Town And Country Nursing And Rehabilitation Center

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency in the facility’s posting of daily nurse staffing information for a census of 89 residents. Observation of the posted staffing information showed that for all three shifts (6:00 AM–2:00 PM, 2:00 PM–10:00 PM, and 10:00 PM–6:00 AM), the postings did not include the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. Record review of posted nurse staffing hours from 10/01/2025 through 01/07/2026 confirmed that during this entire period, the facility’s postings lacked documentation of actual hours worked for any of the three shifts. In written communication and interviews, the Administrator stated the facility did not have a policy on posted nurse staffing information and acknowledged responsibility for ensuring the information was posted. The Administrator explained that a new staffing person was now responsible for posting the hours and that it had been a group effort, but could not explain why the actual hours worked were not transferred to the staffing posting form or documented for the period reviewed. The Administrator acknowledged that without documenting actual hours worked, they would not know if expected hours were met. In a separate interview, the DON also could not explain why the actual hours were not included on the posted nurse staffing information and acknowledged that the actual hours were not documented.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including medication errors, were reported to the appropriate authorities within the required timeframes. Specifically, a medication error occurred when an RN administered an incorrect dose of morphine to a male resident with diagnoses of lung cancer and chronic obstructive pulmonary disease. The physician's order specified that the resident should receive 10 mg of morphine sulfate (0.5 ml) by mouth every hour as needed for pain or shortness of breath. However, the RN administered a higher dose than ordered, with documentation and interviews indicating that either 1 ml or 2 ml was given, equating to 20 mg or 40 mg, respectively, instead of the prescribed 10 mg. The discrepancy in the amount administered was confirmed through record reviews, medication administration records, and narcotic count sheets, as well as interviews with the DON and the RN involved. The DON and Administrator both acknowledged the error and discussed it with their corporate team. Despite the facility's policy requiring immediate reporting of such incidents to the State Survey Agency and other authorities, the incident was not reported as required. The Administrator and DON decided, after consultation, that the event did not meet the criteria for reporting, referencing a provider letter, and therefore did not notify the State Survey Agency. The facility's own policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or distress, and outlines specific procedures for reporting such events within set timeframes. In this case, the failure to report the medication error involving the administration of an incorrect dose of morphine to the resident constituted a violation of both facility policy and regulatory requirements for timely reporting of alleged neglect.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property were reported immediately, but not later than 24 hours, to the administrator and appropriate authorities as required. Specifically, a medication error occurred when a resident was discharged and was mistakenly sent home with four medications belonging to another resident. The error was discovered after the discharged resident was seen at home by a VA nurse, who found the incorrect medications and confirmed they had not been taken. The medications were subsequently destroyed by the VA nurse. Interviews and record reviews revealed that the medication error was not reported to the State Survey Agency as required by regulation. The facility administrator stated that regional staff advised that reporting the incident was unnecessary, resulting in a failure to follow established procedures for reporting such incidents. The affected residents included one with intact cognition and another with severe cognitive impairment, both with significant medical histories. The facility's policy required verification of medications sent home with residents, which was not followed 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 maintain a medication error rate below 5%, resulting in a 10% error rate during 28 observed medication administration opportunities. Specifically, three medication errors were identified involving two residents. For one resident with atrial fibrillation and cerebral infarction, the nurse withheld Apixaban due to the medication being out of stock and not reordered in a timely manner, and also withheld Amiodarone based on a blood pressure reading, despite there being no physician-ordered parameters for withholding the medication. The nurse confirmed that the process was to order medications before running out, but this was not followed, leading to missed doses. For another resident with cirrhosis, the nurse was unable to administer Xifaxan because it was not available in the medication cart or emergency stock, and had not been reordered before supplies were depleted. The facility's policy required medication carts to be adequately stocked and medications to be held only when physician-ordered parameters were not met. The DON confirmed that medications should have been ordered in advance to prevent missed doses, and that the facility relied on a local pharmacy for same-day delivery of out-of-stock medications.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident with moderate cognitive impairment and multiple medical diagnoses was able to communicate effectively with caregivers in her preferred language, English. The resident reported difficulty communicating with staff who primarily spoke Spanish. Observations revealed that two CNAs, who did not speak English, attempted to use translation applications on their phones to communicate with non-Spanish speaking residents but were unable to effectively use these tools or facilitate meaningful communication. A review of Resident Council meeting minutes indicated that language barriers were a known issue among residents, with reports of difficulty communicating with staff. The Director of Nursing confirmed that staff were instructed to use translation applications and to notify the Charge Nurse if communication difficulties arose, acknowledging that staff's inability to communicate could affect resident care and well-being. Facility policy requires that residents be fully informed in a language they understand, but this was not achieved in the case described.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to ensure a resident's right to participate in the development and implementation of his person-centered plan of care. The resident, who had diagnoses including peripheral neuropathy, hypertension, dysphagia, osteomyelitis, and benign prostatic hyperplasia, was found to have intact cognition based on a BIMS score of 15. Despite this, the resident reported not being invited to a care plan meeting for a long time and had only attended one meeting the previous year. Record review confirmed that the last care plan meeting attended by the resident was in August 2024. Interviews with facility staff, including the MDS Nurse, DON, and Administrator, revealed that while the resident's responsible party (his son) was invited to care plan meetings, the resident himself was not invited, despite being cognitively able to participate. Facility policy states that residents and their representatives are encouraged to participate in care planning and should be informed in advance of meetings. The failure to invite and include the resident in care plan meetings was verified through review of care plan signature sheets 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 ensure the use of the least restrictive alternative and did not provide adequate assessment, care planning, or ongoing re-evaluation for the use of a seatbelt restraint for a resident with Lennox-Gastaut Syndrome, wheelchair dependence, aphasia, and gastrostomy status. The resident was observed on multiple occasions wearing a seatbelt restraint while in her wheelchair, and staff interviews confirmed that the restraint was used every time the resident was in the wheelchair. The care plan referenced the use of the seatbelt for safety due to falls and seizures, but did not include interventions to address risks related to restraint use, monitoring or supervision requirements, or parameters for release of the restraint. Record review revealed that there was no active physician's order specifying the application, monitoring, or removal of the seatbelt restraint. The medication and treatment administration records included tasks for staff to document the resident wearing the seatbelt, but did not provide additional monitoring directives. There was also no evidence of a specific assessment related to restraint use in the electronic medical record, and the consent form for restraint use was incomplete, lacking details about the type of restraint. Interviews with staff indicated that less restrictive alternatives were not attempted prior to the use of the restraint, and that the restraint was only removed at the end of the day when the resident went to bed. The facility's policy requires behavioral interventions to be exhausted before restraint use, documentation of less restrictive alternatives, ongoing re-evaluation, and care planning to address risks, but these steps were not followed. The facility relied on the request of the resident's mother for continued restraint use without proper documentation or assessment as required by policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident assessment accurately reflected the use of a restraint device for one resident. Specifically, the quarterly Minimum Data Set (MDS) for a female resident with Lennox-Gastaut Syndrome, wheelchair dependence, aphasia, and gastrostomy status did not document the use of a seatbelt restraint, despite multiple observations of the resident wearing the seatbelt while in her wheelchair. The MDS indicated that no trunk restraint was used, and there was no active physician order for the seatbelt in the electronic medical record (EMR) at the time of review. Documentation within the resident's care plan and other scanned documents confirmed the medical need for the seatbelt, with consent from the resident's mother and signatures from the interdisciplinary care team, including a physician. Staff interviews revealed that the resident used the seatbelt every time she was in her wheelchair, and the MDS nurse acknowledged awareness of this ongoing use. However, the MDS was completed based on the medication administration record (MAR), which did not include an order for the seatbelt, leading to inaccurate reporting. Facility policy required documentation of restraint use and release in the clinical record, which 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 develop and implement a comprehensive, person-centered care plan for a resident with complex medical needs, specifically regarding the use of a wheelchair seatbelt restraint and the prevention of gastrostomy tube (g-tube) dislodgement. The resident, a female with Lennox-Gastaut Syndrome, seizure disorder, aphasia, and dependence on a wheelchair, was observed using a seatbelt restraint at all times while in her wheelchair. The care plan referenced the use of the seatbelt for fall prevention and seizure safety but did not include specific interventions to address risks associated with restraint use, such as monitoring, supervision, or parameters for release. There was also no physician's order specifying the use or monitoring of the restraint, and the consent documentation was incomplete regarding the type of restraint used. Staff interviews revealed that the seatbelt restraint was applied routinely without documented consideration of less restrictive alternatives or formal processes for monitoring and supervision. The DON confirmed that alternatives were not attempted and that the need for the restraint was not formally re-evaluated, despite facility policy requiring such documentation. The care plan did not address the restraint as a restraint, and staff were unaware of additional documentation or assessment requirements beyond routine application and observation. Additionally, the facility failed to revise the care plan following two hospitalizations for g-tube dislodgement. Although the resident began wearing an abdominal binder to prevent further dislodgement, this intervention was not reflected in the care plan or in the electronic medical record as a routine task for staff. Staff interviews confirmed that checks for the binder's placement were performed out of routine rather than as a documented intervention, and the nurse responsible for care plans had not updated the plan to address the risk of g-tube dislodgement.

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 cardiac pacemaker had the device's make, model, and related information documented in the medical record. Record reviews showed that the resident's admission record did not include a diagnosis description for a cardiac pacemaker, and the care plan lacked the required pacemaker information. The resident's MDS assessment indicated the presence of a pacemaker and moderate cognitive impairment, and the care plan referenced the need for monitoring and documentation of pacemaker-related symptoms, but the specific device details were missing. Additionally, there were no physician orders related to the pacemaker in the resident's consolidated orders. Interviews with staff confirmed awareness of the resident's pacemaker, but the Director of Nursing (DON) acknowledged that the make and model were only available in an email and had not been entered into the resident's record. The corporate administrator stated there was no pacemaker policy, and the care plan preparer indicated that the make and model were added to the care plan only after the surveyor's inquiry. The DON also confirmed the absence of a physician's order for the pacemaker and stated that such devices should have an order for proper monitoring.

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 vision impairment received proper treatment and assistive devices to maintain vision abilities. The resident, who had diagnoses including unsteadiness on feet and muscle wasting, was assessed as requiring corrective lenses and had moderately impaired cognition. Approximately a month prior to the survey, the resident's eyeglasses became broken, with both ear pieces missing, making them unusable. The resident reported the issue to the facility and experienced difficulty watching television and seeing objects at a distance, though he had not sustained any injuries as a result. Despite the resident's report and a documented referral to an optometrist, no appointment had been scheduled by the time of the survey. The LSW was aware of the broken glasses but was initially unaware that both ear pieces were missing. The LSW acknowledged that the typical timeline for optometry appointments was a couple of months and had not yet confirmed an appointment or arranged for timely repair or replacement of the glasses. This lack of timely action resulted in the resident being without necessary corrective lenses for an extended period.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a resident with multiple diagnoses, including Alzheimer's dementia, right femur fracture, osteoporosis, and severe cognitive impairment, was not provided with required hip protectors as ordered by the physician and outlined in the resident's care plan. The care plan specified the use of padded hip protectors at all times to prevent hip fractures due to the resident's high risk for falls. Despite this, observations on three separate occasions revealed that the resident was not wearing the hip protectors. Interviews with staff confirmed that the resident was supposed to have hip protectors in place for safety, and that nursing staff were responsible for ensuring their use. The DON acknowledged that the charge nurse was responsible for ensuring the devices were utilized and that she was ultimately accountable for compliance with physician orders. The facility's fall prevention policy also required maintaining an environment as free from accident hazards as possible and implementing appropriate interventions to minimize complications from falls.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a kitchen staff member, Cook D, failed to maintain proper use of a beard/mustache restraint while handling food. During food temperature checks at the steam table, Cook D's beard guard had fallen, leaving his thin mustache exposed. This was directly observed by surveyors, and Cook D acknowledged that the restraint had fallen and was not covering his mustache at the time. The dietician confirmed that the hair restraint should have covered the mustache, and the dietary manager stated that all kitchen staff are required to wear hair restraints to cover hair while in the kitchen to prevent contamination. The facility's failure to ensure that food service staff properly wore hair restraints was not in accordance with professional standards and the 2017 U.S. FDA Food Code, which requires food employees to wear hair restraints designed to keep hair from contacting exposed food and food-contact surfaces. The incident was confirmed through interviews with the involved staff, the dietician, the dietary manager, and the administrator, as well as through direct observation.

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

Staff failed to properly handle and transport soiled linens for three residents, as observed by surveyors. In one instance, a CNA was seen carrying a soiled blanket with bare hands down the hallway without placing it in a bag, despite facility policy requiring all soiled linens to be bagged before transport. The CNA acknowledged the policy and stated that larger bags were available but not immediately accessible. In another case, a CNA was observed throwing soiled linen into the hallway and then carrying it unbagged with bare hands to the soiled storage area, without performing hand hygiene afterward. The Director of Nursing confirmed that staff are expected to bag soiled linens and perform hand hygiene after handling them, and that appropriate supplies are available. Additionally, staff failed to utilize required personal protective equipment (PPE) when providing high-contact care to a resident on transmission-based precautions (TBP) due to a gastrostomy tube and catheter. During an observation, a CNA was seen providing a bed bath to the resident without wearing PPE, despite signage and a PPE cart being present outside the room. The CNA admitted to forgetting to wear the required gown, gloves, and mask due to being in a hurry. The LVN present during the observation also acknowledged that PPE should have been worn during care for this resident. Facility policy and CDC guidelines provided to surveyors specify that soiled linens must be bagged at the bedside and that staff must wear appropriate PPE when caring for residents on TBP. The Director of Nursing confirmed that staff had been trained on these requirements and that failure to follow them could result in cross-contamination.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a male resident with a history of acute on chronic diastolic heart failure, type 2 diabetes mellitus, hyperlipidemia, hypertension, and atrial fibrillation did not receive his prescribed Metoprolol succinate extended-release 50 mg tablet once daily for hypertension for a period of 11 days. The resident's medication regimen was changed by a nurse practitioner, discontinuing Metoprolol tartrate and initiating Metoprolol succinate per the resident's VA doctor's recommendation. However, the new order for Metoprolol succinate was not entered into the facility's medication administration system, resulting in the resident not receiving the medication as ordered from 09/14/2024 to 09/24/2024. During this period, the resident continued to receive other medications for heart failure and hypertension, including Entresto, Lasix, and Spironolactone. Blood pressure readings taken during the missed medication period showed values that were generally stable, though some readings were low. The resident was aware of the missed doses but reported no changes in his condition and did not experience any adverse effects during the 11 days without Metoprolol succinate. Interviews with nursing staff and the DON revealed uncertainty about who was responsible for updating the new medication order in the system. The nurse practitioner who made the order was no longer employed at the facility, and it was unclear whether the order was communicated and transcribed according to facility procedures. The failure to update and transcribe the new medication order led to the resident missing the prescribed medication for hypertension for 11 days.

Penalty

No penalty information released

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

Summary

The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records during medication administration. On the observed date, the ADON administered medications to a male resident with diagnoses including Parkinson's disease, laryngeal cancer, dementia, and Alzheimer's disease in a common area where approximately six other residents were present. The ADON verbally stated the names of the medications in a loud manner, making the resident's medical information accessible to others in the area. The resident was unable to participate in an interview due to cognitive impairment. Interviews with the ADON and DON confirmed that the resident's privacy and confidentiality were not maintained, as the ADON acknowledged that other residents could have overheard the medical information. Facility policy states that resident information must be kept confidential, but this was not followed during the incident. The deficiency was identified through observation, interviews, and record review.

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 with multiple diagnoses, including acute on chronic diastolic heart failure, type 2 diabetes mellitus, hyperlipidemia, hypertension, and atrial fibrillation. On a specific date, a medication aide held the resident's prescribed Metoprolol succinate due to a low blood pressure reading of 101/34, as per physician orders to hold the medication if systolic blood pressure was less than 110 or pulse less than 60. The aide notified the charge nurse, who then re-checked the blood pressure manually and recalled it being higher, possibly 115/58, and stated she notified the nurse practitioner as per protocol. However, the charge nurse did not document the re-checked blood pressure or the notification to the nurse practitioner in the resident's nursing notes. The nurse admitted to forgetting to document this information, having written it on another paper instead. The facility's policy requires that each resident's medical record contain an accurate and complete representation of the resident's experiences, including timely documentation. This lapse resulted in incomplete and inaccurate medical records for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper infection control practices during medication administration for one resident. Specifically, the Assistant Director of Nursing (ADON) was observed administering medications to a resident, then returning to the medication cart and preparing medications for another resident without performing hand hygiene. The ADON then administered medications to the second resident and exited the room without sanitizing or washing his hands at any point during the process. Both the ADON and the Director of Nursing (DON) acknowledged during interviews that hand hygiene should have been performed between residents, in accordance with infection control training and facility policy. The residents involved had significant medical histories, including diagnoses such as Parkinson's disease, laryngeal cancer, dementia, Alzheimer's disease, alcoholic cirrhosis of the liver, cellulitis, lung cancer, and a history of urinary tract infections. Facility records and care plans indicated that at least one resident was at risk for respiratory infections and confusion. The facility's policy for oral medication administration required hand hygiene before handling medications and after administration, which was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not measure the resident's wounds weekly on nine occasions and did not provide wound care treatments as ordered by the physician on two occasions. This deficiency was identified during observations, interviews, and record reviews. The resident, who was readmitted to the facility with multiple diagnoses including an acquired absence of the left leg below the knee, type 2 diabetes, gangrene, atherosclerosis of the arteries of the left leg with ulceration of the ankle, and peripheral vascular disease, had a comprehensive care plan that included interventions for wound care. However, the wound care nurse, LVN K, documented the same wound measurements as the wound care physician on several occasions without independently measuring the wounds, as was expected on a weekly basis. Additionally, the facility failed to provide wound care treatments as ordered on two occasions. The wound care nurse admitted to not changing the resident's dressing for two days and falsely documenting that the treatment was completed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the missed treatments and emphasized the importance of following physician orders and documenting treatments accurately to avoid potential negative outcomes for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary wound care treatments and services to a resident with pressure ulcers, as ordered by the physician. The resident, who was admitted with diagnoses including contact dermatitis and corns, had unhealed pressure ulcers and required specific treatments. However, the facility did not administer wound care treatments on 22 occasions, as evidenced by blank entries in the Treatment Administration Records (TARs) for various dates. During observations and interviews, it was noted that the resident's feet did not have the required dressings, and there was no residual betadine on the wounds, indicating a lack of proper wound care. The Licensed Vocational Nurse (LVN) responsible for wound care admitted to not following physician orders, such as omitting kerlix dressings without an order to do so and failing to document verbal orders for wound care. The LVN also did not cleanse the wound before applying treatment, which is against professional standards of practice. Interviews with the Director of Nursing (DON) and other staff revealed a lack of awareness of the missed treatments and a failure to ensure that wound care was provided as ordered. The DON and Assistant Director of Nursing (ADON) acknowledged the importance of documenting treatments and following physician orders to prevent potential infections and delayed healing. The facility's policy required documentation of treatments and verbal orders, but this was not consistently followed, leading to deficiencies in the resident's 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 facility failed to maintain accurate and complete medical records for several residents, leading to potential risks for improper care. For Resident #1, there were multiple instances where treatments were not documented according to facility policy. The resident had a complex medical history, including diabetes and peripheral vascular disease, and required specific wound care treatments. However, the Treatment Administration Record (TAR) showed blanks on several dates, and there was no documentation explaining these omissions. Interviews revealed that the resident sometimes refused care due to pain, but this was not consistently documented. Resident #3 also experienced significant documentation issues, with numerous occasions where wound care treatments were not recorded. This resident had spina bifida and cellulitis, requiring daily wound care. Despite the resident's report of receiving care, the TAR had multiple blanks, and there were no progress notes explaining the lack of documentation. The resident mentioned that wound care was sometimes missed on weekends, but specific dates and staff were not identified. For Resident #4, the facility failed to document the application of compression wraps and other treatments for lymphedema on several occasions. The resident had Alzheimer's disease and often refused care from nurses other than a specific LVN, which contributed to the documentation gaps. Similarly, Resident #6's wound assessments were not documented in a timely manner, with a significant delay in recording wound progress evaluations. Interviews with facility staff, including the DON and ADON, highlighted a lack of awareness and oversight regarding these documentation deficiencies, which could lead to repeated treatments and discomfort 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 include mandatory training as part of its infection prevention and control program, specifically lacking written standards, policies, and procedures as required by S483.80(a)(2). This deficiency was identified through observations, interviews, and record reviews, revealing that 18 out of 28 nurses had not completed hand hygiene training, and 18 had not completed hand hygiene competency evaluations. Additionally, all 28 nurses had not completed wound care training, and 26 had not completed wound care competency evaluations. This lack of training and competency verification could potentially place residents at risk of receiving care from staff without the necessary skills. During observations, specific instances of inadequate hand hygiene were noted. For example, LVN K was observed performing wound care on a resident without performing hand hygiene before the procedure and washing hands for only 9 seconds afterward. Similarly, RN L was observed touching a mask with ungloved hands and failing to perform hand hygiene before donning a new mask. RN L also washed hands for less than the recommended 20 seconds multiple times during wound care procedures, which could lead to cross-contamination and infection. Interviews with staff revealed gaps in training and documentation. LVN K admitted to not performing hand hygiene due to nervousness and was unsure about the documentation of her wound care training. RN L, who had recently started working at the facility, stated she received wound care training but did not consistently follow hand hygiene protocols. The ADON and DON acknowledged the lack of documented competencies and training for staff, with the DON admitting responsibility for ensuring appropriate training and competency evaluations. The facility's policy on infection prevention and control emphasized staff education and competency, but the facility lacked a specific policy regarding nurse training and competency evaluations.

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 pain management for a resident during wound care, which was inconsistent with professional standards of practice and the resident's care plan. The resident, who had severe cognitive impairment and a history of chronic pain, was not assessed or treated for pain prior to or during the wound care procedure. Despite the resident's verbal expressions of pain and physical gestures indicating discomfort, the attending RN continued with the treatment without administering pain medication beforehand. The resident had a history of Alzheimer's Disease, Peripheral Vascular Disease, and Dementia, and was on a regimen of opioids and other pain medications. During the wound care procedure, the resident repeatedly expressed pain by saying 'ay, ay' and reaching for her right calf, but the RN did not recognize these as signs of pain. The RN believed the resident was not in pain due to the absence of frowning or other typical pain indicators and continued the treatment without pausing to reassess or administer pain relief. Interviews with facility staff revealed a lack of clarity and consistency in assessing and managing pain during treatments. The RN and LVN involved in the procedure had differing interpretations of the resident's expressions of pain, and the facility's policy did not specify when pain assessments should be conducted. The Director of Nursing acknowledged the importance of assessing pain before treatments but noted that the facility's policy lacked specific guidance on timing. This oversight in pain management could lead to unnecessary discomfort and decreased quality of life 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 that all drugs and biologicals were stored in locked compartments, as evidenced by the treatment cart being left unlocked on three separate occasions. During an observation, RN L was seen entering a resident's room to provide wound care, leaving the treatment cart unlocked. After completing the treatment, RN L exited and re-entered the room, again leaving the cart unlocked. The treatment cart contained items such as betadine, alcohol pads, and triple antibiotic ointment. At the time of the observation, there were two CNAs, a nurse, a resident, and unlicensed staff present in the hallway. Interviews with RN L and the Director of Nursing (DON) confirmed that the facility's policy required medication and treatment carts to be locked when unattended. RN L acknowledged the risk of leaving the cart unlocked, as residents could access the contents and potentially harm themselves. The DON reiterated that leaving carts unlocked posed a safety issue, especially with confused residents who might gain access to the medications and treatments stored in the carts. The facility's policy, dated 10/1/19, clearly stated that medication carts must be locked at all times when not in use and should not be left unattended in resident care areas.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices observed during wound care for two residents. LVN K did not perform hand hygiene before providing wound care to a resident and washed her hands for only 9 seconds after completing the care. She admitted to not performing hand hygiene due to nervousness with the state investigator present and acknowledged the expectation to perform hand hygiene between glove changes. Similarly, RN L was observed not performing hand hygiene appropriately during wound care for another resident. She touched the outside of her mask with ungloved hands, donned a new mask without hand hygiene, and repeatedly washed her hands for less than the recommended 20 seconds. RN L also failed to sanitize her hands before retrieving additional supplies from the treatment cart. Despite receiving training on hand hygiene and infection control, RN L did not adhere to the facility's policy, which requires washing hands for at least 20 seconds to prevent cross-contamination and infection.

Penalty

Fine: $75,832

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 pharmaceutical services to meet the needs of a resident, resulting in a serious incident involving a fentanyl overdose. The deficiency was identified when a resident, who had multiple medical conditions including COPD, diabetes, hypertension, bipolar disorder, and quadriplegia, was found unresponsive and suffering from respiratory failure. The resident was admitted to the hospital with multiple fentanyl patches on his body, which had not been reported by the facility staff. This oversight led to the administration of Narcan in the emergency room to counteract the overdose. The investigation revealed that the facility did not adhere to the physician's orders for the fentanyl patch, which was to be changed every 72 hours. On the day of the incident, the resident was found with two fentanyl patches, one of which appeared to have been on for an extended period. Interviews with the facility staff, including nurses and a CNA, indicated a lack of thorough checks for existing patches on the resident's body, leading to the application of an additional patch without removing the old one. The staff involved were aware of the protocols for fentanyl patch application but failed to conduct a full body search to ensure no other patches were present. The facility's internal investigation and interviews with staff highlighted discrepancies in the documentation and communication regarding the fentanyl patches. The DON stated that the facility could account for all patches given to the resident, yet the hospital records and EMS reports contradicted this claim. The failure to properly monitor and document the administration of fentanyl patches resulted in a critical situation that required emergency medical intervention.

Removal Plan

• The Director of Nursing and/or designee has reviewed all current residents with fentanyl patch orders.
• The Director of Nursing and/or designee has observed current residents for appropriate patch placement and documentation.
• The Director of Nursing and/or designee will review new admissions to ensure that any new orders for fentanyl patch are complete and patch is placed appropriately.
• Licensed nursing staff received re-education on appropriate order, placement and documentation of fentanyl patch, including identifying signs and symptoms of possible overdose.
• Licensed Nursing Staff re-educated on appropriate disposal of Fentanyl Patches.
• Licensed Nursing Staff re-educated on validation of patch placement.
• Direct care staff re-educated on communication to supervisor of any displaced or dislodged patch, to ensure M.D. orders are followed.
• Re-education initiated with Licensed Staff and completed with Licensed staff and Direct care staff. Those that are PRN, PTO/FMLA will complete prior to next schedule shift. Re-education will continue for any new hires and as part of the orientation process.
• Re-education will be validated using employee roster.
• The Director of Nursing or designee will review the 24-hour report in the morning clinical meeting to ensure that any new orders for fentanyl patch are documented and placed appropriately. This will be an ongoing process.
• The Director of Nursing or designee will ensure new admissions have complete orders and correct placement for fentanyl patch. Placement of patches will be rotated on upper body.
• The facility does have Narcan available in the event of an overdose situation for residents who are prescribed Fentanyl.
• The Director of Nursing or designee will monitor compliance every shift, then every shift 3 times per week, then 1 x a week. The results of findings will be discussed in the monthly QAPI meeting and the plan will be continued as needed. The DON or designee will utilize a validation log to document findings.
• The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the admissions and the 24-hour report in the morning clinical meeting.
• An Ad-Hoc QAPI was conducted by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F755 and to develop the above-mentioned plan of care.

Penalty

Fine: $75,832

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

Summary

The facility failed to ensure that licensed nurses had the necessary competencies and skill sets to care for residents' needs, as evidenced by the incident involving two LVNs and a resident. The LVNs did not follow the physician's order for fentanyl patch application, which resulted in the resident becoming unresponsive and suffering respiratory failure. The resident, a 74-year-old male with multiple health conditions including COPD, diabetes, hypertension, bipolar disorder, and quadriplegia, was found with multiple fentanyl patches upon arrival at the hospital, indicating a potential overdose. The record review revealed that the LVNs were marked as competent to perform tasks related to transdermal patches, including fentanyl, but failed to conduct a thorough check for existing patches on the resident's body. On the day of the incident, one LVN removed and applied a fentanyl patch without fully inspecting the resident for other patches, and the other LVN witnessed this process. The facility's policy required a full body search and proper documentation of patch placement, which was not adhered to, leading to the resident's adverse reaction. Interviews with the involved staff and the DON confirmed that the LVNs were aware of the fentanyl protocols but did not follow them correctly. The DON acknowledged the discrepancy in the documentation regarding the patch placement and the lack of a full body search. The facility's policy on transdermal patch application was not followed, and the requested Nursing Staff Competency policy was not provided by the exit of the survey.

Penalty

No penalty information released

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

Summary

The facility failed to implement a comprehensive care plan to meet the medical and nursing needs of Resident #1, who required weekly skin assessments. Despite having an active order for weekly skin evaluations, the facility did not complete these assessments consistently. Specifically, there were no weekly skin evaluations documented for the weeks of 04/01/2024 and 04/15/2024. This lapse in care was identified through record reviews and interviews with staff members, who confirmed the missed assessments and their responsibilities in conducting them. Resident #1, a [AGE] year old male with diagnoses including cellulitis and hemiplegia following a cerebral infarction, was at risk for impaired skin integrity. The resident's care plan, which included weekly skin inspections, was not followed as required. Interviews with LVN B, Treatment Nurse D, and LVN C revealed that the nurses were responsible for completing the skin assessments, but there was a lack of consistent follow-through. LVN B and LVN C had divided responsibilities for skin assessments based on room assignments, but the assessments for Resident #1 were missed. The Director of Nursing (DON) confirmed that the skin assessments were supposed to be tracked and reviewed during morning meetings, but this process was not effectively implemented. The facility's policy on skin assessments required weekly evaluations to prevent and manage pressure injuries, but this policy was not adhered to in the case of Resident #1. The failure to conduct these assessments could lead to missed early signs of skin issues, potentially resulting in worsened conditions that require more intensive treatment.

Penalty

Fine: $75,090

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 assistance devices to prevent accidents for four residents. Resident #50, who had a history of alcohol abuse and was prescribed multiple medications, experienced multiple falls and was found with cigarettes and a lighter despite needing supervision. The facility's records showed that Resident #50 often signed himself out, returned smelling of alcohol, and was administered his medications without proper monitoring. Staff interviews revealed that the facility did not have beer on hand, and nurses documented administering beer without actually doing so, indicating a lack of proper supervision and documentation practices. Resident #15, who also had a history of alcohol abuse and was prescribed methadone, experienced similar issues. He frequently signed himself out, returned smelling of alcohol, and was found with cigarettes and a lighter despite needing supervision. The facility's records and staff interviews indicated that Resident #15 was often unsupervised while smoking and that his falls were not properly connected to his alcohol use. The DON and other staff members were unaware of the residents' routines and the lack of proper documentation and supervision. Resident #47 was found with empty liquor bottles and extra Percocet pills, indicating potential substance abuse. The facility failed to monitor and supervise her properly, leading to falls and the risk of polypharmacy. Resident #82 was allowed to have toxic hair dye without a doctor's order or supervision, posing a safety risk. The facility's failure to monitor and supervise these residents adequately placed them at risk for serious harm, accidents, or major injury.

Penalty

Fine: $75,090

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 all drugs and biologicals in locked compartments under proper temperature controls and permitted unauthorized personnel to have access to the keys. This deficiency was observed in the case of a resident who was hospitalized and diagnosed with an overdose related to self-medication with Diphenhydramine and Hydrocodone. The resident's medications were kept at her bedside, which led to an incident where she was found unconscious and subsequently hospitalized. The resident had a history of severe mental cognition impairment and was known to be resistive to care and non-compliant with medication regimens. The resident's care plan included interventions to educate her and her family about the importance of complying with treatment and care, as well as monitoring her for safety due to her use of anti-anxiety medications. Despite these interventions, the resident was found with a large bottle of Benadryl and Norco at her bedside, leading to her overdose. Interviews with the resident, her family, and facility staff revealed that the resident did not remember taking the medications and that her family was unaware of the facility's policies regarding bringing medications into the facility. The facility's policies on medication storage and disposal, as well as abuse, neglect, and exploitation, were not adequately followed. The Director of Nursing (DON) and other staff members were aware of the incident but failed to take appropriate actions to prevent it. The facility's failure to monitor and control the storage of medications at the resident's bedside placed her at significant risk for harm, leading to her hospitalization and diagnosis of overdose.

Penalty

Fine: $75,090

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. During an initial kitchen tour, it was observed that sanitizing buckets were stored near food products, and personal beverages were present in the kitchen work area. Additionally, the juice machine dispenser was found to be dirty, with dried dark red substances inside the nozzles. Opened milk jugs were undated, and a prepared salad in the refrigerator was not discarded by its discard date. An open package of cheese was found in the freezer, and cooked eggs in the freezer lacked a discard date. Furthermore, the handwashing sink did not provide hot running water, with the temperature only reaching 76°F, which is below the required minimum of 85°F for proper hand hygiene practices. Interviews with the Cook/Dietary Aide and the Dietary Manager confirmed that personal beverages should not be in the kitchen work area, sanitizing buckets should not be near food products, and the juice machine needed to be cleaned. They also acknowledged the importance of labeling and dating food products, sealing packages properly, and ensuring that the handwashing sink provides warm water. The Dietary Manager and Registered Dietitian (RD) reiterated these points and confirmed that the water temperature issue had been fixed. Record reviews of the facility's policies on General Kitchen Sanitation, Food Storage, and Hand Hygiene, as well as the Food Code from the U.S. Public Health Service and FDA, supported the observations and interviews. These policies emphasize the importance of storing toxic chemicals away from food products, labeling and dating refrigerated and frozen foods, and ensuring that handwashing sinks provide warm water. The facility's failure to adhere to these standards could place residents at risk for foodborne illness.

Penalty

Fine: $75,090

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to the administrator and the State Survey Agency. This deficiency was observed in four residents. Resident #52 was hospitalized due to an overdose related to self-medication with Diphenhydramine and hydrocodone, but the incident was not reported to the state agency or investigated by the facility. The DON acknowledged awareness of the incident but could not explain why it was not reported. Resident #50 had multiple incidents involving alcohol consumption, medication administration, and subsequent falls. Despite being assessed as needing supervision while smoking, Resident #50 was found with cigarettes and a lighter on multiple occasions. The facility did not report these incidents to the state agency or conduct an investigation. The nursing staff documented the incidents in progress notes and 24-hour reports but did not escalate them further. Resident #15, who had a history of alcohol abuse and was assessed as needing supervision while smoking, was involved in multiple incidents of drinking beer, receiving methadone, and falling. The facility did not report these incidents to the state agency or investigate them. Similarly, Resident #47 was found with empty liquor bottles and was suspected of trading Percocet for alcohol. Despite these findings, the facility did not report the incidents to the state agency or conduct an investigation. The failure to report and investigate these incidents could place residents at risk for abuse, neglect, exploitation, and mistreatment.

Penalty

Fine: $75,090

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

Summary

The facility failed to ensure that Resident #12, who was unable to carry out activities of daily living, received the necessary services to maintain good hygiene. Resident #12, a male with paraplegia, an acquired absence of the left leg below the knee, and major depression, did not receive a shower for 7 days. The resident was assessed as needing substantial assistance for showers, requiring help from staff. Despite being scheduled for showers twice a week, the resident reported not being showered for two weeks, leading to frustration and feelings of neglect. Interviews with staff revealed inconsistencies in the shower schedule and documentation. LVN M and LVN C had different understandings of the shower schedule, and CNA AA admitted to sometimes not documenting showers and not always being present on scheduled days. The Director of Nursing (DON) confirmed the lack of documentation for showers and acknowledged the resident's claim of not receiving assistance. The facility's policies on activities of daily living and abuse, neglect, and exploitation were reviewed, highlighting the requirement to provide necessary care and services to prevent deterioration in residents' abilities and to protect their health and welfare.

Penalty

Fine: $75,090

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 resident preferences for individual activities and independent activities designed to meet the interests and support the physical, mental, and psychosocial well-being of two residents. Resident #48, a [AGE] year-old female with paraplegia, major depressive disorder, and generalized anxiety disorder, expressed that there were not many activities tailored to her interests, such as arts and crafts or sitting on the back patio with cats. Despite her care plan indicating these preferences, she was often unable to participate in these activities due to the patio door being locked and staff being unavailable to supervise or unlock the door. The Activities Director confirmed that residents could only sit outside during smoking breaks, limiting Resident #48's ability to engage in her preferred activities, leading to feelings of loneliness and lack of engagement. Similarly, Resident #62, a [AGE] year-old female with spina bifida, major depressive disorder, and anxiety disorder, also reported a lack of activities that interested her. Her care plan included preferences for arts and crafts, listening to music, and going outdoors, but she stated that these activities were not provided. The Social Worker acknowledged that he had not had the chance to implement new activity ideas since starting at the facility. The facility's failure to provide activities that met the residents' interests and needs was confirmed through interviews and observations, and no policy on resident activities was provided upon request.

Penalty

Fine: $75,090

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's interdisciplinary team failed to review and revise the care plan after each assessment for three residents. Specifically, Resident #18's care plan did not include information about the use of dentures, despite observations and interviews indicating the resident had a loose-fitting upper denture. The care plan lacked details on the status of the dentures, cleaning frequency, and staff assistance required, which was not addressed in the comprehensive assessment dated 1/15/2024 or the care plan dated 03/29/2024. Additionally, Resident #8's care plan was not updated following an attempted elopement incident. Despite a nursing note documenting the resident's agitated behavior and multiple attempts to exit the building, the care plan had not been revised since 02/06/2020. Interviews with staff revealed a lack of awareness about the resident's exit-seeking behavior, and the Director of Nursing confirmed that the care plan should have been updated to reflect the incident. The facility's policies on elopement and comprehensive care plans were not followed, leading to these deficiencies.

Penalty

Fine: $75,090

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 assist Resident #18 in obtaining appropriate dental services after her upper dentures became loose and were recommended to be replaced by the dentist. Despite the dentist's recommendation for new dentures and multiple follow-up attempts by the dental provider, there was no documentation indicating that Resident #18 had seen a dentist since the initial visit. The resident's family expressed concerns about the lack of communication and assistance from the facility, noting that the loose dentures made it difficult for Resident #18 to eat and had fallen out before. The Director of Nursing (DON) was unaware of the status of the denture replacement and could not provide documentation of any recent dental visits for the resident. The facility also failed to assist Resident #81 in obtaining appropriate dental services after she and her family requested it due to her lack of natural teeth. Resident #81 had not received any dental services for a year, and her responsible party had repeatedly requested help from the facility. The dental provider had sent documentation to the physician indicating the necessity for services, but there was no evidence that the resident had seen a dentist or that any attempts were made to replace her dentures. The Social Worker, who started their position recently, was unsure if Resident #81 had been seen by the dentist. The facility's policy on dental services required routine dental inspections and timely referrals for residents with lost or damaged dentures. However, the facility did not adhere to this policy, resulting in residents not receiving necessary dental care. This deficiency could affect residents with dentures, contributing to mouth pain, difficulty eating, and weight loss.

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 proper discharge planning and coordination for two residents, leading to significant deficiencies in their post-discharge care. Resident #2, who had a moderate cognitive impairment and required extensive physical assistance, was discharged without the necessary home health services and durable medical equipment (DME). Despite multiple communications and awareness among staff, including the Rehabilitation Director, Administrator, and ADON, the required services were not arranged. The family member had to independently secure home health, hospice, and medical equipment post-discharge, highlighting a severe lapse in discharge planning and coordination by the facility staff. Similarly, Resident #3, who was cognitively intact and required wound care services, was discharged without confirmed home health services. The discharge order specified the need for home health and wound care services, but these were not in place at the time of discharge. The MDS Coordinator and ADON attempted to coordinate services but failed to ensure they were confirmed and in place. The resident was provided with wound care supplies for a few days but had to manage his own wound care until home health services began, which was not immediately arranged by the facility. Interviews with various staff members, including the Social Worker, MDS Coordinators, LVNs, and the Administrator, revealed a lack of clear communication and responsibility for discharge planning. The facility's discharge policy was not followed, and there was confusion among staff about their roles in the discharge process. This lack of coordination and adherence to policy resulted in residents being discharged without the necessary support and services, placing them at risk for unmet care needs and potential harm.

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 Staff C, who was hired as a Social Worker, was appropriately licensed to practice social work in the State of Texas. Staff C had graduated with a master's degree in social work but had not passed the licensing exam and was scheduled to retake it. Despite this, she was hired and assigned duties that required a licensed social worker, such as resident assessments, discharge planning, and elder abuse assessments. Staff C's personnel file lacked licensure information, and she confirmed during an interview that she was not licensed and had not received adequate training for her role. The HR Manager and the Administrator were aware of her unlicensed status but proceeded with her employment under the title of Social Worker, without verifying her licensure or providing sufficient oversight and training. The Regional Social Worker, who was supposed to be a resource, also did not provide direct oversight or training to Staff C. The facility did not have a contract for a licensed social worker to assist in the absence of a licensed social worker and lacked a policy for social services or social workers. This deficiency could place residents at risk of not receiving care and services from properly trained and supervised 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 a resident's right to formulate an advance directive, specifically an Out-of-Hospital Do Not Resuscitate (OOH DNR) order. The resident's OOH DNR was incomplete, lacking the required signatures from two witnesses, rendering the document invalid. Despite this, the resident's medical record and care plan indicated DNR status, which was not supported by a valid OOH DNR document. The resident's admission agreement and MDS assessment indicated full code status, conflicting with the DNR status noted in the medical record. The resident had moderate cognitive impairment and fluctuating cognition, complicating the situation further. The social worker and other staff members were aware of the incomplete OOH DNR but did not take appropriate steps to rectify the situation, leading to confusion about the resident's code status. The social worker, who was new and unlicensed, was unsure of the process for obtaining a valid OOH DNR and did not feel comfortable signing the document without witnessing the resident's signature. The Director of Nursing (DON) and other staff members also failed to verify the validity of the OOH DNR, resulting in the resident being listed as DNR in the medical record without proper documentation. Interviews with the resident and emergency contact revealed that the resident did not sign an OOH DNR and wanted to be full code status, further highlighting the discrepancy in the resident's code status documentation.

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 person-centered care plans that included measurable objectives and timeframes for two residents. Resident #2's care plan did not include discharge planning and goals, despite having a moderate cognitive impairment and requiring extensive physical assistance. The resident was discharged home with a wheelchair and home health services, but the discharge plan and summary were incomplete and lacked necessary signatures and dates. Interviews with staff confirmed that discharge planning should have been included in the care plan from the time of admission. Similarly, Resident #3's care plan also lacked discharge planning and goals. This resident, who was cognitively intact, was discharged home with orders for home health services and wound care. However, the care plan did not reflect these discharge plans. Staff interviews revealed that the MDS Coordinator was responsible for updating care plans, and the DON acknowledged that discharge planning should be part of the care plan to ensure a safe discharge. The facility's policy on comprehensive care plans was not followed, leading to these deficiencies.