Valley Grande Manor

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 obtain required consent before placing a resident in a secured unit, thereby not ensuring the resident was fully informed and understood the care and treatment to be furnished. The resident was an older female with a history of liver cirrhosis, TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension, originally admitted in 2022 and readmitted in 2025. Record review on 03/20/26 showed no consent form for placement into the secured unit. The facility’s Secured Unit Admission Criteria, dated 3/2026, specified that consent must be received for placement in the secured/locked area. According to progress notes dated 03/11/26, the resident experienced a change in condition with shortness of breath. In interviews, LVN B stated the resident was placed in the secured unit the prior week because she needed close monitoring after an episode of shortness of breath requiring oxygen, and confirmed that consent is required when a resident is placed in the secured unit. The DON reported that the resident was moved to the secured unit on the night of 03/11/26 for closer monitoring due to the change in condition and that there were more staff available in that unit. The DON acknowledged that a consent was required for any secured unit placement, that no consent was obtained for this resident even though she remained there only overnight, and stated she did not know why consent was not obtained and that this was against the resident’s rights.

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 protect a resident from involuntary seclusion when the resident was placed in a secured unit without meeting the unit’s admission criteria and without a physician order. The resident was an elderly female with liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension. Her most recent MDS showed a BIMS score of 4, indicating severely impaired cognition, but documented no hallucinations, delusions, or behavioral symptoms directed toward others. Record review of the order summary for the relevant date showed no order for the resident to be placed in the secured unit. According to staff interviews, the DON directed that the resident be moved to the secured unit late at night due to an episode of shortness of breath, stating that there were more staff available there to monitor her. The usual nurse for the secured unit reported that the resident had been placed there the prior week for closer monitoring after shortness of breath, and that the DON handled the placement. Another LVN stated that the resident had been in her regular room without issues one day and was in the secured unit the next morning, and that she was later directed by the DON to return the resident to her original room. The DON acknowledged that shortness of breath is not a criterion for secured unit placement and that the unit’s criteria require behavioral issues, while the facility’s written secured unit admission criteria require cognitive impairment and assessment of high-risk behaviors such as self-harm or harm to others. The resident did not have documented behavioral issues meeting these criteria.

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 failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple medical and psychiatric diagnoses, including liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension. The resident’s quarterly MDS showed severely impaired cognition (BIMS score of 4), an active diagnosis of anxiety disorder, use of an antianxiety medication, and the presence of a wander/elopement alarm. Record review showed an active order for Lorazepam 0.5 mg twice daily for anxiety and confirmed that the resident wore a Wander Guard device. However, the resident’s care plan, initiated months earlier, contained no focus, goals, or interventions related to Lorazepam use, the Wander Guard, or the resident’s placement in a secured unit. Interviews with staff confirmed awareness of these treatments and safety measures but also confirmed that they were not incorporated into the care plan. The MDS nurse acknowledged knowing the resident was taking Lorazepam and wearing a Wander Guard, had documented the Wander Guard on the MDS, and stated that both the medication and device should have been added to the care plan but were not. The LVN assigned to the secured unit reported that the resident had been placed in the secured unit the prior week for closer monitoring after an episode of shortness of breath requiring oxygen and stated that care plan updates were the responsibility of the MDS nurse or DON. The DON confirmed shared responsibility with the MDS nurse for implementing and revising care plans, acknowledged awareness of the resident’s Lorazepam use, Wander Guard, and recent placement in the secured unit for closer monitoring, and stated that these changes should have been added to the care plan but were not, despite a facility policy requiring ongoing assessment and revision of care plans as resident conditions change.

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 obtain a written, signed, and dated physician order for a resident’s placement in a secured unit, as required by facility policy. Record review showed that a female resident with diagnoses including liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension, and a severely impaired BIMS score of 4, had no physician order dated 03/11/26 for placement in the secured unit on her Order Summary Report. The resident’s admission record reflected an original admission date of 12/06/22 and a readmission date of 08/01/25. The facility’s Secured Unit Admission Criteria, dated 3/2026, specified that a physician order for placement would be obtained for secured unit placement. Interviews confirmed that the resident was moved to the secured unit without a physician order. LVN B, the usual nurse for the secured unit, stated the resident was placed there the prior week for closer monitoring after an episode of shortness of breath and that the DON handled the placement; LVN B was unsure whether an order was required for a Wander Guard. LVN D reported that the resident was in her regular room on one day and in the secured unit the next morning, and that she was told in report the resident had shortness of breath overnight and was placed in the unit for closer observation, then later directed by the DON to return the resident to her room. The DON stated the resident was placed in the secured unit around 11:00 p.m. and returned to her room the following morning, acknowledged there was no physician order for the placement despite policy requiring one, and stated she did not know why she had not obtained the order. Review of the facility’s Wandering and Elopements Policy showed no criteria or implementation guidance for the use of a Wander Guard.

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 in accordance with accepted professional standards and its own Charting and Documentation policy. A female resident with liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension had a severely impaired cognition score (BIMS of 4) and was identified on the MDS as having a wander/elopement alarm. On observation, a Wander Guard was noted on her right wrist, and staff, including an LVN and the DON, acknowledged awareness that the device was in place. However, record review showed no progress note or change in condition entry documenting when or why the Wander Guard was initiated, who placed it, or any associated assessment, despite the facility policy requiring documentation of changes in condition and procedures/treatments with date, time, provider, and assessment details. The facility also failed to document the resident’s placement in a secured unit. An LVN assigned to the secured unit reported that the resident had been moved there the previous week because she experienced shortness of breath and required oxygen and closer monitoring, and stated that the DON handled the placement. The DON confirmed that the resident had been placed in the secured unit due to an episode of shortness of breath and the need for closer monitoring and more staff presence. Despite these changes in the resident’s status and location, the resident’s medical chart contained no progress note or change in condition entry reflecting the transfer to the secured unit, contrary to the facility’s policy that all nurses should update the medical record to reflect new conditions and changes in the resident’s status.

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 protect a resident from misappropriation and exploitation of property by allowing a housekeeping staff member to obtain money from the resident for the staff member’s own personal use. The resident was an elderly male with vascular dementia, severe cognitive impairment as evidenced by a BIMS score of 4, and care plan documentation of impaired cognitive function and thought processes. He required supervision or touching assistance with eating and substantial/maximal assistance with toileting and bathing. Despite these cognitive and functional limitations, the resident reported that he had given $40.00 from his safe to a housekeeping employee, who only returned $10.00. The resident stated that no staff had stolen from him and that he felt safe, but he acknowledged that he had given the housekeeping staff member money and had not been fully repaid until later. The administrator later confirmed that the resident had informed him that he lent $40.00 to the housekeeping staff member, who had only repaid $10.00 at that time, and that the staff member admitted to receiving the money. The facility’s own Abuse Prevention Program policy stated that residents have the right to be free from misappropriation of resident property and exploitation, yet the incident occurred when the housekeeping staff member accepted and used the resident’s money for personal expenses.

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 was free from chemical restraints that were not required to treat a medical symptom by administering the antipsychotic medication olanzapine (Zyprexa) without an adequate clinical indication. The resident was an elderly male with diagnoses of Alzheimer's disease and vascular dementia, and an MDS assessment showed a BIMS score of 3, indicating severely impaired cognition. The resident’s care plan and physician’s order documented the use of olanzapine 10 mg orally twice daily with the indication listed only as "Alzheimer's disease, unspecified," and the order did not include an end date. The MDS identified the resident as receiving a high‑risk antipsychotic, and the care plan interventions were limited to monitoring for side effects, effectiveness, and adverse reactions every shift. Record review of the e‑MAR showed that olanzapine 10 mg was administered over the reviewed period. During interviews, the pharmacist stated that Alzheimer's disease was not an appropriate diagnosis for an antipsychotic medication and that use of an antipsychotic in a resident with Alzheimer's disease could cause death. The ADON similarly stated that ordering an antipsychotic for Alzheimer's disease could cause death and was not recommended for residents with Alzheimer's or dementia. The DON confirmed the resident was on olanzapine and read the order from the computer, acknowledging that the indication of Alzheimer's disease was allowed because the resident came from the hospital with that order. The facility’s own antipsychotic medication use policy stated that antipsychotic medications may be considered for residents with dementia only after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed, but the documentation reviewed did not show such an indication or assessment beyond the Alzheimer's diagnosis.

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 related to medication storage and security when a wound care medication cart was observed left unlocked and unattended outside a resident room. During the observation, the LVN responsible for the wound care cart exited the room, and the surveyor informed her that the cart was unlocked; the LVN then locked the cart. The cart contained drugs and biologicals and was required by facility policy to be locked when not in use and never left unattended while unlocked. In an interview, the LVN acknowledged she was responsible for the wound care cart and stated she was expected to lock it when walking away, explaining that she had left it unlocked because she forgot. She further stated that if the cart was left unlocked, a resident could open a drawer and take items not intended for them. In a separate interview, the DON confirmed the expectation that staff lock medication carts when they walk away and stated that a resident or visitor could grab medication from an unlocked cart and be harmed. Review of the facility’s undated “Storage of Medications” policy showed that all drugs and biologicals must be stored in a safe, secure manner, with all compartments containing medications locked when not in use and medication carts not left unattended while unlocked.

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 Minimum Data Set (MDS) assessments accurately reflected the current status of three residents. For one resident, the quarterly MDS assessment did not document three separate falls, each resulting in varying degrees of injury, that occurred on specific dates. Another resident's quarterly MDS assessment omitted documentation of an incident involving physical aggression. Additionally, a third resident's quarterly MDS assessment failed to record behaviors such as delusions, refusal of care, and a fall that resulted in minor injury. These omissions were identified through observations, interviews, and record reviews, indicating that the assessments did not accurately capture the residents' conditions and events as required.

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 multiple medical conditions, including dementia, generalized muscle weakness, lack of coordination, mood disorder, type 2 diabetes, and chronic kidney disease. The resident was identified as high risk for falls, with a fall risk evaluation score of 13 and a BIMS score of 2 indicating severe cognitive impairment. Despite a history of multiple falls resulting in injuries such as a laceration to the back of the head and a skin tear, the care plan did not include the use of a fall mat, even though one was observed in place next to the resident's bed. The care plan interventions focused on call light accessibility, appropriate footwear, monitoring for pain or injury, therapy evaluation, and offering activities, but omitted documentation of the fall mat as an intervention. Interviews with facility leadership, including the ADON and DON, revealed uncertainty about whether the fall mat was in use and acknowledged that if it was being used, it should have been included in the care plan to ensure staff awareness and consistent implementation. The facility's policy required that care plans incorporate identified problem areas and be revised as residents' conditions change, but this was not followed in the case of the fall mat intervention for this resident. The omission of the fall mat from the care plan was identified through observations, 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 in accordance with accepted professional standards for two residents. In one instance, a nurse did not document a resident's change of condition following an incident where the resident was found on the floor. Although the nurse assessed the resident and notified the responsible party, she did not complete a change of condition form, did not document notification of the nurse practitioner, and did not perform a fall risk evaluation or neuro checks. The nurse relied on another resident's account that the individual was crawling, and therefore did not consider it a fall, despite not witnessing the event herself. The nurse also could not recall if any orders were given by the nurse practitioner. For another resident, there were multiple documentation failures related to incidents of aggressive behavior and a fall. The change of condition form for the aggressive behavior was completed and signed by the DON several days after the incident, with vital signs and other information recorded for a later date rather than at the time of the event. Similarly, the change of condition form for the fall included vital signs and blood glucose readings from dates that did not correspond to the incident, including a blood glucose value from two years prior. The primary nurse did not complete the required documentation at the time of the incidents, and the DON later completed some of the forms after the fact. Interviews with facility staff, including the ADON and DON, confirmed that the nurses involved had been trained on proper documentation procedures, including the need to complete change of condition forms, risk assessments, and to notify appropriate parties. The facility's own policy required that all incidents, accidents, or changes in condition be recorded in the resident's medical record, including notification of family and physicians. Despite this, the required documentation was not completed at the time of the incidents, resulting in incomplete and inaccurate medical records for the residents involved.

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 certified nursing assistant (CNA) failed to follow proper infection control practices during incontinent care for a male resident with significant medical needs, including type 2 diabetes, muscle weakness, dementia, bowel incontinence, and an indwelling catheter. During the observed care, the CNA used the same disposable cleansing wipe multiple times on different areas, crumpling and reusing the wipe instead of discarding it after a single use. This practice was observed repeatedly throughout the procedure, including care of the genital and buttock areas. Interviews with staff revealed inconsistent understanding and application of infection control protocols. The CNA involved stated that facility training allowed for folding and reusing wipes as long as a clean area was used, while another CNA and an LPN both indicated that wipes should be used once and then discarded to prevent cross-contamination. The Assistant Director of Nursing (ADON) acknowledged that best practice was to use one wipe per swipe and dispose of it, but also described some ambiguity in staff training regarding the reuse of wipes if a clean area remained. Review of the facility's policies and competency assessments confirmed that disposable items should be discarded after use, and FDA guidance also supports immediate disposal of used wipes to prevent cross-contamination. Despite regular in-service training and competency checks, the observed practice did not align with facility policy or best practice, resulting in a failure to maintain an effective infection prevention and control program for residents requiring incontinent care.

Penalty

Fine: $22,320

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

Summary

A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

Fine: $15,935

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

Summary

A deficiency occurred when a resident with severe cognitive impairment, dementia, stroke, and left hemiplegia, who was care planned as dependent on two staff for transfers and showers, was left unattended in a shower chair by a single CNA. The resident required a mechanical lift with two-person assistance for transfers, as documented in her care plan and MDS. Despite these requirements, the CNA attempted to manage the transfer alone and turned away to retrieve the mechanical lift, during which time the resident fell from the shower chair. The fall resulted in the resident sustaining acute fractures to the right great toe and first metatarsal, as confirmed by x-ray, and a laceration to the top lip. The resident experienced pain requiring PRN analgesics and a new order for tramadol, as well as a referral to orthopedics. The incident was witnessed, and the CNA involved acknowledged that she was alone with the resident, despite knowing the resident was a two-person assist, and attributed this to staffing shortages at the time. Interviews with staff confirmed that the facility's policy and the resident's care plan required two-person assistance for transfers and use of the mechanical lift. The CNA admitted to performing two-person assists alone on several occasions due to short staffing. There was no documentation of in-service training following the incident, and the fall was not reported as neglect, despite facility policy and regulatory definitions that classify such failures to provide necessary services as neglect.

Penalty

Fine: $15,935

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 significant cognitive and physical impairments. The resident, an elderly female with diagnoses including dementia, stroke with left hemiplegia, diabetes, epilepsy, and hypertension, was assessed as having severe cognitive impairment and was dependent on two staff members for bathing and transferring, as documented in her care plan and MDS assessments. Despite these documented needs, the care plan contained inconsistencies regarding the level of assistance required for bathing, and interventions were not consistently implemented as specified. On the day of the incident, a CNA provided a shower to the resident alone, despite the care plan indicating a two-person assist and the use of a mechanical lift for transfers. The CNA attempted to transfer the resident from the shower chair to the bed without assistance, during which the resident fell and sustained acute fractures to her right foot and a laceration to her lip. The CNA later stated that due to staffing shortages, she had performed two-person assists alone on several occasions, and acknowledged the risks involved. There was no documentation of any in-service training the CNA claimed to have received following the incident. Interviews with other staff confirmed that the expectation was for two staff to assist with such transfers, and that failure to do so could result in injury. The DON was not present at the time of the incident but reviewed the notes afterward. The facility did not provide a care plan policy when requested. The failure to implement the care plan as written, specifically regarding the required level of assistance for bathing and transferring, directly led to the resident's fall and injuries.

Penalty

Fine: $15,935

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 implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically for a resident with severe cognitive impairment and multiple medical conditions, including dementia, stroke, diabetes, epilepsy, and hypertension. The resident was care planned as dependent on two staff for transfers and required a mechanical lift with two-person assistance. Despite these documented needs, the resident was left in a shower chair with only one CNA present, who turned away to retrieve the mechanical lift, leaving the resident unattended. During this time, the resident fell from the shower chair and sustained acute fractures to the right great toe and first metatarsal, as confirmed by x-ray. Progress notes documented the resident's pain and subsequent administration of pain medication, as well as a referral to orthopedics. Interviews with staff revealed that the CNA was aware the resident required two-person assistance but proceeded alone due to staffing shortages. The CNA also reported having to perform two-person assists alone on several occasions. Further interviews indicated a lack of clarity among staff regarding abuse and neglect reporting procedures, and there was no documentation of in-service training following the incident. The facility's policies defined neglect as the failure to provide necessary goods or services to avoid harm, and provided an example similar to the incident that occurred. The facility did not report the fall as neglect, nor did it provide immediate in-service training to address the deficiency.

Penalty

Fine: $15,935

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

Summary

The facility failed to ensure timely reporting of alleged neglect and a fall with injury involving a resident with severe cognitive impairment and significant physical limitations. The resident, who required a two-person assist and mechanical lift for transfers due to dementia, stroke, and hemiplegia, experienced a fall while being transferred by a single CNA, contrary to her care plan. The fall resulted in a fractured right great toe and a laceration to the lip, with subsequent pain requiring medication and orthopedic referral. Following the incident, the resident's family member alleged neglect, expressing concern that such accidents should not occur under 24-hour facility care. The allegation was communicated to facility staff, but the incident and the neglect allegation were not reported to the State Survey Agency within the required timeframe. Facility policy and federal regulations mandate immediate reporting of such incidents, especially when they involve potential neglect or result in serious injury. However, the facility did not notify the State Survey Agency within two hours of the incident or within 24 hours for the neglect allegation, as required. Interviews with staff revealed confusion and inconsistency regarding the reporting requirements and the circumstances of the fall. The CNA involved admitted to performing a two-person assist transfer alone due to staffing shortages, acknowledging that this practice increased the risk of resident falls. Despite the family member's initial allegation of neglect, the administrator did not report the incident, citing the family member's later recantation. The facility's failure to report both the fall with injury and the neglect allegation constituted a deficiency in meeting regulatory requirements for timely reporting of suspected abuse, neglect, or injury.

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 nurse failed to properly verify and account for a resident's controlled medication, specifically Morphine Sulfate Oral Solution, during a required narcotic count. The nurse, LVN C, signed off on the narcotic count based on another nurse's statement that the medication was in the refrigerator, without physically checking or confirming its presence. Subsequent review and interviews revealed that the morphine was missing and could not be located, despite being required to be stored in a double-locked medication cart and included in the shift-to-shift narcotic count. The resident involved was an elderly female with multiple diagnoses, including severe cognitive impairment, polyosteoarthritis, osteomalacia, and dementia. She had a physician's order for morphine to be administered as needed for pain, but her pain assessment at the time indicated no pain. The last documented administration of the morphine was several days prior to the incident. The facility's narcotic count records and staff interviews confirmed that the medication was present during previous counts, but was unaccounted for during the shift change involving LVN C. Interviews with nursing staff and review of facility policy confirmed that the standard procedure required both the oncoming and outgoing nurses to physically verify and count all controlled substances at each shift change. The failure to follow this procedure by not physically verifying the presence of the morphine led to the medication being unaccounted for. The incident was reported to the Director of Nursing, and the missing medication was not found despite a search. The facility's policy and staff statements emphasized the importance of accurate narcotic counts to ensure all medications are accounted for at all times.

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

Dietary Aide A entered the facility's only kitchen to retrieve snacks without wearing a hairnet, as observed by surveyors. During interviews, Dietary Aide A admitted to forgetting to wear the required hairnet due to being late and acknowledged awareness of the policy and the potential for food contamination if hair is not properly restrained. The Dietary Manager (DM) and Assistant Dietary Manager (ADM) both confirmed that all staff are required to wear hairnets in the kitchen to prevent food contamination, and that this requirement is regularly communicated to staff during meetings. A review of the facility's Food Preparation and Service policy, revised in April 2019, confirmed that food and nutrition services employees are required to wear hair restraints to prevent hair from contacting food. The failure to follow this policy placed all 92 residents who receive meals from the kitchen at risk for food contamination and foodborne illness, as the kitchen is the sole source of meal preparation and distribution in the facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. The resident, a female with a history of cerebral infarction, dysphagia, gastrostomy status, and type 2 diabetes mellitus, experienced a significant weight loss due to the facility's failure to transcribe and initiate the correct enteral feeding order. The resident's feeding order was supposed to be 65ml for 22 hours, but it was incorrectly entered as 65ml for 20 hours, leading to a 6-pound weight loss over a two-month period. The deficiency was identified through interviews and record reviews, which revealed that the dietary recommendation for the resident's feeding was agreed upon by the physician assistant but was not accurately reflected in the physician orders. The Assistant Director of Nursing (ADON) admitted to inputting the order incorrectly and acknowledged that the error was due to not double-checking the entry. The ADON also stated that the error was brought to her attention in December, at which point the order was corrected. The facility's policy on charting and documentation requires that medical records be complete and accurate, but this was not adhered to in this case. The ADON and the Director of Nursing (DON) were responsible for monitoring and ensuring orders were correctly input, but the ADON admitted to not having formal training on weights and accurate order documentation, relying instead on on-the-job training. This lack of accurate documentation and monitoring led to the resident not receiving the necessary nutritional intake, resulting in 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 develop and implement a person-centered care plan for two residents, which included measurable objectives and timeframes to address their medical, nursing, and psychosocial needs. Specifically, the care plans for two residents did not include documentation of their skin conditions, namely rashes, which were identified in their comprehensive assessments. This oversight could potentially place residents at risk for not receiving appropriate treatment and services. For one resident, the facility's records indicated a history of Alzheimer's disease, anxiety disorder, dysphagia, and polyneuropathy. Despite multiple nurse practitioner notes documenting a generalized scattered rash and a psoriatic rash over several months, the resident's care plan did not include any mention of these skin conditions. The MDS nurse, responsible for updating care plans, was unaware of the resident's rash and acknowledged that the care plan was not updated properly. Another resident, with diagnoses including parkinsonism, peripheral vascular disease, chronic kidney disease, vascular dementia, type 2 diabetes mellitus, and hemiplegia, also had a rash documented in their medical records. A change in condition noted by the wound care nurse indicated a new onset rash, yet the care plan did not reflect this condition. Interviews with facility staff, including the MDS nurse, ADON, and LVN, revealed a lack of awareness and understanding of the facility's care plan policy, contributing to the failure to update the care plans accurately.

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 clinical records in accordance with accepted professional standards and practices for a resident, specifically regarding the documentation of a skin rash. The resident, an elderly female with Alzheimer's disease, anxiety disorder, dysphagia, and polyneuropathy, was noted to have a generalized scattered rash by the Nurse Practitioner (NP) on multiple occasions. However, the skin observation tools completed by the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) did not document the presence of this rash, despite the facility's policy requiring comprehensive skin assessments. Interviews with the LVN and ADON revealed that they were responsible for completing the skin assessments but failed to document the rash observed by the NP. The LVN admitted to possibly overlooking the rash and stated that she was not notified of it during her assessments. The ADON also did not recall the rash during her assessments and suggested that the omission might have been due to copying previous assessments or focusing on more acute issues. Both staff members acknowledged the importance of accurate documentation for ensuring appropriate treatment and compliance with facility policy. The facility's policy on charting and documentation emphasized the need for objective, complete, and accurate records. Despite training sessions on skin assessments, the LVN and ADON did not adhere to these standards, resulting in incomplete documentation of the resident's condition. This deficiency in record-keeping could potentially affect the care and treatment of residents by leading to errors or delays in addressing their medical needs.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that an adequate emergency water supply was readily available and stored in a safe and sanitary manner. The emergency water supply was stored in a warehouse-type building located 0.2 miles from the facility, which lacked air conditioning and had vent openings to the outside. During an observation, surveyors noted that the water jugs were dusty, some jugs lacked caps, and others had makeshift coverings such as paper napkins secured with rubber bands. The storage conditions did not comply with the facility's policy, which required water to be stored in a cool, dark place. Interviews with facility staff revealed a lack of awareness and responsibility regarding the condition of the emergency water supply. The Maintenance Supervisor, who was responsible for checking the water supply every two months, was unaware of the missing caps and the unsanitary conditions. The Dietary Manager and the Administrator also did not know about the deficiencies in the water storage. The facility's policy, based on guidelines from the Federal Emergency Management Agency, was not followed, potentially placing residents at risk due to the possibility of contaminated water.

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 residents had the right to formulate an advance directive, specifically an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order, for three residents. For Resident #30, the OOH-DNR form was not completed correctly as the physician did not sign in the appropriate section, which is required to validate the document. This oversight could potentially lead to the resident receiving cardiopulmonary resuscitation (CPR) against their wishes. Similarly, Resident #3's OOH-DNR form was incomplete because the physician did not sign the section designated for two physicians to act on behalf of an adult who is incompetent or unable to communicate. This lack of a proper signature rendered the DNR form invalid, risking the possibility of unwanted resuscitation efforts. For Resident #57, the OOH-DNR form was missing a signature from the second witness in the required section. This omission also invalidated the DNR form, which could result in the resident being treated as a full code, contrary to their advance directive. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), the Director of Nursing (DON), and the Social Worker (SW), revealed a lack of consistent procedures and oversight in ensuring that DNR forms were completed and signed correctly, highlighting a systemic issue in the facility's handling of advance directives.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate pharmaceutical services for 25 residents who were insulin-dependent, as evidenced by missing calibration logs for blood glucose meters. The absence of these logs spanned several dates across different wings of the facility, indicating a systemic issue in maintaining accurate records. The facility's policy required regular calibration checks to ensure the accuracy of blood glucose readings, but these were not consistently documented. Interviews with staff, including LVNs and the DON, confirmed that the night shift was responsible for these calibrations and logs, yet significant gaps in documentation were found. The lack of updated calibration logs could lead to inaccurate blood glucose readings, which are critical for managing insulin-dependent residents. The facility's policy and the Blood Glucose Monitoring System User's Guide both emphasize the importance of control solution testing to verify the accuracy of test results. Despite this, the facility did not adhere to these guidelines, potentially compromising the health and safety of the residents. Staff interviews revealed an awareness of the importance of calibration, but the execution was inconsistent, leading to the identified deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to notify a resident's representative and the Office of the State Long-Term Care Ombudsman in writing about a transfer to the hospital. This deficiency was identified for one resident who was transferred due to critical potassium levels. The resident had a history of Alzheimer's disease, encephalopathy, pneumonia, and Type 2 Diabetes Mellitus. Despite the transfer, there was no documentation that the required notifications were made in writing, as mandated by the facility's policy. Interviews with facility staff, including a Registered Nurse (RN), the Director of Nursing (DON), and the Business Office Manager (BOM), revealed that the facility's practice was to inform the resident's representative via telephone rather than in writing. Additionally, the local Ombudsman confirmed that the facility was not sending notices of discharges or transfers. The facility's policy requires written notification to the resident's representative and the Ombudsman, including details about the transfer, appeal rights, and contact information for advocacy services.

Penalty

No penalty information released

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

Summary

The facility failed to provide a written notice of the bed-hold policy to a resident and their representative during a transfer to the hospital. This deficiency was identified for one resident among four reviewed for transfers. The resident, who had diagnoses including Alzheimer's disease, encephalopathy, pneumonia, and Type 2 Diabetes Mellitus, was transferred to a hospital due to critical potassium levels. However, there was no documentation indicating that the resident or their representative received a written copy of the bed-hold policy at the time of transfer. Interviews with facility staff, including a Registered Nurse (RN), the Director of Nursing (DON), and the Business Office Manager (BOM), revealed that the facility did not provide written information about the bed-hold policy during transfers. The RN and DON stated that information was communicated verbally over the phone, and the BOM indicated that the nurses were responsible for providing such information. A review of the facility's policy on transfer or discharge notice confirmed that written notification, including the bed-hold policy, should be provided to residents and their representatives before or at the time of transfer.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical and nursing needs. Specifically, the care plan did not reflect the resident's order for continuous oxygen at 2 liters per minute via nasal cannula. This oversight was identified during a review of the resident's records, which showed an indefinite order for oxygen that was not included in the care plan. Observations confirmed that the resident was using oxygen, but the care plan did not document this need. The resident, an elderly female with diagnoses including chronic obstructive pulmonary disease, transient ischemic attack, and hypertension, had a moderately intact cognitive status. Despite the presence of signage indicating oxygen use and the resident's acknowledgment of feeling better since being on oxygen, the facility's policy on comprehensive care plans did not mention the resident's oxygen order. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed they were unable to determine if the lack of care planning for the oxygen order resulted in any 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 respiratory care consistent with professional standards for two residents who required oxygen therapy. Resident #40, a female with chronic obstructive pulmonary disease and other health issues, was observed receiving oxygen at 2.5 liters per minute (Lpm) via nasal cannula, contrary to the physician's order of 2.0 Lpm. Despite the discrepancy, staff members, including an LVN and the ADON, noted that there were no negative effects from the increased oxygen level. However, the failure to adhere to the prescribed oxygen level represents a deviation from the physician's orders. Similarly, Resident #3, who has multiple health conditions including Alzheimer's and congestive heart failure, was observed receiving oxygen at 4 Lpm instead of the ordered 2 Lpm. The resident was not in distress during observations, but the LVN responsible for the resident acknowledged the incorrect setting and noted that maintaining the higher oxygen level could lead to respiratory issues. The DON confirmed that nurses are responsible for checking oxygen settings every shift, but there was a lapse in ensuring the correct oxygen level was maintained for Resident #3. The facility's policy on oxygen administration requires verification of physician orders and adherence to prescribed treatments. However, the observations and interviews revealed that the oxygen settings for both residents were not consistent with the physician's orders, indicating a failure in following the facility's procedures for safe oxygen administration. This deficiency could potentially place residents at risk of respiratory complications, although no immediate negative outcomes were reported.

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 effective infection prevention and control program, as evidenced by improper incontinent care practices observed for two residents. Resident #17, a male with severe cognitive impairment and multiple health conditions including Alzheimer's and chronic kidney disease, was not provided proper perineal care by CNA K. During an observation, CNA K did not clean the resident's penis, scrotum, and inner thighs adequately and failed to sanitize her hands between glove changes. Similarly, Resident #11, a female with severe cognitive impairment and various health issues such as heart failure and dementia, also received inadequate perineal care. CNA K used only one wipe to clean the resident's inner thighs and did not rinse or dry the perineal area. Both CNA K and CNA L failed to sanitize their hands between glove changes, which is a critical step in preventing infections. Interviews with the CNAs revealed that they were aware of the potential for infection due to their lapses in hand hygiene and perineal care. Despite having been trained and having competency checks, they admitted to forgetting key steps in the process. The Director of Nursing confirmed that CNAs have access to necessary supplies and are expected to follow proper procedures, but could not provide documentation of recent infection control training.

Penalty

Fine: $8,021

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 resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with Alzheimer's disease and dementia from eloping undetected. The resident was admitted to the facility and eloped on the same day, spending the night outside in the backyard of a nearby church before being found the next morning by police. The resident was taken to the hospital for evaluation after being found lethargic and shivering, having spent the night outside in the cold. The initial assessment of the resident indicated that he required limited assistance with bed mobility and transfers, but there was no indication of exit-seeking behavior. However, the facility did not complete a comprehensive assessment to identify potential exit-seeking tendencies. On the night of the incident, the resident was last seen walking in the facility's B wing north corridor. The staff initiated a search and notified the police, but the resident was not found until the next morning. The facility's investigation revealed that the resident likely exited through a side door that did not have an alarm, which was used by staff and residents to access the patio. Interviews with staff indicated that they were not aware of the resident's exit-seeking behavior and that the facility's elopement procedures were not effectively implemented. The facility's policy required staff to promptly report any resident suspected of being missing and to initiate a search of the building and premises. However, the staff did not have adequate information about the resident's potential exit-seeking behavior, and the side door without an alarm allowed the resident to exit the building undetected. The facility's failure to provide adequate supervision and secure the environment led to the resident's elopement and subsequent hospitalization.

Removal Plan

• The side door lock was changed; the dead bolt was replaced with a keypad, and a code alert was installed.
• All staff were in-serviced on the topic of elopement.
• All new admissions with diagnosis of dementia will need a wander guard.
• Nurses and CNAs are to do a walking round at the start and at the end of their shifts.
• The only door without an alarm was replaced with a magnetic lock with power supply, an all-weather keypad, and a 24V supply with back-up battery port.
• All residents who were at risk of wandering had a current face sheet and demographic information in the elopement binder.
• Maintenance Director tested all exit doors and ensured the alarm was activated if a resident with a wander guard tried to exit.
• Staff were in-serviced on the topics of facility policy and procedure related to identifying residents with exit seeking tendencies, redirecting, and the facility's code used for elopements.

Penalty

Fine: $8,021

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 a resident in advance of the risks and benefits of proposed care and treatment. Specifically, the facility did not ensure that consent forms were properly completed or signed by a responsible party before administering an antipsychotic medication (Nuplazid) to a resident. This resident, a female with severe impaired cognition, was given the medication without the necessary informed consent, which is a violation of resident rights and facility policy. The resident, who has diagnoses including dementia with behavioral disturbance, Parkinson's disease, heart disease, type 2 diabetes mellitus, chronic kidney disease, and macular degeneration, was admitted to the facility earlier in the year. Despite the facility's policy requiring informed consent for antipsychotic medications, the resident received Nuplazid from April 20th to April 25th without a signed consent form. The responsible party was contacted on April 25th and verbally reviewed the medication's potential side effects but had not signed the consent form by the time of the survey. Interviews with facility staff, including an LVN and the DON, revealed that the signing of consent forms does not always happen immediately. The DON acknowledged the delay between the doctor's order and the responsible party's signing of the consent. The facility's policy clearly states that residents and their representatives must be informed of the risks, benefits, and purpose of antipsychotic medications, and they have the right to refuse such treatments. This lapse in procedure placed the resident and potentially other residents at risk of receiving treatments without proper informed consent.

Penalty

Fine: $8,021

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 written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not conduct an investigation after a mechanical lift incident involving a resident. The incident occurred when the straps of the Hoyer lift tore during a transfer, leaving the resident dangling above the bed and at risk of injury. Despite the resident's fear and the potential for harm, the incident was not reported or investigated as neglect by the staff involved or the administration. The resident involved was a [AGE]-year-old female with multiple medical conditions, including a benign neoplasm of the brain, diabetes, hyperaldosteronism, morbid obesity, major depressive disorder, anxiety disorder, drug-induced polyneuropathy, and lymphedema. She required maximal assistance for various activities of daily living and was dependent on assistance for all transfers by two persons. During the incident, the resident was being transferred from her bed to a shower chair when the straps of the Hoyer lift tore, causing her to dangle above the bed. The CNAs involved managed to lower her back onto the bed without injury, but the incident was not reported or investigated. Interviews with various staff members, including the Administrator, DON, ADON, and CNAs, revealed inconsistencies in their accounts of the incident and a lack of proper reporting and investigation. The facility's policy on abuse, neglect, exploitation, or misappropriation was not followed, as the incident was not thoroughly investigated. The failure to investigate the incident placed the resident and potentially other residents at risk for similar incidents in the future.

Penalty

Fine: $8,021

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 neglect were reported immediately to the State Survey Agency within the required timeframe. Specifically, the facility did not report an unwitnessed fall of a resident on 09/03/23, which resulted in a laceration to the right eyebrow and an acute fifth metacarpal neck fracture. Additionally, the facility did not report an incident on 09/28/23 where the same resident was observed with redness to the right forehead and right eyelid without any explanation of how the redness occurred. Furthermore, the facility delayed reporting an injury of unknown origin that occurred on 01/10/2024, only submitting the report on 01/16/2024, well beyond the 24-hour requirement. The resident involved, a female with severe cognitive impairment, was admitted to the facility on 01/11/24 and had multiple diagnoses including dementia with behavioral disturbances, Parkinson's disease, heart disease, type 2 diabetes mellitus, chronic kidney disease, and macular degeneration. The resident was totally dependent on staff for transfers, toileting, and showering. The care plan for the resident indicated that she was at risk for falls due to impaired mobility and incontinence, with specific interventions to anticipate and meet her needs, ensure proper footwear, and follow facility protocol in the event of a fall. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's policy required immediate reporting of allegations involving abuse, neglect, injuries of unknown origin, and other serious incidents. However, the DON and Administrator failed to ensure timely reporting of the incidents involving the resident. The facility's policy on reporting and investigating abuse, neglect, exploitation, or misappropriation of resident property was not followed, as evidenced by the lack of timely reports in the state database (TULIP) for the incidents on 09/03/2023 and 09/28/2023, and the delayed report for the incident on 01/10/2024.

Penalty

Fine: $8,021

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

Summary

The facility failed to thoroughly investigate an incident involving a resident during a transfer using a mechanical lift. The resident, who had multiple medical conditions including a benign brain tumor, diabetes, and morbid obesity, experienced a frightening incident where the loops on the straps of the Hoyer lift sling tore, leaving her dangling above her bed. Despite the resident's fear and the potential for serious injury, the incident was not reported or investigated as required by the facility's policy on abuse, neglect, and exploitation reporting and investigating. The CNAs involved did not report the incident immediately, and the torn sling was discarded without further examination or documentation. Interviews with various staff members, including the Administrator, DON, ADON, and CNAs, revealed inconsistencies in the understanding and reporting of the incident. The DON and Administrator did not consider the incident as neglect because no injuries occurred, and it was witnessed by staff. However, the facility's policy mandates that all allegations of abuse and neglect be thoroughly investigated, which was not done in this case. The lack of a thorough investigation and proper documentation of the incident placed the resident and potentially other residents at risk. The facility's failure to investigate the incident properly was evident from the lack of an incident report and the disposal of the torn sling without assessment. The resident expressed her fear and concern about the incident, but her concerns were not adequately addressed. The facility's policy on investigating allegations was not followed, leading to a deficiency in ensuring the safety and well-being of the residents.