Ignite Medical Resort El Paso, Llc

Penalty

Fine: $53,825

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

Summary

The deficiency involves the facility’s failure to immediately notify the physician when a resident’s blood glucose (BG) levels exceeded ordered parameters and to consistently perform ordered BG monitoring. An older female resident with type 2 DM with hyperglycemia, early-onset Alzheimer’s disease, hypertension, and a vesicointestinal fistula was admitted with physician orders for BG monitoring before meals and at bedtime, with instructions to notify the provider if BG was less than 60 mg/dL or greater than 400 mg/dL. Review of the order summary and admitting physician orders confirmed these parameters. However, record review showed multiple BG readings well above 400 mg/dL over several days without documented physician notification, and there was no evidence that bedtime BG checks were performed as ordered. Specifically, the resident’s record showed BG values of 512 mg/dL on one day, 482 mg/dL on the next day, 459 mg/dL on a later day, and 492 mg/dL on another day, all documented without any corresponding evidence that the physician was notified, despite the explicit order to notify for BG values greater than 400 mg/dL. The medication administration record and BG logs also showed no documented nighttime BG checks, even though the orders required monitoring before meals and at bedtime. The resident’s care plan identified insulin therapy and BG monitoring with goals for BG within normal limits and interventions including monitoring, documenting, and reporting adverse effects of insulin therapy and following hypo/hyperglycemia protocols, but the actual documentation did not reflect adherence to these monitoring and notification requirements. Interviews with facility staff and external PACE providers further described inconsistent communication and incomplete implementation of ordered treatments. The NP from PACE stated she was not notified that the resident’s BG had been over 400 mg/dL and that, upon later review, insulin and BG monitoring orders had been provided but were not implemented as ordered by the facility. A PACE RN reported that he was notified of elevated BG and gave instructions for additional sliding scale insulin and close monitoring, and that long-acting insulin should have continued, but there was no documentation in the facility record to support these communications or new orders. Facility nurses described elevated BG readings in the 400–500 mg/dL range, sometimes unreadable on the glucometer, ongoing use of sliding scale insulin, delays or gaps in admission order processing, and uncertainty about whether antibiotics ordered were administered. The resident was ultimately transferred to the hospital with hyperglycemia and UTI and was admitted to the ICU for DKA and septic shock. The facility’s own policy on blood glucose monitoring required following physician notification parameters when results were outside ordered ranges, but the documented practice for this resident did not meet those requirements, leading surveyors to identify an Immediate Jeopardy situation related to failure to notify the physician of out-of-parameter BG results and failure to carry out ordered BG monitoring. Additional interviews with leadership and other staff highlighted that medication reconciliation and admission review processes were inconsistent and that there was no standardized daily review of medications or BG monitoring for accuracy and completeness. The ADON and DON acknowledged that medication pass audits were not done daily, that there was no consistent daily process to review medications, and that communication with external providers such as PACE was often inconsistent. The DON and Medical Director described expectations that urgent situations be evaluated immediately and that orders be implemented without delay, but also acknowledged that residents with worsening conditions were sometimes transferred to the hospital rather than having earlier interventions. The MDS nurse stated that she did not recall seeing documentation regarding antibiotic therapy or BG monitoring for this resident and that follow-up on such treatments depended on nursing processes. The PACE NP later stated that prophylactic antibiotics and insulin management had been ordered but not administered, and that the resident’s decline, including DKA and sepsis, was attributed in part to missed medications and lack of timely intervention. These documented failures in BG monitoring, physician notification, and implementation of ordered treatments formed the basis of the cited deficiency.

Removal Plan

• Conduct mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; obtain verbal and written confirmation of understanding; implement ongoing competency checks; ensure policies are readily available from the CNO/ACNO; incorporate training and written competencies for new hires upon hire.
• Review Resident #2’s current hospitalization status with the hospital and confirm ICU admission for DKA and septic shock; confirm resident did not return to the facility.
• Hold nurse meetings with all nursing staff who cared for Resident #2 to review specific failures (missing bedtime BG checks, failure to notify provider of BG >400, failure to administer continuous glucose monitoring device, failure to communicate about unavailable supplies).
• Provide mandatory re-education for all licensed nursing staff (RNs/LPNs) emphasizing: obtaining BG readings exactly as ordered; immediate provider notification when results are outside parameters; immediate notification to physician/CNO/ACNO when ordered supplies/equipment are unavailable; and clarifying unclear or unimplementable orders prior to implementation.
• Establish a communication protocol with the local PACE organization requiring nursing staff to contact PACE providers immediately for clinical concerns, significant changes in condition, out-of-parameter lab/glucose values, and inability to implement orders due to unavailable supplies or unclear orders; in-service RNs/LVNs on the protocol.
• Implement a redundant notification system requiring that when any BG result is outside ordered parameters, the nurse must immediately notify the physician/PACE provider and document date/time, person contacted, and response received; in-service RNs/LVNs on the system.
• Conduct a facility-wide review to identify residents at risk for similar failures related to physician notification, BG monitoring, or implementation of orders.
• Review all current residents to identify those with active BG monitoring orders.
• Complete a comprehensive chart audit of residents with BG monitoring orders to verify monitoring was performed as ordered, identify out-of-parameter results, and confirm timely documented provider notification; report identified issues to physicians and obtain clarifying or new orders as needed; initiate continued daily monitoring by CNO/ACNO/nurse manager.
• Conduct a Root Cause Analysis (RCA) including staff interviews and fishbone analysis to identify underlying causes of the IJ event.
• Revise the Blood Glucose Monitoring Policy to require immediate physician notification for out-of-parameter BG results and to require documentation of the exact time of the out-of-parameter result, exact time of provider notification, name of person contacted, and provider response or orders received; educate staff on the revised policy.

Penalty

Fine: $53,825

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

Summary

The deficiency involves the facility’s failure to assess a newly admitted resident prior to admission and to identify and implement critical physician orders related to antibiotic therapy and blood glucose management. The resident was an adult female with diagnoses including a vesicointestinal fistula, hypertension, type 2 diabetes mellitus with hyperglycemia, and early-onset Alzheimer’s disease, and was cognitively intact with a BIMS score of 14. Admitting physician orders included long-acting insulin (Semglee), sliding-scale insulin (NovoLOG), use of a FreeStyle Libre 2 continuous glucose monitoring (CGM) sensor, blood glucose checks before meals and at bedtime with provider notification if values were <60 or >400 mg/dL, and prophylactic antibiotics (Ciprofloxacin and Metronidazole) following recent surgery and hospitalization. The facility’s records from admission through several days afterward showed no evidence that the antibiotic orders were transcribed or administered, and no baseline blood glucose assessment was completed upon admission. From admission through the days leading up to the resident’s hospitalization, multiple blood glucose readings were documented in the 459–512 mg/dL range, which exceeded the ordered notification parameter of >400 mg/dL. Despite these critically elevated readings, there was no documentation that the physician or PACE providers were notified as required by the resident’s orders and the facility’s blood glucose monitoring policy. The medication administration record and blood glucose logs also showed no documented nighttime blood glucose checks, even though orders specified monitoring before meals and at bedtime. Although a FreeStyle Libre 2 CGM sensor was documented as applied on one date, interviews with nursing staff and leadership revealed that staff were unfamiliar with consistent use of the Libre system, had not been trained, and did not routinely utilize CGM devices, instead relying on glucometer readings. Interviews with PACE nurses and the PACE NP indicated that orders for antibiotics, probiotics, insulin, and the CGM device had been sent upon the resident’s discharge from the hospital, but these orders were not implemented as written by the facility. PACE staff reported that the resident had multiple blood glucose readings outside ordered parameters without physician notification, that nighttime blood glucose checks were not obtained as ordered, and that the continuous glucose monitoring system was not implemented. Facility staff, including LVNs and RNs involved in the admission and subsequent care, acknowledged delays and discrepancies in medication reconciliation, uncertainty about whether antibiotics were ordered or administered, lack of training and supplies for the Libre device, and inconsistent communication with external providers. The DON and ADON further acknowledged that medication reconciliation was not completed for this resident upon admission, that hospital records were not consistently reviewed prior to implementing care, and that there was no standardized process to ensure implementation of continuous glucose monitoring orders. As a result of these failures, the resident was later transferred to the hospital, where she was admitted to the ICU with diagnoses of diabetic ketoacidosis and septic shock, and treated for hyperglycemia and infection, including E. coli and yeast identified in cultures. An Immediate Jeopardy situation was identified by surveyors related to these failures in assessment, medication reconciliation, implementation of physician orders for antibiotics and blood glucose management, and required physician notification for out-of-parameter glucose readings. The facility’s own policies on physician orders and blood glucose monitoring required that orders be valid, clear, and implemented safely, and that physicians be notified when glucose results were outside ordered parameters, but these policies were not followed in the resident’s case. Interviews with the DON, ADON, Medical Director, and MDS staff confirmed that admission assessments were not consistently completed prior to residents’ arrival, that not all admissions received pre-admission review of hospital records, and that oversight of blood glucose monitoring and continuous glucose monitoring devices was inconsistent and lacked a standardized process. These combined actions and inactions led to the cited deficiency for failure to provide needed care and services in accordance with the resident’s preferences, goals, and professional standards of practice.

Removal Plan

• Conducted mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; staff provided verbal and written confirmation of understanding.
• Implemented ongoing competency checks for staff; ensured policies are readily available from the CNO/ACNO; required new hires to complete training and written competencies upon hire.
• Reviewed the resident’s hospitalization status with the hospital and confirmed ICU admission for DKA and septic shock; confirmed the resident did not return to the facility.
• Held nurse meetings with all nursing staff who cared for the resident to review specific failures in blood glucose monitoring, provider notification, administration of the CGM device, and communication of unavailable supplies.
• Provided mandatory re-education for all licensed nursing staff on the Blood Glucose Monitoring Policy and Physician Notification requirements, including obtaining BG readings as ordered, immediate provider notification for out-of-parameter results, notifying leadership/providers when supplies/equipment are unavailable, and clarifying unclear/unimplementable orders prior to implementation.
• Established a communication protocol with the local PACE organization requiring nursing staff to contact PACE providers immediately for clinical concerns, significant changes in condition, out-of-parameter lab/glucose values, and inability to implement orders due to unavailable supplies or unclear orders; in-serviced RNs/LVNs on the protocol.
• Implemented a redundant notification system requiring that when any BG result is outside ordered parameters, the nurse must immediately notify the physician/PACE provider and document date/time/person contacted and response received; in-serviced RNs/LVNs on the system.
• Conducted a comprehensive review to identify other residents at risk for failures in physician notification, blood glucose monitoring, or implementation of physician orders.
• Reviewed all residents to identify those with active blood glucose monitoring orders.
• Completed chart audits of residents with BG monitoring orders to verify monitoring as ordered, identify out-of-parameter results, and confirm timely documented provider notification; reported identified issues to physicians and obtained clarifying/new orders; instituted continued daily monitoring by CNO/ACNO/nurse manager.
• Reviewed all residents to identify those with orders for continuous monitoring devices or specialized medical equipment.
• Physically verified that all residents with ordered devices/equipment had the devices in place and functioning as ordered.

Penalty

Fine: $53,825

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

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to antibiotic therapy and blood glucose management. An [AGE]-year-old female resident with diagnoses including vesicointestinal fistula, hypertension, type 2 diabetes mellitus with hyperglycemia, and early-onset Alzheimer’s disease was admitted following hospitalization and surgery for colostomy placement. Her physician orders included long-acting insulin (Semglee), sliding-scale insulin (NovoLOG), blood glucose monitoring before meals and at bedtime with provider notification for values <60 or >400 mg/dL, a continuous glucose monitoring (CGM) sensor (FreeStyle Libre 2), and prophylactic antibiotics (Ciprofloxacin and Metronidazole) along with other medications. Record review showed that from admission through several days, the antibiotic orders were not transcribed onto the MAR and no doses were administered, and the CGM sensor was not implemented. During the same period, the resident’s blood glucose readings were repeatedly and significantly elevated, with documented values of 512 mg/dL, 482 mg/dL, 459 mg/dL, and 492 mg/dL. Despite an order to notify the provider if blood glucose was <60 or >400 mg/dL, there was no evidence in the record that the physician was notified of these out-of-parameter results. Additionally, there was no documentation of nighttime blood glucose checks, even though orders required blood glucose monitoring before meals and at bedtime. Staff interviews revealed that some medications, including long-acting insulin, were not immediately available or did not appear on the MAR, and that staff relied on sliding-scale insulin without obtaining new physician orders or consistently documenting provider notifications. Nursing staff also reported communication delays with on-call providers and PACE, and acknowledged that no new orders were obtained despite persistently elevated blood glucose levels. Multiple interviews with PACE clinicians and facility leadership confirmed that the ordered prophylactic antibiotics and CGM device were not implemented as prescribed, and that providers were not notified of missed medications or abnormal blood glucose values. PACE staff stated that antibiotics (Ciprofloxacin and Metronidazole), probiotics, insulin, and other routine medications had been ordered upon discharge from the hospital, but the facility failed to administer the antibiotics and did not apply the ordered glucose monitoring sensor. The DON and ADON acknowledged that medication reconciliation was not completed upon admission for this resident, that there was no standardized process to ensure baseline blood glucose assessment or consistent review of hospital records, and that oversight of admission orders and blood glucose monitoring was inconsistent. The resident ultimately required transfer to the hospital, where she was admitted to the ICU with DKA and septic shock, and hospital staff documented hyperglycemia, UTI, markedly elevated WBC, and the need for sepsis protocol, IV antibiotics, and insulin drip. Facility policies in place at the time required that blood glucose monitoring be completed per provider orders, that physicians be notified when glucose results were outside ordered parameters, and that insulin be administered only upon a physician’s order. The physician orders policy required that all physician orders be valid, safe, and clarified if unclear prior to implementation. Interviews with the DON, ADON, and other staff indicated that these policies were not consistently followed: there was no daily process to review medications for accuracy or completeness, medication pass audits were intermittent, and staff did not consistently notify physicians when medications were unavailable or when ordered treatments (such as the CGM sensor) could not be implemented. Communication gaps with external providers, particularly PACE, and lack of a standardized admission and reconciliation process contributed to the failure to transcribe and administer antibiotics, to perform ordered bedtime blood glucose checks, to notify providers of critical glucose values, and to implement the ordered continuous glucose monitoring device for this resident.

Removal Plan

• Conducted mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; obtained verbal and written confirmation of understanding; implemented ongoing competency checks; incorporated training and written competencies into new-hire orientation; made policies readily available via CNO/ACNO/Administrator.
• Reviewed the resident’s hospitalization status with the hospital and confirmed ICU admission for DKA and septic shock; confirmed the resident did not return to the facility.
• Held nurse meetings with all nursing staff who cared for the resident to review specific failures, including missing bedtime blood glucose checks, failure to notify the provider of blood glucose greater than 400, failure to implement CGM, and failure to communicate about unavailable supplies.
• Provided mandatory re-education for all licensed nursing staff on the Blood Glucose Monitoring Policy and physician notification requirements, emphasizing obtaining blood glucose exactly as ordered, immediately notifying the provider when out of parameters, notifying physician/CNO/ACNO when supplies or equipment are unavailable, and clarifying unclear or unimplementable orders prior to implementation.
• Established a communication protocol with the local PACE organization requiring nursing staff to contact PACE providers immediately for clinical concerns, significant changes, out-of-parameter lab or glucose values, and inability to implement orders due to unavailable supplies or unclear orders; in-serviced RNs/LVNs on the protocol.
• Implemented a redundant notification system requiring that when any blood glucose result is outside ordered parameters, the nurse must immediately notify the physician/PACE provider and document date/time/person contacted and response received; in-serviced RNs/LVNs on the system.
• Conducted a comprehensive review to identify other residents at risk for failures in physician notification, blood glucose monitoring, or implementation of physician orders.
• Reviewed all current residents to identify those with active blood glucose monitoring orders.
• Completed a chart audit of residents with blood glucose monitoring orders to verify monitoring was performed as ordered, identify out-of-parameter results, and confirm timely provider notification; reported issues to physicians and obtained clarifying or new orders; initiated continued daily monitoring by CNO/ACNO/nurse manager.
• Reviewed all current residents to identify those with orders for continuous monitoring devices or specialized medical equipment; verified implementation and identified no issues.

Penalty

Fine: $53,825

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

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to blood glucose monitoring and sharps disposal for two residents. During observation of a blood glucose check for Resident #11, an LVN prepared materials, entered the room, performed the test, and then exited to the medication cart. The LVN removed his gloves by folding them inward while the used lancet remained inside the balled-up gloves, and then discarded the gloves and lancet in the regular trash. He did not disinfect the glucometer or perform hand hygiene after completing the blood sugar check. When questioned, he stated that because lancets retract, he threw them in the trash. In a separate observation involving Resident #10, an RN who reported this was her first nursing job gathered supplies for a blood glucose check without sanitizing them before entering the resident’s room. Once inside, she picked up a urinal holder from the floor by the rim and handed it to the resident, then accepted it back and placed it on the bedside table. She did not perform hand hygiene or change gloves after handling the urinal holder and proceeded to check the resident’s blood sugar using the same gloves. After completing the procedure, she wrapped the used lancet in her gloves and discarded them in the trash, and then went to another resident’s room without cleaning or sanitizing the glucometer or the area on the medication cart used for the procedure. Interviews with the ADON, DON, and Administrator confirmed that facility policy required lancets to be treated as sharps and disposed of in sharps containers, and that these practices were considered infection control issues. The ADON stated lancets were to be discarded in sharps containers because they did not always retract and could be harmful to housekeeping and other staff. The DON stated that used lancets needed to be disposed of in sharps containers and that staff should know they were considered sharps. The LVN reported he had only received basic glucometer training, could not recall being checked off on blood glucose testing, and could not recall recent in-services on infection control or hand hygiene. The RN stated she had not been trained on infection control at the facility, relied mainly on nursing school knowledge, and acknowledged she should have changed gloves and that lancets were supposed to be discarded in sharps containers. Facility policies on infection control and blood glucose monitoring required hand hygiene before and after resident contact, proper sharps disposal in puncture-resistant sharps containers, and cleaning of the glucometer before and after each use.

Penalty

Fine: $53,825

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 an injury of unknown origin involving a resident was reported immediately to the state agency and other required authorities, as required by facility policy and regulation. During rounds, the ADON found Resident #9 in bed in an abnormal position, with the resident’s head at the foot of the bed. The resident had extremely limited mobility at baseline and required assistance with transfers, and had a history of removing their oxygen, typically set at 2–3 liters. On assessment, the resident was noted to have temporal swelling, EMS was contacted, and the resident was transferred to the hospital. Hospital evaluation confirmed a rib fracture and head injury consistent with a fall, and the fall was unwitnessed. The resident was confused and unable to clearly describe how the fall occurred. The ADON reported the incident to the DON and notified the resident’s family member. The DON acknowledged awareness of the incident and stated it was discussed in a morning administrative meeting, but there was uncertainty about whether it should be reported to the state. The DON indicated she was still getting used to the reporting process and had informed the Administrator. The Administrator stated that reporting decisions were based on whether the cause of the incident was unknown and that if staff believed they knew how an incident occurred, it might not be considered reportable. He acknowledged that the resident sustained a fracture but did not complete reporting because staff believed they understood how the fall occurred, and he did not personally interview the resident, relying instead on staff reports. Facility policy on Abuse & Neglect required that all alleged or suspected violations involving mistreatment, neglect, abuse, injuries of unknown origin, and misappropriation of resident property be investigated and reported immediately to the state agency complaint hotline, and that injuries of unknown origin or suspicious injuries be immediately investigated to rule out abuse.

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 two residents with indwelling urinary catheters had their catheter collection bags covered with privacy bags, as observed during multiple interviews and record reviews. In both cases, the residents' catheter bags were left uncovered and visible, either lying on the floor or hanging from the bed or wheelchair, without the use of privacy bags. Staff members, including CNAs and an LVN, acknowledged that privacy bags should always be used to maintain resident dignity and that it is the responsibility of all staff to ensure this is done during regular rounding. For one resident, the catheter bag was observed on the floor while the resident was asleep in bed. The CNA present stated that all catheter bags should be in privacy bags and attributed the uncovered bag to it possibly having fallen. The resident's care plan included monitoring for complications related to catheter use but did not specify the use of privacy bags. Similarly, another resident was observed on two occasions with an uncovered catheter bag, once while sitting in a wheelchair and once while in bed. The resident stated that the lack of a privacy bag did not bother her, but staff reiterated that privacy bags are required for dignity and privacy. Review of facility policies revealed that while the Resident Rights policy emphasized the importance of dignity, privacy, and confidentiality, the Catheterization of Urinary Bladder policy did not specify the use of privacy bags. Staff interviews consistently indicated that privacy bags are expected to be used and are available in the facility, but this practice was not consistently followed, resulting in the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring wound care treatment was administered according to physician's routine, PRN, and STAT orders. The physician's order for wound care was incorrectly entered into the Treatment Administration Record (TAR), resulting in the resident not receiving wound care as prescribed. Documentation verifying that wound care was consistently completed was not available, and staff interviews revealed uncertainty about whether the care was provided and properly documented. The resident involved was an older adult male with multiple diagnoses, including pulmonary embolism, rheumatoid arthritis, chronic congestive heart failure, osteoporosis, chronic pain syndrome, and a chronic left foot ulcer. Upon admission, the resident had a stage 3 pressure ulcer on the sacrum and was receiving antibiotics via a PICC line for sepsis related to his wound. The care plan included interventions for skin integrity and wound care per physician orders, but there was no documentation to confirm that these interventions were carried out as ordered. Interviews with the DON, RN, and Medical Record Director indicated that the wound care order was not properly entered into the TAR, and there was no documentation of wound care being completed for the resident. The DON acknowledged responsibility for reviewing orders but stated that the transition between DONs led to a lapse in order review. The facility's policy required complete and clear documentation of physician orders and prompt, accurate transcription by nursing staff, but these procedures were not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program for one resident reviewed for infection control. Specifically, a resident with multiple diagnoses, including type 2 diabetes, acute kidney failure, and obstructive uropathy requiring an indwelling urinary catheter, was observed with her catheter drainage bag resting on the floor while she was asleep in bed. Facility records indicated that catheter care orders required anchoring the tubing and checking skin integrity every shift and as needed. The resident's care plan also included interventions to monitor catheter placement and signs and symptoms of urinary tract infection. Despite these documented protocols, the catheter bag was not properly secured, resulting in it coming into contact with the floor. Interviews with multiple staff members, including CNAs and an LVN, confirmed that all nursing staff were responsible for ensuring catheter bags were not on the floor and that staff were expected to round on residents every two hours. Staff acknowledged that a catheter bag on the floor posed an infection risk and that this was not in accordance with facility policy or proper protocol. The facility's infection control policy emphasized maintaining a safe and sanitary environment to prevent the transmission of communicable diseases, but this was not followed in the observed incident.

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 functioning resident call light system in multiple resident halls, resulting in residents being unable to effectively summon staff assistance. Observations revealed that while corridor call lights illuminated when activated by residents, there was no audible alert in the resident rooms or at the nurse's stations. Multiple instances were documented where residents activated their call lights, but the system failed to ring or alert staff, and no staff were present at the nurse's station to visually monitor the corridor lights. Staff members, including nurses and CNAs, were observed performing other duties such as medication administration and meal tray collection, further reducing the likelihood of timely response to resident needs. Interviews with staff indicated a lack of awareness and communication regarding the malfunctioning call light system. Some staff members noticed that the call lights only rang once or not at all, but did not report these issues to the Maintenance Director. The Maintenance Director himself was unaware of the ongoing problems until prompted by the surveyor and only initiated contact with the call light system vendor after the issue was brought to his attention. Documentation of monthly QA checks indicated that the system was previously reported as functioning, but these checks did not identify the current widespread failure. Further interviews revealed that the central receiver panels at the nurse's stations were nonfunctional, described as "fried," and had not been working for an undetermined period. Staff and confidential sources reported that the system had been inoperable for several months, requiring staff to visually monitor corridor lights as a workaround. The facility's policy required immediate notification and alternative arrangements in the event of a call light outage, but these procedures were not effectively implemented, as evidenced by the lack of timely reporting and the absence of alternative communication methods for 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 provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications as ordered for five residents. Multiple medications, including Dapagliflozin Propanediol, Levothyroxine, Acetylcysteine Solution, Eliquis, Memantine HCI, Farxiga, Folic Acid, Pravastatin Sodium, Alendronate Sodium, Sodium Chloride, Linagliptin, Calcium 600 + D, Rifaximin, Symbicort Inhalation Aerosol, Aspirin, Colace, Latanoprost Ophthalmic Solution, Lidocaine External Patch, Prenatal Vitamin, Calcium Antacid Chewable, Vitamin C, Advanced Probiotic, Lisinopril, and Amoxicillin, were not administered to residents as ordered by their physicians. Documentation in the Medication Administration Records (MARs) frequently indicated that medications were not given due to unavailability or pending delivery, with staff using a code to denote this status and referencing nurse's notes for further explanation. Interviews with nursing staff and facility leadership revealed that although staff were trained to notify physicians and nursing supervisors when medications were unavailable, this notification did not consistently occur. Several nurses admitted to not informing physicians when medications were not administered due to lack of availability, despite being aware of the requirement to do so. The Medical Director and attending physicians confirmed they were not notified about missed doses, and expressed that they expected immediate notification in such cases. In some instances, medications were delayed due to pending cost approval or issues with the pharmacy's formulary, but these delays were not communicated to the prescribing practitioners. The affected residents had complex medical histories, including conditions such as esophageal cancer, heart failure, diabetes mellitus, non-Alzheimer's dementia, osteoporosis, chronic kidney disease, hepatic encephalopathy, atrial fibrillation, Alzheimer's disease, and glaucoma. The failure to administer prescribed medications and to promptly consult with physicians or nurse practitioners when medications were unavailable was documented for each resident. The MARs and nurse's notes consistently showed missed doses over multiple days, with staff citing medication unavailability as the reason, but without evidence of timely physician notification or alternative arrangements to obtain the medications.

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 drugs and biologicals were stored and handled in accordance with federal, state, and local laws, as well as accepted professional standards. During an observation, a cardboard box containing medication blister packets, including controlled substances such as Alprazolam, Dronabinol, and Tramadol, was left unattended on the nurse's station countertop. A licensed vocational nurse (LVN) was later observed removing these medications from the box, which had been left unattended earlier in the morning. The LVN also left several medication blister packets unattended on the counter while stepping away from the nurse's station, during which time non-nursing staff and a resident were present in the area. Packing slips for the medications were not signed by the receiving nurse as required. Interviews with nursing leadership confirmed that pharmacy deliveries should be handed directly to a nurse and never left unattended at the nurse's station. The delivery person and the receiving nurse are both required to sign and date the delivery slip, but this procedure was not followed. The facility's policy also requires that a signed copy of the delivery receipt be returned to the pharmacy and retained for reconciliation, which was not done in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of all residents, as determined by resident assessments and individual care plans. Observations revealed that during multiple shifts with a resident census of 51, only two CNAs and three nurses were present, despite the regular staffing pattern calling for three CNAs per shift. This staffing shortage led to missed showers, delayed response to call lights, and delayed incontinent care for dependent residents. Multiple residents and family members reported waiting 20-30 minutes or more for assistance, with some residents left wet for extended periods. Interviews with residents, family members, CNAs, and nurses consistently described the impact of insufficient staffing. Residents reported long wait times for call light responses and care, with CNAs rushing to provide assistance due to their workload. Staff confirmed that rounds could not be made every two hours as required, and that showers were often missed or delayed. CNAs were assigned up to 18-19 residents each, making it difficult to provide timely care, including incontinence checks and assistance with activities of daily living. Staff also reported high turnover and that the facility had been short of CNAs for several weeks to months. Review of staffing schedules and grievance records corroborated the ongoing staffing issues. The facility's schedules showed multiple instances where only two CNAs were scheduled instead of the required three. Grievance forms documented complaints from residents, families, and staff about understaffing, delayed call light responses, and inadequate care. The Executive Director acknowledged the CNA shortage and attributed it to staff leaving for higher pay, but was not aware of specific concerns related to delayed care. There was no policy or procedure on staffing, and grievances were sometimes left unresolved or only addressed through staff re-education.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate and complete medical records for a resident in accordance with accepted professional standards. Specifically, a nurse did not document in the Nurse's Notes that the physician was notified when the resident's family member was observed giving the resident water with ice chips, which was not compliant with the resident's NPO (nothing by mouth) order. The nurse only documented that the speech therapist was notified, and there was no record of physician notification regarding this non-compliance. Additionally, the facility did not ensure that licensed staff promptly wrote physician's telephone orders and entered new orders into the Medication Administration Record (MAR). On a separate occasion, the same nurse received new orders from the physician for a chest x-ray, saline nasal spray, and oxygen at 1 liter, but failed to write the telephone order and did not enter these new orders into the MAR. The nurse acknowledged being trained to immediately document telephone orders and update the MAR but did not provide a reason for the omission. The resident involved had a complex medical history, including esophageal cancer, heart failure, diabetes, non-Alzheimer's dementia, dysphagia, and was dependent on enteral feedings via a gastrostomy tube. The care plan specified NPO status with G-tube feedings and highlighted the resident's high risk for aspiration. The facility's policy required documentation of unusual events, changes in condition, and communication with physicians, but these requirements were not met in the instances described.

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 nurse staffing data was posted daily and made readily accessible to residents and visitors. Observations and record reviews revealed that the daily staffing sheet posted by the main entrance was last updated on 11/20/25, and no subsequent updates had been made. Interviews with the Assistant Chief Nursing Officer and the Executive Director confirmed that the previous Chief Nurse Officer, who was responsible for posting the data, left employment on 11/20/25. Since then, the Assistant Chief Nursing Officer had not been granted access to the electronic PPD reports required to complete and post the daily nurse staffing data. As a result, the required nurse staffing information was not maintained or posted as mandated, and the facility was unable to provide its policy on nurse staff data when requested by the state surveyor. The lack of updated postings meant that residents, their families, and visitors did not have access to current information regarding the facility's staffing schedule and census.

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 that included measurable objectives and time frames to address the use of wound vacs for two residents. Both residents had documented medical needs for wound vac therapy as part of their treatment for lower extremity wounds, as indicated by physician orders and medical records. However, review of their care plans revealed that the use of wound vacs was not included, despite being a significant aspect of their care. For one resident, records showed a recent toe amputation and the presence of a wound vac to the distal lower leg, with physician orders specifying that the wound vac should not be removed or changed until seen by a surgeon. The care plan initiated upon admission did not address the wound vac, even though the resident was cognitively intact and required this specific intervention. Similarly, another resident with a history of chronic conditions and a diabetic foot ulcer had physician orders for wound vac therapy, but the care plan failed to include this treatment. Interviews with nursing staff, the DON, and the administrator confirmed that wound vac therapy should have been included in the care plans as it is essential for individualized care and communication among staff. Staff acknowledged that the omission could lead to miscommunication and that it was the responsibility of various team members to ensure care plans were accurate and up to date. Review of the facility's care plan policy also indicated that baseline care plans should be developed upon admission and updated as needed, but this was not followed in these cases.

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 professional standards for food service safety, as observed in their kitchen operations. A trash can next to a handwashing sink was not hands-free due to a damaged lid, posing a risk of contamination. In the walk-in refrigerator, a loosely wrapped and unlabeled package of brownish/yellow shredded lettuce was found, which was not fresh or appropriate for use. Similarly, in the walk-in freezer, a sealed storage bag containing an unknown food item, identified as beef, was not labeled or stored properly. These lapses in labeling and storage could lead to food contamination. The dishwashing and sanitization machine was found dirty, with a dried caked-on substance on top and streaking down the front, which could compromise the cleanliness of dishes. The kitchen ice machine also had a dried caked-on substance around the ice dispenser door, raising concerns about potential contamination of ice. Additionally, multiple vents over cooking prep areas were observed with dust and debris, and the wall and ceiling in a kitchen prep area had dried yellow splatter from a previous incident involving a blender. These conditions indicate a lack of adherence to cleanliness standards in the kitchen. Interviews with the Dietary Manager (DM) and other staff revealed awareness of these issues, but they had not been addressed in a timely manner. The DM acknowledged the risks associated with these deficiencies, including potential contamination of food and clean dishes. The facility's policies on food storage and cleaning were not followed, as evidenced by the lack of labeling, improper storage, and unclean equipment and surfaces. These failures could place residents at risk for food-borne illness and food contamination.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurate medical records for a resident who experienced a fall. The incident occurred when the resident, who had a history of lack of coordination, weakness, and falls, was found sitting on the floor by the toilet. Despite the fall being documented in the progress notes, an incident report was not completed as required by the facility's policy. Interviews with the staff involved revealed that the fall was not documented in the incident/accident log, and there was confusion among the staff regarding the responsibility for completing the incident report. The Director of Nursing (DON) confirmed that an incident report should have been generated for the fall to ensure accurate resident records and proper tracking of incidents. The lack of an incident report could potentially affect the care provided to the resident, particularly in terms of monitoring for injuries and ensuring appropriate notifications. The facility's policy mandates that all incidents and accidents affecting residents, which are not expected outcomes of their condition, should be documented in a written report. However, in this case, the policy was not followed, leading to incomplete documentation of the resident's fall incident.

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 an incident involving a resident with dementia. During an observation, it was noted that a dirty brief and wipes smeared with feces were left on the floor of the resident's room, wrapped in a linen. This oversight occurred after a CNA had changed the resident's brief but became distracted and did not dispose of the soiled items properly. The CNA acknowledged the lapse, citing that she had intended to return to dispose of the items but was sidetracked by another task. The Director of Nursing (DON) confirmed that CNAs and charge nurses are responsible for ensuring that soiled briefs and wipes are disposed of in a trash bag immediately after perineal care. The facility's policies on handling soiled linen and perineal care emphasize the importance of preventing the spread of infection by properly disposing of soiled items. However, the perineal care policy did not explicitly state the requirement for disposing of dirty briefs and wipes in a trash bag or can, which may have contributed to the oversight.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to professional standards for food service safety, as observed in their kitchen sanitation practices. During an inspection, a large plastic tub in the walk-in refrigerator was found containing a torn open plastic bag of raw, pre-cut white meat without any label or date. The tub had approximately 0.5 inch of bloody liquid collected at the bottom, indicating leakage from the open bag, although no spillage was noted outside the tub. Additionally, a 5-pound bag of frozen, sliced, yellow-colored vegetables was found in the walk-in freezer without any label or date. Interviews with the Food Service Director and the Registered Dietician revealed lapses in food handling procedures. The Food Service Director admitted uncertainty about when the meat was removed from the freezer and acknowledged that the meat should have been sealed and labeled with a use-by date. The Registered Dietician confirmed that all food removed from original packaging should be labeled and dated, and suggested that the meat should have been placed in smaller, resealable bags to prevent leaking. The facility's policy on food receiving and storage mandates that all foods stored in the refrigerator or freezer be covered, labeled, and dated, which was not followed in these instances.

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 improper hand hygiene and glove use during incontinence care for a resident. A certified nursing assistant (CNA) did not change gloves or wash hands after handling soiled materials, which could lead to the spread of infection. The CNA acknowledged the lapse in protocol, despite having received infection control training during orientation. Additionally, the facility did not implement enhanced barrier precautions for residents with indwelling devices or open wounds, as recommended by the CDC. Observations revealed that rooms of residents requiring such precautions lacked appropriate signage and personal protective equipment (PPE). The Director of Nursing (DON) and Assistant Directors of Nursing (ADONs) were aware of the CDC guidelines but had not fully implemented them due to a lack of in-service training for all staff and uncertainty about corporate directives regarding PPE placement. The facility's administration was informed of the CDC's enhanced barrier precautions but had not acted on them due to recent changes in nursing leadership and a lack of awareness of the guidelines. The absence of a policy on enhanced barrier precautions and incomplete staff training contributed to the facility's failure to protect residents from potential infection transmission.

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 conduct accurate assessments for four residents, leading to discrepancies in their care plans and diagnoses. Resident #10's Admission MDS Assessment did not reflect her diagnosis of anxiety, despite her care plan indicating she was on antianxiety medication. Similarly, Resident #15's Admission MDS Assessment failed to accurately reflect his skin status and diagnosis of anxiety, even though he was prescribed Hydroxyzine for anxiety and had a sore on his foot that was not documented. Resident #28's Medicare 5 Day MDS Assessment did not include his diagnosis of Diabetes Mellitus, although he was receiving insulin as per a sliding scale order. His care plan also lacked any mention of diabetes management. Resident #237's Admission MDS Assessment omitted his diagnosis of chronic pain, despite receiving scheduled and as-needed pain medication, including opioids. His care plan did address his chronic pain, but the MDS assessment did not reflect this. The MDS Coordinator, responsible for completing all comprehensive assessments, acknowledged the oversight in transferring diagnoses from one assessment to the next. She relied on physician's orders and hospital documents for information but failed to include certain diagnoses in the MDS assessments. The Director of Nursing confirmed that the facility followed the MDS 3.0 RAI Manual for assessment procedures, yet these deficiencies in accurate resident assessments were identified.

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 three residents, which included measurable objectives and timeframes to meet their highest practicable physical, mental, and psychosocial well-being. Resident #10 did not have a care plan addressing her antipsychotic medication use, despite being prescribed Seroquel for dementia and anxiety. The MDS assessment did not identify anxiety as a diagnosis, and there was no care plan in place for the antipsychotic medication use. Resident #15's care plan was incomplete, lacking documentation for several critical areas, including vision, psychosocial status, urinary status, skin status, active diagnoses, and anti-anxiety medication use. Although he was prescribed Hydroxyzine for anxiety, this was not reflected in his care plan. Additionally, there was no care plan for the wound care required for his right lower extremity cellulitis, nor were there enhanced barrier precautions in place, despite observable swelling and redness in his feet. Resident #28's care plan did not address his diabetes diagnosis or insulin use, even though he was receiving insulin as per a sliding scale. The MDS Coordinator acknowledged that the care plans were not accurate, attributing the deficiencies to the baseline care plans completed by nurses on admission. The MDS Coordinator also noted that the care plans were not routinely reviewed or updated unless a change was personally brought to her attention.

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 not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified in three residents who were reviewed for unnecessary medications. Resident #10 was administered Seroquel, an antipsychotic medication, without an appropriate diagnosis to justify its use. The resident's care plan did not include any information regarding the use of this medication, despite her being cognitively intact and having no reported behaviors. Resident #21 was given risperidone, another antipsychotic, without a documented diagnosis indicating the necessity of the medication. Although the resident had a history of delusions and was taking risperidone for major depression with psychosis, the physician's order did not specify what the medication was intended to treat. The Director of Nursing (DON) acknowledged that the prescription should have indicated the treatment purpose to ensure the correct medication was administered for the correct diagnosis. Resident #137 received Seroquel without a supporting diagnosis for its use. The resident's care plan did not address the use of this psychotropic medication, and the DON was unaware of the resident's antipsychotic medication regimen until informed by a staff member. The facility's policy mandates that each resident's drug regimen be free from unnecessary drugs, including antipsychotics, unless necessary to treat a specific condition as documented in the clinical record.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During observations, three out of four medication carts were found unlocked and unattended in various locations, including hallways and near the nurse's station. Specifically, the 100 Hall medication cart was left unlocked and unattended multiple times, allowing potential access to anyone passing by. Similarly, the 300 Hall medication cart was observed unlocked and unattended, with staff walking by without securing it. The 200 Hall medication cart was also found in the same unsecured state at different times throughout the day. Interviews with the Assistant Directors of Nursing (ADONs) and the Director of Nursing (DON) revealed that the expectation was for medication carts to be locked when not in use. The ADONs mentioned that they monitored the carts by conducting frequent rounds and ensuring that keys were not left on top of the carts. The DON acknowledged the risk of drug diversion or residents accessing the medication carts when left unlocked. The facility's policy on medication storage emphasized that only authorized staff should have access to medication storage areas, and all medications should be securely stored in locked cabinets or carts.

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 necessary laboratory services for Resident #136, as per the physician's orders dated 05/29/24. The resident, a [AGE] year old female with diagnoses including acute embolism and thrombosis, was admitted to the facility and required specific lab tests: ESR, CBC with differential, and C Reactive protein test. Despite the resident's intact cognition and ability to communicate, the laboratory tests were not conducted, which was confirmed through interviews and record reviews. The resident and her responsible party (RP) both reported that the physician's orders were handed to the charge nurse, LVN B, but the tests were not performed. Interviews with the Director of Nursing (DON) and LVN B revealed a lack of clarity and communication regarding the physician's orders. The DON was aware of the resident's doctor's appointment but was not informed of any returned orders. LVN B, who was the charge nurse on duty when the RP delivered the orders, could not recall receiving them, citing a busy day with two new admissions as a possible reason for the oversight. The facility's policy on physician orders was reviewed, but it did not appear to have been followed in this instance, leading to the deficiency in providing timely laboratory services.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the safe and appropriate administration of IV fluids for a resident, specifically in the care and maintenance of a midline catheter. A resident, who was cognitively intact and had a history of multi-drug resistant organism and septicemia, was receiving IV medications through a midline catheter. The resident's midline dressing became wet and was noted to be brown-tinged and peeling away from the skin. Despite the facility's policy requiring dressing changes every seven days or as needed if the dressing was compromised, the dressing was not changed after it became soiled. The resident reported that the dressing got wet during a flushing procedure by a student nurse, and although the line was assessed by an external company and deemed functional, the dressing was left unchanged. Interviews with facility staff, including the Assistant Directors of Nursing (ADONs) and the Director of Nursing (DON), revealed that the facility nurses were responsible for changing midline dressings per physician orders and facility policy. The DON confirmed that all nurses were trained to perform midline dressing changes and were expected to assess the site at least once per shift. However, the dressing was not changed as required, which could increase the risk of infection. The facility's policy clearly stated that dressings should be changed if they were wet, dirty, or not intact, yet this protocol was not followed in this instance.