The Chateau Waco

Penalty

No penalty information released

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

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen reviewed for sanitation. During observation and interview, dented cans were seen on a lower shelf under the food preparation table, and [NAME] A stated that the previous DM had instructed cooks to use the dented cans first rather than discard them or return them to the supplier. [NAME] B also stated that the dented cans on the lower shelf were separated from regular cans for use first in cooking, and she said her training had told her to use dented cans first, although she did not personally use them because she believed undamaged cans should be used. The SFDM stated that the facility practice should have been to place dented or damaged cans in the DM's office and/or dump them out, and that they were not to be used for resident meals because metal shavings could get into food. The ADM and DON stated they were not aware the previous DM had told cooks to use dented cans, and they described the process as checking cans before unloading and returning or refusing damaged cans. Review of the 2022 FDA Food Code and the August 2021 TFER showed that damaged or dented cans may present a serious hazard and that food must be obtained from approved sources and be in sound condition for human consumption.

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 Resident #39 was treated with dignity and respect. Resident #39 was a woman with diagnoses including COPD, hyperlipidemia, cerebral infarction, and major depressive disorder. Her quarterly MDS showed a BIMS score of 14, indicating no cognitive impairment, and her care plan identified depression with a goal that she would not exhibit signs of isolation. The care plan interventions directed staff to convey acceptance, establish a trusting relationship, and support her mood and behaviors. During an observation, MA F was heard entering Resident #39's room and saying, "Why are you walking around with scissors? What is wrong with you?" MA F then told the resident to "come over here and sit-down little girl" in a demeaning manner. The resident's husband stated he and his wife had ongoing issues with MA F and that the way MA F communicated with them made him feel angry and hurt for his wife. Other staff interviewed stated residents should always be spoken to with respect and that calling a resident "little girl" would not be appropriate.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident observed for infection prevention. Resident #69 was a female with diagnoses including Type II Diabetes, vascular dementia, respiratory disorders and diseases, hypertension, sleep apnea, uninhibited neuropathic bladder, transient cerebral ischemic attack, and congestive heart failure. Physician orders dated 02/23/2026 indicated Enhanced Barrier Precautions (EBP) for high resident contact care activities, with indwelling catheter care each shift, and the care plan directed staff to use gowns and gloves for all personal care. During observations on 03/18/2026, CNA C and CNA D performed peri care and catheter care for Resident #69 using aseptic technique, cleansing hands and changing gloves at appropriate intervals, but they did not wear gowns while providing the care. At the time of the observation, there was no sign on the resident’s door or name plate indicating EBP, and there was no supply of PPE outside the door as was noted at other resident rooms with EBP indicators. The observed care included catheter and peri care, which staff identified as care that typically requires EBP when a resident has an indwelling device. Interviews with CNA C, CNA D, LVN E, WCN, the IP, the DON, and the ADM showed that staff understood residents with catheters, wounds, feeding tubes, and other devices were typically placed on EBP and that gowns and gloves were expected for high-contact care. Staff also stated that EBP status was usually identified by a sign on the door, an EBP sticker by the name plate, information in PCC, and report from the nurse. The IP stated she was responsible for placing the signs, though she believed a sign had been placed on Resident #69’s door and may have been removed by a disgruntled staff member. The facility policy titled IPCP standard and Transmission-Based Precautions-Infection Control stated that EBP requires gown and glove use during high-contact resident care activities, including indwelling urinary catheter care and wound care.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident with multiple pressure ulcers and complex wound care needs. The resident was an elderly male with diagnoses including essential hypertension, dysphagia, edema, severe cognitive impairment (BIMS score of 3), and multiple pressure ulcers on the left distal medial foot, left lateral foot, right hip, left hip, coccyx, and sacrum related to reduced mobility. Physician orders directed specific wound treatments to the coccyx, sacrum, left distal medial foot, left lateral foot, and left hip, including the use of zinc oxide, Dakins solution, normal saline, alginate calcium, and dressings at prescribed frequencies. Record review of the Medication Administration Record (MAR) showed that on one date, wound treatments ordered three times every shift for the coccyx and sacrum were not signed off by an RN for the 7:00 PM and 11:00 PM times, and daily wound treatments for the left distal medial foot, left lateral foot, and left hip were not signed off for the 7:00 AM–7:00 PM period. On another date, the coccyx and sacrum treatments ordered three times every shift were not signed off by a different RN for the 7:00 PM time. The DON and ADM both stated that the expectation was for nurses to sign off in the electronic MAR (Matrix) once treatments were completed, and that an unsigned MAR entry would indicate the treatment was not completed. In interviews, the wound care doctor reported visiting weekly, debriding the resident’s foot on a mid-month date, and finding exposed bone, after which the resident was sent to the hospital for a higher level of care. The wound care doctor stated the resident had daily wound care treatments and that unsigned treatments on the identified dates would not have made the wounds worse, and he was not aware of any missed treatments. The resident’s responsible party stated the resident had been very sick, in and out of the hospital, and was sent out again for a change in condition, and she did not blame anyone for the resident’s health decline. RN A stated he provided all wound treatments on the identified date but did not sign them off because he was assisting with other nursing duties afterward, and acknowledged it was expected to sign off when treatments were completed and that lack of a signature would indicate the treatment was not done. RN B’s interview was initiated but not completed in the report excerpt. These findings demonstrate incomplete and inaccurate documentation of ordered wound treatments in the resident’s medical record.

Penalty

Inspection fine: $16,149

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

Summary

A significant medication error occurred when a resident, who had recently returned from a hospital stay, was administered five doses of Valacyclovir 1000mg after the hospital discharge summary had clearly stated to discontinue the medication. The resident had a history of acute and subacute infective endocarditis and required hemodialysis. Upon readmission, an agency nurse was responsible for entering the resident's medications into the electronic medical record but failed to discontinue Valacyclovir as ordered in the hospital discharge instructions. The medication error was not immediately identified, and the resident received multiple doses of the discontinued medication over two days. The error was discovered only after the resident exhibited confusion, slurred speech, and inability to follow commands, as reported by a family member and confirmed by a bilingual LVN. The resident was subsequently assessed by a nurse practitioner and transferred back to the hospital, where the diagnosis of metabolic encephalopathy due to Valacyclovir toxicity was made. Interviews revealed that the agency nurse responsible for the error was unfamiliar with the electronic medical record system and did not seek assistance or clarification. The facility's medication reconciliation policy required review of discharge medication profiles with readmission orders, but this process was not properly followed, resulting in the administration of a discontinued medication and subsequent harm to the resident.

Penalty

Inspection fine: $16,149

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

Summary

A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or incidents described.

Penalty

Inspection fine: $16,149

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

Summary

Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The report specifically notes the failure to provide prompt notification to all required parties when significant events impacting the resident occurred.

Penalty

No penalty information released

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

Summary

The facility failed to permit a resident to remain in the facility and did not document the reason or provide notice of discharge in the resident's medical record. The resident, a male with diagnoses including metabolic encephalopathy, gastric reflux, prostate disease, Parkinson's disease, and cognitive communication deficit, was sent to the emergency room for evaluation after exhibiting out-of-character behavior involving an incident with a staff member. Despite the hospital finding no medical changes and clearing the resident for return, the facility refused to accept him back and did not provide the required written discharge notice to the resident, his representative, or the Long-term Care Ombudsman. Interviews with facility staff confirmed that the normal process is to issue a 30-day discharge notice and assist with safe discharge planning, but this was not followed in the resident's case. The resident's chart did not contain a discharge notice, and discharge paperwork was still in process after the resident was denied re-admission. The facility's own policy requires written notification and documentation of discharge at least 30 days in advance, which was not adhered to 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 incorporate recommendations from the PASARR Level II determination and evaluation report into a resident's assessment, care planning, and transitions of care. Specifically, the facility did not submit a Nursing Facility Specialized Services (NFSS) request within 20 days of the Interdisciplinary Team (IDT) meeting for a resident with multiple mental health diagnoses, including schizoaffective disorder and major depressive disorder with psychotic features. The care plan identified the need for coordination with mental health services, but the required documentation and timely submission of the NFSS request were not completed as required. The delay was attributed to staff being unaware of the IDT meeting and confusion over responsibility for submitting the NFSS, resulting in the initial request being submitted late and subsequently denied before being resubmitted and accepted. Interviews with facility staff revealed lapses in communication and understanding of the PASARR process. The MDS nurse was on vacation during the IDT meeting and only learned of it later, while the Director of Rehabilitation was unaware of the meeting and did not know how to complete the NFSS form. The administrator acknowledged awareness of the issue but stated it occurred under previous administration. Facility policy requires timely coordination and documentation for PASARR services, but these steps were not followed, leading to a deficiency in ensuring the resident received the necessary specialized services 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 immediately notify a resident's representative and the Congestive Heart Failure (CHF) clinic of significant changes in the resident's physical status, specifically a substantial weight gain, as required by provider orders. The resident, who had diagnoses including acute on chronic heart failure, generalized anxiety disorder, and early-onset Alzheimer's disease, experienced a weight increase of over 13 pounds within a week. Provider orders specified that the CHF clinic should be notified of a weight gain of 2 or more pounds overnight or 3-5 pounds in one week, but there was no documentation that such notification occurred during the period in question. Nursing progress notes and interviews confirmed that although daily weights were recorded and the resident exhibited symptoms such as shortness of breath and low oxygen saturation, the CHF clinic was not informed of these changes. Nursing staff acknowledged awareness of the notification requirement but did not follow through, and there was no evidence of follow-up to ensure the CHF clinic was made aware. The lack of notification resulted in the resident requiring IV Lasix for fluid overload when eventually seen at the CHF clinic. Interviews with the resident's family, the CHF clinic RN supervisor, and the resident's physician all confirmed that the CHF clinic was not notified of the weight gain, which delayed care and led to the need for more intensive intervention. The facility's policy required prompt notification and documentation of changes in condition, but this was not adhered to in this case. The deficiency was identified as Immediate Jeopardy due to the failure to follow provider orders and ensure timely medical evaluation and treatment.

Removal Plan

• The facility activity report and the 24-hour report will be audited by the Director of Nursing/Designee to identify any documentation that indicates changes in resident's condition and notification to provider as ordered.
• The Director of Nursing will be reeducated by the Clinical Consultant on following providers orders to prevent a delay in treatment and change in condition including: prompt notifications documented in residents medical record to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; nursing leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor; shortness of breath; weight gain in residents with Congestive Heart Failure causing shortness of breath.
• Licensed nurses, including PRN nurses, will be reeducated by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; shortness of breath; weight gain in Congestive Heart Failure residents causing shortness of breath. Licensed Nurses, including PRN nurses not receiving this education will receive prior to their next scheduled shift and this will be completed in New Hire orientation.
• Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months.
• The Administrator will oversee the continuation of this plan.
• Ad Hoc QAPI will be held.
• The Medical Director was notified of the Immediate Jeopardy and contents of this plan.
• Monitoring included the following: Record review completed of the facility 24-hour report. Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up.
• Ongoing training will be provided to any oncoming agency, PRN, or new 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 ensure that a resident with a diagnosis of congestive heart failure (CHF) received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not notify the CHF clinic of the resident's significant weight gain as required by provider orders. The resident experienced a weight increase of more than 10 pounds within a week, as documented in daily weight records, and exhibited symptoms such as shortness of breath and low oxygen saturation levels. Despite clear physician orders to notify the CHF clinic for weight gains of 2 or more pounds overnight or 3-5 pounds in one week, there was no documentation in the nursing progress notes that such notifications were made during the period of weight gain. Interviews with nursing staff confirmed that although weights were taken and abnormal findings were reported during shift handovers, no direct notification was made to the CHF clinic. The resident's care plan also included interventions to monitor for respiratory distress and to contact the medical provider if noted, but these interventions were not fully implemented as required. The lack of timely notification resulted in the resident requiring IV Lasix administration at the CHF clinic after the significant weight gain and onset of shortness of breath. Family members and clinical staff from the CHF clinic confirmed that they were not informed of the resident's weight changes by the facility, which led to a delay in care. The facility's own policy required prompt notification and documentation of changes in condition, but this was not followed in this case, as confirmed by interviews with the DON, nursing staff, and the resident's physician.

Removal Plan

• The facility activity report and the 24-hour report will be audited by the Director of Nursing/Designee to identify any documentation that indicates changes in resident's condition and notification to provider as ordered.
• The Director of Nursing will be reeducated by the Clinical Consultant on following providers orders to prevent a delay in treatment and change in condition including: prompt notifications documented in residents medical record to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; nursing leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor; shortness of breath; weight gain in residents with Congestive Heart Failure causing shortness of breath.
• Licensed nurses, including PRN nurses, will be reeducated by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; shortness of breath; weight gain in Congestive Heart Failure residents causing shortness of breath. Licensed Nurses, including PRN nurses not receiving this education will receive prior to their next scheduled shift and this will be completed in New Hire orientation.
• Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months.
• The Administrator will oversee the continuation of this plan.
• Ad Hoc QAPI will be held.
• The Medical Director was notified of the Immediate Jeopardy and contents of this plan.
• Monitoring included the following: Record review completed of the facility 24-hour report. Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up.
• Record review of an in-service titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers of changes.
• Record review of an additional in-service on prompt notifications to providers, documentation, and validation in clinical morning meetings.
• Record review of in-service titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms.
• Record review of a staff in-service revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms.
• Record review of a staff in-service revealed staff were educated on prompt notifications to providers, documentation, notifications to required medical staff of weight changes as ordered, shortness of breath, and weight gain in Congestive Heart Failure residents causing shortness of breath.
• Record Review of training titled: Change of Condition revealed staff were trained on licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered.
• Record review of the Adhoc QAPI for F684 revealed the meeting included the ADM, DON, CC, and MD.
• Record Review of a signed statement by the DON revealed notification to the MD regarding Immediate Jeopardy.
• Record review of the new hire orientation packet which included an added section revealed the following: respiratory care all nurses validate resident is receiving oxygen per MD orders; change of condition recognition and notification to providers; prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record; notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB; policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities.
• Record review of education provided to the only 2 agency nurse staff working revealed education included change of condition and CHF education.
• Record review of an email from the DON to RN C revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify.
• Record review of an email from the DON to LVN B revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure.
• Record review of text messages from the DON to LVN A revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify.
• Record review of text messages from DON to LVN D revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify.
• In-service training and verbal assessment for LVN E prior to her shift on changes of condition and the need to notify providers, including a PowerPoint on CHF management.
• In-service training and verbal quiz for LVN F prior to her shift on changes of condition, who to notify, weight gain, CHF management including s/s and concerns to look for.
• Ongoing training to any oncoming agency, PRN, or new staff.
• Review completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review.

Penalty

Inspection fine: $25,325

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

Summary

The facility failed to provide necessary respiratory care to a resident who required continuous oxygen therapy. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), was sent to medical appointments on two occasions with empty portable oxygen tanks. This resulted in the resident experiencing shortness of breath, anxiety, and confusion due to low oxygen levels. The resident's care plan did not adequately address her need for oxygen therapy, and there was a lack of proper monitoring and verification of oxygen supply before her appointments. Interviews with the resident, her private caregiver, and the responsible party revealed that the issue of empty oxygen tanks had been a recurring problem. Despite a grievance filed in January and an emergency care-plan meeting to address the issue, the facility staff failed to consistently check and ensure the oxygen tanks were full before the resident's medical appointments. The resident's oxygen saturation levels dropped to critically low levels during these appointments, necessitating intervention by the medical clinic staff to stabilize her condition. The facility's interim Director of Nursing (DON) and Administrator were unaware of the emergency plan for increased monitoring of the resident's oxygen needs. The facility had recently acquired new oxygen regulators, but staff were not adequately trained on their use, leading to improper attachment and monitoring of the oxygen tanks. The lack of adherence to the facility's oxygen therapy policy and the failure to ensure the resident's oxygen needs were met resulted in an Immediate Jeopardy situation, placing the resident at risk of harm.

Penalty

Inspection fine: $25,325

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 care plan for a resident, who was admitted with diagnoses including acute on chronic systolic heart failure and chronic obstructive pulmonary disease. The care plan did not address the resident's need for oxygen, monitoring for shortness of breath, or the requirement for specialty medical appointments related to her conditions. Additionally, the care plan did not account for the resident's need for substantial assistance with activities of daily living such as showering, dressing, and toileting hygiene. The resident's medical records indicated she required continuous oxygen therapy and had specific physician orders for oxygen use and monitoring. However, the facility did not ensure the oxygen tanks were properly filled and functioning during her medical appointments, leading to instances where the resident was transported with empty oxygen tanks. This oversight resulted in the resident experiencing confusion, anxiety, and difficulty breathing, as reported by both the resident and her responsible party. Interviews with facility staff revealed a lack of coordination and responsibility in updating the resident's care plan. The MDS Coordinator acknowledged the absence of a care plan for the resident's COPD, CHF, and oxygen use, citing logistical challenges in updating care plans during meetings. The Interim DON confirmed that the care plan should have included interventions and monitoring for the resident's conditions, but these were not implemented, potentially affecting the resident's care and well-being.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not weigh three residents according to physician orders. Resident #1, a female with diagnoses including congestive heart failure, edema, hypertension, and type II diabetes, was ordered daily weights but was only weighed on five occasions over a two-week period. Resident #2, a male with severe cognitive impairment and diagnoses including acute kidney failure and congestive heart failure, was also ordered daily weights but was only weighed once over a three-week period. Resident #3, a female with type II diabetes, congestive heart failure, morbid obesity, and pressure ulcers, was ordered daily weights but was weighed only four times over a two-month period. The Director of Nursing (DON) acknowledged that physician orders should always be followed and emphasized the importance of regular weighing for residents with congestive heart failure to monitor for excess fluid on the heart. The facility's in-service training on weights highlighted the necessity of collecting weights on the day they are due. However, the facility's Physician Orders Policy did not address the importance of following physician orders, contributing to the oversight in monitoring the residents' weights as prescribed.

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 respiratory care for three residents, leading to deficiencies in oxygen therapy management. Resident #2, a male with severe cognitive impairment and multiple health issues, was observed using an oxygen concentrator without a physician's order or an 'Oxygen in Use' sign on his door. His care plan and physician orders did not reflect any need for continuous oxygen therapy, indicating a lack of proper documentation and oversight. Resident #4, a male with chronic obstructive pulmonary disease and no cognitive impairment, was found with an empty oxygen tank while eating lunch in the dining room. His oxygen tubing was not bagged and was left on the floor, posing a risk of infection and tripping hazards. Despite having a physician's order for continuous oxygen therapy, his oxygen saturation was not adequately monitored, and staff failed to ensure his oxygen supply was maintained. Resident #6, a female with severe cognitive impairment and a history of stroke, was observed with her nasal cannula tubing disconnected from the oxygen concentrator, and the water cannister was empty. Although her oxygen saturation was checked and found to be low, staff did not immediately address the disconnection issue. The facility's Director of Nursing acknowledged the importance of proper oxygen administration and monitoring but noted that the facility's practices were not consistently followed.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection control program, as evidenced by two separate incidents involving staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. In the first incident, a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) while providing care to a resident with a wound on EBP. Despite having received training on EBP, the CNA admitted to not wearing a gown or mask because she did not notice the sign indicating the need for PPE on the resident's door. In the second incident, a Licensed Vocational Nurse (LVN) used a pulse oximeter on a resident on EBP for catheter use and failed to clean or sanitize the device before placing it back in her pocket. The LVN acknowledged the need for cleaning equipment used on multiple residents but did not have sanitizing wipes readily available near the resident's room. The LVN also admitted to using a sanitizing wipe to clean her pocket, which was not an acceptable practice according to the facility's Director of Nursing (DON). Interviews with the Assistant Director of Nursing (ADON) and the DON revealed that both were responsible for staff training on infection control and expected staff to follow EBP protocols, including wearing appropriate PPE and not placing equipment in pockets. The facility's policy on EBP required the use of gowns and gloves during high-contact resident care activities, and signage was posted to indicate the necessary precautions. However, the staff's failure to adhere to these protocols could potentially lead to the spread of infections among 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 develop and implement comprehensive person-centered care plans for four residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental and psychosocial needs. Specifically, the care plans for two residents did not include anticoagulant medications, one resident's care plan omitted opioid medication, and another resident's care plan failed to include antiplatelet medication. This oversight could potentially place residents at risk for not receiving necessary care and services or having important care needs identified and met. Resident #10, a severely cognitively impaired female with diagnoses including cerebral infarction, dysphagia, dementia, and hypertension, was receiving anticoagulant medication Eliquis as per physician's orders. However, her care plan did not reflect this medication. Similarly, Resident #39, also severely cognitively impaired with diagnoses including cerebral infarction and anxiety, was on Eliquis, but her care plan did not include this medication. Both residents were observed to be unaware of their surroundings, and no visible bruising was noted on Resident #10. Resident #12, a cognitively intact male with a history of traumatic brain injury, dysphagia, and congestive heart failure, was receiving opioid medication acetaminophen-codeine, but this was not included in his care plan. Resident #57, a severely cognitively impaired male with diagnoses including anxiety, dementia, and atrial fibrillation, was on aspirin, an antiplatelet medication, which was not reflected in his care plan. Interviews with staff revealed a lack of clarity and responsibility regarding the updating and accuracy of care plans, with the MDS coordinator and DON acknowledging the oversight and the potential negative effects of not monitoring medications in care plans.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This deficiency was observed in four residents who were dependent on staff for assistance with bathing. The facility's records indicated that these residents did not receive showers or bed baths as scheduled, and there was no documentation of refusal of care by the residents. For instance, one resident, who was cognitively intact and dependent on staff for bathing, did not receive a shower or bed bath on multiple scheduled days, and there was no indication that she refused care. Another resident, who had moderate cognitive impairment and required substantial assistance with bathing, missed seven scheduled shower opportunities over a 14-day period. Despite the resident expressing a desire for consistent showers, the facility's records did not indicate any refusals of care. Similarly, a third resident, who was cognitively intact and dependent on staff for bathing, was only bathed twice within a 17-day period, despite being scheduled for more frequent showers. This resident expressed a desire to feel clean but noted the difficulty staff had in using a mechanical lift for his showers. The fourth resident, who had severely impaired cognition and was unable to refuse care, was only bathed three times within a 17-day period. The resident's family member expressed concern about the lack of showers and noted that the resident was nonverbal and incapable of refusing care. Interviews with staff revealed inconsistencies in the documentation and reporting of shower refusals, as well as challenges in staffing that may have contributed to the missed showers. The facility's policy required necessary care to ensure residents maintained proper hygiene, but this was not consistently followed.

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 received care consistent with professional standards to prevent and treat pressure ulcers. Specifically, the facility did not complete weekly skin assessments for three residents, which were ordered by physicians. These residents were at risk for pressure ulcers due to their medical conditions, and the lack of assessments could lead to the development or worsening of pressure ulcers. Resident #3, a cognitively intact female with paraplegia and a stage 3 pressure ulcer, did not receive the required weekly skin inspections from December 1 to December 17, 2024. Similarly, Resident #41, a cognitively intact male with a history of pressure ulcers, also missed weekly skin inspections during the same period. Resident #52, who had severely impaired cognition and was dependent on others for bathing, only received one skin inspection during the first half of December 2024, despite being at risk for pressure ulcers. Interviews with facility staff, including LVNs and the DON, revealed that the responsibility for completing skin assessments lay with the nurses. However, the assessments were not completed due to reliance on agency nurses, making it difficult to ensure tasks were completed. The facility's policy required documentation of care and treatment, but the skin assessment policy was not provided upon request. The failure to conduct these assessments could lead to undetected skin issues and worsening outcomes for residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in their comprehensive assessments. Resident #39's quarterly MDS assessment did not reflect her hospice services, despite physician orders and care plans indicating she was on hospice care. This oversight could result in inadequate care planning and service provision for her end-of-life needs. Resident #42's annual MDS assessment inaccurately documented her medication regimen, listing an anticoagulant instead of the antiplatelet medication she was actually receiving, as per her physician's orders and care plan. This discrepancy could lead to inappropriate monitoring and management of her medication, potentially affecting her treatment outcomes. Similarly, Resident #57's admission MDS assessment incorrectly recorded an anticoagulant medication instead of the antiplatelet medication he was prescribed. His care plan did not address the antiplatelet medication, which could result in a lack of necessary monitoring and interventions. Interviews with the MDS nurse and DON revealed that the responsibility for accurate MDS assessments lies with the MDS nurse and corporate oversight, highlighting a lapse in the facility's assessment processes.

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 label drugs and biologicals in accordance with currently accepted professional principles, as observed in the medication carts for the 100, 200, and 300 halls. Thirteen unidentified loose pills were found in these carts, and a personal purse was stored in the bottom drawer of the medication cart for the 200 and half of the 300 hall. These practices could lead to drug diversion due to medications not being properly disposed of and secured. Interviews with multiple staff members, including Medication Aides (MAs) and Licensed Vocational Nurses (LVNs), revealed inconsistencies in handling loose pills and personal items in medication carts. MA E admitted to disposing of loose pills when noticed but acknowledged that routine checks of blister packs could prevent pills from falling out. MA F and LVN A both stated that personal items should not be stored in medication carts due to potential cross-contamination and theft risks. However, there was uncertainty among staff about specific policies regarding loose pills and personal items in medication carts. The Director of Nursing (DON) confirmed that it is not acceptable for staff to store personal items in medication carts and acknowledged the potential for theft and contamination. The DON was unsure if there was a specific policy on loose pills but mentioned that staff are trained during monthly audits. The facility's Medication Management Program outlines that unused doses should be destroyed following facility policy, but the report indicates a lack of consistent adherence to these procedures.

Penalty

Inspection fine: $14,433

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

Summary

The facility failed to ensure adequate supervision and proper use of assistance devices for Resident #1, leading to an accident during a transfer using a mechanical lift. Resident #1, a female with multiple medical conditions including a fracture of the left femur, poly osteoarthritis, and hemiplegia, was being transferred from her wheelchair to her bed. The care plan specified the use of a mechanical lift for transfers, but the CNAs involved did not position the resident correctly in the lift sling, nor did they ensure adequate space for the lift's operation. During the transfer, CNA B did not position Resident #1 in the center of the lift sling, and CNA D failed to maintain a hand on the resident for support. The room's limited space further complicated the transfer, as the lift could not be maneuvered properly. As a result, Resident #1 leaned forward and slid out of the sling, falling to the floor and landing on the metal leg extensions of the lift. This incident was captured on video, which showed the resident tilting to the left and not being over the bed at the time of the fall. Following the fall, Resident #1 was assessed and initially found to have no injuries, but later x-rays revealed an acute fracture of the distal femur. Interviews with staff indicated that the room's arrangement and the resident's positioning in the sling were contributing factors to the incident. The facility's policy on mechanical lifts emphasized the need for a clear path and adequate space, which 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 ensure that each resident received at least three meals daily at regular times comparable to normal mealtimes in the community. This deficiency was observed in five residents, who experienced delays in receiving their meals, leading to feelings of hunger, agitation, and diminished self-worth. For instance, Resident #1 did not receive his lunch tray on time and expressed hunger and frustration. Resident #2 often missed breakfast before leaving for dialysis and sometimes went without eating until dinner. Resident #3 reported feeling unimportant and hungry due to late meal service, while Resident #4 and Resident #5 also experienced delays in receiving their meals, with Resident #5 noting that this issue had persisted for about two years and had been discussed in resident council meetings without resolution. Observations on specific dates revealed that meal trays were not served at the posted times. For example, on one occasion, no lunch trays were served in the dining room by 1:00 PM, and on another, breakfast trays were not delivered by 8:24 AM. Interviews with staff members confirmed that meals had been consistently served late for a couple of months, causing residents to become agitated and upset. One staff member mentioned that meals were typically an hour late, and residents were unhappy with the delays. Despite these observations and resident complaints, the Administrator did not acknowledge that meals were being served late. The facility's nutrition policies and procedures, dated June 2023, specified that meals should be served at the posted times, but this was not adhered to, resulting in the deficiency. The failure to provide timely meals placed residents at risk of malnutrition, dehydration, and decreased quality of life.

Penalty

No penalty information released

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

Summary

The facility failed to provide special eating equipment and utensils for residents who needed them, as well as appropriate assistance during meals and snacks. This deficiency was observed in four residents. Resident #1, who required finger foods due to spastic hemiplegia and other conditions, was not provided with the appropriate diet, resulting in spilled scrambled eggs on the dining table and floor. Resident #6, who had severe cognitive impairment and required built-up and right-angled utensils along with a two-handled cup, was not provided with these items during both breakfast and lunch. Resident #7, who required built-up utensils, was observed eating with her hands due to the absence of these utensils. Resident #8, who needed weighted utensils due to severe cognitive impairment and other conditions, was also not provided with the necessary equipment, leading to spilled food on the table and floor during both breakfast and lunch. Interviews with the DON and AD confirmed the importance of these adaptive devices for adequate nutrition and dignity during meals. The facility's Nutrition Policies and Procedures were not followed, as the meal trays did not include the required adaptive equipment listed on the residents' tray tickets.

Penalty

No penalty information released

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

Summary

The facility failed to establish and maintain an infection prevention and control program, leading to improper procedures during blood sugar checks for two residents. LVN A did not use a clean gauze to wipe the residents' fingers after collecting blood samples and reused the alcohol pad instead. Additionally, LVN A did not properly clean Resident #11's skin surface before administering insulin, using a back-and-forth motion instead of the recommended circular motion. These actions were observed during blood sugar checks and insulin administration for Resident #10 and Resident #11, both of whom were cognitively intact and had multiple medical diagnoses including Type 2 Diabetes and Hypertension. During interviews, LVN A admitted to reusing alcohol pads and not following proper cleaning procedures, despite being trained otherwise. The DON confirmed that the correct procedure involves using a clean gauze and cleaning injection sites in a circular motion. The facility's policies and procedures, as well as the Lippincott's blood glucose monitoring procedure, were reviewed and found to support the correct practices that were not followed by LVN A. This failure in infection control practices could lead to the spread of infections among 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 inform the responsible party (RP) of a decision to transfer a resident to another facility. Resident #9, a female with severe cognitive impairment and multiple diagnoses including Intellectual Disability, Bipolar Disorder, and Type 2 Diabetes, was transferred without the RP's approval. The RP had initially given permission for referral packets to be sent to other nursing facilities but had requested to be contacted before any transfer was finalized. However, the facility did not follow through with this request, leading to the resident being moved without the RP's knowledge or consent. The social worker (SW) initiated the referral process and informed the RP about the resident's behaviors, but she was out sick when the referral was accepted. The Admission Coordinator (ADMC) assumed the SW had notified the RP and proceeded with the transfer arrangements. The SW and ADMC both assumed the other had communicated with the RP, resulting in a lack of proper notification. The facility's policy on resident rights emphasizes the importance of involving residents and their representatives in significant decisions, but this was not adhered to in this case.