Paradigm Northwest

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 care and prevention consistent with professional standards, specifically by not turning and repositioning three residents at least every two hours and PRN as care planned and per facility policy. One resident, an older male with severe sepsis, multiple stage 3 and 4 pressure ulcers, unstageable pressure ulcers, venous/arterial ulcers, malnutrition, and high Braden risk, had care plan interventions that included turning/repositioning during rounds and PRN, use of pillows/positioning devices, a low air loss mattress, heel protectors, and nutritional supplements. Despite these orders and his extensive sacral and buttock wounds, surveyors repeatedly observed him lying on his back without pillows or wedges on multiple occasions over two days. His turning/repositioning task documentation showed no turns recorded for one full day and only two turns documented the next day, and a wedge intended for him was found on his roommate’s bed. A second resident, an older female dependent for all ADLs, frequently incontinent, malnourished, with a PEG tube, tracheostomy, and mild Braden risk, was care planned as at risk for pressure wounds with interventions including assistance with turning/repositioning during rounds and PRN and provision of pressure-reducing devices. At the time of a recent MDS, she had no pressure ulcers, but subsequent skin observations documented development of sacral redness on two separate dates. During the survey period, she was repeatedly observed lying on her back in bed, and she reported that she never got turned from side to side. There were no extra pillows or wedges observed in her room, and turning/repositioning task documentation reflected only one turn documented on one day and two turns documented the following day. A third resident, an older female with spinal stenosis, movement disorder, severe obesity, total dependence for toileting, Hoyer-lift transfers, and always incontinent of bowel and bladder, was identified as at risk for pressure wounds with a care plan calling for assistance with turning/repositioning during rounds and PRN and use of padding and positioning devices. Her Braden score indicated mild risk, and a recent skin/wound note documented open skin on the backs of both thighs that had reopened from old wounds. Over multiple observations across two days, she was consistently found lying on her back in bed and repeatedly stated that staff never came in to turn or reposition her and that she was usually out of bed by midday. Turning/repositioning documentation showed only two turns recorded on one day and an entry indicating she could turn herself during the night, despite her dependence for mobility. Staff interviews revealed that while one LVN stated residents were turned every two hours and that she oversaw this, another RN acknowledged staff were not 100% compliant with turning/repositioning, and the administrator believed staff were turning residents but not documenting it, even though the facility’s policy required organized, planned, and documented turning/repositioning for residents at risk for skin breakdown.

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 necessary assistance with activities of daily living, specifically toileting and incontinence care, to residents who were unable to perform these tasks independently. For one resident with normal cognition, spinal stenosis, type 2 diabetes, heart failure, movement disorder, severe obesity, and a history of TIA/CVA, the MDS documented total dependence for toileting, use of a Hoyer lift, and continuous bowel and bladder incontinence, with identified risk for pressure ulcers. Her care plan required routine rounding with incontinence care and brief changes for both urinary and bowel incontinence, and assistance with incontinent care as part of pressure injury prevention. Despite this, documentation and interviews showed prolonged periods without being checked or changed. On one day, the cognitively intact resident reported she had last been changed at 4:30 a.m. and remained soiled with urine when interviewed and observed at 9:58 a.m. and again at 12:00 p.m., stating that staff had turned off her call light and said they would get an aide, but no one had changed her. Later that afternoon she reported she had finally been changed but did not recall when. On the following day, she again reported being last checked/changed at 4:30 a.m., and at 9:15 a.m. and 10:32 a.m. she remained in bed, stated she was soiled with urine, and that no one had come despite her call light being turned off and assurances that a CNA would come. She reported being changed only shortly before lunch, indicating more than six hours without incontinence care on one day and more than seven hours on the next, while record review of bladder elimination tasks showed only two changes documented on the first day and one change documented early the next morning. A second resident, with hemiplegia/hemiparesis after stroke, type 2 diabetes, hypertension, lack of coordination, severe cognitive impairment (BIMS 0/15), frequent bowel and bladder incontinence, and risk for pressure ulcers, also did not receive timely incontinence care. Her care plan required routine rounding with incontinence care and brief changes, assistance with toileting and incontinent care, and extensive assistance for toileting/incontinence care to maintain cleanliness and dignity. She reported routinely not seeing an aide for four or more hours at a time and having to wait about two and a half hours to be changed when already soiled with urine and feces. She stated that staff would come in and turn off her call light without informing an aide she needed cleaning, and on the day of the survey she reported not being checked, changed, or asked about her needs since 8:30 a.m., despite a CNA stating she had checked the resident before lunch. Bladder elimination documentation showed only three changes on that day and one change early the following morning. The facility’s own ADL policy required support for residents’ highest practicable level of functioning, including personal care tasks such as toileting, delivered by direct care staff such as CNAs, but the observed and documented care did not meet these expectations for these two residents. Interviews with staff further illustrated the inaction contributing to the deficiency. An LVN and a med aide both stated that residents were to be checked and changed every two hours and as needed, even if sleeping, but the residents’ accounts and documentation did not reflect this frequency. A CNA assigned to the cognitively intact resident acknowledged she was responsible for that resident and a heavy hall with trach and vent residents and stated she was on her way to assist only after the resident had already been waiting and remained soiled. The administrator reported that she rounded on every resident twice daily and that leadership conducted Ambassador Rounds, and that concerns identified during rounds would be addressed through in-services and care huddles; however, the residents’ reports, grievance log entry for ADL concerns, and bladder elimination records showed that residents continued to experience extended periods without incontinence care, contrary to their care plans and the facility’s ADL policy. The facility’s March grievance log documented that the second resident had previously filed a complaint about ADLs, specifically on an earlier date in the same month, indicating that concerns about incontinence care and assistance with ADLs had been raised prior to the surveyor’s observations and interviews. Despite this, the survey findings showed that on multiple occasions the residents’ call lights were turned off without timely follow-through on incontinence care, and that the documented frequency of changes did not align with the stated practice of checking and changing residents every two hours and as needed. The combination of resident statements, staff interviews, care plans, physician orders for diuretic medications that increase urination, and bladder elimination task records demonstrated that the facility did not consistently provide the necessary services to maintain grooming and personal hygiene for these residents who were unable to manage their own toileting and incontinence needs.

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 implement proper infection prevention and control practices during extensive wound care for Resident #2. Resident #2 was an adult male with severe sepsis with septic shock, osteomyelitis, COPD, type 2 diabetes, multiple stage 3 and stage 4 pressure ulcers, several unstageable pressure ulcers, venous/arterial ulcers, a wound infection being treated with IV ertapenem, an indwelling catheter, a colostomy, and a PEG tube. His care plan and physician orders documented numerous wounds on the sacrum, buttocks, heels, feet, ankle, toes, and lower leg, with detailed instructions for cleansing with normal saline, application of betadine, Santyl, honey fiber, calcium alginate, and bordered dressings. The facility’s infection control program policy stated that it would follow evidence-based practices and that the Infection Preventionist would provide training and competency assessments, while the DON stated that hand hygiene and glove changes were required between each wound and when moving from dirty to clean tasks. During an observed wound care session, RN O prepared supplies on a cleaned bedside table, including gauze, iodine, saline, bordered gauze patches, Santyl, honey fiber, calcium alginate, dry gauze, a chuck, a tongue depressor, a bio bag, and gloves. She donned a gown and two pairs of gloves without performing hand hygiene, then adjusted the resident’s oxygen tubing and bed. After turning the resident and removing his brief, she removed only the outer pair of dirty gloves and donned new gloves over the inner pair without washing or sanitizing her hands. She removed dirty wound bandages, again only changing the outer gloves and never cleaning her hands. When cleansing the large sacral and left thigh wounds, she used gauze soaked in saline but flipped and reused the same piece of gauze instead of using a fresh piece each time, and then proceeded to dry the wound without changing gloves or performing hand hygiene. Following cleansing, RN O applied Santyl to the sacral wound using the same tongue depressor multiple times and repeatedly placed the tip of the Santyl tube directly on the tongue depressor. She applied honey fiber to the sacrum and left thigh wounds, and when a piece of honey fiber fell onto the resident’s brief, she picked it up and reapplied it to the wound. She repeatedly removed gloves and donned new ones without any hand hygiene between glove changes. As she moved from one wound to another on the left knee, left lower extremity, left heel, left foot and toes, right heel, right forefoot and toes, and right upper leg, she consistently reused individual pieces of gauze more than once for cleansing with saline and iodine, failed to change gloves or clean her hands between cleaning and applying treatments, and did not change gloves between separate wound sites. At the end of care, she still had dirty gloves on when she touched the resident’s clean draw sheet and blanket. In a subsequent interview, RN O acknowledged that she did not wash her hands between wounds, stated that doing so would take too long given the number of wounds, and admitted there was a risk of infection and cross contamination, while the DON confirmed that the observed practices did not follow the facility’s infection control expectations.

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 develop and maintain a timely, person-centered, comprehensive care plan and to ensure that it was reviewed and revised by an interdisciplinary team with resident and representative involvement. For Resident #1, a male with multiple complex diagnoses including metabolic encephalopathy, stroke, Type 2 diabetes, end-stage renal disease, cognitive communication deficit, dependence on renal care, and a left below-knee amputation, the care plan dated 1/1/26 addressed only wound care. The care plan documented pressure injuries to the right hip, right heel (stage 3), sacrum (stage 3), and an unstageable wound to the left BKA, but contained no additional information regarding other care needs. Despite the resident’s severe cognitive impairment (BIMS score of 6) and total or maximal dependence for most ADLs, the care plan was not expanded to address his broader clinical and behavioral needs. Record review showed extensive, ongoing refusals by the resident of medications, blood sugar checks, meals, ADLs, and wound care over a period of weeks, yet these refusals were not incorporated into the care plan. Progress notes documented repeated refusals of insulin, blood sugar checks, antibiotics, pain patches, and other medications on numerous dates, as well as refusals of meals and both meals and accuchecks during specific shifts. Wound care notes indicated that the resident sometimes allowed assessment but then refused completion of treatments, stating that wound care had already been done, and continued to refuse despite reorientation and education. Staff also documented that attempts to notify the family member (FM) were sometimes unsuccessful, and that the resident’s wounds showed decline, including increased redness and irritation in the gluteal folds, while refusals of wound care persisted. Interviews with staff revealed that the care plan was not updated to reflect the resident’s consistent refusals or his nutritional issues. The DON acknowledged that none of the refusals were documented in the care plan and attributed care plan updating primarily to the MDS nurse, who had resigned and taken time off during the resident’s admission. The WCN stated she was familiar with the resident’s multiple wounds and frequent refusals of care and that she contacted the FM to encourage cooperation. A CMA reported that the resident appeared very depressed, frequently said “not right now” to medications, and that she tried multiple strategies (pudding, soda, ice cream, soup) to facilitate medication administration, but he continued to refuse. The DSS stated she did not realize she was responsible for completing care plans and initially held care plan meetings without involving department heads. The DM reported she was not made aware of the resident’s meal refusals, and the RA stated the resident refused follow-up weekly weights after the admission weight. Facility policies required care plan meetings upon admission and after significant changes, and required care plan review and revision upon status changes, but these processes were not carried out for this resident’s ongoing refusals and nutritional concerns. The resident’s point-of-care documentation showed low meal intake and frequent non-occurrence of meals, yet this was not translated into care plan interventions. Nutrition task records indicated that on multiple days the resident consumed only 0–25% or 26–50% of meals, and on several days meal intake was marked as not occurring. The RA confirmed that after the initial admission weight of 185.5 lbs, the resident refused subsequent weekly weights, and no additional weights were documented. Despite these patterns, the dietician was not successfully contacted by surveyors, and the DM stated she had not been informed of the refusals. Staff interviews further showed that some CNAs and nurses were unaware of the full extent of the resident’s refusals, relying instead on verbal shift reports rather than an updated care plan. Overall, the facility did not revise the care plan to address the resident’s persistent refusals of medications, ADLs, meals, and wound care, and did not ensure interdisciplinary, resident, and representative participation in developing and updating a comprehensive, person-centered care plan as required by facility policy. The ADM and DON described that care plan completion was a shared responsibility between nurse management and the MDS nurse, with corporate support available in the MDS nurse’s absence, but this process did not result in an updated plan for this resident. The DSS acknowledged she had not been educated initially on completing care plans and did not involve department heads in early care plan meetings. The DON stated that care plans not being updated could affect how aides provided care, but indicated that staff relied on daily nurse communication instead. Facility policies on care plan revisions specified that upon identification of a change in status, the nurse should notify the MDS coordinator, physician, and resident representative, and that the IDT should collaborate on interventions and update the care plan accordingly. Despite clear documentation of significant changes and ongoing refusals in the record, these steps were not followed for Resident #1, resulting in a care plan that remained limited to wound care and did not reflect his current needs and behaviors.

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 Resident #10 had a properly completed advance directive for an Out of Hospital Do Not Resuscitate (OOH-DNR) order. Resident #10 was admitted with diagnoses including bipolar disorder, major depressive disorder, type 2 diabetes, and morbid obesity, and her admission record indicated that she requested DNR status. Her care plan also documented a code status of DNR and included interventions to inform the MD and staff, maintain a copy of the code status on the chart, and ensure the code status was signed and placed in the clinical record. Record review of the OOH-DNR form showed it was signed by the resident and by MD S, but it was not signed by two witnesses. The physician’s signature appeared under a statement indicating that all persons who signed above must sign below acknowledging the document had been properly completed, but that acknowledgment section was not completed by two witnesses. The Social Worker stated she ensures OOH-DNR documents are completed with the resident, physician, and either a notary or two witnesses, and the ADON acknowledged that Resident #10’s OOH-DNR form was incomplete. The facility policy stated that once a DNR is signed by the resident or legal representative, it needs to be witnessed by an individual who is not a staff member.

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 refer a resident with newly evident or possible serious mental disorder for a new PASRR Level I review after a significant change in status. Resident #3 had diagnoses and documented history that included bipolar disorder, schizoaffective disorder, paranoid schizophrenia, anxiety disorder, and other psychiatric concerns, along with records showing treatment with psychiatric medications and psychiatric assessments noting serious mental illness. Record review showed the resident’s admission PASRR Level I screening dated 5/13/24 indicated no evidence of mental illness. However, subsequent records documented multiple psychiatric diagnoses and histories, including bipolar disorder, schizophrenia, delusions, hallucinations, mood lability, suicidal ideation, and homicidal ideation. The resident’s care plan also identified PASRR positive status related to severe mental illness and included coordination with LMHA or MHMR, while later MDS assessments continued to list psychiatric diagnoses and antianxiety or antidepressant medications. Despite these findings, the facility did not complete a new PASRR Level I when the resident’s psychiatric condition changed. During interview, the MDS Coordinator stated the initial PASRR should have indicated mental illness and acknowledged that a new PASRR Level I had not been filed until the investigator requested the Level 2 documentation and the facility audited the record. The DON stated that if a resident was marked negative when they should have been positive, or if a new PASRR Level I was not completed after a new diagnosis, the resident could be without potential resources they could have had.

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 #10 that addressed her medical, nursing, mental, and psychosocial needs, including measurable objectives and time frames. Resident #10 was admitted with diagnoses including bipolar disorder, major depressive disorder, type 2 diabetes, and morbid obesity. A progress note dated 7/7/25 documented a diagnosis of depressive disorder, single episode, severe without psychotic features, and stated that she admitted to severe depression that had been present for several years, with symptoms described as constant and overwhelming. The resident’s care plan dated 9/15/25 addressed psychotropic medication use and included interventions to give medication as ordered and monitor for adverse reactions and depressive-driven behaviors such as spontaneous crying, sad mood, self-imposed isolation, and mood not easily altered. However, the record did not show a care plan specifically developed for her major depressive disorder symptoms. The admission MDS showed a BIMS of 15 and did not indicate that she felt down, depressed, or hopeless. A psychological services note dated 12/7/25 documented major depressive disorder, ongoing guilt, unresolved memories, and emotional functioning impacted by past pain and regret. During observation on 12/9/25, Resident #10 was tearful and crying, shared sad memories from her past, and said she had been feeling sad for a long time. The DON stated that symptoms of depression should be addressed in the care plan, and the MDS Coordinator stated that tearfulness or sadness should be care planned, but also said the psychotropic medication care plan should be sufficient for depressive symptoms.

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 enteral feedings were administered as ordered for two residents who were dependent on tube feeding for nutrition and hydration. Resident #9 was readmitted with diagnoses including dementia, muscle wasting and atrophy, hypothyroidism, and severe protein-calorie malnutrition, and her care plan identified her as at risk for unplanned weight loss, dehydration, and nutritional complications. Her physician order required Jevity 1.5 at 50 mL/hour via g-tube continuously for 22 hours, but on observation the feeding was running at 44 to 45 mL/hour instead of the ordered rate. On one occasion, the pump was found inactive and beeping, with the formula bottle showing it had been hung the prior evening and still containing approximately 775 mL the next morning. Staff interviews showed the feeding pump had been paused during care and was not restarted promptly, and one LVN acknowledged she had set the pump at 45 mL/hour instead of the ordered 50 mL/hour because she was using the previous order. The LVN stated CNAs could pause the pump and nurses were supposed to restart it, but she had not been notified that morning that the pump was idle. The DON later stated that if the pump remained paused too long it would alarm, and when informed of the observation she acknowledged those were calories the resident was not receiving. Resident #3 was admitted with tracheostomy status, quadriplegia, dysphagia, gastrostomy status, muscle wasting and atrophy, and multiple pressure ulcers including stage 4 and stage 3 wounds. His care plan identified him as at risk for aspiration, unplanned weight loss, dehydration, and nutritional complications, and his physician ordered Jevity 1.5 at 70 mL/hour with 60 mL/hour free water flush via G-tube continuously for 22 hours. Although the MAR/TAR showed nurse initials documenting the feeding as given, surveyors observed the pump beeping and not running, with a 1500 mL bottle hung at 4:00 a.m. and only about 200 mL missing by 11:40 a.m., which was less than expected for the ordered rate.

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 medication error rate remained below 5 percent. Surveyors found a medication error rate of 16 percent, based on 4 errors out of 25 opportunities, involving 1 of 8 residents reviewed for medication errors. The errors were identified during observation and record review for a resident with a feeding tube and severely impaired cognitive skills for daily decision making. Resident #71 had diagnoses including mood disorder with manic features, adjustment disorder with mixed anxiety and depressed mood, gastro-esophageal reflux disease, vitamin deficiency, and hypokalemia. Her orders included Escitalopram 10 mg via g-tube daily, Lansoprazole DR ODT 30 mg via g-tube daily, a multivitamin via g-tube daily, and Potassium chloride CRys ER 20 mEq via g-tube daily. During observation, LVN W prepared Escitalopram 5 mg instead of the ordered 10 mg, prepared Multivitamin with minerals instead of the ordered multivitamin without minerals, and prepared Lansoprazole DR ODT and Potassium micro 20 mEq ER for g-tube administration. The pharmacy label for Lansoprazole instructed that it be dissolved in apple juice if given via g-tube, and the label for Potassium ER instructed not to crush and to dissolve in water for g-tube administration. LVN W crushed both medications, placed them in separate cups, dissolved them in water, and administered them via g-tube. In interview, she stated she gave one 5 mg Escitalopram tablet instead of two, gave the wrong multivitamin product, and crushed medications that should not have been crushed. The DON stated staff should check the rights of medication administration and pharmacy labels, and the facility policy required staff to follow pharmacy and manufacturer specifications and not crush enteric-coated or sustained/extended-release 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 establish and maintain an infection prevention and control program for Resident #5, who had a tracheostomy, chronic respiratory failure, diabetes, a stage 3 pressure ulcer, and was dependent for toileting, bathing, lower body dressing, and incontinence care. The resident’s record showed she was on Enhanced Barrier Precautions (EBP) because of an indwelling medical device, and the care plan and physician orders required gown and gloves during high-contact care activities, including changing briefs, providing hygiene, device care, and wound care. During an observation, CNA D provided incontinence care to the resident while wearing gloves but no gown, despite the resident being on EBP. The resident’s dirty brief was observed on the floor next to the bed rather than in the trash can. In interview, CNA D stated she was unaware EBP applied to residents with trachs and acknowledged that without a gown she could get germs on herself and give them to others. She also stated the brief on the floor could cause contamination. The DON stated that EBP was required for residents with open wounds, lines, and trachs, and that gown and gloves were required for patient care such as wound care, incontinent care, and medication administration. The DON also stated that not following EBP could cause cross contamination and that a dirty brief on the floor caused contamination and could be spread around. The facility policy stated that EBP requires gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices, including tracheostomies.

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 storage, preparation, and service in the kitchen. Specifically, staff did not obtain or document food temperatures for the lunch meal prior to serving, as required by facility policy. The staff member responsible for preparing the meal admitted to not taking the temperatures due to being distracted by the workload, despite having been trained on the procedure. The facility's policy mandates that food temperatures be checked and recorded before each meal to ensure food safety. Additionally, during an observation of the walk-in refrigerator, a storage bag of peaches and a container of cooked rice were found without labels or use-by dates. The Dietary Manager confirmed that food should be labeled immediately and that she typically checks for proper labeling during her rounds. The Administrator also stated that all opened food items should be properly stored, dated, and labeled before being put away. Facility policies require that repackaged or opened foods be labeled with the common name and date, and that refrigerated, ready-to-eat foods be covered, labeled, and dated with a use-by date.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident receiving respiratory support had a physician order for oxygen therapy. Resident #1 was admitted with diagnoses including acute and chronic respiratory failure, cerebral infarction, aphasia, type 2 diabetes mellitus, pneumonitis due to inhalation of food and vomit, and a stage 3 sacral pressure ulcer. The resident’s face sheet showed oxygen in use, the admission MDS indicated a BIMS score of 0 with total dependence for self-care and mobility, and the MDS also documented that the resident was on oxygen. Record review showed multiple references that the resident was receiving oxygen via nasal cannula at 2 liters per minute. The baseline and comprehensive care plans both identified oxygen use as a focus and included interventions such as following physician orders for oxygen therapy delivery and monitoring oxygen saturation. Hospital records, admission/readmission documentation, progress notes, and physician notes all reflected that the resident continued to require oxygen via nasal cannula and nebulizer treatments, and observations on 9/23/25 showed the resident lying in bed with oxygen at 2L via NC in place. Despite these records showing ongoing oxygen use, the physician orders reviewed for the period from 9/5/25 through 9/23/25 contained no order for oxygen. During interview, an LVN stated that residents on oxygen should have an order in the chart, and the Interim DON stated the policy required an order for oxygen and that staff should have called the MD to obtain one if it was missing. The facility policy on physician orders required all orders to be accurate, timely, and documented in the medical record, and the oxygen therapy policy stated that oxygen therapy should be started at the prescribed liter flow and documented in the medical 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

Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's well-being.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that staff did not consistently follow prescribed care plans or honor the expressed wishes and goals of the resident. The lack of adherence to orders and resident preferences resulted in care that was not aligned with the individualized needs of the resident.

Penalty

No penalty information released

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

Summary

A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulatory standards. For the first resident, who had multiple complex diagnoses including respiratory failure, cerebral infarction, sepsis, metabolic encephalopathy, diabetes, hypertension, narcolepsy, congestive heart failure, and a right above-the-knee amputation, the care plan did not address all areas triggered by the comprehensive assessment. Specifically, the care plan omitted interventions for cognition, activities, communication, and returning to the community, despite these needs being identified in the resident's assessment. Similarly, the second resident, who had a history of anemia, neurogenic bladder, aphasia, Parkinson's disease, dehydration, hypokalemia, malnutrition, dysphagia, fracture, urinary tract infection, cognitive deficit, lack of coordination, muscle weakness, schizophrenia, and falls, also had an incomplete care plan. The care plan failed to address cognition, activities, and nutrition, even though these areas were triggered in the assessment. The Director of Nursing confirmed that the facility did not have an MDS Coordinator at the time, and that not all triggered areas were being captured in the care plans.

Penalty

Inspection fine: $27,358

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 pest control program, resulting in the presence of live gnats in one of six hallways (Hall 200) and in a resident's room. Observations on the specified date revealed approximately 12 gnats in Hall 200 and about 10 gnats flying in the resident's room. The resident, a cognitively intact female with multiple diagnoses including Bipolar disorder, acute respiratory failure, type 2 diabetes, and cognitive communication deficit, reported that the issue with gnats had been ongoing and that pest control had never treated her room. No food was observed in the resident's room at the time of inspection. Interviews with facility staff indicated that pest control services were provided bi-weekly or weekly, depending on the situation, and that the most recent treatment occurred the previous week. However, the pest control service reports showed that while the facility was treated for gnats in some areas on one occasion, the resident's room was not specifically treated, and a previous treatment did not include gnats. The facility's pest control policy requires an effective program to prevent or eliminate infestations, but the ongoing presence of gnats in multiple areas, including a resident's room, demonstrated a failure to fully implement this policy.

Penalty

No penalty information released

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

Summary

The facility failed to revise and update the comprehensive care plans for two residents following significant changes in their medical conditions. For one resident, who had a complex medical history including respiratory failure, COPD, neuromuscular bladder dysfunction, and dependence on a ventilator, the care plan did not reflect the presence of a suprapubic catheter after a physician order was made for a urethral indwelling catheter. Despite documentation in progress notes and direct observation confirming the presence of a suprapubic catheter, the care plan continued to address only urinary incontinence and not the catheter. For another resident, who was dependent on staff for all activities of daily living and had severe contractures due to multiple diagnoses such as anoxic brain injury, sepsis, and persistent vegetative state, the care plan did not include interventions for contractures. Medical records and staff interviews confirmed the presence and severity of the contractures, but the care plan was not updated to address this condition until it was identified during the survey process. The facility's policy required care plans to be reviewed and revised upon any change in resident status, with the MDS Coordinator and interdisciplinary team responsible for updating interventions. However, in both cases, the care plans were not revised in a timely manner to reflect the residents' current needs, as evidenced by the lack of documentation and care plan updates for the suprapubic catheter and contractures.

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 practices during tracheostomy care for a resident. During an observation, a respiratory therapist (RT) was seen providing tracheostomy care to a female resident with multiple diagnoses, including acute respiratory failure, ventilator dependence, hypertension, diabetes, COPD, and tracheostomy status. The RT donned a mask, gown, and two pairs of gloves before beginning care. After suctioning the resident, the RT removed the outer gloves and then proceeded to open a tracheostomy care kit and put on sterile gloves over the initial pair of gloves, without performing hand hygiene between glove changes. The RT was interviewed and stated that she did not sanitize her hands between glove changes because she had sanitized them before leaving the nurses station and believed that wearing two pairs of gloves at all times was sufficient. She indicated that her practice was to maintain a clean pair of gloves throughout the procedure, which she believed negated the need for additional hand hygiene during the process. The Director of Nursing (DON) confirmed during an interview that staff are expected to wash or sanitize their hands between glove changes, especially during tracheostomy care, and that the facility's policy requires hand hygiene before donning sterile gloves and after removing gloves. The DON was unsure why the RT used multiple pairs of gloves and acknowledged that failure to perform hand hygiene as required could result in infection. Review of the facility's tracheostomy care policy further supported the need for hand hygiene at specific points during the procedure.

Penalty

Inspection fine: $14,433

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

Summary

The facility failed to provide basic life support, including CPR, to a resident in need of emergency care before the arrival of emergency medical personnel. The deficiency involved a resident who was found unresponsive in her wheelchair. RN A, upon being notified by CNA B, checked the resident's pulse, found none, and left the room to retrieve the crash cart without calling a code blue or instructing CNA B to do so. This resulted in a delay in initiating CPR. When RN A returned with the crash cart, he attempted to use the AED but could not locate the pads, further delaying the emergency response. During the CPR attempt, RN A performed chest compressions with improper technique, and LVN A failed to ensure a proper seal with the bag valve mask, compromising the effectiveness of the resuscitation efforts. The crash cart was not adequately prepared, as the AED pads were not readily accessible, contributing to the delay in providing life-saving measures. The EMS report indicated that the CPR provided was of low quality, with inadequate chest compression rate and depth, which did not meet the American Heart Association's standards for high-quality CPR. The resident involved was a female with multiple diagnoses, including respiratory failure, Crohn's disease, and severe cognitive impairment, and was dependent on assistance for activities of daily living. She was confirmed to be full code, meaning resuscitation efforts should have been initiated immediately upon finding her unresponsive. The facility's failure to promptly and effectively respond to the resident's unresponsive state placed her at risk of harm, as evidenced by the delay in CPR initiation and improper CPR technique.

Removal Plan

• The Administrator and DON notified the Medical Director of the IJ and held an ADHOC QAPI meeting to review the IJ template and POR.
• The Director of Nursing conducted a 1:1 education with RN A on CPR Policies and Procedures.
• The DON initiated education with Nurses and Respiratory Therapist on CPR Policies and Procedures.
• All Nurses and Respiratory Therapists will not be allowed to work their assigned shift until training is completed.
• Education will be provided in orientation for new hires.
• The DON initiated education with CNAs on their role in a code blue situation.
• CNAs will not be allowed to work their assigned shift until training is completed.
• The Regional RT and Clinical Team conducted a Mock Code with return demonstration with all staff on site.
• The Regional RT and Clinical Team will conduct routine Mock Codes to ensure education compliance.
• The facility will maintain compliance with professional standards by treating residents who are Full Code and unresponsive by following specific procedures.
• The facility inspects and replenishes crash cart daily and after code events by DON/designee.
• The Administrator reviewed the facility policy and no changes were required.
• Monitoring of the plan of removal included education in-service attendance records and mock code demonstrations.
• Observation of the two facility crash carts revealed both were fully stocked and code blue ready.

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, specifically in the storage, preparation, distribution, and serving of food. During an observation of the facility's kitchen, it was noted that several food items were not discarded according to the facility's policy, which mandates that potentially hazardous leftover foods be discarded after 72 hours. Specifically, a plastic container of shredded Monterey cheese and a container of gravy, both dated 9/20/24, and a plastic bag of green salad dated 9/15/24, were found in the refrigerator past the allowable time frame. The Dietary Food Service Manager acknowledged that these items should have been used or discarded prior to their expiration dates and that it was her responsibility, or that of a designee, to check the refrigerator daily for expiring food items.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified for two staff members, the Activities Director and the Dietary Manager, who were reviewed for compliance with abuse and neglect policies. The facility's policy on Abuse, Neglect, and Exploitation (ANE) Prohibition, revised in April 2024, outlines seven key components, including screening and training. However, the facility did not ensure that employee misconduct registry (EMR) checks were completed at least once every 12 months for the Activities Director and the Dietary Manager, as required. The Activities Director's EMR was checked 22 months after the initial check, and the same delay occurred for the Dietary Manager. The Human Resources Director, who started in August 2023, stated that EMR checks were supposed to be completed annually and upon hire, but he was unsure of the exact timing when he started. He relied on a facility roster to determine when staff were due for checks but did not account for overdue checks. The HR Director admitted that if a background check was not completed, the facility would not know if an employee had any negative records, indicating a gap in the facility's compliance with its own policies and procedures.

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 establish and maintain an effective infection prevention and control program, as evidenced by the actions of RN C, CNA A, and CNA B. RN C was observed administering G-tube medications to a resident without wearing the required personal protective equipment (PPE), specifically a gown, despite the resident being on Enhanced Barrier Precautions (EBP). RN C admitted to being unsure about when to wear PPE, indicating a lack of clear communication and training regarding the facility's infection control protocols. Similarly, CNA A and CNA B were observed providing incontinence care to another resident without wearing gowns, even though the resident was also on EBP. The CNAs were confused about the meaning of the EBP sign and associated it with isolation precautions, demonstrating a misunderstanding of the facility's infection control measures. This confusion was compounded by the absence of PPE outside the resident's room, which the CNAs expected to see if the resident was on isolation. Interviews with the Infection Preventionist, the Director of Nursing (DON), and the Administrator revealed that the facility believed staff were adequately trained on infection control and EBP. However, the observations and staff interviews indicated otherwise, as staff were not clear on when to use PPE. The facility's policy on EBP required gown and glove use during high-contact resident care activities for residents with indwelling medical devices, but this policy was not effectively communicated or implemented among the staff.

Penalty

No penalty information released

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

Summary

The facility failed to properly dispose of garbage and refuse, as observed with one of the two dumpsters reviewed for food and nutrition services. During an observation, it was noted that the dumpster located behind the dietary department was 3/4 full of garbage and had its door open. This was contrary to the facility's policy, which requires that dumpster doors be kept closed when not in use to prevent vermin, pests, and insects from accessing the garbage and potentially entering the facility. The Food Service Manager confirmed that it was the responsibility of staff from dietary, nursing, and housekeeping to ensure the dumpster doors are kept closed when not in use. The facility's policy on waste disposal, dated June 2019, also reflected the requirement to cover waste containers and keep the dumpster closed at all times.

Penalty

No penalty information released

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

Summary

The facility failed to honor a resident's right to refuse care, specifically the changing of soiled linens, which led to a situation where the resident felt her dignity was compromised. The resident, who has a history of dementia and moderate cognitive impairment, expressed a desire not to have her sheets changed despite them being wet. The CNA involved proceeded with changing the linens against the resident's wishes, which resulted in the resident becoming upset and alleging that she was physically mishandled during the process. The resident, who was visibly upset and shaking, claimed that the CNA had thrown her into bed, causing her to hit her head on the wall. Although a subsequent medical evaluation revealed no acute injuries, the incident left the resident agitated and distressed. The resident's care plan included interventions for her cognitive impairments, such as providing necessary cues and stopping care if she became agitated, but these were not followed during the incident. Interviews with staff and the resident's family highlighted the resident's agitation and the failure to respect her refusal of care. The CNA admitted to continuing with the linen change despite the resident's protests and acknowledged that she should have sought assistance from a nurse to de-escalate the situation. The facility's policy on resident rights emphasizes the importance of respecting residents' dignity and their right to refuse care, which was not upheld in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely incontinence care to a resident who was unable to perform activities of daily living independently. The resident, a female with a history of muscle wasting, convulsions, heart failure, type 2 diabetes, muscle weakness, and cerebral infarction, was frequently incontinent of bowel and bladder and required substantial assistance with all ADLs. Despite having a care plan in place to address her incontinence and prevent skin breakdown, the resident was not changed regularly, leading to skin irritation and moisture-associated skin damage. Observations and interviews revealed that the resident was left in a soiled brief for extended periods, sometimes from 5:00 am until the next morning. The Shower Tech and CNAs confirmed that the resident was not changed regularly, with some staff members neglecting to perform necessary care. The resident's brief was often found completely saturated, contributing to the worsening of her skin condition. The facility's policy required residents to be checked and changed every two hours, but this was not consistently followed. Interviews with staff, including the Unit Manager and DON, indicated that the expectation was for residents to be checked and changed every two hours and as needed. However, the staff did not adhere to this schedule, resulting in the resident's prolonged exposure to moisture and subsequent skin issues. The facility's failure to provide adequate incontinence care placed the resident at risk for further skin breakdown and infection.

Penalty

No penalty information released

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

Summary

The facility failed to maintain the dignity and quality of life for a resident by not changing the soiled linens on his bed during the 6am-2pm shift. The resident, who has multiple medical conditions including Parkinson's disease and is moderately cognitively impaired, was observed with wet and stained sheets that had not been changed since he got out of bed at 9:30 am. The resident mentioned that he had wet himself during the night and was unsure if the staff were aware of the condition of his linens. Despite being in his wheelchair since breakfast, the linens remained unchanged until later in the afternoon. Interviews with the CNA responsible for the resident's care revealed that she was unaware of the resident being out of bed and did not notice the soiled linens. The CNA admitted that linens should be changed as needed, especially if they are dirty or soiled, and acknowledged the risk of skin tears from not changing them. The Director of Nursing confirmed that the oversight occurred because the med aide, who assisted the resident with his shower, did not change the linens, and the CNA did not follow up. The facility's policy emphasizes maintaining a clean and respectful environment, which was not upheld in this instance.