Park Place Care 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 that residents who were unable to complete activities of daily living received the necessary services to maintain good grooming and personal hygiene, specifically fingernail care, for five residents reviewed. Resident #1 had diagnoses including metabolic encephalopathy, vascular dementia, diabetes, stroke, hemiplegia, and need for assistance with personal care, and her BIMS score was 6. Her care plan directed staff to check nail length, trim, and clean her nails on bath days or as needed, but during observation her fingernails were about 3-4 mm past the fingertip and she stated she did not like them that long. CNA A later observed that her nails needed to be cleaned and definitely trimmed. Resident #34 had diagnoses including cerebral infarction, Parkinson's disease, malnutrition, contracture in the right hand, aphasia, and need for assistance with personal care, with a BIMS score of 00. Her care plan identified an ADL self-care deficit and need for assistance with bathing. During observation, both hands were contracted and her fingernails were about 3 mm past the fingertip. Later, LVN B observed that her nails were a little long and needed to be cleaned, and noted dark unidentifiable substance under the right hand fingernails. LVN B also stated that with the contracture, the resident could scratch herself and it could get infected. Resident #42 had diagnoses including cognitive communication deficit, muscle weakness, diabetes, chronic diastolic heart failure, lack of coordination, and major depression, with a BIMS score of 4. His care plan required assistance and supervision with hygiene and grooming, and the ADL personal hygiene record showed daily assistance but no fingernail trimming documentation from 02/04/2026 through 03/05/2026. The resident stated staff had not come around to trim or offer to trim his fingernails, and observation showed fingernails approximately one inch long on both hands on two separate days. Resident #51, who had Parkinson's disease, weakness, and need for assistance with personal care, had a BIMS score of 15 and care plan for ADL assistance, but his fingernails were observed about 3 mm past the fingertip and he stated staff had offered to trim his toenails, but not his fingernails. Resident #72, who had diagnoses including stroke, diabetes, vascular dementia, hemiplegia, schizophrenia, and need for assistance with personal care, had a BIMS score of 14 and a care plan directing staff to check nail length and trim on bath days and as necessary; his fingernails were observed about 4 mm past the fingertip with dark unidentifiable substance underneath, and he stated it had been a couple of weeks since his nails were cut.

Penalty

No penalty information released

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

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one kitchen reviewed for sanitation. During observations of the walk-in refrigerator, surveyors found multiple opened food items that were not properly dated or labeled, including an opened bottle of Italian dressing, an opened container of mayonnaise, an opened container of mustard, and a clear bottle containing an unidentifiable orange substance that the DM identified as thousand island dressing. A steam pan containing a white, creamy, unidentifiable substance was dated but not labeled, and the DM stated it was cream of mushroom soup and did not need to be labeled. Five bags and pans of individually stored meat and egg products were sitting on one large steam pan, but only one item was labeled for the entire tray. A container of strawberry glaze had round black spots on the lid, which the MD later identified as mildew from condensation and humidity in the walk-in refrigerator. In the dry storage room, a bag of pecans dated 11/21/2025 was open to air and was in a resealable bag that was not sealed. In the kitchen, the fryer was uncovered when not in use and had crumbs on top and a brown stain. A small metal pan above the range top was covered with a black substance that was flaking off, and the back of the stove/oven had several white unidentifiable streaks that were raised and dry. The trash can next to the three-compartment sink was overflowing and uncovered while not in use, and staff were near the service line serving lunch. During interviews, the DM stated that opened items should be dated, but also said some items did not need an open date if they had an expiration date or were on one tray together. The DM said the black substance on the pan was wear and tear and that the fryer had been used for dinner on 3/02/2026 and 3/03/2026, even though the cycle menu for 3/03/2026 lunch did not include fried items. The ADM stated that food should be dated and labeled and that items should be sealed, but when asked if the fryer should be covered when not in use, he said he would get back to the surveyor. The report stated these failures could place residents at risk for foodborne illness.

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 each resident had the right to secure and confidential personal and clinical records for 1 of 20 residents reviewed, Resident #92. During observation on 03/03/2026 at 9:22 a.m., the 400-hall charting computer at the nursing station was left unlocked with Resident #92's personal medical information displayed on the screen and visible to unauthorized individuals. The nurse assigned to 400 Hall, LVN D, was not present at the nursing station at the time, and she returned about 5 minutes later to turn the computer screen off. During interview, LVN D stated she had received HIPAA in-service a few months earlier and knew she was supposed to lock the computer screen when stepping away from the nursing station. She stated that everyone who worked with charting computers was responsible for closing and locking them when not in attendance, and that leaving Resident #92's clinical information displayed could be harmful because anybody could see it. The DON stated the facility's policy was to minimize charting computer screens when stepping away and that staff were responsible for locking screens to prevent unauthorized access to private clinical information. The ADM stated that whoever used the computer was responsible for shutting it down so residents' information was not visible. Record review showed the facility had a Confidentiality policy and a Resident Rights policy stating residents have a right to privacy and confidentiality of personal and medical records, but no policy regarding closing computer screens was available.

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 a system of accurate reconciliation and to ensure that controlled drug records were in order for one medication cart, affecting Resident #50. During observation of the 400-hall medication cart, the controlled medication reconciliation showed Lorazepam 0.5 mg for Resident #50, and the controlled medication log reflected 117 tablets when the count should have been 120 tablets. The discrepancy involved three tablets of Lorazepam 0.5 mg. Resident #50 was a 77-year-old female with diagnoses including cerebral infarction, anemia, and Alzheimer’s disease with late onset. Her quarterly MDS assessment showed a BIMS score of 11, indicating moderate cognitive impairment, and the assessment also noted mood symptoms such as feeling down, depressed, or hopeless. Her care plan identified behavior problems related to yelling, screaming, and hitting, with interventions to administer anti-anxiety medications as ordered and monitor for side effects and effectiveness. Record review showed an active order for Lorazepam oral tablet 0.5 mg, three tablets by mouth three times a day for generalized anxiety disorder. The MAR showed Lorazepam 1.5 mg was administered at 7:00 a.m. by CMA C, but during interview CMA C stated she gave the medication and did not sign for it in the controlled medication log. She said she was supposed to sign it right away, got busy, and forgot. The DON stated that charge nurses and CMAs were responsible for monitoring accurate controlled medication counts and signing controlled medications as soon as they were administered, and the ADM stated that if controlled medications were not monitored and properly counted it could potentially harm residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide food in a form designed to meet individual needs for 2 residents who were ordered mechanically altered diets with ground meat. Resident #72 was admitted with diagnoses including cognitive communication deficit, weakness, dysphagia, and need for assistance with personal care. His care plan directed staff to serve his mechanically altered diet as ordered, and his diet order specified mechanical soft texture. Resident #11 was admitted with diagnoses including dysphagia, muscle weakness, need for assistance with personal care, and GERD. Her care plan directed staff to offer her diet as ordered by the physician, and her diet order required mechanically ground meat. During lunch observation, the DM placed ribs in a blender and pulsed them, then placed the food on the service line. The pulsed ribs appeared stringy and were not ground. Resident #11 was observed eating in the dining room and stated the meat would be better if she could eat it, that it would not go down, and that it looked like it had been pulled apart rather than mechanically chopped. Her meal ticket listed ground meat in two places. Resident #72 was also observed eating, and his meal ticket reflected that his meat needed to be ground, but the meat was observed to be shredded. LVN I stated she checked trays for texture and said Resident #11's meat did not look ground like hamburger meat and Resident #72's plate did not look ground. The DOR stated that Resident #72 required ground meat and that Resident #11 required mechanical soft meat, which should be like hamburger meat. The DOR also stated that if residents were served food that was not the correct texture, they could have aspiration. The DM stated mechanical soft was a ground beef texture for meats and that if food was not the correct texture, it could be a choking hazard. The DON stated the incorrect texture may have been an oversight, and the ADM stated the kitchen used a machine to mince and chop meat and that trays went through several check points. The facility policy stated mechanical soft diets are individualized and that regular with mechanical ground meat diets consist of minced and moist meat and flaked fish served in sauce or gravy.

Penalty

Inspection fine: $80,135

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

Summary

The deficiency involves the facility’s failure to immediately consult the resident’s physician and notify the DON and responsible party when a resident experienced a fall and subsequent significant changes in mental and psychosocial status. The resident was an older man with a history of right femur fracture, hemiplegia/hemiparesis following a stroke, type 2 diabetes, aphasia, dysphagia, gait abnormalities, and unsteadiness on his feet. His care plan identified him as at risk for falls and requiring assistance with ADLs and transfers, and his MDS assessments showed moderate to severe cognitive impairment. Despite these identified risks and functional limitations, there was no documentation of neurological checks or incident documentation for a fall that occurred on 12/07/2025, and no immediate notification to the physician, NP, DON, or family. On the night of the initial fall, a CNA found the resident on the floor by his bed after he apparently attempted to transfer to his wheelchair. The CNA reported that the resident complained of pain and pointed to his chest, and LVN A assessed him, took vital signs, administered PRN tramadol, and assisted him back to bed. However, LVN A did not notify the NP, MD, DON, or family, did not initiate neurological checks for this unwitnessed fall, and did not complete timely documentation of the incident. A late entry note was not entered until 12/17/2025, and there were no updated fall interventions documented between 12/07/2025 and 12/13/2025. Staff interviews confirmed that facility protocol required immediate assessment, notification of provider, DON, responsible party, completion of an incident report, and initiation of neurological checks for unwitnessed falls, but these steps were not followed for this event. In the days following the unreported fall, multiple staff observed changes in the resident’s behavior and function. The NP noted on 12/12/2025 that the resident had been more withdrawn over the past week, that he reported a fall approximately four days earlier that had not been reported, and that he had pain and bruising of the right arm with difficulty moving it. Radiology studies were ordered and completed on several areas of the right extremity, showing soft tissue swelling but no acute fracture. Staff, including CNAs and LVNs, reported that before the fall the resident was more independent with transfers, ambulation, and toileting, and that after the fall he required more assistance and became incontinent. Another unwitnessed fall occurred on 12/13/2025, for which the NP and responsible party were notified and neurological checks were initiated, but the interventions documented were limited to encouraging the resident to use the call light and obtaining a therapy evaluation several days later. Ultimately, further imaging on 12/17/2025 revealed a right shoulder dislocation and a nondisplaced fracture of the greater trochanter of the right proximal femur, and the resident underwent surgical repair of the hip. The surveyors determined that the facility failed to immediately consult the physician and appropriately respond to the initial fall and subsequent behavioral changes, leading to an Immediate Jeopardy finding related to notification of changes in condition.

Removal Plan

• Conduct in-service training for all licensed nursing staff (including PRN, agency, and new staff) on the facility's Notification of Physician Change in Condition policy, emphasizing mandatory immediate reporting of any resident falls or significant changes in condition to the physician and DON, including documentation requirements and timelines.
• Provide in-service training for the DON and Administrator on the Risk Management protocol by the Area Director of Operations and Regional Compliance Nurse.
• Implement a revised notification protocol requiring the nurse discovering or responding to a fall to conduct an immediate assessment of the resident and notify the DON and treating physician/NP.

Penalty

Inspection fine: $80,135

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 maintain an environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents for a cognitively impaired male resident with significant mobility and neurologic deficits. The resident had a history of right-sided hemiplegia/hemiparesis following a stroke, aphasia, muscle weakness, gait and mobility abnormalities, dysphagia, unsteadiness on his feet, and used a wheelchair. His care plan identified him as at risk for falls, with interventions such as keeping the call light within reach, educating him about safety reminders, and re-educating him to lock wheelchair brakes prior to transfers. Assessments showed he required varying levels of assistance for transfers and mobility and had moderate to severe cognitive impairment, yet he was often treated as mostly independent in transfers and ambulation. On or about early December, the resident experienced an unwitnessed fall near his bed at night. A CNA found him on the floor by the bed, with his feet under the bed, apparently having fallen while trying to transfer to his wheelchair. The CNA notified the LVN, who assessed the resident, took vital signs, administered PRN tramadol for reported pain, and assisted him back to bed. However, the LVN did not notify the NP, MD, DON, responsible party, or administration, did not initiate neurological checks despite the fall being unwitnessed, and did not complete an incident report or timely documentation of the fall. A late entry note documenting the fall was not entered until 12/17, and there was no evidence of post-fall monitoring, neurological assessments, or new fall-prevention interventions being implemented after this initial fall. Staff later reported that the resident became more withdrawn, stopped going to the dining room, and changed his usual routine, but these changes were not documented or communicated as potential signs of injury or change in condition. Subsequently, the resident sustained another unwitnessed fall near the bathroom when he missed sitting on his wheelchair after using the bathroom. This second fall was reported to the NP and responsible party, and neurological checks were initiated, but the only documented intervention was to encourage the resident to use the call light or ask for assistance—an intervention that was already in place prior to the fall. A therapy evaluation was not ordered until several days after the second fall, and there was no evidence of immediate, enhanced fall-prevention measures or increased monitoring following either fall. Radiology studies ordered after the delayed recognition of bruising and pain revealed multiple areas of soft tissue swelling and ultimately a nondisplaced fracture of the greater trochanter of the right proximal femur, requiring surgical repair. Interviews with multiple staff, including CNAs, LVNs, the RN, DON, ADM, DOR, and NP, confirmed that facility policy required immediate assessment, neurological checks for unwitnessed falls, timely incident reporting, and prompt notification of providers, DON, and family after any fall, as well as 72-hour monitoring and review for new interventions. These required actions were not carried out after the first fall, and new or enhanced interventions were not promptly implemented after either fall, leading to the identified deficiency. The facility’s own staff acknowledged that the resident’s functional status declined after the first fall, with increased need for assistance and incontinence, yet this change was not linked to a documented fall event or followed by appropriate reassessment and care plan revision. The DON and ADM both stated that they were not informed of the initial fall until days later and that interventions were not added until after the delay. The NP reported that she discovered bruising and swelling on the resident’s arm and noted his withdrawal and pain before any fall had been reported to her, and she ordered x-rays based on her findings rather than on timely fall notification. Review of facility policies and staff interviews showed that the expected fall protocol—immediate assessment, neurological checks for unwitnessed falls, incident reporting, timely notification, and prompt implementation of individualized interventions—was not followed for this resident, resulting in delayed identification and treatment of injuries and failure to implement timely, effective fall-prevention measures after repeated falls.

Removal Plan

• Effective immediately, all licensed nursing staff including PRN, Agency and New Staff will be in-serviced by the Director of Nursing (DON) and Administrator (ADM) on the facility's Fall Prevention Policy, emphasizing mandatory post-fall assessments including neurological checks, vital signs monitoring, and timely notification of providers and administration for every fall.
• Orientation for all new hires will include Fall Prevention Policy training before assuming duties.
• Facility Administrator and DON will be in-serviced on the Risk Management protocol by the Area Director of Operations and Regional Compliance Nurse.
• The facility will implement a fall follow-up protocol requiring the nurse assigned at the time of the fall to complete a detailed incident report immediately and document all neurological and vital signs assessments in the resident's medical record within the same shift.
• The DON or designee will ensure consistent compliance with the fall follow-up protocol.
• The interdisciplinary team including the DON, Medical Director, and Therapy Director will review and update Resident #1's care plan to incorporate individualized fall prevention interventions tailored to his multiple fall risks and clinical status, including frequent monitoring, assistance with transfers, and immediate post-fall interventions.

Penalty

Inspection fine: $12,618

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

Summary

A deficiency occurred when a resident with severe cognitive impairment and multiple neurological diagnoses exited the facility unsupervised. The resident was able to leave through a door at the end of a hallway, descend eight steps, cross a parking lot and two traffic lanes, and reach the center median of a road with a 40 MPH speed limit. At the time of the incident, the resident's care plan did not include interventions for elopement risk, and her most recent elopement assessment indicated she was not at risk for elopement. Staff statements and documentation confirmed that the resident was not being directly supervised when she left the building, and the door alarm system was not functioning reliably, as it would automatically shut off after 15 seconds and was not always audible to staff in nearby offices. Interviews with staff revealed that prior to the incident, the facility's elopement prevention measures were insufficient. Staff were not alerted to the resident's exit until a passerby notified them after seeing the resident in the road median. The alarm system on the exit doors was described as inconsistent, with alarms sometimes failing to sound or being inaudible. Staff also reported that the resident was not previously identified as high risk for elopement, and her care plan did not reflect any elopement interventions. The lack of supervision and inadequate alarm system allowed the resident to leave the premises unnoticed. Documentation showed that the resident was able to walk with supervision or touching assistance and had a history of cognitive impairment, including a BIMS score indicating severe impairment. Despite these risk factors, the facility did not have appropriate elopement precautions in place for her. The incident was identified as Immediate Jeopardy, as the resident was exposed to significant danger by being unsupervised outside the facility and in proximity to a busy road.

Penalty

Inspection fine: $12,618

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 security and proper handling of controlled medications awaiting destruction, resulting in the misappropriation of an unknown quantity of these medications and the associated Drug Destruction Log. The controlled medications, which included narcotics, were stored in a locked cabinet within the DON/ADON shared office. The keys to this cabinet were inconsistently managed, with the DON initially responsible but later transferring the responsibility to the ADON, who kept the keys on her person. The office itself was secured with a keypad lock, but the code was accessible to multiple staff members. At some point between 09/22/25 and 09/26/25, the ADON placed discontinued narcotics in the cabinet and organized the medication cards, but could not specify the exact number of medications present, as this information was only recorded on the missing log. On 09/30/25, when a nurse attempted to add more narcotics to the discontinued medication cabinet, it was discovered that all but one card and a few bottles of liquid medication were missing, along with the Drug Destruction Log. The facility's process required that discontinued controlled medications be counted and signed by two nurses, with the medication and log then locked in the cabinet. However, the lack of a consistent and secure key management system, as well as unclear responsibility for the storage and documentation, contributed to the loss. The DON, who had only recently started working at the facility, was unfamiliar with the facility's medication disposal policy and relied on the ADON for guidance, further compounding the lack of oversight. Interviews with staff revealed that the expectation was for controlled medications awaiting destruction to be double-locked and accessible only to authorized personnel. However, the actual practice deviated from policy, with keys being shared and stored in unsecured locations, and the office code being known to several individuals. The missing medications and log could not be accounted for, as the control drug count sheets were also missing, making it impossible to determine the exact quantity of medications lost. The facility's policies required strict adherence to federal and state regulations regarding controlled medication handling, but these procedures were not followed, resulting in the misappropriation.

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 regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents 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 effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility records and interviews, which revealed gaps in staff training and oversight, as well as a lack of clear reporting mechanisms for suspected incidents. The absence of these preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.

Penalty

No penalty information released

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

Summary

The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated and reported within the required timeframe. Specifically, when a resident reported that her roommate hit her and twisted her arm, the incident was not fully investigated and the Provider Investigation Report (PIR) was not submitted to the State Survey Agency within the mandated five working days. The PIR, which was due within five days of the incident, was instead submitted nearly three weeks later. The residents involved included one with moderately impaired cognition due to dementia and another with severely impaired cognition and a history of agitation. The initial allegation was documented by an LVN, who assessed the resident and notified the DON, administrator, responsible party, and nurse practitioner. The resident's arm was examined, and an X-ray was ordered, but there was no evidence of injury. The roommate denied the allegation. Despite these actions, the required comprehensive investigation and timely reporting were not completed as per facility policy and state regulations. Interviews with facility staff revealed confusion regarding the roles and responsibilities for investigating and reporting the incident. The DON and administrator both acknowledged delays and gaps in the investigation process, including late completion of safe surveys and failure to locate or submit the PIR on time. Review of facility policy confirmed the requirement for thorough investigation and reporting of all allegations within five working days, which was not met in this case.

Penalty

Inspection fine: $19,630

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 housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on one of its halls. Observations revealed a black circular substance, identified as mold, under the wallpaper in the rooms of three residents. The housekeeper reported that mold had been present in the housekeeping storage room for three to four months and had informed the maintenance director, but no action had been taken. The maintenance director confirmed the presence of mold behind the wallpaper in the residents' rooms and stated that he had notified the administrator, but had not received a response. The director of nursing and the administrator both stated they had not been informed about the mold, and neither had taken steps to address the issue prior to the survey. The residents affected included individuals with significant medical histories, such as dementia, hypertension, diabetes, kidney disease, Alzheimer's disease, heart failure, and metabolic encephalopathy. Some residents were unable to communicate effectively due to cognitive impairment or other conditions. The facility's own policy requires the provision of housekeeping and maintenance services to ensure a safe, clean, and comfortable environment, but this was not upheld, resulting in residents being exposed to an unclean and potentially hazardous environment.

Penalty

Inspection fine: $19,630

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

Summary

The facility failed to thoroughly investigate and report two separate incidents involving allegations of neglect and injury of unknown origin for two residents. For one resident with severe cognitive impairment and multiple diagnoses including dementia, Alzheimer's disease, and a history of falls, an incident involving injury of unknown origin was reported. However, the investigation lacked documented interviews with the RN and MA who were present at the time of the incident, and the findings were not submitted to the state agency within five working days. Similarly, for another resident with intact cognition and multiple chronic conditions, an allegation of neglect was reported, but there were no documented interviews with the CNAs involved, and the findings were also not submitted within the required timeframe. Record reviews revealed that the facility's investigation reports and self-reporting checklists indicated interviews were either not completed or not documented, despite being checked off as done. The administrator stated that interviews had been conducted and were either in the binder or her office, but only one staff interview was found, and the remaining interviews were not provided to the surveyor upon request. The facility's policy requires a thorough investigation and timely reporting to the state agency, but these steps were not followed for the incidents involving both residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide written notification of discharge to a resident and the resident's representative when the resident was transferred into police custody. The resident, who had a history of diabetes, chronic pain, and repeated falls, was cognitively intact as indicated by a BIMS score of 15. On the day of the incident, law enforcement arrived at the facility to take the resident into custody, and the Director of Nursing (DON) documented that all belongings and medical information were sent with the resident. However, there was no evidence that a written discharge notice was provided to the resident or their representative at the time of transfer. Interviews with facility staff, including the Social Worker, Administrator, and DON, revealed that the decision to discharge the resident was made based on information from law enforcement that the resident would remain in custody until trial. The staff acknowledged that the usual 30-day written notice for facility-initiated discharges was not given, and instead, verbal notifications and voicemails were left for the resident's Power of Attorney (POA) and the ombudsman. The facility also did not provide written documentation of the reasons for discharge in a language and manner understandable to the resident and their representative. Further review indicated that the facility's policies require written notice of discharge or transfer, including in emergency situations, and that such notices should be provided to the resident, their representative, and the ombudsman. Despite these policies, the facility did not issue the required written notice when the resident was taken into police custody and subsequently discharged. The ombudsman confirmed that the resident had previously appealed a discharge and won, and expressed that the resident should have been accepted back after the arrest and hospital stay, but the facility refused readmission based on its policy regarding registered sex offenders.

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 was free from neglect, resulting in a significant deficiency. On the night in question, a resident was left unattended for approximately six hours, during which time he fell and remained on the floor without assistance. The resident, who had a history of Alzheimer's disease, generalized anxiety disorder, and dementia, was found with an abrasion on his left arm and was combative and speaking Spanish when discovered. His care plan indicated he required supervision or assistance with toileting and was at high risk for falls. The incident occurred when CNA A and LVN B did not perform the required checks on the resident throughout the night. CNA A admitted to not checking on the resident during her rounds and only discovered him on the floor at around 4:30 am. LVN B also confirmed that she did not see the resident again until notified by CNA A. Both staff members acknowledged that failing to check on residents every two hours constituted neglect. The facility's video footage confirmed that no staff entered the resident's room for the six-hour period, during which the resident attempted unsuccessfully to get back up after his fall. The Director of Nursing (DON) and the Administrator reviewed the video footage and confirmed the timeline of events. The DON noted that the resident made several attempts to reposition himself but was unsuccessful. The Administrator stated that the staff should have seen the resident on the floor if they had opened the door, indicating that the required checks were not performed. Both CNA A and LVN B were suspended and later terminated following the investigation. The facility's policy on abuse and neglect emphasized the importance of frequent checks, but there was no specific policy on the frequency of these checks.

Penalty

Inspection fine: $15,538

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

Summary

The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for two residents, leading to deficiencies in the management of peripherally inserted central catheter (PICC) lines. Resident #1 did not have orders to change her PICC line dressing after it was placed, resulting in the dressing not being changed from 12/18/24 until 01/09/25. Additionally, there were no orders to flush the PICC or monitor the insertion site for signs of infection during this period. The nursing staff, including the Assistant Director of Nursing (ADON), were not trained or competent in managing PICC lines, as evidenced by the ADON's improper dressing change technique and lack of sterile procedure. Resident #2 also experienced deficiencies in PICC line management. There were no orders to flush the PICC or monitor the insertion site for signs of infection from 11/13/24 through 11/27/24. The resident was transferred to an acute hospital with a fever and was diagnosed with sepsis and pneumonia, with blood cultures positive for Candidiasis. The facility's failure to provide adequate training and competency checks for nursing staff on PICC line management contributed to these deficiencies. The deficiencies resulted in the identification of an Immediate Jeopardy (IJ) situation on 01/09/25, indicating a serious threat to resident health and safety. The facility's lack of proper protocols and training for central line care placed residents at risk for infection, hospitalization, and potentially more severe outcomes. The report highlights the need for consistent monitoring and adherence to professional standards in the administration of IV fluids and PICC line care.

Removal Plan

• DON completed 100% audit of current residents with central venous line - no further issues identified.
• All nurses will be in-serviced on proper dressing change and care of a central venous line by the DON and/or Designee.
• All nurses will be in-serviced on infection prevention and monitoring for infection of a central venous line by the DON and/or Designee.
• All nurses will be in-serviced on receiving and validating central venous line management care with ordering physician by the DON and/or Designee.
• All nurses/agency nurses will not be allowed to begin work until they have received the above in-services/trainings by the DON and/or Designee - staff were able to verbalize comprehension post in-servicing.
• DON in-serviced by compliance nurse - DON was able to verbalize comprehension post in-servicing.
• The medical director was notified of the immediate jeopardy situation.
• The DON / designee will view each PICC/central venous line dressing 3xwk to ensure compliance - it will be maintained on a monitoring log.
• The DON / designee will review Real time key word for any new orders for PICC/Central Venous Line 5 times a week to ensure compliance it will be maintained on a monitoring log.
• DON/Designee will validate all new orders of PICC/Central Venous Line 5 times a week to ensure compliance it will be maintained on a monitoring log.
• The QA committee will review findings and makes changes to the plan if needed.

Penalty

Inspection fine: $15,538

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 licensed nurses demonstrated the necessary competencies and skill sets to care for a resident with a central line, leading to potential risks of infection and improper medication administration. Six nurses, including the ADON, RN A, and LVNs B, C, D, and E, were involved in the care of a resident who had a PICC line inserted for intravenous medication administration. The nurses were not knowledgeable or competent in the facility's central line policy, as evidenced by the lack of proper dressing changes, flushing, and monitoring of the central line site. The resident, a female with intact cognition, was admitted with diagnoses including chronic ulcer, venous hypertension, and cellulitis, requiring intravenous medications such as Piperacillin-Tazobactam and Vancomycin. Despite the critical nature of the resident's condition, the MAR/TAR records showed that the central line site was not monitored, flushed, or had its dressing changed as per the facility's policy. The dressing was not changed from the time of insertion on December 18 until January 9, and the site was covered with tape, obscuring visibility and preventing proper assessment. Interviews with the nursing staff revealed a lack of training and competency in central line care. RN A admitted to having no prior experience with PICC lines and was uncomfortable performing dressing changes. The ADON, who performed a dressing change, did not follow sterile procedures and failed to change the caps, mistaking the central line for a peripheral IV. The DON and MD expressed expectations for proper central line maintenance, which were not met, as evidenced by the absence of specific competencies or skills checks for central lines in the proficiency audits provided for the involved nurses.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to professional standards for food service safety, as evidenced by multiple sanitation issues observed in the kitchen. The ice machine was found to have mold on the inside door and inner upper wall, and the seal on the top of the ice machine door was cracked. The microwave had dried food debris caked on its interior top, and the meat slicer was dirty with dried food debris and had a rusty slicing blade. Additionally, trash receptacles in the kitchen were observed without lids, and ingredient bins had scoops left inside them, contrary to best practices. Food items in the kitchen were not properly labeled and dated, which could lead to the use of expired or unidentified food products. Observations revealed several bags of food in the walk-in freezer and dry storage area that were unsealed, unlabeled, and undated. This included bags of frozen hushpuppies, onion rings, chicken tenders, fish fillets, broccoli cuts, cherry pies, brown sugar, pasta, cake mix, gelatin, peanuts, pudding mix, cocoa, powdered sugar, and tortillas. The lack of proper labeling and dating could result in foodborne illnesses if expired or spoiled food is served to residents. The facility also failed to maintain proper handwashing facilities, as sinks were observed to be leaking. Hair restraint practices were not consistently followed, with staff observed wearing inadequate hair coverings, such as a ball cap with hair extending below it and a beard guard that did not fully cover facial hair. The dietary manager admitted to not maintaining daily or monthly cleaning logs and was unsure of the potential harm rust on a meat slicer blade could cause to residents. These deficiencies in sanitation and food handling practices could place residents at risk of foodborne illness.

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 and sanitary environment to prevent the transmission of infections among residents. LVN B did not label wound care dressings for several residents, including those with chronic ulcers and pressure injuries. This omission was observed during wound care for multiple residents, where dressings lacked initials and dates, which are crucial for tracking the timing of wound care and monitoring for drainage. Additionally, LVN B did not use a barrier between a resident's wound and the bedding, increasing the risk of cross-contamination. Another significant deficiency involved LVN N, who provided catheter care to a resident without wearing the required Enhanced Barrier Precautions (EBP), such as gloves and gowns. This resident had an indwelling catheter and was supposed to be under EBP to prevent infection transmission. Despite the presence of signs and available PPE, LVN N handled the catheter without the necessary protective equipment, which could lead to infection risks for both the resident and staff. Interviews with staff, including the DON and ADM, revealed that the facility had policies in place for wound care and EBP, but these were not consistently followed. The DON and ADM acknowledged the importance of labeling wound dressings and using barriers during wound care, as well as adhering to EBP for residents with indwelling devices. The failure to comply with these infection control measures was attributed to lapses in following established protocols and ensuring staff training.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's call light bell was within arm's reach, which is a reasonable accommodation of the resident's needs and preferences. The deficiency was identified for a resident who was diagnosed with cerebral infarction, hemiplegia, and hemiparesis, resulting in significant physical impairments. The resident required substantial to maximum assistance for various activities of daily living and used a wheelchair for mobility. Despite these needs, the call light bell was found on the floor, out of reach, which prevented the resident from calling for assistance when experiencing pain. During an observation and interview, the resident expressed that she did not know the location of her call light bell and felt sad about its inaccessibility. A registered nurse later entered the room, noticed the misplaced call light bell, and repositioned it within the resident's reach. The nurse instructed the resident on how to use the call light bell to request help. Interviews with facility staff, including a CNA and the DON, confirmed that the call light bell should always be within reach of residents, whether they are in bed or in a chair, to address their needs promptly. The facility lacked a specific policy on call light bell placement, but staff were trained to ensure accessibility. The facility's Resident Right Policy emphasized the right of residents to receive services with reasonable accommodation. The failure to provide the resident with access to the call light bell could lead to unmet needs and psychosocial harm, as the resident was unable to communicate her needs effectively.

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 manage the personal funds of a resident, identified as Resident #25, who was unable to access her funds in a timely manner for a dental appointment. Resident #25, a female with multiple medical conditions including dementia and major depressive disorder, had intact cognition as indicated by a BIMS score of 15. She required funds for a dental visit co-pay, which Medicaid did not cover, but was unable to receive the necessary amount from the facility's trust fund in time for her appointment. The Business Office Manager (BOM) explained that residents could immediately receive amounts up to $75, but larger amounts required a special request, which could take up to two days to process. The BOM was unavailable on the day of Resident #25's appointment, and no other staff facilitated the fund disbursement, resulting in the cancellation of her dental visit. The facility's policy stated that trust funds should be accessible during normal business hours, but the process for special requests was not clearly communicated or documented. Interviews with the BOM and other staff revealed that there were other personnel with access to the financial system who could have processed the request, but this was not done. The Administrator expressed that residents should receive their funds according to policy, acknowledging that failure to do so could negatively impact residents' ability to pay for necessary services. The deficiency highlights a lapse in the facility's management of resident trust funds, affecting Resident #25's ability to attend her scheduled dental appointment.

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 had the right to receive packages unopened, which is a violation of resident rights. This deficiency was identified during a Resident Council interview where two residents expressed concerns about receiving packages that had already been opened. The residents reported that while their mail and letters remained unopened, packages were often opened before they received them. This practice was reportedly due to safety concerns, as staff feared the presence of contraband or harmful items. Resident #14, a female with intact cognition and multiple health conditions including major depressive disorder and anxiety, expressed that packages were opened possibly due to a past incident involving another resident. She was concerned about receiving all items she ordered. Resident #253, a male with intact cognition and a history of cerebral infarction and other health issues, stated that staff opened packages due to fears of contraband. He mentioned that a small hammer he ordered was confiscated, and he felt that the practice of opening packages began with the arrival of a new administrator. Interviews with facility staff, including the Business Office Manager (BOM) and the Administrator (ADM), revealed that packages were supposed to be delivered unopened. However, any staff member who answered the facility door could receive packages, which were then left at the reception desk. The BOM and ADM acknowledged that delivering opened packages could negatively affect residents. The facility's policy on resident rights confirmed that residents have the right to receive packages delivered to the facility through means other than the postal service.

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 a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. The resident, an elderly male with multiple diagnoses including Parkinson's Disease, fractures, diabetes, heart disease, depression, and cognitive impairment, was not provided with a care plan addressing daily activities. This oversight was identified during a review of the resident's care plan, which lacked documentation regarding daily activities, despite the resident's history of social isolation and cognitive challenges. Observations and interviews revealed that the resident often stayed in bed, watching television or sleeping, and was not participating in activities or socializing. Staff interviews indicated that the resident sometimes refused care, medications, or meals, and preferred to stay in bed. Although the resident occasionally left the room to visit common areas, this was not consistent, and there was no care plan in place to address or encourage participation in daily activities. The Activity Director noted that the resident did not engage much with staff or other residents and had not been care-planned for one-on-one activities due to refusal. The facility's policy on comprehensive care planning emphasizes the need for person-centered care plans that address medical, nursing, mental, and psychosocial needs, respecting resident rights and preferences. The policy requires care plans to be developed collaboratively with the interdisciplinary team and the resident, and to be reviewed and updated regularly. However, in this case, the lack of a care plan for daily activities placed the resident at risk of social isolation and diminished quality of life, as the facility did not adequately address the resident's needs and preferences in this area.

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 timely repair of a custom wheelchair for a resident, which was necessary for her mobility and comfort. The resident, who had a history of hemiplegia, stroke, and other significant health issues, was using a loaner wheelchair that did not meet her specific needs. The resident's custom wheelchair had been awaiting repair since August, and despite the facility's initial contact with the repair company, no further follow-up was conducted until December. The resident's representative expressed concerns about the delay, noting that the custom wheelchair had been broken and awaiting repair for three months. The facility's staff, including the Director of Rehabilitation (DOR) and Occupational Therapist (OT), acknowledged the delay and lack of communication with the repair company. The DOR admitted that after the initial contact with the repair company, no further action was taken until prompted by the resident's representative. The facility's administration recognized the potential negative impact on the resident due to the delay in repairs. However, there was no specific policy in place to address such situations, and the facility did not have a record of a positioning/mobility equipment policy. The lack of timely follow-up and communication with the repair company contributed to the deficiency in providing appropriate care and treatment according to the resident's needs and preferences.

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 requiring respiratory care was provided with a functional BiPAP machine, consistent with professional standards of practice and the resident's care plan. The resident, who had been diagnosed with respiratory failure and sleep apnea, had a care plan that included the use of a BiPAP machine as needed. However, the resident's BiPAP machine was found to be in an unusable condition, lacking a wall outlet plug, a nasal mask, and having a discolored and dirty air intake filter. The resident expressed a desire to use the BiPAP machine despite previous non-compliance, but was unable to do so due to the machine's condition. The Director of Nursing (DON) acknowledged that the machine had been returned to the resident from storage without the necessary components, and the responsibility for the machine's upkeep was left to the resident and the supplier. However, the facility's policy indicated that it was responsible for providing ongoing therapy and maintaining the BiPAP system. Interviews with facility staff revealed that the facility was responsible for ensuring the BiPAP machine was operational and that the resident's non-compliance did not negate this responsibility. The facility's failure to maintain the BiPAP machine in a usable condition could place residents at risk of complications from respiratory distress.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan. The deficiency involved a resident who required an appointment with a neurologist as ordered by their cardiologist. Despite the cardiologist's referral being faxed to the facility, the appointment was not scheduled in a timely manner, which could place the resident at risk of not receiving necessary medical care. The resident, who has a history of strokes and other medical conditions such as sleep apnea, COPD, type II diabetes, mild cognitive impairment, and PTSD, expressed difficulty in getting the facility to make the necessary neurologist appointment. The facility's social worker initially faxed the referral with incorrect diagnoses, leading to a refusal from the neurologist. Subsequent attempts to contact the neurologist were made, but no appointment was scheduled, and the social worker did not document the calls made to the neurologist's office. Interviews with facility staff, including the social worker, DON, and administrator, revealed that the facility was aware of the issue but did not take adequate steps to resolve it. The facility's policy on resident rights emphasizes the importance of planning and implementing care in accordance with the resident's preferences and goals, which was not adhered to in this case. The resident's NP acknowledged that the referral should have been followed up on sooner, indicating a lapse in the facility's processes for ensuring timely medical care for its residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary respiratory care for a resident diagnosed with sleep apnea, as outlined in the resident's care plan. The resident, a male with multiple health conditions including sleep apnea, chronic obstructive pulmonary disease, and mild cognitive impairment, was not provided with a CPAP machine as required by his care plan. The care plan, updated on 10/29/24, specified the use of a CPAP/BIPAP during sleep, but the CPAP order was discontinued on 4/29/24, and there was no current order for its use. Observations revealed the absence of a CPAP machine in the resident's room, and interviews with the resident indicated that he was concerned about not having access to the CPAP machine, which was not transferred to his new room. Interviews with facility staff, including the DON and the administrator, revealed a lack of awareness regarding the resident's need for a CPAP machine and the details of his care plan. The DON, who had been working at the facility for a few months, was unaware of the resident's sleep apnea diagnosis and the care plan's requirements. The administrator also did not know why the CPAP order was discontinued and was unaware of the care plan's inclusion of the CPAP. The resident's NP was not informed of the discontinuation of the CPAP order and assumed it was being offered nightly, despite the resident's frequent refusal of treatments. The facility's policies on resident rights and comprehensive care planning emphasize the resident's right to participate in their care and the facility's responsibility to provide services as outlined in the care plan, which were not adhered to 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 provide a safe, clean, comfortable, and homelike environment by not replacing a countertop over a set of cabinets in the dining room for about a year. Observations revealed that the cabinets were partially covered with plywood, stained green tablecloths, and a bath towel, with exposed drawers containing various items and debris. Interviews with staff indicated that the countertop had been missing for a significant period, with varying accounts of when it was removed, ranging from a year to two years ago. The Maintenance Director and the Administrator mentioned that a replacement had been ordered, but there was no clear timeline for its installation. A resident expressed dissatisfaction with the appearance of the dining room, describing it as looking bad and junky. Staff members also noted that the absence of the countertop made the environment less homelike and that residents had complained about it in the past. The facility's Residents Rights policy emphasizes the importance of maintaining a safe, clean, comfortable, and homelike environment, which was not upheld in this instance. The Administrator acknowledged the issue and mentioned discussions with the Ombudsman, but no adverse effects on residents were reported other than complaints about the countertop's absence.

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 immediately notify the resident's representative of a significant change in the resident's physical status, specifically a metacarpal fracture, for one of the residents reviewed. The resident, a female with severe cognitive impairment and a history of falls, was not reported to have a fracture until ten days after the x-ray results were received. This delay in communication was confirmed through interviews and record reviews, highlighting a lapse in the facility's protocol for notifying resident representatives of significant health changes. The resident's progress notes indicated that an x-ray was completed to assess a fracture, and a subsequent order was made for an orthopedic evaluation. However, the resident's representative was not informed of the fracture until much later, which was confirmed during a telephone interview with the representative. The Director of Nursing acknowledged that it was expected for resident representatives to be notified immediately of any changes in condition, such as fractures or falls, as part of the facility's protocol. The facility's Resident Rights Policy also mandates immediate notification of significant changes in a resident's condition.

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 who had not previously used psychotropic drugs was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. The resident, an elderly female with diagnoses including unspecified dementia, anxiety, depression, and age-related cognitive decline, was administered Zyprexa, an antipsychotic medication, without a preexisting mental illness warranting its use. The resident's quarterly MDS assessment indicated severe cognitive impairment, and her care plan noted a risk of falls related to psychoactive drug use. The facility's psychiatrist indicated that the resident's Zyprexa prescription was for aggression, which he deemed an acceptable diagnosis if the resident posed a potential danger to others. However, the Director of Nursing stated that aggression was not an appropriate diagnosis for Zyprexa, which should be prescribed for conditions like bipolar disorder, schizophrenia, or psychosis. The facility's policy on psychotropic drugs emphasized that such medications should only be administered to treat specific conditions as diagnosed and documented in the clinical record.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents or their representatives were informed in advance about the risks and benefits of proposed care, treatment alternatives, and options, specifically for one resident reviewed for consents. The deficiency involved the administration of Xanax, a psychotropic medication, to a resident without obtaining a written consent from the resident's representative. The resident, a female with diagnoses including dementia, major depressive disorder, generalized anxiety disorder, and mild cognitive impairment, was administered Xanax on multiple occasions without documented consent. The Director of Nursing (DON) acknowledged that consent for psychotropic medications must be obtained before administration to prevent chemical restraint and ensure that the resident's representative can make informed decisions regarding their care. Despite the facility's policy requiring documented consent for psychotropic drugs, the resident's electronic medical record showed no signed consent form for Xanax. The facility had conducted an in-service training to reeducate nurses on obtaining consents for psychotropic medications, but the deficiency still occurred.

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 drugs were limited to 14 days unless the attending physician or prescribing practitioner documented their rationale for extending the order in the resident's medical record. This deficiency was identified for a resident who was prescribed Xanax, a medication used to treat anxiety. The resident, a female with a history of dementia, major depressive disorder, generalized anxiety disorder, and mild cognitive impairment, was admitted to the facility and had a physician order for Xanax without a specified stop date. The medication was administered on multiple occasions over a period exceeding 14 days without documented justification for the extended use. The Director of Nursing (DON) acknowledged during an interview that PRN psychotropic medication orders should not be open-ended and must be limited to 14 days to allow for assessment of the medication's effectiveness and necessity. The facility's policy on psychotropic drugs, revised in 2017, also stipulated that PRN orders for such medications should be limited to 14 days. The lack of a stop date for the PRN Xanax order for the resident could lead to overmedication or unnecessary medication use, posing a risk of sedation or chemical restraint.