Woodway Nursing & Rehab

Penalty

Inspection fine: $28,120

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 ordered daily wound care to a resident with multiple pressure ulcers, resulting in an infected left hip wound. The resident, a 75-year-old man, was admitted with severe protein-calorie malnutrition, metabolic encephalopathy, peripheral vascular disease, and existing pressure ulcers, including sacral and right heel ulcers and osteomyelitis of the right ankle and foot. On readmission from the hospital, he had multiple pressure injuries: unstageable pressure ulcers on both hips, a stage 4 ulcer on the left posterior shoulder, a stage 3 coccyx ulcer, an unstageable ulcer on the left medial lateral foot, and a DTPI on the left 5th toe. Physician orders dated 2/11/26 required that each wound be treated every day shift with normal saline, pat dry, and application of Santyl, calcium alginate, and border foam dressings, and that the DTPI on the 5th toe be treated with betadine and iota every day shift. Despite these orders, the treatment administration record (TAR) showed wound care documented only on 2/22/26, with all wound care documentation left blank for 2/23/26, 2/24/26, and 2/25/26. Nursing staff interviews revealed inconsistent and uncorroborated accounts of whether wound care was actually performed on those days. RN A stated she last dressed the wounds on 2/23/26 and could not explain the lack of documentation; no other staff could confirm that wound care occurred that day. LVN E claimed she performed wound care on 2/24/26 but admitted she did not document it in the TAR, stating she could not find the resident’s name and did not seek assistance from other nurses. CNA and nurse interviews about wound care performed on 2/26/26 indicated that the dressings still bore RN A’s initials from the prior treatment and appeared unchanged for 2–3 days, with staff noting a bad odor and drainage from the left hip wound. On 2/27/26, observations and interviews documented that the resident’s room had a strong foul odor, which staff attributed to his wounds. During wound care that day, the Wound Care Doctor found the right hip wound to be very dark with mostly eschar and moderate drainage, and described the left hip wound as unstageable, very smelly, and appearing infected, with purulent and serosanguinous drainage and a yellow-tinged exudate that suggested depth. The left hip wound measured larger than previously documented and was diagnosed as infected. The Wound Care Doctor stated that if the resident had received wound care on the missed days, it could have helped prevent the decline of the left hip wound, although he could not say the infection was unavoidable due to the resident’s comorbidities and poor nutrition. Hospice staff also stated that while the resident’s wounds were considered unavoidable due to his condition, having wounds that were not being treated constituted neglect and that infections were avoidable. These findings led surveyors to identify an Immediate Jeopardy situation related to failure to provide necessary pressure ulcer treatment and services as ordered.

Removal Plan

• Resident #1 was immediately assessed by the Wound Care Doctor and diagnosed with an infected unstageable pressure ulcer to the left hip.
• Physician orders were obtained for Clindamycin 450 mg three times daily for 14 days to treat the wound infection.
• Wound care resumed immediately per physician order (daily day shift treatment).
• Wound cultures were ordered and obtained.
• The DON initiated direct oversight of wound care completion and documentation.
• The facility reviewed the census and identified all residents with wounds.
• A 100% audit was completed of all wound treatment orders and TAR documentation.
• Head-to-toe skin assessments were completed for all current residents.
• Any identified documentation gaps were immediately corrected and treatments were provided.
• All licensed nurses were re-educated on the wound care policy, including treatment frequency, dressing type, and documentation requirements.
• Staff education included expectations for notifying the physician of any changes in wound condition.
• A daily wound care assignment sheet was implemented to ensure accountability.
• The DON or designee will perform daily spot checks of wound treatments.
• A daily audit of all wound treatments will be conducted for 14 days.
• Weekly audits will be conducted thereafter for 30 days.
• Audit results will be reviewed in the QAPI meeting.
• Staff failing to follow wound care procedures will receive immediate counseling and retraining.
• The facility will verify that all residents are receiving wound care as ordered, all licensed nurses have completed re-education, and monitoring systems are in place and functioning to ensure ongoing compliance.

Penalty

Inspection fine: $28,120

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 basic life support, including CPR, to a resident who was a documented Full Code prior to the arrival of emergency medical personnel. The resident, an elderly male with dementia, cerebral infarction (stroke), and COPD, was admitted under hospice services with orders that Hospice A be notified of any change in condition. His advance directives and physician orders identified him as Full Code with CPR to be initiated if his heart or breathing stopped. However, his MDS assessment and care plan did not document his Full Code status, and his code status was incorrectly listed as DNR in the code status binder at the nurse’s station. On the day of the incident, the resident’s vital signs were incompletely documented, with no blood pressure, temperature, pulse, or respirations recorded, although an oxygen saturation of 99% via nasal cannula was documented by LVN A in the afternoon. The resident had a BIMS score documented as staff-assessed, and a progress note indicated he was moderately impaired but able to make decisions regarding tasks of daily life. Later that day, CNA B found the resident unresponsive in bed while passing dinner trays, noting that his skin appeared yellow and he did not respond to touch or verbal stimuli. CNA B immediately informed LVN A that the resident was unresponsive and not breathing. LVN A reported that upon entering the room, she assessed the resident, took his pulse and blood pressure, but did not document the readings and could not recall them. She confirmed that the resident was unresponsive, warm to the touch, and without respirations or detectable airway movement. Despite the resident’s actual Full Code status in the medical record and hospice documentation, LVN A did not initiate CPR because she relied on the code status binder, which incorrectly listed the resident as DNR. She contacted the nurse practitioner and DON to report the resident’s death and misidentified the deceased resident as a different individual. Hospice A later confirmed that the resident had always been Full Code with their agency and that he had personally signed the Full Code documentation. The facility’s CPR policy required CPR to be performed if a resident did not show obvious signs of clinical death, but no CPR was initiated for this resident, and hospice was not notified at the time of death.

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 safeguard confidential electronic medical records and to provide a resident’s medical records upon repeated written requests. On Hall C, a computer mounted to the wall was observed logged into the medical record system under a CNA’s user account and left unattended. The CNA’s name was visible on the screen, and the OT who observed the computer stated that the CNA should not have logged into the system and left it unattended because it contained private resident records and orders. The ADON and DON both stated that the computer should not have been left logged in, as unauthorized individuals could access resident information, including social security numbers, home addresses, and diagnoses. When a different CNA later logged into the same computer, the DON confirmed that from the home screen staff did not need an additional password to access resident records. The deficiency also includes the facility’s failure to respond to multiple written requests for a deceased resident’s medical records submitted by the resident’s representative through an outside entity. Five letters, each containing a certified and first-class mailing, were sent to the facility’s President/CEO or the facility’s parent company, requesting the resident’s complete medical record for a specified time period and including an authorization form for release of protected health information signed by the resident’s representative. The letters also included a copy of the resident’s death certificate and the representative’s state ID. Postal tracking showed that some letters had not reached their destination, one was returned to sender, and one was received and signed for at a postal facility. The facility had undergone a name change, but the parent company remained the same. Record review showed that the resident was an older male with multiple serious medical diagnoses, including anemia, Parkinsonism, pressure ulcers, Alzheimer’s disease, quadriplegia, dysphagia, acute respiratory failure with hypoxia, and pneumonia. He was coded on the MDS as rarely or never understood, with short- and long-term memory problems and total dependence on staff for all ADLs. Staff interviews revealed that the social worker, medical records staff, and business office managers (both current and former) denied receiving or being aware of any medical records requests for this resident. The Administrator, who had been in his position for about a month, described a process in which the DON would send medical records requests to the business office manager and stated that if mail was addressed to the previous company, he would not sign for it and the letters would be sent back. He reported that the facility did not receive any mail or letters related to this resident, despite the documented mailings and statutory requirements under Texas Civil Practice and Remedies Code Sections 74.051 and 74.052 for providing medical records within a specified timeframe after receipt of a written request accompanied by a proper authorization.

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 significant medication error occurred when a resident returned to the facility from the hospital and did not receive prescribed IV antibiotics, including Vancomycin and Meropenem, as ordered by the hospital physician. The resident, who had multiple complex medical conditions such as respiratory failure, sepsis, pneumonia, and a tracheostomy, was supposed to continue IV antibiotic therapy upon readmission. However, due to a lack of communication and incomplete transfer of clinical records, the antibiotics were not administered for several scheduled doses. The admitting nurse did not receive a report from the hospital at the time of the resident's return and did not take further steps to obtain the necessary information, such as contacting the hospital, the ADON, or the Administrator. As a result, the resident's medication administration record (MAR) did not include the required antibiotics, and the medications were not initiated until the following evening, resulting in four missed doses. The ADON and other staff members later confirmed that the omission was due to missed communication and oversight in reviewing updated clinical records sent by the hospital. Interviews with facility staff revealed that the absence of a Clinical Marketer and the lack of a clear process for handling admissions without a hospital report contributed to the breakdown in communication. The Business Office Manager had attempted to facilitate the transfer of information, but the updated medication list was not reviewed in a timely manner. The resident's physician was eventually notified of the missed doses and adjusted the treatment plan accordingly.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident who was readmitted from the hospital. Upon the resident's return, the room had not been cleaned prior to admission, as required by facility policy. Observations revealed that the resident's room contained a used bottle of enteral feeding, respiratory supplies, white sand-like debris on the nightstand, a used suction catheter in the nightstand drawer, and debris on the floor and under the bed. Additionally, the second bed in the room was unmade, with stained sheets and a used alcohol swab present. Interviews with staff confirmed that the room was not cleaned before the resident's readmission. The CNA and RN both stated that the room was dirty and disorganized, and neither knew who had placed certain items, such as disinfectant wipes, in the room. The RN admitted to attempting to clean the room herself upon the resident's arrival, as there were no clean sheets on the bed, and she had to use linens from the other bed. The respiratory therapist also confirmed that used suction tubing should have been discarded but was found in the resident's drawer. Further interviews with housekeeping staff and the Housekeeping Director revealed a lack of clear communication regarding the need to clean the room prior to the resident's readmission. The Housekeeping Director stated that rooms should be deep cleaned and disinfected after discharge and before admission, but this process was not followed due to a communication gap. The facility's policy on resident rights affirms the right to a safe, clean, and comfortable environment, 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

A deficiency occurred when a certified nursing assistant (CNA) failed to follow Enhanced Barrier Precautions (EBP) while providing direct care to a resident with multiple complex medical conditions, including a gastrostomy tube, end stage renal disease, and severe cognitive impairment. The resident was under physician orders for EBP, which required staff to don a disposable gown and gloves when providing care. On the observed date, signage indicating EBP requirements was posted on the resident's door, and personal protective equipment (PPE) was available at the entrance. Despite these measures, the CNA admitted to not wearing a disposable gown while performing incontinent care for the resident, stating she was in a hurry to prepare the resident for dialysis. The facility's Assistant Director of Nursing (ADON), who also served as the Infection Control Preventionist, confirmed that all staff were expected to use gloves and gowns when providing care to residents with devices such as gastrostomy tubes. The ADON acknowledged that failure to don appropriate PPE during care increased the risk of cross-contamination. Review of the facility's infection prevention and control policy indicated that the facility was required to maintain an infection control program in accordance with national standards, which was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to protect residents from abuse, neglect, and exploitation, specifically involving two residents with histories of aggressive and inappropriate behaviors. One resident, with severe cognitive impairment and a history of mood disorders and aggression, was involved in multiple incidents, including a physical altercation with a roommate and an episode of inappropriate sexual behavior toward another resident. Despite documentation of these behaviors in progress notes and care plans, the care plan did not address sexually inappropriate behavior, and interventions for aggressive conduct were inconsistently implemented or documented. Staff interviews revealed a lack of awareness and follow-up regarding the sexual incident, and the psychiatric provider was not notified of the event, missing an opportunity for timely intervention. Another resident, with moderate cognitive impairment and a history of depression, suicidal behavior, and aggression, was also involved in the physical altercation. This resident had previously exhibited verbal and physical aggression toward roommates and staff, including threats and throwing objects. The care plan and psychological notes did not address these behaviors or the altercation, and there was no evidence of comprehensive behavioral interventions or adjustments following repeated incidents. Staff interviews indicated that both residents were known to be incompatible as roommates due to their aggressive tendencies, yet they were placed together, leading to a physical altercation resulting in injury and an ER visit. The facility's investigation and documentation of the incidents were incomplete. The Provider Investigation Report lacked staff statements and did not indicate whether law enforcement or the Ombudsman were notified. Staff interviews revealed inconsistent reporting and follow-up on behavioral incidents, and there was no evidence of increased supervision or staffing adjustments after the altercation. Facility policies required immediate safety strategies and thorough investigations, but these were not fully implemented, leaving residents at risk of harm from abuse and neglect.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents receiving enteral nutrition via feeding tubes received appropriate treatment and services to prevent complications related to tube dislodgement. Two residents with a history of restlessness and behaviors such as pulling on or removing their G-tubes did not have adequate interventions in place, such as abdominal binders, to prevent repeated dislodgement of their feeding tubes. This resulted in multiple incidents where the residents pulled out their G-tubes, requiring hospitalization for tube replacement, and in one case, an IV pole fell on a resident's head during an episode of pulling on the tube, causing injury. For one resident, medical records indicated a history of severe cognitive impairment, dependence on staff for all care, and ongoing behaviors including agitation and attempts to pull out her G-tube. Despite these documented behaviors and multiple incidents of tube dislodgement, the resident's care plan did not address the risk of G-tube removal or include interventions such as an abdominal binder. Staff interviews confirmed that the resident was known to be restless and to pull on her tube, but no consistent preventive measures were implemented prior to the incidents. A second resident with similar cognitive and behavioral issues also experienced multiple episodes of G-tube dislodgement, leading to repeated hospitalizations. The care plan and physician orders for this resident did not include the use of an abdominal binder or other interventions to address the risk of tube removal until after several incidents had already occurred. Staff interviews and record reviews revealed a lack of communication and documentation regarding these behaviors, and the care plans were not updated to reflect the residents' needs for preventive interventions until after the deficiencies were identified by surveyors.

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 appropriate treatment and services to residents diagnosed with mental disorders or psychosocial adjustment difficulties, as evidenced by multiple incidents involving three residents. One resident with a history of schizoaffective disorder, bipolar disorder with severe psychotic features, and paraplegia exhibited escalating behaviors, including frequent calls to 911, verbal aggression, yelling, and a suicide attempt. Despite documented behaviors and repeated hospitalizations, there were no behavior monitoring or intervention orders in place, and staff were unaware of the resident's extensive history of suicide attempts and aggressive behaviors. The care plan did not adequately address the resident's risk for self-harm or aggression, and the interdisciplinary team failed to review or act upon hospital discharge records detailing the resident's psychiatric history and recent suicide attempt. Another resident with schizophrenia and anxiety disorder demonstrated severely impaired cognition and exhibited aggressive behaviors, including yelling, cursing, throwing objects, and making suicide threats. The care plan did not address suicidal behavior or suicide threats, and there was no evidence of behavior monitoring or interventions specific to these risks. Staff documented multiple incidents of physical and verbal aggression, as well as statements of intent to self-harm, but interventions were limited to medication administration and attempts at verbal redirection, which were often unsuccessful. The facility did not implement comprehensive behavioral interventions or monitoring to address the resident's escalating behaviors and suicide threats. A third resident displayed continuous behaviors such as pacing, banging on doors, and intrusive interactions with other residents and staff, but the facility failed to provide treatment and services to correct these behaviors. The lack of appropriate interventions and monitoring for residents with significant mental health and behavioral needs resulted in repeated incidents requiring emergency intervention, including police involvement and physical restraint. The facility's failure to assess, monitor, and address the residents' mental and psychosocial needs placed residents at risk for harm and did not support their highest practicable mental and psychosocial well-being.

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 live pests in multiple areas. Observations revealed live gnats in the shower room on Hall C and on a towel placed on a resident's abdomen in Room D11, with additional gnats circling around the resident. The gnats remained undisturbed even when the towel was removed and discarded. Further observations identified gnats flying in the Hall C shower room and a cockroach running across the counter at the C & D Hall nursing station, which was killed by an RN. Staff interviews confirmed awareness of the pest issue, and pest control records indicated that the most recent treatment focused on the kitchen area, not the affected locations. The facility's pest control policy states that an ongoing program is maintained to keep the building free of insects and rodents. However, the presence of gnats and cockroaches in resident care and staff areas demonstrates a failure to implement the policy effectively. The deficiency was identified through direct observation, staff interviews, and review of pest control service records, which did not reflect comprehensive or recent treatment of the problem areas.

Penalty

No penalty information released

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

Summary

The facility failed to provide evidence that an alleged violation involving a resident-to-resident altercation was thoroughly investigated. Specifically, there was no documentation indicating whether the Ombudsman or law enforcement were notified, and the investigation lacked witness statements from staff members. The incident involved two residents in a secure unit, one of whom reported being hit in the eye by his roommate, resulting in redness to the eyelid. The event was not witnessed by staff, but immediate actions were taken to separate the residents and notify the Director of Nursing (DON) and Social Worker (SW). Both residents involved had histories of dementia and behavioral issues, including verbal and physical aggression and wandering. One resident had a BIMS score indicating severe cognitive impairment, while the other had moderate impairment and hemiplegia. The care plans for both residents did not fully address the aggressive behaviors or the specific altercation, and documentation showed that one resident was moved to another room following the incident. Progress notes indicated that staff observed threatening behavior and physical aggression, but the facility's Provider Investigation Report (PIR) did not include required notifications or staff interviews. Interviews with the interim and previous administrators revealed inconsistencies in reporting and investigation practices. The interim administrator stated that abuse allegations should be reported to the state, Ombudsman, and police, and that staff interviews should be conducted, but she was unable to locate the full investigation report. The previous administrator claimed to have completed an internal investigation and staff interviews but did not report the incident to law enforcement, citing the residents' dementia and confusion. The facility's abuse and neglect policy required immediate reporting and notification of law enforcement for reasonable suspicion of a crime, but there was no evidence these steps were followed.

Penalty

Inspection fine: $205,13964 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

Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for all residents, as evidenced by widespread lack of clean bed and bath linens, inadequate hot water for bathing, and missing privacy curtains in multiple rooms. Observations revealed that numerous residents were found lying on bare mattresses due to a shortage of linens, with linen closets across all halls frequently empty. Residents and staff consistently reported that the facility's washing machines had been broken for weeks, resulting in laundry being sent to a local laundromat, which did not meet the needs for timely and adequate linen supply. Additionally, hot water was unavailable or insufficient in several resident rooms and shower areas, leading to residents receiving cold or no showers. Multiple residents, including those with significant medical needs such as skin breakdown risk, incontinence, and limited mobility, reported feeling unclean, cold, and neglected due to the lack of clean linens and inability to bathe properly. Some residents expressed emotional distress, with one resident becoming tearful and describing the situation as inhumane. Staff interviews corroborated these findings, noting that the lack of linens, towels, and other essential supplies made it difficult to provide proper care, and that residents sometimes had to use towels as briefs or go without necessary hygiene items. Staff also reported that the process for returning personal clothing from the laundromat was unreliable, leading to lost items and further resident dissatisfaction. Environmental observations further documented that privacy curtains were missing in several rooms, compromising resident privacy. Maintenance staff confirmed ongoing issues with the facility's hot water system, and housekeeping staff noted that trash had not been picked up for extended periods, contributing to unsanitary conditions. The facility's own policies defined neglect as the failure to provide necessary goods and services to avoid physical harm or emotional distress, yet the documented actions and inactions resulted in residents experiencing discomfort, lack of dignity, and inadequate support for daily living.

Penalty

Inspection fine: $205,13964 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 all residents from neglect by not providing adequate clean linens, towels, and essential care supplies across all units. Multiple residents were observed lying on bare mattresses due to a lack of linens, and several reported feeling cold, unclean, dirty, and neglected. The facility's washing machines had been broken for an extended period, resulting in laundry being sent to a local laundromat, which led to delays and loss of personal clothing. Staff interviews confirmed ongoing shortages of linens, towels, briefs, gloves, and wipes, making it difficult to maintain resident hygiene and comfort. Some staff reported using towels as makeshift briefs or sheets, and residents sometimes went without showers due to a lack of hot water or clean towels. Residents with significant medical needs, such as those with paralysis, chronic wounds, incontinence, and at risk for skin breakdown, were particularly affected. Several residents expressed emotional distress, with one resident crying and describing the situation as inhumane. Observations and interviews revealed that the lack of clean linens and hot water persisted for weeks, and residents often had to wait for clean items to be returned from the laundromat. Staff also reported that the process for returning personal clothing was unreliable, leading to further resident dissatisfaction and loss of dignity. The facility also failed to provide hot water in resident rooms and showers, resulting in residents receiving cold or no showers. Water temperature checks confirmed that several rooms and shower areas had only lukewarm water. Additionally, there were insufficient supplies for resident care, including briefs, gloves, and wipes, which further compromised the ability to provide adequate care. Staff interviews indicated that these shortages were ongoing and affected all shifts, with some staff bringing their own gloves to work. The cumulative effect of these failures led to widespread neglect, as defined by the facility's own policies and federal regulations.

Penalty

Inspection fine: $205,13964 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

A deficiency was identified when staff failed to follow the care plan for a male resident with a history of stroke, hemiplegia, and multiple chronic conditions, including functional quadriplegia and contractures. The resident's care plan required the application of a hand roll to his contracted left hand daily, as well as passive range of motion (ROM) exercises. During observation, the resident was found in bed with his left hand severely contracted and without a hand roll in place. The resident reported that he previously had a hand roll, but it had been lost and not replaced. Interviews with staff revealed uncertainty about who was responsible for ensuring the hand roll was in place and why it was missing. Record review showed that the care plan did not address the resident's left hand contracture or nail care, focusing instead on bilateral feet contractures and general ADL deficits. The care plan included interventions for ROM and the use of a hand roll, but these were not implemented as required. Staff interviews indicated a lack of clarity regarding care plan responsibilities and the importance of the hand roll in preventing further contracture and maintaining skin integrity. Facility policy required comprehensive, person-centered care plans with measurable objectives, but this was not followed in the resident's case.

Penalty

Inspection fine: $205,13964 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

A deficiency occurred when a male resident with multiple complex medical conditions, including hemiplegia, functional quadriplegia, and dependence on staff for most activities of daily living, sustained an injury to his left hand middle finger. The injury happened when two CNAs quickly removed his long sleeve shirt due to an ant being on him, causing his finger to get caught, resulting in pain and significant bleeding. The resident reported that the nurse clipped the damaged fingernail and that a wound care nurse applied a dressing, but he was unsure of the exact date or the staff involved. Upon observation, the resident's left hand middle finger was found wrapped in an undated dressing secured with scotch tape, with a visible red spot indicating bleeding. The resident described ongoing soreness in the finger. The Director of Nursing (DON) was unaware of the injury and, upon removing the dressing, observed a large cut below the nail bed with no active bleeding but noted the resident's pain and the presence of thick, dried, bumpy skin on the fingertip. The DON acknowledged that the injury had not been reported or documented as required. Record review revealed no physician orders for treatment of the finger, no change in condition forms, no accident or incident reports, and no skin assessments addressing the injury. The resident's care plan did not address hand contractures, nail care, or the specific injury. Facility policy required prompt investigation and reporting of all accidents or incidents, but this process was not followed in this case, resulting in a lack of appropriate follow-up care and documentation for the resident's injury.

Penalty

Inspection fine: $205,13964 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 accurately assess and document a resident's upper extremity impairment in both the Minimum Data Set (MDS) and the care plan. The resident, a male with a history of stroke, hemiplegia, hemiparesis, and functional quadriplegia, was observed to have a contracted left hand and reported that his left hand did not function due to a previous stroke. Despite these significant impairments, the quarterly MDS did not reflect any upper extremity functional limitation or contractures, and the care plan only addressed contractures in the feet, omitting the hand contracture and related care needs. During interviews, the MDS nurse acknowledged missing the upper extremity impairment in the MDS, although she believed it was included in the care plan, which was not the case. The Chief Nursing Officer (CNO) confirmed that the MDS is a multidisciplinary assessment tool intended to drive the plan of care and that missing information could result in missed care opportunities. The CNO also noted that therapists should educate nursing staff on interventions such as splint use, but this was not documented or implemented for the resident. Facility policy requires comprehensive, person-centered assessments and care plans that address all physical, psychosocial, and functional needs, using information from multiple sources. In this case, the assessment and care planning process did not capture or address the resident's upper extremity impairment, resulting in incomplete documentation and potentially inadequate care planning for the resident's needs.

Penalty

Inspection fine: $205,13964 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

A deficiency occurred when the facility failed to provide necessary nail care and personal hygiene services to a resident who was unable to perform activities of daily living independently. The resident, a male with a history of acute respiratory failure, hemiplegia, hemiparesis, stroke, functional quadriplegia, and other significant medical conditions, was cognitively intact but required substantial assistance with personal hygiene and was totally dependent for lower body dressing. Observations revealed that the resident had long, dirty fingernails on both hands, with one hand contracted and a finger wrapped in an undated dressing. The resident reported that his finger was injured when it got caught on his shirt as two CNAs quickly removed his clothing, resulting in pain, bleeding, and the need for the nurse to clip the damaged nail. Interviews with staff indicated a lack of awareness and responsibility regarding the resident's nail care and the injury. The CNA interviewed was unaware of the injury and acknowledged the resident's nails needed cleaning and trimming, noting the risk of infection. An LVN stated she was unsure who was responsible for nail care and was unaware of the injury, while the DON indicated that nursing staff were responsible for nail care and that periodic rounds should be conducted to monitor residents' needs. However, there was no clear documentation or evidence that nail care was being provided or monitored for this resident. Record reviews showed no physician orders for nail care, no documentation of nail care or refusals in the resident's progress notes or ADL reports, and the care plan did not address the resident's hand contractures, nail care, or the skin injury to the finger. Facility policies required prompt documentation and notification of changes in condition, as well as regular skin assessments and investigation of incidents, but these were not followed in this case, as there was no documentation of the injury or related care in the resident's records.

Penalty

Inspection fine: $205,13964 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 a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed that multiple resident bathrooms had loose toilets and sinks that were dislodging from the wall in several rooms. Additionally, the window screen in one resident room was found to be cut open with jagged edges, and the windowpanes were held in place with duct tape, some of which was aged and dirty. There was also evidence of leaves and dirt accumulating between the screen and the window. The outside trash dumpster area was observed to have trash bags, boxes, and other debris on the ground, with the trash bin too full to close properly. Staff and residents reported that the trash had not been picked up for an extended period, resulting in an unpleasant odor and sightings of rodents around the area. The trash was located near a frequently used entrance, and the smell was reported to be noticeable inside the facility as well. Maintenance issues were also identified regarding the facility's hot water supply. Multiple resident rooms and common areas were found to have water temperatures below the required range, following a circulation pump failure that was not immediately resolved. Maintenance staff acknowledged the importance of maintaining appropriate water temperatures for resident hygiene and health, and facility policy required regular checks and documentation of water temperatures, which were not consistently met during the period in question.

Penalty

Inspection fine: $205,13964 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 complete and accurate medical records for a resident who sustained an injury to his left middle finger. The resident, who had multiple diagnoses including acute respiratory failure, hemiplegia, functional quadriplegia, and was cognitively intact, was observed with a contracted left hand and a dressing on his middle finger. The dressing was undated, and the resident reported that the injury occurred when his finger got caught on his shirt as two CNAs quickly removed his long sleeve shirt due to an ant being present. The resident stated the incident was painful, resulted in bleeding, and required the nurse to clip the damaged fingernail and apply a dressing. He also reported receiving pain medication after the incident, but could not recall the exact date or the names of the staff involved. Upon review of the resident's medical chart, there was no documentation of the injury, no change in condition form, no accident or incident report, and no skin assessment addressing the injured finger. The care plan did not address the skin injury, hand contractures, or nail care, and only referenced bilateral feet contractures and ADL self-care deficits. Interviews with nursing staff, including an LVN, the DON, and the CNO, revealed that none were aware of the injury, and all confirmed that there was no documentation or incident report related to the event. The facility's policies required prompt documentation and reporting of accidents, incidents, and changes in condition, as well as updating care plans and notifying the physician and family, but these procedures were not followed in this case. The lack of documentation and failure to follow established policies resulted in incomplete and inaccurate medical records for the resident. This omission was identified through observation, interview, and record review, and was found to be inconsistent with accepted professional standards and practices for maintaining resident medical records.

Penalty

Inspection fine: $15,891

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

Summary

The facility failed to ensure a safe environment for a resident, resulting in a burn injury. The resident, who had a history of dementia, schizoaffective disorder, muscle wasting atrophy, and spastic hemiplegia, was served coffee at an unsafe temperature. The resident, who required supervision while eating, received a hot cup of coffee without a lid, leading to a spill and subsequent burn on her left hand. The incident was reported by the resident to the nursing staff, who observed reddened skin and provided immediate care. The facility did not maintain a temperature log for coffee prior to distribution, which contributed to the incident. The dietary staff member involved, who was not fully trained on the specifics of serving coffee, provided the resident with a fresh batch of coffee without verifying the temperature. The staff member claimed to have placed a lid on the cup, but the resident reportedly removed it, leading to the spill. The lack of proper training and documentation of coffee temperatures were significant factors in the occurrence of the burn. Interviews with staff revealed that the dietary manager had not conducted in-service training related to coffee temperature management prior to the incident. The dietary manager and staff were unaware of the risks associated with serving hot beverages at high temperatures. The facility's policy on hot liquids emphasized the need for safety evaluations and interventions for residents with conditions that increase the risk of burns, but these measures were not effectively implemented, resulting in the resident's injury.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision for two residents, leading to deficiencies in care. Resident #4, a female with severe cognitive impairment and a history of falls, did not have a fall mat in place at her bedside as required by her care plan. Observations on multiple occasions confirmed the absence of the fall mat, and staff interviews revealed confusion and lack of communication regarding the necessity of the mat. The DON acknowledged the oversight and indicated that the fall mat was an intervention to prevent injury, although it would not prevent falls. Resident #10, a male with severe cognitive impairment and multiple health issues, was left unattended in his wheelchair for an extended period, resulting in a fall. Despite being at risk for falls due to his condition, staff failed to provide the necessary supervision. Video footage showed that he was left alone in his room for over three hours, during which he fell and sustained a head injury. Interviews with staff revealed a lack of awareness and communication about the resident's fall risk and the need for supervision while in the wheelchair. The facility's policies on fall risk management and wheelchair safety were not adequately followed, contributing to the incidents. Staff interviews highlighted inconsistencies in understanding and implementing care plans and safety measures. The facility's failure to adhere to its policies and ensure proper supervision and safety interventions placed residents at risk of injury.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate foot care for Resident #1, who was a [AGE] year-old male with a history of Type 2 diabetes mellitus, anemia, muscle wasting, and sepsis. Despite a podiatrist consult being noted in the resident's progress notes on 6/10/2024, Resident #1 did not receive podiatry services to have his toenails trimmed. Observations revealed that his toenails were extended and curled past the toenail bed, approximately 1/2 inch long, with dry and flaky skin on his feet. Resident #1 expressed discomfort and a desire to have his toenails cut, which had not been done since his admission to the facility. Interviews with facility staff, including an LVN, SW, MDS RN, DON, NP, and the Administrator, highlighted a lack of communication and follow-through in ensuring Resident #1 received necessary podiatry services. The SW was responsible for adding residents to the podiatry service list, but Resident #1 was not included despite the documented need. The DON and NP acknowledged the risk of infection and skin issues due to the resident's elongated toenails, especially given his diabetic condition. The facility's policy indicated that podiatry services should be facilitated through the Social Service Department, but this was not effectively executed. The facility's failure to provide timely podiatry care for Resident #1 was a result of inadequate coordination and communication among staff members. The resident's toenails were not monitored or addressed during routine skin assessments and shower reviews, leading to a neglect of his foot care needs. This oversight placed Resident #1 at risk for complications, particularly due to his diabetes and the potential for ingrown toenails to cause infection.