Vintage Health Care Center

Penalty

No penalty information released

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

Summary

The facility failed to ensure residents had the right to retain and use personal possessions, including clothing, for 4 of 8 residents reviewed for personal property. The deficiency involved Residents #3, #5, #8, and #9, all of whom were cognitively intact based on MDS BIMS scores ranging from 13 to 15. The report states that this failure could place residents at risk for emotional distress, embarrassment, and lower self-esteem. Resident #3 was a female with diagnoses including UTI, tremor, Alzheimer's disease, sleep apnea, chronic pain, irritable bowel syndrome, right shoulder pain, overactive bladder, and abnormal uterine and vaginal bleeding. Her care plan reflected extensive ADL assistance needs, including help with bathing, dressing, toileting, and transfers. During interview, she stated some of her clothes were stolen, she had received other residents' clothes, her wheelchair had been broken by staff while her belongings were being moved, and her TLC Roku television had been broken and replaced with a different television. Resident #5, who had diagnoses including UTI, difficulty walking, lack of coordination, and chronic pain, stated she no longer sent personal items to laundry because items had been lost, including a hallmark quilt and three sets of socks, and that her family now picked up and cleaned her laundry. Resident #8, a male with diagnoses including acute respiratory failure with hypoxia, type 2 diabetes, chronic venous hypertension with bilateral lower extremity ulcers, sepsis due to MRSA, CHF, right internal jugular vein thrombosis, GERD, MRSA infection, paralysis of the vocal cords and larynx, pleural effusion, and extensive burns, stated several personal clothes were missing and that items sent to laundry during the week prior had not been returned despite his name being on the clothing and a written note listing the items. Resident #9, a female with multiple sclerosis, paraplegia, functional quadriplegia, weakness, difficulty walking, and lack of coordination, stated many of her clothes had gone missing, including black shorts, gray shorts purchased from Amazon, underwear, and washcloths, and she stated her name was on all of the missing clothing. Staff interviews confirmed that residents' clothing had gone missing after being sent to laundry, with one nurse stating some residents did not have clothes and staff had brought them clothing, and a CNA stating clothes went to laundry and did not return. The housekeeping supervisor stated items were only not returned if they lacked a name and room number, while the grievance log showed Resident #8 filed a grievance for missing clothes.

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 housekeeping services necessary to maintain a sanitary and comfortable interior for 3 residents reviewed for environment. The deficiency involved not having clean bed linens available on shower or bath days for Resident #3 and Resident #7, and not having clean bath towels available for Resident #9 on shower days. The report states that this affected residents' ability to receive showers and baths as scheduled because staff were waiting on clean linen from laundry. Resident #3 was a cognitively intact female with diagnoses including UTI, tremor, Alzheimer's disease, sleep apnea, chronic pain, IBS, right shoulder pain, overactive bladder, and abnormal uterine and vaginal bleeding. Her care plan reflected she required staff assistance with bathing and other ADLs. She stated her bed linens were not always changed on shower days and that at times there were no clean bed linens available. She also stated staff would leave dirty linen in her room. Resident #7 was a male with diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle wasting, lack of coordination, restless legs syndrome, chronic pain syndrome, paraplegia, BPH with lower urinary tract symptoms, and contractures of both knees. His MDS reflected moderate cognitive impairment and dependence for multiple ADLs. He stated his bed sheets were not changed on bath days and that, if he was lucky, staff would change his linens once a week. Resident #9 was a cognitively intact female with multiple sclerosis, paraplegia, functional quadriplegia, weakness, difficulty walking, and lack of coordination. She stated there had been times when there were no clean linens and she was unable to take her shower, and that she had to purchase towels to shower. Staff interviews confirmed that clean linens and towels were often unavailable, showers were delayed, and laundry issues were affecting resident care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that dependent residents received their scheduled showers or baths and that the missed care was documented with a reason. The deficiency involved 5 of 8 residents reviewed for ADL care: Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7. Record review showed each of these residents had care plans identifying bathing assistance needs, and several had MDS assessments showing dependence or substantial assistance needs for personal hygiene, toileting hygiene, dressing, transfers, or bathing-related care. The facility’s PCC records showed multiple scheduled shower or bath days with no documentation that the care was completed and no explanation for the omissions. Resident #3 had diagnoses including UTI, tremor, Alzheimer’s disease, sleep apnea, chronic pain, IBS, right shoulder pain, overactive bladder, and abnormal uterine and vaginal bleeding. Her MDS reflected a BIMS score of 15 and dependence for toileting hygiene, and her care plan required staff assistance with bathing. PCC documentation showed scheduled showers on Tuesdays, Thursdays, and Saturdays, but no showers/baths were documented on 05/05/26 and 05/21/26. Resident #3 stated she did not receive a bath on 05/23/26 and said staff would lie and say she refused, but she never refused her showers. Resident #4 had orthopedic aftercare and osteoarthritis, with a BIMS score of 05 and dependence for personal hygiene, showering/bathing, oral hygiene, toileting, dressing, and footwear. His care plan required staff assistance with bathing. PCC documentation showed scheduled showers on Mondays, Wednesdays, and Fridays, but no showers/baths were documented on 05/01/26, 05/04/26, 05/11/26, and 05/13/26. Resident #4’s family stated the facility promised to shower him on admission but did not do so, and the family reported giving him bed baths on multiple occasions before facility staff provided his first bath. Residents #5, #6, and #7 also had care plans and MDS findings showing bathing or hygiene assistance needs, and PCC documentation showed missed shower or bath dates with no reason documented. Resident #5 stated she often did not receive her showers and wanted her three showers per week. Resident #6 stated he only showered about two times during his stay and that staff did not inform him of shower times or provide supervision. Resident #7 stated he did not always receive his scheduled bed baths and that it depended on which staff were on duty.

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 two residents had their call lights within reach while they were in bed on 05/27/26. Resident #1 was a female with diagnoses including legal blindness, lumbar spondylolysis, and osteoarthritis. Her MDS reflected a BIMS score of 12, indicating moderate cognitive impairment, and she was dependent on staff for multiple ADLs including hygiene, dressing, bathing, toileting, transfers, and bed mobility. Her care plan identified her as at risk for falls and pressure ulcers and directed staff to keep her call light within reach, tell her where it was because of her blindness, and cue her to use it for assistance. Resident #2 was a female with diagnoses including osteoarthritis, seizures, unsteadiness on feet, muscle wasting, difficulty walking, lack of coordination, and rheumatoid arthritis. Her MDS reflected a BIMS score of 15, indicating she was cognitively intact, and she needed supervision or touching assistance with eating, toileting, bed mobility, transfers, and toilet transfer. Her care plan identified fall risk and ADL self-care deficits and directed staff to place frequently used items within easy reach, keep her call light within reach, and encourage her to use it for assistance. During observation, Resident #1 was lying in bed with her call light wrapped around the bedrail and the button facing the floor, and she could not reach it. Resident #2 was lying in bed with her call light on the floor behind her oxygen tank and also could not reach it. LVN A later confirmed both call lights were not within reach and stated they needed to be within reach so residents could call for help. CNA E stated she forgot to place Resident #1's call light within reach and said she was ultimately responsible for ensuring Resident #2's call light was within reach.

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 reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents on a specific date. For one resident with severe cognitive impairment, multiple fractures, and a care plan identifying her as a fall risk with an intervention to keep the call light within reach, the call light was observed lying on the floor near the nightstand while she was in bed. The resident stated she needed help with repositioning but did not know where her call light was. A CNA and an LVN both observed and acknowledged that this resident’s call light was out of reach, and the LVN also noted that the resident’s fall mat was not placed alongside her bed despite her fall risk status. Three additional residents were also found with call lights out of reach during observations. One resident with vascular dementia and a history of repeated falls had an active care plan specifying that her call light should be within reach and that she required a safe environment including a working and reachable call light; however, her call light was observed on the floor on the left side of her nightstand, out of her reach while she was in bed. Another resident, who was legally blind and had generalized anxiety disorder, had a care plan identifying her as a fall risk with interventions including a reachable call light and a safe environment, yet her call light was observed on the floor behind the headboard and out of reach while she was in bed. A fourth resident, diagnosed with lack of coordination, difficulty walking, and anxiety disorder, also had an active care plan identifying her as a fall risk with interventions requiring a reachable call light and a safe environment. During observation, this resident’s call light was found on the floor next to her bed and out of reach. Multiple staff interviews, including with CNAs, an LVN, the ADON, and the DON, confirmed that facility policy and expectations required call bells to be within reach of every resident, whether in bed or in a wheelchair, and that all staff were responsible for ensuring this before leaving the room. The facility’s written call light/bell policy stated that staff must leave the resident comfortable and place the call device within the resident’s reach before leaving the room.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards, physician orders, and care plans for three residents who required respiratory support. For Resident #1, a male with congestive heart failure and an active diagnosis of acute respiratory failure, surveyors reviewed his comprehensive MDS and physician orders dated 04/22/26 and found no physician orders for use of a nebulizer device. During observation on 04/22/26 at 8:59 a.m., his nebulizer mask was seen lying unbagged on the nightstand, and he reported he had not used it since the previous night. For Resident #2, a female with congestive heart failure, COPD, and an active diagnosis of acute respiratory failure and COPD, record review on 04/22/26 showed no physician orders for use of an oxygen device. During observation and interview at 9:00 a.m., she was lying in bed with the nasal cannula for the oxygen concentrator on the floor and unbagged. She stated she had complications with the nasal cannula a few days earlier because it had gotten fluid on it and was hurting her nose, that she had been trying to get it replaced but staff had not responded, and that she had not used it for a few days and really needed it to help with breathing. Facility staff, including LVN E, the DON, and ADON J, acknowledged that oxygen use requires physician orders and that the resident did not have active orders for oxygen until 04/22/26. For Resident #6, a female with diagnoses including acute kidney failure, a left femur fracture, and COPD, record review of active physician orders dated 04/16/26 did not show an order for oxygen use or care, while her active care plan dated 03/05/26 listed COPD with an intervention to give oxygen therapy as ordered by the physician. Her quarterly MDS dated 04/03/26 reflected severe cognitive impairment and a diagnosis of COPD. During observation on 04/22/26 at 9:05 a.m., her nasal cannula was seen lying on the floor unbagged. Multiple staff members, including LVN E, ADON K, CNAs U and V, and the DON, stated that nasal cannulas should always be bagged when not in use per facility policy and that all staff were responsible for ensuring this, and they described that failure to bag the devices could result in infection, cross-contamination, respiratory distress, or tripping hazards.

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 failures to honor residents' rights to dignity and privacy in two separate situations. For one resident with severe cognitive impairment and a diagnosis of difficulty swallowing, the comprehensive care plan noted a nutritional problem but did not include any intervention indicating the need for assisted feeding. During a noon meal observation, a medication aide was seen feeding this resident while standing over him as he sat in his wheelchair, rather than sitting at eye level. Two LVNs present observed the aide feeding in this manner and acknowledged that staff were expected to sit at eye level when feeding residents for reasons of dignity and to ensure residents did not choke. The DON and ADON also stated that staff were to sit at eye level when feeding residents for dignity and safety. The medication aide later stated she knew she should be sitting down when feeding the resident but chose to stand so she could monitor the entire dining area to ensure other residents did not choke. She also stated that staff were supposed to sit at eye level to feed residents but thought it was acceptable to stand. This conduct, combined with the lack of a specific assisted-feeding intervention in the resident's care plan despite his swallowing difficulty and severe cognitive impairment, contributed to the dignity-related deficiency identified by surveyors. In a separate incident, another resident with severe cognitive impairment, acute kidney failure, and a left femur fracture had an active physician order for an indwelling urinary catheter that specified the Foley drainage bag must be in a privacy bag while the resident was in bed or in a wheelchair on every shift. The resident's active care plan contained no problem, goals, or interventions related to indwelling urinary catheter care. During observation, the resident was seen lying in bed with the catheter drainage bag visible from the hallway and not covered by a privacy bag, contrary to the physician's order. Multiple staff members, including an LVN, the ADON, a CNA, and the DON, stated that the Foley catheter drainage bag should always be covered with a privacy bag to maintain dignity and privacy, and that it was the responsibility of nursing staff to ensure the privacy cover was in place. The facility's resident rights policy stated that residents have the right to a dignified existence and personal privacy, which was not upheld in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a dependent resident received necessary ADL services, specifically scheduled showers, to maintain personal hygiene. The resident, a morbidly obese female with an intact BIMS score of 13, was admitted in late March 2026 and required maximum assistance for ADLs, with a comprehensive care plan documenting total dependence on staff for self-care and no mention of shower refusals. Review of progress notes from admission through late April 2026 showed no documentation of shower refusals, and there were no shower sheets on file for the resident for March and April 2026. Facility policy required that bathing frequency and type be based on resident preference, skin condition, tolerance, and energy level, and that showers be documented on shower sheets. During interviews, the resident reported she had been in the facility about a month and had only received one shower and one bed bath, stating she had never refused a shower and preferred showers over bed baths. She reported staff told her there were issues with the Hoyer lift and that she wanted her hair washed. An LVN stated he was unfamiliar with the resident but confirmed that a shower sheet should be completed for each shower and that refusals should be addressed by the floor nurse. The DON and ADON stated the resident was scheduled for showers three evenings per week and that CNAs were responsible for completing shower sheets, which were to be signed by the charge nurse. A CNA reported providing a bed bath on April 18 and said he completed a shower sheet but left it in a basket instead of giving it to the charge nurse; he also described difficulty using the Hoyer lift because the shower chair was too small and uncomfortable for the resident. The facility’s own bathing policy emphasized the role of bathing in removing soil, microorganisms, and body odor and promoting comfort and cleanliness.

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency in the facility’s failure to maintain a resident’s environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents. Record review showed that the resident was an elderly female with severe cognitive impairment (BIMS score of 7) and active diagnoses including fractures of the neck and femur, and a history of rib fractures. Her MDS indicated she required maximum assistance with toileting and showering. The resident’s comprehensive care plan, dated 10/01/25, identified her as a fall risk and specified use of a fall mat as an intervention to provide cushioning to the landing area if she fell from bed. On observation, surveyors found the resident lying in bed with her fall mat leaning against the wall instead of being placed alongside the bed as care-planned. A CNA, when interviewed, confirmed that the resident was a fall risk and stated that the bed should be in a low position with the fall mat placed next to it to limit injury if the resident fell out of bed. An LVN similarly acknowledged that the resident should have a fall mat in place and that staff should be checking for this during rounds. The DON and ADON also confirmed that the resident was a fall risk, that a fall mat alongside the bed was a planned intervention, and that staff were responsible for ensuring the resident’s area was set up for fall prevention when she was in bed. The facility’s Resident Rights policy stated that residents have the right to be free from neglect.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the resident environment remained free of accident hazards as was possible for the doorway to the Clean Linen Storage on the secure unit. On 02/10/2026 at 1:15 PM, the clean linen closet door with a numerical combination locking handle was observed left open approximately 1 inch with the closet light on. No staff were visible in the hall, and two secure unit residents were seen walking nearby. The door had a sign stating, "Please make sure the door is completely closed behind you." At 1:19 PM, a secure unit staff member walked by the open door and exited the secure unit without noticing, and no staff member was observed at the nurse's station next to the closet. The clean linen closet contained shelving units holding clean sheets, gowns, blankets, towels, pillow cases, incontinent supplies, adult diapers, bed pads, premoistened adult washcloths, a container of Sani-Cloth Germicidal Disposable Wipes, and an opened case of large powder free stretch vinyl exam gloves. During interviews, MA C, CNA E, GVN D, and the Adm stated that doors with combination locks should remain closed and locked when not in use, especially on the secure unit, and that residents with dementia could be harmed if they entered the room or accessed items inside. The Adm stated the purpose of these storage areas was to ensure the room and items within remained secured, and that training on combination lock doors occurred when codes changed and when new employees began work.

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 review the risks and benefits of bed rails or grab/assist bars with residents or resident representatives and failed to obtain informed consent before the bars were installed or left in place for multiple residents. Surveyors found this issue for 7 of 8 resident rooms observed and reviewed for grab/assist bars, including residents with varying levels of cognitive and functional impairment. The report also states that the facility failed to have evidence of assessment for several residents regarding entrapment risk and safe use of the bars, and failed to follow assessment recommendations for two residents who were identified as not appropriate for grab/assist bars. Resident #10 had diagnoses including difficulty walking, unsteadiness on feet, lack of coordination, depression, anxiety, Alzheimer's disease, and atherosclerotic heart disease. The resident's MDS showed wheelchair use, dependence for toileting hygiene, substantial assistance for footwear and bed mobility, and moderate to extensive assistance for multiple transfers and dressing tasks. The care plan included use of a grab/assist bar and a 1/4 rail, but the bed rail assessment dated 05/08/2025 indicated the resident was not a candidate for a bed rail or grab/assist bar at that time. Despite this, surveyors observed a grab bar attached and raised on the bed. Resident #12 had diagnoses including chronic venous hypertension with ulcer, depression, PTSD, COPD, diabetes, cerebral infarction, and bradycardia, with a BIMS score of 11 indicating moderate cognitive impairment. The care plan had no focus or intervention related to bed rails or grab/assist bars, and the EHR contained no assessment or consent form. Surveyors observed a grab bar attached and raised on the bed. Resident #49, Resident #56, Resident #63, Resident #64, and Resident #80 also had grab bars attached and raised on their beds, while the record review showed no evidence of consent and, for several of them, no assessment for safety or appropriateness. Resident #63 had a BIMS score of 0 and required assistance with multiple ADLs and transfers; Resident #64 had a BIMS score of 12 and was documented as independent with all functional abilities; and Resident #80 had diagnoses including unsteadiness on feet, cognitive communication deficit, seizures, and cerebral infarction, with no completed MDS and no assessment or consent in the record.

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 pharmaceutical services in accordance with currently accepted professional principles for three residents reviewed for pharmaceutical services. For Resident #44, who had unspecified pain, moderately impaired cognition with a BIMS score of 08, and an order for Hydrocodone-Acetaminophen 10-325 mg every 4 hours as needed for severe pain, MA C documented the 7:00 AM dose on the MAR on 02/11/2026, but the controlled medication logbook on the medication cart did not reflect that the dose was given that day. For Resident #48, who had anxiety disorder, intact cognition with a BIMS score of 15, and an order for Clonazepam 0.5 mg twice daily for anxiety, MA C documented the morning dose on the MAR on 02/11/2026, but the controlled medication logbook did not reflect that the dose was given. For Resident #62, who had neuropathy, intact cognition with a BIMS score of 13, and an order for Pregabalin 100 mg three times daily for neuropathy, MA C documented the 8:00 AM dose on the MAR on 02/11/2026, but the controlled medication logbook on the medication cart did not reflect that the dose was given.

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

Food was not stored, prepared, distributed, and served in accordance with professional standards in the facility kitchen. During observations in the kitchen, surveyors found a gallon-size freezer bag of small plastic cups of ketchup in the refrigerator with a preparation date of 02/02/2026 and a use-by date of 02/09/2026, a gallon-size freezer bag of small plastic cups of orange-colored sauce with the same preparation and use-by dates, and a gallon-size freezer bag of small plastic cups of shredded cheese dated 02/03/2026 with a use-by date of 02/10/2026. Surveyors also observed eight loaves of bread in the bread pantry with a best-by date of 01/26/2026. In the dry storage area, surveyors found eight cans of peppers in the bread pantry dated 10/08/2024 with a best-by date of December 2025. The FSS stated she had been responsible for ensuring the kitchen met guidelines for food storage and sanitization and confirmed the observations were oversights. She stated staff who received deliveries were responsible for labeling items and placing them properly. The ADMIN stated everything needed to be dated, opened items needed an open date and expiration date, and that failure to follow policy could result in food-borne illness. The facility policy stated items should be examined for expiration dates, shelf-stable items should be dated if no manufacturer date was present, and any product with a stamped expiration date should be discarded once that date passed.

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 reasonable accommodation of resident needs and preferences for one resident when the call light in her room was not kept within her reach. Resident #14 was a female with dementia and hearing loss, admitted and later readmitted to the facility. Her MDS assessment dated 12/24/2025 reflected severely impaired cognition with a BIMS score of 04, and the quarterly assessment indicated she required staff assistance with mobility and self-care needs. Her care plan dated 12/04/2025 identified her as at risk for falls and included an intervention to ensure the call light was within reach. During an observation and interview on 02/10/2026 at 9:14 AM, Resident #14 was sitting in her wheelchair near the foot of her bed, and her call light was observed on the floor between the wall and the head of the bed. When asked about it, she did not appear to understand the question. The Staffing Coordinator stated the call light should have been within arm's reach, picked it up from the floor, and placed it on the bedside rail near the resident's wheelchair. She stated the resident could not hear well and used the call light to request help with transfers to the toilet. Later interviews with an LVN, ADON, DON, and the administrator confirmed that staff were expected to ensure call lights were in reach before leaving a resident's room and that call lights were monitored during rounds.

Penalty

No penalty information released

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

Summary

The facility failed to ensure resident privacy and confidentiality in a shared room where authorized electronic monitoring (AEM) was in use. Observations showed a sign on the shared room door for two residents stating, “This room is being electronically monitored.” The deficiency centered on the facility’s failure to have the roommate’s consent, or the roommate’s responsible party consent, documented in the active section of the EHR for the resident who was moved into the room with ongoing AEM. Record review showed one resident in the room had requested electronic monitoring, and the care plan included an intervention to obtain consent from the roommate or the roommate’s responsible party for AEM. The other resident in the room had diagnoses including acute respiratory failure with hypoxia, muscle wasting and atrophy, unsteadiness on feet, difficulty walking, generalized anxiety disorder, COPD, Alzheimer’s disease with late onset, chronic systolic heart failure, unspecified dementia, and type 2 diabetes mellitus without complications. That resident’s quarterly MDS indicated severe cognitive impairment with a BIMS score of 0 and need for assistance with multiple activities of daily living and transfers. Record review for the resident placed in the room with AEM revealed no consent from the resident or responsible party to be moved into a room with ongoing AEM. Interviews with nursing staff and the DON confirmed that consent from the resident or responsible party, and from any roommate or their responsible party, was required for AEM in a shared room, and that the signed consent should be in the EHR. The facility policy also stated that other residents in the room, or their guardian or legal representative if applicable, must consent to AEM.

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 safe and appropriate respiratory care for a resident who had a physician order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath and a care plan addressing oxygen therapy related to ineffective gas exchange. The resident’s record reflected intact cognition with a BIMS score of 15, and staff stated he used a portable oxygen tank on his wheelchair when leaving his room and oxygen in his room when needed. During observation, the resident was away from his room and the nasal cannula remained connected to the oxygen concentrator with the tubing left unbagged on the bed. Staff members, including an LVN, ADON, DON, and the Administrator, stated the nasal cannula should have been stored in a bag when not in use and that staff were responsible for monitoring this during rounds for infection control. The resident also stated he usually placed the tubing in the bag himself so he would not have to wait for staff.

Penalty

No penalty information released

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

Summary

The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one resident reviewed for medication storage. Resident #31, a female with osteoarthritis, blindness in one eye, low vision in the other eye, intact cognition, and assistance needs for mobility and self-care, had a topical analgesic ointment on her bedside table when she was not in her room. Her care plan reflected impaired visual function and interventions to encourage use of glasses and visual aides, and her physician orders did not include an order for topical analgesic ointment or self-administration of medication. During observation, the ointment was found on the bedside table and was removed by the Staffing Coordinator, who stated it should not have been in the room. Staff interviews reflected that medication should not be in residents’ rooms and should be locked in the nurse’s or medication aide’s cart. The ADON and DON also stated medications should not be at the bedside, and the Administrator stated medications should be secured so the right resident gets the right amount of medicine. The facility policy allowed bedside storage only for sublingual and emergency medications or for residents authorized to self-administer medications with a written prescriber order and interdisciplinary approval.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the confidentiality and privacy of residents' personal and medical information for fifteen out of twenty-five residents reviewed. Multiple lists containing sensitive medical information, such as residents using oxygen, those with Foley catheters, on dialysis, with g-tubes, and with pacemakers, were left unattended and visible on top of a nurse's cart in the hallway. These lists included residents' last names and specific medical interventions or devices, making the information accessible to anyone passing by, including unauthorized individuals. Additionally, a medication blister pack containing a resident's full name, medication details, prescription number, physician's name, and pharmacy information was left unattended on top of a medication cart outside the nurses' station. Observations confirmed that the paper with residents' last names and medical interventions was left in plain view on a nurse's cart, and staff interviews revealed uncertainty about who placed the paper there. The Assistant Director of Nursing (ADON) initially stated that the list was not considered a HIPAA violation because it only included last names, but did not respond when asked if the medical information itself was confidential. The Director of Nursing (DON) acknowledged that the information was medical in nature and should have been kept confidential, regardless of the circumstances that led to it being left out. Further interviews with staff, including the medication aide and the ADON, confirmed that the blister pack left on the medication cart was considered a HIPAA violation due to the presence of identifiable and confidential information. Staff admitted that the information should have been secured or at least flipped over to prevent exposure. The facility's policy on resident rights explicitly states that residents have the right to personal privacy and confidentiality of their personal and medical records, which was not upheld in these instances.

Penalty

No penalty information released

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

Summary

Facility staff failed to store drugs and biologicals in locked compartments as required by state and federal regulations. During observations, surveyors found that medicated creams (zinc oxide), a vial of nebulizer solution, and a tube of topical pain reliever were left inside the rooms of four residents. These items were visible and accessible on top of drawers or side tables, rather than being secured in medication carts or locked storage. Staff interviews confirmed that these medications were not supposed to be left in resident rooms and should have been removed after use. The residents involved had various medical conditions, including hemiplegia, hemiparesis, dementia, incontinence, chronic obstructive pulmonary disease, and pain management needs. All residents were cognitively intact according to their BIMS scores. The medications found included zinc oxide for incontinence care, a solution for breathing treatments, and a topical pain reliever for shoulder pain. Staff members acknowledged that these medications were left in the rooms after care was provided and that they did not notice them during their rounds. Interviews with CNAs, an LVN, the ADON, and the DON revealed a lack of adherence to the facility's medication storage policy, which requires all medications and biologicals to be stored securely and only accessible to authorized personnel. Staff admitted they did not know who left the medications in the rooms and recognized that medications should not be left accessible to residents. The facility's policy, reviewed by surveyors, clearly states that medications must be stored safely and securely, accessible only to licensed nursing or authorized staff.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a resident with chronic obstructive pulmonary disease (COPD) was observed to have a nebulizer breathing mask left unbagged on a shelf in his room when not in use. The resident, who was cognitively intact and had physician orders for as-needed nebulizer treatments, stated he would use the breathing treatment if experiencing shortness of breath but could not recall the last time it was used. During the observation, the mask was not stored in a clean plastic bag as required for infection control. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that the expectation was for breathing masks to be bagged when not in use to prevent contamination and infection. The LVN admitted she had not noticed the unbagged mask during her morning rounds and was unsure when it was last used. The facility's policy on oxygen administration included goals for safe delivery and infection prevention, but a specific policy on bagging the breathing mask was not provided at the time of the survey.

Penalty

Inspection fine: $198,559

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 due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.

Penalty

Inspection fine: $198,559

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 area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.

Penalty

Inspection fine: $198,559

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 and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as expected. The report specifically notes the absence or inadequacy of a program designed to prevent and control infections within the facility, as required by regulatory standards.

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's right to reasonable accommodation of needs and preferences was met, specifically regarding the accessibility of the call light system. The resident involved was an elderly female with diagnoses including spondylosis and legal blindness, and she was severely cognitively impaired, requiring significant assistance with daily activities. Her care plan included an intervention to keep the call light within her reach and to inform her of its location due to her visual impairment. On the day of the survey, the resident was observed in bed with her call light placed on a shelf out of her reach. When asked, she was unaware of the call light's location and was unable to find it herself. Staff interviews confirmed that the call light should always be within reach, especially for residents with significant impairments. A nurse and a CNA both acknowledged that the call light was not accessible and that it was their responsibility to ensure it was placed appropriately after providing care. Further interviews with facility leadership, including the DON, Administrator, and ADON, confirmed the expectation that all staff are responsible for ensuring call lights are within reach of residents before leaving the room. The facility's policy on resident rights also states that residents have the right to reasonable accommodation of their needs and preferences, which includes access to communication devices such as call lights.

Penalty

No penalty information released

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

Summary

The facility failed to provide safe and appropriate respiratory care for two residents requiring oxygen therapy. For one resident with chronic obstructive pulmonary disease (COPD) and moderate cognitive impairment, observations revealed that the humidifier bottle attached to his oxygen concentrator was empty while he was receiving oxygen via nasal cannula. The resident reported nasal dryness and could not recall when the bottle last contained water. The assigned LVN admitted to not noticing the empty humidifier during morning rounds and only refilled it after the deficiency was identified. For another resident with COPD and severe cognitive impairment, her nasal cannula, used for nighttime oxygen therapy, was found unbagged and stored directly inside a drawer, with the prongs in contact with other items. The resident confirmed that staff typically removed the cannula in the morning. The LVN acknowledged that the cannula should have been stored in a plastic bag to maintain cleanliness and prevent infection, but had not noticed its improper storage during rounds. Upon discovery, the LVN discarded the unbagged cannula and planned to replace it. Interviews with the DON, Administrator, and ADON confirmed that facility expectations and policy require humidifier bottles to contain water during oxygen administration and nasal cannulas to be bagged when not in use. The facility's policy on oxygen administration specifies the need for humidification to prevent drying of mucous membranes. Despite these expectations, staff failed to ensure proper respiratory care practices for both residents.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an indwelling Foley catheter, as required by federal regulations. Despite the resident's significant medical history, including cancer, cerebrovascular accident, metabolic encephalopathy, and severe cognitive impairment (BIMS score 5/15), there was no care plan addressing the management and care of the Foley catheter. The resident had physician orders for specific catheter care, including monthly changes, care every shift, and monitoring for complications, but these were not reflected in the resident's comprehensive care plan. Observations and record reviews revealed that the resident was confused, unable to respond to questions, and had a Foley catheter drainage bag improperly positioned on the floor with the catheter strap detached. Interviews with the DON and Administrator confirmed that care planning is a team responsibility and should be updated upon admission and with any change in condition. Facility policies also require daily review of care plans for changes, but this was not done for the resident's Foley catheter, resulting in the 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 provide necessary assistance with activities of daily living (ADLs) related to nail care for two residents who were dependent on staff. One resident, a male with a history of cerebrovascular accident, muscle weakness, and moderate cognitive impairment, was observed with long fingernails containing brown matter underneath. He reported that he had requested staff assistance to clean and trim his nails, but this was not done. His care plan included interventions for nail care to be performed on bath days and as needed, but these interventions were not followed. Another resident, a male with diabetes, anxiety, bipolar disorder, and schizophrenia, was found to have long, cracked toenails. He was totally dependent on staff for ADLs and was unsure who could safely trim his toenails due to his diabetic condition. His care plan specified that nail care, particularly for diabetic residents, should be provided by a nurse, and a podiatry consult was available as needed. Observations and interviews with staff confirmed that nail care responsibilities were not carried out as required, and the process for referring diabetic residents for podiatric care was not followed.

Penalty

No penalty information released

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

Summary

A resident with a history of cancer, cerebrovascular accident, metabolic encephalopathy, and anxiety, who was severely cognitively impaired, was readmitted to the facility with an indwelling Foley catheter. The physician's orders specified monthly catheter changes, catheter care and drainage bag emptying every shift, and monitoring for complications, with instructions to ensure the catheter strap was in place and holding. However, the resident's comprehensive care plan did not include any plan for indwelling Foley catheter care. During observation, the resident was found lying in bed with the Foley catheter drainage bag placed on the floor and the catheter tubing inadequately secured to her leg, as the catheter strap had come off and was draped over the catheter. Nursing staff confirmed that the drainage bag should not be on the floor and the tubing should be properly secured, acknowledging that failure to do so could lead to cross-contamination and infection. Facility policy also required that catheter tubing and drainage bags be kept off the floor and properly secured, but these procedures were not followed in this instance.

Penalty

Inspection fine: $10,551

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 provide adequate monitoring, supervision, and implementation of assistive devices to prevent accidents for a resident with dementia who was newly admitted. The resident, who had a history of impaired cognitive function, risk for falls, and was at risk for wandering, was admitted from a short-term general hospital. Upon admission, the resident was oriented to his room and directed to the dining area for lunch. After lunch, he was last seen at the nurse's station and later in his room unpacking. Within approximately two hours and twenty minutes of admission, the resident could not be located, and a code orange was initiated. The facility did not identify potential hazards or follow internal systems in place to prevent the resident's elopement. The required elopement risk assessment and other admission assessments had not been completed at the time of the incident, as the resident eloped before the four-hour window for completing these assessments. The facility's leadership team had reviewed pre-admission clinical documents but did not find concerning information related to wandering or elopement risk, and the secured unit available was female-only, which influenced the admission decision. The resident was missing for approximately two hours before being located by local law enforcement about a mile from the facility. Interviews with staff confirmed that the resident did not express a desire to leave or appear confused immediately prior to the incident. The facility's policy required an elopement risk assessment upon admission, but this was not completed before the resident's elopement. The failure to complete timely assessments and implement appropriate safety measures resulted in the resident's unsupervised exit from the facility.

Penalty

Inspection fine: $34,860

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

Summary

The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident representative of a significant change in the resident's physical status. This deficiency was identified in the case of a post-operative resident who had undergone back and pelvis surgery. The resident's surgical incision site showed signs of drainage, which was not promptly reported to the attending physician or surgeon, leading to an infection that required hospitalization and further surgical intervention. The report details that the facility's Treatment Nurse noticed the drainage from the surgical site and informed the facility's wound care doctor, who was not the resident's provider. The wound care doctor advised the Treatment Nurse to notify the surgeon, but this was not done. The Treatment Nurse delegated the task of notifying the surgeon to another nurse, who did not follow through. As a result, the resident's condition worsened, and the infection led to a return to the hospital for additional surgery. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's condition. The attending physician and the nurse practitioner were not informed of the changes in the resident's incision site, and there was no documentation of any assessment or notification to a provider about the incision site drainage. The facility's Director of Nursing and Administrator acknowledged the failure to notify the surgeon and the attending physician, which was crucial for infection control and the resident's safety.

Removal Plan

• 100% skin sweep of all residents completed by the DON, ADON, and Charge Nurses.
• All residents with wounds including surgical wounds were assessed by the DON for potential decline in wound status. No acute changes noted.
• Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e., new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified.
• All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site. DON/designee to monitor weekly for compliance.
• All surgical wounds/incisions changes or decline in condition will be reported to the surgeon of the incision site and attending physician. DON/designee to monitor weekly for compliance.
• DON/designee to ensure surgeon contact information is available in resident's EMR upon admission. DON/designee to monitor weekly for compliance.
• DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds. DON/designee to monitor weekly for compliance.
• Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect.
• The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds. The DON or Designee will ensure that the wound was assessed and notification to the Attending MD as well as the Surgeon was completed timely.
• An ADHOC QAPI meeting was completed to include the IDT team and Medical Director.
• The following in-services were initiated by the DON, ADON and regional nurse. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation prior to taking an assignment. All agency staff will be in-serviced prior to their scheduled shift.
• All Charge Nurses: Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e. new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified.
• Non-licensed nursing staff: Abuse and Neglect Policy- failure to report a change in condition on a resident such as a new or worsening wound, could be considered neglect.
• Notification of Change in Condition Policy- Reporting negative changes in condition involving wounds to the charge nurse immediately. Changes include a soiled dressing, foul odor, redness, or complaints of pain to the wound. If the charge nurse is not available, the DON or ADON will be notified.

Penalty

Inspection fine: $34,860

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 treatment and care in accordance with professional standards of practice and the comprehensive resident-centered care plan for a resident who was reviewed for quality of care. The facility did not ensure that physician orders for treatment, care, and monitoring of the resident's surgical site incision were obtained upon admission, which resulted in a subsequent infection that required hospitalization and surgical intervention. Additionally, the facility did not complete or document any skin/incision/wound assessments of the resident's surgical incision site, leading to the infection. The resident, a cognitively intact female with a BIMS score of 15, was admitted to the facility with relevant diagnoses including metabolic encephalopathy, subluxation of lumbar vertebra, wedge compression fracture of thoracic vertebrae, protein-calorie malnutrition, anxiety, and major depressive disorder. Despite having undergone back and pelvis surgery prior to admission, the facility's baseline care plan did not address the resident's surgical care needs. There was no evidence of surgical site assessment, treatment, or care documentation in the resident's records, and physician orders for monitoring the surgical site were not observed for the month of September. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's surgical site condition. The treatment nurse reported the incision site drainage to a wound care doctor, who was not the resident's provider, and delegated the responsibility to notify the surgeon to another nurse, who did not recall being asked to do so. The attending doctor and nurse practitioner were not informed of any incision site changes or concerns, and the facility's policy on notifying physicians of changes in status was not followed. This failure to monitor and report changes in the resident's condition led to a delay in medical intervention and a decline in the resident's health, resulting in hospitalization and further treatment.

Removal Plan

• 100% skin sweep of all residents completed by the DON, ADON, and Charge Nurses.
• All residents with wounds including surgical wounds were assessed by the DON for potential decline in wound status.
• The Administrator and DON were in-serviced 1:1 on Notification of Change in Condition Policy.
• All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site.
• All surgical wounds have treatment orders, upon admission.
• All skin assessments, upon admission and weekly reflect any surgical incision.
• DON/designee to monitor new surgical incision resident orders during daily stand up to ensure treatment orders are in place and admission assessment includes surgical incisions.
• DON/designee to ensure surgeon contact information is available in resident's EMR upon admission.
• DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds.
• Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect.
• The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds.
• An ADHOC QAPI meeting was completed to include the IDT team and Medical Director.
• All Charge Nurses were in-serviced on monitoring surgical wounds daily and reporting changes, ensuring treatment orders are in place, and updating baseline care plans.
• Non-licensed nursing staff were in-serviced on Abuse and Neglect Policy and Notification of Change in Condition Policy.

Penalty

Inspection fine: $34,860

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

Summary

The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by two specific incidents involving improper sanitation practices. In the first incident, a Medical Assistant (MA) did not sanitize a blood pressure measurement device between its use on two residents. The device was used on a male resident with multiple health issues, including major depressive disorder, type 2 diabetes, and hemiplegia, and a female resident with dementia, chronic kidney disease, and heart disease. The MA acknowledged the oversight during an interview, and the Director of Nursing (DON) confirmed that the device should have been sanitized between uses to prevent infection spread. In the second incident, a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) failed to use hand sanitizer while distributing lunch trays to residents. The RN was observed placing trays in front of residents without sanitizing hands between each tray, and the CNA was instructed by a corporate staff member to sanitize hands after passing multiple trays without doing so. Both staff members acknowledged the importance of hand hygiene to prevent cross-contamination, and the DON reiterated the expectation for staff to use hand sanitizer before and after handling each tray. The facility's policies on infection control and hand hygiene emphasize the importance of sanitizing reusable equipment and performing hand hygiene to prevent infection transmission. Despite regular in-service training on these procedures, the observed lapses in practice indicate a failure to adhere to established protocols, potentially putting residents at risk of illness and exposure to communicable diseases.

Penalty

Inspection fine: $34,860

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, identified as Resident #44, received appropriate care to prevent the re-development of a pressure ulcer on her right heel. Despite physician orders to use a pressure off-loading boot every shift, Resident #44 was observed without her heel protector while resting in bed. The heel protectors were found on a table at the foot of her bed, and instructions for their use were posted above them. The resident's nurse aide was unaware of the requirement for the heel protector and had to consult with the resident's nurse, LVN Z, who confirmed that the heel protector should have been in place. Further interviews revealed that the Treatment Nurse emphasized the importance of the heel protector in preventing the reopening of the resident's previously stage four pressure wound, which had since closed. The Director of Nursing (DON) also stated that it was expected for the nursing staff to ensure the use of pressure-relieving devices as per physician orders. The facility's policy on skin integrity management highlighted the need for additional heel protection, yet this was not adhered to, leading to the deficiency.

Penalty

Inspection fine: $34,860

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 fall mat was appropriately placed for a resident identified as a fall risk. On the date of observation, the fall mat intended to prevent injury was found folded and not in use on the floor beside the resident's bed. The resident, who was admitted from an acute care hospital and was on hospice, had a history of dementia, anxiety disorder, pain, and a pressure ulcer. The comprehensive care plan for the resident included the use of a fall mat as a precautionary measure due to her impaired visual function, communication problems, and risk for falls related to dementia, poor balance, and weakness. During the observation, the resident's nurse aide acknowledged the resident's fall risk and corrected the placement of the fall mat upon noticing it was not in use. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) both confirmed that the fall mat should be in place while the resident was in bed to minimize the risk of injury. The facility's policy on preventative strategies to reduce fall risk and comprehensive care planning emphasized the importance of implementing individualized care plans to prevent falls, which was not adhered to in this instance.

Penalty

Inspection fine: $34,860

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 a baseline care plan for a resident within 48 hours of admission, which is a requirement to ensure effective and person-centered care. The resident, a cognitively intact female with multiple medical conditions including metabolic encephalopathy, spinal issues, malnutrition, anxiety, and depression, was admitted to the facility and required substantial assistance with mobility and personal care. Despite these needs, the baseline care plan did not include necessary instructions for surgical incision site care, which was a critical aspect of her immediate care requirements. The deficiency was identified through interviews and record reviews, which revealed that the baseline care plan provided to the resident did not document any assessment, treatment, or care instructions for her surgical incision site. The facility's administrator and Director of Nursing (DON) acknowledged the oversight, with the DON noting that she had just started her role at the time of the resident's admission. The facility's policies on baseline care plans and skin integrity management did not specifically address surgical site care, contributing to the oversight. The lack of a comprehensive baseline care plan placed both the resident and facility staff at risk by not ensuring continuity of care and communication among staff, which is crucial for resident safety and preventing adverse events shortly after admission. The facility's failure to include surgical site care in the baseline care plan was a significant oversight, as it did not meet professional standards of quality care and left the resident's immediate needs unaddressed.

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 pest control program, resulting in the presence of gnats in both the kitchen and dining hall. During an observation, at least 20 gnats were seen in the kitchen, and 12 gnats were observed in the dining hall while residents were eating lunch. The facility's pest control log indicated that a pest control company had visited the facility a week prior to treat for flies, fruit flies, and gnats in various areas, including the kitchen and dining hall. However, the treatment was ineffective in eliminating the gnats. Interviews with staff revealed that the gnats had been an ongoing issue since the start of summer. The kitchen staff had informed the maintenance department about the problem, but the maintenance director had prioritized other issues, such as a gas leak and plumbing problems, over addressing the gnat infestation. Although the pest control company recommended using bug lights, they had not been installed until the day of the observation. The facility's policy on insect and rodent control was undated, but it stated that arrangements should be made with a reputable company for regular spraying for insects, including rodent control when required.