The Jefferson

Penalty

Inspection fine: $61,065

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 protect a cognitively impaired resident from physical abuse during an attempt to obtain a urine specimen. The resident had benign prostatic hyperplasia and was documented as severely cognitively impaired on the admission MDS, with a BIMS score of 4/15 and urinary status coded as always incontinent. A physician’s order dated 01/24/2025 directed that a urinalysis with culture and sensitivity be obtained every shift for three days. On the evening of 01/28/2025, an LPN attempted to collect a urine sample. When the resident was unable to void into a urinal, the LPN proceeded with an in-and-out catheterization despite the resident’s cognitive impairment and subsequent resistance. During the catheterization attempt, the resident verbally and physically resisted the procedure. According to the resident’s friend, who was present, the resident stated words such as “Don’t do that” and crossed his legs, and later grabbed his penis to stop the nurse. The LPN then called for assistance from two CNAs. The friend reported being asked to step into the hallway, where she heard the resident yelling but could not make out his words. Staff interviews and written statements confirmed that the CNAs held the resident’s arms and legs while the LPN inserted the catheter in order to obtain the urine specimen. The LPN later acknowledged that the resident was restrained during the procedure and that she believed restraining residents in this manner was common practice, and she expressed surprise when informed that residents have the right to refuse care and cannot be restrained against their will. Bright blood was noted in the urine during the catheterization, at which point the LPN stopped the procedure, removed the catheter, and documented that the resident appeared anxious but stable. Later that night and early the following morning, staff documented that the resident experienced discomfort and pain with urination, with hematuria and blood clots noted in the brief. The on-call NP was notified and ordered transfer to the hospital, where the resident was found to have an indwelling urinary catheter with blood in the urine. Facility investigation, including staff interviews and review of statements, concluded that the CNAs had held the resident’s arms and legs while the LPN catheterized him, and the allegation of abuse was substantiated as willful infliction of injury by forcing a procedure against the resident’s will, resulting in bleeding and hospitalization.

Removal Plan

• The allegation was reported, investigated and substantiated for abuse.
• Staff members involved were placed on paid administrative leave pending investigation and subsequently terminated and reported to their respective licensing agencies.
• Immediate skin assessment completed on the resident; no skin impairment or changes noted.
• The resident was evaluated by the facility social worker for psychosocial distress related to the incident; no distress was reported or observed.
• Residents with orders for straight catheterization were identified as potentially affected.
• Immediate skin checks were completed for all residents.
• Resident interviews were conducted and no care issues or abuse issues were identified.
• Staff members were in-serviced and educated on abuse policies and procedures and who the abuse coordinator is.
• Staff were educated on a resident's right to refuse or decline care and procedures and how nursing staff are to respond when a resident refuses care or treatment.
• Staff were educated to offer alternatives if possible and provide education on the needed treatment.
• Abuse and Neglect Prevention Training will be assigned and monitored for all new hires during orientation and annually for all employees.
• Resident grievances will be monitored continually for concerns regarding abuse.
• All SNF team members will be trained upon hire and annually to observe signs of abuse with cognitively impaired residents and report concerns to the Administrator.
• The DON or designee will audit skin checks weekly for a portion of the resident census to monitor for concerns.
• The Administrator or designee will conduct resident interviews weekly to monitor satisfaction with care and monitor for reports of abuse.
• Compliance and audit results will be monitored through the facility QAPI program, with the Administrator responsible for ongoing compliance.

Penalty

Inspection fine: $61,065

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 facility staff physically restraining a cognitively impaired resident during an in-and-out catheterization to obtain a urine specimen, despite the resident’s resistance and inability to consent. The resident had benign prostatic hyperplasia and was documented as severely cognitively impaired on the admission MDS, with a BIMS score of 4/15 and always incontinent in the urinary continence section. A physician’s order directed that a urinalysis with culture and sensitivity be obtained every shift for three days. On the evening in question, the LPN attempted to obtain the ordered urine specimen via straight catheterization after the resident was unable to void into a urinal. According to the facility’s own investigation and staff statements, when the LPN entered the room to insert the catheter, the resident verbally resisted by saying “Don’t do that” and crossed his legs. The LPN then called for assistance from two CNAs. The visitor present was asked to leave the room, and while in the hallway, the visitor heard the resident yelling but could not make out the words. CNA statements and the facility’s synopsis of events documented that the two CNAs held the resident’s arms and legs while the LPN proceeded with the catheter insertion in order to obtain the urine specimen. The facility’s findings concluded that the CNAs did hold the resident’s extremities during the procedure and that the resident was restrained against his will. During the catheterization, bright blood was noted in the urine sample, and the LPN stopped the procedure when blood was seen entering the catheter tubing. Nursing notes documented that the resident appeared anxious but stable immediately afterward. Later that night and early the following morning, the resident experienced discomfort and pain with urination, with hematuria and blood clots noted in the brief, leading to notification of the on-call NP and transfer to the hospital. The facility’s grievance report and investigation summary documented that the catheter was used for a urine sample against the resident’s will, resulting in bleeding in the groin area and hospitalization, and that the allegation of abuse by restraint was substantiated based on staff interviews and the definition of abuse in the facility’s policy as willful infliction of injury or unreasonable confinement with resulting physical harm, pain, or mental anguish.

Removal Plan

• Staff members involved were placed on paid administrative leave pending investigation and subsequently terminated and reported to their respective licensing agencies.
• Immediate skin assessment completed on Resident 42; no skin impairment or changes noted.
• Resident 42 was evaluated by the facility social worker for psychosocial distress related to the incident; no distress was reported or observed.
• Residents with orders for straight catheterization were identified as potentially affected.
• Immediate skin checks were completed for all residents.
• Interviews were conducted with residents and no care issues or restraint issues were identified.
• CNAs, LPNs, RNs, Dietary, Social Services, Housekeeping, Therapy, Maintenance, Activities and MDS Coordinator were in serviced and educated on restraint policies and procedures and who the coordinator to whom concerns should be reported.
• Staff were educated on a resident's right to refuse or decline care and procedures and how nursing staff are to respond when a resident refuses care or treatment.
• Staff attending the training were educated to offer alternatives if possible and provide education on the needed treatment.
• New hire and annual training will be assigned and monitored for completion.
• Training regarding restraint use will be given for all new hires during orientation and annually for all employees.
• Resident grievances will be monitored continually for concerns regarding restraint use.
• The DON or designee will audit skin checks weekly for 50% of resident census to monitor for concerns.
• The Administrator or designee will conduct resident interviews to monitor satisfaction with care and monitor for reports of restraint use.
• Compliance and audit reports will be monitored through the facility QAPI program.
• The Administrator is responsible for ongoing compliance.

Penalty

Inspection fine: $61,065

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 prevent an allergic reaction for a resident with a documented severe shellfish allergy when the resident was served and consumed lobster ravioli provided by the facility. The resident’s electronic health record listed a shellfish allergy categorized as a food allergy with a severe reaction manifestation and severity, and this allergy was also reflected in the resident’s care profile. The resident had a cognitive communication deficit and was assessed as moderately impaired in cognition for making daily decisions, scoring 12 out of 15 on the BIMS. Despite these documented conditions and allergy information, the facility’s dinner menu for the skilled nursing floor included lobster ravioli, and the resident received and ate 100% of this meal. Around the time of the evening meal, the resident activated the call bell, and an LPN responded. The resident reported difficulty breathing and stated that the dinner served was shellfish, to which he was allergic. The LPN obtained vital signs, which were documented as blood pressure 124/74, heart rate 121, temperature 97.8°F, and oxygen saturation 96% on room air. Although the vital signs were noted to be within normal limits, the resident continued to report trouble breathing. The LPN attempted to contact the on-call physician service but was unable to reach a provider and then called 911 to have the resident transferred to the emergency room for further evaluation and medical management. The LPN later confirmed that the lobster ravioli had come from the facility. At the hospital, the resident was evaluated for acute onset shortness of breath and undifferentiated shock after exposure to shellfish, briefly requiring vasopressor support. The hospital documentation noted a differential diagnosis of bronchiolitis versus allergic reaction, and the resident was treated with 25 mg of Benadryl and admitted for further evaluation. Facility interviews and documentation indicated that the dietary department had a process in which resident food allergies were to be communicated via a notify form and posted allergy lists in the pantry, and that dietary aides were expected to reference these lists when plating meals. The dietician stated that the resident knew he ordered lobster ravioli and that the dietary aide should have caught the shellfish allergy, while a dietary aide described relying on the posted allergy list when plating meals. Despite these procedures and the posted allergy information, the resident with a documented severe shellfish allergy was able to order, receive, and consume lobster ravioli, resulting in an allergic reaction that required emergency treatment and hospitalization and was cited as Immediate Jeopardy with harm.

Removal Plan

• Reinforce use of the communication log posted in the Skilled Nursing pantry.
• Dietary staff verify identified residents with food allergies at each meal service using a daily updated log and dietary notification communication of resident allergies provided to dining staff.
• Educate all Skilled Nursing Facility staff (including agency staff) on the facility process: nursing enters orders into PCC; nursing completes diet notification form including food allergies and provides it to dietary; allergy is reflected on the menu ticket following manual order transcription; kitchen staff receive and verify diet order including any food allergies; kitchen staff sign and acknowledge resident food allergy via the compliance log with every meal.
• Ensure all nursing and dietary staff are educated before start of their shift; staff on PTO are educated upon return prior to next assigned shift.
• DON (or designee) audits new admission records weekly to ensure data entry and communication form process was followed for a defined period or as determined by the QAPI committee.
• Dietary Manager (or designee) monitors meal tickets for residents with food allergies weekly to ensure food allergies are included on the meal ticket for a defined period or as determined by the QAPI committee.
• Monitor process compliance and audit results in the facility QAPI program; administrator responsible for ongoing compliance.

Penalty

Inspection fine: $61,065

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 uphold a resident’s right to refuse care and treatment when attempting to obtain a urine specimen from Resident #42. The resident had diagnoses including benign prostatic hyperplasia and was documented on the admission MDS with a BIMS score of 4/15, indicating severely impaired cognition for making daily decisions, and was coded as always incontinent. A physician’s order directed that a urinalysis with culture and sensitivity be obtained every shift for three days. On the evening in question, the LPN attempted to collect a urine sample via in-and-out catheterization after the resident was unable to void into a urinal. According to the facility’s synopsis and staff statements, when the LPN entered the room to insert the catheter, the resident verbally and physically resisted the procedure. A friend visiting the resident reported that the resident said “Don’t do that” and crossed his legs, and later grabbed his penis to stop the nurse. The LPN then called for assistance from two CNAs. The friend was asked to step into the hallway, where she heard the resident yelling but could not make out his words. CNA #14 reported that he and CNA #15 held the resident’s legs and arms while the LPN catheterized him, and the facility’s investigation concluded that the CNAs restrained the resident’s arms and legs during the catheter insertion. The LPN confirmed that the resident was restrained during the procedure and stated that restraining residents during care was common practice, and she expressed surprise when informed that residents have the right to refuse care and cannot be restrained against their will. During the catheterization, bright blood was noted in the urine sample, and the LPN stopped the procedure and removed the catheter. A health status note documented that the resident appeared anxious but stable, with no signs of shock or distress at that time, and the on-call NP was notified and directed staff to monitor the resident. Later that night and early the following morning, staff documented that the resident had discomfort and pain with urination, hematuria, and blood clots noted in the brief, and the NP ordered transfer to the emergency room. The resident was hospitalized due to hematuria and returned with an indwelling urinary catheter and blood in the urine. The facility’s grievance report and internal investigation documented that the urine catheter was placed for a specimen after the resident’s refusal, that staff held the resident down during the procedure, and that the incident was substantiated as abuse and a violation of the resident’s rights. Interviews with other staff further described the expected procedure for obtaining a urine specimen and the requirement to stop if a resident refuses, asks to stop, or shows distress, and to notify the physician if urine cannot be obtained. The Senior Director of Nursing Services, another LPN, and a CNA all acknowledged that residents have the right to refuse care, treatments, or procedures and agreed that the resident’s rights were violated in this incident. The facility’s abuse, neglect, and exploitation policy states that each resident has the right to be free from abuse and that team members must not engage in or permit abuse. The events described show that, despite the resident’s severe cognitive impairment, staff proceeded with catheterization by physically restraining the resident after he verbally and physically resisted, resulting in bleeding, pain with urination, hematuria, and hospitalization.

Penalty

Inspection fine: $61,065

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 maintain the emergency medical (crash) cart in a sanitary and ready-to-use condition and did not ensure required emergency supplies were present and unexpired on one health care unit. During observation of the crash cart, surveyors found the oxygen tank at only 2% full and noted missing items that were listed as required, including oxygen masks, nasal cannulas, normal saline, a second nonrebreather mask, standard oxygen masks, a blood spill kit, and a second bottle of distilled water. The suction machine on top of the cart was only covered with mesh, allowing air and dust to enter, and the Ambu bag used for resuscitation was not in a protective bag. Multiple items were expired or compromised, including several packets of lubricating jelly (some expired and one with an unreadable date), a suction catheter package with a rip rendering it non-sterile, suction connecting tubing and non-conductive connecting tubing that were past their expiration dates, a box of large gloves that was expired, and an open box of surgical masks that was expired. Bandage scissors required to be in the cart were not present; instead, there were dirty scissors that were not bandage scissors. Interviews and document review showed that the facility’s process for maintaining the crash cart was not effectively implemented. An LPN stated that the night shift nurse was responsible for ensuring the crash cart was stocked and free of expired items, acknowledged that the oxygen tank was empty, and confirmed that the Ambu bag was open and not sterile and that all supplies should be current and available for emergencies. The DON reported that the night nurse was supposed to check the cart each shift using the Emergency Cart Daily Checklist and restock items from the supply room, and that the cart should be restocked immediately after use. Despite this, the Emergency Cart Daily Checklist documented that the cart had been checked daily over a multi-week period, even though the above deficiencies were present at the time of survey. Review of resident code status on the unit showed that 24 of 25 residents were full code, meaning CPR must be initiated if they stop breathing or their heart stops, and the crash cart would be used in such events. Review of the facility assessment did not show documentation of the required emergency equipment needed to address medical emergencies, as specified in the facility’s CPR Certification policy.

Penalty

Inspection fine: $61,065

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 conduct and maintain an accurate, comprehensive facility-wide assessment that reflects necessary resources, including emergency medical equipment, and current administrative leadership. The facility assessment reviewed on 2/3/2025 listed various medical and non-medical equipment such as Hoyer lifts, sliding boards, transfer devices, grab bars, wheelchair-accessible transportation, feeding tube equipment and bolus services, wheelchairs, specialty cushions, air mattresses, nebulizer and oxygen services, and noted that the facility did not have access to rental CPAP and BiPAP machines, requiring new admissions after 1/1/2024 to provide their own devices and supplies. However, the assessment did not address emergency medical equipment required to meet residents’ emergent medical needs. In addition, the assessment did not show evidence of participation or sign-off by the current Medical Director, Director of Nursing, Administrator, Social Worker, or a representative from the Governing Body. During an interview, the Administrator stated he had been in the position for only a month and had not yet reviewed the facility assessment, despite acknowledging that the assessment must be reviewed at least annually and when there are changes in administrative staff. The Director of Nursing had been in the role since July 2025, yet the assessment had not been updated to reflect the current administrative team. Facility policy on the Governing Body indicated that the Skilled Nursing Administrator is responsible for annual review and ongoing updates of the facility assessment as needed, with data reported to the Governing Body and reviewed through QAPI programs. Despite this policy, the assessment remained outdated and incomplete regarding both administrative staff changes and emergency medical equipment needs at the time of the survey.

Penalty

Inspection fine: $61,065

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 ensure appropriate competencies for 15 of 15 nurses regarding PICC line care. A review of the resident list showed three current residents were receiving PICC line care and services, and competencies for PICC line care were requested for an initial sample of five nurses. The DON stated she did not have the requested competencies, and the Senior Director of Nursing Services later stated the facility did not have PICC line care competencies for any of the current nurses. The facility reported a total of 15 nurses, including four facility nurses and 11 agency nurses, and no policy regarding nursing competencies was provided. The facility also failed to provide evidence that CNA #11's competencies were verified at the time of hire. HR records showed CNA #11 was hired on 10/10/25, but the Director of HR could not find any evidence collected at or prior to hire, including proof of CNA licensure. She stated she could not say for certain that CNA #11 was actually a licensed care provider during employment at the facility. The DON stated that competency is vital for staff to provide quality resident care and that without evidence at hire, the facility does not have a way to determine a CNA's ability to do the job.

Penalty

Inspection fine: $61,065

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

Summary

The facility failed to provide evidence of required CNA training for five of five CNA records reviewed: CNAs #5, #6, #7, #8, and #9. Surveyors requested evidence that annual performance reviews had been completed and that any subsequent regular trainings were based on the results of those reviews, but the facility could not produce the requested documentation. The facility policy reviewed, Team member Manager - Performance Reviews, did not contain information related to CNA trainings tied to the outcome of annual performance reviews. During interviews, the Director of HR stated she had provided all the information she could locate and did not have the requested evidence for the CNA trainings. The DON stated she had not completed a CNA evaluation since starting with the company and was not sure how CNA trainings were developed from annual evaluations. The Director of HR stated that trainings after the initial 30 days were tracked through a software system and that she emailed employees when trainings were due, but she did not have any role in tailoring CNA training to the results of annual performance reviews. The administrator and DON were informed of the concerns, and no additional information was provided before exit.

Penalty

Inspection fine: $61,065

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 have evidence of QAPI meetings from July 2023 through December 2023, despite a request on entrance for documentation showing QAPI activity since the last survey on 1/12/2023. Based on staff interview and facility document review, no notes or other evidence could be found to show that a QAPI meeting occurred during that time frame. During an interview on 2/19/2026 at approximately 4:00 p.m., the Administrator stated the facility should conduct QAPI meetings at a minimum quarterly and said he searched but could not find any notes from July 2023 through December 2023 to evidence a QAPI meeting. The facility policy, Quality Assurance and Performance Improvement (QAPI) Program, states that the QAPI committee is to meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program.

Penalty

Inspection fine: $61,065

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 evidence attendance at QAPI meetings for 2024. During surveyor review, a request was made for documentation showing the participants of the QAPI meetings since the last survey, and the facility did not provide signature sheets. On interview, the Administrator stated that the facility used a computer program during 2024 to list meeting attendants and that there were no signature sheets, only a printout of names. The Administrator also stated he believed actual signatures were required for meeting attendance. The facility policy for the QAPI Program stated that the QAA Committee must be interdisciplinary and include, at a minimum, the DON, the Medical Director or designee, at least three other staff members including at least one leader such as the Administrator, Owner, Board Member, or other individual in a leadership role, and the Infection Preventionist.

Penalty

Inspection fine: $61,065

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 prevention policy when staff physically restrained a resident during an attempt to obtain a urine specimen. Resident #42 had diagnoses including benign prostatic hyperplasia and was severely cognitively impaired, with a BIMS score of 4 out of 15 on the most recent comprehensive MDS. The physician’s order called for UA C&S every shift for 3 days. During the evening attempt to collect the specimen, the resident was unable to urinate in the urinal, and staff proceeded with in-and-out catheterization. The facility note documented bright blood in the urine sample, and the catheter was removed. The resident later developed hematuria, blood clots in the brief, pain with urination, and was sent to the hospital. Facility interviews and written statements showed that the resident was held down during the catheterization. CNA #14 stated he and CNA #15 held the resident’s arms and legs while the LPN catheterized him. CNA #15 stated he assisted with the urine collection. The LPN stated she attempted catheterization, called for two CNAs when the resident became combative, and stopped when blood was noted in the catheter tubing. The facility’s investigation summary stated that the written and verbal statements supported that the CNAs held the resident’s legs and arms while the LPN catheterized him, and the allegation of abuse was substantiated. The report also documented that the resident’s friend witnessed the resident saying not to do that and heard him yelling while staff were in the room. The facility also failed to verify licenses at the time of hire for LPN #8, LPN #9, CNA #10, and CNA #11. Despite requests for evidence of verification, none was provided. Human Resources stated that applicants are asked to bring a copy of their current license at interview and that license verification is part of the facility’s abuse prevention program. The DON stated that license verification at hire is important to ensure staff competence and prevent resident abuse.

Penalty

Inspection fine: $61,065

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 the comprehensive care plan for incontinence care for a resident with a history of CVA with hemiparesis, hemiplegia, and fibromyalgia. The resident’s care plan identified bladder incontinence related to impaired mobility and directed staff to assist with toilet use using a walker and to observe, document, and report possible causes of incontinence. During observations, the resident was found in bed wearing an adult brief, and the resident stated that night shift CNAs did not want to take the time to get her out of bed to the bathroom and wanted her to use the brief instead. The resident also stated there were no female urinals or bedpans available for use, and no bedpans were found in the unit storage room during the survey. The facility also failed to implement the care plan for PICC care for a resident with an intraspinal abscess, neuromuscular dysfunction of the bladder, and polyarthritis. The resident’s care plan directed staff to observe and report changes at the access site, including redness, swelling, tenderness, or pain, and the physician order required the IV site to be observed every shift and before and after intermittent medications and dressing changes. Review of the TAR showed missing documentation for IV site observation on multiple day, evening, and night shifts. An LPN stated that all PICC care documentation was on the TAR and that if it was not documented, there was no evidence of care being provided. The facility failed to implement care plan interventions for a resident receiving anticoagulant therapy for atrial fibrillation, with the care plan directing that the resident remain free of discomfort or adverse reactions related to anticoagulant use. The MAR/TAR did not evidence monitoring for adverse reactions to anticoagulants. The facility also failed to follow the care plan for a resident with a stage II sacral pressure injury, where the care plan required weekly reassessment and documentation of wound size and characteristics. The record did not show further documentation of the pressure injury until a later weekly skin check noted intact skin. In addition, the facility failed to implement the care plan for a resident on diuretic therapy for CHF when a scheduled bumetanide dose was not given and the progress note stated the medication was awaiting pharmacy supply.

Penalty

Inspection fine: $61,065

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 follow physician orders for three residents by not administering medications as ordered or by administering medications incorrectly. One resident with dementia, anemia, hypothyroidism, and a history of embolism and thrombosis of the left lower extremity was given another resident’s medications for five days, including atorvastatin, losartan, and Plavix. The resident’s record showed these medications were entered as new orders for that resident even though they were intended for another resident returning from a cardiology appointment, and the eMAR documented administration of those medications on multiple consecutive days. For another resident, staff did not administer Metoprolol Succinate even though the medication was available in the facility’s backup pharmacy system. The physician’s order called for Metoprolol Succinate ER 25 mg daily for heart failure, and the MAR showed the dose was marked with a code indicating other/see progress note. The progress note stated the facility was awaiting pharmacy supply, while the backup pharmacy system contained 28 tablets on hand. A third resident with CVA with hemiparesis, hemiplegia, and fibromyalgia received Clonidine HCl 0.1 mg outside the scheduled administration time on multiple occasions. The order required the medication twice daily for hypertension with hold parameters for low blood pressure and low heart rate, but the audit report showed repeated late administrations ranging from about one hour late to several hours late. The resident stated that the Clonidine was being given late and that the doses were being given too close together, and staff interviews confirmed that medications given outside the scheduled time were considered medication errors.

Penalty

Inspection fine: $61,065

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 parenteral catheter care for multiple residents with IV access, including failure to obtain or follow physician orders for PICC line dressing changes, IV flushes, site maintenance, and monitoring. Resident #2 had a PICC line in the right chest, was cognitively intact, and the clinical record contained a physician order for the PICC line but no orders for dressing changes. The resident was observed with a dated dressing absent on the PICC site, and stated staff had changed the dressing every two days for the first two weeks but had not changed it since then. An LPN stated PICC dressing changes should be ordered, changed every seven days, dated, and documented on the MAR or TAR. Resident #6 had a physician order for IV Vancomycin through a PICC line in the right upper arm, but the record did not contain any orders for PICC dressing changes. The resident was observed with a PICC dressing that had no date. An LPN stated nurses should verify physician orders for PICC dressing changes, that the dressing should be changed every seven days, and that completion should be documented on the MAR or TAR. Resident #25 had a one-time order for IV Sodium Chloride, and the MAR showed the infusion was completed, but the record did not include further indications for IV access, orders for routine IV site maintenance or flushes, or documentation reflecting the IV site after the infusion. The resident was observed with a peripheral IV in the right forearm covered by a transparent dressing dated 2/14/26, and stated the IV had been placed a few days earlier because staff had difficulty obtaining access. Resident #22 had a PICC line to the left upper arm, and the care plan and physician orders included dressing changes, securement device changes, and observation of the IV site for redness, swelling, drainage, bleeding, infiltration, and extravasation. The TAR was missing documentation for ordered IV site observation on multiple shifts and dates. The resident stated staff did not always monitor the PICC line, and two LPNs described PICC care as requiring assessment for signs of infection and documentation on the TAR. The Administrator and DON were informed of the concerns, and no facility policy was provided for the cited issues.

Penalty

Inspection fine: $61,065

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 and serve food in a sanitary manner in the kitchen. On 2/17/26, dietary staff were observed running loaded dish racks through the automatic dishwasher even though the wash-cycle temperature gauge never registered any temperature. OSM #6 stated the dishwasher was broken, and OSM #7 stated the gauge had not displayed an actual temperature for at least two days. Neither staff member stopped the process, and wet steam table pans and half steam table pans were stacked on top of each other on a drying rack after the cycle. The Dietician was informed of the broken gauge, and OSM #9 stated staff should have been using a waterproof thermometer with each dish rack to verify the wash temperature. On 2/18/26, the facility chef stated the dishwasher temperature gauge had been broken since 2/15/26 and that staff should have been using a waterproof thermometer to confirm the wash temperature, but the staff observed on 2/17/26 were not doing so. He also stated a chemical sanitizer had been added to the rinse cycle, but he did not know whether staff had been testing the water-to-sanitizer ratio and could not provide records of such testing over the prior two days. Later that day, a dietary staff member serving lunch on the 3rd floor pantry wore gloves but repeatedly touched plate surfaces, serving pieces, the refrigerator, bread, the steam table, sandwiches, and potato chips without changing gloves or sanitizing hands. The Director of Dining Services stated staff should change gloves and sanitize hands whenever gloves may have become contaminated and that wet dishware should never be stacked directly on top of each other.

Penalty

Inspection fine: $61,065

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 state regulations at the time of hire for four of five staff records reviewed: LPN #8, LPN #9, CNA #10, and CNA #11. Based on staff interviews and facility document review, the facility did not provide evidence that professional licensure was verified at the time these employees were hired. Virginia state regulation 12VAC5-371-210 requires the nursing facility to verify that a nurse aide is a certified nurse aide in good standing before allowing the individual to perform resident care duties. On 2/23/26, facility staff were asked to provide evidence of license verification at the time of hire for the four employees, whose hire dates were identified by the Director of HR as 3/18/25 for LPN #8, 3/24/25 for LPN #9, 5/13/25 for CNA #10, and 10/10/25 for CNA #11. Despite multiple requests, no evidence of verification at the time of hire was provided. The administrator and DON were informed of the concern, and the DON stated that license verification at the time of hire is important to make sure staff members are competent and to prevent resident abuse. The Director of HR stated she was responsible for overall license verification and described a process that included obtaining a copy of the license during the initial interview and later verifying it through the state department of health professions, with an additional verification by the employee's manager after the employee had started work with residents.

Penalty

Inspection fine: $61,065

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 Quality Assurance and Performance Improvement (QAPI) Program was not provided for five of ten staff records reviewed, including CNA #5, RN #1, OSM #3, OSM #4, and OSM #5. On 2/20/26, surveyors requested evidence of QAPI training for these staff members, but review of records provided by the Director of Human Resources did not show that the training had been completed. The Director of Human Resources stated that new employees receive required trainings through a third-party education provider at hire, and that completed training records are transferred into another third-party software system. She stated that she does not personally verify which trainings are required by regulation for each employee and only receives notifications from the third party about due trainings, which she then relays to staff. A review of the facility’s onboarding curriculum for all staff and annual training assignments for all team members showed no information related to QAPI training.

Penalty

Inspection fine: $61,065

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 training for five of five CNA records reviewed, including CNAs #5, #6, #7, #8, and #9. Surveyors found no evidence that the CNAs’ regular trainings were based on the results of their individual annual performance reviews. On 2/20/26, the survey team requested evidence of annual performance reviews and documentation showing that subsequent regular trainings were based on those reviews for the five CNAs. On 2/23/26, the Director of HR stated she had provided all information she could locate and did not have the requested training evidence for the CNAs. On 2/24/26, the DON stated she had not completed CNA evaluations since starting at the facility and was unsure how CNA trainings were developed from annual evaluation results. The Director of HR stated that trainings after the initial 30 days were tracked through a software system and that she emailed employees when trainings were due, but she did not tailor CNA training to annual performance review results. The facility policy, Team member Manager - Performance Reviews, contained no information related to CNA trainings based on annual performance review outcomes.

Penalty

Inspection fine: $61,065

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 the physician and responsible party when ordered medications were not available and therefore not administered to a resident. For Resident #24, a physician order dated 1/21/2026 directed administration of Metoprolol Succinate ER 25 mg by mouth once daily for heart failure. The January 2026 MAR reflected this order, and on 1/21/2026 at the 9:00 a.m. dose, the nurse documented a "9," indicating "Other/See Progress Note." The corresponding progress note at 11:53 a.m. on 1/21/2026 stated "Awaiting pharmacy supply," indicating the medication was not available for administration. Resident #24 also had a physician order dated 1/17/2026 for Bumetanide 0.5 mg by mouth once daily as a diuretic, which was likewise documented on the January 2026 MAR. On 1/21/2026 for the 9:00 a.m. dose, a "9" was again documented, with the progress note at 11:53 a.m. stating "Awaiting pharmacy supply." Interviews with an LPN and the DON confirmed that when a medication is not in the cart and not in the backup pharmacy system, the nurse is expected to contact the pharmacy, notify the physician and responsible party that the medication is not available, and document this in the medical record. The facility reported having no policy on notification of the physician or responsible party, and the record contained no documentation that the physician or responsible party were notified when these medications were not administered due to lack of pharmacy supply.

Penalty

Inspection fine: $61,065

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 follow professional standards of practice when obtaining a urine specimen for Resident #42, who had severe cognitive impairment and was always incontinent per the most recent MDS. The physician’s order for the resident specified a UA with culture and sensitivity every shift for three days but did not include an order to obtain the specimen via straight catheterization. Despite this, on the evening of 01/28/2025, an LPN attempted an in-and-out catheterization to collect the urine sample after determining the resident was unable to urinate into a urinal. During the procedure, bright blood was noted in the urine sample, and the catheter was removed. The LPN notified the on-call NP and documented that the resident appeared anxious but stable. According to the facility’s internal investigation and staff statements, the LPN called two CNAs into the room when the resident became combative during the catheterization attempt. The resident’s friend, who was present initially, reported that the resident said “Don’t do that” and crossed his legs when the nurse attempted to insert the catheter, and that staff then asked her to step into the hallway. While in the hallway, she heard the resident yelling. CNA statements and the facility’s synopsis of the event documented that the CNAs held the resident’s arms and legs while the LPN inserted the catheter in order to obtain the urine specimen. The facility’s investigation concluded that the resident was restrained during the procedure and that this was a common practice according to the LPN’s own statement, despite the resident’s right to refuse care. Following the catheterization, the resident was later noted around 5:00 a.m. on 01/29/2025 to have discomfort and pain with urination, hematuria, and blood clots in the brief. Vital signs were documented as stable, and the on-call NP was notified and ordered transfer to the ER. The resident returned from the hospital later that day with an indwelling urinary catheter and blood in the urine. The facility’s grievance report documented that the resident and representative alleged a catheter was used for a urine sample against the resident’s will, resulting in injury and hospitalization. The facility’s Medical Director and nursing leadership, when interviewed by surveyors, stated that professional standards required a physician’s order for straight catheterization if a clean-catch specimen could not be obtained and that the procedure should be stopped and the physician notified if the resident refused or showed distress. They acknowledged that the LPN and CNAs did not follow these standards when they proceeded with catheterization without a specific catheter order and while the resident was being held down.

Penalty

Inspection fine: $61,065

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 residents’ drug regimens were free from unnecessary drugs by not implementing required monitoring for medications with significant risk profiles. For one resident receiving Enoxaparin Sodium 40 mg daily for DVT prophylaxis, a physician’s order dated 2/12/26 directed staff to monitor for specific anticoagulant side effects, including discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, and nosebleeds, with documentation of ‘Y’ or ‘N’ on the MAR to reflect monitoring and findings. Review of the clinical record, including the February 2026 MAR, treatment administration record, and nurses’ notes, showed that this monitoring order was not implemented, despite daily administration of Enoxaparin from 2/12/26 through 2/20/26 and staff acknowledgment that such monitoring should be documented on the MAR. Another resident had a physician’s order for Metoprolol Tartrate 12.5 mg once daily for hypertension, with parameters to hold the dose if the systolic blood pressure was less than 100. The February 2026 MAR reflected the order but did not provide a place to record the blood pressure reading prior to administration. Review of the vital signs section and skilled nurses’ notes revealed no documented blood pressures on several days when the medication was ordered, and there was no evidence that blood pressure was taken before administration on those dates. An LPN stated that when a medication has parameters, the nurse should take the blood pressure and, if the medication is held, notify the physician, but the documentation reviewed did not show that this process occurred on the identified days. A third resident with diagnoses including hypertension and atrial fibrillation with a pacemaker was receiving anticoagulant therapy, as reflected on a recent MDS and a comprehensive care plan that focused on anticoagulant use and included an intervention that the resident would be free of discomfort or adverse reactions related to anticoagulant therapy. A physician’s order dated 12/28/25 directed Apixaban 2.5 mg orally every morning and at bedtime for coagulation management. Review of the MARs for December 2025, January 2026, and February 2026 showed no documentation of anticoagulation monitoring since admission, despite the ongoing Apixaban therapy and the care plan focus on monitoring for adverse reactions. An LPN described the facility’s process for monitoring anticoagulant side effects, including checking for blood in stool or urine, bruising, and ecchymosis and notifying the provider, but the resident’s records did not contain evidence that such monitoring was documented.

Penalty

Inspection fine: $61,065

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 physician-ordered laboratory tests for two residents. For one resident (R6), the clinical record showed a physician’s order dated 2/11/26 for a Vancomycin trough level to start on 2/16/26 and to be obtained every Monday. Review of the resident’s clinical record did not contain laboratory results for the Vancomycin trough level that was due on 2/16/26. On 2/20/26, the DON stated she could not provide the laboratory results for that date. An LPN later explained that lab orders are entered and scheduled in the computer system, then written in a lab communication book; the night shift nurse is to verify labs due the next day and place a face sheet in the lab communication book, and an outside lab company obtains the lab on the due date. The facility did not provide a policy regarding laboratory services. For another resident (R24), the facility staff did not obtain laboratory tests as ordered by the physician. The physician orders included labs that were to be completed on 1/20/2026, but the DON confirmed on 2/20/2026 that these lab tests were not completed as ordered and that there was no documentation explaining why the labs were done a day late. The Administrator, DON, General Manager, and Senior Director of Nursing Services were informed of these concerns during the survey, and no additional information was provided prior to exit.

Penalty

Inspection fine: $61,065

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 promote dignity and respect for Resident #5, who was admitted with diagnoses including CVA with hemiparesis, hemiplegia, and fibromyalgia. The most recent MDS coded the resident as cognitively intact with a BIMS score of 15 out of 15, while Section GG indicated the resident was dependent for mobility, transfers, bathing, and dressing and required supervision for eating. The care plan identified bladder incontinence related to impaired mobility and stated the resident was dependent with assistance of one helper for toilet use and required a walker for toilet use. Observations on 2/18/26 and 2/19/26 found Resident #5 in bed wearing an adult brief. The resident stated that night shift CNAs did not want to take the time to get her out of bed to the bathroom and wanted her to use the brief instead, and that the facility did not have female urinals or bedpans for her to use. At 8:15 AM and again at 2:00 PM on 2/19/26, no bedpans were found in the unit storage room. CNA #1 checked the supply room and a second room and found no bedpans, stating that they were agency and did not know where additional supplies were kept. The DON was informed that no bedpans were found on the unit and stated that additional bedpans were kept on the P3 level and supply would bring them up. The Administrator and DON were later informed of the resident's dignity issue.

Penalty

Inspection fine: $61,065

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

Summary

The facility failed to maintain an accurate MDS record for Resident 25 by incorrectly coding section N-0350 on the admission assessment with an ARD of 2/9/2026. The MDS indicated the resident received insulin one day in the past seven days, even though the resident’s BIMS score was 15 out of 15, showing cognitive intactness for daily decisions, and the resident stated during interview that they had never been diabetic or received insulin. Review of the resident’s February 2026 MAR and physician’s orders found no insulin orders and no documented insulin administrations since admission. When the MDS Coordinator reviewed the assessment, the coordinator stated section N-0350 had been coded incorrectly and that the resident should not have been coded as receiving insulin injections.

Penalty

Inspection fine: $61,065

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 implement Resident #34’s baseline care plan for anticoagulant therapy after the resident was admitted following ORIF surgery to the left hip. The baseline care plan dated 2/11/26 documented that the resident was receiving Lovenox (Enoxaparin Sodium) and required medication administration as ordered, daily monitoring for side effects and effectiveness, and observation, documentation, and reporting of adverse reactions such as blood in urine or stool, nausea, vomiting, diarrhea, bruising, sudden mental status changes, and significant changes in vital signs. The clinical record showed a physician’s order dated 2/11/26 for Enoxaparin Sodium 40 mg/0.4 ml, one injection daily for DVT prophylaxis, and the MAR showed the medication was administered daily from 2/12/26 through 2/20/26. A physician’s order dated 2/12/26 also directed anticoagulant monitoring for specific signs and symptoms and required documentation of whether monitoring was completed and whether any listed findings were observed, but review of the February 2026 MAR, TAR, and nurses’ notes did not show that this order was implemented. During interview, an LPN stated that anticoagulant monitoring is ordered or care planned and nurses sign off on the MAR to show the monitoring was done.

Penalty

Inspection fine: $61,065

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

Summary

The facility failed to review and revise the comprehensive care plan for one resident to include the resident's use of glasses. The resident's clinical record included a Service Evaluation and Health assessment documenting that the resident wore glasses, and the admission MDS with an assessment reference date of 11/24/24 documented that the resident wore corrective lenses. However, the comprehensive care plan initiated on 11/19/24 did not include documentation about the resident's use of glasses. During interview, the MDS Coordinator stated the resident did not have a diagnosis related to vision impairment and that the resident's vision was not impaired when wearing glasses, so the care plan was not revised to include the glasses. The MDS Coordinator also stated the care plan should reflect devices a resident needs because that was the purpose of the care plan.

Penalty

Inspection fine: $61,065

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 a resident with hearing aids and glasses to support the resident’s highest level of communication functioning and ADL abilities. The resident’s clinical record documented that the resident wore glasses and hearing aids, and a physician’s order directed that the hearing aids be charged at night, applied in the morning, and removed per schedule. A nurse’s note later documented that the hearing aid was not found per CNA and that the wife was aware. A speech therapy note documented that the resident was received in a wheelchair and was not wearing glasses or hearing aids during the session. The SLP removed distractions, presented a task, then donned the resident with glasses after noticing they were not being worn. The resident’s son later assisted in putting on the hearing aids after the SLP observed they were not in place. During interviews, an OT and an LPN stated that glasses and hearing aids should be used to support communication and ADLs, and the Administrator and DON were informed of the concern. The facility did not provide a policy regarding ADLs, hearing aids, or glasses.

Penalty

Inspection fine: $61,065

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 ADL care, specifically incontinent care, for a dependent resident with a history of CVA with hemiparesis, hemiplegia, and fibromyalgia. The resident’s MDS coded her as cognitively intact with a BIMS score of 15/15 and as dependent for mobility, transfers, bathing, and dressing, with supervision for eating. Her care plan identified bladder incontinence related to impaired mobility and directed that she was dependent on one helper for toilet use and required a walker for toilet use, with observation, documentation, and reporting for possible causes of incontinence such as a bladder infection. Observations showed the resident in bed wearing an adult brief on two separate mornings, and she stated that night shift CNAs did not want to take the time to get her out of bed to the bathroom and wanted her to use the brief instead. She also stated that the facility did not have female urinals or bedpans for her to use and that she was not being treated with dignity and respect. Surveyors found no bedpans in the unit storage room or a second room checked by CNA #1, who said she was agency and did not know where additional supplies were kept. The ADL record for January and February 2026 contained multiple missing entries across day, evening, and night shifts. CNA #2 described night care as rounds made at the start of the shift and then positioning herself to see call lights, stating there was no every-two-hour rounding on nights and that residents were assisted to the bathroom if they needed one person, but two-person assistance required help. The administrator and DON were informed of the concern, and no facility policy was provided.

Penalty

Inspection fine: $61,065

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 a thorough assessment of a stage 2 pressure injury for Resident #36 from the resident’s admission until 1/25/25. The clinical record showed a Service Evaluation and Health assessment documenting a stage 2 pressure injury on the sacrum, and a nurse’s note dated 11/19/24 also documented a stage 2 pressure injury on the sacrum. A physician order dated 11/19/24 directed Desitin External Paste 40% to the sacrum every shift for the stage 2 pressure ulcer/injury. Further review of the record did not reveal additional documentation of pressure injury assessment until 1/25/25, when a weekly skin check note documented the resident’s skin was intact. During interview, LPN #1 stated a pressure injury assessment should include measurement, color, and odor, and said facility nurses do not complete full weekly pressure injury assessments because they alert the wound physician when a resident has a pressure injury and he completes the assessments. The wound physician did not evaluate Resident #36 until 1/9/25 for new excoriation of the buttock. The Administrator and DON were informed of the concern, and the facility did not provide a policy regarding pressure injuries.

Penalty

Inspection fine: $61,065

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 appropriate care and services for an indwelling catheter for Resident #9. The resident was admitted with diagnoses including neuromuscular dysfunction of the bladder and had a most recent comprehensive MDS showing a BIMS score of 12 out of 15, indicating moderate cognitive impairment for daily decision-making. A physician order for indwelling Foley catheter care was in place. During observation, the resident was in bed with the head of the bed raised and an over-the-bed table positioned in front of her. The catheter collection bag was hanging on the side of the bed, and the tubing ran from the resident to the bag. A section of the tubing was observed resting on the base of the over-the-bed table. When informed of the observation, the DON stated that the tubing should not be in contact with anything to prevent infection.

Penalty

Inspection fine: $61,065

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 services for Resident #22, who was admitted with diagnoses including intraspinal abscess, neuromuscular dysfunction of the bladder, and polyarthritis. The resident’s most recent MDS, a Medicare 5-day assessment with an ARD of 2/6/26, coded a BIMS score of 14 out of 15 and indicated the resident was not cognitively impaired, with moderate assistance needed for mobility, transfers, and dressing, dependence for bathing, and supervision for eating. Observations on 2/17/26 and 2/18/26 showed the resident’s incentive spirometer sitting uncovered on the bedside table with the mouthpiece also laying on the table, and the resident stated on 2/17/26 that it had not been covered during her time in the facility. On 2/18/26, LPN #3 stated the incentive spirometer should be kept in a plastic bag for infection control, and a CNA was observed placing it in a plastic bag. The Administrator and DON were informed of the concern on 2/23/26, and no facility policy for the incentive spirometer was provided.

Penalty

Inspection fine: $61,065

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 required physician visits were completed for Resident #7. The resident was seen by a physician on 3/12/25, but the clinical record showed no physician or physician extender visit until 6/19/25, a gap of 99 days. After that visit, the resident was not seen again by a physician or physician extender until 9/3/25, a gap of 76 days. During an interview on 2/21/26, the DON stated that most residents do not stay long term and that the facility does not really track physician visits. The facility did not provide a policy regarding physician visits.

Penalty

Inspection fine: $61,065

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 verify licensure at the time of hire for two of three CNA records reviewed, CNA #10 and CNA #11. On 2/23/26 at 9:00 a.m., staff were asked to provide evidence that licensure had been verified at the time of hire for both CNAs. According to the Director of Human Resources, CNA #10 was hired on 5/13/25 and CNA #11 was hired on 10/10/25, but despite multiple requests, no evidence of license verification at the time of hire was provided. On 2/23/26 at 5:02 p.m., the Administrator and DON were informed of the concern. The DON stated that license verification at the time of hire is important to make sure staff members are competent and to prevent resident abuse. On 2/24/26 at 12:19 p.m., the Director of HR stated she was responsible for overall license verification and explained that the potential employee brings a copy of their current license at the initial interview, she verifies it through the state department of health professions after management approval, and the employee’s manager verifies it again after the employee starts working with residents. The facility’s abuse policy stated that the Business Office Coordinator/designee performs background checks prior to hiring and that the community must not employ individuals with certain abuse-related findings or disciplinary actions against their professional license.

Penalty

Inspection fine: $61,065

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

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when staff failed to ensure Bumetanide was available for administration for Resident #24. The physician ordered Bumetanide 0.5 mg by mouth once daily for diuretic use, and the January 2026 MAR documented the order. On 1/21/2026, the 9:00 a.m. dose was marked with a 9, indicating other/see progress notes. The progress notes documented at 11:53 a.m. on 1/21/2026 stated, "Awaiting pharmacy supply." Review of the backup pharmacy system in the medication room did not show Bumetanide Oral Tablets were available. An LPN stated that if a medication is not in the cart, the nurse should check the backup pharmacy system, notify the pharmacy if it is not there, and notify the physician if the medication was not given. The DON stated the nurse should check the backup system, call the pharmacy if needed, and then notify the physician and responsible party and document in the medical record. The facility policy stated the provider pharmacy assists with acquisition, receipt, dispensing, and administration of medications to meet resident needs.

Penalty

Inspection fine: $61,065

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

Medications and biologicals were not stored in a safe manner for two residents. For one resident, heparin flushes ordered for intravenous use every shift were observed in the resident’s room on the dresser and over-bed table rather than in a locked storage area. The resident was lying in bed during the observations, and an LPN stated that heparin flushes should be kept in the medication room or medication cart until ready for use and should not be left in resident rooms because they are medication. For another resident, who was unable to self-administer medications but had a BIMS score of 15 indicating cognitive intactness, a box of ibandronate 150 mg was found in the bedside nightstand drawer during an interview. The resident stated the medication had been brought from home by the resident’s son and that the doctor was aware it was in the drawer, while also stating the doctor had instructed the resident not to take it and would order it. The clinical record did not contain an order for ibandronate, and an LPN stated home medications brought in by family should be placed in a locked medication cart and not kept at the bedside.

Penalty

Inspection fine: $61,065

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 complete and accurate clinical record for Resident #108 regarding the resident’s discharge from the skilled nursing unit. The census information showed the resident was discharged on 4/26/26, and a progress note dated 4/27/26 stated that the guest was discharged from the unit AMA before an assessment could be conducted. However, the clinical record contained no additional documentation describing the discharge or the events surrounding it. During interview, an LPN stated she was on duty when the resident left the unit and described that the resident’s son told her the resident wanted to leave after a CNA accidentally spilled water on the resident’s overbed table while cleaning it up. The LPN said the resident decided not to remain in the skilled nursing unit because of the spill, and that the son tried to keep the resident there. She stated the resident signed out AMA before leaving, and that the Administrator instructed her to complete a grievance form. The DON confirmed that the grievance form was not part of the clinical record and that a nurse’s note should have been written so the record would accurately reflect the events surrounding the discharge.

Penalty

Inspection fine: $61,065

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

Summary

The facility failed to provide evidence of required training in effective communication for three of ten staff records reviewed: OSM #3, a speech and language pathologist, CNA #6, and LPN #6. On 2/20/26, surveyors requested evidence that these staff members had completed the required training, but a review of records provided by the Director of Human Resources did not show completion of the effective communication training for any of the three staff members. During an interview on 2/24/26, the Director of Human Resources stated that new employees receive a list of required trainings through a third-party education provider and complete the trainings online, after which she transfers completion records to another third-party software system. She stated that she does not personally verify which trainings are required for each employee and only receives notifications from the third party when trainings are due. A review of the facility's annual training assignments for direct care staff for 2026 showed that January training included "Communicating Effectively" for CNAs, Lead CNAs, LPNs, LVNs, and RNs. No additional information was provided prior to exit.

Penalty

Inspection fine: $61,065

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 training in resident rights and facility responsibilities for one of ten staff records reviewed, OSM #3, a speech and language pathologist. On 2/20/26, surveyors requested evidence of this training, but the facility records provided by the Director of Human Resources did not show that the training had been completed. On 2/24/26, the Director of Human Resources stated that new employees receive a list of required trainings through a third-party education provider at hire, that the trainings are completed online, and that completion records are transferred to another third-party software. She also stated that she does not personally verify which trainings are required for each employee and does not keep up with the specific subject matter trainings required by regulations. A review of the facility’s onboarding curriculum for all staff showed resident rights as part of the required training.

Penalty

Inspection fine: $61,065

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 abuse, neglect, and exploitation training for one of ten staff records reviewed, OSM #3, a speech and language pathologist. On 2/20/26, surveyors requested evidence of this training, but a review of records provided by the Director of Human Resources did not show that the training had been completed. On 2/24/26, the Director of Human Resources stated that new employees receive required trainings through a third-party education provider, that completion records are transferred to another software system, and that she does not personally verify which trainings are required for each employee or keep track of specific regulatory training requirements. A review of the facility's onboarding curriculum showed that abuse and neglect prevention was listed as a required training.

Penalty

Inspection fine: $61,065

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 ten staff records reviewed, OSM #3, a speech and language pathologist. On 2/20/26, surveyors requested evidence of infection control training for OSM #3, but a review of records provided by the Director of Human Resources did not show that the training had been completed. During an interview on 2/24/26, the Director of Human Resources stated that new employees receive required trainings through a third-party education provider, that completed trainings are transferred into another third-party software, and that she does not personally verify which trainings are required for each employee or keep up with the specific subject matter trainings required by regulations. Facility documents reviewed included onboarding curriculum listing online required training for Understanding Bloodborne Pathogens and annual training assignments for 2026 listing Infection Control: Essential Principles.

Penalty

Inspection fine: $61,065

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

Summary

The facility failed to provide evidence of required compliance and ethics training for one of ten staff records reviewed, OSM #3, a speech and language pathologist. On 2/20/26, surveyors requested evidence of the training, and the facility records provided by the Director of Human Resources did not show that the training had been completed. During an interview on 2/24/26, the Director of Human Resources stated that new employees receive a list of required trainings through a third-party education provider, that the trainings are completed online, and that she transfers completion records to another third-party software after completion. She also stated that she does not personally verify which trainings are required for each employee and does not keep up with which subject matter trainings are required by regulations. A review of the facility's onboarding curriculum for all staff showed an online required training for Compliance and Code of Conduct.

Penalty

Inspection fine: $61,065

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 ten staff records reviewed, OSM #3, a speech and language pathologist. On 2/20/26, surveyors requested evidence of behavioral health training for OSM #3, but facility records provided by the Director of Human Resources did not show that the training had been completed. The Administrator and DON were informed of the concern on 2/23/26 at 5:02 p.m. During an interview on 2/24/26 at 12:19 p.m., the Director of Human Resources stated that new employees receive a list of required trainings through a third-party education provider and that she transfers completion records into another third-party software, but she does not personally verify which trainings are required for each employee and does not keep up with specific subject matter trainings required by regulations. A review of the onboarding curriculum for all direct care staff showed online required training that included Behavioral Expressions.