Dayton Nursing And Rehabilitation

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 alleged violations involving abuse were reported immediately, and no later than 2 hours after the allegation was made, to HHSC for 4 of 4 residents reviewed for abuse and neglect. The report states that the facility did not report an allegation involving Resident #1 and Resident #2 until 19 hours after staff were aware of the incident, did not report an allegation involving Resident #3 until almost 22 hours after staff were aware of the incident, and did not report an allegation involving Resident #4 until almost 9 hours after staff were aware of the incident. Resident #1 was a male with diagnoses including Alzheimer's disease, generalized anxiety disorder, and post-traumatic stress disorder, and his quarterly MDS showed severely impaired cognition with a BIMS of 6. Resident #2 was a male with diagnoses including Alzheimer's disease, bipolar disorder, mood disorder, major depressive disorder, and generalized anxiety disorder; his quarterly MDS showed intact cognition with a BIMS of 15. The Provider Investigation Report showed the incident involving Resident #1 and Resident #2 occurred on 09/22/25 at 06:50 p.m. and was categorized as Abuse, while the HHSC TULIP Portal showed the facility was aware of the incident on 09/22/25 at 07:00 p.m. and the report was received on 09/23/25 at 02:41 p.m., 19 hours and 41 minutes later. Resident #3 was a female with diagnoses including bipolar disorder, major depressive disorder, and generalized anxiety disorder, and her quarterly MDS showed severely impaired cognition with a BIMS of 7. Resident #4 was a female with dementia, and her admission MDS showed moderately impaired cognition with a BIMS of 11. The Provider Investigation Report showed the incident involving Resident #3 occurred on 01/15/26 at 02:00 p.m. and was categorized as Abuse, while the HHSC TULIP Portal showed the facility was aware at 02:00 p.m. and the report was received on 01/16/26 at 11:56 a.m., 21 hours and 56 minutes later. For Resident #4, the Provider Investigation Report showed the incident occurred on 05/01/26 at 07:30 p.m. and was categorized as Abuse, while the HHSC TULIP Portal showed the facility was aware on 05/01/26 at 11:30 a.m. and the report was received at 08:14 p.m., 8 hours and 44 minutes later. The Administrator stated she thought abuse that did not cause serious bodily injury was to be reported within 24 hours and said she missed the part in the Provider Letter and policy that abuse was to be reported within 2 hours whether or not there was serious bodily injury.

Penalty

Inspection fine: $15,327

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 safe, appropriate pain management for a resident who required wound care and had an order for acetaminophen-codeine at bedtime and every 8 hours as needed for pain. The resident was a female with diagnoses including Alzheimer's disease, osteoporosis with current pathological fracture, and diabetes. Her care plan and physician orders included treatment for wounds on the left lateral malleolus, left great toe plantar side, and left heel, with daily dressing changes and wound care interventions. During an observation of wound care, the WCN prepared to treat the resident's coccyx wound, then removed the boot and the resident hollered out, grimaced, and moaned. When asked if she was in pain, the resident said her pain was "so, so." The WCN continued with care. The WCN then removed the dressing from the left ankle wound, cleaned it, and applied treatment while changing gloves without hand hygiene. When the dressing to the left great toe was removed and later reapplied, the resident again yelled out in pain, but the WCN continued the wound care. The WCN later stated she should have stopped and medicated the resident for pain, and the DON stated the WCN should have stopped the treatment and medicated the resident to prevent pain. The record also showed the resident had new unstageable wounds identified by the wound doctor, including a left lateral malleolus wound with slough and granulation tissue and a left great toe wound that was unstageable with eschar. The facility's pain clinical protocol stated nursing staff will identify situations where increased pain may be anticipated, such as wound care. The deficiency was based on the failure to assess for pain and provide pain medication before wound care, and the failure to stop wound care when the resident repeatedly vocalized pain.

Penalty

Inspection fine: $15,327

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 drug regimens for 2 of 8 residents reviewed were free from unnecessary psychotropic medications because the orders did not include appropriate diagnoses for the medications. Resident #1’s record showed diagnoses including bipolar disorder, COPD, depression, anxiety disorder, malaise, and herpes viral infection, but September 2025 physician orders listed Risperdal 1 mg at bedtime and bupropion 100 mg daily with no indications for use. Resident #37’s record showed diagnoses including type 2 diabetes, atherosclerotic heart disease, atrial fibrillation, fracture of the head of the left femur, CKD stage 3, intestinal obstruction, chronic pain, hypertension, anxiety disorder, and osteomyelitis, but the September 2025 physician orders listed duloxetine 30 mg daily with no indication for use. During record review and interview on 09/17/25 at 4:00 p.m., an LVN acknowledged that the orders were missing diagnoses for the psychotropic medications on Residents #1 and #37’s orders and stated it was the CN’s responsibility to place the diagnoses with the psychotropic medications. During an interview later that day at 4:10 p.m., the DON and Administrator stated they expected the diagnoses to be placed on the orders when they are written. A policy regarding indication for use for medications was requested from the Administrator but was not provided before exit.

Penalty

Inspection fine: $15,327

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

Each resident's drug regimen was not kept free from unnecessary medications because several ordered medications had no documented indication on the physician orders. Resident #1, a female with diagnoses including bipolar disorder, COPD, depression, anxiety disorder, malaise, and herpes viral infection, had orders for Anoro Ellipta, lidocaine adhesive patch 4% to the right knee, Mucinex, omeprazole, potassium, allopurinol, and montelukast without indications for use. Resident #3, a male with diagnoses including osteomyelitis of the right ankle and foot, peripheral vascular disease, atrial fibrillation, systolic CHF, cirrhosis of the liver, COPD, type 2 diabetes mellitus, and Alzheimer's disease, had multiple medications ordered without indications, including docusate sodium, Tradjenta, amiodarone, melatonin, hydrocodone-acetaminophen, methocarbamol, Eliquis, furosemide, levothyroxine, meloxicam, metoprolol succinate, Miralax, and omeprazole. Resident #5, a female with diagnoses including respiratory failure, centrilobular emphysema, peripheral vascular disease, seasonal allergic rhinitis, and Alzheimer's disease, had acidophilus and loratadine ordered without indications for use. Resident #37, a female with diagnoses including type 2 diabetes, atherosclerotic heart disease, atrial fibrillation, fracture of the head of the left femur, chronic kidney disease stage 3, intestinal obstruction, chronic pain, hypertension, anxiety disorder, and osteomyelitis, had Admelog insulin lispro with meals, aspirin, gabapentin, methocarbamol, metoprolol succinate, atorvastatin, losartan, meloxicam, and omeprazole ordered without indications. During record review and interview, an LVN acknowledged the orders were missing diagnoses for the medications on these residents' orders, and the DON and Administrator stated they expected diagnoses to be placed on the orders when written.

Penalty

Inspection fine: $15,327

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 served to residents was palatable, attractive, and at a safe and appetizing temperature. During interview, Resident #8 said the food at the facility was not good, that he preferred not to eat there, and that he kept snacks in his room because he did not get enough to eat. He also stated that the meat was always overcooked, dry, and tough. The weekly menu for the spring/summer 2025 cycle included sugar glazed ham, butter beans, spinach with cheese, cornbread, and a marshmallow brownie. During lunch observation, Residents #3 and #5 were seated in the dining room with trays that included ham, spinach with cheese, and butter beans. Resident #5 backed away from the table and said the ham was not good and that he could not eat it, leaving the tray behind. Resident #3 picked up the ham with her hands, attempted to bite it, and said it was too tough to bite; she then placed it back on the tray and said none of the food was good. During the same meal, 6 unnamed residents did not eat the ham, which appeared dry and overcooked. In confidential interviews, 3 anonymous residents said the ham served at lunch was dry, hard, overcooked, very hard to chew, and almost inedible, and that most meats served at the facility were overcooked and hard to chew. The DM said no one complained to her about the meat being tough, and the Administrator said the facility had been thinking of developing a resident council team just to work on the food.

Penalty

Inspection fine: $15,327

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 individual needs for residents on a pureed diet. During an observation on 09/16/25 at 12:00 p.m., [NAME] D prepared pureed pot roast turkey for residents and pureed the au gratin potatoes, stating there were 4 residents on a pureed diet. During a later observation and interview at 12:40 p.m., the test tray for the pureed diet included pot roast turkey, au gratin potatoes, and a vegetable melody. The pot roast turkey contained small bits and was not smooth, and the au gratin potatoes contained small pieces of potatoes. [NAME] D stated he should have let the meat and potatoes run longer in the food processor and said the pureed diet should be smooth and a pudding consistency to prevent choking. During an interview at 12:43 p.m., the DM stated the facility had 4 residents who received pureed diets and that pureed food should not have lumps and should be smooth. Record review of the facility's Therapeutic Diets policy stated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care, and that if a mechanically altered diet is ordered, the provider will specify the texture modification. A reference reviewed on the internet stated that Level 4 pureed foods are usually eaten with a spoon, do not require chewing, and have a smooth texture with no lumps.

Penalty

Inspection fine: $15,327

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

Food was not stored, prepared, and served under sanitary conditions in the kitchen and refrigerator. During observation on 09/15/25 at 8:00 a.m., the dish machine was run three times and reached 120 degrees Fahrenheit, but when Dietary Aide B ran it a fourth time and tested it, there was no color change on the sanitizer test strip. She stated she had not been trained on what to do if the dish machine did not have sanitation chemicals and reviewed the manufacturer signage, which indicated the sanitization chemical level should be 50 ppm. After surveyor intervention, the DM arrived with new test strips and again found no color change when the machine was tested. She then attempted to manually get chemicals into the machine using a prime switch and stated dietary would use the 3-compartment sink and paper goods until the repair company fixed the dish machine. During the same observation period, the refrigerator contained 3 sandwiches without labels or dates, and Dietary Aide B stated the sandwiches had no date showing when they were placed in the refrigerator. At 9:00 a.m., the surveyor observed 3 streaks of a black substance under the 3-compartment sink on the wall, each approximately 4 inches by 5 inches, and 2 streaks of black substance under the drying area from the dish machine, each approximately 3 inches by 4 inches. The DM later stated the areas should be clean and free of discolored areas and that all items in the refrigerators should be labeled and dated to prevent food borne illness. Record review of the facility's Food Receiving and Storage policy indicated refrigerated foods are to be labeled, dated, and monitored so they are used by the use-by date, frozen, or discarded.

Penalty

Inspection fine: $15,327

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 during wound care for 3 of 15 residents reviewed. For Resident #3, who had diagnoses including osteomyelitis of the right ankle and foot, peripheral vascular disease, atrial fibrillation, systolic congestive heart failure, cirrhosis, COPD, type 2 diabetes mellitus, and Alzheimer's disease, the WCN did not wash or sanitize her hands when entering the room and did not sanitize her hands twice when changing gloves during wound care. The resident had multiple arterial, venous, and diabetic ulcers on both legs and toes, and the WCN also did not wash her hands before donning clean gloves to move from care of the left leg to the right leg. For Resident #4, who had intact cognition, required substantial/maximal assistance with bed mobility, and had a stage 4 pressure ulcer to the coccyx, the Wound Care Nurse entered the room without gloves after gowning outside the room, adjusted the privacy curtain, and then donned gloves without washing or sanitizing her hands. During wound care, she changed gloves without performing hand hygiene. The resident had three visible open areas associated with the coccyx wound, including a sacral wound and two wounds on the right side, with surrounding redness extending to the left buttocks and down the right leg. The nurse cleansed each wound, then used the same wooden spoon to apply wound gel to all three separate open areas and later applied collagen and dressings. For Resident #15, who had Alzheimer's disease, osteoporosis with current pathological fracture, and diabetes, the Wound Care Nurse performed wound care to multiple sites including the coccyx, left lateral malleolus, left great toe plantar side, and left heel. During the procedure, she changed gloves several times without performing hand hygiene, including after cleaning the ankle wound and before applying medical honey, and again before moving to the left great toe wound. She also changed gloves without hand hygiene before applying new gloves for the toe wound. The nurse later stated she should have used hand sanitizer during each glove change and said she became nervous while the resident was yelling out during care.

Penalty

Inspection fine: $15,327

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 treat a resident with respect and dignity when the ADON entered the resident's room without knocking first. The resident was a [AGE]-year-old male admitted with diagnoses including osteomyelitis of the right ankle and foot, peripheral vascular disease, atrial fibrillation, systolic congestive heart failure, cirrhosis of the liver, COPD, type 2 diabetes mellitus, and Alzheimer's disease. The quarterly MDS indicated he had minimal difficulty hearing, clear speech, and was able to make himself understood and understand others. During an observation, the WCN was performing wound care on the resident with the room door closed when the ADON opened the door and entered without knocking. The WCN had to yell out "Patient Care" to stop the ADON from entering further. In interviews, the WCN said staff were normally good about knocking before entering but did not know why the ADON did not knock. The ADON said she thought the resident was in the dining room for an activity and did not realize he was in the room receiving wound care; she stated staff should always knock before entering a resident's room. The resident later said staff would sometimes forget to knock before entering and that it sometimes bothered him.

Penalty

Inspection fine: $15,327

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 right to formulate an advance directive was provided for Resident #5, who had diagnoses including respiratory failure and Alzheimer's disease. Physician orders showed a DNR order, and the quarterly MDS indicated the resident had severely impaired cognition with a BIMS score of 4 out of 15. The care plan included code status: DNR and noted that advance directives would be reviewed by the care plan team quarterly and as needed. Record review of the OOH-DNR form showed Section A was signed by the resident and Section B was signed by the RP, but the bottom of the form, which stated that all persons who signed above must sign below acknowledging the document had been properly completed, was not signed by either the resident or the RP. During interview, the resident stated she did not want CPR and wanted to pass peacefully. The DON, LVN C, and Administrator stated an incomplete OOH-DNR would mean the resident was a full code, and the Administrator said hospice obtained the DNR but the facility was ultimately responsible. The facility policy stated a DNR order form must be completed and signed by the attending physician and the resident or legal surrogate and placed in the front of the medical record.

Penalty

Inspection fine: $15,327

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 consult the resident’s physician and notify the resident’s representative when there was a significant change in the resident’s physical status. Resident #15 was a female readmitted to the facility with diagnoses including Alzheimer’s disease, osteoporosis with current pathological fracture, and diabetes. Her record showed memory impairment, inability to complete the BIMS, and multiple wounds, including a wound to the left lateral malleolus, a wound to the plantar side of the left great toe, and a left heel area treated with betadine. During wound care observation, the wound care nurse was preparing and performing treatment to the resident’s coccyx, left ankle, and left great toe. While the boot was being removed and the dressings were being changed, the resident hollered out, grimaced, and moaned, and when asked, stated her pain was “so, so.” The wound care nurse stated the resident did not normally cry out like this and that the pain was new. She also stated she would report changes to the nurse and did not call the physician or wound care physician. The record review of nurse notes for the relevant period showed no indication that the physician or wound care physician was notified of the resident’s increased pain. The Administrator stated staff were leaving notes for the primary physician to see when he made rounds, and the DON stated the nurses should have called the wound care physician. The wound care physician stated he had not been notified of the increase in pain and said the facility needed to notify him or the primary physician if there was a change in pain level because it could indicate infection or changes in the wound.

Penalty

Inspection fine: $15,327

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 #13’s quarterly MDS accurately reflected her medication status. Record review showed the resident was a female readmitted to the facility with diagnoses including a history of pulmonary embolism and dementia. Her quarterly MDS indicated she had a BIMS score of 4, was dependent for most ADLs, and was taking an anticoagulant medication. However, the physician’s order for September 2025 showed Aspirin EC 81 mg daily for ischemic heart disease, and the MDS Nurse later stated that Aspirin was coded incorrectly as an anticoagulant instead of an antiplatelet. The MDS Nurse said she began completing MDS assessments for the facility remotely and had not been formally trained on completing MDS, relying on the RAI manual and prior webinar updates. She also stated she had never visited the facility or assessed a resident in person. The DON said he was responsible for reviewing all MDS and approving them, but he missed that Aspirin had been coded as an anticoagulant for Resident #13 when it should have been coded as an antiplatelet. The Administrator stated the MDS Nurse and DON were responsible for ensuring all MDS were coded correctly. The facility also failed to ensure Resident #15’s quarterly MDS accurately reflected the number of unstageable pressure ulcers. Record review showed the resident had diagnoses including Alzheimer’s disease, osteoporosis with current pathological fracture, and diabetes. Her quarterly MDS indicated 1 unstageable pressure ulcer and no other unstageable pressure ulcers, but the care plan, physician orders, and progress notes documented two unstageable wounds: one to the left lateral malleolus and one to the left great toe plantar side. The MDS Nurse reviewed the record and stated she had miscoded the assessment and that the pressure wounds should have been coded as 2 unstageable pressure ulcers.

Penalty

Inspection fine: $15,327

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 resident with multiple pressure injuries received all ordered wound treatments during wound care. Resident #15 was a readmitted female with diagnoses including Alzheimer’s disease, osteoporosis with current pathological fracture, and diabetes. Her record showed wounds to the left lateral malleolus, left great toe plantar side, left heel, and coccyx, with physician orders in September 2025 for daily wound care including cleansing, betadine, medical honey, alginate, collagen, and dry dressings as ordered for each site. During observation and interview, the WCN performed wound care to the coccyx, left lateral malleolus, and left great toe, but did not initially treat the left heel wound. After the surveyor asked whether there were any additional areas, the WCN acknowledged the left heel wound and stated she had forgotten it. She then donned new gloves, painted the left heel with betadine, and left it open to air. The record also showed the wound care policy required verification of physician orders.

Penalty

Inspection fine: $15,327

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

Pharmaceutical services failed to ensure accurate administration of medications for one resident when the order for Flonase was unclear and was not clarified before administration. Resident #12 had a physician order dated 01/31/25 for Flonase Allergy Relief (fluticasone propionate) spray, suspension, 50 mcg/actuation, 1 spray nasal once daily at 09:00 a.m., but the order and the September 2025 MAR did not indicate which nostril was to receive the spray. During medication pass on 09/17/2025 at 09:25 a.m., MA D administered Flonase nasal spray as 1 spray to each nostril. During later record review and interview, MA D stated the order did not indicate whether the spray was to be given in one nostril and which nostril, or whether it was to be administered into each nostril. MA D reviewed the medication box and found the prescription label indicated 1 spray to each nostril daily. The DON, LVN C, and the Administrator acknowledged the order was unclear and stated the medication would not be administered correctly the way the order read. The facility policy stated the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication.

Penalty

Inspection fine: $15,327

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

Keep all essential equipment working safely was cited after surveyors observed that the facility did not maintain the gas stove in safe operating condition. During an observation and interview on 09/15/25 at 7:55 a.m., the gas stove in the kitchen was found to have six burners total, and the left back burner would not light automatically when the knob was turned to the on position. The DM stated that the burner sometimes had to be lit with matches. During an interview on 09/17/25 at 7:55 a.m., the Administrator said she expected staff to notify her of equipment issues and stated that the burner was fixed immediately. Record review of the facility policy titled Sanitization, revised November 2022, indicated that dishwashing machines are to be operated according to manufacturer's instructions, including required wash temperature, final rinse, and chemical solution maintenance.

Penalty

Inspection fine: $15,327

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

Summary

The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on A Hall, where an empty unlocked resident room was being used as a storage room. During an observation, the room door was shut but unlocked and contained a half-full container of pesticide powder sitting on a dresser. The container label stated to keep out of reach of children and animals, and the personal safety warnings directed to avoid contact with skin, eyes, or clothing. No staff were in sight at the time of the observation. During interview, the Maintenance Supervisor stated he forgot to lock the door and acknowledged that residents were confused and wandered about the facility, and that chemicals should be in sight or locked up. The Administrator later stated the Maintenance Supervisor locked the door after forgetting and that a self-locking door was installed after surveyor intervention.

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 observed that the facility failed to maintain sanitary conditions in the kitchen, specifically regarding the cleanliness of food preparation equipment. During an inspection, multiple items were found with brown colored buildup, including baking sheets, muffin pans, steam table lids, and saucepans. These items were observed to have buildup on both the inside and outside edges, and some were stacked together while still dirty. Staff interviews confirmed that efforts were being made to clean the equipment, but the buildup remained present at the time of the survey. A review of the facility's Sanitization Policy indicated that all equipment, food contact surfaces, and utensils are to be cleaned and sanitized using heat or chemical solutions. The FDA Food Code was also referenced, which requires food-contact surfaces of cooking equipment and pans to be free of encrusted grease deposits and other soil accumulations. Despite these policies, the facility did not ensure that the kitchen equipment was properly cleaned and sanitized, as evidenced by the observed buildup on multiple items.

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 infection prevention and control program, which is essential for providing a safe, sanitary, and comfortable environment for residents. The deficiency was identified through interviews and record reviews, revealing that the facility did not maintain a system for trending infections from July 2023 through July 2024. This lack of documentation and tracking could potentially place residents at risk of cross-contamination and the development of infections. Interviews with the facility's Administrator and the Regional MDS Nurse, who assumed the role of Infection Control Nurse, indicated that the previous Director of Nursing (DON) had left the facility in July 2024 and allegedly deleted the facility's computer records, including those related to infection trending. The Regional MDS Nurse admitted to not completing any infection trending after taking over the position. The facility's policy on infection surveillance, revised in September 2017, emphasized the importance of identifying individual cases and trends to guide appropriate interventions and prevent future infections. However, the absence of infection tracking and trending documentation highlighted a significant gap in the facility's infection control practices.

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 accurate assessments for two residents, leading to potential risks in their care. Resident #4, a female with dementia, anxiety, and depression, was inaccurately assessed in the MDS as receiving anticoagulant and antidepressant medications, despite physician orders indicating otherwise. The resident had a history of depression but had not been on antidepressant medication since March 2024 and was only taking aspirin, which should not have been coded as an anticoagulant. Resident #12, a male with COPD, was inaccurately assessed in the MDS as not using tobacco, despite being a current everyday smoker. The resident's care plan and smoking risk assessment indicated he smoked every few hours and required supervision while smoking. Observations confirmed that the resident smoked daily and was monitored by staff during smoking times. Interviews with the Regional MDS nurse, DON, Administrator, and Regional Consultant revealed that the inaccuracies were due to oversight and system errors. The Regional MDS nurse acknowledged the errors and stated that the MDS assessments were not double-checked for accuracy, leading to misinformation about the residents' statuses. The facility's policy and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual were not adhered to, resulting in the deficiencies.

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 included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #2, an elderly female with hemiplegia and hemiparesis following a cerebral infarction, did not have a care plan for a trauma-induced wound on her right heel. Despite physician orders for daily wound care, the Treatment Nurse, who was responsible for writing care plans for new wounds, did not create one. The Regional MDS Nurse, who was the Treatment Nurse's supervisor at the time, acknowledged the oversight and admitted that it was his responsibility to ensure care plans were complete and accurate. Resident #3, an elderly male with a cerebral infarction due to embolism, was admitted to hospice services but did not have a corresponding care plan. The Corporate MDS Nurse, responsible for ensuring comprehensive care plans, confirmed the absence of a hospice care plan for Resident #3. The Administrator stated that every resident should have a person-centered care plan, and the Regional MDS Nurse was the interim DON when these care plans were not written. The facility's policy requires comprehensive person-centered care plans to be developed and implemented for each resident, describing the services needed to maintain their highest practicable well-being.

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's drug regimen was free from unnecessary medication by not monitoring for side effects of the anticoagulant medication Eliquis. The resident, a male with a diagnosis of deep vein thrombosis, was prescribed Eliquis 5 mg twice daily. However, the facility did not document monitoring for side effects such as bleeding, which is crucial for patients on anticoagulant therapy. The absence of monitoring was confirmed through record reviews and interviews with staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The ADON acknowledged that the monitoring was overlooked and should have been included in the computer system when the order was entered. The DON, who was new to the position, confirmed that monitoring for side effects was not in place and emphasized the importance of such monitoring to prevent potential bleeding risks. The facility's policy on anticoagulant therapy required staff to monitor for complications and manage related problems, but this was not adhered to in the case of 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 store all drugs and biologicals in locked compartments under proper temperature controls, as required by their Medication Labeling and Storage policy. During an observation, two 30-count cards of venlafaxine, an antidepressant, were found left unattended on the desk at the nurses' station, accessible to staff, residents, and visitors. This incident occurred when an LVN left the medication out with the intention of returning it to the pharmacy but left the nurses' station without securing it. Interviews with the LVN, the DON, and the Administrator confirmed that medications should not be left unsecured and unattended, as they could be accessed by unauthorized individuals. The facility's policy clearly states that all medications and biologicals must be stored in locked compartments and that only authorized personnel should have access to them. The failure to adhere to this policy could lead to the misappropriation of property and drug diversion, posing a risk to residents.

Penalty

Inspection fine: $14,668

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 basic life support, including CPR, to a resident who required emergency care, despite having physician orders and advance directives indicating a full code status. The incident involved a resident who was found unresponsive by a CNA at around 4:00 a.m. The CNA immediately notified an LVN, who failed to verify the resident's code status and instead called hospice. This led to a delay of approximately 2.5 hours before CPR was initiated, during which time the resident was pronounced dead by EMS upon their arrival. The resident, a male with diagnoses including cerebrovascular disease, pneumonia, and anoxic brain damage, had a care plan indicating a full code status. Despite this, the LVN did not initiate CPR or call 911, mistakenly believing that the resident's hospice status precluded the need for resuscitation. The LVN admitted to not checking the resident's code status and was more concerned with completing her other duties. The hospice nurse, upon arrival, informed the LVN that the resident was a full code, prompting the LVN to return to the facility and initiate CPR, but it was too late. Interviews with staff revealed that the facility had a system in place to identify residents' code statuses, including a binder on the crash cart and information in the computer. However, the LVN failed to utilize these resources. The facility's policy required CPR to be initiated unless a DNR order was present, which was not the case for this resident. The failure to provide timely CPR and call emergency services directly led to the resident not receiving potentially life-saving measures in a critical situation.

Removal Plan

• Immediate suspension of LVN A
• CPR audit conducted on all direct care staff
• Abuse/Neglect in-service
• In-service on emergency procedures for codes (CPR)
• Performed mock codes
• Held CPR training recertification class

Penalty

Inspection fine: $101,719

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 appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For the first resident, the facility did not conduct proper assessments or provide necessary treatments for a pressure injury on the right dorsal foot, which deteriorated to an unstageable wound with eschar. Despite the resident's cognitive intactness and multiple diagnoses, including end-stage renal disease and a recent surgical procedure, the facility did not document or notify the physician about the worsening condition from 02/14/2024 to 02/27/2024. The resident eventually required hospitalization for wound irrigation, debridement, and graft application due to the severity of the wound and associated infection. Additionally, a pressure injury on the resident's right buttock was identified only upon hospital admission, indicating a lack of comprehensive skin assessments by the facility staff. For the second resident, the facility failed to monitor and treat a blister on the right heel, which was noted upon readmission. The blister deteriorated into an unstageable wound with eschar, but the facility did not document the changes or notify the physician in a timely manner. Weekly skin assessments from 02/23/2024 to 03/15/2024 did not reflect the presence of the blister, and there was no documentation of physician notification about the wound's progression. The resident's care plan and physician orders were not updated to address the worsening condition, leading to a delay in appropriate wound care and treatment. Interviews with facility staff, including LVNs, the DON, and the ADON, revealed inconsistencies in wound care practices and communication lapses regarding the residents' conditions. The facility's failure to adhere to professional standards of practice for pressure ulcer prevention and treatment resulted in significant deterioration of the residents' wounds, necessitating advanced medical interventions and hospitalizations.

Penalty

Inspection fine: $101,719

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 treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident reviewed for quality of care. The facility did not coordinate care with the orthopedic surgeon and attending NP/MD regarding a change in the resident's skin condition at the surgical area on the right lower extremity. This lack of coordination and communication led to the deterioration of the resident's pressure injury, which eventually required hospitalization, surgical debridement, and graft application. The resident, who had multiple diagnoses including a displaced trimalleolar fracture, osteomyelitis, and end-stage renal disease, was admitted to the facility with an external fixator on the right lower extremity. Despite the orthopedic surgeon identifying a scab and discolored skin on the resident's right foot, the facility did not document any assessment or treatment for this condition. Weekly skin assessments and other required documentation were either missing or incomplete, and there was no evidence of communication with the orthopedic surgeon or attending physician regarding the identified pressure injury. Interviews with facility staff revealed that the focus of care was primarily on the external fixator pin sites, and the dark or discolored area on the top of the resident's right foot was not adequately addressed. The facility's failure to follow up on outside appointments and obtain necessary documentation further contributed to the lack of appropriate care. The resident's condition worsened, leading to significant pain, infection, and the need for surgical intervention, highlighting the facility's deficiencies in care coordination and documentation.

Penalty

Inspection fine: $101,719

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

Summary

The facility failed to ensure the physician was consulted for a change of condition for a resident who returned from the hospital with a blister on her right heel. The resident, who had dementia and high blood pressure, was readmitted with a fracture of the femur. Despite the hospital discharge records noting the blister, the facility did not notify the physician for treatment orders upon the resident's return. Weekly skin assessments initially noted the blister but later failed to document it, and there was no record of the physician being notified of the blister's progression to an unstageable wound with eschar. Interviews with the DON, MD, NP, and ADON revealed that the facility's staff did not follow the protocol for notifying the physician of the change in the resident's condition. The MD and NP were unaware of the blister until much later, and the weekly skin assessments were found to be incorrect for several weeks. The facility's policy required prompt notification of changes in medical condition to the physician, but this was not adhered to, leading to a delay in treatment for the resident's wound.

Penalty

Inspection fine: $101,719

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 a comprehensive person-centered care plan for a resident with new pressure injuries. The resident, a male with multiple diagnoses including anoxic brain damage, cerebrovascular disease, and sepsis, was identified with new pressure injuries on his buttocks. Despite the identification of these injuries and the subsequent orders for wound care, the resident's care plan was not updated to reflect these new needs. The resident's medical records indicated that he was moderately cognitively impaired and had triggered a care area assessment for pressure ulcers. However, the care plan dated after the identification of the new pressure injuries did not include these new issues. Nursing progress notes and a wound care consult confirmed the presence of the injuries and detailed the treatment plan, but this information was not incorporated into the resident's care plan. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that the care plan should have been updated to include the new pressure injuries. The ADON acknowledged that the care plan was not accurate and up-to-date, which could lead to staff being unaware of the resident's needs. The Administrator attributed the oversight to a change in staff and confirmed that the new MDS Coordinator and charge nurses were responsible for updating care plans. The facility's policy on care planning emphasized the importance of an interdisciplinary team in developing and updating care plans based on resident assessments.

Penalty

Inspection fine: $101,719

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 comprehensive care plan within 7 days after the completion of the comprehensive assessment or no more than 21 days after admission for one of the residents reviewed. Specifically, Resident #3, who was admitted and readmitted on specified dates, did not have a comprehensive care plan from 02/02/2024 to 03/20/2024. The care plan should have been completed by 02/17/2024. Resident #3 had significant medical conditions, including cardiac issues, hypertensive chronic kidney disease, and a history of a fractured hip, which required careful monitoring and management. Despite these needs, the comprehensive care plan was not developed in the required timeframe, potentially placing the resident at risk of not receiving appropriate care and services. Observations and record reviews indicated that Resident #3 had 2+ edema in both lower extremities and episodes of asymptomatic hypotension. The resident's medical records showed that the cardiologist and attending nurse practitioner were aware of these conditions and had provided new orders. Interviews with the resident confirmed that she was aware of her cardiac issues and the efforts being made to manage her condition. However, the absence of a comprehensive care plan meant that these interventions were not formally documented and integrated into her care plan. Interviews with facility staff, including the ADON and the Administrator, revealed that the comprehensive care plan for Resident #3 was missed due to a change in staff. The previous MDS Coordinator, who was responsible for completing the care plans, had resigned, and the new MDS Coordinator had not completed the necessary documentation. The ADON acknowledged that the lack of a comprehensive care plan could lead to residents not receiving adequate care. The facility's policy required that a comprehensive, person-centered care plan be developed within seven days of the completion of the MDS assessment, but this was not adhered to in Resident #3's case.

Penalty

Inspection fine: $101,719

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 admitted for rehabilitation services. The resident, who had multiple serious diagnoses including acute respiratory failure, pneumonia due to COVID-19, hypertension, myocardial infarction, and pulmonary embolism, was admitted to the facility but did not have an initial admission assessment completed by the assigned LVN. Additionally, there was no documentation on the Medication Administration Record (MAR) indicating what medications the resident was admitted with or whether any medications were administered during the resident's short stay at the facility. The LVN responsible for the resident's admission acknowledged that she did not complete the necessary documentation due to the resident arriving late in the evening and subsequently experiencing a medical emergency that required transfer back to the hospital. The LVN cited being overwhelmed with other emergencies and a high number of residents to care for as reasons for the incomplete documentation. She also mentioned that she became ill and was unable to return to the facility to finish the documentation. The facility's administrator confirmed that the documentation was incomplete and stated that the issue was addressed with the LVN over the phone. The facility's policy requires that all services provided to the resident, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. However, in this case, the required documentation was not completed, leading to a deficiency in maintaining accurate medical records for the resident.