted to go across the street to visit a friend and that he had previously left the facility without notifying staff to go to a corner store. The care plan included reminders about safety concerns and a psychiatric review for anxiety and agitation related to missing his friend, but there was no care planning addressing his ongoing elopement risk despite multiple Elopement Risk Assessments scoring him as an elopement risk. His record also showed a documented elopement incident, and during observation and interview he was unable to recall the incident or state the facility’s procedure for leaving, indicating he would simply walk out the front door and was unsure if he should tell staff. Another female resident with a diagnosis of psychotic disorder with delusions had an annual MDS showing severely impaired cognition and no documented wandering behavior, but her most recent Elopement Risk Assessment scored her as an elopement risk. Her care plan did not contain any interventions or planning related to elopement risk. During observation, she was seen interacting with staff in a common area but was unable to participate meaningfully in an interview due to her mental status and did not answer interview questions, instead focusing on her personal history. A male resident with herpesviral encephalitis had an admission MDS indicating intact cognition and no wandering behavior, but his Elopement Risk Assessment score also indicated elopement risk, with no corresponding elopement-related care planning in his care plan. He was observed alone in an unoccupied wing inspecting a handrail, with no staff present, and reported he had never attempted to leave the facility before ending the interview. Another male resident with dementia had an annual MDS showing severely impaired cognition and daily wandering behavior, and his most recent Elopement Risk Assessment also indicated elopement risk, yet his care plan contained no elopement-related planning. He was observed sleeping in bed and declined to participate in an interview. Facility leadership, including the RCN and ADO, reported that there had been a leadership change, that the DON was new and had not yet reviewed all care plans, and that Elopement Risk Assessments were intended to alert the IDT so that risks and interventions, including possible secured unit placement, could be determined and incorporated into care plans. The facility’s comprehensive care planning policy stated that risks identified in the MDS or otherwise should be assessed and considered for care plan development, but this was not done for the four residents’ elopement risks.

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 facility failed to protect a resident's right to be free from neglect by not providing daily wound care or regular skin assessments over a period of nearly one month. The resident, who had significant medical conditions including quadriplegia, kidney disease, cirrhosis, and a history of pressure ulcers, was dependent on staff for mobility and personal hygiene. Despite being at high risk for pressure ulcers and having documented wounds, the facility did not ensure that wound care orders were entered into the electronic medical record (EMR), nor did nursing staff consistently provide or document wound care and skin assessments as required by facility policy. The resident had multiple wounds, including a Stage IV pressure ulcer on the left ankle and a surgical wound following a right below-knee amputation (BKA). Wound care physician assessments and outpatient clinic notes documented the presence and worsening of these wounds, with evidence of infection, necrosis, and exposed bone. Nursing staff interviews revealed a lack of awareness or follow-through regarding wound care orders, with some staff stating they did not provide care due to missing orders in the EMR. The Assistant Director of Nursing (ADON) acknowledged responsibility for entering wound care orders but admitted to missing this task, resulting in the absence of documented wound care for the left ankle. The resident's condition deteriorated, with observations of soiled dressings, malodor, and purulent drainage. The lack of wound care and monitoring led to the development of osteomyelitis and septic shock, necessitating hospitalization and a left BKA. Interviews with staff, the wound care physician, and the hospital case manager confirmed that wound care was not performed as ordered, and concerns raised by outside care teams were not addressed by facility staff. Facility policies required weekly skin assessments and prompt notification of physicians for changes in wound status, but these were not followed, resulting in neglect and significant harm to 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 a resident with surgical wounds received necessary treatment and services consistent with professional standards of practice. Specifically, the resident did not receive weekly skin assessments during a specified month, and care to the right surgical wound was not provided as ordered by the physician. Documentation showed that the treatment administration record was not initialed as completed on multiple occasions, and there were no weekly skin or pressure ulcer assessments documented until after the resident was admitted to the hospital. The resident, who had a complex medical history including lung cancer, quadriplegia, kidney disease, hepatitis C, cirrhosis, and encephalopathy, was at high risk for pressure ulcers and had multiple unhealed pressure ulcers documented on assessment. Despite care plan interventions requiring weekly wound assessments and monitoring, staff failed to complete these assessments and did not consistently follow physician orders for wound care. Interviews with nursing staff revealed a lack of awareness regarding wound care orders and inconsistent documentation and monitoring of the resident's surgical site. The resident was ultimately admitted to the hospital with an infection of the right below-knee amputation site, presenting with low blood pressure, significant ulcers, and signs of sepsis and osteomyelitis. Hospital records confirmed the presence of infected wounds and critical illness requiring urgent intervention. Facility policy required weekly skin assessments and timely documentation, but these were not followed, as confirmed by staff interviews and record reviews.

Penalty

No penalty information released

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

Summary

A resident with multiple complex medical conditions, including quadriplegia, kidney disease, cirrhosis, and a history of bilateral below-knee amputations, developed a Stage IV pressure ulcer on the left ankle. Despite being at high risk for pressure ulcers and having a care plan in place that required regular wound assessments and treatments, there were no wound care treatment orders for the left ankle documented in the facility's records for the entire month of September. Additionally, there were no weekly skin or pressure ulcer assessments recorded during this period until after the resident was admitted to the hospital. Multiple wound care physician assessments documented the presence and progression of the Stage IV ulcer, with specific treatment plans outlined in the physician's notes. However, these orders were not transcribed into the facility's electronic medical record (EMR) or treatment administration records, resulting in the nursing staff being unaware of the required wound care interventions. Interviews with nursing staff revealed a lack of awareness regarding the resident's wound care needs, with several nurses and CNAs stating they did not know about the wound or did not perform any wound care. The wound care nurse, who was responsible for entering physician orders into the EMR, acknowledged missing the transcription of these orders, and as a result, wound care was not provided as required. The resident's condition deteriorated, with observations of soiled dressings, malodor, and exposed bone, ultimately leading to infection, sepsis, and the need for a left below-knee amputation. The facility's own policies required prompt notification of the physician and initiation of treatment orders in the absence of existing orders, as well as weekly skin and ulcer assessments, none of which were followed. The deficiency was identified through record review, staff and resident interviews, and direct observation, confirming that the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent 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 an effective infection prevention and control program for three residents who required enhanced barrier precautions (EBP) or had indwelling devices. One resident with a Foley catheter did not have a sign posted at the room entrance indicating the need for EBP, despite the care plan specifying this intervention. Staff interviews confirmed that the resident was on EBP and that signage was required, but the sign was not present during observation. Another resident with a Foley catheter was observed with the catheter tubing touching the floor while sitting in a wheelchair at the nurse's station. The care plan for this resident included an intervention to keep the drainage bag off the floor, but this was not followed. Staff acknowledged that catheter tubing should not touch the floor and that all nursing staff were responsible for ensuring proper catheter care to prevent infection. A third resident with a gastric tube also did not have an EBP sign posted at the room entrance, although the care plan required it. PPE supplies were present outside the room, but staff were unsure about the responsibility for posting EBP signs. Interviews with staff and the administrator confirmed the importance of EBP signage and proper catheter care, and that training had been provided, but the required practices were not consistently implemented.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including diabetes, stroke, and hydronephrosis, was observed lying in bed with a foley catheter bag attached to the side of the bed without a privacy cover. The contents of the foley bag were visible from the open bedroom door. The resident's care plan and physician orders specified that the foley bag should be in a privacy bag while in bed or in a wheelchair. Despite this, the privacy cover was not in place during the observation. Interviews with staff revealed that the nurse assigned to the resident was aware of the missing privacy cover and had attempted to locate one but was unsuccessful, subsequently notifying the interim DON. The nurse confirmed that it was the responsibility of nursing staff to ensure privacy covers were used and that she had received training on this requirement. The administrator also confirmed that all foley catheter bags should have privacy covers or be positioned to maintain privacy, and that staff had been trained accordingly. However, the facility did not have a specific policy on privacy covers for foley bags, relying instead on a general resident rights 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 post the required daily nursing staffing information in a prominent and accessible location for residents, staff, and visitors on two consecutive days. On the first day, the staffing poster displayed at the receptionist desk was outdated, showing a date from several weeks prior. On the following day, the display holder was observed to be empty during two separate observations, with no current staffing information available. Record reviews confirmed that staff schedules existed for both days, listing the numbers of licensed nurses, medical assistants, and certified nurse aides scheduled, but this information was not posted as required. During an interview, the Administrator confirmed that the Assistant Director of Nursing (ADON) was responsible for updating and posting the daily staffing information and had been directed to do so. The Administrator acknowledged the importance of posting this information for families, visitors, and regulatory compliance. It was also noted that the facility did not have a formal policy for posting staffing information but stated that regulatory guidelines were followed.

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 timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.

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 comprehensive person-centered care plan was developed and implemented for a resident, which resulted in unmet needs related to smoking policy noncompliance and aggressive behaviors. The resident, a male with a history of Bipolar Disorder, Chronic Viral Hepatitis C, Depression, and Anxiety, was admitted to the facility and had a BIMS score indicating no cognitive impairment. Despite being aware of the facility's smoking policy, the resident repeatedly violated it by smoking in non-designated areas and during non-smoking times, which was not addressed in the care plan with effective interventions. Additionally, the resident exhibited verbally disruptive and aggressive behaviors towards staff and others, which were not adequately addressed in the care plan. The resident's aggressive actions included throwing objects at staff, making verbally abusive threats, and attempting to physically harm staff members. These behaviors were documented in progress notes, but the care plan did not reflect interventions to manage or mitigate these behaviors. Interviews with facility staff, including the DON, Social Worker, and MDS Nurse, revealed that the care plan should have been updated to reflect the resident's noncompliance with the smoking policy and aggressive behaviors. The facility's policy required care plans to be updated with changes in resident condition or behavior, but this was not done, leading to a deficiency in providing appropriate care and interventions 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 provide adequate pharmaceutical services to meet the needs of a resident, leading to multiple medication administration errors. On two separate occasions, Licensed Vocational Nurses (LVN) did not administer Hydrocortisone gel to the resident's face within the scheduled administration time. Additionally, a Medication Aide (MA) documented that medications were administered to the resident when they had not been, and prepared medications were stored in unlabeled cups in the medication cart. The resident involved was an elderly male with a history of cerebral infarction, hemiplegia, hypertension, and depression. His care plan included specific interventions for hypertension and potential uncontrolled pain, requiring precise medication administration. However, the resident reported not receiving his morning medications, including a face cream, and expressed frustration over the issue. The MA responsible for administering the medications admitted to signing off on the Medication Administration Record (MAR) before actually administering the medications, which is against the training received. Further investigation revealed that the MA was administering Lidocaine patches instead of the prescribed Lidocaine gel, and had prefilled medications stored in the cart, which could lead to errors. Interviews with the Director of Nursing (DON) and the resident's physician highlighted the importance of accurate documentation and adherence to medication administration protocols. The facility's policies and training records indicated that staff were trained on the correct procedures, but these were not followed, resulting in the deficiencies observed.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. Specifically, the facility did not schedule an ENT appointment for the resident as ordered by the physician in April 2024, nor did it schedule a vascular appointment ordered in October 2024. These failures were identified during a review of the resident's records and interviews with staff and the resident. The resident, a male with a history of cerebral infarction, hemiplegia, and depression, was admitted to the facility and required referrals to an ENT for dysphagia and a vascular specialist for an abdominal aortic aneurysm. Despite multiple attempts by the facility's staff to schedule these appointments, issues such as insurance coverage, staff turnover, and communication breakdowns led to significant delays. The resident expressed frustration over the lack of follow-through, noting that his communication and swallowing had improved with speech therapy but believed further improvement could have been achieved with specialist intervention. Interviews with various staff members, including the ADON, LVNs, and the Admissions Director, revealed a lack of clarity and responsibility regarding the scheduling of appointments. The ADON and other staff members were unaware of the status of the referrals, and there was confusion about who was responsible for scheduling. The resident's physician and NP expressed concern and frustration over the delays, emphasizing the importance of timely specialist evaluations for the resident's health conditions.

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, specifically during medication administration. This deficiency was observed when a medication aide, identified as MA B, did not perform hand hygiene after administering medications to one resident and before administering medications to another. This lapse in protocol was noted during a medication administration observation, where MA B handled medication cups and a blood pressure cuff without washing hands in between interactions with two residents. The first resident, a male with severe cognitive impairment and an asymptomatic HIV infection, received his medications without incident. However, MA B did not perform hand hygiene before proceeding to check the blood pressure and administer medications to the second resident, who also had severe cognitive impairment and was diagnosed with viral hepatitis C. Interviews with MA B and the Director of Nursing (DON) confirmed that staff had been trained on the importance of hand hygiene to prevent cross-contamination and infection. Despite this training, MA B acknowledged the failure to adhere to hand hygiene protocols during the observed medication administration. The facility's policy on infection control emphasizes hand hygiene as the primary means of preventing infection transmission, and MA B had previously been evaluated as satisfactory in infection control practices. However, the observed failure to perform hand hygiene between residents posed a risk of cross-contamination and infection spread.

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, clean, and comfortable environment for a resident, as observed in one of the resident rooms. The deficiencies included a broken footboard on the resident's bed and the absence of bed linen, which were not addressed for over 24 hours. The resident, an 81-year-old male with severe cognitive impairment due to dementia, was found sleeping without linen and with a broken footboard. Despite being alert and oriented to person and place, the resident did not report the issues to the staff, expressing sadness over the situation. The facility's records showed no maintenance order for the broken footboard, indicating a failure in communication between nursing staff and maintenance. Additionally, the housekeeping supervisor confirmed that there was sufficient linen available, yet the resident's bed remained without linen for over a day. The Director of Nursing acknowledged the dignity issue related to the lack of bed sheets, and the maintenance director confirmed the absence of a work order for the bed repair. The facility's policy on resident rights emphasizes the right to be treated with respect and dignity, which was not upheld in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate and complete medical records for a resident, as evidenced by discrepancies between the Nurse Kardex and the CNAs' electronic record system (POC) regarding the resident's bathing schedule. The resident, a 47-year-old male with a history of nontraumatic intracranial hemorrhage, anxiety, cognitive deficits, and dysphasia, was documented in the Kardex as not receiving showers on specific dates in October 2024, while the POC indicated that showers were given on all scheduled days. This inconsistency in documentation could lead to an inaccurate overall view of the resident's care and services. Interviews with the resident, the resident's representative, and facility staff revealed that the resident did not receive a shower on one of the scheduled days, which was confirmed by both the resident and the representative. The Director of Nursing (DON) acknowledged the lack of a structured system for documenting shower days and PRN showers, which may have contributed to the discrepancies. The DON and staff members, including an LVN and a CNA, were unable to explain the differences between the Kardex and the POC, highlighting a failure in proper documentation practices within 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 maintain clinical records in accordance with accepted professional standards and practices, specifically in documenting medication administration for two residents. For one resident, the Medication Administration Record (MAR) for August 2024 showed missing documentation for prescribed medications, including Gabapentin and HYDROcodone-Acetaminophen. The resident reported that nursing staff refused to administer Gabapentin due to a perceived high dosage, and there were multiple instances where pain medication was not documented as administered, nor were pain assessments recorded. Another resident's MAR also exhibited missing documentation for several medications, including Lasix, Lisinopril, Meloxicam, and others, on various dates in August 2024. Interviews with the resident and nursing staff revealed that medications were not consistently documented, and there was a lack of explanation for the missing entries. Nursing staff acknowledged the importance of documenting medication administration and the implications of missing entries, which could suggest that medications were not given. Interviews with the Director of Nursing (DON) and other nursing staff highlighted a systemic issue with documentation practices. The DON admitted that routine audits on MAR documentation were not consistently performed, leading to gaps in the records. The facility's policy required immediate charting of administered medications and documentation of any withheld or refused doses, but this was not adhered to, resulting in incomplete and inaccurate medical records for the residents involved.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several maintenance and cleanliness issues observed during a survey. In one room, there were loose tiles around the toilet, a rusted bolt securing the toilet, and an excessive accumulation of dust and debris on top of the mirror and paper towel dispenser. Additionally, the vent across from the bathroom had a large accumulation of dust. A resident in this room expressed distress over the dirt and dust, which was corroborated by the Corporate RN and the Maintenance Director, who acknowledged the need for tile replacement and additional cleaning. Further observations revealed additional deficiencies, including a non-functioning light in the Secured Unit shower room, a broken toilet seat hinge in another room, and broken window blinds, water marks on ceiling panels, and a separated ceiling exhaust fan in yet another room. In one bathroom, two out of three lights were not functioning, and the toilet was not properly secured, allowing it to move. These issues were acknowledged by the Maintenance Director and the Administrator, who recognized the need for repairs to improve resident safety and quality of life.

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, as evidenced by the late administration of medications to 10 out of 24 residents reviewed. The medications were administered by MA B and RN H, who were responsible for ensuring timely medication administration. The delays ranged from 53 minutes to nearly three hours, affecting medications critical for managing conditions such as anxiety, hypertension, diabetes, and chronic pain. These delays were not reported to supervisors, indicating a lapse in communication and protocol adherence. Resident #3, for example, received her medications, including baclofen, torsemide, buspirone, and gabapentin, significantly later than prescribed. Similarly, Resident #4's clonazepam was administered late, which is crucial for managing her anxiety disorder. Resident #19's insulin was administered late, after her breakfast, due to a lack of communication between the DON and RN H, who took over the nursing duties late and without a proper handover. Additionally, the facility stored an expired insulin injection pen for Resident #24, which was discovered during an observation. The insulin pen was used beyond its recommended 28-day period, posing a risk of ineffective diabetes management. The facility's policies on medication storage and administration were not adhered to, as evidenced by the expired insulin and the late administration of scheduled medications, which should have been administered within one hour of the scheduled time.

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 meals that were palatable, attractive, and at a safe and appetizing temperature for several residents. Observations revealed that meals were served cold to seven residents, including those with diagnoses such as muscle wasting and protein-calorie malnutrition. The meals were delivered on open, uncovered racks, and there were significant delays in serving the meals to the residents, resulting in cold and unpalatable food. Specific instances included Resident #25 receiving a breakfast meal 1 hour and 2 minutes after delivery, and Resident #13 receiving a meal 58 minutes after delivery, both of which were cold and unpalatable. Other residents, such as Resident #61 and Resident #37, also reported receiving cold meals. The delays in meal service were attributed to the process of checking meal accuracy and the limited number of CNAs available to serve the meals. Interviews with residents and staff highlighted ongoing issues with meal service, with residents expressing dissatisfaction with the temperature and appeal of their meals. The facility's admission packet promised enjoyable meals, yet observations and resident feedback indicated a failure to meet this standard. The facility administrator acknowledged the issue and expressed an intention to improve meal service quality and timeliness.

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 was found to have deficiencies in food storage and sanitation practices in the kitchen. During an observation, an opened bag of corn flakes cereal was discovered in the dry storage room, stored in a zip-locked bag that was not sealed. This improper storage method could lead to spoilage and contamination from pests. The Dietary Manager (DM) acknowledged that the bag should have been sealed and stated that it was the responsibility of all dietary staff to properly seal, label, and date food items. All staff were reportedly up to date on food handler certification. Additionally, the facility failed to maintain the appropriate concentration of chlorine sanitizer in the dish machine. Observations revealed that the dish machine, which uses a chemical sanitizer, did not have any chlorine present during the sanitizing cycle, as indicated by a test strip that did not change color. The DM later adjusted the sanitizer container and manually pumped sanitizer into the machine, achieving the correct chlorine level. The DM suggested that an air bubble in the line might have caused the issue. A review of the facility's policy and the Food Code indicated that the dish machine should be tested for proper temperature and sanitizer concentration before use, but no discrepancies were noted in the temperature/sanitizer log for the month.

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 reasonably accommodate the needs and preferences of a resident, specifically Resident #24, who was left in her bed with the call light button underneath her left back. Resident #24 was semi-paralyzed on her left side and unable to reach the call light button, which was essential for her to request assistance. This oversight was observed during a survey on 07/09/2024, when Resident #24 expressed that she did not know where her call light was and could not use her left side to reach it. The call light was found underneath her left side back, and she stated she could not turn to access it. Further investigation revealed that the care plan for Resident #24, who had a history of falls, dementia, and generalized muscle weakness, required that her call light be within reach. A CNA observed the situation and repositioned the call light so that Resident #24 could hold it with her right hand. Additionally, the Maintenance Director was unaware of any issues with the call light system, and the regional DON confirmed that the facility lacked a specific policy for the nurse call light system, relying instead on CMS and state agency guidelines.

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 all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys. This deficiency was observed in the medication room on the second floor, which was left unattended and unlocked. The room, located at the beginning of the resident's hallway, contained multiple residents' medications and had a key latch door handle that was unlocked. During interviews, LVN A, the nurse on duty for the second floor, stated she was busy serving residents' breakfasts and was unaware that the medication room was unattended and unlocked. Similarly, MA B, who was administering medications to residents, was also unaware of the situation. The Administrator and RN C acknowledged that having an unattended and unlocked medication room posed a safety concern for residents. A review of the facility's policy on medication storage, dated 2003, indicated that medications and biologicals should be stored safely, securely, and properly.

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 dispose of garbage and refuse for one of its two dumpsters, specifically Dumpster #2. Observations revealed that the door of Dumpster #2 was not completely shut, it lacked a drainage plug, and there were ants present, indicating a pest issue. During interviews, the Dietary Manager (DM) acknowledged that the door was open, which created an unsanitary condition and could lead to rodent proliferation. The Maintenance Director confirmed the absence of a drain plug and the presence of ants. Additionally, the facility did not have a policy in place for maintaining the dumpsters and the surrounding area. A review of the Food Code by the U.S. Public Health Service and the FDA highlighted the requirement for receptacles to have tight-fitting lids or doors and drain plugs in place.

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 working call system was available in each resident's bathroom and bathing area, specifically affecting one resident. On a specific date, a resident utilized his call light, which did not illuminate the nurse call light directly outside and above his room door. This malfunction could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctions or is out of reach. The resident, who was admitted with diagnoses including left-sided hemiparesis and general anxiety disorder, was assessed as medically complex and needed support for his conditions. His care plan emphasized the importance of having a working and reachable call light. During an observation and interview, it was noted that the call light panel at the nurses' station sounded an alarm and illuminated the light designated for the resident's room, but the light outside the room was not functioning. The resident expressed that he needed assistance, and no one was coming to his aid. A CNA confirmed the malfunction and stated she would report it to the maintenance director, who later acknowledged being unaware of the issue. The regional DON confirmed that the facility's call light system should be available and functioning for all residents, although there was no specific policy for the system in place.

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 residents, staff, and the public. During an observation on the 2300 resident hallway, a ceiling fan in the Soiled Utility Room was found to have dust and dirt particles in the vent slats. This deficiency was identified during a survey conducted with the Maintenance Director, who acknowledged the issue. The facility's policy on Preventative Maintenance/Work-Order Request, dated 2003, states that the facility will repair or replace damaged or broken equipment or building amenities as needed.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate medical records for a resident, specifically in the transcription of a Morphine order. The resident, who was cognitively impaired with a BIMS score of 3, had a history of chronic systolic heart failure, COPD, anxiety, depression, dementia, and chronic pain. The resident's MAR indicated a Morphine order of 20 mg in 1 ml liquid, but the actual medication bottle prescribed contained a concentration of 20 mg in 5 ml liquid. This discrepancy was not reflected in the electronic health record (EHR), leading to a transcription error. Interviews with facility staff, including an RN and the DON, confirmed awareness of the transcription error, although they stated the resident received the correct dosage. The hospice patient care manager and the hospice MD also acknowledged the transcription error, noting that the pharmacy sent a higher concentration than ordered. Despite the error in documentation, the primary care physician confirmed that the resident received appropriate doses of Morphine for pain management. The facility's policy on medication administration emphasizes adherence to the five rights of medication, which was not followed in this instance.

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 honor a resident's right to be present and to consent when Administrator A entered the resident's room and disposed of personal items without the resident's permission. This incident involved a cognitively intact female resident with a history of end-stage renal disease, anxiety, and major depressive disorder. The resident was not present during the room cleaning, which occurred while she was at a dialysis appointment. Upon returning, the resident discovered that some of her personal belongings, valued at approximately $300, had been thrown away, leading to emotional distress and feelings of worthlessness. The facility's internal investigation revealed that Administrator A, along with housekeeping staff, entered the resident's room to dispose of trash and expired food items. However, the resident had not given permission for this action, nor was she informed of the specific date when the cleaning would occur. Witnesses, including LVNs and a hospitality aide, confirmed that the resident was visibly upset and crying at the nurse's station after discovering the missing items. The facility's Corporate RN acknowledged that the administrator's actions could be considered a violation of resident rights, as the resident was not present and had not consented to the removal of her belongings. Interviews with various staff members, including the ADON, DON, and the current administrator, confirmed that entering a resident's room without permission and disposing of personal items is a violation of resident rights. Despite attempts to recover or replace the missing items, the resident remained upset and expressed a lack of trust in the staff. The former administrator admitted to entering the room without the resident's presence, citing safety and infection control concerns, but failed to respect the resident's rights to personal possessions and to be free from interference.

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 respect the dignity and personal possessions of a resident, specifically concerning the resident's electronic monitoring device. On a specific date, a hospitality aide was observed turning off the resident's camera without permission. This action was captured on video, showing the aide adjusting the resident's position in bed and then moving towards the camera to turn it off. This incident was part of a broader concern raised by a family member who alleged that staff would turn off the resident's monitoring device and neglect the resident. The resident involved was an elderly male with a history of hemiplegia, dementia, and paranoid personality disorder. He was moderately impaired according to his BIMS score and had a care plan addressing sexual acting out behaviors and non-compliance with medications. Despite these challenges, the resident was his own responsible party. The facility's records indicated that the resident had been sexually inappropriate with staff, but there was no documentation of the camera being turned off in the nurse's notes. Interviews with various staff members, including LVNs and hospitality aides, revealed a lack of awareness or acknowledgment of the camera being turned off. The Director of Nursing mentioned that the resident's roommate had been unplugging the camera, leading to the decision to room the resident alone. The facility's Resident Rights policy emphasized the right to retain and use personal possessions, which was not upheld in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's personal belongings from being misappropriated by a former administrator. The incident involved a cognitively intact resident who was undergoing dialysis treatment. During the resident's absence, the former administrator entered the resident's room without permission and removed personal items, including clothing and figurines, which the resident valued at $300. The resident returned to find her belongings missing, leading to emotional distress and feelings of worthlessness. The facility's internal investigation revealed that the former administrator, along with housekeeping staff, entered the resident's room to dispose of trash and expired food items. However, the resident was not informed of the specific date of the cleaning, nor was she present during the process. Witnesses, including nursing staff and aides, confirmed that the resident was visibly upset and cried for an extended period after discovering her belongings had been discarded. The facility's policy on resident rights was violated, as staff are required to obtain permission before entering a resident's room and removing items. Interviews with staff and the resident highlighted the emotional impact of the incident, although no long-term psychosocial harm was observed. The facility attempted to rectify the situation by purchasing replacement items for the resident. Despite these efforts, the incident underscored a breach of resident rights and the need for adherence to policies regarding the handling of personal property.