Epic Nursing & 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 use the services of a Registered Nurse for at least 8 consecutive hours, 7 days a week from 3/30/2026 to 5/7/2026. Record review of the Daily timecard for 3/22/26 to 5/8/26 showed no RN time entries for 3/30/2026, 4/8/2026, 4/13/2026, 4/17/2026, 4/22/2026, 5/1/2026, 5/6/2026, and 5/7/2026. The facility’s average daily census was 68, and the DON stated she knew the DON hours could not be counted as RN coverage when the census was over 60. The DON also stated the facility had about a dozen gaps in RN coverage since March 2026 after the full-time wound care RN left in March. During interviews, the DON said the facility had been trying to hire an RN or use agency nurses but could not get nurses to come out to cover in the area. The ADM acknowledged the RN coverage issues and stated the DON was on call 24 hours a day, 7 days a week, but also acknowledged the DON was the only RN in the building at times. The RNC stated he understood the average daily census was 68 and that the DON hours could not be included as RN coverage, and he expressed concern that staff would not have access to RN insight for assessments or higher clinical care. Facility policy stated that an RN provides services at least eight hours every 24 hours, seven days a week.

Penalty

Inspection fine: $22,406

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 residents from abuse and neglect, as evidenced by multiple incidents involving three residents. One incident involved a female resident with severe cognitive impairment, including dementia and a BIMS score of 4, who was found engaging in sexual activity with a male resident, also diagnosed with dementia and other neurological conditions. Staff discovered both residents naked from the waist down and engaged in sexual activity. Prior to this, the same two residents were found lying in bed together, fully clothed, with the male resident's hand on the female resident's leg. In both cases, staff failed to recognize or report the incidents as abuse or neglect, despite being trained to do so, and did not immediately notify the administrator as required by facility policy. Another incident involved a nonverbal female resident with severe cognitive impairment and a history of aggressive behaviors. A CNA was observed by therapy staff forcefully grabbing and shaking the resident's wrist after the resident attempted to slap the CNA. The physical therapist intervened, and the resident became emotional and refused therapy, not returning to her baseline until the following day. The CNA denied shaking the resident's arm but was terminated following an investigation that confirmed physical abuse. Interviews with staff revealed a lack of understanding and inconsistent application of abuse and neglect reporting protocols. Several staff members, including CNAs and LVNs, admitted to not reporting incidents as abuse or neglect because they did not perceive the actions as malicious or because the residents involved were confused. The administrator was not notified of the incidents in a timely manner, and the facility's policies regarding immediate reporting and protection from abuse were not followed.

Penalty

Inspection fine: $22,406

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 residents' right to be free from abuse and neglect, as evidenced by multiple incidents involving three residents. One incident involved a female resident with severe cognitive impairment and a male resident, both diagnosed with dementia, who were found engaging in sexual activity. Staff discovered the two residents in a state of undress and engaged in sexual behavior, but did not immediately recognize or report the incident as abuse or neglect. Staff interviews revealed a lack of understanding regarding the reporting requirements for abuse, particularly when both residents involved had cognitive impairments. The incident was not reported to the administrator until the following day, contrary to facility policy and staff training, which required immediate reporting of all abuse, neglect, or exploitation (ANE) incidents. Another incident involved the same male resident, who was found on a separate occasion lying in bed with the same female resident, fully clothed but with his hand on her leg. This event was also not reported as abuse or neglect, as staff did not perceive the behavior as malicious or inappropriate due to the residents' confusion and cognitive status. The lack of documentation and timely reporting of these events indicated a failure to follow established protocols for identifying and responding to potential abuse or neglect, especially among residents with dementia and impaired safety awareness. A third incident involved a nonverbal female resident with severe cognitive impairment who was physically abused by a CNA. The CNA forcefully grabbed and shook the resident's arm after being slapped by the resident, an action witnessed by therapy staff. The resident became emotional and refused further care, with her behavior not returning to baseline until the following day. The incident was reported to the administrator by the therapy staff, and the CNA was subsequently terminated. However, the social worker was not immediately informed, and the incident highlighted a breakdown in communication and adherence to abuse prevention policies among staff.

Removal Plan

• Resident 1 and Resident 2 were immediately separated from each other.
• Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker.
• The social worker performed trauma informed care assessment.
• Medical Director was notified, and orders obtained for psychiatric services.
• Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented.
• Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity.
• The Business Office Manager was immediately terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds.
• The resident's funds were replaced by the facility.
• All residents with behaviors documented as an incident report and/or in the progress notes will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors.
• If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed immediately.
• Daily audit of resident behaviors and interventions will be reviewed and noted in resident chart.
• Audits will be conducted for behavioral events.
• The Regional Business Office Director completed an audit for residents trust funds with no discrepancies noted.
• Staff assigned to the secured unit, in which there are consistent staff members, other facility staff including PRN staff and agency staff will be interviewed for any additional incidents or residents that may have been affected by resident-to-resident abuse.
• Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations.
• Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.
• Audits by the Regional Business Office Manager.
• Resident Fund Management Service will be audited.
• Education provided to all staff by the Administrator: Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator).
• Education to staff on Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene.
• Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing.
• All Facility staff will complete prior to working their next shift.
• New employees and agency staff will be educated upon hire and/or prior to working a shift.
• Knowledge will be verified via test and verbal discussion with affirmative feedback.
• Staff that handle resident funds, Business Office and Human Resources Director will undergo retraining on financial policies, ethical standards, and proper fund management procedures.
• Education provided to Nursing Staff by the Director of Nursing on Resident Kardex that will contain the updated care plans and interventions following behavioral events.
• Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing.
• Testing and verbal confirmation are utilized to assess knowledge retention.
• Annual training via Relias regarding resident's rights, theft, misappropriation and abuse.
• All Facility staff, new hire and agency will complete prior to working their next shift.
• Knowledge will be verified via test and verbal discussion with affirmative feedback.
• During daily meeting, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following any resident-to-resident or other inappropriate behavior.
• Will be reviewed during daily meeting and then weekly thereafter.
• Reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager.
• Medical Director informed of this plan at the Ad Hoc QAPI.

Penalty

Inspection fine: $22,406

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, neglect, exploitation, or misappropriation of resident property were reported immediately to the Administrator as required. In multiple instances, staff did not recognize or report incidents of potential abuse or neglect within the mandated timeframes. For example, two residents with severe cognitive impairment and dementia were observed engaging in sexual activity on two separate occasions. Staff who witnessed or were informed of these incidents did not immediately report them to the Administrator, as required by facility policy and regulatory guidelines. Instead, the incidents were either not reported at all or were reported with significant delay, and some staff did not recognize the events as abuse or neglect due to the residents' cognitive status. Additionally, another incident involved the Business Office Manager confessing to the Marketing Director that she had taken a resident's credit card and used it for personal expenses totaling $3,700. The Marketing Director did not immediately report this confession to the Administrator, instead waiting until the following day. This delay in reporting was contrary to the facility's policy, which requires immediate notification of the Administrator and other authorities in cases of suspected exploitation or misappropriation of resident property. Interviews and record reviews confirmed that staff, including CNAs, LVNs, and administrative personnel, were aware of the requirement to report abuse, neglect, and exploitation immediately but failed to do so in these cases. The Administrator confirmed that she was not notified of the incidents in a timely manner and that staff were expected to follow the facility's reporting policy. These failures resulted in the facility being cited for not protecting residents from abuse, neglect, or exploitation by not ensuring timely reporting and investigation of alleged violations.

Removal Plan

• Resident 1 and Resident 2 were separated from each other.
• Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker.
• The social worker performed trauma informed care assessment.
• Medical Director was notified, and orders obtained for psychiatric services.
• Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented.
• Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity.
• The Business Office Manager was terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds.
• All residents with behaviors documented as an incident report and/or in the progress notes for the previous 90 days will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors.
• If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed.
• Audit of resident behaviors and interventions will be reviewed and noted in resident chart.
• Audits will be conducted for behavioral events.
• The Regional Business Office director completed an audit for residents' trust funds based on the immediate jeopardy.
• Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations.
• Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.
• Weekly audits by the Regional Business Office Manager.
• Weekly Resident Funds Management Service audits by the Regional Business Office Manager.
• If a discrepancy is found, it will be investigated by the regional business office manager, facility administrator, and Regional VP of Operations.
• Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator).
• Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene.
• Staff will be educated to separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing.
• All Facility staff will complete them prior to working their next shift.
• New employees and agency staff will be educated upon hire and/or prior to working a shift.
• Knowledge will be verified via test and verbal discussion with affirmative feedback.
• Staff that handle resident funds will undergo retraining on financial policies, ethical standards, and proper fund management procedures.
• The resident will be monitored for aggressive/inappropriate behaviors.
• When no longer exhibiting aggressive/inappropriate behavior that warranted the 1:1 observation the Interdisciplinary Team and Physician will collaborate for the discontinuation of 1:1 observation.
• Reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager.

Penalty

Inspection fine: $22,406

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

Summary

A deficiency occurred when a resident with severe cognitive impairment and a history of dementia and falls was able to elope from the facility. The resident, an elderly female with a BIMS score indicating severe cognitive impairment, was not identified as an elopement risk on her initial assessment, but her care plan did indicate a need for routine monitoring due to her cognitive status and risk for falls. On the day of the incident, the resident exited the facility when a visitor held the door open for a CNA entering the building. The CNA, who worked on the secured unit and was unfamiliar with the resident, did not recognize her as a resident because she was dressed in a way that resembled a visitor and was carrying a purse. The resident was found outside the facility by a passerby and was returned by a member of the public. Staff interviews revealed that the resident was not outside for more than five minutes and did not sustain any injuries. The incident was not immediately recognized by staff, and the CNA involved later acknowledged not recognizing the resident as someone who should not be leaving the building. The facility's security measures, including non-functioning cameras and lack of staff presence at the front door, contributed to the resident's ability to leave unnoticed. The facility's policies required the environment to be as free from accident hazards as possible and for residents to receive adequate supervision to prevent accidents, including unsafe wandering. However, the failure to recognize the resident as a resident, combined with the lack of effective monitoring and security at the exit, resulted in the resident's elopement. The incident was identified as Immediate Jeopardy, as it placed the resident at risk for harm.

Penalty

Inspection fine: $22,406

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

Summary

The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for three residents. For one resident with severe cognitive impairment and multiple medical diagnoses, the care plan was not updated after incidents involving being found in bed with another resident and a subsequent sexual activity incident. The only care plan in the electronic medical record focused on wandering and general safety, without addressing the new behavioral concerns or interventions related to these incidents. Another resident, also with dementia and additional medical conditions, exhibited inappropriate sexual behaviors on multiple occasions, including being found in bed with another resident and attempting to kiss others. Despite these documented behaviors, the care plan was not updated in a timely manner to include interventions addressing these behaviors. The care plan was only revised after several incidents had already occurred, and prior to that, there were no entries related to his sexual behaviors. A third resident, with severe cognitive impairment and a history of falls, had an initial elopement risk assessment completed that indicated the need for routine monitoring. However, the care plan did not include interventions for routine monitoring as required. Staff interviews revealed that communication lapses between agency nurses and the MDS coordinator contributed to the omission, and the care plan was not updated to reflect the necessary interventions following the assessment.

Penalty

Inspection fine: $22,406

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 immediately notify the responsible party (RP) of a resident following a significant change in the resident's status. Specifically, a female resident with severe cognitive impairment and multiple medical diagnoses, including dementia, was found lying in bed with a male resident in a room that did not belong to either of them. The male resident, who also had dementia and other neurological and medical conditions, was fully clothed and had his hand on the female resident's leg. The incident was documented by an LVN, who redirected the male resident and notified the Director of Nursing (DON), but did not recall notifying the responsible parties for either resident. Review of the female resident's records showed no documentation of the incident or notification to her RP on the date it occurred. The care plan for the female resident included interventions to ensure family and physician awareness of behaviors or changes, but there was no evidence these were followed in this instance. Similarly, the male resident's care plan, updated after the incident, included interventions for sexually inappropriate behavior and required family and physician notification of such behaviors, but there was no documentation that this occurred for the incident in question. Interviews with facility staff and the administrator confirmed that the incident was not reported to the responsible parties as required. The administrator stated she was unaware of the incident and expected immediate notification to both herself and the residents' RPs. The family member for the female resident reported only being notified of a later incident and expressed concern about not being informed of the earlier event. Facility policy requires notification of changes in condition or incidents affecting residents, but this was not followed in this case.

Penalty

Inspection fine: $22,406

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 from exploitation and misappropriation of property when the Business Office Manager (BOM) took the resident's net spend credit card and used it for personal expenses, withdrawing a total of $3,700. The resident, who had severe cognitive impairment as indicated by a BIMS score of 0 and was care planned for visual impairment and secure storage of personal items, had his wallet stored in the business office while he was hospitalized. Upon the resident's return, his responsible party (RP) noticed the credit card was missing from the wallet, which was being held by the BOM. The BOM confessed to the Marketing Director that she had taken and used the resident's credit card for personal use, initially stating she used $2,000, then $3,000, and admitted she could not return the money. The Marketing Director did not immediately report the confession to the Administrator (ADM), instead waiting until the following morning. The incident was subsequently reported to the ADM, and the police were contacted, but no charges were pressed as the resident received the money back. Interviews with staff, including the Social Worker (SW) and interim Director of Nursing (DON), revealed they were not aware of the incident until after it occurred. The facility's investigation confirmed the misappropriation, and the BOM was terminated. The facility's policy required protection of residents from exploitation and misappropriation by anyone, including staff, and outlined the need for protocols to prevent and identify theft or exploitation. The failure to prevent the BOM from accessing and using the resident's credit card constituted a violation of these policies.

Penalty

Inspection fine: $22,406

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

Summary

The facility failed to conduct an initial comprehensive, accurate, and standardized assessment of a newly admitted resident's functional capacity within the required 14-day timeframe. Specifically, a male resident with diagnoses including dementia, Parkinson's disease, hypotension, anxiety disorder, and benign prostatic hyperplasia was admitted, but no Minimum Data Set (MDS) assessment was completed within the mandated period. Review of the electronic medical record confirmed the absence of the MDS assessment, and the MDS Coordinator acknowledged that the assessment was not completed on time, citing being behind on assessments and initially misclassifying the resident as respite due to his hospice status. Further interviews revealed that the Administrator was unaware of the overdue MDS assessments and that the MDS Coordinator, who was responsible for timely completion, reported both to regional MDS staff and directly to the Administrator at the local level. Facility policy requires comprehensive assessments to be completed within 14 days of admission, in accordance with the Resident Assessment Instrument (RAI) User Manual. The failure to complete the assessment as required resulted in the resident not having their care and treatment needs fully assessed within the appropriate timeframe.

Penalty

No penalty information released

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

Summary

The facility failed to provide the required services of a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, as mandated. Observations and record reviews revealed that there was no RN coverage on multiple dates, specifically from 8/11 to 8/15, 8/18 to 8/22, 8/25 to 8/28, and on 9/1 and 9/2. The Daily Nurse Staffing Reports and interviews with staff confirmed that there were zero scheduled RN hours on these dates, despite the facility having a census of 72 residents. The Director of Nursing (DON) and other staff members were unaware that the DON's hours could not be used to fulfill the RN staffing requirement when the average daily census exceeded 60 residents. The facility did not have any other RNs scheduled to cover the required hours during the identified periods, and the RN who typically provided coverage was out on leave and not replaced. Interviews with the DON, staffing coordinator, and administrator revealed a lack of understanding regarding the RN coverage requirements, particularly that the DON's hours could not be counted toward the mandated RN coverage when the census was above 60. The facility's own policy stated that a RN must provide services at least eight hours every 24 hours, seven days a week, and that the DON may only serve as charge nurse if the average daily occupancy is 60 or fewer residents. Despite this, the facility relied solely on the DON's hours and did not ensure additional RN coverage, resulting in noncompliance with federal staffing requirements.

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 by not administering morning medications to 35 out of 72 residents on a specific date, resulting in 305 medication errors. The missed medication administration was due to a medication aide (MA) calling in sick after the shift had started and not coming to work. The MA notified the DON via text message early in the morning, but the DON did not inform anyone at the facility that the MA would not be present. As a result, no arrangements were made to cover the medication pass for the affected halls. Multiple staff interviews confirmed that the absence of the MA went unnoticed until late in the morning, at which point another MA was called in to pass medications. By then, the morning medication pass for two halls had been entirely missed. Nurses and other staff became aware of the situation only after residents had not received their scheduled medications. The medical director was notified and gave orders not to administer the missed medications but to monitor residents' vital signs for 12 hours and report any changes in condition. The incident was documented as medication errors for all affected residents. Resident records and staff interviews indicated that the residents involved had various significant medical diagnoses, including cerebral infarction, dementia, schizoaffective disorder, Huntington's disease, atrial fibrillation, and cancer. Progress notes and interviews confirmed that vital signs were monitored and no adverse outcomes were observed or reported at the time. The facility's own policy required medications to be administered in a safe and timely manner, with staffing schedules arranged to prevent interruptions, but these procedures were 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

A deficiency occurred when a resident with diagnoses including anxiety disorder, unspecified dementia, schizophrenia, and cognitive communication deficit was able to access and potentially ingest a cup containing a bleach and soap solution. The resident, who was dependent in several activities of daily living and had impaired decision-making abilities, was observed by kitchen staff with a cup that had been used to soak dishes in a diluted bleach solution. The staff member immediately intervened and notified nursing staff. The resident was assessed, found to be alert and oriented, and was subsequently sent to the emergency room for evaluation, where no toxic substances were detected and all laboratory results were normal. Interviews with staff revealed that the cup containing the bleach solution was left accessible on a cart in the kitchen doorway, allowing the resident to obtain it. The facility's policy on safety and supervision was reviewed, which emphasizes both a facility-oriented and individualized approach to resident safety. The incident demonstrated a failure to ensure that hazardous cleaning solutions were not accessible to residents, particularly those with cognitive impairments and a history of impaired decision-making.

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 in one of five halls reviewed, specifically in the secure unit hallway. Observations revealed water stains and a black substance on the ceiling, which staff members identified as resulting from a previous air conditioning leak. The black substance was described by both the LVN and DON as appearing to be mold. The Maintenance Director acknowledged awareness of the water stains but stated he had not been notified about the black substance. He indicated that the air conditioning leak had been repaired weeks prior and was waiting for the ceiling to dry before proceeding with repairs, as required by facility policy to obtain three estimates before work could begin. Interviews with staff confirmed that the issue had persisted for some time, with the LVN and DON both expressing concern about the presence of the black substance and its potential to be mold. The DON and Maintenance Director both stated that the black substance could cause respiratory issues for residents and staff if it was indeed mold. The facility's Homelike Environment policy requires a clean, sanitary, and orderly environment, which was not met in this instance due to the unresolved ceiling damage and possible mold presence.

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 food service safety standards in its main kitchen, as observed during a survey. The ice machine in the tray-serving area was found to have dried white drip stains, brownish and white build-up, and black build-up on various parts, indicating it had not been cleaned as required. Additionally, several opened packages of food in the dry goods pantry, including powdered milk, elbow macaroni pasta, cornmeal, long grain rice, breadcrumbs, and instant potatoes, were not securely closed after opening, which could lead to contamination. On a subsequent observation, an uncovered container of diced peaches and 12 dessert cups containing fruit salad were found on a cart and preparation space in the kitchen, respectively. These items were uncovered while being prepared for meal distribution, increasing the risk of cross-contamination. Furthermore, during meal plating and serving, it was noted that the cook's hair was not fully covered, and the dietary aide's hair was partially uncovered due to wearing a warm cap over the hairnet, which could result in hair contaminating the food. Interviews with the dietary aide and manager confirmed the importance of covering food and hair to prevent contamination. The dietary aide acknowledged the oversight in not covering the desserts and the container of peaches, while the dietary manager emphasized the need for securely closing food packages to prevent contamination and attract pests. The facility's policies on ice machine maintenance and food storage were reviewed, highlighting the need for adherence to safe food handling 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 maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 8 days during the 6-month review period. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have the required RN coverage on specific dates between April and June 2024. The absence of RN coverage was confirmed by reviewing CMS PBJ staffing reports, which showed no RN hours recorded on eight specific dates. During interviews, the Director of Nursing (DON) acknowledged the lack of RN coverage and stated that managers, including herself, would come in when there was no licensed nurse available. The DON, who is on salary, mentioned that her weekend work was not reflected in the payroll system but was documented on a paper form. The facility had concerns with RN staffing on weekends and had since hired a weekend supervisor who is an RN. The Interim Administrator also confirmed awareness of the RN coverage lapse and stated that the DON was expected to cover when needed. The facility's policy requires RN services for at least 8 consecutive hours a day, 7 days a week, which was not met during the specified period.

Penalty

No penalty information released

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

Summary

The facility failed to provide proper respiratory care for a resident, specifically in the storage of a nebulizer mouthpiece. The resident, a cognitively intact male with a history of influenza and acute cough, was observed to have his nebulizer mouthpiece improperly stored on a bag of chips and on top of the nebulizer, rather than in a protective bag. This improper storage was noted during observations and interviews on two separate occasions, indicating a lapse in following professional standards of practice and the resident's comprehensive care plan. Interviews with facility staff, including an LVN and the ADON, confirmed that the mouthpiece should have been stored in a bag when not in use to prevent contamination and infection. The facility's policy on oxygen administration did not provide guidance on the storage of respiratory items, contributing to the oversight. This deficiency in care could potentially place the resident at risk for respiratory infection due to the lack of adherence to proper storage protocols.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by two separate incidents involving improper hand hygiene practices by staff members. In the first incident, a Certified Nursing Assistant (CNA) did not change gloves or use hand sanitizer while providing incontinence care to a resident. The CNA was observed cleaning the resident and handling clean briefs without changing gloves or sanitizing hands, which could lead to cross-contamination. The CNA acknowledged the lapse in protocol, admitting to forgetting her hand sanitizer and recognizing the importance of hand hygiene in preventing the spread of germs. In the second incident, a Licensed Vocational Nurse (LVN) failed to perform proper hand hygiene while providing wound care to another resident. The LVN was observed changing dressings on the resident's feet without washing hands or using hand sanitizer between glove changes. Additionally, the LVN used a gloved finger to apply ointment directly to the wound, which was against the facility's policy. The LVN also improperly handled a bottle of normal saline, which was used in multiple rooms, increasing the risk of contamination. Both incidents highlight a failure to adhere to the facility's hand hygiene policy, which requires handwashing or the use of hand sanitizer before and after resident contact, after glove removal, and when moving from a soiled to a clean body site. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the importance of these protocols in preventing cross-contamination and infection, emphasizing the need for staff to follow proper procedures consistently.

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 treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not document the fluid intake for a resident with a fluid restriction order due to congestive heart failure (CHF). The resident, who had moderate cognitive impairment and was dependent on assistance for daily activities, had a physician order for a fluid restriction of 1.5 liters per day. However, the facility did not document the resident's fluid intake from December 17, 2024, to February 12, 2025. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) was aware of the need to document the resident's fluid intake but did not know why it had not been done prior to February 12, 2025. The Director of Nursing (DON) and the interim Administrator (ADM) both stated that physician orders should always be followed and emphasized the importance of documenting fluid intake for residents with CHF to prevent potential negative outcomes such as weight gain. The Medical Doctor (MD) also expected the facility to follow the physician order, although he noted that there would not be any major negative outcome due to the resident receiving diuretic medication and attending cardiology appointments.

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 thoroughly investigate and report the results of an alleged abuse and neglect incident involving a resident who experienced an unwitnessed fall. The incident occurred on January 27, 2025, and the facility was required to submit a five-day report to the state by February 1, 2025. However, the report was not submitted, which could potentially place residents at risk for continued abuse or neglect without appropriate corrective actions being taken. The resident involved was an elderly female with diagnoses including primary generalized osteoarthritis, dysphagia, and primary hypertension, and had moderate cognitive impairment as indicated by a BIMS score of ten. Interviews with the Director of Nursing (DON) and the interim DON revealed a communication breakdown regarding the responsibility for submitting the report. The interim DON acknowledged that the report was completed but not sent to the state due to a misunderstanding about who was responsible for its submission.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents who were unable to perform activities of daily living received necessary services to maintain personal hygiene. Specifically, two residents did not receive showers according to their scheduled times, as documented in their electronic medical records (EMR). This deficiency was observed through a review of the residents' care plans, general orders, and bathing tasks, which showed multiple instances where showers were not provided or documented. Resident #1, a female with moderately impaired cognition and various medical conditions, was scheduled to receive showers on Mondays, Wednesdays, and Fridays. However, from December 2, 2024, to January 13, 2025, there were numerous occasions where showers were not documented as having occurred. Observations on January 14, 2025, revealed that Resident #1 had poor personal hygiene, including facial hair and a foul odor from her feet, indicating a lack of proper bathing care. Resident #2, a female with severe cognitive impairment and other medical diagnoses, was scheduled for showers on Tuesdays, Thursdays, and Saturdays. Similar to Resident #1, her EMR reflected multiple missed showers during the same period. Although she appeared clean during an observation on January 14, 2025, the lack of documentation and adherence to her shower schedule was evident. Interviews with facility staff confirmed the failure to document and provide showers as required by the residents' care plans and facility policies.

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 care plan accurately reflected the dietary needs of a resident diagnosed with Alzheimer's disease and mild protein-calorie malnutrition. The resident, who had severe cognitive impairment, was prescribed a diet of regular, pureed, and nectar thick liquids by their physician. However, the care plan dated two days after the physician's order did not include these dietary instructions, indicating a lapse in updating the care plan to reflect the resident's current needs. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the MDS Coordinator was responsible for updating care plans when there were changes in condition or orders. The MDS Coordinator acknowledged the omission, suggesting it might have been mistakenly deleted, and emphasized the importance of entering orders promptly to ensure proper care. The Administrator confirmed the expectation that care plans be updated with new orders to meet residents' medical needs, highlighting the risk of improper care if updates are not made.

Penalty

Inspection fine: $8,827

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

Summary

The facility failed to ensure a safe environment and adequate supervision for two residents, leading to their elopement. Resident #1, a male with severe cognitive impairment and a history of dementia, was identified as a risk for elopement. Despite this, he managed to leave the facility unsupervised. His care plan included risks for wandering and injury, but these measures were insufficient to prevent his elopement. Similarly, Resident #2, also with severe cognitive impairment and diagnosed with vascular dementia, eloped from the facility. He was able to climb over a fence using chairs, indicating a lack of adequate supervision and environmental safety measures. Interviews with staff revealed that Resident #2 was left alone in the courtyard, which was against the facility's policy, and he was found in a nearby hospital parking lot by a staff member. The facility's policy on safety and supervision was not effectively implemented, as evidenced by the elopement incidents. Both residents used objects to overcome physical barriers, highlighting the inadequacy of the facility's preventive measures. The staff interviews confirmed that the residents were at risk of serious harm due to these lapses in supervision and environmental safety.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents were free from physical and verbal abuse, as evidenced by an incident involving a resident who was physically abused by a Licensed Vocational Nurse (LVN). The incident occurred when the resident, who has moderate cognitive impairment and physical limitations, was being redirected from another resident's room. During this process, the resident reportedly became upset and began to resist, leading to an altercation with the LVN. According to interviews and records, the LVN allegedly hit the resident on the right arm multiple times after the resident attempted to grab and bite the LVN. This account was corroborated by one Certified Nursing Assistant (CNA), while another CNA did not witness the LVN hitting the resident. The resident later reported the incident to another staff member, expressing that she felt safe in the facility and had no other concerns. The facility's policies on abuse prevention and reporting were not effectively implemented, as the incident was not immediately reported by the staff involved. The delay in reporting was attributed to fear of retaliation. The facility's policy mandates that any suspected abuse should be promptly reported to management to ensure the safety and well-being of residents.

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 from misappropriation and exploitation of property by allowing a Certified Nursing Assistant (CNA) to take money from the resident for personal use. The resident, who had severe cognitive impairment and was fully dependent on staff for daily activities, reported giving $300 to the CNA, who admitted to receiving the money. The resident expressed no concern about getting the money back, stating he felt safe in the facility and had plenty of money. The facility's administrator was informed of the incident by another CNA and immediately began an investigation. The CNA involved admitted to taking the money despite being trained on the facility's policy against misappropriation of property. The administrator suspended the CNA and planned to terminate her employment. Interviews with the Director of Nursing (DON) and the administrator revealed that staff were regularly in-serviced on abuse and reporting procedures, and the facility had policies in place to prevent such incidents. The facility's policies on abuse prevention and reporting emphasize the responsibility of all employees and associated individuals to report any incidents of neglect, abuse, or misappropriation of resident property. The policies define misappropriation as the wrongful use of a resident's belongings or money without consent and outline procedures for preventing and addressing such incidents. Despite these policies, the incident occurred, highlighting a lapse in adherence to the established protocols.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of abuse within the required timeframe for a resident with moderate cognitive impairment and multiple medical conditions, including spastic hemiplegia and dysphagia. The incident involved a Licensed Vocational Nurse (LVN) allegedly hitting the resident on the arm during an attempt to redirect her from another resident's room. The incident was reported by a Certified Nursing Assistant (CNA) to the Director of Nursing (DON) the following day, exceeding the 24-hour reporting requirement. Interviews revealed that the CNA who witnessed the incident delayed reporting due to fear of retaliation from the LVN. The CNA eventually reported the incident to the DON when contacted for a shift the next day. The DON then informed the Administrator, who is also the Abuse Coordinator, and initiated an investigation. The facility's policy mandates immediate reporting of suspected abuse to management, which was not adhered to in this case. The investigation included interviews with staff members present during the incident. Conflicting accounts were given, with one CNA confirming the LVN hit the resident, while another did not witness the alleged abuse. The LVN denied hitting the resident, stating she only blocked the resident's attempts to hit her. The facility's policy on reporting abuse emphasizes the importance of immediate reporting to prevent further harm, which was not followed, potentially placing residents at risk.

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 quarterly Minimum Data Set (MDS) assessment accurately reflected the resident's active diagnosis of dementia. This deficiency was identified during a review of the resident's records, which showed that the MDS did not include the dementia diagnosis, despite it being documented in other parts of the resident's medical records, such as the care plan and physician recertification. The MDS Coordinator, who was responsible for completing the MDS, was unaware of the dementia diagnosis and stated that the diagnosis information was carried over from previous assessments. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged the oversight and emphasized the importance of accurate MDS assessments for appropriate resident care. The resident in question was a male with multiple diagnoses, including malignant neoplasm of the prostate, type 2 diabetes mellitus with proliferative diabetic retinopathy, schizoaffective disorder, major depressive disorder, muscle wasting and atrophy, and post-traumatic stress disorder. The resident's Brief Interview for Mental Status (BIMS) score indicated moderate impairment, yet the MDS did not reflect any neurological diagnoses. Interviews with facility staff revealed that the MDS Coordinator and the DON were responsible for ensuring the accuracy of MDS assessments, and the ADM expected all assessments to be completed accurately. The facility's policy required comprehensive assessments to be consistent with progress notes, care plans, and resident observations.

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 accurate medical record for a resident, specifically omitting the diagnosis of dementia from the resident's face sheet. This oversight was identified during a review of the resident's medical records, which included a face sheet, a Quarterly Comprehensive MDS assessment, and a care plan. The face sheet, dated July 18, 2024, did not list dementia as a diagnosis, despite other documents, such as the care plan and a physician recertification, indicating the resident had been diagnosed with dementia. Interviews with facility staff, including the MDS Coordinator, DON, and ADM, revealed that there was a lack of clarity regarding who was responsible for ensuring the accuracy of the face sheet, and all acknowledged the importance of accurate documentation for providing appropriate care. The resident in question was a male with multiple diagnoses, including malignant neoplasm of the prostate, type 2 diabetes mellitus with proliferative diabetic retinopathy, schizoaffective disorder, major depressive disorder, muscle wasting and atrophy, and PTSD. The resident's BIMS score indicated moderate cognitive impairment, yet the Quarterly MDS assessment did not reflect any neurological diagnoses. The facility's policy on charting and documentation emphasized the need for complete and accurate records to facilitate communication among the interdisciplinary team. The failure to include dementia in the resident's face sheet could lead to inadequate care due to inaccurate assessments, as acknowledged by the facility's staff during interviews.

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 three residents received the necessary services to maintain grooming and personal hygiene. Resident #1, who had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs), was found in bed with a strong odor of urine, no sheets, and had not been cleaned or dressed despite requesting help all morning. Resident #2, who had no cognitive impairment but required moderate assistance with personal hygiene, reported waiting up to an hour for staff to respond to call buttons and was often asked to use the bathroom in her brief, leading to feelings of neglect and indignity. Resident #3, who required substantial assistance with toileting and had limited use of her right arm, also reported long wait times for staff assistance and expressed frustration with agency staff who were unfamiliar with her care needs. Observations and interviews revealed that the facility had significant staffing issues, with regular staff not showing up and agency staff being overloaded. The facility's staffing coordinator and other staff members confirmed that the facility was not always fully staffed and that the staffing levels were determined by a formula based on the facility budget and resident census, without considering the acuity of residents' care needs. This led to residents waiting long periods for care, feeling neglected, and experiencing diminished quality of life. The facility's policy stated that adequate staffing should be maintained to meet residents' needs, but interviews with staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed that the staffing levels were not adjusted based on the residents' health conditions or care requirements. This resulted in residents being left soiled or wet for prolonged periods, strong odors of urine in the hallways, and residents feeling unimportant and frustrated due to the lack of timely care.

Penalty

No penalty information released

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

Summary

The facility failed to assess the care required by the resident population, considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts when determining staffing requirements. This failure was evident in the cases of three residents who required varying levels of assistance and care. For instance, one resident with severe cognitive impairment and paraplegia was dependent on staff for all activities of daily living (ADLs) and was often left unattended and soiled for prolonged periods. Another resident with Huntington's Disease and muscle wasting required partial assistance but reported long wait times for care and being asked to use the bathroom in her brief, leading to feelings of neglect and indignity. A third resident with atrial fibrillation and cerebral infarction required substantial assistance and expressed concerns about the competency of agency staff in using her stand-up lift, leading to reluctance in asking for help and extended wait times for care. The facility's staffing decisions were based on a predetermined formula that considered the facility budget and current resident census but did not account for the specific needs and acuity levels of the residents. Interviews with staff, including CNAs, LVNs, and the DON, revealed that the staffing levels were often inadequate to meet the residents' needs, leading to rushed and impersonal care. Staff reported feeling overwhelmed and unable to provide timely assistance, resulting in residents waiting for extended periods for basic care needs such as toileting and hygiene. Observations confirmed strong odors of urine in multiple hallways and residents left unengaged and unattended. Complaints made to the state on behalf of the residents highlighted issues with staffing shortages, residents being left soiled, and the facility having a strong odor of urine. Interviews with residents corroborated these complaints, with reports of long wait times for care, feelings of neglect, and being asked to use the bathroom in their briefs. The facility's reliance on agency staff to fill gaps further exacerbated the issue, as these staff members were often unfamiliar with the residents' specific care needs. The facility's policy on staffing, dated April 2007, stated that adequate staffing would be maintained to meet residents' needs, but the current practices did not align with this policy, leading to unmet needs and compromised resident care.