Pleasant Springs Healthcare 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

Surveyors identified that the facility failed to provide trauma-informed, culturally competent care by not accurately identifying and documenting a resident’s history of trauma. The resident was an adult female with diagnoses including bipolar disorder, mild recurrent major depressive disorder, obsessive-compulsive disorder, and anxiety disorder, and had an intact cognition with a BIMS score of 14. Her Quarterly MDS indicated she felt down, depressed, or hopeless. Despite this, her care plan and Social History did not reflect any history of trauma. In contrast, a diagnostic assessment completed by the facility’s psychological services documented that her mental health issues began around age 15 following sexual abuse, religious cult trauma, and generational family trauma. During interviews, the resident reported multiple traumatic experiences, including witnessing her parents’ marital conflict and fights, nearly dying after being hit in the face with a seesaw, and being sexually abused at age 15. She stated she had many traumas, still had mental scars, and that remembering these events caused her anxiety, though she felt safe in the facility and could not specify particular triggers. The Social Worker, who was responsible for completing social history assessments and identifying trauma history, acknowledged the resident had significant issues and childhood suffering but did not document a trauma history, did not recall all details shared, and did not review the psychological services notes. The Social Worker also stated she was unsure who was responsible for reviewing those notes. The Administrator, who had recently started at the facility, was unaware of the resident’s trauma history and stated she expected the Social Worker to assess for trauma and review psychological services documentation. The facility’s trauma-informed care policy required that trauma history be assessed during the Social Service History Assessment on admission and that the comprehensive care plan be culturally competent and trauma informed, which was not done for this resident.

Penalty

Inspection fine: $17,220

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 keep the environment as free of accident hazards as possible and to provide adequate supervision to prevent avoidable accidents for a cognitively impaired resident and in a communal shower room. A female resident with severe dementia and other medical conditions, including longstanding atrial fibrillation and stage 3A chronic kidney disease, had a BIMS score of 3 indicating severely impaired cognition. Her MDS showed dependence on staff for toileting, personal hygiene, bathing, and transfers, and that she required at least setup or cleanup assistance with eating and supervision or touching assistance for wheelchair mobility. Her care plan identified her as at risk for wandering and elopement, with interventions including staying with her when exit seeking, notifying the charge nurse, and later one-on-one supervision and structured activities. Elopement risk assessments on multiple dates, including shortly before the incident, identified her as an elopement risk, and progress notes documented wandering and exit-seeking behaviors, including pushing on a locked courtyard door. On one occasion, the resident exited the facility without staff knowledge and was found outside in the driveway near a busy public street. A nurse taking trash outside saw the resident in her wheelchair in the driveway outside the gate by a hall exit, headed toward the road. Staff interviews indicated the resident had been wandering and exit seeking that day and previously, and that she had been roaming around the facility and “caught the door behind somebody else leaving.” One nurse reported that the alarm on the B Hall laundry exit door did not sound when the resident exited, and a CNA stated that someone, possibly a housekeeper, had left the laundry door open. Staff could not recall how long it had been since they last saw the resident before she was found outside. The DON stated she was notified that the resident had been found outside and brought back in without injury, and that staff had reported the resident had been wandering on the wrong hall and needing redirection, although the DON also stated that, to her knowledge, the resident had not been exit seeking. The facility also failed to provide adequate supervision to prevent the same resident from spilling hot coffee on herself. The resident’s care plan identified an ADL self-care deficit and later documented that she was at risk of burns from hot liquids, requiring physical assistance with hot liquids, a cup with a lid, protective clothing or lap protector, and upright positioning with a table when consuming hot liquids. An event nurse’s note documented that the resident sustained a burn in the dining room from coffee or another hot liquid, with blanchable redness on the left abdomen and left upper thigh, and that she had cognitive impairment, refused to call for assistance, wandered, required cueing, and resisted redirection. A weekly skin assessment later documented specific measurements of reddened areas on the left thigh. The MDS Coordinator and LVN involved acknowledged that the resident spilled coffee on herself, that she had redness without blistering, and that lids on her drinks were discussed or implemented afterward. Nursing assistants interviewed later reported they had not been instructed which residents required lids on coffee, observed that lids were used inconsistently, and were not aware of any prior burns. In addition, the facility failed to maintain a safe environment in the Hall C communal shower room. During an evening observation, the shower room door on Hall C was found open and unoccupied, with wet floors and scattered puddles of water. An open cabinet adjacent to the shower stall contained an open K-Quat spray cleaner bottle and a tub and tile cleaner spray bottle on a shelf, and a resident was sitting unsupervised in the hallway across from the shower room. Nursing staff and CNAs interviewed stated that baths and showers were not scheduled on that shift, that they had not assisted with showers that evening, and that cleaning supplies should be stored behind closed cabinet doors with the shower room door closed and locked after use. They acknowledged that a resident could wander into the shower room, slip on the wet floor, or access and spray the cleaning chemicals. The DON and Administrator both stated that all staff were responsible for ensuring safety, that cleaning supplies should be kept out of resident access, and that the shower door should be closed and locked when water was on the floor, and the Administrator confirmed there was no policy addressing accidents/supervision or the shower room and storage of cleaning supplies.

Removal Plan

• One on one monitoring of Resident #1 until discharged from the facility
• Resident #1's care plan was updated
• Trauma Assessment for Resident #1
• Physician notification
• Elopement risk assessments completed for all other residents
• Care plans updated for those determined to be at risk for elopement
• In-service on Elopement and Abuse and Neglect
• Notified families to be mindful of residents attempting to exit the facility and not to share a door code with the residents
• Signage placed at visitor exits to be mindful of residents attempting to exit the facility
• Doors were checked for alarms functioning properly
• Elopement drills were conducted once every shift
• Medical Director was notified
• Visitors were observed through daily rounds for allowing residents to exit the facility unsupervised

Penalty

Inspection fine: $17,220

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 a safe, clean, comfortable, and homelike environment on Hall C by not ensuring the area was free of offensive, musty urine odors. Over multiple days of observation, surveyors repeatedly noted a musty urine odor on Hall C at various times of day. On several occasions, staff present on the hall, including a CNA, the Social Worker, and the Corporate Compliance Nurse, acknowledged smelling an offensive odor, though some were unable to identify its exact source. At one point, staff were observed transferring soiled laundry with a pungent musty urine odor from a resident’s room into a bag after learning that the resident’s family was not actually washing the resident’s laundry, contrary to what the resident had told staff. Interviews with facility leadership and staff showed inconsistent awareness of the odor problem. The Housekeeper Supervisor attributed the odor to a possible incontinence episode in the hallway or someone walking by. The ADON and DON both stated they had not noticed any offensive or urine odors on Hall C and reported that residents had not complained to them about odors. They each stated that all staff were responsible for ensuring the facility did not have offensive odors, and the DON described expectations that CNAs change sheets on shower days, clean mattresses when necessary, and keep residents clean and dry to prevent odors. The facility’s undated Resident Rights policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment and that staff and management are to minimize institutional characteristics, including institutional odors, but the persistent musty urine odor on Hall C demonstrated a failure to meet this standard during the survey period.

Penalty

Inspection fine: $17,220

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 protect residents from abuse and neglect, including failure to provide timely incontinent care and repositioning, failure to protect a resident from verbal abuse by a CNA, and an allegation of physical abuse by the ADON. One cognitively intact female resident with dementia, anxiety, depression, diabetes mellitus, and atrial fibrillation was care planned as needing staff assistance for ADLs, including one-person assistance for bathing, two-person assistance with a mechanical lift for transfers, and staff supervision for toileting, bed mobility, dressing, and eating. She was also care planned for bladder incontinence and impaired mobility, with interventions including application of barrier cream after incontinent episodes. A later care plan entry documented a potential psychosocial well-being problem related to an allegation of verbal abuse. Video evidence from one date showed this resident lying in bed on her back, not turned, repositioned, or provided incontinent care from 1:56 PM until 7:55 PM. On another date, a time-lapse video from 5:45 AM to 11:45 AM showed no staff entering the room to check, change, or reposition her for six hours. In interviews, the resident’s family member reported calling the facility and requesting incontinent care because no staff had checked on the resident since before 6 AM when night shift staff last checked her. A nursing assistant assigned to the resident on one of the dates stated she had not been in the room to provide care because she had not had time and acknowledged she was new and found it difficult to care for all assigned residents, adding that residents should be checked every two hours and that not doing so could be considered neglect. Another CNA who cared for the resident on the earlier date recalled arriving around mid-afternoon, possibly entering the room only to provide fresh ice and asking the resident if she needed changing, then not changing her until about 8 PM after a family call, and could not recall changing her at any other time that shift. This CNA stated she should have made rounds on every resident every two hours to check and clean them and acknowledged that failing to do so placed the resident at risk for neglect. The DON and Administrator both stated their expectation that CNAs check residents at least every two hours and recognized that extended periods without checks placed residents at risk for neglect. The same cognitively intact resident was also subjected to degrading verbal interactions by a CNA during incontinent care, captured on video with audio. The video showed the resident lying in bed on her back when the CNA entered, snatched gloves from the wall box, and responded condescendingly when the resident said she needed to be changed, telling her there was a line and that there were no “first privileges.” When the resident commented that the CNA did not like her job, the CNA replied hatefully that she liked her job but not when people could not wait in line, and further stated that the resident thought she was privileged and kept hitting her call light. The resident remarked that someone must have “peed in [the CNA’s] cheerios,” and the CNA responded that she had been doing this too long to “deal for people like this” and that she would not hold her tongue for anyone. While providing care, the CNA continued to interject instructions in a rude manner, pointing and telling the resident to roll. The resident later told surveyors that a staff member had talked mean to her when she asked to be changed, that the staff member must have had a bad day, and that she did not want that staff member back in her room. The resident’s family member reported bringing the video of the verbal interaction to the ADON and asking her to watch it, and requested that the CNA not be allowed back in the resident’s room because of how she talked to and treated the resident. The family member stated the ADON declined to watch the video, said she did not need to see it and would retrain the aide, and then walked away to move tables in the dining hall, leaving the family member standing there. In her interview, the ADON acknowledged declining to watch the video when it was offered, stating that the family member told her the CNA had provided all care perfectly but needed to talk to the resident when providing care. She said she did not retrain the CNA, did not initiate any reporting or investigation because she believed everything was done correctly, and told the CNA only to do the required care and get out of the resident’s room. The ADON stated she did not consider it important to talk to residents while providing care and said she did not receive a request from the family to keep the CNA out of the room. She also stated that if allegations of abuse were not reported and investigated properly, residents were placed at risk of abuse. A second resident, an elderly female with senile degeneration of the brain, dementia, and atherosclerotic heart disease, had a quarterly MDS showing she was usually understood and usually understood others, but with a BIMS score of 5 indicating severely impaired cognition and disorganized thinking. She required supervision or touching assistance with eating and was dependent on staff for toileting and transfers, and was incontinent of bowel and bladder. Her care plan documented an ADL self-care performance deficit related to impaired mobility, cognition, weakness, and reliance on staff for ADL assistance. An anonymous staff person reported that about three months prior, this resident was in the dining room hollering “Help! Help!” when the ADON walked by; the resident reached out to grab the ADON to stop her, and the ADON hit the resident on the hand and told her to leave her alone and not touch her. The anonymous reporter stated they then went to assist the resident, that another staff member also witnessed the incident, and that they were tired of injustices residents experienced. They reported that the ADON often refused to assist residents and that they had reported this to the DON, who did nothing, which was why they had not reported the hand-hitting incident earlier. The anonymous reporter further stated that many employees had witnessed the ADON’s mistreatment of residents and reported it to the DON but would not report it further due to fear of being fired. Another staff member named as a witness denied seeing the ADON abuse or mistreat residents and denied seeing the ADON hit this resident. The Administrator reported that the ADON was suspended related to the allegation of hitting this resident. When interviewed, the resident, who was confused, stated she did not remember any staff hitting or mistreating her and said everyone treated her well, but her confusion was evident when she answered her ringing cell phone by picking up her drink and saying hello. The DON stated that abuse should be reported immediately to the abuse coordinator and that if staff would not report to her, they should go to the Administrator, and that failure to report abuse and neglect immediately placed residents at risk of not being protected from abuse. The Administrator stated she expected staff to follow the abuse and neglect policy and report abuse and neglect immediately, that she was not aware of any abuse allegations involving this resident, and that abuse not being reported placed residents at risk of further abuse. The facility’s undated Abuse and Neglect policy stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and that residents should not be subjected to abuse by anyone, including facility staff, other residents, consultants, volunteers, staff of other agencies, family members, friends, or others. The policy defined abuse to include deprivation of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being, and specified that instances of abuse cause physical harm, pain, or mental anguish, including verbal, sexual, physical, and mental abuse. Physical abuse was defined to include hitting, and mental abuse to include humiliation and harassment. Neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy required that all reports or suspicions of abuse, neglect, or potentially criminal behavior be investigated per facility protocol, reviewed by the Administrator and/or Abuse Preventionist within 24 hours, and reported to state authorities within specified time frames. It also required any employee with reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation to make an immediate verbal report to the Abuse Preventionist or designee and to the Administrator, with mandated reporting to state and/or adult protective services.

Penalty

Inspection fine: $17,220

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 its written abuse and neglect policies in response to specific allegations involving two residents. For one resident with dementia, anxiety, depression, diabetes, and atrial fibrillation, who was cognitively intact with a BIMS score of 15 and required staff assistance for ADLs and incontinence care, a video dated 12/15/25 showed a CNA entering the resident’s room, abruptly taking gloves, and responding condescendingly and hatefully when the resident stated she needed to be changed. The CNA told the resident there was a “line” and “no first privileges,” stated she did not like when people could not wait, and made repeated comments implying the resident felt “privileged,” while continuing care in a rude and demeaning manner. The resident’s family later brought this video to the ADON and reported concerns about how the CNA talked to and treated the resident, and requested that the CNA not be allowed back in the resident’s room. The ADON declined to watch the video when it was offered by the family and did not report the allegation to the abuse coordinator or initiate an investigation as required by the facility’s abuse and neglect policy. The ADON stated that the family told her the CNA had provided all care correctly but did not talk to the resident during care, and therefore she believed there was nothing to report or investigate. She also stated she did not retrain the CNA, and that she told the CNA to perform the required care and leave the room without conversing with the resident. The ADON indicated she did not watch the video because the family frequently brought videos and she did not consider this an actual complaint. The DON similarly reported that, based on what the ADON told her at the time, she believed the family’s concern was only that the CNA did not talk to the resident during care and therefore did not see a need to view the video or treat it as an abuse allegation at that time. A second deficiency involved a separate incident reported by an anonymous staff member concerning another resident with severe cognitive impairment (BIMS score of 5), dementia, senile brain degeneration, and dependence on staff for toileting and transfers. About three months prior to the interview, this resident was in the dining room calling out “Help! Help!” when the ADON walked by. According to the anonymous staff member, the resident reached out to grab the ADON to stop her, and the ADON hit the resident’s hand and told her, “Leave me alone don’t touch me.” The anonymous staff member then went to assist the resident. The staff member reported that another employee also witnessed the incident and that many employees had observed the ADON’s mistreatment of residents and reported concerns to the DON, but they did not report this specific incident further due to fear of being fired and a belief that prior reports to the DON had not resulted in action. The Administrator later stated she was not aware of any abuse allegations involving this resident until the anonymous report was made. The facility’s written policy required all employees to immediately report any suspected abuse, neglect, exploitation, or mistreatment to the Abuse Preventionist or designee and the administrator, and to ensure all such reports were promptly investigated, but this did not occur in either case.

Penalty

Inspection fine: $17,220

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 multiple failures to ensure medications and biologicals were securely stored and properly handled on three of four medication carts. On one evening, two unattended medication carts at the nurse’s station were found unlocked, and the surveyor was able to open both carts while staff and a resident were nearby. A medicine cup containing white powder was observed on top of one cart. A LVN on duty stated the carts belonged to another LVN who had left the facility for break about 20 minutes earlier, acknowledged that carts should be locked when not in use or out of sight, and admitted she had not realized the carts were left unlocked or that the cup with white powder was on top of the cart. She waited approximately 10 minutes before locking the carts. When the LVN who owned the carts returned from break, she confirmed the carts were the A/B Medication Aide Cart and the A/B Nurse Medication Cart and identified the white powder as antifungal powder, stating it should not have been left on top of the cart and that carts should be locked at all times when unattended. On another day, a red pill in a medication cup was observed on top of an unattended medication cart, with multiple residents and staff around it. A medication aide identified the cart as the C/D Medication Aide Medication Cart and stated she had dropped the pill earlier and placed it on top of the cart to dispose of it, but could not recall what medication it was. She acknowledged that medications to be disposed of should not be left on top of the cart and should instead be placed immediately in the biohazard box on the cart. The DON stated that medication carts should be locked when not within eyesight, medications should not be left on top of carts, and medications needing disposal should be destroyed immediately. The Administrator stated she expected staff to lock medication carts and not leave medications on top of them. The facility’s written policy on Medication Storage in the Facility required that medications and biologicals be stored safely, securely, and properly, with medication rooms, carts, and supplies locked or attended by authorized personnel.

Penalty

Inspection fine: $17,220

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

Summary

Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen. During observation, an opened, unsealed cardboard box containing mushrooms was found stored in the refrigerator directly on top of onions that were inside Ziploc bags. A 4 pound 2 ounce dented can of caramel sauce dessert topping was stored on the rack with undented cans. In the dry storage area, two opened loaves of bread were not sealed properly; one loaf had the bag twisted and tucked underneath without being knotted, and the other loaf was only folded halfway and tucked underneath. The facility’s written policy required open packages of food to be stored in closed containers with covers or in sealed bags and dated as to when opened, and the FDA Food Code 2022 required food packages to be in good condition to protect contents from adulteration or contaminants and noted that dented cans may present a serious potential hazard. In interviews, the Dietary Manager stated that opened bread bags should be tied closed, dented cans should not be stored with undented cans, and food should be stored properly for food safety, acknowledging that improperly sealed food could go bad and cause stomach issues and foodborne illness, and that dented cans could allow bacteria to enter. The Dietary Manager also reported that she checked the kitchen daily to ensure proper food storage and had not noticed any issues, and she believed the cardboard box with mushrooms was stored properly. Another dietary staff member stated that opened bread should be sealed with a twist tie or knotted, did not know why the loaves were not properly stored, and also believed the cardboard box with mushrooms was stored properly, while confirming that dented cans should be removed and returned to the vendor. The Administrator stated that cardboard boxes should not be stored on top of food because they are dirty and could contaminate other items, that everything in the refrigerator should be sealed and dated, and that dented cans should not be stored with undented cans, and identified the Dietary Manager as responsible for ensuring proper food storage.

Penalty

Inspection fine: $17,220

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

Summary

The deficiency involves the facility’s failure to ensure that a cognitively intact resident was treated with respect and dignity during the provision of incontinent and personal care. The resident was an elderly female with dementia, generalized anxiety disorder, depression, diabetes mellitus, and atrial fibrillation, who required staff assistance with ADLs, including toileting and incontinence care. Her care plan documented bladder incontinence, impaired mobility, and the need for staff assistance and supervision with toileting and bed mobility. On one occasion, video dated 02/14/26 showed the resident lying in bed on her left side with the privacy curtain open while CNA AA provided incontinent care. CNA AA left the room to obtain additional supplies and left the resident’s buttocks uncovered and exposed, with the curtain still open, allowing anyone entering the room to see her. In a subsequent interview, CNA AA acknowledged caring for the resident around that time, did not recall leaving her uncovered, and stated that not using the privacy curtain and leaving a resident uncovered placed the resident at risk for loss of dignity. The DON and Administrator both stated they expected CNAs to provide privacy during incontinent care and to ensure residents were covered. On another occasion, a surveyor entered the resident’s room and observed her lying in bed with her gown lifted to her chest, completely exposed from the chest down, while the window blinds were open. CNA Q then went to close the blinds and stated that the blinds should have been closed before starting care and that being seen undressed would be embarrassing for the resident. The resident reported that she wanted staff to close the blinds but sometimes forgot to ask. The ADON and DON both stated that staff were expected to treat residents with dignity and respect, and that blinds should be closed prior to personal care such as dressing or incontinent care to prevent embarrassment. The facility’s Resident Rights policy stated that residents have the right to a dignified existence and to be treated with respect and dignity in a manner that promotes or enhances quality of life.

Penalty

Inspection fine: $17,220

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 required written notice of transfer or discharge, in a language and manner understandable to the resident and representative, for one resident who was discharged. The resident was an adult male with paranoid schizophrenia, diabetes mellitus, anxiety, hypertension, and a cognitive communication deficit, who had a documented memory problem but was cognitively independent in daily decision-making. His discharge MDS indicated an unplanned discharge to the hospital with no anticipated return. Nursing progress notes documented that he was transferred to the hospital on an emergency basis for abnormal behavior and suicide threats, but the section indicating to whom notice was provided was left unchecked. The facility’s policy required that emergency transfers be treated as facility-initiated transfers, with notice of transfer provided to the resident and resident representative as soon as practicable, and that if a discharge decision was made while the resident was hospitalized, a discharge notice must be sent to the resident, representative, and the State LTC Ombudsman. The resident’s responsible party reported she was not notified of his discharge or transfer to another nursing facility and only learned of his new placement three days after his admission there, during which time he was without clothing, personal belongings, or family involvement. She stated that when she spoke with the DON the day before the transfer, there was no mention of a planned transfer to another facility. The Social Worker acknowledged knowing the resident had been sent to the ER and that another nursing facility accepted him while he was out, and stated she did not speak with the responsible party during the discharge process, though she did notify the ombudsman. The DON stated she called the responsible party about the behavior incident that led to the hospital transfer but did not discuss discharge to the hospital or the other facility and acknowledged that someone should have called the responsible party and that the failure was a violation of resident rights. The Administrator, who was not employed at the time of discharge, also stated the responsible party should have been notified prior to discharge and that the failure violated the rights of the resident and responsible party.

Penalty

Inspection fine: $17,220

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 effective infection prevention and control program in multiple areas of care and environment. For one cognitively intact female resident with dementia, anxiety, depression, diabetes mellitus, atrial fibrillation, bladder incontinence, impaired mobility, and an ADL self-care deficit, a CNA provided incontinent care without adhering to proper hand hygiene and glove use. During the observed episode, the CNA loosened and rolled the soiled brief under the resident, wiped fecal smears from the buttocks, and then, without changing gloves or performing hand hygiene, tucked a clean brief underneath, removed the soiled brief, applied the clean brief, repositioned the resident, straightened the gown, and touched clean linens while still wearing the contaminated gloves. The CNA later acknowledged she should have performed hand hygiene and changed gloves when moving from dirty to clean tasks and that failure to do so could result in cross contamination and infection. The facility also failed to maintain cleanliness and proper handling of soiled items in a communal shower room on one hall. An unoccupied shower room was observed with four wet towels spread on the floor, two soiled wet washcloths hanging from the shower stall railing, and a lidded trash bin that could not close due to overflowing trash, with a folded gown placed on top of the lid. Nursing staff on the shift reported that baths or showers were not scheduled for that shift, stated they had not assisted residents with showers, and indicated they had no knowledge of the shower room being used. Staff interviewed stated that used supplies should have been picked up and the shower room cleaned after use, and that dirty supplies should be picked up and properly disposed of to prevent cross contamination. Additionally, the facility did not ensure proper handling and storage of clean linens. A linen cart on one hall was observed uncovered, and the CNA assigned to that area stated she may have become busy and forgotten to close the cover. She acknowledged that the linen cart should remain covered to prevent cross contamination and decrease the chances of residents getting an infection. Facility policies reviewed, including the perineal care policy and the infection control plan, required appropriate glove use, hand hygiene before and after glove use, proper disposal of soiled items, and handling and storing linens in a manner that prevents the spread of infection. Interviews with the RN, DON, and Administrator confirmed expectations that staff follow proper procedures for incontinent care, shower room cleanliness, and keeping linen carts covered to prevent cross contamination and infection.

Penalty

Inspection fine: $17,220

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 sufficient nursing staff on a 24-hour basis to meet residents’ needs in accordance with the facility assessment, which set a 3.0 PPD for direct nursing care. Multiple confidential staff interviews described frequent short staffing, with CNAs reporting they were often the only aide on a hall that included residents requiring two-person assistance. Staff stated they were unable to complete all assigned tasks, including showers and baths, and that residents sometimes remained dirty or were not gotten out of bed for mealtimes. Several CNAs reported that when they requested help from medication aides or management, they were told those staff were busy, and that nurse management was not assisting with direct care when staffing was short. The DON acknowledged that staff had reported needing more CNAs during staff meetings and stated that the goal was to have one CNA per hall, but also said it had not been reported that staff could not complete their tasks. The Administrator similarly stated it had not been reported that staff were unable to complete their tasks, asserted that staffing needs were being met, and indicated there was no staffing policy. Record review showed the facility assessment, last reviewed on 07/24/2025, required 3.0 PPD of direct nursing care, while facility hours for specific dates in February 2026 demonstrated that the total PPD worked did not reach 3.0 on several of those days. The Area Director of Operations reported he did not know how to generate facility hours for the full months requested, and the complete facility hours for January and February 2026 were not provided upon exit.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure accurate medication administration and adherence to documented drug allergies for one resident. The resident was admitted with diagnoses including traumatic brain injury, diabetes, and muscle weakness, and had a clearly documented allergy to Metformin on the face sheet, physician orders, care plan, hospital records, and the December MAR. Despite this, there was a physician order for Metformin HCL 500 mg by mouth twice daily starting on 12/19/25, and the medication was administered multiple times. The admission MDS showed the resident had moderately impaired cognition with a BIMS score of 11 but was able to understand and be understood. Record review showed that Metformin was documented as an allergy in multiple parts of the medical record, including the face sheet, physician orders, care plan, hospital records, and MAR. The MAR for December indicated that LVN A administered an evening dose of Metformin on 12/19/25, MA B administered morning doses on 12/20/25, 12/21/25, and 12/22/25, and MA C administered evening doses on 12/20/25 and 12/21/25. A nursing progress note entered by the ADON on 12/19/25 at 8:46 p.m. documented that the system had identified a possible drug allergy for the Metformin order, but there was no documentation at that time that the allergy was clarified with the ordering provider or with the resident before the medication was administered. Interviews with staff revealed that LVN A recalled giving the initial dose of Metformin but could not remember if it was listed as an allergy or whether an electronic warning appeared. LVN A stated she discussed allergies with the resident, who denied having allergies she could think of, and the nurse did not know when the Metformin allergy was entered into the record. MA B confirmed administering Metformin and stated it was not on the allergy list she saw and that she was unaware of the allergy, adding that if it had been listed, the system should have warned her or a nurse should have informed her. The ADON and DON both acknowledged that Metformin was already listed as an allergy in the electronic medical record when the provider wanted to restart it, and the DON stated she would have expected the ADON to document the conversation with the resident clarifying that the prior issue with Metformin was stomach upset. The Administrator stated he expected nurses to follow physician orders and to document any clarifying conversations about allergies. The survey finding concluded that the facility failed to provide pharmaceutical services and procedures that assure accurate administration of drugs and biologicals when staff administered a medication listed as an allergy for this resident. Family interviews further confirmed that Metformin had been listed as an allergy for the resident and that the family had been told by the ADON that the resident did not have a reaction when it was given. The family member reported that the resident had not taken Metformin in years and did not know why it was administered again, and that the system had alerted the facility to the allergy. The facility’s admission/readmission policy required notification of applicable allergies to appropriate departments, but the documented allergy to Metformin did not prevent the medication from being ordered and administered on multiple occasions before it was placed on hold on 12/22/25 and discontinued on 12/23/25. The surveyors determined that this failure could place residents at risk for inaccurate drug administration.

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 Director of Nursing (DON) did not serve as a charge nurse or Certified Nursing Assistant (CNA) when the average daily occupancy was 60 or more residents, as required. Record reviews showed that the DON performed CNA duties on 15 separate days and served as a charge nurse on one day during the month of October, despite the census ranging from 66 to 72 residents. Documentation and interviews confirmed that the DON regularly provided direct care, including incontinent care, dressing residents, and rounding, often due to staff call-ins and shortages. The DON stated she was unaware of the regulation prohibiting her from working as a CNA or charge nurse when the census exceeded 60 and explained that she stepped in to ensure residents received care when staffing was insufficient. Interviews with other staff, including LVNs and the ADON, corroborated that the DON and ADON frequently worked on the floor to cover for absent staff. The Administrator and Regional Nurse Consultant (RNC) were also aware of the DON's actions but were not familiar with the regulatory requirement restricting the DON from performing these roles at higher census levels. The DON's job description included augmenting floor staffing if needed, but the facility did not ensure the DON was able to fulfill her designated administrative duties for 40 hours per week due to her involvement in direct care tasks.

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 implement a comprehensive person-centered care plan for three residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #8, an elderly female with a left arm fracture, was not provided with a care plan addressing her fracture, the use of a sling, or her refusal to wear it. Despite being noncompliant with wearing the sling due to discomfort, this was not documented in her care plan, leaving staff unaware of her needs. Resident #7, diagnosed with Alzheimer's disease and other conditions, had a care plan that required staff to remain outside the shower for safety due to her cognitive impairment and risk of falls. However, staff interviews revealed that they did not follow this plan, as they allowed her to shower independently without supervision. This lack of adherence to the care plan was due to staff being unaware of her cognitive issues and the specific requirements outlined in her care plan. Resident #44, an elderly male with Parkinson's disease and other health issues, experienced significant weight loss, which was not reflected in his care plan. Despite physician orders for weight management interventions, such as weekly weight checks and appetite stimulants, the care plan did not address his weight loss. The MDS Coordinator acknowledged that the weight loss should have been care planned, indicating a failure to update the care plan to reflect the resident's current needs and ensure appropriate follow-up by the nursing 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 provide respiratory care consistent with professional standards for three residents requiring oxygen therapy. Resident #9's oxygen concentrator was observed with a thin layer of white particles and thick gray fuzzy material on the vents. Despite being responsible for cleaning the concentrators, the night shift staff did not maintain the equipment properly, as confirmed by LVN P and the Housekeeping Supervisor. This lack of maintenance could lead to overheating of the concentrator and potential respiratory issues for the resident. Resident #61's oxygen concentrator filter was found to be dirty on two separate occasions. LVN G confirmed that the concentrator was supposed to be cleaned by the Sunday night shift, but this was not done, posing infection control issues. The resident, who required total assistance and had severe cognitive impairment, was at risk due to the facility's failure to ensure clean respiratory equipment. Resident #29's oxygen concentrator also had gray fuzzy material on the filter, and the resident was unaware if the staff cleaned it. Interviews with various staff members, including LVN Q, the ADON, and the Maintenance Supervisor, revealed confusion and inconsistency regarding the responsibility and frequency of cleaning the concentrators. The facility's policy on oxygen administration was not followed, leading to potential respiratory infections for the 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 adequate pharmaceutical services for two residents, leading to the administration of anti-hypertensive medications outside of prescribed parameters. Resident #20, an elderly female with severe cognitive impairment and a history of Alzheimer's disease, bradycardia, and hypertensive urgency, was administered Hydralazine despite her heart rate being below the prescribed threshold on two occasions. The medication was given even though her heart rate was 52, which was below the hold parameter of less than 55. Similarly, Resident #26, also with severe cognitive impairment and a history of paroxysmal atrial fibrillation and chronic diastolic heart failure, received Losartan and Metoprolol on multiple occasions when her blood pressure readings were below the prescribed parameters. The medications were administered despite systolic blood pressure readings being close to or below the hold parameter of less than 110, and diastolic readings being below 60. Interviews with facility staff, including a medication aide, LPN, ADON, Administrator, and Regional Compliance Nurse, revealed a lack of adherence to medication administration protocols. The staff acknowledged the importance of following the physician's parameters to prevent potential harm to residents, such as dizziness or cardiac arrest. The facility's policy on medication administration emphasized monitoring specific parameters, but these were not consistently followed, leading to the deficiencies noted 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 provide food that was palatable, attractive, and at a safe and appetizing temperature for four residents and during one of the three meals reviewed. Residents expressed dissatisfaction with the food, describing it as too salty, undercooked, bland, or overly spicy. Specific complaints included food being too salty, doughy breakfast croissants, and a lack of flavor. A confidential group interview also revealed that the food was considered pitiful and bland, with some meals being too spicy. During an observation, the Dietary Manager and surveyors sampled a lunch tray, finding the meatloaf and mashed potatoes satisfactory, but the green bean casserole was bland. The Dietician acknowledged past complaints but believed improvements had been made. The Dietary Manager admitted to ongoing complaints about the food's taste and spiciness, despite menu changes. The Administrator confirmed the existence of food complaints and mentioned the establishment of a food committee to address these issues. The facility's policy emphasized the importance of preparing food to maximize flavor, appearance, and nutritional value, but the execution fell short, leading to resident dissatisfaction.

Penalty

No penalty information released

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

Summary

The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both regular operations and emergencies. The assessment, last completed on 07/24/24, did not accurately reflect the staffing needs as it contained incorrect information. The facility's CMS 802 Resident Matrix indicated a census of 72 residents, but the staffing ratios documented were not adhered to, leading to inadequate staffing levels across various shifts. Interviews with staff revealed consistent understaffing issues. CNAs reported working with fewer aides than required, making it difficult to provide adequate care, such as timely rounds and responding to call lights. For instance, during the 2 pm-10 pm shift, CNAs often worked with only three aides instead of the four documented in the assessment. Similarly, during the 10 pm-6 am shift, aides reported working with only two to three aides, which was insufficient to meet the residents' needs. This understaffing was corroborated by the facility's Payroll-Based Journal, which showed a 1-star staff rating, indicating suboptimal staffing levels. The facility's management was aware of the staffing discrepancies but failed to address them effectively. The Administrator admitted to using the wrong staffing sheet in the facility assessment binder and relied on a PPD formula to determine staffing needs. However, the software used for this purpose was not verified by surveyors, and the Administrator could not provide evidence of its accuracy. The facility's policy required an annual review and update of the assessment, but this was not adequately performed, leading to a failure in ensuring sufficient staffing to meet resident care 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 facility failed to ensure that residents had access to a clean, comfortable, and homelike environment, specifically by not providing enough bed pads for residents experiencing incontinence. During a confidential group interview, residents reported that when they requested bed pads, CNAs informed them that there were not enough available. Observations confirmed that linen carts on multiple halls were lacking bed pads, and staff interviews revealed that management was aware of the shortage but had not addressed it. The Housekeeping Supervisor noted that the issue had been discussed in morning meetings, but no orders for additional bed pads had been placed. Interviews with CNAs and the Regional Compliance Nurse highlighted that staff were aware of the shortage and had reported it to management, but no action had been taken. The Administrator stated she was unaware of the shortage and the discussions in morning meetings. The facility's policy on resident rights emphasized the importance of providing a safe, clean, and comfortable environment, including clean bed and bath linens, 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 ensure prompt efforts were made to resolve grievances for a resident who reported missing clothing items. The resident, who had moderate cognitive impairment, informed the laundry aide about the missing items, which included a pair of white pants with black trim, a denim shirt with pink cuffs, a blue shirt, and a pair of white socks with black and red around the top. Despite the resident's repeated reports over several months, the laundry aide did not file a grievance or notify the Environmental Services Manager, who was unaware of the issue. The Environmental Services Manager and the Administrator both acknowledged the importance of returning personal clothing to residents, but no grievance was filed, and the missing items were not replaced. The facility's grievance policy, which mandates prompt efforts to resolve grievances, was not followed, leading to the deficiency. The failure to address the resident's grievance could potentially impact the quality of life for residents, as their personal property was not returned or replaced in a timely manner.

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 baseline care plan for a resident that included necessary instructions for effective and person-centered care. Specifically, the baseline care plan did not address the resident's use of oxygen, which was a critical component of her care due to her medical conditions. The resident, a female with diagnoses including congestive heart failure, obstructive sleep apnea, and asthma, was admitted with an order for oxygen use at 2-4 liters per minute via nasal cannula. Despite this, the baseline care plan initiated shortly after her admission did not include her oxygen use, which was observed to be in use during her stay. Interviews with facility staff, including an LVN, the MDS Coordinator, the Regional Compliance Nurse, and the Administrator, revealed a lack of clarity and consistency in the process of completing and locating the baseline care plan. The admitting nurse was responsible for completing the baseline care plan, but it was not properly documented or reviewed in a timely manner. The MDS Coordinator and Regional Compliance Nurse acknowledged the importance of including oxygen use in the baseline care plan to ensure all staff were aware of the resident's needs. The facility's policy required the development of a baseline care plan within 48 hours of admission, but this was not adhered to in this case, leading to a deficiency in care planning for the resident's oxygen 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 facility failed to provide necessary services for activities of daily living (ADLs) to two residents, leading to deficiencies in personal hygiene care. Resident #58, a male with vascular dementia, muscle weakness, pneumonia, and hypertension, did not receive proper fingernail care. Observations revealed that his fingernails were long and had black debris underneath, and he expressed a desire to have them trimmed. Despite his moderate cognitive impairment, there was no record of him refusing nail care, and the staff responsible for his care were unaware of the issue. Resident #70, a female with type 2 diabetes, muscle weakness, hypothyroidism, and hypertension, did not receive her scheduled showers. She reported not having a shower for over a week and a half, which led to a rash on her stomach. Despite being scheduled for showers three times a week, the staff failed to ensure she received them. Interviews with staff revealed a lack of awareness and accountability regarding her shower schedule, and there was no documentation of her refusing showers. The facility's staff, including the charge nurse, CNAs, and ADON, were not fully aware of the deficiencies in ADL care for these residents. The charge nurse admitted to not being 100% sure if residents received their showers, and the ADON, who had been employed for three weeks, was unaware of the issues. The facility's policy on resident rights emphasizes the importance of maintaining dignity and quality of life, but the lack of adherence to ADL care protocols resulted in a failure to meet these standards.

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 environment was free from accident hazards by allowing razors to be kept in a resident's bathroom. Resident #47, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found to have multiple razors in a plastic bag hanging off the handrail in her bathroom. This oversight was discovered during an observation, and interviews with staff revealed a lack of awareness and understanding of the policy regarding razors in resident rooms. The presence of razors posed a potential safety risk, as the resident could have injured herself or others. Interviews with various staff members, including a CNA, a hospice aide, an LVN, the ADON, the Regional Compliance Nurse, and the Administrator, indicated that there was confusion and inconsistency in the enforcement of the facility's policy on razors. The staff acknowledged that razors should not be in resident rooms due to the risk of injury, but there was no clear accountability or routine checks to prevent this from happening. The facility's Resident Admission Packet explicitly listed razors as items not allowed in resident rooms, yet this policy was not effectively communicated or enforced, leading to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident or their responsible party was informed and participated in treatment decisions regarding the use of psychoactive medications. Specifically, the facility did not complete Form 3713 for a resident who was prescribed Seroquel, an antipsychotic medication, for depression. The form was missing diagnostic criteria and assessment findings necessary for the use of the medication, which is required to inform the resident or their representative of the risks and benefits of the treatment. The resident in question was a female with a history of stroke, Parkinson's disease, and dementia, who was severely cognitively impaired. Despite this, the facility's records showed that she was prescribed Seroquel for depression and had been receiving the medication regularly. However, the consent form for the use of this psychotropic medication was incomplete, lacking essential information about the diagnostic criteria and assessment findings that justified the medication's use. Interviews with facility staff, including an LVN, the ADON, and the facility's physician, revealed that there was a lack of awareness and oversight regarding the completion of the consent form. The physician was unaware that the form was incomplete, and the ADON acknowledged that the nurse who received the order was responsible for obtaining the consent. The facility's policy requires that consent forms for psychotropic medications be filled out completely and signed before administration, but this was 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 adequate pharmaceutical services for two residents, leading to discrepancies in medication administration and record-keeping. Resident #2, who has a history of cognitive impairment and anxiety, was not properly accounted for when taking Ativan during leaves of absence. The facility did not ensure that the medication release forms were signed by the resident's family member, and there were inconsistencies in the reconciliation of Ativan tablets upon the resident's return. Interviews with staff revealed that discrepancies in the medication count were not reported to the Director of Nursing (DON) or the Administrator, and the facility's policy did not adequately address the reconciliation of medications upon a resident's return. Resident #1, who has a diagnosis of paroxysmal atrial fibrillation, did not receive her prescribed dose of Eliquis on a specific date. The medication aide, MA B, failed to administer the medication due to a lack of attention and did not utilize the facility's emergency medication supply. The pharmacy had not sent the refills in a timely manner, and the DON was not informed of any issues with medication refills. The facility's policy required that medications be administered as ordered unless contraindicated, but this was not followed in Resident #1's case. The facility's failure to ensure proper medication administration and reconciliation could lead to medication errors and inaccurate records. The Administrator and DON were not adequately informed of the discrepancies, and the facility's policies did not sufficiently address the procedures for medication reconciliation when residents returned from leaves of absence. These deficiencies highlight a lack of oversight and communication within the facility regarding pharmaceutical services.

Penalty

Inspection fine: $15,945

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 resident environment was free from accident hazards, specifically by not securing a freestanding closet to the wall. This oversight resulted in a serious incident involving a resident who was moderately cognitively impaired and had a history of falls. The resident attempted to retrieve clothing from the unsecured closet, lost his balance, and pulled the closet down on top of himself, leading to a severe head injury. The resident, an elderly male with diagnoses including orthostatic hypotension, heart failure, muscle weakness, and a history of falls, was found on the floor with the closet toppled over him. He sustained a laceration to the back of his head and was bleeding. Despite being alert and oriented, the resident was sent to the emergency room for further evaluation due to the severity of the bleeding and the impact of the closet falling on him. Hospital records indicated that the resident developed a subdural hematoma, which worsened, leading to an altered level of consciousness. Despite undergoing an emergency craniotomy, the resident's condition was critical, and he eventually expired. The facility's failure to secure the closet to the wall was a significant factor in the incident, as the resident's attempt to steady himself by holding onto the closet led to the accident.