Village Creek Rehabilitation And Nursing Center

Penalty

Inspection fine: $58,150

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

Summary

The deficiency involves the facility’s failure to implement its written abuse prohibition policies and procedures to identify, report, and protect residents from abuse, specifically in relation to two cognitively intact residents who were in a relationship and shared a room. The facility’s Abuse Prohibition Policy defined abuse to include physical, mental, and verbal abuse, and required that any allegation of abuse made by residents, staff, or visitors be reported immediately to the Abuse Coordinator and investigated. The policy also required immediate protection of residents, monitoring of staff and resident behaviors to identify potential abuse, and specific steps for resident‑to‑resident incidents, including separating residents, assessing for injury, notifying the physician and family, completing incident reports, and contacting the Abuse Coordinator. One resident, an adult male with paraplegia, major depressive disorder, and anxiety disorder, and another resident, an adult female with cerebral infarction, severe visual impairment, bipolar disorder, and anxiety disorder, both had intact cognition with BIMS scores of 15/15 and had requested to room together. The male resident had care plan entries documenting a history and potential for verbally aggressive and accusatory behavior toward staff and residents, and episodes of verbal aggression/irritability when care for his girlfriend/roommate was not provided immediately. On one occasion, nursing notes documented that the female resident reported crying and being upset because her boyfriend yelled at and belittled her in front of others, and she expressed a desire to move out of the shared room. The LVN reported this to the social worker, who spoke with the resident; the resident later recanted and stated she loved him, and the male resident stated he had only told her to tell the nurse about her stomach pain. The Administrator was aware of this incident but, based on the recantation, did not consider it reportable and did not treat it as an abuse allegation under the policy. On a subsequent date, a CNA completed a written witness statement indicating she had observed the male resident yell at the female resident and call her a derogatory term, specifically “[f‑ing retard].” The CNA believed the Abuse Coordinator would see this in the statement, but the Administrator later stated she had not seen that portion of the statement. The Administrator acknowledged that such language would constitute verbal abuse and would be reportable to the state agency, yet the incident was not reported to the Abuse Coordinator or to the state agency as required by policy. Later, both a CNA and a medication aide witnessed the male resident pushing the female resident in her wheelchair and shoving her into trash and dirty linen barrels in the hallway. Both staff members stated they did not consider this to be abuse and therefore did not report it to the Administrator or Abuse Coordinator. The Administrator reported she was unaware of this physical incident until informed by the CNA shortly before the surveyor interview and acknowledged that it could be considered physical abuse and would be reportable. These failures to recognize, report, and respond to resident‑to‑resident verbal and physical abuse incidents, despite clear policy requirements and prior knowledge of the male resident’s behavioral history, led to the cited deficiency and the identification of an Immediate Jeopardy situation.

Removal Plan

• Attempted to separate Residents #14 and #55; both residents refused a room change.
• Initiated 1:1 monitoring for Resident #14 due to refusal to change rooms; monitoring to continue until risk is fully mitigated and IDT determines supervision can be safely reduced.
• Reviewed and updated care plans for Residents #14 and #55 to reflect supervision needs and behavioral concerns.
• Provided education to Residents #14 and #55 regarding personal safety and boundaries, risks associated with unsupervised interactions, and the facility’s responsibility to intervene when safety concerns arise; ongoing reinforcement planned.
• Completed a trauma-informed psychosocial assessment for Resident #55 to evaluate for emotional distress, coercion, or unmet needs; continued monitoring initiated.
• Assessed both residents for physical and psychosocial harm; no additional injury identified.
• Completed life satisfaction rounds to ensure no other residents were negatively affected; no negative findings.
• Notified the Medical Director regarding the alleged failure to follow abuse policies and procedures.
• In-serviced Administrator and DON on abuse policy and reporting procedures; competency validated via quiz.
• In-serviced facility staff on abuse policy and reporting procedures; competency validated via quiz; staff not allowed to work next scheduled shift until training completed.
• Incorporated the abuse training material into new hire orientation and ongoing.
• Audited incident reports for the last 3 months to ensure no other reportable incidents were missed; no negative findings.
• Audited grievances for the last 3 months to ensure no other reportable issues were missed; no negative findings.
• Implemented a protocol for resident-to-resident abuse when both residents refuse room change: immediate enhanced supervision, revise care plans, complete IDT review, assess capacity and risks, involve physician and responsible parties, and consider alternative interventions; ongoing reassessment until risk is fully mitigated.
• Established monitoring/QA process: Administrator/DON daily review of all incidents, grievances, and behavior notes, then weekly, then monthly; random staff interviews to validate understanding of abuse reporting; QAPI Committee review; immediate re-education and disciplinary action as indicated.

Penalty

Inspection fine: $58,150

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 nursing staff were competent to use, maintain, and test the only automated external defibrillator (AED) according to the manufacturer’s guidelines. During observation, the AED was found outside the nurse’s station in a black zipped case, intermittently beeping, with the electrode pads not attached and a red X indicator light displayed. When the device was examined, the red X remained lit and the AED indicated that the battery needed to be changed. Interviews with multiple licensed nurses showed that they were not responsible for checking whether the AED was functioning properly, and several stated they had not been trained on the specific AED in use at the facility. One nurse said she had AED training, but the trainer used a different type of AED. Another nurse stated she had not received instruction from the facility on how to check the current AED until the day before the interview. Staff also stated they were unsure what the red X meant, and one nurse said she only checked whether the AED was available as part of a crash cart checklist. The DON stated that the night nurses were responsible for readiness checks and documentation, including checking for expired pads and whether the machine was functioning properly. The DON also stated that the facility’s AED training had been done using a different AED than the one the facility had on hand. The Administrator said she had not noticed the beeping, the disconnected electrodes, or the red X indicator, and was not aware that staff did not know what to check for to determine whether the AED was ready for use. The Medical Director stated he expected the AED to be functioning with all necessary items at all times and said that if nurses were not familiar with the current AED, education was needed.

Penalty

Inspection fine: $58,150

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 appropriate care and services to prevent urinary tract infections for a resident with an indwelling suprapubic catheter. The resident had multiple diagnoses including neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, an artificial opening to the urinary tract, multidrug resistance, quadriplegia, and severe cognitive impairment with a BIMS score of 0. His care plan identified that he was at risk for frequent UTIs, dislodgement, and other catheter-related complications, and included monitoring and reporting signs of UTI such as blood-tinged urine, cloudiness, no output, fever, chills, altered mental status, and changes in behavior or eating patterns. Staff observed blood in the resident’s suprapubic catheter tubing and drainage bag over several days, including dark red blood, bright red blood, and a clot in the drainage bag. The resident also had blood noted in his brief, and a CNA reported that he said he had pain in his groin region. Nursing documentation did not reflect the blood in the catheter or the resident’s pain until the surveyor intervened. A nurse stated she had seen scant blood in the tubing and drainage bag, did not assess vital signs, did not document the findings, and did not notify the physician because she was used to seeing blood in the resident’s urine. Another nurse stated she noticed dark blood in the drainage bag, did not call the physician because the urine was usually dark, and could not recall why she did not document the catheter change. The resident’s order summary included an order to check the suprapubic leg strap for placement and change it as needed every shift, but the report states he did not have a suprapubic strap in place to prevent dislodgement or trauma. The DON and Administrator stated staff were expected to assess, document, and notify the DON and physician immediately when blood was noted in the catheter tubing or drainage bag. The physician stated he had not been made aware of the blood in the urine and would have ordered testing to determine whether the resident had a UTI or had become septic if notified.

Penalty

Inspection fine: $58,150

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 physician was notified when Resident #41’s blood pressure medication was held repeatedly because her blood pressure was outside the ordered parameters. Resident #41 was a female resident with diagnoses of Alzheimer’s disease with late onset, dementia, and hypertension. Her quarterly MDS indicated a BIMS score of 6, showing severe cognitive impairment, and her care plan addressed hypertension with interventions to monitor for side effects and give antihypertensive medications as ordered. Resident #41’s March 2026 MAR showed Olmesartan Medoxomil 40 mg daily ordered for hypertension with instructions to hold for SBP less than 110 and DBP less than 60. The medication was held on 14 of 23 days in March because her blood pressure readings were below the ordered parameters or otherwise outside them. The record review showed no documentation in the nurse’s notes that the physician was notified about the repeated holds. During interviews, MA N and MA K stated they did not notify the charge nurse each time the medication was held, and LVN L stated she was not made aware that the medication had been held 14 out of 23 times. The DON reviewed the MAR and acknowledged she had been unaware of the repeated holds and that best practice would be to notify the physician when medications with parameters were held on consecutive occasions. The resident’s physician stated he was not aware the medication had been held 14 times and said he would have reviewed and discontinued the medication if he had been informed.

Penalty

Inspection fine: $58,150

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 gastrostomy tube medication administration met professional standards of quality for two residents who both had dysphagia and gastrostomy tubes and received most of their nutrition and fluids through the tube. Resident #9 had diagnoses including cerebral infarction, left hemiplegia/hemiparesis, dysphagia, gastroparesis, and a gastrostomy tube. Her care plan and physician orders required the tube to be flushed with water before and after medication administration and between each medication. During observation, an LVN administered medications through the tube without flushing with water before the medications, between the medications, or after the medications. The LVN later stated she did not realize she had not flushed the tube and said she would not have done anything different. Resident #10 had diagnoses including cerebral infarction, left hemiplegia/hemiparesis, dysphagia, and a gastrostomy tube, with severely impaired cognition and a BIMS of 04 out of 15. His care plan and physician orders required the gastrostomy tube to be flushed with water before and after medication administration and between each medication. During observation, an LVN mixed GlycoLax in water and then mixed crushed gastrostomy tube medications with that mixture. The LVN flushed the tube with the GlycoLax mixture instead of water before medication administration and between medications, and also mixed residual medication in the cup with the GlycoLax mixture before continuing with the remaining medications. She stated she would not have done anything different and acknowledged that mixing crushed medication with the GlycoLax/water mixture and flushing after each medication could be considered drug cocktailing. The DON stated gastrostomy tubes should be flushed with water before, after, and between medications, and that medications should not be cocktailed because there could be a reaction of the medications mixed. The Administrator stated she expected staff giving medications to know how to do it correctly and follow the policy. The facility policy required each medication to be administered separately, with water used for dilution and flushing, and directed that the tube be flushed with water between medications and after the last medication.

Penalty

Inspection fine: $58,150

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 medication error rate of less than 5 percent. Surveyors identified 5 medication errors out of 31 opportunities, resulting in a 16.13 percent error rate involving 3 of 6 residents reviewed during medication pass observations. The errors involved medication administration through gastrostomy tubes and an oral medication dose that did not match the physician order. For one resident with a gastrostomy tube and orders for NPO status, metoclopramide via tube before meals and at bedtime, and tube flushing with water before and after medications and between each medication, an LVN administered multiple medications through the tube without flushing before, between, or after the medications. The LVN also gave metoclopramide during the medication pass and stated she would not have done anything differently. The LVN later said she did not realize the tube had not been flushed as ordered and believed the metoclopramide order should be clarified as to when to administer. For another resident, an MA administered docusate sodium 100 mg, 1 capsule, even though the physician order was for 2 capsules by mouth twice daily. For a third resident with a gastrostomy tube and orders to flush with water before and after medication administration and between each medication, an LVN mixed GlycoLax with water and then used that mixture to dilute crushed medications and to flush the tube before and between medications, rather than using water. The LVN acknowledged that this could be considered drug cocktailing. The DON and Administrator stated staff should know how to administer medications correctly and follow the policy.

Penalty

Inspection fine: $58,150

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

Summary

The facility failed to ensure that residents were free from significant medication errors involving Midodrine, a medication used to raise blood pressure, for 3 of 8 residents reviewed. The report states that Residents #5, #4, and #10 received Midodrine even when their blood pressure readings were outside the physician-ordered hold parameters. The deficiency was identified through record review of physician orders, MARs, care plans, MDS assessments, and staff interviews. Resident #5 had multiple diagnoses including chronic respiratory failure with hypoxia, gastrostomy, quadriplegia, tracheostomy, colostomy, neuromuscular dysfunction of the bladder, multidrug resistance, and atrial fibrillation. His MDS showed severely impaired cognition with a BIMS of 0, and his care plan included administering medications per MD orders and monitoring blood pressure. Physician orders for Midodrine changed over time, with hold parameters listed for elevated SBP and later for SBP greater than 130 and DBP greater than 80. The January, February, and March 2026 MARs showed numerous doses of Midodrine given when blood pressure readings were above the ordered hold parameters. During interviews, multiple nurses acknowledged that Midodrine should have been held when the readings were outside the ordered parameters, and several stated they did not realize they had made medication errors or did not know the medication’s purpose at the time of administration. Resident #4 had a diagnosis of hypotension and intact cognition with a BIMS of 15. His care plan included giving medications as ordered and following physician parameters for medication administration. A physician order directed Midodrine 10 mg every 8 hours with instructions to hold for SBP greater than 130 or DBP greater than 80. The MAR showed doses given when SBP readings were above the hold threshold, including multiple administrations in February and March 2026 when SBP ranged from 132 to 148. Resident #10 had diagnoses including hypotension and orthostatic hypotension, with severely impaired cognition and a BIMS of 4. His care plan also directed staff to give medications as ordered and follow physician parameters. A physician order directed Midodrine 10 mg every 8 hours with instructions to hold for SBP greater than 140 or DBP greater than 90. The MAR showed Midodrine given when DBP was 98, 92, and 91, and when SBP was 145 to 154 with DBP as high as 104.

Penalty

Inspection fine: $58,150

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 planned menus were followed and prepared according to the weekly menu for 1 of 4 meals reviewed, the lunch meal. The weekly menu for 03/23/2026 listed smothered chopped steak, black-eyed peas, spinach, garlic cheese biscuit, sherbert, tableside condiments, water, and a choice of beverage. However, the menu board posted outside the dining room listed a different lunch menu of spaghetti, tossed salad, vegetable blend, garlic cheese biscuit, and sherbert, and there was no substitute or everyday menu posted in the dining room and no weekly menu posted in the dining room. During the dining room observation, residents were served spaghetti noodles with spaghetti sauce containing ground meat, tossed salad, vegetable blend, garlic biscuit, a beverage, and condiments. The DM stated the planned lunch menu was not served because the new supplier had not delivered the order and the DDM told staff to prepare spaghetti instead. The DM also stated the weekly menu had been in a frame in the dining room but had fallen and the glass shattered, and the signage was not replaced. The DM stated the residents had a right to know in advance what they were receiving for meals so they could choose an alternative if they did not like what was being served. The DDM stated the new supplier had provided a menu when the facility changed suppliers, but the supply truck was delayed and the lunch menu had to be changed. He stated the menu change was approved by the RD, but the weekly menu provided to the survey team was not updated. He also stated he was not aware that the alternate substitute menu, everyday available menu, and weekly menu were supposed to be posted in the dining room. The Administrator stated she was not aware the lunch menu had been changed from the scheduled menu and said the weekly scheduled menu was not located in the dining room during the tour, though a weekly scheduled menu was found at the nurses' station. The facility policy stated menus are planned in advance, served as written unless changed for preference, unavailability, or a special meal, and are posted in the nutritional service department, dining room, and resident/patient care areas.

Penalty

Inspection fine: $58,150

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 encoded, accurate, and complete discharge MDS assessment for one resident was electronically transmitted to the CMS system. Resident #56 was admitted with diagnoses including ventricular premature depolarization, dementia, type 2 diabetes mellitus, anxiety, high blood pressure, and muscle weakness, and the record showed a discharge date of 11/22/2025. The discharge MDS was dated 11/25/2025, with the RN Assessment Coordinator signing it as complete, but the assessment was not transmitted to CMS as required. Record review showed the discharge MDS was completed and signed, and the electronic record listed it among the resident’s MDS assessments, but it remained untransmitted. During interview, the MDS Nurse stated the assessment had been batched and sent to software for submission, but she was unsure why it was not transmitted and later identified that it had been labeled as do not submit to CMS in the transmitting process. The DON, Administrator, and CCS stated the MDS Nurse was responsible for timely completion and transmission of MDS assessments, and the facility policy required non-comprehensive assessments to be submitted within 14 days of the MDS completion date.

Penalty

Inspection fine: $58,150

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 one resident’s drug regimen was free from unnecessary medications when Carvedilol, ordered for hypertension, was administered even though the resident’s blood pressure was below the prescribed hold parameter. Resident #9 was a female admitted with diagnoses including stroke affecting her left non-dominant side with paralysis, high blood pressure, and difficulty swallowing with a feeding tube. Her quarterly MDS indicated a BIMS score of 10, showing moderate cognitive impairment, and her care plan included interventions to give hypertension medications, monitor vital signs, notify the MD of significant abnormalities, and assess for side effects. The physician order for Carvedilol 12.5 mg via PEG tube twice daily directed staff to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the January and March 2026 MAR showed the medication was given on two occasions when the blood pressure was outside the ordered parameters, including readings of 109/65 and 106/54. During interview, an LVN stated that if other blood pressure medications were held, she must have clicked the administered box by error and said she would not have given the medication if the blood pressure was below the set parameters. The DON, Administrator, and Regional Nurse stated medications were expected to be administered according to physician orders and parameters, and the facility policy stated medications are administered according to prescriber orders and within the ordered timeframe.

Penalty

Inspection fine: $58,150

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

Summary

The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident observed during a dressing change. Resident #9 was a female admitted with a gastrostomy tube, and her records showed she was rarely understood by others, sometimes understood others, had moderately impaired cognition with a BIMS of 10 out of 15, and received most of her calories and fluid intake through tube feeding. Her care plan and physician orders indicated she required gastrostomy tube site care every shift, including cleansing the site with soap and water, patting dry, applying split gauze, and securing it. During an observation of the gastrostomy tube dressing change, the LVN removed the dressing, cleaned the area, and then, without changing gloves or performing hand hygiene, obtained the clean dressing and applied it to the gastrostomy tube site. She stated she would not have done anything different at the time. Later, she acknowledged that gloves should be changed between dirty and clean procedures, hand hygiene should be performed before putting on clean gloves, and clean items should not be touched with gloves used to clean a wound or gastrostomy tube site. The DON and Administrator also stated that gloves should be changed between dirty and clean procedures and that hand hygiene should be done between glove changes.

Penalty

Inspection fine: $58,150

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 working automated external defibrillator (AED) for emergency CPR use. During an observation, the only AED available in the facility was located outside the nurse’s station in a wall holder, intermittently beeping, with the electrode pads not attached and a red X indicator light showing that it was not in safe operating condition. The DON later removed the AED from its case and confirmed that the pads were not attached and that the device was beeping. The DON stated that the night nurses, LVN H and LVN J, were responsible for conducting readiness checks and documenting them, including checking for expired pads and whether the machine was functioning properly. She said she was not aware the AED was not ready for use. The Administrator also stated she had not noticed the missing electrodes, the beeping, or the red X indicator, and said the nighttime nurses were responsible for checking and documenting the AED each night. The DON and Administrator both indicated that CPR included use of the AED, and the DON said the nurses had been trained on AED use, although the training used a different AED than the one the facility had on hand. Record review showed the old crash cart checklist only had a check mark for AED #1 and did not indicate whether a red X or green check mark was present, whether electrodes were attached, or whether the unit was beeping. A revised form later included fields for daily date, green check visible, no red X, pads present, battery ok, no beeping, issues, and staff initials. The facility’s policy stated that AED equipment was available for emergency use and that the DON or designee would test and document the AED’s operating status according to the manufacturer’s guidelines. The manufacturer’s manual stated the unit should not be used if it displayed a red X or emitted a beeping tone and that the electrode cable should remain connected at all times. Record review also showed the facility had not tested the AED according to the manufacturer’s guidelines for 23 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 ensure that an alleged violation involving possible abuse was reported immediately to the Administrator as required by policy. Specifically, a resident with severe cognitive impairment and multiple complex diagnoses, including Type 2 diabetes, seizure disorder, autistic disorder, and cerebral palsy, was found to have several yellow-colored, faded bruises under the upper part of his right arm. The resident's responsible party (RP) noticed the bruising and reported it directly to an LVN, who documented the finding in the nurse's notes but did not escalate the report to the ADON, DON, or Administrator. The LVN assessed the resident, who was unable to communicate how the bruising occurred due to his cognitive impairment, and noted that the resident was not in distress or acting outside his normal behavior. Despite being trained on the facility's policy to report bruises of unknown origin, the LVN did not notify supervisory staff or the Administrator, as required. There was no incident report or grievance filed regarding the bruising, and neither the ADON, DON, nor the Administrator were made aware of the incident until it was brought to their attention during the survey. Facility policy clearly states that all employees must report any allegation of abuse, neglect, or misappropriation of resident property to the Abuse Coordinator immediately, and that all incidents of unknown origin must be investigated. The failure to report the bruising as required resulted in the incident not being investigated in a timely manner, as the appropriate facility leadership was not informed.

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 nurse medication cart on Hall 100 was observed to be left unlocked and unattended at the main nurse station for six minutes, with the drawers facing the hallway and the lock mechanism indicating it was unsecured. During this time, the nurse responsible for the cart, LVN E, was in a resident's room with the door closed and out of sight of the cart. The cart contained various medications, including over-the-counter aspirin, vitamins, minerals, eye drops, accu-check strips, glucometers, and a locked compartment with controlled substances and multiple residents' medication bubble-blister packets. The unlocked cart was accessible to unauthorized individuals and residents passing by. LVN E acknowledged responsibility for the cart and admitted to forgetting to lock it before leaving to speak with a resident. She confirmed awareness of the policy requiring the cart to be locked at all times when not in use and stated she had received in-service training on this requirement earlier in the year. The Director of Nursing and the Administrator both confirmed the facility's policy and expectation that medication carts be locked and secured when not in use, and that only authorized personnel should have access to medications. Facility policy documents reviewed also specified that all drugs and biologicals must be stored in locked compartments and that medication carts are not to be left unlocked and unattended.

Penalty

Inspection fine: $13,250

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, who required assistance with personal care and had a history of morbid obesity and lack of coordination, was not provided adequate supervision and assistance during perineal care in bed. The resident's care plan identified a risk for falls but did not specify the number of staff required for assistance. The Minimum Data Set (MDS) assessment indicated that the resident needed physical assistance from two or more persons for bed mobility, but the Kardex listed only one-person assist. This discrepancy led to a certified nursing assistant (CNA) providing perineal care alone, during which the resident rolled off the bed and fell to the floor. Following the fall, the resident complained of pain in the right arm and was assessed by staff. X-rays were ordered, and the resident's family and physician were notified. Initial mobile x-ray results suggested acute rib fractures, but subsequent hospital imaging did not confirm these findings. The resident reported significant pain after the incident, particularly in the chest and knees. Interviews with staff revealed that the CNA had relied on the Kardex, which indicated one-person assist, despite other documentation requiring two-person assistance. Staff acknowledged the importance of verifying the correct level of assistance in the electronic health record before providing care. Further investigation found inconsistencies between the Kardex, care plan, and MDS assessments regarding the required level of assistance for the resident. The facility's policy required accurate communication and documentation of assistance needs, but this was not followed in this case. The failure to ensure that all care documentation matched and to provide the correct number of staff for bed mobility directly led to the resident's fall and subsequent pain.

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 in the laundry area, which is crucial for preventing cross-contamination and infection. During an observation, it was noted that the laundry area had only a sheer curtain separating clean and dirty linen, allowing airflow between the two areas. This curtain was inadequate, as it left a significant portion of the doorway uncovered, failing to prevent the potential spread of contaminants. The Laundry Supervisor acknowledged the issue, stating that rubber curtain flaps had been requested from the maintenance department months prior, but they had not been installed. The Administrator was unaware of the need for these flaps until the surveyor's intervention, at which point the flaps were reportedly installed. The facility's Laundry Operations policy from 2016 indicated the necessity of a process to sort soiled linen without cross-contaminating clean linen, which was not effectively implemented 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 adhere to professional standards for food service safety by not ensuring that dietary staff members' hair was completely contained with effective hair restraints. During multiple observations, it was noted that Dietary Staff A and Dietary Staff B had hair that was not fully covered by hair restraints while preparing meals for residents. Specifically, Dietary Staff A's hair was observed to be outside the hair restraint at the neckline on several occasions, and Dietary Staff B had hair sprigs eluding from the ears to the neckline area. Both staff members acknowledged they had been trained on hair hygiene, yet their hair remained unsecured during food preparation. The Dietary Manager and the Administrator both confirmed that the expectation was for all dietary employees to have their hair completely contained in hair restraints while involved in food preparation and serving. The facility's policy, dated October 2023, also indicated that all staff members should have their hair off the shoulders and confined in a hair net or cap. The failure to comply with these standards could result in unsanitary conditions, as unsecured hair could potentially land in the food being prepared 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 maintain a safe and sanitary environment in several areas, including two linen/storage rooms, two hall ceiling vents, and the nurse's station ceiling. Observations revealed that the ceiling above the nurse's station had brown and yellowish stains around the vent, and there was an open area in the sheet rock. Additionally, two of the three vents on Hall 4 were discolored with a grayish substance extending onto the ceiling. In Hall 3's linen storage room, a section of the ceiling had been removed, exposing the attic, and the remaining ceiling was covered with grayish black spots. The room also had a musty smell, and the top shelf was covered with a thick black substance. Hall 2's linen/supply closet had a hole and water damage on the ceiling. Interviews with the Maintenance Supervisor and the Administrator revealed that the water damage occurred due to AC duct work sweating in October and November 2024. Although bids for repairs were received, no decision had been made on the plans for fixing the duct and sheet rock repairs. The Administrator acknowledged the need for maintenance and took pictures of the affected areas to discuss with regional corporate maintenance. However, she was unable to find a policy on maintaining the environment, indicating a lack of documented procedures for addressing such issues.

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 safe, clean, comfortable, and homelike environment for two residents, leading to a deficiency in maintaining a sanitary and comfortable living space. Resident #2, who was cognitively intact with a BIMS score of 13, had discoloration in his room, with grayish to black spots around the light switch and electrical receptacle, as well as along the door frames. These spots had been present since his admission, and he expressed a desire for the areas to be painted. Similarly, Resident #13, also cognitively intact with a BIMS score of 14, experienced the same issue with discoloration in his room. He reported that the black and gray spots had been present for months, and although a housekeeper attempted to clean the area with a bleach rag, the mildew persisted. The Administrator acknowledged the issue, noting that bids for water damage repair had been sent to the corporate office, but was unable to provide a policy on maintaining the environment.

Penalty

Inspection fine: $54,438

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 sexual abuse by another resident on two separate occasions. The first incident occurred when a male resident was observed flicking the breast of a female resident in the TV room. Despite being removed from the area and notified, the facility did not implement a care plan to prevent further inappropriate behaviors. The second incident involved the same male resident placing his hand inside the female resident's pants while she was in her wheelchair near the nursing station. This incident led to the male resident being placed on one-to-one supervision, but it was discovered that he had an outstanding warrant for continuous sexual abuse of a child. The male resident had a history of severe cognitive impairment and was mobile with a wheelchair, which was not initially recognized by the facility staff. After the first incident, staff were instructed to keep the male resident away from female residents, but there was no formal monitoring system or interventions in place for supervision. The facility's abuse prohibition policy required immediate separation of residents involved in incidents and assessment of the victim, but these measures were not effectively implemented. Interviews with staff revealed a lack of training on monitoring behaviors after inappropriate behavior was identified. The facility's failure to follow its abuse prevention policy and update care plans and interventions placed residents at risk of further incidents. The facility's in-service records indicated that staff were retrained on abuse prevention and reporting, but not all staff had been trained on monitoring behaviors after an inappropriate behavior was identified.

Penalty

Inspection fine: $54,438

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to incidents of abuse. Resident #1, a male with severe cognitive impairment and a history of brain injury, was involved in two incidents of sexual abuse against Resident #2, a female with severe cognitive impairment and cerebral palsy. Despite these incidents, Resident #1's care plan did not include interventions to address his sexually inappropriate behaviors, and he was not adequately supervised, allowing him to engage in further inappropriate conduct. Resident #3, a female with cognitive intactness and mood disorders, was involved in verbal and emotional abuse towards Resident #4, a male with schizophrenia and intellectual disabilities. Resident #3's care plan did not include interventions to prevent her abusive behavior, despite reports of her making emotionally abusive comments and manipulating Resident #4. The facility's failure to update and implement effective care plans for these residents placed them and others at risk of harm and distress. Interviews with facility staff revealed a lack of awareness and training regarding the supervision and monitoring of residents with identified inappropriate behaviors. The previous MDS LVN responsible for updating care plans admitted to not knowing why the care plans were not updated, and the facility's policy on comprehensive person-centered care plans was not followed. This oversight resulted in the facility being out of compliance, with deficiencies identified by surveyors.

Penalty

Inspection fine: $54,438

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

Summary

The facility failed to report an allegation of neglect involving a resident within the required 24-hour timeframe to the State Agency. The incident involved a resident who had a tracheostomy and was dependent on tracheostomy care and oxygen therapy. The resident's family member alleged that the resident only received tracheostomy care once a week prior to being discharged home, contrary to the physician's orders for tracheostomy care every shift and as needed. This allegation was reported to the facility on April 22, 2024, but was not reported to the State Agency until April 25, 2024, due to the previous administrator misreading an email from the corporate office that contained the allegation. The resident, who was cognitively intact and dependent for all activities of daily living, was at risk of neglect due to the facility's failure to provide the necessary tracheostomy care as per the physician's orders. The facility's records indicated that tracheostomy care was completed as ordered, but the family member's allegation suggested otherwise. The facility's policy required that all allegations of neglect be reported within 24 hours, but this was not adhered to, potentially placing residents at risk of physical harm, mental anguish, and emotional distress.

Penalty

Inspection fine: $54,438

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 clinical records for a resident, identified as Resident #5, which is a violation of accepted professional standards and practices. The deficiency was identified during a review of the resident's ADL task sheet, which showed incomplete documentation of care provided on specific dates. Resident #5, a female with a history of cerebral infarction and atherosclerotic heart disease, required varying levels of assistance with daily activities such as bed mobility, toileting, and transferring. However, the ADL task sheet lacked documentation for two consecutive days, raising concerns about the accuracy of the records. Interviews with facility staff, including the ADON and a CNA, revealed that CNAs were expected to document all ADL care assistance on task sheets every shift. Despite this expectation, the documentation for Resident #5 was incomplete, and the ADON acknowledged that the facility policy stated that if care was not documented, it was considered not done. The CNA interviewed could not recall the resident but confirmed that documentation was a recurring issue. The facility's administrator also emphasized the importance of accurate documentation to ensure residents receive necessary services.