Mountain View Health Services

Penalty

Fine: $43,2405 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 resident with multiple complex medical diagnoses, including hypertensive heart and chronic kidney disease, end-stage renal disease, major depressive disorder, and anxiety disorder, was admitted to the facility for respite care under hospice services. The resident exhibited agitation and aggressive behaviors, such as tipping over furniture, banging objects, and attempting to access the medication cart. Staff documented these behaviors and contacted the physician, hospice nurse, and DON for guidance. Orders for PRN medications were obtained, but according to the Medication Administration Record, these were not administered. As the situation escalated, the DON instructed staff to call 911, and the resident was transferred to the hospital for evaluation and treatment. After being treated and cleared at the hospital, the resident was returned to the facility by EMS. Upon arrival, facility staff, under the direction of the DON, refused to allow the resident back into the building, citing concerns for staff safety. Police and fire department personnel were also present and attempted to facilitate the resident's return, but staff continued to deny entry, locked the doors, and refused communication. EMS reported that the resident was left outside for an extended period, during which she was unable to access restroom facilities and soiled herself. Multiple attempts by EMS, police, and hospital staff to resolve the situation were unsuccessful, and the resident was ultimately transported back to the hospital. Interviews with the DON, LPN, and Administrator revealed a lack of coordination and communication regarding the resident's status, medication management, and the facility's responsibilities for a respite hospice patient. Staff expressed fear and uncertainty about accepting the resident back, and there was confusion about whether the resident was still under the facility's care. The DON acknowledged that no assessment was performed upon the resident's return, and the Medical Director was not involved in determining a safe discharge. The incident resulted in a prolonged delay and failure to ensure a safe and appropriate transfer or readmission for the resident.

Penalty

Fine: $155,370

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 for two residents, leading to deficiencies in care. Resident 46 experienced ongoing emesis and abdominal pain, but the facility did not ensure timely monitoring or intervention. Despite receiving a stat order for an ultrasound, the facility delayed contacting the contracted radiology provider, resulting in a significant delay in obtaining the ultrasound. The resident continued to experience symptoms without adequate assessment or communication with the physician, ultimately leading to the resident's death. Resident 46 had a complex medical history, including hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder. Despite these conditions, the facility staff failed to document and communicate the resident's change in condition effectively. Multiple staff members observed the resident's deteriorating condition, including vomiting and abdominal pain, but there was a lack of coordinated response and communication with the medical team. Similarly, Resident 298, who had a history of dementia, hypertension, and acute kidney failure, did not receive timely diagnostic testing for a suspected deep vein thrombosis. The facility canceled a scheduled appointment and failed to ensure the ultrasound was performed promptly. This lack of timely intervention and communication with healthcare providers contributed to the deficiency in care for both residents.

Removal Plan

• The community management team implemented a morning Standup meeting with Nursing to get report from previous day's activities/concerns. If changes in condition are noted from communication notes, DON or ADON will verify MD team had been notified and if notification has not been made will do so at that time. Consultants will attend morning meetings when in-person and participate in random morning meetings when offsite to ensure compliance.
• The nursing team implemented a new shift communication form that will be relayed at shift change with oncoming nurse for concerns/follow-up items still pending at shift change. All forms will be left in the drawer at nurse's station for management review at the next morning standup meeting. Consultants will provide training on this process.
• A new CNA communication program/sheets implemented as a way for CNAs to communicate with oncoming shift and report to nurse. Sheets will be collected daily and reviewed during the daily standup meeting with department managers. Consultants will provide education and training on this process.
• Nursing implemented a new Communication and Follow-Up book that will remain at the nursing station. The book is a duplicate copy book with highlights and follow-up items from the previous day. The original will be removed and reviewed at daily manager Standup meeting. Consultants will provide education and training on this process.
• Communication improvements made between the building and MD team by adding the DON and Administrator to the secure messaging app between the MD group and Facility. Areas of concern or issues that arise will be addressed in the manager stand-up meeting.
• Representatives from the consulting organization reviewed and assessed the facility's policies and procedures regarding changes in resident condition. The consultants provided the community with a change of condition policy to adopt. The consultants provided education and training with licensed nursing and nursing assistants.
• Facility in coordination with the consulting organization, the consultants will complete record reviews of all residents to ensure no resident has experienced a change in condition not previously identified. Any findings of change of condition will be reported to the resident's attending physician and the resident's representative. This information will be communicated with the DON and Administrator at the manager stand-up meeting.
• The consultants ongoing will review daily progress notes to ensure documented changes of condition are timely identified and action steps are taken with resident changes of condition.

Penalty

Fine: $155,370

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 timely radiology and diagnostic services for two residents, leading to a finding of Immediate Jeopardy. Resident 46, who had a history of serious medical conditions including hemiplegia, chronic obstructive pyelonephritis, and severe sepsis, was not provided with a stat ultrasound as ordered by the physician. Despite the order being documented at 9:30 PM, the facility did not attempt to have the ultrasound performed until the following morning, and the contracted radiology provider informed them that ultrasounds were not performed on weekends. The facility failed to notify the physician of this delay, and the resident continued to experience symptoms such as vomiting and abdominal pain without appropriate intervention. Resident 46's condition deteriorated over several days, with multiple staff members observing symptoms such as dark brown emesis and abdominal pain. Despite these observations, there was a lack of communication and documentation regarding the resident's condition and the delay in obtaining the ultrasound. The resident was eventually scheduled for an ultrasound at a local hospital, but unfortunately, passed away before the procedure could be completed. Interviews with staff revealed issues with communication between shifts and with the contracted radiology provider, contributing to the delay in care. Resident 298 also experienced a delay in receiving a necessary diagnostic test. The resident, who had a history of dementia and other medical conditions, was ordered to have a right lower extremity ultrasound to rule out a deep vein thrombosis (DVT). However, the ultrasound was not performed until several days later, despite the seriousness of the condition. The facility did not communicate effectively with the contracted radiology provider or the resident's physician, resulting in a delay in diagnosis and treatment.

Penalty

Fine: $155,370

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 policies were established and implemented to correct identified quality deficiencies, resulting in multiple areas of immediate jeopardy and harm. Specifically, two residents did not receive treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. One resident experienced ongoing emesis and abdominal pain without proper monitoring for changes in condition, while another resident with a deep vein thrombosis did not receive appropriate care. These failures resulted in immediate jeopardy for one of the residents. Additionally, the facility did not provide adequate supervision and assistance devices to prevent accidents, leading to a resident suffering an acute complete femoral neck fracture with partial displacement. The facility also failed to provide timely radiology and diagnostic services, as two residents did not receive ultrasounds as ordered by their physician, resulting in immediate jeopardy for one resident. Furthermore, pain management was not provided to a resident with an acute femoral neck fracture before being discharged to the hospital. These deficiencies were identified during the current recertification survey, along with several areas of non-compliance that were also cited in the previous survey.

Penalty

Fine: $155,370

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

Summary

The facility failed to provide adequate supervision and interventions to prevent falls for a resident, identified as Resident 298, who suffered multiple falls resulting in a serious injury. Resident 298 was admitted with diagnoses including dementia and hypertension, and was assessed as a high risk for falls. Despite this, a Fall Management Care Plan was not implemented initially. The resident experienced several falls, including a witnessed fall on 4/11/24, an unwitnessed fall on 5/18/24, and another fall on 5/19/24, without new interventions being put in place to prevent further incidents. Following the falls, the facility's response was inadequate. The care plan interventions were vague and not effectively communicated to staff, as evidenced by the lack of a clear 'at-risk plan' and the absence of new preventive measures after each fall. The resident continued to fall, including an assisted fall on 5/20/24, which was not followed by any new interventions. The resident eventually suffered an acute complete femoral neck fracture, which was not immediately identified or treated, leading to a delay in appropriate medical care. Interviews with staff, including the DON and CNAs, revealed confusion and inconsistency in the implementation of fall prevention strategies. The DON admitted that the 'at-risk plan' was not a valid intervention and that the facility's approach to fall prevention was insufficient. The lack of a systematic approach to monitoring and addressing the resident's fall risk contributed to the resident's injury and highlighted deficiencies in the facility's fall prevention protocols.

Penalty

Fine: $155,370

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 maintained acceptable nutritional status, resulting in significant weight loss. Resident 298, who had diagnoses including dementia and acute kidney failure, was admitted with a care plan addressing potential nutrition deficits. Despite having orders for a fortified diet and nutritional supplements, the resident experienced a 10.41% weight loss from June 2 to July 11, 2024. The care plan was not revised to address this weight loss, and the resident's medical record indicated that they did not receive the prescribed nutritional supplement shakes from June 1 to July 12, 2024. Interviews with facility staff revealed that the nutritional supplement shakes were supposed to be administered with medication passes and recorded in the Medication Administration Record (MAR). However, the facility did not document the amount of shake consumed by the resident. The Registered Dietitian confirmed the resident's fortified diet and the facility's process for monitoring weight loss, but the Director of Nursing acknowledged the failure to provide the shakes as ordered. This oversight contributed to the resident's malnutrition and significant weight loss.

Penalty

Fine: $155,370

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

Summary

The facility failed to provide adequate pain management for a resident with an acute complete femoral neck fracture prior to their discharge to the hospital. Resident 298, who had a history of dementia, hypertension, acute kidney failure, and anxiety disorder, experienced multiple falls within the facility. Despite having a care plan in place to manage pain, the resident did not receive any pain medication until after the fracture was identified. The resident's medical records indicated several falls, including an unwitnessed fall and an assisted fall, which were not properly documented or followed up with appropriate pain assessments. The resident was noted to have right hip pain and was unable to stand, yet no pain management was administered. The facility's staff, including the NP and DON, failed to recognize the severity of the resident's condition, resulting in a delay in pain management and treatment. Interviews with facility staff revealed a lack of communication and oversight in managing the resident's pain. RN 5 identified the absence of pain medication and brought it to the physician's attention, leading to a prescription for Tramadol. However, this intervention came too late, as the resident was already in significant pain and required hospital evaluation and treatment for the fracture.

Penalty

Fine: $155,370

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 designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis, as required. The DON was not working the mandated 40 hours per week. Instead, the DON worked 12-hour shifts on Mondays, Wednesdays, and Fridays, and was also assigned to resident care during these shifts. This scheduling did not meet the full-time requirement for the DON position. Interviews with the DON and the Administrator revealed discrepancies in the understanding of the DON's schedule, with the Administrator incorrectly stating that the DON worked on Tuesdays instead of Fridays. Additionally, the nurse's schedule for July 2024 showed that the DON was not consistently available, with several days marked as unavailable or only partially available. An RN expressed concerns about the DON's availability, noting that the DON was often scheduled to work the floor rather than fulfill administrative duties, which hindered communication and oversight.

Penalty

Fine: $155,370

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 observed during a survey. The low temperature dishwashing machine consistently failed to reach the required minimum temperature of 120 degrees Fahrenheit, with recorded temperatures not meeting this standard throughout July 2024. During an observation, the dish machine did not exceed 100 degrees Fahrenheit during its cycles. Additionally, improper food storage practices were noted in the walk-in refrigerator, where a whole ham was stored above pre-made peanut butter and jelly sandwiches, bagged fruit, and strawberry dessert cups. Onions were also found stored on the floor of the refrigerator, contrary to safe food storage guidelines. Further observations revealed that food items were not properly stored or chilled. Uncovered breakfast meal trays were left on the counter at the central nurse's station, and yogurt cups on a snack cart in the hallway were not kept on ice. Similarly, a Mighty Shake was left on a nurse's medication cart without ice to keep it cool. These practices indicate a lack of adherence to food safety protocols, potentially compromising the safety and quality of food served to residents.

Penalty

Fine: $155,370

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 the designated Infection Preventionist (IP), who was responsible for the infection prevention and control program, had completed specialized training in infection prevention and control. The Director of Nursing (DON), who was the designated IP, had not completed the necessary training and certification. During an interview, the DON stated that she had completed the training but had not yet taken the test required for certification. She mentioned that she had until November 2024 to take the test and believed she completed the training in May 2024. However, she was unable to provide documentation to confirm her completion of the specialized training. The DON acknowledged that she was informed during a previous survey in October 2022 about the need to obtain her IP certification. Despite this, she did not begin the training until January 2024, citing other responsibilities as the reason for the delay. The DON admitted to being busy with other tasks related to infection control, such as learning about enhanced barrier precautions and multidrug-resistant organisms, and was still working on implementing these strategies. She also noted that she did not have the necessary programs in place in the computer system to manage infection control effectively.

Penalty

Fine: $155,370

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

Summary

The facility failed to establish an effective infection prevention and control program (IPCP), as evidenced by multiple observations and interviews. A nurse was observed administering a medication to a resident after it had been dropped on a contaminated surface, indicating a lack of proper protocol for handling such incidents. The Director of Nursing (DON) confirmed that staff should discard any dropped medication and reorder it, highlighting a gap in staff training and adherence to infection control procedures. Additionally, the facility did not ensure proper hand hygiene and use of personal protective equipment (PPE) among staff. Certified Nursing Assistants (CNAs) and dietary aides were observed failing to change gloves or sanitize hands between tasks, such as serving meals and touching various surfaces. This lack of hand hygiene was consistent across multiple observations, suggesting a systemic issue in maintaining sanitary conditions during resident care activities. The facility also failed to properly store medical supplies, as respiratory equipment was kept in a bathroom used by staff, which the DON acknowledged was inappropriate. Furthermore, the facility lacked a system for tracking and trending infections, and the DON was unable to provide an infection control binder or policy for antibiotic stewardship. These deficiencies indicate a significant oversight in the facility's infection control practices, potentially compromising resident safety.

Penalty

Fine: $155,370

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 dignified existence for its residents, as evidenced by several observations and interviews. Three residents were served meals on disposable dishware, which was justified by a dietary aide as being more convenient for staff and residents eating in their rooms. This practice was not extended to residents dining in the communal dining room, who received meals on reusable dishware. Additionally, a resident was observed wearing socks with holes, indicating a lack of attention to personal clothing needs. Furthermore, a resident expressed dissatisfaction with the way a Business Office Manager communicated about her financial account, feeling lectured and ignored. The facility also demonstrated inadequate response times to call lights, with several instances of call lights remaining unanswered for extended periods. On multiple occasions, call lights were observed to be on for over an hour before being addressed by staff. In one instance, a CNA prioritized other tasks over responding to a call light, leaving a resident to wait. These observations highlight a failure to promptly address residents' needs, contributing to a lack of dignified care and communication within the facility.

Penalty

Fine: $155,370

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 its residents. Observations revealed multiple deficiencies, including brown carpet stains in several resident rooms, a television antenna hanging precariously from a curtain hook, damaged window blinds, and a brown substance on the floor that was transferred onto a resident's wheelchair tires. These issues were noted over several days, indicating a persistent problem with maintaining cleanliness and safety in the facility. Interviews with housekeeping staff and the facility's administration revealed that while rooms were reportedly cleaned daily, maintaining cleanliness was challenging. The administrator acknowledged a long-standing carpet discoloration due to a sprinkler incident but did not prioritize its removal, citing it as merely an aesthetic issue. The Director of Nursing identified the hanging antenna as a safety hazard, contradicting the administrator's assessment. These observations and interviews highlight a lack of effective communication and prioritization of resident safety and comfort within the facility.

Penalty

Fine: $155,370

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 proper documentation and communication during the transfer and discharge of three residents, leading to deficiencies in care transitions. Resident 25 was transferred to the hospital without any documentation indicating the basis for the transfer. The Director of Nursing (DON) acknowledged the lack of a progress note for the resident's change of condition and transfer, citing time constraints as the reason for the oversight. Resident 298 experienced a similar issue, where the facility did not provide the hospital with necessary information, including the practitioner's name, resident representative information, advanced directives, and comprehensive care plan goals. The lack of access to a printer at the nurses' station further complicated the situation, as staff had to manually reconcile medication lists, causing delays in the resident's hospital care. Interviews with staff revealed that the DON had been advocating for better support and resources, but these requests were not addressed by management. Resident 47 was discharged from the facility without a discharge summary or documented basis for the discharge. The DON mentioned that the process for completing discharge summaries had been inconsistent since January 2024, and there was an option to complete the summary in the electronic health record, which was not utilized. The facility's failure to maintain proper documentation and communication during resident transfers and discharges highlights significant gaps in their processes, impacting the quality of care provided to residents.

Penalty

Fine: $155,370

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident 32, with multiple diagnoses including COPD and respiratory failure, had several care needs identified in the Minimum Data Set (MDS) assessment, such as visual function, ADL abilities, and oxygen therapy. However, the care plan was incomplete, lacking specific plans for these needs. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the care plan was started but not completed, and should have included oxygen therapy. Resident 35, with a history of cerebral infarction and hemiplegia, was observed with a severely impaired left foot and was not receiving physical or occupational therapy. The care plan did not include person-centered or measurable interventions for his left-sided weakness and Ankle Foot Orthosis (AFO) use. Interviews with the DON and ADON indicated that there was no Restorative Nursing Assistant program, and the resident was not on physical therapy treatments. The Occupational Therapist (OT) confirmed issues with the AFO fit, but the care plan lacked specific interventions to address these concerns. Other residents, including Residents 17, 26, 7, and 24, also had deficiencies in their care plans related to oxygen therapy. The care plans lacked guidance on changing or cleaning nasal cannula tubing or oxygen concentrator humidifiers. Interviews with the DON highlighted that care plans should be revised with changes in condition or new diagnoses, but the nursing staff was not consistently implementing or updating care plans. The DON expressed challenges in managing care plans alongside other responsibilities, indicating systemic issues in care plan management within the facility.

Penalty

Fine: $155,370

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 the interdisciplinary team reviewed and revised the comprehensive care plans for six out of thirty sampled residents after each assessment, including both comprehensive and quarterly review assessments. This deficiency was observed in the cases of residents with significant changes in their conditions or in response to implemented interventions. For instance, Resident 32, who was admitted with multiple diagnoses including COPD and was on hospice care, reported pain in his legs, feet, and arm, yet his care plan was not updated to address his pain management or hospice care needs. Resident 35, who had a history of cerebral infarction and other complex medical conditions, was observed with a severely impaired left foot and was not receiving physical or occupational therapy. Despite having an orthotic device that was not fitting properly, the care plan had not been revised since its initiation in 2021, failing to address the resident's current mobility and therapy needs. Similarly, Resident 17 and Resident 26 had care plans related to oxygen therapy that had not been updated for over a year, despite their ongoing respiratory issues. Additionally, Resident 3, who had a history of stroke and significant mobility issues, was found to have a contracture in her left hand, yet her care plan did not reflect her current needs for assistance with activities of daily living. Resident 298 experienced a significant weight loss over a short period, but no revisions were made to his care plan to address this issue. Interviews with facility staff, including the DON and ADON, revealed that care plans were not being updated in a timely manner due to time constraints and workload, contributing to the deficiency in care plan management.

Penalty

Fine: $155,370

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 respiratory care for several residents, as evidenced by the lack of orders and documentation for changing oxygen concentrator tubing and humidifiers. For Resident 17, who had multiple complex diagnoses including severe sepsis and acute respiratory failure, there were no orders or records indicating that the oxygen concentrator tubing or humidifier had been changed. The resident's care plan lacked guidance on the maintenance of these respiratory aids, despite the resident's reliance on oxygen therapy. Similarly, Resident 26, diagnosed with schizoaffective disorder and asthma, had no documented orders for changing the oxygen concentrator tubing or humidifier. Observations revealed that the resident was not wearing the nasal cannula while the concentrator was running, and there was no documentation of tubing changes in the medical records. The care plan for Resident 26 also failed to provide instructions for the maintenance of oxygen equipment. Resident 32, who required continuous oxygen therapy due to acute and chronic respiratory failure, was observed using a standard nasal cannula instead of the prescribed mustache cannula. This discrepancy was not addressed in the resident's care plan, and staff interviews revealed a lack of understanding regarding the appropriate equipment. Additionally, Residents 7 and 24 were found to have undated oxygen tubing, with no orders or documentation for changes, indicating a systemic issue in the facility's management of respiratory care equipment.

Penalty

Fine: $155,370

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 five residents were seen by a physician at the required intervals. Specifically, residents were not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Resident 7 had not been seen by a physician for approximately 5.5 months, while Resident 24 also had not been seen for the same duration. Resident 28 had not been seen for approximately 11 months, and Resident 29 had not been seen by a physician since admission. Resident 44 had only one documented physician visit. The Director of Nursing (DON) acknowledged that the facility's medical providers discussed with the nursing staff which residents needed to be seen or were due for recertification visits. However, the facility failed to ensure compliance with the required physician visit schedule, as evidenced by the significant gaps in physician visits for the identified residents. The DON confirmed that the facility MD was required to see residents every 60 days, but this requirement was not met for the residents in question.

Penalty

Fine: $155,370

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

Summary

The facility failed to provide adequate pharmaceutical services by not accurately acquiring, receiving, dispensing, and administering medications for four residents. Specifically, licensed nursing staff did not sign out controlled substances and reconcile them at the time of administration. This deficiency was identified during a review of the Medication Administration Records (MAR) and Controlled Drug Records for the residents involved. Resident 38, who was diagnosed with dementia with agitation, essential hypertension, and neurocognitive disorder with Lewy bodies, did not receive their ARISE medications as scheduled. The medications included amlodipine, citalopram, lisinopril, olanzapine, spironolactone, Senna, hydrocodone-acetaminophen, and lorazepam. Although the medications were eventually administered, they were not documented in the Controlled Drug Record at the time of administration. RN 1 admitted to not documenting the administration of medications promptly, citing being overwhelmed as a reason. Similar issues were found with Residents 3, 1, and 4, where medications such as clonazepam, gabapentin, oxycodone, lorazepam, pregabalin, morphine sulfate, and modafinil were not signed out in the Controlled Drug Record despite being marked as administered in the MAR. The Director of Nursing acknowledged that medications should be signed out at the time of administration, but noted that sometimes they might be signed out within the hour.

Penalty

Fine: $155,370

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

Summary

The facility failed to ensure that residents were free from significant medication errors, affecting four out of thirty sampled residents. One resident, identified as Resident 32, experienced multiple missed doses of a respiratory medication, Fluticasone-Salmeterol, due to a hospice service error in providing the correct dosage. The resident, who was on hospice care for conditions including COPD and respiratory failure, reported not receiving the medication since a previous Friday, which was confirmed by the MAR showing missed doses. The RN in charge acknowledged the error, attributing it to the hospice sending the wrong dose and the medication supply lasting only 15 days. Another resident, identified as Resident 38, was not administered their ARISE medications on time, which included essential medications for hypertension, depression, and anxiety. The resident was observed to be agitated and not eating well, which was linked to the delayed administration of medications. The RN responsible admitted to not documenting the administration of medications until later in the day, citing being overwhelmed and cutting corners as reasons for the delay. This resulted in the resident receiving a double dose of hydrocodone-acetaminophen and lorazepam, which were not signed out in the Controlled Drug Record. Additionally, Resident 4 received pregabalin, a time-sensitive medication, at incorrect times, deviating from the physician's order. The facility's flex time policy for medication administration conflicted with the specific timing required for pregabalin, leading to inconsistent administration times. Lastly, Resident 298 received a double dose of warfarin due to overlapping physician orders and a lack of clear communication among staff. The DON acknowledged the error and emphasized the importance of timely communication and judgment in handling medication errors, but the incident highlighted a significant lapse in medication management and administration protocols.

Penalty

Fine: $155,370

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 timely laboratory services for three residents, resulting in delayed urinalysis (UA) testing. Resident 18, who had a history of schizophrenia and other conditions, exhibited symptoms of a urinary tract infection (UTI) on August 10, 2024. Despite a urine sample being ready for pickup, the laboratory did not collect it promptly, and the results were not available in a timely manner. The Director of Nursing (DON) and Licensed Nurse (LN) 3 were unable to locate the urine dip results, indicating a lack of proper documentation and follow-up. Resident 44, diagnosed with Alzheimer's disease and other medical conditions, showed increased confusion and weakness, prompting a physician to order a UA and culture and sensitivity (C&S) test. Although the urine sample was collected on August 10, 2024, the laboratory did not pick it up as scheduled. The Assistant Director of Nursing (ADON) confirmed that the results had not been received, attributing the delay to the lab company's processing time. This delay in obtaining lab results hindered the timely diagnosis and treatment of potential infections. Resident 8, with a history of schizoaffective disorder and chronic kidney disease, also exhibited UTI symptoms. A urine sample was collected, but the facility faced challenges in sending it to the lab due to a lack of access to a printer for necessary documentation. The DON and LN 3 acknowledged the issue, and the DON expressed frustration over the inability to print orders on weekends. The facility's reliance on a lab company with limited pickup schedules further complicated the situation, resulting in delayed lab processing and communication issues between the facility and the lab company.

Penalty

Fine: $155,370

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 administer care in a manner that effectively and efficiently utilized its resources to ensure the highest practicable well-being of its residents. This was evidenced by multiple areas of immediate jeopardy and harm identified during the survey. Specifically, two residents did not receive treatment and care in accordance with professional standards and their comprehensive care plans. One resident experienced ongoing emesis and abdominal pain without adequate monitoring for changes in condition, while another resident with a deep vein thrombosis did not receive appropriate care, resulting in immediate jeopardy for one of the residents. Additionally, the facility did not provide adequate supervision and assistance devices to prevent accidents, leading to a resident suffering an acute complete femoral neck fracture with partial displacement. The facility also failed to provide timely radiology and diagnostic services, as ordered by a physician, resulting in immediate jeopardy for a resident. Furthermore, a resident with a femoral neck fracture was not provided pain management before being discharged to the hospital. These deficiencies were compounded by repeated non-compliance in several areas identified in both the current and previous surveys.

Penalty

Fine: $155,370

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 effectiveness of the medical director in implementing resident care policies and coordinating medical care, resulting in multiple areas of immediate jeopardy and harm. Specifically, two residents did not receive treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. One resident experienced ongoing emesis and abdominal pain without appropriate monitoring for changes in condition, while another resident with a deep vein thrombosis did not receive necessary care, leading to immediate jeopardy for one of the residents. Additionally, the facility did not provide adequate supervision and assistance devices to prevent accidents, resulting in a resident suffering an acute complete femoral neck fracture with partial displacement. The facility also failed to provide timely radiology and diagnostic services, as ultrasounds ordered by the physician were not conducted, leading to immediate jeopardy for a resident. Furthermore, pain management was not provided to a resident with a femoral neck fracture before being discharged to the hospital. These deficiencies were identified alongside numerous areas of non-compliance cited in a previous survey, which were again noted during the current recertification survey.

Penalty

Fine: $155,370

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, accurately documented, and readily accessible medical records for its residents, as evidenced by the misplacement of documents in the wrong resident files. Specifically, progress notes for two residents were found in another resident's medical record, an appointment referral note for one resident was located in another's chart, and an occupational therapy order for a different resident was found in yet another resident's file. This issue affected six out of thirty sampled residents, indicating a systemic problem with the facility's record-keeping practices. The Business Office Manager admitted that there was no dedicated person for managing medical records, and the task was left to the Receptionist or available Certified Nursing Assistants, leading to inconsistencies and errors in filing. Additionally, the facility failed to secure resident medical records properly, as observed in the Director of Nursing's office. Three large stacks of papers containing resident protected health information and personally identifiable information were found unsecured and unmonitored in the DON's office, with the door left open. This lack of security and oversight further compromised the confidentiality and integrity of resident records, highlighting significant deficiencies in the facility's management of sensitive information.

Penalty

Fine: $155,370

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 was found to be deficient in maintaining a written transfer agreement with one or more hospitals certified by Medicare or Medicaid. During a survey, the State Survey Agency (SSA) requested the hospital transfer agreement from the facility's Administrator. Initially, the Administrator was unable to locate the agreement. In a subsequent interview, the Administrator admitted that the existing agreement was outdated and that he had contacted two local hospitals to update it. However, the Administrator had only reached out to one of the hospitals via email. Despite these efforts, the facility failed to provide the SSA with an updated hospital transfer agreement.

Penalty

Fine: $155,370

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

Summary

The facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. During an interview, the Director of Nursing (DON) admitted to not tracking or trending infections within the facility and was unable to provide the infection control binder to the State surveyor. Additionally, the DON acknowledged the absence of a policy for antibiotic stewardship. The DON mentioned that staff should be hand sanitizing between resident contacts and washing hands after leaving a resident's room to prevent the spread of infections. However, the infection control binder was never presented to the State surveyor, indicating a lack of documentation and oversight in infection control practices.

Penalty

Fine: $155,370

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 was found to have inadequate outside ventilation, as evidenced by persistent and strong urine odors throughout various areas during the survey. Observations were made on multiple occasions across different halls, including the 100, 200, and 300 halls, as well as the solarium and main lobby. The odors were consistently noted near specific rooms and common areas, indicating a widespread issue. Interviews with housekeeping staff revealed that rooms were cleaned daily, and cleaning supplies were used to remove odors, yet the problem persisted. A Certified Nursing Assistant (CNA) mentioned resorting to using perfume to mask the overwhelming smell after changing a resident's soiled brief. The presence of a koi fish pond in the solarium was noted, which may contribute to the moisture and odor issues in that area. Despite regular cleaning efforts, the strong urine odors were observed repeatedly over several days, suggesting that the facility's ventilation system was insufficient to address the problem. The report does not mention any specific residents' medical conditions or history related to the deficiency, focusing instead on the environmental conditions and staff observations.

Penalty

Fine: $155,370

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

Summary

The facility failed to inform the resident representative for two residents when there was a significant change in their physical, mental, or psychosocial status, or when there was a need to alter treatment significantly. Resident 46 experienced a change in condition, including black tarry vomit, constant diarrhea, and acute hypoxic respiratory failure, which led to hospitalization. Despite these significant changes, the facility did not attempt to contact the resident's power of attorney or any family member, as the previous power of attorney was deceased, and no efforts were made to identify another representative. Resident 46's medical records revealed multiple instances where the facility staff failed to document communication with the resident's physician or family regarding ongoing health concerns, such as brown emesis and abdominal pain. The resident was found deceased with no prior notification to the family or power of attorney about the change in condition. The facility's documentation did not indicate awareness of the deceased power of attorney or attempts to identify another representative. Similarly, Resident 25 experienced a significant change in condition, including difficulty breathing and ashen appearance, leading to hospitalization. The Director of Nursing acknowledged the lack of documentation regarding the change of condition and transfer. There was no evidence in the medical record that the resident's physician or representative was notified of these changes, highlighting a failure in communication and documentation by the facility.

Penalty

Fine: $155,370

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 alleged violations involving abuse, neglect, and mistreatment in a timely manner, as required by regulations. For Resident 41, an incident of alleged physical abuse was not reported to the State Survey Agency (SSA) until three days after the event. The incident involved a confrontation during a shower where the resident became agitated and physically aggressive towards a Certified Nursing Assistant (CNA). Despite the incident being documented and the facility administration being notified on the same day, the report to the SSA was delayed due to issues with the online submission portal. In another case, Resident 29 experienced an unwitnessed fall and was later found to have a bruise, leading to allegations of neglect by the resident's nephew. The facility did not report this incident to the SSA until 14 days after the fall occurred. The resident had a history of multiple medical conditions, including dysarthria, gastro-esophageal reflux disease, and chronic kidney disease. The delay in reporting was attributed to the administrator's uncertainty about the necessity of reporting the incident as neglect. Both incidents highlight the facility's failure to adhere to the required timelines for reporting allegations of abuse and neglect. The facility's administration was aware of the incidents shortly after they occurred, but the reports to the SSA were not submitted within the mandated timeframes. This deficiency in timely reporting could potentially impact the safety and well-being of the residents involved.

Penalty

Fine: $155,370

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

Summary

The facility failed to thoroughly investigate alleged violations of neglect concerning a resident who experienced multiple falls, resulting in a significant injury. Resident 298, who had a history of dementia, hypertension, acute kidney failure, and anxiety disorder, was admitted to the facility without a fall management care plan, despite being identified as a high risk for falls. The resident experienced several falls, including an unwitnessed fall and an assisted fall, without appropriate interventions being implemented to prevent further incidents. On multiple occasions, the facility did not document new interventions following the resident's falls, and there was a lack of evidence that the falls were thoroughly investigated for neglect. The resident sustained a complete femoral neck fracture with partial displacement, which was not immediately identified or addressed. The facility's staff, including the Director of Nursing (DON) and Nurse Practitioner (NP), failed to recognize the severity of the resident's condition, resulting in delayed medical evaluation and treatment. Interviews with facility staff revealed inconsistencies in the implementation of fall prevention measures and a lack of clarity regarding the resident's care plan. The DON admitted to not understanding the purpose of an 'at-risk plan' and acknowledged that the facility's interventions were not adequately addressing the resident's fall risk. The Administrator did not consider investigating the falls as neglect, citing the NP's assessment and the resident's history of frequent falls as reasons for not pursuing further investigation.

Penalty

Fine: $155,370

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 a resident's range of motion impairment on the Minimum Data Set (MDS) assessment. Specifically, for one resident, the MDS assessment did not document any impairment in range of motion for both upper and lower extremities, despite the resident's condition indicating otherwise. The resident, who had a history of a stroke resulting in left-side weakness, was unable to walk or use her left hand or arm and required extensive assistance from facility staff to get out of bed. Observations confirmed a contracture in the resident's left hand, and interviews with facility staff corroborated the resident's limited mobility and need for assistance. The Assistant Director of Nursing (ADON) admitted to not following guidelines regarding range of motion assessments on the MDS. The ADON mistakenly believed that if staff assisted the resident with movement, it should be recorded as no impairment. This misunderstanding led to the inaccurate documentation of the resident's condition. The Director of Nursing (DON) confirmed the resident's physical limitations, including a contracture in the left hand, which should have been documented as an impairment in the MDS assessment.

Penalty

Fine: $155,370

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 discharge summaries were included in the medical records for two residents, leading to a deficiency. Resident 47, who had multiple diagnoses including anxiety disorder, major depressive disorder, and a history of malignant neoplasm of the prostate, was discharged on May 15, 2024. However, upon review of the medical record on July 31, 2024, no discharge summary or basis for the discharge was found. The Director of Nursing (DON) acknowledged that the process for completing discharge summaries had been sporadic since January 2024, despite the availability of a discharge summary form in the electronic health record. Similarly, Resident 248, with diagnoses including rheumatoid arthritis, chronic pulmonary edema, and opioid use, was discharged to another skilled nursing facility. The medical record review from July 28, 2024, to August 14, 2024, revealed no discharge summary or follow-up progress notes. An interview with the Administrator confirmed the discharge but lacked further details. This lack of documentation for both residents indicates a failure in the facility's discharge process, contributing to the deficiency noted by the surveyors.

Penalty

Fine: $155,370

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 maintain or improve the range of motion for two residents with limited mobility. Resident 35, who had a history of cerebral infarction and other significant health issues, was observed without the necessary ankle foot orthosis (AFO) and did not receive the recommended daily prolonged stretching exercises. Despite recommendations from an outside orthotic clinic for a custom AFO and daily stretching to prevent further deformity, these interventions were not implemented. The resident's medical records did not reflect these recommendations, and the facility staff, including the Director of Nursing (DON), were unaware of the orthotic clinic's summary until it was requested by the State Survey Agency. Resident 1, with multiple diagnoses including rheumatoid arthritis and muscle wasting, was observed with contractures in her hands and without any splints or rolled hand towels, which were part of her care plan. The care plan included passive range of motion exercises and the use of splints as tolerated, but these interventions were not being followed. Interviews with the resident and staff revealed that the resident did not receive exercises or have access to splints, and there was no documentation of any refusals by the resident to use these aids. The DON confirmed that there was no Restorative Nursing Assistant (RNA) program in place and that the facility relied on therapy referrals, which were not being actively pursued for this resident. The facility's lack of a structured program for maintaining or improving residents' range of motion, combined with the absence of follow-through on therapy recommendations and care plan interventions, contributed to the deficiencies observed. The DON and other staff members were not adequately informed or proactive in ensuring that necessary treatments were provided, leading to a failure in addressing the residents' needs for maintaining their physical mobility and preventing further decline.

Penalty

Fine: $155,370

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 an indwelling catheter was assessed for its removal as soon as possible, unless clinically necessary. Resident 298, who was admitted with an indwelling catheter due to urinary retention following a surgical procedure, continued to have the catheter without a documented diagnosis justifying its continued use. The resident's medical records indicated that the catheter was initially placed due to retention after a hospital stay, but subsequent notes did not provide a clear rationale for its continued use. The deficiency was further highlighted by the lack of a facility policy or procedure regarding the management of urinary catheters, as confirmed by interviews with the Licensed Nurse and the Director of Nursing. The Director of Nursing was unable to recall why the resident had a urinary catheter or if a urologist had been consulted. Additionally, the resident experienced complications such as hematuria and a urinary tract infection, which were documented in the health status notes, but there was no clear documentation of a diagnosis necessitating the catheter's continued use.

Penalty

Fine: $155,370

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

Summary

The facility failed to obtain laboratory services only when ordered by a qualified practitioner, resulting in deficiencies for two residents. Resident 8, who had multiple diagnoses including schizoaffective disorder and chronic kidney disease, had a urinalysis (UA) collected without a physician's order. The UA was collected due to the resident's complaints of burning upon urination, but there was no documented physician's order for this test. The Director of Nursing (DON) and Licensed Nurse (LN) 3 acknowledged the lack of an order and discussed issues related to the inability to print orders on weekends, which contributed to the oversight. Resident 18, diagnosed with schizophrenia and other conditions, had a Complete Blood Count (CBC) performed without a physician's order. The CBC results indicated a slightly decreased platelet level, and the nursing staff was advised to encourage nutrition and hydration. However, there was no documented order for the CBC, and the DON was unaware of the order or results mentioned in the progress note. This lack of documentation and order highlights a failure in the facility's process for managing laboratory tests. The interviews with the DON and LN 3 revealed systemic issues, such as the inability to access a printer on weekends, which hindered the proper documentation and processing of laboratory orders. The DON expressed the need for administrative support to ensure staff could print orders as needed. These deficiencies indicate a breakdown in communication and procedural adherence, leading to unauthorized laboratory tests being conducted without proper orders.

Penalty

Fine: $155,370

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 promptly notify the ordering physician of critical x-ray results for a resident, leading to a delay in necessary medical intervention. Resident 298, who had a history of dementia, hypertension, acute kidney failure, and anxiety disorder, experienced multiple falls over a weekend. On the following Monday, the resident complained of acute right hip pain, prompting a recommendation for immediate x-rays. Despite the urgency, the x-ray results, which indicated an acute complete femoral neck fracture with partial displacement, were not communicated to the physician until the following morning. The x-ray was ordered on the morning of May 21st, but the mobile x-ray company did not arrive until late that evening. The results, showing a significant fracture, were available by 6:23 PM but were not acted upon until the early hours of May 22nd. During this time, the resident was in distress and unable to sleep, indicating a need for urgent care that was not provided. The delay in notifying the physician and the subsequent delay in sending the resident to the emergency room for evaluation and treatment contributed to the deficiency. Interviews with the Director of Nursing (DON) revealed a lack of clarity and urgency in the process for handling STAT orders and communicating critical results. The DON admitted that the process was not as secure as desired and that the decision to send a resident to the hospital was often left to the discretion of the nurse on duty. This lack of a structured protocol for handling urgent medical situations contributed to the delay in care for Resident 298, highlighting a significant deficiency in the facility's response to acute medical needs.

Penalty

Fine: $155,370

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 file signed and dated reports of radiological and other diagnostic services in the resident's clinical record, specifically for one resident. This resident, who had diagnoses including dementia, hypertension, acute kidney failure, and anxiety disorder, was admitted and readmitted to the facility. An ultrasound was performed on the resident's right lower extremity, revealing a deep vein thrombosis, but the report was not filed in the medical record. The Director of Nursing (DON) acknowledged the absence of a policy for urgent ultrasounds and noted that the nursing staff lacked critical thinking skills, which contributed to the oversight. Additionally, the resident experienced right hip pain following a fall, prompting an order for a STAT x-ray. The x-ray revealed an acute femoral neck fracture, but the results were not filed in the resident's medical record, nor were they signed or dated. The DON explained the process for handling x-ray orders, which involved contacting a mobile x-ray company and notifying the MD once results were available. However, the process was not secure, and the x-ray results were not properly documented or communicated in a timely manner. The DON admitted that the facility's procedures for handling STAT orders and filing diagnostic reports were inadequate. The x-ray company was contacted, and the x-ray was performed several hours later, with results faxed to the facility. Despite this, the results were not entered into the resident's medical record, and the resident was not sent to the hospital until the following day. The DON recognized the need for improvement in the facility's processes to ensure timely and accurate documentation of diagnostic services.

Penalty

Fine: $155,370

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 properly dispose of garbage and refuse, as observed on 7/30/24. A large black plastic garbage bag containing empty aluminum soda cans was stored outdoors directly outside the kitchen entrance. The bag was torn open, and the cans were spilling onto the concrete ground. During an interview, the Dietary Manager (DM) acknowledged awareness of the situation, explaining that a resident was collecting the cans for recycling. The DM also mentioned that a recent windstorm had torn open the bags of soda cans.

Penalty

Fine: $155,370

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 arrange necessary specialist appointments for two residents, leading to a deficiency in providing required services. Resident 35, who has a complex medical history including cerebral infarction, diabetes, and Charcot's arthropathy, was not scheduled for an orthopedic specialist appointment despite a physician's order. The order was issued after the resident expressed concerns about foot pain and malformation, which required specialist intervention. The receptionist, responsible for scheduling, confirmed that no appointment was made as the order was not entered into the appointment book by the nursing staff. Similarly, Resident 25, with a history of sepsis, respiratory failure, and COPD, did not have a pulmonary function test appointment scheduled, as ordered by the physician. The receptionist stated that the order was not in the appointment book, and thus, the appointment was not made. The DON acknowledged the oversight and noted the resident's ongoing health issues, emphasizing the importance of the test. The failure to schedule these appointments highlights a breakdown in the facility's process for managing specialist referrals.

Penalty

Fine: $155,370

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 medication error rate below five percent, as evidenced by observations on 7/29/2024, where two medication errors were identified out of 35 opportunities, resulting in a 5.71% error rate. Specifically, a resident with multiple diagnoses, including Huntington's disease and bipolar II disorder, was administered Carafate after consuming a meal, contrary to the physician's order to administer it before meals. Additionally, the resident received pregabalin two hours after the prescribed time of 6:00 AM, which was noted as a time-sensitive medication. Interviews with RN 1 and the Director of Nursing (DON) revealed discrepancies in the administration times due to the facility's flex time policy for medication passes. RN 1 acknowledged the error in administering Carafate and pregabalin outside the specified times, while the DON confirmed that the pregabalin should have been administered between 6:00 AM and 7:00 AM. The facility's memorandum on medication pass times allowed for flexibility, but the specific physician's orders for the resident were not adhered to, leading to the identified medication errors.

Penalty

Fine: $155,370

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

Summary

The facility failed to ensure that all drugs and biologicals were stored and labeled according to accepted professional principles. Specifically, for one resident, a narcotic medication was improperly handled. The resident, who had a physician's order for Oxycodone 5 mg to be taken as needed for low back pain, was receiving Oxycodone 10 mg tablets. The tablets were being cut in half, and the unused half was placed back into the bubble pack and sealed with tape, which is against proper medication storage protocols. The deficiency was observed during a narcotic count reconciliation conducted by a Licensed Nurse (LN) and the Director of Nursing (DON). The LN admitted to placing the half tablet back into the bubble pack, stating it was what she had been taught. The DON acknowledged that this practice was incorrect and that the unused half should have been wasted with a witness. The DON also noted that the resident did not take the medication regularly, and the pharmacy had sent the incorrect dosage, leading to the practice of cutting the tablets in half.

Penalty

Fine: $155,370

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 each resident's medical record included documentation of education regarding the benefits and potential side effects of the pneumococcal immunization, as well as documentation of the administration or refusal of the immunization. Specifically, for two residents, there was no evidence that they were provided with the necessary education about the pneumococcal vaccine. Additionally, their medical records lacked documentation of their pneumococcal immunization status, whether it was administered or refused. Resident 7, who was admitted with multiple diagnoses including dementia and schizoaffective disorder, had no documentation in their medical record regarding their pneumococcal immunization status. Similarly, Resident 24, admitted with conditions such as chronic viral hepatitis C and type 2 diabetes, also had no documentation of their pneumococcal immunization status. The Director of Nursing (DON) acknowledged the missing information and stated that the facility offered the pneumococcal immunization upon admission, but the records were incomplete. The DON also mentioned that the immunization consents for these residents were completed on the day of the interview.