Lynn Care Center

Penalty

Inspection fine: $38,110

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 protect multiple residents from physical abuse by other residents, primarily on the memory care unit, over an extended period. Resident-on-resident altercations repeatedly occurred in which one resident struck, hit, pulled hair, or otherwise physically contacted another resident, often involving the same aggressor. For example, one resident repeatedly struck other residents in the face, head, shoulder, arm, and mouth, and pulled another resident’s hair while they were seated in the dining room. In many of these events, staff documented that the aggressor resident became agitated or combative, particularly when other residents were in her personal space, when she perceived staff as needing protection, or immediately after receiving care. The clinical records and final event synopses show that affected residents were typically seated in common areas such as the dining room or wandering on the memory care unit when they were struck or otherwise physically abused. In several cases, staff or other residents witnessed the incidents and separated the residents, and progress notes documented assessments showing either no visible injury or minor findings such as a small red spot on the nose, bruising to the upper lip, or a fall to the floor after being hit on the shoulder. Many of the residents involved had cognitive impairment and were unable to recall the incidents when interviewed afterward, though one resident later described being “whacked” across the face. Staff interviews acknowledged that residents on the memory care unit wander, can become easily agitated, and are especially vulnerable due to cognitive status and limited ability to communicate symptoms. Across all cited residents, the comprehensive care plans in place at the time of the incidents did not contain information related to these episodes of resident-to-resident abuse. Care plans for residents who were struck, hit, or had their hair pulled lacked any documentation of the abuse incidents or individualized approaches addressing these behaviors or the residents’ vulnerability to further altercations. This absence of care plan interventions was noted for multiple residents who experienced one or more abusive encounters, including those who were struck on more than one occasion by the same aggressor. Facility staff, including nursing and social services personnel, stated in interviews that any willful striking, hitting, smacking, or hair-pulling by one resident toward another constitutes physical abuse and that residents have the right to be free from abuse, consistent with the facility’s written abuse policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. In addition to the repeated incidents involving a primary aggressor on the memory care unit, other residents were abused by different residents who became combative when their personal space was invaded. In these cases, staff witnessed residents being hit on the arm or chest and a resident being struck on the shoulder, causing a loss of balance and a fall. Progress notes documented that affected residents were assessed and often had no recall of the negative encounters. Despite these documented events and staff recognition that such conduct constitutes abuse, the corresponding care plans for the abused residents did not reflect the incidents or any related information. The pattern of resident-to-resident physical abuse, combined with the lack of care plan documentation addressing these events, formed the basis of the cited deficiency and led to a determination of immediate jeopardy for residents on the memory care unit.

Removal Plan

• Place Resident #99 on 1 on 1 supervision until the resident is discharged or a significant change in condition limits the resident's physical ability to come in contact with another resident.
• Provide follow up psychosocial support from social services to Residents #58, #94, #25, #13, #41, and #68.
• Screen all residents for evidence of abuse and neglect.
• Complete an abuse questionnaire for residents who are interviewable (BIMS score of 8 or greater).
• Complete a head to toe physical assessment for non-verbal residents or residents with a BIMS score of 7 or below.
• Address any identified concerns according to the HVHC Abuse and Neglect Policy.
• Conduct an audit of all incident reports for the last 30 days to ensure that all events meeting the reporting requirements were reported to the appropriate parties.
• Reeducate all staff of the facility/agency on the HVHC Abuse and Neglect Policy, including abuse prevention, types of abuse, abuse reporting, and the Elder Justice Act specifically pertaining to resident to resident altercations.
• Require any staff not present for the education to receive mandatory education prior to the start of their next shift.
• Prohibit staff from returning to work until the mandatory education has been completed.
• Include this training in new hire orientation as part of the new hire process.
• Require all agency staff to complete this education prior to starting work in the facility.
• Provide reeducation to facility leadership (NHA, DON, social services, activities) on abuse reporting and investigating allegations of abuse and resident altercations.

Penalty

Inspection fine: $38,110

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 ensure an environment free from accident hazards and to provide adequate supervision and care to prevent accidents for residents with known behavioral and fall risks. One resident with non-Alzheimer’s dementia, depression, severe cognitive impairment, and a long history of physical aggression toward others repeatedly assaulted other cognitively impaired residents on the memory care unit. Despite documented episodes of hitting, grabbing, throwing objects, wandering into other residents’ rooms, and striking residents with fists and objects, the resident continued to wander and interact with others on the unit without consistently implemented, sustained close supervision. Facility documentation showed multiple resident-to-resident altercations over many months, including incidents where the resident struck others in the face and head, sometimes causing visible injuries such as redness to an eye and bruising on the bridge of the nose. Clinical records, change-in-condition notes, and psychiatry progress notes described this resident as having recurrent, sometimes unprovoked, violent outbursts triggered by perceived threats to possessions, food, or personal space, and as being unpredictable and increasingly aggressive toward both staff and residents. Staff statements indicated that the resident could ambulate independently but required someone to walk with them due to fall risk, and that the resident had a history of hitting other residents. However, supervision practices on the memory care unit were described as having staff stationed in the common area and CNAs rounding on rooms every couple of hours, rather than continuous or 1:1 supervision for this resident despite the pattern of aggression. Nursing staff acknowledged that repeated resident-to-resident assaults constituted abuse and that repeated incidents indicated residents were not being adequately supervised. A second deficiency involved another resident with dementia, severe cognitive impairment, poor standing balance, and high fall risk who sustained a fall with serious injury. This resident’s MDS, therapy evaluations, and fall risk assessments documented substantial to maximal assistance needs for sit-to-stand and transfers, poor standing balance, impulsivity when standing, and a fall risk score above the facility’s threshold for being at risk. The resident’s care plan included an intervention instructing staff not to leave the resident alone in the room. On the night of the incident, a CNA assisted the resident onto the toilet in the resident’s bathroom, then left the resident alone on the toilet with the bathroom door closed while physically redirecting the roommate to another bathroom. When the CNA returned after this brief absence, the resident was found on the bathroom floor complaining of right hip and elbow pain, with contusions noted to the right elbow and side of the head. Hospital evaluation confirmed a right hip fracture and intracranial hemorrhage. This sequence of events demonstrates that the resident was left unsupervised during a high-risk toileting transfer despite known fall risk and documented need for close assistance, resulting in a fall and serious injury.

Removal Plan

• Place Resident #99 on 1 on 1 supervision until the resident is discharged or a significant change in condition limits the resident's physical ability to come in contact with another resident.
• Conduct an audit of Point of Care behavior documentation to ensure that residents identified with aggressive behaviors have interventions and care plans in place to provide adequate supervision.
• Reeducate all staff of the facility/agency on the HVHC Safety and Supervision of Residents Policy.
• Require all staff to complete mandatory education prior to the start of their next shift.
• Do not allow any staff member to return to work until the mandatory education has been completed.
• Include this training in new hire orientation as part of the new hire process.
• Require all agency staff to complete this education prior to starting work in the facility.

Penalty

Inspection fine: $38,110

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 review and revise comprehensive care plans for multiple residents after substantiated resident-to-resident abuse incidents involving the same aggressor. Facility records, including final synopses of events and progress notes, documented that one resident repeatedly struck or otherwise physically contacted other residents on the memory care unit, typically when others entered her personal space or touched staff she was interacting with. Despite these documented abuse events and follow-up psychosocial support visits, the comprehensive care plans for the abused residents did not contain any information related to the incidents or any updated approaches following the altercations. For one resident, an event synopsis dated in February described that she was struck on the right side of her face by another resident who became combative on the memory care unit. Staff who frequently cared for both residents reported that both wandered throughout the unit and that the aggressor could become agitated and combative when residents were in her personal space. A progress note documented a support visit related to the altercation, during which the abused resident was unable to recall the event but stated she felt safe and happy. However, review of her comprehensive care plan, dated the prior month, showed no information related to this abuse incident. Another resident experienced multiple separate incidents with the same aggressor in April. Facility synopses and nursing notes documented that the aggressor allegedly struck this resident in the face and nose after the resident got into the aggressor’s personal space and food, and on another occasion punched her in the upper lip after the resident grabbed a CNA’s arm. Notes described small red marks and later separation of the residents, but the comprehensive care plan, dated in February, contained no entries related to these abuse incidents. Similarly, a third resident was documented as being hit on the right side of her face by the same aggressor after the aggressor became combative in the bathroom area; progress notes described assessment and a follow-up visit related to a negative encounter with another resident, but her care plan, dated in March, lacked any abuse-related information. A fourth resident had at least two documented abuse incidents with the same aggressor. In June, progress notes recorded that she was sitting in her wheelchair when the aggressor approached and hit her in the face with a comb; assessment at that time showed no injuries, and a support visit later that day documented that she had no recall of the encounter and stated she felt safe. In November, another incident was documented in which the aggressor hit her in the face with a padded box after she gently touched the aggressor’s arm; subsequent notes recorded bruising to the upper lip and a follow-up visit where the resident did not recall the negative encounter or provide information about her comfort level among others. Review of her comprehensive care plan, dated the previous December, revealed no information related to any of these abuse incidents. Interviews with facility staff confirmed that the care plans for these abused residents were not updated after the incidents. The director of social services stated she is responsible for following up on psychosocial needs after resident-to-resident altercations and that the abused resident’s care plan should be updated after any such event. A registered nurse explained that the care plan is used to ensure all care team members provide appropriate care and that it should be updated for any victim of abuse, noting that unit managers ordinarily update care plans. A unit manager LPN stated that care plans should be updated after an incident of abuse because such an event could trigger a trauma response, and that floor nurses do not typically update care plans. The facility’s own policy on comprehensive person-centered care planning stated that the interdisciplinary team is responsible for reviewing and updating care plans when there has been a significant change in condition or when goals, needs, and preferences change, yet the care plans for the four residents remained unrevised regarding the documented abuse events.

Penalty

Inspection fine: $38,110

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 prepare, store, and serve food in a sanitary manner in the kitchen. During observation of the tray line, two kitchen aides were placing resident lunch trays, but one aide was not wearing a hair net and the other did not have his mustache covered. In the reach-in refrigerator, surveyors observed two trays containing 78 cups of pasta salad with no date showing when the salads were prepared. In the dairy refrigerator, a container with about six ounces of pureed turkey and another with about eight ounces of sliced ham were also found without dates. Surveyors also observed a food processor on a preparation table with the lid sitting upside-down on the bowl, and both the lid and inside of the bowl had leftover food debris. When asked how to determine whether the food processor was clean and ready for use, the dietary manager stated the lid would be turned upside-down on the bowl, but after the debris was observed she stated it was not clean and directed a kitchen aide to remove it for washing. The dietary manager later stated that hair nets and beard or mustache coverings should always be worn in the kitchen, that prepared and leftover food should be dated, and that the food processor should have been checked after washing to ensure it was clean.

Penalty

Inspection fine: $38,110

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

Summary

Facility staff failed to promote the dignity of Resident #45 during feeding assistance. Resident #45 had diagnoses including swallowing difficulties and, on the most recent comprehensive MDS with an ARD of 11/07/2025, scored 3 out of 15 on the BIMS, indicating severe cognitive impairment for daily decision-making. GG0130 Self-Care coded the resident as requiring moderate assistance for eating. On 01/06/2026 at approximately 9:15 a.m., an observation showed CNA #3 standing next to the resident's bed while assisting with breakfast. During an interview later that morning, CNA #3 stated she was standing while feeding the resident and that she should have been sitting while assisting with the meal, adding that it was not dignified for the resident to stand and feed them.

Penalty

Inspection fine: $38,110

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 clean and homelike environment for two residents. For one resident who was severely impaired in making daily decisions, staff observed an approximately 20-inch floor fan in the room that was being used while the resident was in bed. The fan cage had dust fibers and a dried brown/gray substance on the inside, and the condition remained the same during repeated observations. An LPN stated nursing did not clean the fan and that housekeeping was responsible, while the environmental services supervisor stated housekeeping only wiped the outside of the fan and did not clean the inside cage or blades unless maintenance took it apart. A work order to clean the inside of the fan was created later, and no prior evidence of cleaning was provided. For another resident admitted on a Saturday, the resident’s son filed a grievance that the room smelled of urine all weekend and that staff addressed it by opening windows, leaving the resident cold. The grievance record noted the room issue was investigated and that affected carpet would be removed, the floor bleached, and an area rug applied. The environmental services supervisor stated the roommate had been urinating on the carpet, the room smelled very strongly of urine when the resident and family arrived, and the carpet stain was not new. She said she scrubbed the carpet, removed curtains, scrubbed the walls, and briefly opened the window, but the odor remained and the room was not a homelike environment.

Penalty

Inspection fine: $38,110

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 implement its abuse policy for timely reporting of abuse allegations involving Resident #99. The policy stated that alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than 2 hours after the allegation is made when the event involves abuse or results in serious bodily injury. Clinical record review showed that on 10/24/2025 at 9:30 PM, a change in condition note documented that another resident stated R99 was going through her drawers and was aggressive toward her when she asked R99 to stop. A nursing note at the same time documented that the roommate stated R99 punched her in the face. The facility synopsis of events listed an initial report date of 10/25/2025, and the fax confirmation showed the state agency was notified at 8:35 AM on 10/25/2025. The record also showed a second resident-to-resident altercation on 11/2/2025 at 8:56 PM, when R99 was documented as hitting another resident in the face with a padded sewing box after the other resident reached out and gently touched her. Both residents were assessed and no injuries were noted, and all parties were notified. The facility synopsis of events listed an initial report date of 11/3/2025, with fax confirmation showing state agency notification at 10:50 AM on 11/3/2025. During interviews, an LPN stated resident-to-resident altercations were to be immediately separated, assessed, and reported because they had to be reported. A CNA stated such incidents were to be reported to the charge nurse immediately and that she knew they had to be reported within 2 hours. The DON stated staff were supposed to report within 2 hours and said the incidents on 10/24/2025 and 11/2/2025 were probably not brought to her attention until the next day.

Penalty

Inspection fine: $38,110

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

Summary

The facility failed to report an abuse allegation to the state agency within the required time frame for one resident involved in resident-to-resident altercations. Documentation showed that on 10/24/2025, a roommate reported that the resident was going through her drawers and became aggressive when asked to stop, with a nursing note stating the resident punched the roommate in the face. On 11/2/2025, another resident-to-resident altercation was documented in which the resident hit another resident in the face with a padded sewing box after the other resident reached out and gently touched her; both residents were assessed and no injuries were noted. Facility records showed the initial reports were dated the day after each incident, with fax confirmations sent at 8:35 AM on 10/25/2025 for the first event and 10:50 AM on 11/3/2025 for the second event. Interviews with staff indicated that resident-to-resident altercations were to be immediately separated, assessed, and reported up the chain of command, and that such incidents were supposed to be reported within two hours. The DON stated the incidents on 10/24/2025 and 11/2/2025 were probably not reported to her until the next day.

Penalty

Inspection fine: $38,110

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 staff failed to notify the long-term care ombudsman of the discharge of Resident #119. The clinical record documented that the resident was discharged to home via the family’s car, was alert and oriented at the time of discharge, had no acute distress noted, and left the facility accompanied by family with all belongings taken. Review of the record did not show evidence that the ombudsman was notified of the discharge. During interview, the director of social services stated that monthly notifications were sent to the ombudsman for residents transferred or discharged to the hospital, but notifications were not sent for residents discharged or transferred to other facilities, and she stated she was not aware that this was required.

Penalty

Inspection fine: $38,110

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

Summary

Facility staff failed to obtain a Level I PASARR prior to admission for two residents. For one resident, the most recent MDS annual assessment with an ARD of 12/11/2025 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for daily decisions. The resident had been admitted under Medicare, but the clinical record did not show that a Level I PASARR was completed before admission. When asked on 01/12/2026, the regional director of clinical services stated the PASARR Level I had not been completed for this resident. For a second resident, the clinical record also did not evidence a completed Level I PASARR prior to admission. The resident was admitted with diagnoses including cerebral atherosclerosis and unspecified dementia. Staff were unable to provide a Level I PASARR when requested, and the regional director of clinical services stated it was not available. The director of social services stated the hospital should complete the Level I PASARR before admission and that admissions normally obtained it from the hospital and used a checklist to verify completion, but if it was not done before admission, she could complete it.

Penalty

Inspection fine: $38,110

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 respiratory care and services in a sanitary manner for two residents. One resident was in a persistent vegetative state and required an invasive mechanical ventilator and tracheostomy care. During observed tracheostomy care, a respiratory therapist donned gloves before entering the room but did not wear a gown or mask. The therapist removed soiled gauze with gloved hands and did not remove the gloves or sanitize hands before cleansing around the stoma or replacing clean gauze. The resident also had an order for enhanced barrier precautions. Facility staff interviews stated that enhanced barrier precautions require gloves and a gown, and that tracheostomy care also requires a mask because of the risk of bodily fluids being sprayed into the air. Staff further stated that gloves should be changed and hands sanitized between handling dirty and clean gauze around a tracheostomy. The facility policy for tracheostomy care stated that a mask and eyewear will be worn if splashes, spattering, or spraying of blood or body fluids is likely, and that soiled gloves should be removed before applying clean gloves to clean the stoma and apply clean gauze. For another resident with sleep apnea who was ordered CPAP at bedtime, the CPAP nasal mask was repeatedly observed lying uncovered in the bed or on the bedside table, and no storage bag was present. An LPN observed the uncovered mask and stated it was not covered and needed to be placed in a bag to prevent contamination. The resident’s MDS coded the resident as cognitively intact and as having a non-invasive mechanical ventilator.

Penalty

Inspection fine: $38,110

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 complete annual performance evaluations for two of five CNA records reviewed, CNA #5 and CNA #6. Facility staff did not provide evidence of a required annual performance evaluation within the past 12 months for either employee. CNA #5's most recent performance evaluation was dated 11/27/2024, and CNA #6's most recent performance evaluation was dated 03/05/2024. On 01/09/2026, the surveyor requested the most recent performance evaluations for CNA #5 and CNA #6, and the records were reviewed on 01/12/2026. During a telephone interview on 01/12/2026, OSM #11, human resources, stated that employee performance evaluations should be completed annually and that she was trying to get all performance evaluations up to date. The facility policy stated that the job performance of each employee shall be reviewed and evaluated at least annually, with evaluations completed after the 90-day probationary period and at least annually thereafter.

Penalty

Inspection fine: $38,110

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 written agreements for contracted wound care services. During document review, staff were asked to provide contracts for hospice, dialysis, mobile X-ray, mobile laboratory, dental, podiatry, ophthalmology/optometry, wound care, and psych services, but the review of facility contracts did not reveal an agreement for the contracted wound care company. The facility's policy stated that written, signed, and dated agreements are to be maintained for each consultant or consulting group. During an interview, the regional director of operations stated that when services are initiated with an outside company, the facility has the company sign an agreement and keeps it at the facility, but he was unable to locate the wound care contract. On the same day the findings were discussed, the administrator, DON, regional director of clinical services, and regional director of operations were made aware of the missing agreement, and no further information was provided prior to exit.

Penalty

Inspection fine: $38,110

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 follow infection control procedures for one resident who was coded on the most recent MDS as being in a persistent vegetative state and as requiring an invasive mechanical ventilator and tracheostomy care. During observed tracheostomy care, a respiratory therapist donned gloves before entering the room and began care without putting on a gown or mask. He used gloved hands to remove soiled gauze around the resident’s tracheostomy and did not remove those gloves or sanitize his hands before cleansing around the stoma or replacing clean gauze around the opening. The resident had a provider order dated 9/22/25 for enhanced barrier precautions. Facility staff interviews stated that enhanced barrier precautions require gloves and a gown, and that tracheostomy care also requires a mask because of the risk of bodily fluids being sprayed into the air. The facility policy for tracheostomy care directed staff to wear a mask and eyewear if splashes, spattering, or spraying of blood or body fluids was likely, and to remove old dressings, discard soiled gloves, apply clean gloves, clean the stoma, and then apply a fenestrated gauze pad. The facility policy for enhanced barrier precautions stated that gown and glove use are to be used with standard precautions during high-contact resident care activities for residents with wounds and/or indwelling medical devices.

Penalty

Inspection fine: $38,110

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

Summary

Facility staff failed to provide required resident rights training for one of five staff records reviewed, OSM #8, a dietary contract employee. On 01/09/2026, the surveyor requested OSM #8's education records, and on 01/12/2026 the record review showed no evidence of the required resident rights training. During a telephone interview on 01/12/2026, human resources staff stated that OSM #8 was a contract employee and only received abuse training, while the regional director of human resources stated that all contract employees receive an orientation packet from the facility's HR department that contains the required trainings and that the training is completed before the employee starts working. After reviewing the record, human resources staff acknowledged that OSM #8 had not received the required resident rights training. Later that day, the administrator, DON, regional director of clinical services, and regional director of operations were informed of the findings.

Penalty

Inspection fine: $38,110

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

Mandatory training on the facility’s QAPI program was not provided for one of five staff records reviewed, specifically OSM #8, a dietary contract employee. During review of OSM #8’s education record, surveyors found no evidence of the required QAPI training. In interviews, HR staff stated that OSM #8 was a contract employee and had only received abuse training, while the regional HR director stated that all contract employees receive an orientation packet containing required trainings completed by HR before they start work. After the record review, HR staff acknowledged that OSM #8 had not received the required QAPI training. The administrator, DON, regional director of clinical services, and regional director of operations were informed of the findings.

Penalty

Inspection fine: $38,110

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 required infection control training for one of five staff records reviewed, OSM #8, a dietary contract employee. On 01/09/2026, the surveyor requested OSM #8's education records, and on 01/12/2026 the record review showed no evidence of the required infection control training. During interviews on 01/12/2026, human resources staff stated that OSM #8 was a contract employee who only received abuse training, while the regional director of human resources stated that all contract employees receive an orientation packet from the HR department containing required trainings completed before work begins. After review of the record, human resources staff acknowledged that OSM #8 had not received the required infection control training. The administrator, DON, regional director of clinical services, and regional director of operations were informed of the findings.

Penalty

Inspection fine: $38,110

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

Summary

Facility staff failed to provide the required training on compliance and ethics for one of five staff records reviewed, OSM #8, a dietary staff member and contract employee. On 01/09/2026, the surveyor requested OSM #8's education records, and on 01/12/2026 the record review showed no evidence of the required compliance and ethics training. During a telephone interview on 01/12/2026, OSM #11, HR, stated that OSM #8 was a contract employee and only received abuse training, while OSM #7, regional director of HR, stated that all contract employees receive an orientation packet from the facility's HR department containing the required trainings and that HR completes the training before the employee starts working. After the record was reviewed, OSM #11 stated that OSM #8 had not received the required training on compliance and ethics. Later that day, ASM #1, administrator, ASM #2, DON, ASM #3, regional director of clinical services, and ASM #4, regional director of operations were informed of the findings.

Penalty

Inspection fine: $38,110

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

Behavioral health training was not provided for one of five staff records reviewed, OSM #8, a dietary contract employee. During record review, the surveyor requested OSM #8's education records and found no evidence of the required behavioral health training. In interviews, human resources staff stated that OSM #8 was a contract employee who only received abuse training, while the regional director of human resources stated that contract employees receive an orientation packet containing required trainings completed by HR before they start work. After review of the record, human resources staff confirmed that OSM #8 had not received the required behavioral health training. The administrator, DON, regional director of clinical services, and regional director of operations were informed of the findings.

Penalty

No penalty information released

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

Summary

Facility staff failed to ensure that prescribed medications were available and administered as ordered for two residents. For one resident, multiple medications including Pantoprazole, Amantadine, Diltiazem, Docusate, Levetiracetam, Oxybutynin, Vimpat, Tizanidine, and Propranolol were not available for scheduled administration times following admission. Documentation in the medication administration record (MAR) and nurse's notes indicated that these medications were on order, not available in the facility's Omnicell system, or awaiting delivery from the pharmacy. The resident was admitted in the afternoon, and the medications were expected to arrive during the night, but several doses were missed as a result of the delay. For another resident, staff did not ensure the availability of Sennoside, Budesonide, Humulin 70/30, and Glycopyrrolate for scheduled administration. The MAR and progress notes documented that these medications were on order and not available at the time they were due. The resident arrived at the facility in the evening, and several doses of the prescribed medications were not administered over multiple days due to unavailability. Interviews with an LPN revealed that the process for obtaining medications for new admissions involved entering orders into the computer system, which then sent them to an out-of-state pharmacy. If medications were not available at the time of administration, staff were expected to check the Omnicell, contact the pharmacy, and, if necessary, reach out to the provider for alternative orders or to hold the medication. The facility's policy required staff to notify the attending physician and document all actions taken. Despite these procedures, the medications were not available for timely administration, and the required notifications and documentation were inconsistently completed.

Penalty

No penalty information released

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

Summary

Facility staff failed to notify physicians and responsible parties when prescribed medications were not available and subsequently not administered to multiple residents. For one resident with a G-tube and complex medical needs, including gastrostomy status, seizures, hypertension, constipation, and bladder spasms, several medications were missed over multiple days. Documentation in the medication administration record (MAR) indicated the medications were not given and referenced progress notes, which showed the medications were on order or unavailable. However, there was no documentation that the physician or responsible party was informed of these missed doses, despite facility policy requiring such notification. Another resident, who required medications for diarrhea and anemia, also experienced missed doses due to unavailability. The MAR and nurse's notes documented that the medications were not available and had been ordered from the pharmacy, but again, there was no evidence that the physician or responsible party was notified of the missed administrations. In one instance, a nurse practitioner was notified, but there was no documentation of communication with the responsible party. A third resident, with orders for medications related to bowel regimen, respiratory failure, diabetes, and secretions, also did not receive several scheduled doses due to medication unavailability. The MAR and nurse/respiratory therapist notes indicated the medications were on order or not available, but there was no documentation of notification to the physician or responsible party. Interviews with nursing staff confirmed the expectation to notify both the provider and responsible party and to document these actions, but this was not reflected in the records reviewed.

Penalty

No penalty information released

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

Summary

Facility staff failed to administer medications and supplements as ordered by physicians for two residents. For one resident, Banatrol and Ferrous Sulfate were not given according to the prescribed schedule. The medication administration records (MAR) showed missed doses, with documentation codes indicating the medications were not available or other issues, and nurse's notes confirmed that the medications were reported as unavailable and on order from the pharmacy. However, interviews with staff revealed that both Banatrol and Ferrous Sulfate were actually available as floor stock or in storage areas, and observations confirmed the presence of these medications in the facility. For another resident, Banatrol was not administered as ordered. The MAR indicated missed doses, with codes for 'Other/See Progress Notes' and 'Hold See Progress Note.' Nurse's notes again cited the medication as being on order from the pharmacy. Staff interviews and observations confirmed that Banatrol was stocked in multiple locations within the facility and had not run out. The facility's policy requires that every effort be made to ensure medications are available to meet residents' needs. Despite this, the staff did not administer the medications as ordered, even though the medications were present in the facility. The deficiency was brought to the attention of the administrator, DON, and regional nurse consultant.

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 staff failed to review and revise the comprehensive care plan for two residents, leading to deficiencies in their care. For Resident #2, the care plan was not updated when the resident was moved to a secured dementia unit. The existing care plan, dated nearly two years prior, identified the resident as an elopement risk and included interventions such as frequent rounding and the use of a wander guard. However, the care plan did not reflect the resident's new living situation in the secured unit, which was confirmed as an expectation by both the Director of Nursing and the unit manager during interviews. Similarly, for Resident #3, the care plan was outdated and did not address the resident's placement in a secured dementia unit. The care plan, last revised several months prior, noted the resident's history of wandering and resistance to care, as well as a risk for falls. Despite an incident where the resident was found outside in a vulnerable position, the care plan lacked updates to reflect the resident's current needs and environment. Interviews with facility staff confirmed that the care plan should have been updated to include the resident's placement in the secured unit. The facility's policy on care planning requires updates to care plans when there are significant changes in a resident's condition or environment, among other criteria. The failure to update the care plans for these residents was acknowledged by the facility's administrative staff, including the administrator and the regional director of clinical operations, during the survey process. No additional information was provided before the survey exit.

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 staff failed to follow professional standards of practice for a resident by not clarifying a physician's order for the application of compression wraps. The resident, who was not cognitively impaired, had a physician's order dated July 5, 2023, for bilateral lower legs to be wrapped with compression wraps once a week for six months to address edema. However, the order did not specify the type of compression wrap to be used. Interviews with several LPNs revealed that there was confusion about the type of wrap to use, with some using kling wrap, which is not considered a compression wrap, and others suggesting the use of Kerlix or ace wraps. The facility's policy requires clarification of orders that do not specify details, but this was not done in this case. The deficiency was identified during a survey when interviews with LPNs and a review of the facility's documentation showed that the order for compression wraps was not clear and had not been clarified with the prescribing practitioner. The facility's administrative staff, including the administrator, director of nursing, and regional director of clinical operations, were made aware of the issue. Despite the facility's policy on clarifying incomplete orders, the lack of clarification led to the improper application of compression wraps for the resident, which was not in accordance with professional standards of practice.

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 staff failed to provide adequate supervision to prevent elopement for three residents, leading to incidents where residents left the facility unsupervised. Resident #2, who was severely impaired in making daily decisions, managed to exit the building and fell on the pavement outside. Despite having a wander guard, the resident was able to leave through a door that was opened by a visitor. The resident had a history of falls and was identified as an elopement risk, yet the interventions in place were insufficient to prevent the incident. Resident #3, also severely impaired in decision-making, was found outside in the garden area of the secured dementia unit after falling. The resident had a history of wandering and falls, and the garden doors were not consistently locked, allowing the resident to access the area unsupervised. The care plan noted the resident's tendency to wander and the need for supervision, but the lack of secured access to the garden area contributed to the incident. Resident #4, moderately cognitively impaired, left the facility and was found at a private residence across the parking lot. The resident was not previously identified as an elopement risk, and the door used for exit was not adequately secured, allowing the resident to leave unnoticed. The resident's care plan did not address elopement risk until after the incident, highlighting a gap in the facility's assessment and monitoring processes.