Longview Hill Nursing And Rehabilitation Center

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 residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for three residents with contractures or limited ROM. The deficiency involved Resident #53, Resident #64, and Resident #103, each of whom had documented contractures or ROM limitations and were observed without the ordered or expected contracture-management devices in place. Resident #53 had diagnoses including cerebral infarction, contractures of both hands, aphasia, and anxiety disorder. Her OT discharge summary stated a long-term goal for her to safely wear a hand roll on the right hand and a palm guard splint on the left hand for up to 8 hours to manage contracture and prevent skin breakdown. However, progress notes did not show refusals of the hand roll or splint, and multiple observations showed both contracted hands without the palm guard splint or hand roll in place while she was in bed or in a broda chair. Staff interviews indicated she was often combative and that staff sometimes could not apply the devices, but the nursing staff were responsible for applying them and documenting refusals. The DON and Administrator stated staff were expected to apply the hand roll and palm guard splint to residents with contractures. Resident #64 had diagnoses including right-hand contracture, muscle wasting and atrophy, and atrial fibrillation. Her MDS indicated a contracture, but her care plan lacked information regarding contracture management. OT records showed she had previously received treatment for her contracture and had progressed to using a hand splint for 4 hours, yet observations on 3/16/26 and 3/17/26 showed her right hand contracted without a hand splint in place. During interview, the resident stated she had previously used a hand roll daily and that it had been about 6 months since she last had one in her hand. The Director of Rehab and facility leadership stated nursing staff were responsible for ensuring residents on the contracture list received appropriate care and that the resident had a splint she was supposed to be wearing daily. Resident #103 had a diagnosis of left-hand contracture. His MDS reflected functional limitation in ROM, and his OT discharge summary showed a goal for him to tolerate wearing a resting hand splint to the left hand for 8 hours. The care plan and order summary did not address contracture management, and there were no ADL tasks for application of a contracture device. Observations on 3/16/26 and 3/17/26 showed his left hand curled into a fist with no splint or device on the hand or arm, and he stated he did not wear a splint even at night. Staff interviews indicated therapy had previously communicated that the splint should be worn when sitting up and removed in bed, but nursing staff were responsible for applying and maintaining the device after therapy discharge. The DON and Administrator stated nursing staff were responsible for ensuring contracture management devices were used as directed.

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 residents received mail delivered to the facility unopened and on Saturdays for 3 of 3 confidential residents reviewed for the right to communication. During a confidential group interview, all 3 residents said their supplies and mail came to them open, and one resident reported receiving a bank card through the mail with the card removed by staff before it was brought to him. The residents also stated they did not receive mail on Saturdays. During staff interviews, the Receptionist said she received mail and packages, sorted the mail, and placed it in department head trays; she initially stated she opened all mail, then recanted and said she only opened magazine mail. The Assistant Activity Director said she did not open residents' mail unless a nurse opened it and said she did not deliver mail on Saturdays because she forgot. The Business Office Manager, ADON, DON, and ADM gave differing accounts of who handled resident mail and whether it was opened, and several stated they were not sure who delivered mail on Saturdays. The ADM stated the receptionist received mail on Saturday and put it in the box, and that mail should be delivered on Saturdays. The only policy provided was titled Resident Personal Belongings and addressed protection of resident property from loss or theft.

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 an accurate MDS was completed for Resident #49, a male resident with Down syndrome, severe intellectual disabilities, and neurofibromatosis. The significant change MDS assessment dated 05/20/25 stated that he was not currently considered by the state level II PASRR process to have a serious intellectual disability or related condition, even though the resident’s PASRR Evaluation dated 08/15/24 reflected that he had intellectual and developmental disabilities and was eligible for PASRR services. The comprehensive care plan dated 09/01/25 identified Resident #49 as PASRR positive for intellectual or developmental disabilities. During interview, the MDS Coordinator stated she completed the significant change MDS and had overlooked the PASRR section in section A, resulting in the miscoding. She stated the resident was clearly PASRR positive and was receiving services in the facility. The Administrator stated he expected MDS assessments to be coded accurately and that care management staff were responsible for monitoring coding accuracy.

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 a comprehensive person-centered care plan for Resident #20 and Resident #111 that included measurable objectives and timeframes to meet their identified medical, nursing, mental, and psychosocial needs. For Resident #20, the record reflected a female resident admitted with dementia, type II diabetes, and COPD, with a quarterly MDS showing a BIMS of 05 and limited range of motion to the lower extremities on one side, along with a history of left hip fracture. Her comprehensive care plan dated 03/17/2026 did not include a care plan related to limited range of motion to the lower extremities and did not include interventions to prevent worsening. For Resident #111, the record reflected a female resident admitted with dementia, type II diabetes, and a left femur fracture. Her quarterly MDS showed a BIMS of 01, indicating severe memory impairment, and documented limited range of motion to the lower extremities on one side with a history of left hip fracture. Her comprehensive care plan dated 03/18/2026 also did not include a care plan related to limited range of motion to the lower extremities and did not include interventions to prevent worsening. During interviews, the MDS Coordinator stated care plans were to include all items coded on the MDS and that the care plan should be reviewed by nursing staff so they would know the individual care instructions for each resident. The DON stated major diagnoses, conditions, medications, and falls should be care planned with interventions to alert staff to potential recurrence and provide instructions. The Administrator stated he expected staff to follow the interventions decided on by the MDS Coordinator and interdisciplinary team, and acknowledged that not having the care items planned could potentially lead to residents not receiving individualized 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 provide an ongoing program of activities based on the comprehensive assessment to meet the interests of and support the physical, mental, and psychosocial well-being of Resident #108. The resident was an older female admitted with diagnoses including Alzheimer's disease, chronic atrial fibrillation, protein-calorie malnutrition, diverticulosis, and depression. The quarterly MDS indicated severe cognitive impairment with a BIMS score of 7, impaired vision, use of a motorized wheelchair, and substantial assistance needed with transfers. Her care plan, initiated in May 2025 and revised in November 2025, identified that she was dependent on staff for emotional, intellectual, physical, and social needs due to physical limitations and included preferences for gospel and oldies radio stations, music, bingo with help, trivia, and assistance and escort to activities. During observation, Resident #108 was found lying in bed without activities, with no TV or music playing in her room. She stated that staff did not offer to get her out of bed for activities and said she would like to be out of bed. Later observations showed her still in bed in the same position and yelling that she needed help, with no activities observed in the room. Another observation showed her sitting up in bed with no activities present. Staff interviews indicated that she enjoyed bingo, small talk, music, and having her nails done, but she also often wanted to return to bed and sometimes refused participation. CNA E stated she should be encouraged more and that a resident could become depressed if activities were not available. The Activity Director stated she did not do any activities with Resident #108 during the week of the observations, although in-room activities were scheduled for Monday, Wednesday, and Friday. She said the resident participated in bingo and sat next to her during that activity, but also noted the resident was yelling in the dining hall and returned to bed. RN F, the ADON, DON, and ADM all stated that resident preferences should be care planned and that residents should be offered activities daily based on those preferences. The facility was unable to provide a policy related to activities when requested.

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 pressure-redistribution mattresses were set correctly for 2 residents with pressure ulcer risk and existing skin issues. Resident #4, a female with diagnoses including cerebral infarction, hemiplegia, hemiparesis, muscle wasting and atrophy, and a stage 3 pressure ulcer of the right buttocks, had orders for a low air loss mattress and for the mattress to be checked every shift. During multiple observations, her mattress setting was documented at 250 pounds, and at one point the mattress was unplugged. Resident #4 stated her bed was not comfortable and was too hard. Resident #14, an 85-year-old female with diagnoses including mild protein-calorie malnutrition, muscle wasting and atrophy, cognitive communication deficit, and generalized muscle weakness, had a care plan identifying potential for pressure ulcer development and an order for a pressure redistribution mattress every shift. During observations, her mattress setting was documented as greater than 350 pounds, then 210 pounds, and then 200 pounds. Resident #14 stated her bed was uncomfortable, wanted another mattress, and said the mattress hurt her butt. She also stated she had a sore between her rectum and private area. Staff interviews confirmed that the mattress settings were expected to match the resident's weight and that nurses were responsible for monitoring the settings. The Treatment Nurse, an LVN, the ADON, the DON, and the Administrator all stated that the pressure redistribution mattress should be set according to the resident's weight and that incorrect settings increased pressure or skin breakdown risk. The facility's pressure injury policy stated that evidence-based interventions for residents at risk or with pressure injuries include appropriate pressure-redistributing support surfaces.

Penalty

No penalty information released

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

Summary

Provide enough food/fluids to maintain a resident's health was not met for Resident #108 when staff failed to keep the resident's water pitcher within reach on multiple observations. Resident #108 was an [AGE]-year-old female admitted with diagnoses including Alzheimer's disease, chronic atrial fibrillation, protein-calorie malnutrition, diverticulosis of the intestine, and depression. The quarterly MDS indicated a BIMS score of 7, severe cognitive impairment, impaired vision, and a need for setup assistance to bring food or liquid to the mouth once placed before her. Her care plan included good nutrition and hydration to promote healthier skin, and physician orders showed a mechanical soft diet with regular liquids and no fluid restriction. During observation and interview, Resident #108 stated she was blind, did not know where her water pitcher was, and was thirsty with a dry mouth. On one occasion her water pitcher was out of reach, and on another her water was on the bedside tray out of reach while she was lying in bed and yelling for help. On a later observation, her water pitcher was again out of reach with an empty cup of orange juice on the bedside table until RN G placed the pitcher within reach. Staff interviews confirmed that the water pitcher should be within reach and that nurses and aides were responsible for ensuring this. The facility was unable to provide a hydration policy when requested.

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 accurate dispensing and administration of medications for 1 resident. During observation on 3/16/26 at 9:55 a.m., Resident #95 was seen with a small plastic pill cup containing approximately 4-6 pills. When approached, the resident took the pills from the cup, placed them in his mouth, and swallowed them, stating that the med aide had given him his medications a few minutes earlier. The resident then said he did not want to speak with the surveyor. During interview on 3/16/26 at 10:09 a.m., MA A stated she had just passed medications in the hall where Resident #95 was located and said she was supposed to watch residents actually take their medications so she could document whether they took them or refused them. The Administrator and DON later stated that medications left at the bedside could place residents at risk and that medication aides were expected to ensure residents took their medications before leaving the room. Record review showed Resident #95 had diagnoses including paraplegia, cognitive communication deficit, and muscle weakness, and the care plan indicated he needed assistance with most ADLs. The facility policy stated medications are to be administered in a manner to prevent contamination or infection and to observe resident consumption of medication.

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 safe and sanitary storage of a resident's food items in a personal refrigerator and dry storage area. During observation, a bag of shredded cheddar cheese in the resident's personal refrigerator was found with an expiration date of September 20, 2024, along with salsa in the room that expired on August 2, 2025, and peanut butter that expired on January 22, 2024. The resident's record showed he was admitted with diagnoses including UTI, major depressive disorder, and COPD, and the MDS indicated he was cognitively intact with a BIMS score of 15 and understood others and made himself understood. During interview, the resident said he ate food in his room that he bought through grocery delivery, did not check expiration dates before eating, and no one came into his room to check the expirations of his food. He stated he did not realize he had food that had expired nearly 2 years ago. The Administrator said it was the responsibility of department heads to ensure personal refrigerators were clean of expired foods, and the DON said department heads were responsible to clean out residents' personal refrigerators and dispose of expired food. The facility policy stated staff shall clean the refrigerator weekly and discard any foods that are out of compliance.

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 refrigerator in the medication room on hall 4 in a safe operating condition. During observation, the refrigerator used to store food for residents who did not have refrigerators in their rooms was found with a brown substance splattered throughout the inside, a large buildup of ice on the cooling element, and a thermometer reading of 42 degrees Fahrenheit, above the facility’s stated limit of 40 degrees Fahrenheit or below. The refrigerator contained sour cream packets, yogurt, cranberry juice, a strawberry shake, coffee creamer, a can of coke, salad dressing, and a protein liquid container. During interviews, RN Q stated the refrigerator did not look good and was not sanitary to eat food from, and said housekeeping was responsible for cleaning refrigerators in medication rooms and resident rooms. The Environmental Supervisor stated she was not responsible for cleaning and defrosting medication room refrigerators and said the nurses were responsible, while also stating the hall 4 medication room refrigerator needed to be cleaned. The ADON and DON stated the nurses and unit managers were responsible for keeping medication room refrigerators clean, defrosted, and at the appropriate temperature, and the Administrator stated he expected staff to keep the refrigerators clean, defrosted, and at a safe storage temperature.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide pressure ulcer prevention and monitoring consistent with its own policies and professional standards for two residents at risk for pressure injuries. For one resident with heart failure, muscle weakness, diabetes, severe cognitive impairment, and identified risk for pressure ulcers, the care plan noted risk factors including fragile skin, incontinence, impaired mobility, and nutritional and hydration risk, with an intervention to identify and document potential causative factors. A Braden Scale assessment documented a score of 21, indicating no risk, but no further Braden assessments were documented for this resident from early June of one year through late February of the following year. A weekly skin check documented no skin issues in late January, and there were no further weekly skin assessments documented from that date through the resident’s discharge to the hospital in late February, despite facility policy requiring weekly full-body skin assessments and quarterly Braden assessments. For this same resident, a wound care NP completed an "At Risk Skin Assessment" in early February, documenting no new skin abnormalities and no active wounds, while noting the resident remained at increased risk due to age, history of falls, and reduced mobility, and recommending continued skin surveillance at routine intervals. Later in February, a change of condition note by an LVN documented a small wound on the buttock, and a subsequent progress note the same day recorded that the resident had a small wound to the buttock and black, tarry stool, after which EMS was called and the resident was sent to the hospital. A hospital wound care nurse note the next day documented that on admission the resident had a Braden score of 14 (moderate risk), required maximum assistance for turning and repositioning, was incontinent of stool, and was saturated in urine with a dry Foley bag. The hospital note identified a POA stage 2 pressure injury to the left buttock with specific measurements and characteristics, macerated tissue to the bilateral buttocks concerning for a moisture component, and pale pink intact scar tissue on the right buttock. The second resident was an older adult with diabetes, dementia, and protein-calorie malnutrition, with severe cognitive impairment and identified risk for developing pressure ulcers. The care plan documented diabetes and bowel incontinence related to cognitive decline. A Braden Scale assessment showed a score of 16, indicating risk for pressure injury, but there were no further Braden assessments documented for this resident for more than two years, despite the facility’s policy requiring quarterly Braden assessments and weekly skin assessments. A wound evaluation by a wound care NP in late February documented a diabetic wound on the right first toe but did not identify any pressure injuries, and a skin check shortly thereafter did not indicate any new skin issues. During interviews, the DON confirmed that Braden assessments were expected quarterly and skin assessments weekly, acknowledged that the last Braden and skin assessments for the first resident and the last Braden for the second resident were significantly outdated, and stated that failure to complete these assessments could result in unrecognized skin problems and lack of appropriate interventions. The Administrator and DON both attributed the missing assessments to a perceived glitch in the electronic charting system that was not triggering the required Braden and skin assessments.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that a resident’s medical power of attorney (MPOA) had timely access to the resident’s medical records, specifically urinalysis (UA) lab results, as required by resident rights regulations. The resident was an older male with a history of cerebral infarction affecting the right middle cerebral artery, dementia without behavioral disturbance, hemiplegia and hemiparesis of the left non-dominant side, cognitive communication deficit, and seizures. His care plan documented impaired cognitive function and dementia, with interventions that included communicating with family/caregivers regarding the resident’s capabilities and needs. A quarterly MDS showed severe cognitive impairment with a BIMS score of 0/15, unclear speech, and dependence or maximal assistance for most ADLs, indicating that the resident relied on his MPOA to act on his behalf. The resident’s medical power of attorney document, dated 1/6/23, appointed a family member as the Agent under Texas law and explicitly authorized the Agent, as the resident’s HIPAA personal representative, to request, receive, and review all medical and hospital records and other protected health information. In December 2025, multiple laboratory specimens were collected for the resident, including on 12/24/25, when a UA related to a UTI was obtained. The MPOA verbally requested the resident’s UA lab results from facility staff, including from the medical records staff and an LVN. According to interviews, the LVN reported she had been instructed not to provide any medical information directly and to direct all such requests to medical records via a release form, regardless of whether the request was for a verbal explanation or a hard copy of records. The MPOA stated she was denied verbal results by the LVN and never received the lab results. The medical records staff member confirmed that the MPOA verbally requested the UA results in December 2025 and that she provided a medical records release form, explaining that facility policy required completion of the form before any records could be released. She stated she did not receive the completed form and therefore did not provide the requested documents. A subsequent letter from a family member to medical records requested an explanation for the denial of the resident’s recent test results, and the company’s legal department responded that, under 45 C.F.R. § 164.524(b)(1), they could require written requests and that no written request from the MPOA had been received. The facility’s Release of Medical and Billing Records Policy required a fully completed authorization form and routing all requests through the legal department before releasing any information. As a result of these practices and requirements, the resident’s MPOA was not given access to the resident’s UA lab results within 24 hours of request, and copies were not provided within two working days, constituting a failure to honor the resident’s right to access records as specified in the regulations.

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 an allegation of abuse involving a female resident with dementia and moderately impaired cognition, who required assistance with activities of daily living and had a sitter present. On the day of the resident's discharge, a sitter was overheard telling EMS personnel that the resident had been abused and that hospice staff were aware. This verbal allegation was reported to the charge nurse and escalated to the Administrator. Despite the report, the Administrator did not interview the resident, her representative, or the caregiver who made the allegation. The Administrator stated that he did not investigate further because the resident had already left the building and was unsure if he had contact information for the sitter. The only interview conducted was with the CNA who overheard the conversation. The DON attempted to call the family member once after the allegation but did not reach them, and no one attempted to contact the caregiver directly. Facility policy requires immediate and thorough investigation of abuse allegations, including identifying and interviewing all involved persons, such as the alleged victim, perpetrator, witnesses, and others with knowledge of the incident. In this case, the investigation was incomplete as key individuals were not interviewed, and the investigation was concluded as unconfirmed without gathering all necessary information.

Penalty

Inspection fine: $73,554

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 significant medication error occurred when a nurse administered the entire evening medication regimen intended for one resident to another resident. The affected resident had a documented allergy to one of the medications, Trazodone, with a known reaction of altered mental status. The nurse failed to verify the correct resident and medication prior to administration, resulting in the resident receiving multiple medications not prescribed to him, including anti-seizure drugs, diabetes medication, and Trazodone. The nurse did not recall checking for allergies before administering the medications and could not specify which medications were given at the time of the incident. Following the administration of the incorrect medications, the resident exhibited symptoms such as drowsiness, slurred speech, and altered mental status. Neurological assessments and vital sign monitoring were inconsistently performed and documented, with several checks missing vital sign data. The nurse and other staff members involved did not consistently follow the facility's protocol for incident reporting, documentation, and investigation. The incident report did not list the specific medications administered, and there was confusion among staff regarding the resident's allergies and the medications involved in the error. Interviews with staff and the resident's representative revealed that the resident's condition deteriorated following the medication error, leading to hospitalization and a stay in the ICU. The nurse, DON, and other staff members provided inconsistent accounts of the events, the medications administered, and the actions taken in response to the error. The facility failed to ensure that medications were administered as ordered, that allergies were checked, and that appropriate monitoring and documentation occurred after the error, resulting in an Immediate Jeopardy situation.

Penalty

Inspection fine: $145,009

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

Summary

The facility failed to consult with the physician when there was a significant change in the physical status of two residents, which was life-threatening. For one resident, the facility did not notify the physician when the resident's PICC line was dislodged, preventing the administration of IV antibiotics for pneumonia. The resident missed several doses of the medication, and the physician was not informed of the situation or the resident's worsening condition until days later, resulting in the resident being transferred to the hospital with pneumonia. Another resident experienced a deterioration in a surgical wound, which was not communicated to the physician. The resident's wound showed signs of infection, including increased drainage and pain, but the facility staff did not notify the physician of these changes. The resident was later admitted to the hospital with a diagnosis of sepsis and an infection at the amputation site. The facility's failure to follow its policy on notification of changes with significant health issues led to life-threatening consequences for these residents. The report highlights the lack of communication and documentation regarding changes in the residents' conditions, which resulted in delayed medical interventions.

Removal Plan

• The Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be evaluated, the physician will be notified. The evaluation will be documented in the resident's clinical record.
• The Director of Nursing /Designee initiated reeducation with Licensed Nurses on the following topics: Documentation in Medical Record, Medication Administration, Notification of Changes Policy to include changes in medication administration, wound care and abnormal radiology results.
• When a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record.
• Licensed Nurses will give shift report from the PCC generated 24 hour report.
• Licensed Nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results.
• Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training.
• The Director of Nursing / designee will review the 24-hour report, the PCC Skin and Wound Module and the PCC Results Module in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative.
• The Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed.
• The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition.
• The Weekend Supervisor will review the 24-hour report in PCC as well as the Results Module (Lab and Radiology) to ensure that Medical Providers are notified of results.
• An Ad Hoc QAPI Meeting was conducted by the Administrator, with the Medical Director, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F580 Notification of Changes and plan to correct.

Penalty

Inspection fine: $145,009

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 care and treatment in accordance with professional standards of practice for two residents, leading to life-threatening consequences. One resident, who had a history of pneumonia, osteomyelitis, and quadriplegia, did not receive IV antibiotics for pneumonia due to a dislodged PICC line. The facility was aware of the dislodged line but failed to replace it or notify the physician promptly, resulting in the resident missing several doses of antibiotics. The resident's condition worsened, and he was eventually diagnosed with pneumonia and admitted to the hospital. Another resident with a surgical wound from a below-the-knee amputation experienced a deterioration in his wound condition. The facility failed to provide consistent wound care and did not notify the physician of the wound's worsening state. The resident was admitted to the hospital with sepsis and an infection at the amputation site. The facility's lack of timely medical intervention and communication with medical providers contributed to the resident's deteriorating condition. The deficiencies identified in the facility's care practices resulted in an Immediate Jeopardy situation, as the failures posed a risk of more than minimal harm to the residents. The facility's inability to ensure timely medical interventions and proper communication with medical providers led to severe health consequences for the residents involved.

Removal Plan

• The Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be evaluated, the physician will be notified. The evaluation will be documented in the resident's clinical record.
• The Director of Nursing /Designee initiated reeducation with Licensed Nurses on the following topics: Documentation in Medical Record, Medication Administration, Notification of Changes Policy to include changes in medication administration, wound care and abnormal radiology results.
• When a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record.
• Licensed Nurses will give shift report from the PCC generated 24 hour report. (PCC generated from clinical documentation).
• Licensed Nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results.
• Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training.
• The Director of Nursing / designee will review the 24- hour report, the PCC Skin and Wound Module and the PCC Results Module in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative.
• The Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed.
• The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition.
• The Weekend Supervisor will review the 24-hour report in PCC as well as the Results Module (Lab and Radiology) to ensure that Medical Providers are notified of results.
• An Ad Hoc QAPI Meeting was conducted by the Administrator, with the Medical Director, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning Quality of Care and plan to correct.

Penalty

Inspection fine: $145,009

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

Summary

The facility failed to provide adequate pharmaceutical services, specifically in the accurate dispensing and administering of insulin to residents. This deficiency was observed in five out of six residents reviewed for medication administration. The issue primarily involved the use of insulin that was past the 28-day labeled precautionary instructions, which could potentially affect the effectiveness of the medication in controlling diabetic symptoms. Resident #3, a male with diabetes mellitus, was found to have been administered Novolog insulin that was opened 31 days prior, exceeding the recommended 28-day usage period. The LVN initially attempted to administer this expired insulin but was stopped and had difficulty locating a new supply. Similarly, Resident #4, a female with type 2 diabetes mellitus, had Humalog insulin that was opened 32 days prior. She received her insulin injection after finishing her meal, contrary to the prescribed timing before meals. Resident #5 had both Novolog and Lantus insulin that were opened 41 and 40 days prior, respectively, both exceeding the 28-day usage period. Resident #6's Lantus insulin did not have an opened date recorded, although there was a designated space for it. Resident #7's Novolog insulin was also past the 28-day usage period. The LVN responsible for administering these medications was not aware of the expiration issue, indicating a lack of proper oversight and adherence to medication administration 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 adhere to professional standards for food safety in its kitchen, as observed during a survey. Specifically, food items were not properly sealed and dated, with two undated containers of instant mashed potatoes found in dry storage and an unsealed box of biscuits in the freezer. Additionally, dietary staff did not wear hair restraints appropriately, as evidenced by an employee's hair being visible outside of the hairnet during meal preparation. These lapses were confirmed through interviews with the dietician, dietary manager, and the staff member involved, all of whom acknowledged the importance of proper food labeling, sealing, and hair restraint to prevent food contamination. The dietician and dietary manager both stated that food items should be labeled with receive and open dates, and sealed if opened, to prevent bacterial growth and potential foodborne illness. The dietary manager also noted that she conducted weekly walkthroughs to ensure compliance with these standards and provided regular training to staff. The administrator confirmed that the dietary manager was responsible for ensuring proper food storage and cleanliness in the kitchen, and that she conducted random walkthroughs to monitor compliance. The facility's policies on food storage and employee sanitation were reviewed, indicating requirements for labeling, dating, and proper hair restraint use.

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 care plans for several residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #17's care plan did not include her verbal and other behavioral symptoms, the diagnosis of COPD, and the use of an antiplatelet medication. Despite having a moderate cognitive impairment and experiencing behavioral symptoms, these issues were not addressed in her care plan, which could have provided necessary interventions to manage her condition effectively. Resident #110's care plan was also incomplete, as it did not address her use of an antiplatelet medication, her risk for pressure ulcers, and her diagnosis of dehydration. This resident had severe cognitive impairment and was at risk for developing pressure ulcers, yet these critical aspects were not included in her care plan. The lack of a comprehensive care plan could lead to inadequate management of her medical conditions and increased risk of complications. Additionally, Resident #21's care plan failed to include her need for dentures, which was crucial for her nutritional intake and to prevent choking and swallowing difficulties. Observations revealed that she often ate without her dentures, which were left soaking in dirty water. Furthermore, Resident #79, who was at high risk for falls, did not have a care plan addressing this risk, despite having a history of falls and related injuries. The absence of a fall risk care plan could result in insufficient preventive measures being in place to protect her from further falls.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the drug regimens of three residents were free from unnecessary medications, specifically antibiotics, which were administered without appropriate lab work or indications for use. Resident #66 received Cephalexin for a suspected UTI without a culture to confirm the infection. Despite the absence of lab work, the resident was administered the full course of antibiotics, as noted in the Medication Administration Record (MAR) and progress notes. Resident #71 was prescribed Macrobid for a suspected UTI, even though a urine analysis showed no pathogens. The resident received the full course of antibiotics, as documented in the MAR, despite the negative lab results. The facility's Infection Control Log and progress notes indicated that the antibiotics were continued based on the family's suspicion of a UTI, rather than clinical evidence. Resident #78 was administered Rocephin and Levaquin for a suspected infection without a clear indication of use. The resident's progress notes and lab results did not support the presence of an infection that required antibiotic treatment. The facility's Infection Control Log incorrectly logged the infection as a UTI, and the antibiotics were administered without meeting the McGreers criteria for infection treatment. Interviews with facility staff revealed a lack of adherence to the antibiotic stewardship program, resulting in the unnecessary administration of antibiotics.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the drug regimens of three residents were free from unnecessary psychotropic drugs due to inadequate behavior monitoring and diagnosis. Resident #17's Wellbutrin dosage was increased without documented behaviors to justify the change. The resident, who had a history of dementia, anxiety, and major depressive disorder, was noted to have moderate cognitive impairment and exhibited behavioral symptoms. However, the facility's records did not indicate any behaviors related to depression that would warrant the increase in medication. Resident #23, who had severe cognitive impairment and a history of dementia, anxiety disorder, and insomnia, was prescribed Depakote for agitation and anxiety. The facility failed to conduct behavior and side effect monitoring for this anticonvulsant medication. Despite receiving multiple doses of Depakote, there was no documentation of behavior or side effect monitoring, which is crucial for assessing the necessity and effectiveness of the medication. Resident #110, diagnosed with cerebral infarction, dementia, insomnia, and anxiety disorder, was prescribed Trazodone for insomnia. The facility did not perform side effect monitoring for the antidepressant, as indicated in the resident's medical records. Interviews with facility staff revealed that nurses were responsible for ordering and documenting behavior and side effect monitoring, but this was not consistently done, leading to potential unnecessary medication use.

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 food that was palatable and served at an appetizing temperature for seven residents. Multiple residents expressed dissatisfaction with the taste and temperature of the food, describing it as bland and sometimes served cold. During interviews, residents consistently reported that the food lacked flavor and was not enjoyable, with specific complaints about the frequent serving of baked fish or chicken with plain white rice. Observations by the Dietary Manager and surveyors confirmed that the food was bland, and some items were not served at the correct temperature, such as cold baked apple slices that were intended to be warm. Interviews with the facility's dietary staff, including the Dietician and Dietary Manager, revealed awareness of food complaints and acknowledged the importance of serving palatable and appropriately tempered meals for residents' nutritional status and overall wellbeing. The Dietary Manager admitted to past food complaints and emphasized the responsibility of dietary staff to ensure food quality. The Administrator also acknowledged resident complaints about food taste and temperature, stating that the kitchen staff and facility staff were responsible for ensuring food quality. Despite daily management rounds to monitor food complaints, the facility did not provide a policy on test trays when requested.

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 fully informed and understood their health status, care, and treatments, specifically regarding the use of antipsychotic medications. For three residents, the facility did not complete the required HHSC Form 3713, which is necessary for obtaining informed consent for antipsychotic or neuroleptic medication treatment. The forms lacked critical information such as clinical indications for use, dosage, frequency, and potential side effects, risks, or benefits of the medications. Resident #68, who had diagnoses of schizophrenia and anxiety disorder, was prescribed Abilify and Risperdal. However, the consent forms for these medications were incomplete, missing essential details about the treatment. Despite the resident's representative believing that the facility had discussed the medications' side effects and benefits, the documentation did not reflect this. Similarly, Resident #79, with diagnoses of depressive episodes and anxiety disorder, was taking Quetiapine but was unaware of the reasons for its use or its side effects, as the consent form was also incomplete. Resident #108, who had multiple diagnoses including seizures and depressive disorder, was prescribed Quetiapine. The consent form for this medication was incomplete, lacking information on the clinical indications, dosage, and potential side effects. Interviews with facility staff, including the LVN, ADON, and DON, revealed a lack of clarity and responsibility in ensuring the completion of these forms. The facility's policy and state regulations require that residents or their representatives be fully informed about the medications, but the failure to complete the forms accurately meant that residents could not make informed decisions about their treatment.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe, clean, and homelike environment for a resident, as observed during multiple inspections. The resident's room was found to have floors covered in dust, dirt, and debris, including white paper and large brown crumbs. Additionally, the resident's personal refrigerator door was splattered with dried white substances, and the bathroom counter had a sticky pinkish dried liquid. The dresser was smeared with a white creamy substance, and the closet contained clean clothing on the floor. The chair in the room had brownish stains. The resident involved was an elderly female with a history of cerebrovascular disease, hypertension, hyperlipidemia, stroke, and dysphagia. She was moderately cognitively impaired and required assistance with daily activities such as toileting, dressing, and bathing. Despite her cognitive status, the resident was understood by others and could understand others, as indicated by her BIMS score of 11. The care plan did not mention her use of dentures for eating, although she required assistance with them. Interviews with facility staff revealed that the housekeeper responsible for cleaning the resident's room had missed several areas, including the sides and front of the dresser and the refrigerator door. The housekeeper acknowledged the importance of maintaining a clean environment for residents, as it is their home. The Environmental Services Supervisor outlined a five-step cleaning process but emphasized that maintaining cleanliness was a group effort. The Director of Nursing and the Administrator both expressed expectations for clean and homelike resident rooms to prevent infection spread, but the facility lacked a specific policy for a homelike environment.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the medication regimen of a resident, specifically the administration of Quetiapine Fumarate, an antipsychotic medication. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, had multiple diagnoses including depressive episodes and anxiety disorder. Despite having an active order for Quetiapine Fumarate, which was administered daily, the MDS assessment did not indicate the use of this antipsychotic medication in the relevant section. This oversight was acknowledged by the MDS coordinator responsible for the assessment, who admitted it was an error on her part. Interviews with the MDS coordinators and the Administrator (ADM) revealed that the facility did not have a specific policy on the accuracy of assessments, relying instead on the Resident Assessment Instrument (RAI) Manual. The ADM and MDS coordinators stated that the MDS assessment is primarily a tool for data gathering and payment, and they did not believe the inaccuracy would affect the resident's care. However, the RAI Manual specifies that all high-risk drug class medications should be coded according to their pharmacological classification, which was not done 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 ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the mental health status of a resident diagnosed with major depressive disorder. The resident's PASRR Level I screening incorrectly indicated no mental illness, despite a diagnosis of major depressive disorder, which was confirmed by the MDS Nurse and the Director of Nurses as qualifying for a positive PASRR Level I. This oversight was identified during a review of the resident's records, which showed the resident had been diagnosed with major depressive disorder and was using psychotropic medication. Interviews with facility staff revealed a lack of understanding and proper procedure regarding PASRR evaluations. The MDS Nurse initially believed that major depressive disorder did not automatically qualify a resident for a positive PASRR Level I, but later acknowledged the error after consulting with the local mental health authority. The Director of Nurses confirmed that residents with qualifying mental illness diagnoses should receive a Level II evaluation. The facility lacked a policy regarding PASRR, as noted in an email from the Administrator, which contributed to 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 ensure that three residents received necessary assistance with personal hygiene, specifically in the removal of facial hair, which is part of their activities of daily living (ADLs). Resident #5, a female with multiple sclerosis and moderate cognitive impairment, was observed with approximately 1-inch gray facial hairs on her chin and sides of her mouth. Despite being dependent on staff for personal hygiene, she was not offered assistance with facial hair removal, leading to embarrassment and a desire for help. Staff interviews revealed that assistance was not provided because it was not requested, highlighting a lack of proactive care. Resident #46, who has severe cognitive impairment and requires supervision for ADLs, was observed with small white hairs on her chin. Although she claimed to manage her own facial hair, she was unaware of its presence and expressed an intention to address it. Staff interviews indicated that facial shaving should occur during showers, but it was not noticed or addressed by the staff, suggesting a gap in supervision and assistance. Resident #51, with severe cognitive impairment, was observed with patches of white-gray chin hair. Despite requesting assistance for hair removal, she reported that aides often claimed they lacked time or would return later, which did not happen. Staff interviews confirmed that facial hair removal should be part of the bathing routine, but it was not consistently offered or performed. The facility's policy mandates assistance with ADLs, including grooming, for residents unable to perform these tasks independently, which was not adhered to 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 ensure adequate supervision and assistance during a mechanical lift transfer for a resident, leading to a potential risk of injury. The incident involved a resident with severe cognitive impairment and functional limitations, who was dependent on staff for transfers and other activities of daily living. During a transfer using a Hoyer lift, two CNAs left the resident unsupervised at the bedside, failing to raise the side assist rail, which resulted in the resident swaying dangerously close to the edge of the bed. The resident, who had diagnoses including dementia and muscle wasting, was observed in a video where the CNAs did not communicate with her during the transfer process. The CNAs walked away from the resident for approximately 15 seconds without ensuring her safety, leaving her at risk of falling. The facility's policy required two staff members to assist with mechanical lift transfers to ensure the resident's safety, which was not adhered to in this instance. Interviews with the facility's staff, including the ADON, DON, and the CNAs involved, revealed that the transfer was not conducted according to the facility's standards. The staff acknowledged the risk posed by the lack of supervision, with one CNA expressing regret upon realizing the resident almost fell. The facility's policy emphasized the importance of a team approach to prevent falls, which was not followed during this 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 acceptable nutritional parameters for a resident, identified as Resident #23, who was at risk for malnutrition and weight loss. Resident #23, an 86-year-old female with dementia, protein-calorie malnutrition, and dysphagia, experienced significant weight loss over several months. Despite the dietician's recommendations to increase the frequency of Med Pass 2.0 from three times a day (TID) to four times a day (QID) to address her declining appetite and nutritional needs, the facility did not implement these recommendations in a timely manner. The dietician made recommendations on multiple occasions, specifically on 11/15/24, 12/06/24, and 12/13/24, to increase the Med Pass frequency to QID. However, the facility's nursing staff did not follow through with obtaining the necessary orders from the physician or nurse practitioner, even though the dietician's recommendations were communicated via email to the administrative staff. The facility's policy required that such recommendations be implemented within 72 hours, but this was not adhered to, resulting in a delay in addressing the resident's nutritional needs. Interviews with facility staff, including the LVN, DON, and ADM, revealed a lack of awareness and follow-up on the dietician's recommendations. The dietician, who had recently been granted order writing privileges, eventually entered the order herself after noticing the facility's inaction. The failure to implement the dietary recommendations placed Resident #23 at risk for further weight loss and nutritional decline, as the Med Pass was intended to supplement her calorie intake and support her nutritional health.

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 administration of medications for a resident, specifically concerning the availability of Wellbutrin SR Oral Tablet Extended Release 200mg. This medication was not available for administration on three separate occasions, which were documented as 10/13/24, 10/14/24, and 11/04/24. The resident, a female with a history of dementia, anxiety, major depressive disorder, and cognitive communication deficit, was dependent on this medication for managing her major depressive disorder. Interviews with facility staff revealed a breakdown in the medication refill process. Licensed Vocational Nurse (LVN) N, who had been with the facility for almost four years, explained that Medication Aides (MAs) were responsible for notifying nurses when a medication needed refilling. The facility had a system in place where the MAs would alert the nurses when the blister pack was running low, specifically when only seven days of medication remained. However, there was a delay in refilling the medication, which could have been due to insurance issues or medication changes, although the pharmacy was noted to be quick in refilling orders once placed. Further interviews with the Director of Nursing (DON) and the Administrator (ADM) highlighted expectations for timely medication refills, emphasizing the importance of ordering before the blister pack reached the blue section, indicating low supply. Despite these protocols, the resident missed doses of Wellbutrin, which could have led to episodes of crying or anxiety due to the lack of medication. The facility's Medication Administration policy required medications to be administered as ordered by the physician, but this was not adhered to in this instance, leading to 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 securely store medications and biologicals, as evidenced by the improper storage of prescription medications for two residents and an unlocked medication cart. For Resident #10, Nystop powder and Venelex ointment were found in the resident's room without proper labeling or storage, contrary to facility policy. Interviews with staff revealed a lack of awareness regarding the prohibition of storing prescription ointments or creams in resident rooms, and the absence of an order for Nystop powder for Resident #10 was noted. Resident #39 was found with a cup containing approximately 10 medications left unattended on his bedside table. The resident reported that staff had left the medications there, and he had forgotten to take them. Facility policy dictates that medications should not be left with residents unsupervised, and staff are responsible for ensuring residents take their medications or return them if refused. Additionally, a medication cart on Hall 200 was observed unlocked and unattended, posing a risk of unauthorized access to medications. The staff member responsible for the cart admitted to leaving it unlocked while attending to another task. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that medication carts should always be locked when not in use to prevent unauthorized access and potential harm.

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 and ensure safe and sanitary storage of food items in a resident's personal refrigerator, specifically for a resident with severe cognitive impairment and multiple diagnoses, including Paranoid Schizophrenia, Dysphagia, and Dementia. During observations, the resident's refrigerator was found to be covered in a dark substance, and a glass of milk inside was growing a white fuzzy substance, indicating spoilage. The resident reported that no one cleans his refrigerator and that consuming food from it has caused him gastrointestinal distress. Interviews with staff revealed that there was a lack of consistent monitoring and cleaning of residents' personal refrigerators. A CNA admitted to occasionally discarding items but had never cleaned the resident's refrigerator. The Director of Nurses stated that staff are required to check and clean residents' refrigerators, but this was not done in this case. The facility's policy mandates weekly cleaning and discarding of non-compliant foods, but this was not adhered to, leading to the potential risk of foodborne illness for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not adhere to enhanced barrier precautions while performing gastrostomy tube feeding for a resident. The LVN failed to don a gown, which is required for residents with gastric feeding tubes to prevent cross-contamination and protect both the resident and staff. This oversight was acknowledged by the LVN, who admitted to forgetting to wear the gown and noted the absence of a sign indicating the need for enhanced barrier precautions. In the second incident, two Certified Nursing Assistants (CNAs) did not follow proper infection control procedures during incontinent care for another resident. The CNAs failed to change their gloves and perform hand hygiene between handling soiled and clean items, and they touched clean surfaces with soiled gloves. This improper technique was captured on video and confirmed by the facility's Assistant Director of Nursing (ADON) and Director of Nursing (DON) as not adhering to the facility's policy, which could lead to cross-contamination and potential infections. Both incidents highlight lapses in following established infection control protocols, despite the staff having been recently in-serviced on these procedures. The facility's infection preventionist and other administrative staff acknowledged the importance of adhering to these protocols to prevent the spread of infections and protect residents' health.

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 uphold the dignity and respect of two residents, leading to deficiencies in their care. For one resident, the facility did not ensure that CNAs explained the procedures before initiating a transfer and providing incontinent care. The resident, who had severe cognitive impairment and was dependent on staff for assistance, was transferred using a mechanical lift without any explanation from the CNAs. The resident's muttering and increased shakiness in her voice indicated distress, yet the CNAs did not communicate with her during the process, leaving her feeling insecure and agitated. In another instance, the facility failed to provide scheduled smoke breaks for a resident residing in the memory care unit. The resident, who had moderate cognitive impairment and was a current tobacco user, was not consistently offered the opportunity to smoke at the scheduled times. Despite having a smoking schedule, the facility did not actively ask the resident if she wanted to smoke, relying instead on the resident to express the desire to smoke. This lack of initiative from the staff led to the resident missing scheduled smoke breaks, which could have been used as an intervention to help with her behaviors. Interviews with staff and family members revealed that the resident's smoking habits were not adequately supported by the facility. The resident's family member expressed concern that the resident did not get to smoke enough, and staff acknowledged that the resident's memory issues prevented her from remembering the smoking schedule. The facility's failure to ensure that the resident was taken to smoke at the scheduled times compromised her right to smoke and potentially affected her quality of life.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from abuse during a mechanical lift transfer and incontinent care. The incident involved two CNAs who roughly handled the resident, failing to communicate with her during the process. The resident, who had severe cognitive impairment and was dependent on staff for assistance, was not informed about the actions being taken, which led to increased agitation and distress. The resident, an elderly female with dementia and other health issues, was observed in a video being transferred to her bed using a Hoyer lift by the CNAs. The CNAs did not explain their actions to the resident, who was placed near the edge of the bed without the side assist rail being raised. The CNAs left the resident unattended for a brief period, during which she swayed dangerously close to the edge. Upon returning, the CNAs continued to handle the resident roughly, pulling her gown and brief without unfastening it, causing her distress. Interviews with facility staff, including the ADON, DON, and Administrator, revealed that the care provided was considered too swift and rough, potentially leading to skin tears and soreness. The staff acknowledged that the CNAs should have used a draw sheet to prevent injury and that the actions observed in the video were concerning. The CNAs involved had received training on abuse and neglect, but their actions during the incident did not align with the facility's policies and expectations for resident 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 provide timely notification to a resident and their representative regarding a discharge. The resident, an elderly female with multiple health issues including acute respiratory failure, congestive heart failure, and severe cognitive impairment, was discharged without a 30-day written notice. The facility did not complete a discharge summary or provide a written notice to the resident's representative, which is required by policy. The resident was admitted to the facility for skilled nursing and therapy evaluation but faced issues with the payor source due to not meeting the 3-midnight hospital stay requirement. This resulted in the resident being discharged home after only a short stay, with the family being informed by phone rather than through a formal written notice. The facility arranged for a home health agency to provide services after the respite care period ended, but the lack of a formal discharge notice was a significant oversight. Interviews with facility staff revealed confusion and a lack of awareness regarding the discharge notice requirements. The Admission Coordinator, Social Worker, and MDS Coordinator all provided conflicting information about the necessity of a discharge notice, citing the resident's short stay and lack of a payor source as reasons for not issuing one. The Administrator acknowledged the oversight but noted that the Business Office Manager, who was responsible for discharge notices, was on medical leave at the time.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that PRN orders for psychotropic medications were limited to fourteen days for two residents, leading to a deficiency in medication management. Resident #1 had a PRN order for Lorazepam, a psychotropic medication, which was not re-evaluated by a physician for more than fourteen days. The resident, who had severe cognitive impairment and a history of dementia and anxiety, received the medication multiple times over several months without documented physician re-evaluation. Similarly, Resident #2, who also had severe cognitive impairment and a history of dementia, had a PRN order for Lorazepam that was not re-evaluated within the required timeframe. Interviews with facility staff revealed a lack of awareness and adherence to the policy requiring re-evaluation of PRN psychotropic medications every fourteen days. LVN A acknowledged the absence of re-evaluation documentation, while LVN B and LVN C expressed differing views on the necessity of re-evaluation based on resident stability. The ADON and DON confirmed the oversight, noting the potential risks of not re-evaluating such medications, including overmedication and the use of chemical restraints. The facility's Medication Management Policy and Procedure mandates ongoing monitoring and re-evaluation of PRN psychotropic medications every fourteen days, with documentation of the physician's rationale if the order is to be extended. However, this policy was not followed for the two residents in question, resulting in a failure to ensure safe and appropriate medication use. The deficiency highlights the need for consistent adherence to established protocols to prevent potential adverse consequences 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 ensure that menus and nutritional adequacy met the nutritional needs of residents in accordance with established national guidelines. This deficiency was observed during two meals where the planned menu was not followed due to a lack of ingredients. The Dietary Manager (DM) reported that the grocery delivery was delayed due to the Labor Day holiday, and the corporate office did not approve the grocery order on time due to budget constraints. As a result, the facility did not have the necessary ingredients to prepare the meals as planned, leading to substitutions that were not reviewed by a dietician. During the period from 09/01/2024 to 09/03/2024, the facility did not maintain a seven-day supply of food, as required by their emergency and disaster planning policy. Observations of the facility's pantry, cooler, and freezer revealed insufficient food supplies to meet the needs of the 123 residents for seven days. The DM admitted that the current food supply was inadequate and that there was no separate area for emergency food supplies. The lack of adequate food supply led to meal substitutions that were not nutritionally equivalent to the planned menu items. Interviews with staff, including the DM, cooks, and the Administrator, highlighted a lack of communication and oversight regarding the food supply and menu substitutions. The DM did not follow the procedure for notifying the dietician of menu substitutions, and the dietician was unaware of the low food supply. The Administrator was not informed of the food supply issues until they became critical, and although petty cash was available for emergency purchases, it was not utilized effectively to address the shortage. The facility's failure to maintain an adequate food supply and follow the planned menu could potentially lead to inadequate nutrition for the residents.