Willow Park Rehabilitation 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 a resident's call light was within reach. Resident #1 was a cognitively intact male with diagnoses including bipolar disorder, muscle wasting and atrophy, schizoaffective disorder, and peripheral vascular disease. His MDS reflected he required setup or clean-up assistance for eating and was dependent on staff for toileting, showering, and personal hygiene. His care plan directed staff to encourage him to use a bell to call for assistance. During an observation and interview, Resident #1 stated he was doing okay and that staff treated him well, but he could not have reached his call light if he had tried. The call light was observed under his bed, wrapped around the bed frame and hanging near the floor, out of his reach. He stated that if he needed help, he would have had to yell for someone because he would not have been able to get to the light. He demonstrated that he could not reach it where it was placed. Staff interviews confirmed the call light was not within reach. A CNA stated the resident could not have reached it and that all residents' call lights should be within reach at all times. An LVN, another CNA, and another LVN gave similar statements that call lights should always be within reach and that failure to do so could prevent residents from getting help when needed. The DON and ADM also stated staff had been trained on call light placement and that residents' call lights should be within reach at all times. Facility policies stated the call light should be accessible to the resident in bed, from the toilet, from the shower or bathing facility, and from the floor.

Penalty

Inspection fine: $43,67013 days payment denial

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 multiple residents from abuse, specifically physical aggression perpetrated by another resident with a history of severe cognitive impairment and behavioral disturbances. Several incidents occurred in which this resident physically assaulted peers, resulting in injuries and hospital evaluation for at least one victim. The aggressive resident had a documented history of Alzheimer's disease, depression, bipolar disorder, anxiety, and mood disorder, with a severely impaired cognition score. Despite being placed on 1:1 supervision due to repeated aggressive episodes, the resident continued to initiate unprovoked physical aggression toward others, including hitting, pushing, and punching fellow residents. The affected residents, all with varying degrees of cognitive impairment and complex medical histories, were subjected to physical aggression on multiple occasions. One resident was hit in the chest and fell, requiring hospital evaluation; another was punched in the face; a third was pushed to the ground; and a fourth was struck on the arm. Care plans for these residents documented the incidents and included interventions such as removal from the aggressor and monitoring for injuries. However, these measures did not prevent further occurrences of abuse, and staff interviews revealed ongoing concerns about the safety of both residents and staff due to the aggressor's unpredictable and escalating behavior. Staff and leadership interviews indicated that attempts to secure psychiatric intervention or alternative placement for the aggressive resident were unsuccessful, as hospitals and other facilities declined admission, and legal barriers prevented emergency detention. Staff reported feeling unsafe and unable to manage the resident's physical aggression, citing the resident's size and strength. The facility's abuse prevention policy emphasized the importance of resident safety, but the repeated incidents and lack of effective intervention resulted in the identification of Immediate Jeopardy by surveyors.

Removal Plan

• Ensure Resident #11 is placed on continuous 2:1 supervision at arm's length.
• Implement physical separation at arm's length between Resident #11 and all other residents at all times, accomplished by in-services to all staff.
• Place Resident #11 in a controlled, low-stimulation environment.
• Search the memory care common area and Resident #11's room to ensure objects that could be used to cause harm are removed from the resident's environment.
• Implement a two-staff approach for all care interactions involving Resident #11.
• Request and complete a psychiatric evaluation for Resident #11, with medication changes and additional diagnosis as a result.
• Review and adjust Resident #11's medication regimen and PRN parameters as clinically indicated.
• Review Resident #11's clinical status to assess for potential medical contributors to aggressive behavior, including pain assessment, vital signs, infection screening, bowel and bladder status, and medication profile.
• Revise the process for managing residents with aggressive behaviors, including early identification of triggers, defined escalation thresholds, and clear staff response expectations.
• Revise Resident #11's behavioral care plan by the interdisciplinary team to include identified triggers, early warning signs, de-escalation techniques, and clear direction for escalation.
• Educate DON and ADON regarding dementia-related aggressive behaviors, resident to resident abuse prevention, and de-escalation strategies, validated by quiz.
• Conduct education for staff on all shifts regarding dementia-related aggressive behaviors, resident-to-resident abuse prevention, and de-escalation strategies; staff, including PRN and Agency, will be unable to work until education is completed and validated by quizzes with a minimum score of 100%.
• Reinforce the Abuse Prevention Policy with specific focus on resident-to-resident aggression.
• Reinforce pathways of resources for staff for psychiatric consultation and alternative placement consideration and place in a binder at the nurses' station for staff accessibility.
• Conduct a house-wide assessment to identify residents at risk for harm, and implement protective interventions for all residents in the memory care unit.
• Provide immediate oversight of supervision levels and resident safety related to aggressive behaviors.
• Provide real time supervision during each shift to ensure protective interventions and separation measures remain in place; any escalation in aggressive behaviors results in immediate re-assessment and modification of interventions.
• Maintain active presence in oversight to ensure continued resident safety and adherence to interventions implemented to remove the jeopardy.
• Monitor resident-to-resident aggression through the QAPI program with trend analysis; review findings by the QAPI Committee and implement corrective actions as needed.
• Conduct ongoing audits to ensure compliance with supervision, care planning, and staff response protocols.

Penalty

Inspection fine: $43,67013 days payment denial

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 personal and medical records remained private and confidential when staff left computers unlocked and unattended at the nurse's station with resident information visible on the screen. On 12/18/2025 at 1:17 p.m., LVN O left a computer open and unsupervised in an open area where residents and other individuals or guests could pass by, and resident information was visible. At 1:25 p.m. the same day, LPN K left a computer unlocked and unattended at the nurse's station with resident information visible on the screen. On 12/19/2025 at 2:15 p.m., LVN O again left a computer unlocked and unattended at the nurse's station with resident information visible to anyone passing by. During interviews, the ADON and ADM stated the staff member using the computer was responsible for ensuring the screen was locked when unattended, and both stated that someone could access a resident's personal information if the computer was left open. The facility's Resident Rights policy stated employees shall treat all residents with kindness, respect, and dignity, and its policy prohibited unauthorized release, access, or disclosure of resident information.

Penalty

Inspection fine: $43,67013 days payment denial

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

Summary

The facility failed to ensure that Resident #9 was informed of and participated in treatment by not obtaining informed consent for Ativan, an antianxiety medication ordered for the resident. Resident #9’s care plan identified the use of anti-anxiety medications related to anxiety disorder and included an intervention to educate the resident, family, or caregivers about the risks, benefits, and side effects of anti-anxiety medications being given. The physician order summary reflected an order for Ativan one tablet by mouth two times daily for anxiety. Resident #9’s quarterly MDS reflected diagnoses of respiratory failure, atrial fibrillation, and hypertension, and indicated the resident was dependent on staff for showering and bathing and had a BIMS score of 02, showing severe cognitive impairment. Record review of the electronic medical record for the stated period showed no informed consent for Ativan on file. During interview, LVN O stated she did not think consent was needed for routine Ativan only as needed, but also stated staff normally obtain consents for Ativan and that the nurse receiving the order was responsible for obtaining it. ADON L stated the nurse who took the order for any medication requiring informed consent should obtain it, and that the purpose of the consent was to ensure the resident or responsible party was informed about the medication’s purpose and side effects.

Penalty

Inspection fine: $43,67013 days payment denial

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 #65’s call light was within reach. Resident #65 was a [AGE]-year-old female admitted on [DATE] with diagnoses including Alzheimer’s disease, contractures of both shoulders, anxiety disorder, and pain. Her quarterly MDS dated 09/29/2025 showed a BIMS score of 03, indicating severe cognitive impairment, and she required substantial to maximal assistance with showering, upper body dressing, and personal hygiene, and was dependent on staff for toileting hygiene, lower dressing, footwear, and personal hygiene. Her care plan identified her as high risk for falls and included the intervention to ensure her call light was within reach and to encourage her to use it for assistance as needed. During observation on 12/16/2025 at 09:59 a.m., Resident #65’s call light was seen hanging toward the floor at the foot of her bed while she sat in a Geri chair about three feet away from it. She could not be interviewed because of her cognitive status. Staff interviews confirmed that it was everyone’s responsibility to keep call lights within reach, that residents would not be able to call for assistance if the call light was not within reach, and that staff were expected to ensure call lights were within reach before leaving resident rooms.

Penalty

Inspection fine: $43,67013 days payment denial

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 assessments accurately reflected resident status for 3 of 6 residents reviewed. Resident #3’s SCSA MDS did not indicate hospice admission in all required sections, even though MDS staff stated the resident had been admitted to hospice on 9/13/2024 and that the omission in section J was missed, while hospice was listed in section O as having a life expectancy less than 6 months. The facility’s MDS Coding Policy stated assessments were to be coded timely and accurately using the most up to date RAI manual. Resident #6’s comprehensive MDS was coded as having an indwelling catheter, but the resident had no catheter order, no catheter-related interventions in the care plan, and was observed standing in the secured unit hallway without a catheter collection bag. Resident #84’s quarterly MDS was coded as having received insulin 7 days out of the last 7 days, but the active orders showed no insulin injection medication, the care plan had no insulin interventions, and an LPN stated she had never administered insulin to the resident since starting work at the facility. The MDS staff acknowledged both coding errors and stated they would need to be corrected.

Penalty

Inspection fine: $43,67013 days payment denial

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 PASRR Level I screening accurately reflected Resident #73’s status. Resident #73 was admitted on 01/17/2025 and had diagnoses that included major depressive disorder, anxiety disorder, type 2 diabetes mellitus, and chronic pain syndrome. The record also showed a Quarterly MDS with a BIMS score of 12, indicating moderate cognitive impairment, and an active diagnosis of major depressive disorder. The PASRR Level I screening dated 01/13/2025 marked Section C Mental Illness as “no,” indicating the resident did not have a mental illness, despite the documented diagnosis of major depressive disorder present at admission. The resident’s care plan identified depression related to major depressive disorder and use of duloxetine for depression, and admission notes also reflected the diagnosis of major depressive disorder. During interview, the MDS D stated the resident had major depressive disorder and should have had a PASRR Level 2 assessment completed because of that diagnosis. The ADM stated it was the MDS Coordinator’s responsibility to ensure the PASRR Level I was completed accurately and also stated the resident should have received a PASRR Level 2 assessment due to major depressive disorder.

Penalty

Inspection fine: $43,67013 days payment denial

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 comprehensive person-centered care plan for Resident #6 that addressed his PTSD and identified triggers. Resident #6 was a [AGE]-year-old male admitted with diagnoses including high blood pressure, arthritis, non-Alzheimer's dementia, anxiety, and PTSD, and his BIMS score was 01, indicating severely impaired cognition. Review of the comprehensive care plan dated 11/19/2025 showed that PTSD had not been care planned and that identified triggers were not listed. The resident's social history assessment completed by the facility SW documented a history of trauma, a PTSD diagnosis, and triggers that caused emotional distress, including loud noises such as banging doors, booming music, and alarms. His occupational history reflected that he had been an infantryman in the army. During interview, the MDS D stated the trauma assessment was the SW's responsibility, but the SW was out on leave, and she completed a Trauma Informed Assessment after the issue was brought to the facility's attention and then added the triggers to the care plan. The ADM stated the facility used a trauma informed evaluation upon admission and expected care plan meetings with families for input when residents could not vocalize their needs.

Penalty

Inspection fine: $43,67013 days payment denial

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 #32’s nails were cleaned and trimmed. Resident #32 was admitted with diagnoses including Rett syndrome, myopia, and conversion disorder with seizure or convulsion. Her annual MDS reflected a BIMS score of 00, indicating severe cognitive impairment, and she was dependent on staff for eating, oral hygiene, toileting hygiene, showering/bathing, dressing, footwear, and personal hygiene. Her care plan identified an ADL self-care performance deficit related to her disease process, profound intellectual disability, and muscle weakness, and directed staff to provide extensive assistance with personal hygiene and oral care. During observations on 12/16/2025 and 12/17/2025, Resident #32’s fingernails on her left hand were noted to be dirty and untrimmed. The resident could not be interviewed due to her cognitive status. In interviews, CNA B stated nail care could be provided by any CNA if the resident was not diabetic, that nail care was usually done on shower days or as needed, and that the resident’s shower days were Monday, Wednesday, and Friday. The ADON and ADM both stated that because the resident was not diabetic, any CNA could have provided nail care, and that nail care should be provided as needed or on shower days; they also stated that if nails were not cleaned or trimmed, residents were at risk for infections or scratching themselves.

Penalty

Inspection fine: $43,67013 days payment denial

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

Summary

The facility failed to ensure adequate supervision to prevent accidents for a resident who was able to leave the building without staff awareness and was later found by survey staff in front of a store approximately 100 yards from the facility. The resident was a male with anemia, schizophrenia, a below-knee leg amputation, and diabetes mellitus. His quarterly MDS reflected a BIMS score of 14, indicating intact cognition. His care plan stated that he was able to sign himself out and smoke independently outside, but also noted that he refused to wear a smoke apron and was observed going to the store and smoking in front of it. On the day of the observation, the resident did not sign himself out on the facility sign-out sheet. Survey staff observed him maneuvering a manual wheelchair in the store parking lot and parking to the left side of the store's front door. During interviews, nursing staff stated that residents could go outside but were not allowed to leave the premises unless they signed out, and that staff completed head counts at the beginning of shifts. The resident was not in his room when staff checked, and staff did not know his whereabouts. The ADON later stated that the resident had returned on his own and that staff had not gone to retrieve him. The ADON also stated that the resident frequently went to the store to smoke, sometimes stayed so long that the store called police and filed a criminal trespassing complaint to get him to return, and that there were no additional interventions in place to ensure residents signed out before leaving. She stated that six residents with high BIMS scores and low wandering risk scores had the facility front door code, including this resident. The resident told survey staff he used the code to let himself out, forgot to sign out because he could not find the binder, and did not recall being educated on the purpose of the sign-out book. The facility's elopement policy required immediate notification of the Administrator/designee and a complete interior and external search if a resident was missing, but staff interviews reflected uncertainty about the missing resident policy and no evidence that the policy was followed when the resident was absent.

Penalty

Inspection fine: $43,67013 days payment denial

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

Summary

The facility failed to ensure that a resident with PTSD received a trauma assessment on admission that identified possible triggers. Resident #6 was admitted with diagnoses including HTN, arthritis, non-Alzheimer's dementia, anxiety, and PTSD, and his BIMS score was 01, indicating severely impaired cognition. His comprehensive care plan dated 11/19/2025 did not care plan him for PTSD and did not list identified triggers. A social history assessment completed by the facility SW on 10/21/2025 documented a history of PTSD, noted that loud noises such as banging doors, booming music, and alarms caused emotional distress, and recorded that the resident had served as an infantryman in the army. During observation on 12/16/2025, Resident #6 was standing in the secured unit hallway and did not answer questions when the surveyor attempted to interview him; he was determined to be non-interviewable due to cognitive impairments. In interview, the MDS D stated that a trauma assessment was the SW's responsibility and that she completed a Trauma Informed Assessment on 12/17/2025 only after the surveyor brought the issue to the facility's attention, then added triggers to the care plan. The ADM stated the facility used a trauma informed evaluation upon admission and expected care plan meetings with families for input when residents could not vocalize their needs. The facility policy titled "Trauma-Informed and Culturally Competent Care" stated that resident screening should be universal, assessments should identify symptoms and triggers, and individualized care plans should address past trauma in collaboration with the resident and family, as appropriate.

Penalty

Inspection fine: $43,67013 days payment denial

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 #13 received necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Resident #13 was a [AGE]-year-old female admitted on [DATE] with diagnoses including chronic kidney disease stage 5, muscle weakness, low thyroid hormone, and insomnia. Her quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment, and documented that she felt down, depressed, or hopeless 7-11 days out of 14 in the prior 2 weeks. Her care plan included monitoring, documenting, and reporting signs or symptoms of depression and obtaining a mental health consult if needed. Record review showed Resident #13 was not on medication for depression and had no order for counseling or psychiatric services. Progress notes documented that she returned from dialysis after leaving AMA and that the dialysis facility verbalized she was emotionally upset. During observation, she was sitting in her wheelchair with her head down and declined to engage with the surveyor. An LVN stated she felt Resident #13 was depressed but had not been evaluated for psychiatric services, and the ADON stated the DON sets up mental health services for residents showing symptoms of depression; however, she was not sure whether the facility provided counseling services. The LVN also stated she had not notified the DON of her concerns for Resident #13's depression.

Penalty

Inspection fine: $43,67013 days payment denial

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

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when dietary staff did not discard an outdated item in the walk-in freezer. During a kitchen tour on 12/16/2025 at 09:00 AM, surveyors observed a clear plastic bag labeled "Tulip Greens with Butter" in the freezer with a use by date of 11/10/2025. During interviews, the DM stated that cooks were responsible for ensuring items were discarded by the use by date and that the observed item should have been used by or discarded by 11/10/2025. The DM, the [NAME], and the ADM each stated that items past their use by date should be discarded and that serving outdated items could cause residents to get sick. Record review of the facility's Food Receiving and Storage policy, revised 06/23/25, stated that all foods stored in the refrigerator or freezer will be covered, labeled, and dated with a use by date.

Penalty

Inspection fine: $43,67013 days payment denial

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

Summary

The facility failed to maintain an infection prevention and control program for two residents during observed care. For a resident with a pressure area to the coccyx and an actual skin impairment to the right outer ankle, who also had peripheral vascular disease, hypertension, diabetes mellitus, moderate cognitive impairment, wheelchair dependence, and unhealed pressure ulcers requiring wound dressings, an LVN removed a soiled coccyx dressing and discarded it, then removed soiled gloves and applied clean gloves without cleansing her hands first before continuing wound care. The resident was observed lying in bed, alert, and stated he was feeling okay and denied pain. For another resident with hypertension, diabetes mellitus, non-Alzheimer's dementia, severe cognitive impairment, wheelchair dependence, mobility impairment, and total incontinence of bowel and bladder, two CNAs prepared to provide peri care while the resident was lying in bed and gave permission for care. The CNAs did not clean their hands with alcohol-based hand sanitizer before donning gloves and starting peri care, and they did not wash their hands between changing gloves when moving from a dirty to a clean site. They completed peri care, disposed of the soiled brief, and then washed their hands with soap and water. The facility policy stated hand hygiene was indicated before handling clean or soiled dressings, when moving from a soiled body site to a clean body site on the same resident, and after glove removal.

Penalty

Inspection fine: $8,281

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 treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency are not provided in the report.

Penalty

Inspection fine: $8,281

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 incident of possible neglect to the State Survey Agency in a timely manner after a resident experienced a fatal choking episode during a meal. The resident, an elderly male with diagnoses including diabetes, vascular dementia, major depressive disorder, and anxiety, was on a mechanically soft diet and required meal assistance as needed. During dinner, the resident began choking, and staff attempted to clear the airway with a finger sweep and abdominal thrusts, but were unsuccessful. The resident's code status was confirmed as Do Not Resuscitate (DNR), and no signs of life were noted after the incident. Despite the severity of the event, the facility did not activate 911 emergency services during the episode. Interviews with facility staff revealed that the incident was not reported to the State Survey Agency because the Director of Nursing (DON) and Administrator believed it was not suspicious and did not constitute neglect, as they were aware of the circumstances and followed internal policy. The DON stated that not calling 911 was not considered neglectful, as it would not have changed the outcome. However, the facility's own policies required reporting all allegations and substantiated occurrences of abuse or neglect, including those resulting in serious bodily injury, to the state agency within specified timeframes. The failure to report the incident as required constituted a deficiency in the facility's abuse and neglect reporting procedures.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from abuse when a Certified Nursing Assistant (CNA) placed her hand over the resident's mouth to prevent her from talking while providing care. The resident, who had a history of dementia, Alzheimer's, cognitive communication deficit, and major depressive disorder, was unable to recall the incident due to her cognitive impairment. The incident was reported by another resident, who was cognitively intact, to a CNA and subsequently to a Licensed Vocational Nurse (LVN). The report was made after the incident occurred during the 2:00 PM to 10:00 PM shift. The facility's incident reports and progress notes did not document the abuse, and there was no head-to-toe assessment of the resident following the incident. Interviews with the Director of Nursing (DON) and LVN confirmed that the incident was reported and that the resident was assessed with no harm found. The facility's policy on abuse prohibition, which was intended to prevent abuse, neglect, and misappropriation of property, was not adhered to in this case, as the resident's right to be free from abuse was violated.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurate medical records for a resident, specifically regarding an incident that occurred on two consecutive days. The resident, a female with a history of dementia, Alzheimer's, cognitive communication deficit, and major depressive disorder, did not have incident reports, assessments, or nursing progress notes documented in her medical chart for the specified dates. This lack of documentation was identified during a review of the resident's face sheet, admission care plan, and MDS, which highlighted her cognitive impairment. Interviews with facility staff, including an LVN and the DON, revealed that the expected documentation was not present in the system despite the LVN's assertion that she had entered the necessary information immediately after assessing the resident. The DON confirmed the absence of documentation and emphasized the importance of timely record-keeping to ensure proper communication among the care team. The facility's policy on charting and documentation, revised in 2017, mandates that all services and changes in a resident's condition be recorded in their medical record to facilitate communication within the interdisciplinary team.

Penalty

Inspection fine: $8,021

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

Summary

The facility failed to provide basic life support, including CPR, to a resident who was in full code status and required emergency care before the arrival of emergency medical personnel. The incident involved a resident who was unresponsive and not breathing, and the staff did not initiate CPR as required. The resident was declared deceased, and this failure was identified as an Immediate Jeopardy situation. The resident in question was an elderly female with a history of dementia, cognitive communication deficit, anemia, hypertension, anxiety disorder, and depression. She was admitted to hospice care but remained in full code status, meaning that life-saving measures like CPR should have been initiated in the event of an emergency. Despite this, the staff, including LVN B, did not perform CPR when the resident was found unresponsive, assuming incorrectly that the resident was DNR due to her hospice status. Interviews with facility staff revealed a lack of awareness and understanding of the resident's code status, leading to the failure to initiate CPR. Staff members, including LVN A and LVN B, admitted to assuming the resident was DNR because she was on hospice, without verifying her actual code status. This assumption led to the inaction that resulted in the resident's death, highlighting a critical deficiency in the facility's emergency response procedures.

Penalty

Inspection fine: $8,021

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

Summary

The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage and handling of food items in the kitchen. Observations revealed multiple instances of food being improperly stored, including cantaloupes and onions with visible mold, open bags of shredded carrots and cheese exposed to air, and meat thawing in a container with blood dripping onto the floor. Additionally, the freezer contained open bags of tortilla chips and boxes of pork steak and beef patty fritters exposed to air. The dry storage area and seasoning shelf also had open containers of food items exposed to air, such as country style gravy mix, instant puree rice, instant food thickener, and ground nutmeg. The Dietary Supervisor, during an interview, stated that she conducted morning walkthroughs of the kitchen and checked temperature logs, ensuring that dietary staff stored food properly by addressing any issues. However, the observations indicated a failure to maintain proper food storage, which could place residents at risk for food-borne illness. The facility's policy on food receiving and storage, dated October 2022, and the FDA Food Code of 2017, both emphasize the importance of storing food in a manner that prevents contamination, which was not adhered to in this instance.

Penalty

Inspection fine: $8,021

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

Summary

The facility failed to ensure that a discharge summary was documented in the medical record of a resident who was discharged. The resident, who had chronic pain related to arthritis, was admitted to the facility and had a care plan that included interventions for pain management. However, upon discharge, there was no discharge summary or documentation of the discharge in the resident's medical records. This lack of documentation was confirmed through interviews with various staff members, including an LVN, the ADON, and the DON, who all indicated that discharge summaries are typically completed in the electronic medical records but were not found in this case. The facility's policy on transfer or discharge documentation requires that details of the transfer or discharge be documented in the medical record and communicated to the receiving healthcare facility or provider. This includes information such as the basis for the transfer or discharge, the resident's condition, and the disposition of personal effects and medications. The absence of a discharge summary for the resident indicates a failure to adhere to this policy, potentially putting residents at risk of not receiving necessary care and services upon discharge.

Penalty

Inspection fine: $8,021

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

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with diabetes. The care plan did not include measurable objectives and timeframes to address the resident's medical needs related to diabetes management. This oversight was identified during a review of the resident's quarterly MDS assessment and comprehensive care plan, which lacked any mention of the resident's diabetes diagnosis despite the resident being prescribed and administered insulin as per physician orders. Interviews with the resident and the MDS Coordinator revealed that the resident was aware of her diabetic condition and insulin treatment. However, the MDS Coordinator, who was responsible for updating the care plan, was unaware that the resident's care plan did not include diabetes management. The absence of an updated care plan meant that staff lacked the necessary information to provide adequate care for the resident's diabetes. Additionally, a policy regarding care plans was requested from the Administrator but was not provided.

Penalty

Inspection fine: $8,021

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

Summary

The facility failed to ensure that drug regimen irregularities identified by the pharmacist were reviewed by the attending physician, and that the physician documented their rationale for making no changes to the medications of a resident. Specifically, the pharmacist recommended gradual dose reductions for psychoactive medications prescribed to a resident, but these recommendations were not followed. The resident, who was cognitively impaired with a BIMS score of 3 out of 15, was taking multiple medications for conditions including anxiety, depression, and schizophrenia. The Director of Nursing (DON) admitted that the facility did not follow up with the pharmacist's recommendations for the month of August. The DON was informed by the Corporate Clinical Specialist that she was responsible for ensuring the physician was informed of pharmacy recommendations, but this was not done. Additionally, a policy regarding pharmacy recommendations was requested from the Administrator but was not provided. This oversight could potentially place residents at risk for prolonged use of unnecessary medications.