Prairie Meadows Rehabilitation And Healthcare Cent

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice by not accurately performing a head-to-toe readmission assessment and not identifying a peripheral IV catheter on a resident’s chest for several days. The resident, an older female with atrial fibrillation, type 2 diabetes mellitus, GERD, open wounds on the right lower leg and left buttocks, and muscle weakness, was originally admitted and later readmitted with hospital documentation that included an order for IV potassium chloride with a central line recommendation. On readmission, the admission MDS and baseline care plan did not reflect that the resident was receiving IV medications, and the skin assessment documented existing skin or wound issues but did not identify any IV on the chest area. The charge nurse who completed the readmission head-to-toe assessment stated she was not aware of an IV and would have documented it if she had seen it, acknowledging that if an IV was not noted on a skin assessment it could get infected. The peripheral IV catheter on the resident’s left breast was not discovered until a family member found it and notified staff on a later date, at which time it was removed by nursing staff, who documented that the catheter was intact and the resident reported no pain. Interviews with another LVN confirmed that a regular peripheral IV catheter was present and appeared normal, and that a proper head-to-toe assessment should have identified and documented such a device. The DON stated that if a resident had an IV, it should have been noted on the readmission skin assessment and that the facility’s usual practice would be to notify the provider and obtain orders for IV care. Facility policies on skin integrity and charting required timely and complete assessment and documentation of all services, treatments, and changes in condition, including devices and procedures, but the presence of the IV catheter on the resident’s chest was not assessed or documented from readmission until it was discovered by the family member.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide appropriate incontinent and catheter care to residents with indwelling catheters, resulting in inadequate perineal cleansing and improper catheter bag positioning. One female resident with anoxic brain damage, neuromuscular bladder dysfunction, and severe cognitive impairment was always incontinent of bowel and bladder and had an indwelling Foley catheter ordered with catheter care every shift. During observed peri care after a bowel movement, the CNA cleansed only the external front perineal area without separating the resident’s legs or labia. When asked to demonstrate the care just provided, the CNA then separated the labia, at which time brown fecal matter was observed in the pubic hair and inner labial area, and subsequent cleansing produced wipes containing brown fecal matter. The CNA later acknowledged she should have opened the resident’s legs more to clean between the labial folds and that not doing so could place the resident at risk of infection. The same resident’s catheter bag was observed hanging on the side of the bed and touching the floor during the incontinent care. The resident’s care plan directed that the catheter bag and tubing be positioned below the level of the bladder and away from the entrance room door, and the facility’s Foley catheter policy instructed staff to secure drainage tubing to the bed frame and allow tubing to rest on the bed surface. The DON stated staff should place a basin under the catheter bag to prevent it from touching the floor and that staff should clean between the labia folds to prevent UTIs. Facility documents showed that the CNA had completed orientation and an incontinent care skills competency checklist indicating she had been evaluated as meeting competency in positioning the resident with legs apart and washing the perineal area from front to back, including thorough cleansing and drying, and the facility’s perineal care policy required staff to separate the labia and wash from front to back, including the inner labial area and rectal area. A male resident with hydronephrosis, dementia with moderate cognitive impairment, and impaired bowel and bladder evacuation used a Foley catheter and was care planned as incontinent of bowel and bladder. His care plan documented that he at times removed his privacy bag and leg strap, pulled on the Foley tubing, carried the bag in his lap or let it drop to the floor, and placed the Foley bag on the bed instead of hanging it on the bed frame. During observation, his catheter bag was seen lying on the floor by his bed on more than one occasion. A CNA stated staff tried to hang the catheter bag on the side of the bed but, due to the low bed position and fall mat, it was difficult to keep the bag off the floor, and that the resident frequently moved the bag himself and sometimes walked while holding it. An LVN acknowledged knowing the catheter bag touched the floor because of the low bed position and stated this could cause an infection, and also reported that when the resident was in his wheelchair he often tried to hook the bag on his belt and had to be redirected that it needed to be lower, while also stating she was not sure what could be done to prevent infection from the bag touching the floor.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurate medical records for one resident by allowing blanks on the Medication Administration Record (MAR). The resident was an older female with atrial fibrillation, type 2 diabetes mellitus, GERD, open wounds on the right lower leg and left buttocks, and muscle weakness, who did not self-administer medications and required partial or moderate assistance with personal hygiene. Her admission MDS showed a BIMS score of 12, indicating moderately impaired cognition. Review of her December MAR showed blanks on specific dates for esomeprazole magnesium 40 mg, ordered for GERD, with no documentation to indicate whether the medication was administered, refused, held, or unavailable. Additional daily scheduled orders on other dates were also left blank without any coding or initials. Nursing progress notes indicated that the resident was in the hospital between certain dates and was later discharged home, but the MAR was not coded to reflect her hospital status or any refusals of medication. During interview, the DON stated that staff were expected to enter a code on the MAR rather than leave entries blank, including codes indicating hospitalization or refusal of medications. The facility’s policy on Charting and Documentation required that medications administered be documented and that documentation be complete and accurate. The presence of blank MAR entries for this resident demonstrated that the facility did not follow its own policy or accepted professional standards for complete and accurate medical record documentation.

Penalty

Fine: $21,645

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

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for a resident who had a stage 3 pressure ulcer. The resident, who had diabetes, morbid obesity, and severe protein-calorie malnutrition, was cognitively able to make decisions and was at risk for pressure ulcers. A stage 3 pressure ulcer on the resident’s left buttock was identified by the Wound Care NP on 11/20/2025, but the facility did not create a corresponding care plan until 12/31/2025, 41 days later. When the care plan was finally created, it incorrectly documented the wound as being on the right buttock instead of the left and did not include interventions addressing the resident’s ongoing refusals of skin assessments and wound care. In the weeks leading up to and following the identification of the reopened stage 3 pressure ulcer, the resident repeatedly refused skin assessments and wound evaluations by the DON, charge nurses, and the Wound Care NP. Weekly body skin checks and wound progress notes documented multiple refusals from late October through the end of December, including refusals to allow assessment of an open area first reported by a CNA on 10/26/2025. Despite these repeated refusals and the presence of a known stage 3 pressure ulcer on the left buttock as of 11/20/2025, the resident’s care plan was not updated in a timely manner to reflect the wound, its correct location, or specific, person-centered interventions to address the refusals and associated risks. On 12/24/2025, staff discovered maggots in the resident’s stage 3 pressure ulcer and in fecal material during a bed bath after the resident had refused incontinent care and wound care for days. CNAs and LVNs reported that the resident frequently refused to be checked, changed, showered, or to receive wound care, often telling staff to leave him alone, turning his face to the wall, or ceasing communication. Nursing notes documented multiple instances where the resident refused wound care, personal hygiene, and bed baths, even after education on the importance of clean, dry skin and wound care. Although the Wound Care NP and physician were notified of the refusals and the presence of maggots, the facility’s care plan still lacked timely, accurate, and comprehensive interventions addressing the resident’s wound, its correct site, and his persistent refusals of care, leading surveyors to identify a failure to develop and implement a comprehensive person-centered care plan consistent with the resident’s assessed needs. Interviews with facility leadership and staff further confirmed that the care plan for the stage 3 pressure ulcer was not created or revised when the wound reopened and that refusals of care were not incorporated into the care plan during the period when the wound was present and worsening. The DON and Administrator acknowledged that delays in revising care plans could result in staff not knowing what to implement for the resident and that the resident might not receive the care outlined in the plan. The MDS nurse stated that care plans were generally reviewed quarterly unless there was a change in the resident, and confirmed that the care plan for the stage 3 pressure ulcer was not revised until 12/31/2025, despite the resident’s history of refusing showers, incontinent care, and wound care. The facility’s own policy required ongoing assessment and timely revision of care plans as residents’ conditions changed, but this process was not followed for this resident’s pressure ulcer and refusal behaviors, resulting in the cited deficiency.

Removal Plan

• Immediately update Resident #1's care plan to address refusal of skin assessments, refusal of wound treatment, and associated risks related to pressure injury deterioration and infection, including person-centered measurable interventions for refusal management, education, monitoring, and escalation.
• Have nursing leadership review the updated care plan with staff to ensure awareness and implementation.
• Provide in-service education for licensed nurses on F656 person-centered care planning requirements, incorporating care refusals into care plans when refusals impact medical/nursing needs, and ensuring care plans include measurable objectives, timeframes, and specific interventions.
• Provide in-service education for licensed nurses and CNAs on proper management and documentation of refusal of skin assessments and wound treatment, required escalation/notification when refusals place a resident at risk, and balancing resident rights with professional standards of care and safety.
• Reinforce a care plan review process requiring care plans to be updated when refusals of treatment/assessment are ongoing, a resident's clinical condition changes, or identified risks increase due to refusal behavior.
• Prevent staff from working until education and competency is completed.
• Incorporate the education into new hire onboarding.
• Implement a defined refusal process: CNAs notify the licensed nurse; the licensed nurse assesses, educates on risks, documents refusal, and notifies charge nurse and DON/designee for high-risk refusals; notify the physician when refusals impact ability to assess/treat conditions requiring medical oversight.
• Assign responsibility for updating the care plan to the licensed nurse in collaboration with the interdisciplinary team, with DON/designee oversight to ensure timely completion and implementation.
• Maintain continuity by updating care plans as long as refusals persist or risks remain, revising based on changes in condition, response, or acceptance of care.
• Monitor care plan updates through DON/designee routine audits and clinical oversight, including review of refusal documentation, care plan accuracy, and staff implementation.
• Provide refusal-of-care training to all direct care staff (licensed nurses and CNAs) covering identification, reporting, documentation, escalation, and implementation of person-centered interventions.
• Conduct weekly audits for four weeks, then monthly thereafter, of residents with pressure injuries and residents with documented refusals of care to verify refusals are reflected in the care plan, care plans include measurable objectives/interventions, and staff are implementing interventions as written; review results through QAPI and implement corrective actions as indicated.

Penalty

Fine: $21,645

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

Summary

The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards of practice and to prevent the development and worsening of a pressure injury for one resident. The resident was an adult with diabetes, morbid obesity, and severe protein-calorie malnutrition, and was identified as at risk for pressure ulcers on a quarterly MDS, with no unhealed pressure ulcers at that time. A previously resolved stage 3 pressure ulcer on the left buttock was reported by a CNA on 10/26/2025 as having reopened, but the resident repeatedly refused skin and wound assessments by the DON, charge nurse, and Wound Care NP over multiple documented dates in late October and November. Despite these refusals, the facility’s care plan for a stage 3 pressure injury was not created and revised until 12/31/2025, 41 days after the ulcer was assessed and identified on the left buttock, and the care plan incorrectly referenced the right buttock and did not include interventions addressing the resident’s refusals. On 11/20/2025, the Wound Care NP assessed the resident and identified a reopened stage 3 pressure ulcer on the left buttock measuring 4 cm x 5 cm x 0.2 cm, with recommendations to cleanse with 0.25% Dakins solution, apply collagen with silver, and cover with a silicone bordered superabsorbent dressing. These wound care recommendations were not implemented in the physician orders until 11/28/2025, resulting in an 8‑day delay in initiating the ordered treatment. During this period and afterward, the resident frequently refused wound care and incontinent care. TARs showed multiple refusals of daily wound care from late November through December, and weekly wound observations documented that the resident was mostly non-compliant with recommended interventions, frequently declined bed baths, and frequently refused to be changed by staff. Nursing notes indicated that staff attempted redirection, offered choices of caregivers, and modified approaches, but the refusals persisted. On 12/24/2025, concerns about the resident’s hygiene, skin integrity, and personal care needs prompted further nursing evaluation. CNAs and LVNs reported that the resident had been refusing incontinent care and showers for days, and when staff ultimately provided a bed bath, they observed maggots in the resident’s bed, groin area, and in feces, as well as in association with the wound. The DON’s weekly wound observation on that date documented that the stage 3 pressure injury on the left buttock had increased in size to 6 cm x 3.5 cm x 2 cm. Interviews with CNAs and LVNs confirmed that refusals were reported to nurses, that staff made repeated attempts to persuade the resident to accept care, and that the resident sometimes delayed or continued to refuse care despite education. The Wound Care NP stated she had not been able to reassess the wound after 11/20/2025 due to ongoing refusals and continued the prior treatment order without change. An Immediate Jeopardy situation was identified on 01/02/2026 related to the failure to timely implement wound care recommendations and to effectively manage and escalate the resident’s ongoing refusals of care in the context of a worsening stage 3 pressure injury. The facility’s own Pressure Injury Prevention Program policy required risk assessment at admission, quarterly, and with significant change in condition, as well as weekly skin checks and timely adjustment of interventions based on assessment findings. Despite this, the resident’s reopened wound identified by CNA report on 10/26/2025 and confirmed by the Wound Care NP on 11/20/2025 did not result in a timely, accurate, and fully developed care plan, and the wound care orders recommended on 11/20/2025 were not implemented until 11/28/2025. Documentation showed repeated refusals of wound care and personal care, but the care plan lacked specific interventions addressing these refusals, and there was no documented explanation from the DON for the delay in starting the recommended wound treatment. These actions and inactions led to the resident’s stage 3 pressure injury worsening in size and to the presence of maggots in the wound and surrounding areas on 12/24/2025, forming the basis of the cited deficiency.

Penalty

Fine: $21,645

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 pest control program and to keep the environment free of pests and rodents, resulting in a resident being found with maggots in a left buttock stage 3 pressure injury. The resident was an adult male with a history of seizures, type 2 diabetes mellitus with hyperglycemia, and hemiplegia/hemiparesis, with documented moderate cognitive impairment (BIMS 12). His MDS showed he was always incontinent of bowel, required substantial assistance with bed mobility, did not use mobility devices, and had range-of-motion impairment on one side of both upper and lower extremities. Clinical records showed that on a prior date a CNA reported the wound on his bottom had reopened, but the resident declined to allow the nurse to assess it. A subsequent NP wound note documented a left buttock stage 3 pressure ulcer with slough and moderate serosanguinous drainage, and orders were in place for specific wound care including cleansing with Dakin’s solution, application of collagen with silver, and a silicone bordered superabsorbent dressing. On the date of the incident, CNAs providing a bed bath reported seeing maggots on the resident and in his feces while he was being turned and cleaned. One CNA stated she was told by a nurse that the resident needed to be changed because he smelled and maggots were found in his groin area; upon pulling down the covers, she observed maggots in the groin area and then moved to wash the resident’s hair. Another CNA reported that while giving the bed bath, they saw maggots on the resident and in his feces and continued with the bath. The DON was informed of the maggots by an LVN, although the DON did not personally witness the insects. The resident later stated that he had previously had issues with flies in his room and that he had notified several staff members, including the DON and the Administrator, about the flies before insects were identified in his wound. Environmental observations by surveyors revealed multiple conditions that could allow pest entry and presence in the facility. A dead fly was observed on the window ledge in the resident’s room. Facility-wide, more than three window screens per hall were missing or ill-fitting, one lobby window had no screen and was partially open, and another window had a torn screen and was open several inches. The exit door at the end of one hallway had a gap between the bottom of the door and the floor. A box with one side cut out, a blanket, and what appeared to be a bowl with food were observed outside an exit door. A dead roach was found in a kitchen cabinet under a sink. Some exit doors lacked flying insect traps, and a dining room exit door was observed propped open during an outdoor activity. Staff interviews indicated that the Administrator had only one reported pest issue in the prior month, pest control was not notified when maggots were found on the resident, and the DON and Administrator reported not having heard concerns about flies in the recent past. The facility’s pest control policy required that windows be screened at all times, but surveyors confirmed torn, missing, and open windows that could allow pests to enter, supporting the finding that the facility failed to maintain an effective pest control program.

Removal Plan

• Upon identification of maggots in Resident #1's left buttock stage 3 pressure injury, nursing staff cleansed the wound, removed all visible insects, and applied a clean, secure dressing.
• The attending physician was notified and wound care orders were reviewed and implemented by the DON.
• Resident #1 was assessed for signs of infection and discomfort and monitored per nursing protocol by the DON/designee.
• An insect fan was placed in the resident's room to reduce fly exposure.
• Emergency pest control services were contacted to provide additional services.
• The Administrator and Maintenance Director conducted a facility-wide inspection.
• All missing, torn, or ill-fitting window screens were repaired, replaced, or secured.
• The DON/Nursing Administration conducted a visual assessment of all residents with wounds to ensure they were free of pests.
• The Administrator notified the Medical Director of the Immediate Jeopardy.
• The Regional Director of Operations in-serviced the Administrator and DON on prompt reporting of insects/environmental concerns, updating the pest control log, maintaining screened/closed windows, monitoring wounds for contamination risks, pest control policy requirements, and prompt follow-up on resident complaints.
• All staff received education on prompt reporting of insects/environmental concerns, maintaining screened/closed windows, monitoring wounds for contamination risks, and pest control policy requirements.
• A post-education quiz will be conducted to determine competency; staff will not be able to work until the quiz is passed with a grade of 100%.
• Education and competency will be incorporated into new hire onboarding.
• Maintenance will complete weekly documented inspections of all windows and screens; deficiencies will be corrected immediately or the window taken out of service.
• Routine pest control services will continue as scheduled.
• Pest control logs will be reviewed weekly by the Administrator or designee.
• Any evidence of insect activity will trigger immediate treatment including prompt assessment, wound protection, removal of insects, physician notification as needed, and immediate environmental and pest control interventions.
• The DON/designee will conduct weekly audits of residents with open wounds to ensure wounds are clean, covered, and free from environmental exposure; findings will be documented and reviewed through QA/QAPI.
• The Administrator and DON will conduct weekly environmental rounds to verify sustained compliance.

Penalty

Fine: $21,645

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 a failure to maintain personal privacy and dignity for a resident during tracheostomy care. A licensed vocational nurse (LVN J) was observed on 12/31/2025 at 9:37 a.m. providing tracheostomy care to Resident #8 with the resident’s room door open, the curtain between the A and B beds open, and the window blinds open. During a subsequent interview, LVN J acknowledged having received training on resident privacy and stated she should have closed the room door and pulled the privacy curtain while providing tracheostomy care, and that providing privacy during care is important for resident dignity. The DON also stated that staff members are expected to pull privacy curtains and close a resident’s room door when any resident care, including tracheostomy care, is provided, and confirmed that staff had been trained on resident privacy. Resident #8’s records showed she was an older adult female with anoxic brain damage, dementia, and tracheostomy status, admitted with multiple complex medical needs. Her quarterly MDS dated 09/23/2025 documented severely impaired cognitive skills for daily decision making, impaired upper and lower extremities, and total dependence on staff for all ADLs and bed mobility. She had an indwelling catheter, a feeding tube for nutrition, and received tracheostomy care, oxygen therapy, and suctioning. Treatment orders included changing trach ties daily and as needed for soiling. The facility’s Resident Rights policy stated that residents have the right to a dignified existence and to be treated with dignity and respect for their personal integrity, which was not followed during the observed episode of tracheostomy care.

Penalty

Fine: $21,645

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 follow its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) requirements, for a resident with multiple indwelling devices. The resident was an older female with anoxic brain damage, dementia, severely impaired cognitive skills, impaired upper and lower extremities, and total dependence on staff for all ADLs and bed mobility. She had a tracheostomy, an indwelling urinary catheter, and a feeding tube, and received tracheostomy care, oxygen therapy, and suctioning. Her physician orders included EBP every shift and daily/prn trach tie changes, and her comprehensive care plan documented that she required EBP related to her feeding tube and tracheostomy. A sign posted outside her room indicated she was on EBP and listed device care for a tracheostomy as a high-contact resident care activity requiring gown and gloves. During an observation, an LVN entered the resident’s room to perform tracheostomy care. The LVN donned gloves, removed the oxygen mask from the resident’s tracheostomy, and attached a new oxygen mask, but did not wear a gown despite the EBP sign and the resident’s EBP orders. In an interview, the LVN acknowledged that residents with Foley catheters, infections, or tracheostomies were on EBP and were identified by a sign outside the doorway, but stated that when caring for residents on EBP, staff were supposed to wear gloves and “maybe” gowns, depending on the situation, and that she did not think a gown was needed for tracheostomy care. The DON stated that residents with indwelling devices such as tracheostomies would be on EBP and that staff were expected to wear a gown and gloves when providing direct care to such residents. The facility’s EBP policy and the posted sign both specified that gown and glove use was required for high-contact activities including device care for tracheostomies, indicating that the observed care did not comply with facility policy and the resident’s EBP orders.

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 professional staff member, specifically an LPN, maintained a current and valid nursing license in accordance with state laws. Record review showed that the LPN's license had expired, and the staff member continued to work one or two shifts after the expiration date. The facility's staff roster and Texas Board of Nursing license verification confirmed the lapse in licensure. The LPN was only notified of the expired license after working these shifts and was subsequently suspended until the license was renewed. Interviews with the administrator and the LPN confirmed that the lapse was due to the LPN forgetting to re-apply for licensure, despite having completed the necessary continuing education. The facility's policy required monthly review and communication of upcoming license expirations, but this process did not prevent the LPN from working with an expired license. The deficiency was identified through both record review and staff interviews.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurate medical records for a resident, specifically by not documenting the resident's weights in the electronic medical record (EMR) for four out of five weeks during the review period. Although the facility's policy required new admissions to be weighed weekly for the first four weeks and for weights to be recorded in the EMR, the resident's weights were missing from the EMR for the weeks in question. The Director of Nursing (DON) acknowledged that weights were sometimes documented on paper and not entered into the EMR, citing being short-staffed as a reason for the omission. The administrator confirmed that the facility's weight monitoring reports relied on data entered into the EMR, and missing entries could affect the facility's ability to detect weight changes. The resident involved was an older male with a history of cerebral infarction, muscle wasting, atrophy, and lack of coordination. He was at moderate risk for malnutrition, obese, and at risk for weight changes due to edema and diuretic use. The resident's progress notes and nutritional therapy evaluation did not contain alternative documentation of weights for the missing weeks. Handwritten records were available but not consistently dated or entered into the EMR as required by facility policy. This incomplete documentation was identified through observation, interviews, and record reviews.

Penalty

Fine: $20,965

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 supervision and assistive devices to prevent accidents for a resident who was confused and required assistance to ambulate. The resident, who had a history of altered mental status, delirium, and severe cognitive impairment, fell out of bed and sustained a left femoral neck hip fracture. At the time of the incident, the resident's bed was not in a low position, and a fall mat was not in place, despite these interventions being part of the resident's care plan. The resident's care plan indicated that he was at risk for falls due to poor balance, unsteady gait, and other medical conditions. The care plan included interventions such as the use of a fall mat and maintaining the bed in a low position. However, on the night of the fall, staff observed that the resident was confused and talking to imaginary people. Despite staff efforts to redirect him, the resident attempted to get out of bed, believing he was getting into a car, which led to his fall. Interviews with staff revealed that the resident had a history of moving his bed to a higher position after staff had lowered it, and there was uncertainty about whether a fall mat was in place at the time of the fall. The staff had been aware of the resident's confusion and had been monitoring him, but the lack of proper interventions and supervision at the critical moment resulted in the resident's fall and subsequent injury.

Penalty

Fine: $20,965

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 report an incident of neglect involving a resident who experienced an unwitnessed fall in his room, resulting in a possible hip injury. The fall occurred on 11/01/2024, and a subsequent CT scan revealed a left femoral hip fracture. Despite the severity of the injury, the incident was not reported to the state agency as required by regulations, as of 11/06/2024. This oversight could potentially place other residents at risk due to delays in reporting such incidents. The resident involved was a male with a history of severe cognitive impairment, requiring substantial assistance for mobility and transfers. His care plan indicated a risk for falls due to various factors, including poor balance and psychoactive drug use. On the night of the fall, the resident was found confused, attempting to get into a car, which was a delusion, and subsequently fell, leading to his transfer to the emergency room where the fracture was diagnosed. Interviews with facility staff revealed a breakdown in the reporting process. The LPN on duty reported the fall to the DON and the facility's contracted physician group, but the incident was not reported to the state. The DON was unaware of the reporting requirements and relied on the regional administrator, who incorrectly determined the incident was not reportable. The facility's policies on incident reporting and abuse prohibition were not followed, contributing to the failure to report the serious injury in a timely manner.

Penalty

Fine: $20,965

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 post daily nurse staffing information for two consecutive days, specifically on 11/05/2024 and 11/06/2024, as required by their policy. During an observation on 11/06/2024, it was noted that the Daily Nurse Staffing Report dated 11/04/2024 was still posted, indicating that the information had not been updated. The Director of Nursing (DON) acknowledged the outdated posting and attempted to locate the current document but was unsuccessful. The DON admitted to not knowing why the postings for the two days in question were not updated and did not perceive any harm from the oversight, citing regular staffing reviews and familiarity of resident families with the staffing schedule. Further investigation revealed that the Assistant Director of Nursing (ADON) had the Daily Nurse Staffing Reports for the missing days in her schedule book, as she was in the process of inputting scheduled hours. The ADON confirmed that the reports were not posted because they were in her possession, but did not provide a reason for why they were not posted on the required days. The facility's policy mandates that staffing information be posted within two hours of the beginning of each shift in a prominent location, and the failure to adhere to this policy could potentially limit access to important staffing data for residents, families, and visitors.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment for four residents. Observations revealed that one resident's bathroom floor molding was detached from the wall, while another resident's bathroom ceiling vent was rusty and covered with dirt particles. Additionally, a third resident's bathroom and bedroom ceiling vents were covered with dust and dirt particles. Furthermore, a fourth resident's toilet was running continuously and would not shut off on its own. The facility's Administrator, upon observation, confirmed the need for repairs in the residents' bathrooms to promote a more homelike environment. The Administrator noted that the maintenance position had been vacant for over a month, and a new Maintenance Director had just started employment. The facility's policy, dated 2021, mandates providing residents with a safe, clean, comfortable, and homelike environment, which was not adhered to in these instances.

Penalty

No penalty information released

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

Summary

The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the Director of Food and Nutrition Services (DM) did not possess the necessary certification, education, or qualifications required for the role. The DM was hired on October 20, 2023, and her personnel file lacked evidence of certification as a dietary manager, food service manager, or any similar national certification. Additionally, she did not have an associate's or higher degree in food service management or hospitality, nor did she have two or more years of experience in a similar position in a nursing facility setting. The DM admitted during an interview that she was not certified and was not enrolled in a certification program. The facility's Registered Dietitian (RD) was contracted and not a full-time employee, which may have contributed to the deficiency in the food and nutrition services. Interviews with the HR Director and the Administrator revealed a misunderstanding regarding the DM's certification status, with the Administrator believing the DM had a year from her hire date to become certified and was enrolled in a program, which was not the case. This lack of appropriate staffing and certification could place residents at risk of foodborne illness and inadequate nutrition, as the facility did not meet the required standards for food service management and safety.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, a bag of strawberries was found in the reach-in freezer without a label indicating a use-by date. Additionally, a loaf of bread and three packages of tortillas in the dry storage room were found to be past their use-by dates. These lapses in food storage and labeling could potentially place residents at risk for foodborne illness. During an interview, the Dietary Manager (DM) acknowledged that the strawberries should have been properly labeled and dated by the cook or dietary aide who returned them to the freezer. The DM also admitted that the loaf of bread and tortillas should have been discarded by the date marked by the facility. Despite routine checks to ensure proper product rotation, these items were missed. The facility's policies on refrigerator and freezer maintenance, as well as dry storage, emphasize the importance of dating food items to ensure proper rotation and adherence to expiration guidelines, which were not followed in these instances.

Penalty

No penalty information released

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

Summary

The facility failed to provide safe and appropriate respiratory care for two residents who required nebulizer treatments. Observations revealed that the nebulizer tubing for both residents was left unbagged and undated on their bedside tables. This practice was inconsistent with professional standards and the facility's policy, which required equipment to be changed every seven days or according to facility protocol. Interviews with the residents indicated a lack of awareness regarding the proper handling of nebulizer tubing. Further interviews with the assigned LVN and the Director of Nursing (DON) confirmed that the nebulizer tubing should have been bagged and dated by the night shift. The LVN admitted to not knowing why the tubing was not properly managed, and the DON acknowledged the oversight, stating that the Assistant Director of Nursing (ADON) was responsible for monitoring this task. The failure to bag and date the nebulizer tubing placed the residents at risk for possible respiratory infections.

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 medications were properly secured for a resident, leading to a deficiency in medication storage practices. Specifically, an albuterol sulfate inhaler was observed on the bedside table of a 74-year-old male resident with diagnoses including spina bifida, asthma, and osteoporosis. The resident had a BIMS score of 13, indicating intact cognition, but there was no physician order allowing him to self-administer medication. The facility's policy required that residents could only self-administer medication if approved by the attending physician and the interdisciplinary care planning team. Interviews with the resident and staff revealed that the resident used the inhaler as needed without notifying the nursing staff, as he did not want to bother them. The assigned nurse was unaware that the inhaler should not be at the bedside, and the Director of Nursing confirmed that the resident should not have any medication at the bedside without a proper order. The facility's policy on medication administration was not followed, as there was no care plan addressing the resident's self-administration of medication.