Garden Village

Penalty

No penalty information released

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

Summary

A resident who was dependent on staff for activities of daily living (ADLs), including bathing and hygiene, did not receive a shower or bath for 11 days after admission. The resident was cognitively intact, incontinent of bowel and bladder, and required assistance from two staff members for ADLs. The resident reported not recalling being offered or refusing showers during this period. The resident developed a yeast rash in the perineal area, which was later treated with an antifungal medication after being examined by the facility physician. The resident's representative reported the lack of showers to facility staff, after which the resident received a shower. Review of the facility's records showed no documentation of shower refusals or alternative bathing methods, such as bed or sponge baths, during the first 11 days of the resident's stay. The resident's name was not entered into the shower/bath schedule book for the appropriate days, and staff confirmed that anyone reviewing the schedule would not have known it was the resident's shower day. The facility's policy required documentation of refusals and provision of necessary assistance for personal hygiene, which was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that food temperatures were consistently monitored accurately and legibly for meals logs reviewed over three months. The facility’s 07/2018 Food and Nutrition Services Food Safety policy stated that foods would be monitored for bacterial growth by checking times and temperatures to ensure safety. During interview, the Dining Services Director stated food temperatures were expected to be obtained when food was taken out of the oven, right before it was served, and at the end of serve out, and also stated the food logs were not completed fully or accurately. Review of the kitchen’s food temperature logs showed that in June 2025, 11 of 93 meal temperatures were not accurately completed and five were illegible; in July 2025, 10 of 93 were not accurately completed and six were illegible; and in August 2025, six of 93 were not accurately completed and three were illegible. The facility also failed to ensure kitchen equipment surfaces were cleaned and sanitized. Observation of the kitchen showed built-up brown, fuzzy, string-like material mixed with oil on the blades of the vents on the dual ovens, dried food and dirt on the lid of the ice machine, dried splattered white and brown food particles on the outside vents of the ice machine, and pink and black moist sediment on a white plastic cover inside the ice machine. The plate warmer also had visible food crumbs on the bottom of both sides. Staff stated cleaning of kitchen equipment was supposed to be completed daily and initialed by the person who cleaned it, and that if the cleaning log had not been initialed then the cleaning had not been done. Review of the kitchen cleaning log for August 2025 showed 25 different items had not been cleaned on 18 different days, and the remaining logs lacked months, days, or dates. A maintenance work history report showed the ice machine had been cleaned only twice over the prior six months.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe, clean, sanitary, and comfortable homelike environment in several areas of the building. In resident rooms 301, 302, and 304, observations showed dried food, crumbs, trash, dust buildup, and liquid stains within the ventilation face plates of the PTAC units. Staff E, the Maintenance Assistant, stated the filters had been cleaned but not under the ventilation face plate, and also stated the food particles and buildup needed to be cleaned and could be a safety concern if the heater component of the PTAC unit was used. The Administrator and another staff member stated the food particles and trash were a hazard within the PTAC units and expected them to be cleaned out by maintenance staff. In the 300's hallway shower room, observations showed two ceiling duct vents with thick dust and grime buildup, a black hole in the wall tile behind the shower room door, and an incorrectly installed rubber doorstop. Staff E stated the vents had been missed, the door must have slammed into the tile, and the doorstop needed to be reinstalled correctly with the tile repaired. In Resident 12's room, observation showed a large gouge in the linoleum flooring with three flapped sections draped back over the floor to cover the subfloor. Staff E stated the gouged flooring was a hazard and needed to be replaced, and the Administrator and another staff member stated the gouge in the flooring was a hazard and would be expected to be fixed.

Penalty

No penalty information released

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

Summary

The facility failed to maintain components of its infection prevention and control program related to the water management program, hand hygiene and glove changes during resident care, and cleaning and disinfecting of environmental surfaces and isolation precaution rooms. The report states the facility’s Water Legionella Water Management Program applied to multiple water systems, including storage tanks, water heaters, shower heads, infrequently used equipment, eye wash stations, and ice machines, but the written policy did not include control measures for ice machines, shower heads, areas of water stagnation, infrequently used equipment, or eye washing stations. The policy also did not identify how monitoring of control measures would be completed, the frequency of monitoring, acceptable ranges, or interventions when control measures were outside acceptable ranges. During interview and record review, Staff E stated the facility did not have a current Maintenance Director and was not familiar with the WMP. Staff E reported completing water temperature checks but not overseeing or completing the changing/flushing of emergency water storage containers, monthly water systems chlorine residual testing, or weekly flushing/inspection of eye washing stations. The control measure logs showed the emergency water storage containers were changed/flushed every six months and were last performed late, monthly chlorine residual testing was not completed for three of four scheduled times in August 2025 and had no documentation for September 2025, and eye washing station flushing/inspection was not completed for two of four scheduled weeks in August 2025 with no September documentation. The ice machine by the main nursing station also had a log last completed late, and during observation Staff E and the surveyor found a two-inch by one-inch black substance under the inner ice storage retainer plate. Staff E stated the substance should not be there and that the ice machine was not monitored properly. Staff B, the DON, stated they were not familiar with the WMP, control measures, acceptable ranges, or testing protocols, and stated the WMP needed to be fixed. The facility also failed to ensure proper hand hygiene and glove changes during incontinent care for three staff members observed. Staff AA and Staff BB completed a mechanical lift transfer and incontinent brief change, but after glove changes they did not perform hand hygiene before continuing resident care, including perineal care and handling items on the resident’s bedside table. Staff AA used the same soiled gloves to communicate with the resident by writing on paper from the bedside table, then touched and rearranged items on the bedside table, closed the privacy curtain, and moved the wheelchair without hand hygiene. In another observation, Staff K removed a soiled brief, cleansed the resident, and continued wearing the same soiled gloves while redressing the resident and handling bed controls and supplies. After removing gloves and disposing of linen and waste, Staff K entered another resident’s room and assisted a transfer without washing hands first. Staff B stated gloves should be changed between soiled and clean tasks and hands should be washed after removing gloves during incontinent care before starting new tasks. The facility also failed to use an EPA-registered disinfectant for environmental cleaning and disinfection of isolation precaution rooms. Staff B stated two residents in the back 400 hallway were on isolation precautions. Housekeeping staff reported using Medline Neutral Floor Cleaner throughout the facility, including the isolation rooms. Staff DD, the Laundry/Housekeeping Director, and Staff FF, a housekeeper, confirmed the same product was used in resident rooms and throughout the facility. During observation, Staff DD and the surveyor could not find an EPA registration number on the chemical, and Staff DD stated they were not aware the chemical was not a registered disinfectant. Staff A, the Administrator, and Staff B stated they were not aware the product used by housekeeping was not a disinfectant, and Staff B stated the facility should be using an EPA registered disinfectant when cleaning and disinfecting isolation precaution rooms.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident was free from interference or coercion regarding the resident’s choice to smoke cigarettes. Resident 4 was admitted with diagnoses including a left arm fracture, depression, and anxiety, and the 08/05/2025 comprehensive assessment showed the resident was cognitively intact and able to make needs known. Hospital documentation showed the resident had smoked cigarettes every day and had a long smoking history. The resident’s signed admission paperwork did not include documentation that the facility’s smoking policy or rules had been provided or signed, and medical records staff later confirmed there was no record that the non-smoking policy had been given in the admission paperwork. The facility changed to a smoke-free campus and had a policy stating smoking paraphernalia would be surrendered to staff and kept in a locked box, with residents informed that violations could place them at risk for discharge. However, the policy did not include a smoking assessment process for residents who chose to continue smoking or guidance on how to safely dispose of cigarettes. Staff records showed the resident was observed with cigarettes in the building, was told the facility was 100 percent non-smoking, and was given a locked box for storage. Staff also documented that the resident was seen leaving the facility, smoking off the property, and disposing of cigarette butts in a rocky area down the road. During the smoking evaluation, staff determined the resident was unsafe to smoke independently because the resident could not retrieve a dropped cigarette and could not demonstrate safe extinguishing or disposal of ashes. After the evaluation, staff informed the resident that the resident was not safe to smoke and discussed possible discharge if unsafe smoking continued. The resident and representative stated staff were upset about the resident smoking cigarettes even when it occurred off the facility property, and the resident reported being told to switch to vaping or risk being transferred or discharged. Staff later stated the resident had a right to smoke but also stated the resident was non-compliant with the smoking policy and that alternative placement would be sought. Staff further acknowledged that the resident had not been reassessed after receiving education and that the facility had no documentation that residents or representatives were informed of the smoke-free policy change.

Penalty

No penalty information released

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

Summary

The facility failed to protect personal privacy for two residents during incontinent brief changes and capillary blood glucose checks. The facility policy, Resident Rights Privacy and Confidentiality, dated 07/2018, stated each resident had the right to privacy during personal care and medical treatments. Resident 34 had severe cognitive impairment, dementia, and an anxiety disorder, and was dependent on staff for ADLs including personal hygiene and dressing. On 09/02/2025, Staff F provided an incontinent brief change in Resident 34's bedroom without pulling the privacy curtain around the bed, even though the resident's bed was closest to the door and the roommate was in the room. On 09/08/2025, Staff J and Staff K also provided incontinent care without drawing the privacy curtains. Staff P stated the door should be closed and the privacy curtain drawn around the bed, including closing the curtain to prevent view from a roommate. Resident 72 had severe cognitive impairment, dementia, and diabetes mellitus, and had a physician's order for CBG checks before meals and at bedtime. On 09/02/2025, Staff L checked Resident 72's blood sugar while the resident was eating lunch in the dining room with other residents present. On 09/04/2025, Staff N stated Resident 72's CBG checks could be done in the lobby or room, and later that day performed a CBG check in the common area while the resident was asleep in a chair in the lobby across from the nurse's station. On 09/08/2025, Staff O stated the resident had been allowed to have the CBG check done while still in bed. Staff P stated CBG checks should be done in the resident's room for privacy, and Staff B, DON, stated treatments and procedures should not be done in common areas but within the resident's room.

Penalty

No penalty information released

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

Summary

The facility failed to monitor person-centered behaviors and obtain informed consent for psychotropic medications for two residents reviewed for unnecessary medications. The deficiency involved Resident 9 and Resident 27, both of whom had mental health diagnoses and were receiving psychotropic medications. The report states this practice placed the residents at an increased risk of receiving medications they did not want or no longer needed and inadequate dosing of medications. Resident 9 was admitted with multiple mental health diagnoses including violent behaviors, hallucinations, depression, and anxiety. The resident’s comprehensive assessment showed moderately impaired cognition and that psychotropic medications were being received. The care plan included mood and behavior interventions and resident-specific behavior monitoring, but the July through September 2025 MAR showed no person-centered behaviors were being monitored. The record also showed orders for Sertraline and Olanzapine, but no consent was obtained for Sertraline. Staff stated they reviewed behaviors during monthly psychotropic meetings, but they did not see person-centered behavior monitoring for Resident 9 and could not explain why it was absent. Resident 27 was admitted and later readmitted with diagnoses including schizoaffective disorder, anxiety, depression, and drug-induced tremors, and was receiving behavioral health services. The resident’s assessment showed moderate cognitive impairment but ability to make needs known. The resident was receiving Risperidone, Perphenazine, and Fluoxetine, and the physician orders addressed adverse side effect monitoring but did not include monitoring of individualized behaviors for medication effectiveness. Although the care plan listed targeted behaviors to be monitored every shift, the September 2025 MAR did not include resident-centered behavior monitoring. Staff confirmed that Resident 27’s individualized behaviors were not being monitored and stated the resident’s general behavior monitoring had dropped off during hospitalization and was not restarted after readmission.

Penalty

No penalty information released

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

Summary

The facility failed to follow up on written bed hold notices with residents and/or resident representatives for 2 of 2 residents reviewed for the discharge process. The facility’s policy titled, Notice of Bed Hold Policy Before/Upon Transfer, stated that written information about the bed hold policy, reserve bed payment policy, bed hold duration, and the resident’s ability to return would be provided before transfer, at the time of transfer, or within 24 hours for an emergency transfer. The facility’s Hospital Transfer Packet guidelines stated that the bed hold policy, authorization to reserve a room/bed, and transfer notification were to be sent with the resident to the hospital, and if the resident could not comprehend the information, the resident representative was to be notified. Resident 27 had diagnoses including diabetes, anxiety, depression, and other mental/behavioral health disorders, and a comprehensive assessment showed moderate cognitive impairment but that the resident could make needs known. After abnormal lab results were received, nursing staff communicated with the provider/resident and the resident was transported by ambulance to the hospital, with hospital paperwork given to paramedics. The record showed no written bed hold information was provided to the resident or resident representative before or at the time of transfer. Resident 82 had severe cognitive impairment, stroke, and dementia, and was dependent on staff for physical and cognitive needs. After a significant change in condition, the resident was transported by ambulance and admitted to the hospital, but the record showed no written notification that the resident or representative received a bed hold notice. Staff interviews indicated the process was expected to include a packet and progress note documentation, but the records reviewed did not show that the bed hold policy was provided or followed up as required.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the safety and supervision of one resident when the missing resident protocol was not implemented after the resident did not return from an outing with family at the expected time. The facility policy required staff to make immediate calls to the resident’s contact number, notify the Administrator and DNS if the resident could not be reached, call 911 for a well-check at the last known location, and contact hospitals to locate the resident. Resident 61 had impaired memory, depression, a chronic inflammatory lung disease causing obstructed airflow, and required substantial assistance from staff for most ADLs and transfers. Resident 61 left the facility with family and was expected back by 8:00 PM, but staff did not treat the resident as missing until hours later. The record showed the day shift nurse was informed the resident was out with family at 6:16 PM, the night nurse learned at 10:30 PM that the resident had not returned, and the DNS was texted at 11:29 PM. The DNS did not read the text until 2:08 AM and then called the facility, learning the resident was still out; 911 was called at 2:34 AM. The administrator stated the resident was later found at a friend’s residence in a wheelchair, watching television, and said they were fine and would not return to the facility. The DNS stated staff failed to follow the missing resident protocol and that there were delays in reporting to administration.

Penalty

No penalty information released

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

Summary

The facility failed to consistently implement nutrition interventions for a resident with dementia, malnutrition, and newly diagnosed neck and tonsil cancer who was receiving weekly chemotherapy and daily radiation. The resident’s comprehensive assessment noted moderate cognitive impairment, independence with eating, and complaints of difficulty or pain with swallowing. During multiple observations, the resident was seen with meals in front of them but stated it was painful to swallow and that they could only drink milk or limited fluids, while meal trays remained largely untouched. The resident repeatedly reported that staff did not offer alternatives when they could not eat the meals served and did not ask what foods they could tolerate. On one occasion, the resident stated they were hungry but could not eat because swallowing was too painful, and that no staff had discussed weight loss, diet, or meal refusals with them to determine a different plan. Meal monitoring from 08/10/2025 through lunch on 09/08/2025 showed frequent low intake, refusals, and undocumented meals. The resident’s weight dropped from 212.5 pounds to 185.5 pounds in 30 days, a 12.71 percent loss. Record review showed the outside cancer provider documented swallowing-related dietary guidance, including avoiding spicy and acidic foods, eating small amounts, using lukewarm or room temperature foods, and adding gravy or sauce for moisture. The provider also discussed with facility staff that the resident should receive nutritionally enhanced meals, snacks between meals, and possible diet texture changes. However, the facility’s diet slip still listed acidic items such as orange juice and citrus fruit and did not reflect nutritionally enhanced meals, extra snacks, or the other documented dietary modifications. The nutritional care plan had not been updated since 07/03/2025, and staff interviews showed they had not discussed intake alternatives with the resident or reviewed the outside dietitian notes from prior cancer treatment appointments.

Penalty

No penalty information released

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

Summary

The facility failed to ensure one resident was free from unnecessary drugs by not providing monitoring and care planning specific to cisplatin chemotherapy. Resident 9 was admitted with dementia and cancer of the neck and tonsil, and the comprehensive assessment showed moderately impaired cognition with pain or difficulty swallowing. The resident was receiving weekly cisplatin and daily radiation treatment, and during observation the resident was lying in bed with the lower part of the face and skin from below the eyes to the upper chest bright red. The resident stated they had pain in the red areas and difficulty eating due to chemotherapy and radiation treatments. Surveyors observed a neutropenic precautions sign on the resident’s door, but it did not include precautions for chemotherapy treatment. Staff stated they monitored the resident for pain, infection, and neutropenia, but there was no other monitoring specific to the chemotherapy or radiation treatment. The September 2025 MAR showed no monitoring for adverse side effects related to the chemotherapy medication. The resident used a bedside commode in the room and did not use toilet paper or perform hand hygiene afterward. The care plan contained no resident-specific plan for cisplatin, no instructions for handling linens, urine, feces, or clothing after treatment, no staff restrictions related to pregnancy or breastfeeding, and no contact information for issues related to chemotherapy treatment.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective pest control program to prevent and deal with flies in Hall 3, including the 300's rooms. The facility policy titled, Physical Environment Safe, Functional, Sanitary Environment, dated July 2018, stated the facility would maintain an effective pest control program to control pests and rodents. Survey observations showed flies entering and gathering in hallways and resident rooms, including Resident 12's room. Resident 12 was admitted with diagnoses including kidney complications, a history of stroke with dysarthria, and multiple wounds requiring daily dressing changes. The 08/11/2025 comprehensive assessment showed some cognitive impairment, but the resident was able to make needs known. During observation and interview, multiple flies were seen buzzing around the resident's face, bed, beard/mustache, lips, head, arms, bedsheets, and bedside table, and the resident stated the flies had been in the room since admission. During a later wound care observation, two flies were again seen around the resident's face and mouth while an LPN performed a dressing change and swatted at a fly. Staff stated flies had been coming into the facility since around the middle of June 2025, that open outer doors near the parking lot and garbage cans allowed flies in, and that fly control devices were not added until later, with the Administrator acknowledging the increased number of flies in the building.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the nursing staff posting was posted daily and reflected the actual nursing staff hours worked during 3 of 3 days of the survey period. On 09/05/2025 at 10:30 AM, surveyors observed that there were no nursing staff postings available within the facility for residents, resident representatives, staff, or visitors to view the actual staff available to provide resident care. On 09/08/2025 at 1:36 PM, the facility again had no nursing staff postings viewable to residents, family, or visitors; the posting was found in a binder with the nursing staff assignments for the day and did not reflect any staffing changes. On 09/09/2025 at 2:38 PM, a nursing staff posting was hanging in the nursing station and was not viewable to residents and visitors, and it also did not reflect any staffing changes. Staff H, the Staffing Coordinator, stated they had a binder for the nursing staff postings and were new to the position and unaware the posting needed to be available for residents, family, and visitors to view current staffing available for resident care. Staff B, the DON, and Staff A, the Administrator, acknowledged that the nursing staff posting had not been readily available for residents, family, or visitors to view the current nursing staff available for resident care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure its Facility Assessment was updated to include specific staffing needs for each resident unit and each shift, as well as plans to maximize direct care staff recruitment and retention. A review of the Facility Assessment dated August 2025 did not show documentation of resident acuity or specific staffing/resource needs for each resident unit in the facility or staffing needs for each shift. It also did not include documentation of how the facility would develop and maintain a plan to maximize recruitment and retention of direct care staff. During an interview and record review on 09/04/2025 at 1:40 PM, the Administrator stated the Facility Assessment was reviewed annually and as needed and was expected to be completed as required, but acknowledged it had not specifically included the correct staffing needs based on the overall resident acuity and population needs of the facility.

Penalty

No penalty information released

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

Summary

The facility failed to electronically submit complete and accurate direct care staffing information, including data for agency and contract staff, to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of 2024, as required by Payroll Based Journal (PBJ) reporting regulations. Review of the CASPER Payroll-Based Journal Staffing Data Report confirmed that the facility did not report staffing data for the period of July 1, 2024, through September 30, 2024. This omission resulted in CMS having inaccurate data related to the facility's nursing home staffing levels. Interviews with facility staff revealed that the Business Office Manager was responsible for PBJ reporting during the relevant period but could not recall if the report was run or submitted, and was unaware that the submission did not go through. The Director of Business Intelligence at the corporate office confirmed that the CASPER report showed no data was submitted and that a confirmation report should have been received. The current Administrator stated they were not in the role at the time and were unaware of the missing submission until the survey. This is a repeat citation from a previous Statement of Deficiencies.

Penalty

No penalty information released

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

Summary

The facility failed to notify the physician and resident representative of a fall experienced by Resident 2, which was not reported until 12 days after the incident. Resident 2, who was admitted with diagnoses including a cerebral vascular accident and hemiplegia, had moderate cognitive impairment and required substantial physical assistance for transfers. The resident was at risk for falls due to confusion and unawareness of safety needs, as documented in their care plan. Despite these risks, the fall on 01/22/2025 was not communicated to the necessary parties, placing the resident at risk for a delay in medical treatment and excluding the resident representative from healthcare decision-making. The incident report for the fall was not completed until 02/03/2025, and the post-fall paperwork initiated by Staff C, an RN, was not documented in the resident's electronic health record. Staff C had a family emergency and left abruptly without notifying the next shift or completing the necessary documentation. The Director of Nurses, Staff B, was unaware of Staff C's departure and expected at least a text message notification. This oversight resulted in a failure to follow the facility's policy on notifying changes in condition and accident hazards supervision, as well as a repeat citation from a previous deficiency statement.

Penalty

No penalty information released

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

Summary

The facility failed to revise the comprehensive care plan for a resident after a significant change in their condition, which placed the resident at risk for injury and unmet care needs. The resident was readmitted with a left neck of the femur fracture and required substantial assistance for activities of daily living and transfers. However, the care plan, last revised on 11/18/2024, did not include updated interventions for the resident's transfer needs, such as the number of staff required for a safe transfer. During an observation, staff members were unsure of the resident's transfer method and weight-bearing status, leading to an improper transfer without the use of a gait belt. Interviews with staff revealed that the care plan should have been updated following the significant change assessment, but this was missed by the MDS Coordinator. The Director of Nursing stated that the nursing staff or unit manager should have updated the care plan upon the resident's readmission, but it was unclear why this was not done. The lack of updated information on the care plan and Kardex led to confusion among staff about the resident's transfer needs, resulting in a transfer that did not adhere to the necessary safety protocols.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to ensure proper assessments and supervision for residents at risk of elopement, resulting in a tragic incident involving Resident 84. This resident, who had moderately impaired cognition and required assistance for activities of daily living, was not assessed for elopement risk upon admission. The facility's elopement procedures were not followed, as staff failed to recognize the resident's absence in a timely manner. Resident 84 was last seen by staff around midnight, but their absence was not noted until their significant other arrived for an appointment the next morning. By the time the facility initiated a search and notified law enforcement, Resident 84 was found deceased in the community. Another deficiency involved Resident 73, who suffered a second-degree burn from hot coffee served without a lid, despite being identified as a safety risk due to impaired cognition. The facility's policy required lids on hot beverages for residents like Resident 73, but this was not adhered to, leading to the resident spilling hot coffee in their lap. The coffee temperature was not consistently checked before serving, contributing to the incident. Additionally, the facility failed to implement safety interventions for Resident 12, who was assessed to require supervision and a smoking apron while smoking. Despite this assessment, Resident 12 was observed smoking unsupervised and without a smoking apron, both on and off facility grounds. The resident was also seen extinguishing cigarettes in a hazardous manner and storing them in their clothing, which posed a fire risk. The facility did not provide a designated area or device for safe cigarette disposal, further compromising safety.

Removal Plan

• Nursing staff identified all residents at risk for elopement who also had diagnoses of Substance Use Disorder (SUD) and updated the care plan.
• Implemented education on the elopement/missing person policy and process.
• Identified and recognized at-risk residents and the process for residents who wished to access the community.
• All education was to be completed prior to all staff's next scheduled shift.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to adequately assess and address changes in residents' conditions, leading to significant deficiencies in care. Resident 83, who was admitted with a right hip fracture and dementia, experienced harm due to a facility-acquired pressure injury. Observations revealed that Resident 83 was often left in discomfort, with visible skin issues and without proper bedding or access to a call light. Despite documented new skin issues, there was a lack of follow-up treatment or monitoring, and staff failed to report or address the resident's pain and skin conditions. Resident 79, who was admitted with schizoaffective disorder and later diagnosed with epilepsy, continued to experience seizures due to the facility's failure to administer prescribed medications in a timely manner. Despite having orders for Midazolam nasal spray and Ativan, these medications were not processed or administered, resulting in ongoing seizure activity. The hospice nurse's orders were not reflected in the resident's medication administration record, and there was a lack of communication and follow-up to ensure the resident received necessary care. The facility also failed to manage constipation for Resident 12, who went extended periods without bowel movements despite having PRN medications available. The nursing staff did not document bowel assessments or notify the physician of the resident's condition. Additionally, the facility did not obtain or report laboratory results for several residents, including Residents 4, 30, and 68, despite repeated orders for necessary tests. This lack of follow-through on lab orders and referrals further exemplifies the facility's deficiencies in providing timely and appropriate care.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to ensure that a resident was free from significant medication errors, resulting in harm to one of the residents. Resident 54, who had a diagnosis of dementia and severely impaired cognition, was mistakenly given an antipsychotic medication intended for another resident. This error led to the resident experiencing acute toxic encephalopathy and increased sleepiness, necessitating a four-day hospitalization. The incident occurred when Staff VV, an LPN, mixed up the medications of Resident 54 with their roommate's medications, failing to adhere to the five rights of medication administration: right patient, right drug, right dose, right route, and right time. The hospital discharge summary indicated that Resident 54 was admitted with low blood pressure and required intravenous fluids. The facility's incident investigation confirmed that Staff VV realized the error and contacted the physician, who ordered the resident to be sent to the hospital. Despite the Director of Nursing Services stating that the resident returned to their baseline with no negative effects, the failure to follow proper medication administration protocols was evident. The Director also acknowledged not reviewing the hospital records upon the resident's readmission, which was an oversight.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to adhere to its food safety policy by not properly discarding expired foods in both the dry food storage room and the walk-in refrigerator. During an observation conducted on a kitchen tour, several expired food items were found, including organic greens, a spring mix salad blend, fresh onions, and boxes of coffee. These items were past their expiration dates, indicating a lapse in the facility's food rotation and monitoring processes. Staff R, the Dietary Manager, acknowledged the deficiency during an interview, explaining that the facility's process involved a first in, first out system to prevent food expiration. However, it was revealed that the cooks, who were responsible for checking expiration dates during each shift, missed these items. Additionally, there was an oversight in monitoring the dry storage area, particularly for items not frequently used, highlighting a need for a more effective system.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in unmet care requirements and potential negative outcomes for their physical and mental health. Observations and interviews revealed that the facility was short-staffed, leading to delays in providing essential care such as bathing, grooming, and assistance with activities of daily living. Residents expressed frustration over not receiving scheduled showers, and staff confirmed that they were unable to complete tasks due to staffing shortages. The lack of adequate staffing also affected the completion of Minimum Data Set (MDS) assessments, with several being completed late or not at all. The facility also failed to address significant changes in residents' conditions, such as the admission of a resident to hospice care without completing a significant change MDS assessment. Additionally, the facility did not prevent the development of pressure injuries, as evidenced by a resident developing a deep tissue injury on their heel due to improper positioning and lack of preventive measures. The facility's restorative care program was insufficient, with residents not receiving necessary therapy to maintain range of motion and prevent contractures. Furthermore, the facility did not ensure proper supervision and training to prevent elopements, as demonstrated by a resident who went missing without an elopement risk assessment or care plan in place. Staff interviews indicated a lack of training on elopement procedures, and the facility's staffing issues contributed to the inability to provide adequate supervision. The resident council meeting and additional resident interviews highlighted ongoing concerns about staffing levels, long wait times for assistance, and inconsistent care quality, particularly on weekends and during shifts with high call-ins.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the regulatory timeframes for six residents, leading to a deficiency in timely care planning and assessment. The residents affected were identified as Residents 2, 11, 1, 19, 49, and 71. Each of these residents had their MDS assessments completed significantly past the required 92-day timeframe, with delays ranging from 26 to 43 days. This delay in completing the assessments placed the residents at risk for delayed care planning and potentially unidentified care needs. The deficiency was acknowledged by the facility staff during interviews. Staff E, the Licensed Practical Nurse and MDS Coordinator, admitted to being aware of the overdue assessments and attributed the delays to being the sole person responsible for completing them after losing part-time assistance. Additionally, the Director of Nursing Services and the Regional Nurse Consultant were also aware of the backlog and were in the process of seeking additional help for the MDS Coordinator. The failure to complete these assessments on time was a violation of the regulatory requirements, as outlined in the Resident Assessment Instrument manual.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to provide necessary care and services to ensure that dependent residents received assistance with dressing, personal hygiene, and shower/bathing. This deficiency was observed in four residents, who were at increased risk for skin breakdown and unmet care needs. Resident 5, who had intact cognition and required substantial assistance, expressed frustration over not receiving scheduled showers due to staff shortages. Documentation showed significant gaps between showers, and there was no record of the resident refusing care. Resident 83, with moderately impaired cognition, was observed in a state of neglect, with unkempt grooming and hygiene. Despite requiring assistance for hygiene and dressing, the resident was found in an unmade bed, with black debris under their nails and an untrimmed beard. Staff interviews revealed a lack of communication and follow-up on the resident's care needs, with no documentation of refusals or attempts to provide care. Resident 18, who was dependent on staff for hygiene, reported not receiving a bed bath for two weeks, despite preferring them. Documentation showed only one bed bath in a month. Similarly, Resident 51, who required substantial assistance, had not received a shower in three weeks and had minimal toenail care throughout the year. Staff interviews indicated a lack of adherence to care schedules and inadequate documentation of care refusals or attempts, contributing to the deficiency.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to serve meals at safe and appetizing temperatures, affecting two of the five residents reviewed for food quality. During a resident council meeting, multiple residents expressed concerns about consistently receiving cold meals. Observations and interviews revealed that Resident 3's breakfast tray was left out of reach and contained items at temperatures below the safe range, such as coffee at 91.1 degrees F and pureed eggs at 79.4 degrees F. Resident 3 reported that their food was often cold because staff were occupied with other tasks. Similarly, Resident 1 received a breakfast tray with items like scrambled eggs at 90.6 degrees F, which were also below the acceptable temperature range. Test trays checked by the Dietary Manager confirmed that both hot and cold foods were not maintained within the safe temperature ranges, with hot foods like breaded chicken at 130 degrees F and cold items like vanilla pudding at 58.5 degrees F. The Dietary Manager acknowledged that the process for handling food outside the acceptable temperature range was not followed, as trays should be reheated or replaced if they had been sitting for over an hour. This oversight placed residents at risk for decreased nutritional intake and potential foodborne illness.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to ensure staff compliance with infection control guidelines during a COVID-19 outbreak, as observed through multiple instances of improper use of personal protective equipment (PPE) and non-adherence to fit testing guidelines for N-95 respirators. Staff members were seen exiting COVID-19 positive rooms wearing surgical masks over their N-95 respirators to avoid replacing them, and some staff did not don the required gown, gloves, or eye protection when entering these rooms. Additionally, staff were inconsistently applying PPE based on whether they were directly caring for COVID-19 positive residents, despite guidelines requiring full PPE for any entry into such rooms. The facility's Respirator Management Program was not followed, as staff with facial hair were improperly fit-tested and allowed to wear N-95 respirators, which compromised the effectiveness of the masks. Staff AA, T, and K were observed wearing N-95 respirators with facial hair, and their fit test records indicated discrepancies in adherence to the requirement for being clean-shaven. Staff H, responsible for fit testing, acknowledged not following the correct procedures and was unaware of the staff's assignments to COVID-19 positive rooms. Interviews with staff revealed a lack of understanding and inconsistent instructions regarding PPE use, with some staff being told to only wear full PPE when caring for COVID-19 positive residents. The Director of Nursing Services was aware of the non-compliance but unsure of the reasons behind it. The Infection Control Preventionist also acknowledged the importance of being clean-shaven for effective respirator use but was unaware of the staff's non-compliance with this requirement.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to provide a written notice of transfer or discharge to five residents and/or their representatives when the residents were hospitalized. This deficiency was identified during a review of the medical records and interviews with staff. The residents involved had various medical conditions, including cellulitis, toxic encephalopathy, dementia, lymphedema, diabetes, severe obesity, quadriplegia, scoliosis, and depression. Despite these conditions, the facility did not issue the required transfer notices, which are essential for ensuring that residents and their representatives are informed of their rights and the reasons for the transfer. Interviews with staff revealed a lack of familiarity with the transfer notice form and a failure to complete it during the discharge process. Staff J, a Licensed Practical Nurse/Unit Manager, admitted to not being familiar with the form and stated that if it was not in the computer system, it was not completed. Additionally, the Director of Nursing Services, Administrator Designee, and Regional Nurse Consultant acknowledged the oversight and recognized that the system for issuing transfer notices was broken. This failure to provide the necessary documentation placed the residents at risk for unmet discharge needs.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to issue a written notice of bed hold to residents or their representatives at the time of hospital transfer, as required by their policy. This deficiency was identified for five residents who were transferred to the hospital. The facility's policy, dated July 2018, mandates that bed hold notifications be provided at the time of transfer or within 24 hours in emergency situations. However, this protocol was not followed, leaving residents and their representatives uninformed about their rights and any associated charges. Resident 5, with intact cognition, was transferred to the hospital for an infection but did not receive a bed hold notice. Similarly, Resident 54, who had severe cognitive impairment, was transferred after receiving incorrect medication, and their representative was unaware of the bed hold policy. Staff interviews revealed a lack of awareness and responsibility regarding the issuance of bed hold notices, contributing to the oversight. Additional residents, including Resident 67 with severe cognitive impairment, Resident 18 with intact cognition, and Resident 51 with intact cognition, were also transferred to the hospital without receiving bed hold information. Staff members, including the Director of Nursing Services and other administrative staff, acknowledged the failure to provide the necessary documentation and recognized the need for system improvements.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to notify a resident, their Resident Representative (RR), or payee when the resident's personal funds account balance was below $200 of the Social Security Income (SSI) resource limit of $2000. This deficiency was identified for one of the five residents reviewed for personal funds, specifically Resident 64. The facility's policy required that the resident or RR be informed when their trust balance was within $200 of the SSI limit, and a copy of the notification should be placed in the resident's financial file. However, this procedure was not followed, placing the resident at risk of losing Medicaid or SSI eligibility. Resident 64 had a trust fund account balance of $6419.37, which exceeded the SSI resource limit. The Business Office Manager, Staff S, acknowledged that there were residents with high balances due to back payments from Social Security and initially stated that residents had 180 days to spend down these funds. However, Staff S later mentioned a nine-month timeframe for spending down the funds, but could not provide documentation to support this claim. Additionally, Staff S admitted to not informing Resident 64's RR about the high balance. The Social Services Director, Staff F, was also not notified of the high balance, contrary to the facility's policy. The Administrator Designee, Staff C, expressed that they would have expected the family or RR to be notified and a spend down initiated.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to inform the Resident Representatives (RR) of two residents, Resident 68 and Resident 79, about significant weight loss, which is a change in condition that should have been communicated. Resident 68, who was admitted with dementia, anxiety disorder, and failure to thrive, experienced a severe weight loss of 5.1% in one month and 13.5% over six months. Despite attending a nutrition at risk meeting where this weight loss was discussed, the RR was not notified, as confirmed by interviews with staff members who acknowledged that the RR should have been informed. Similarly, Resident 79, who was admitted with malnutrition and later to hospice care, experienced a 9.73% weight loss in one month and a 29.92% loss over six months. The RR was not informed of this significant weight loss until a hospice nurse mentioned it during the hospice admission process. Staff interviews revealed confusion about whose responsibility it was to notify the RR, with some staff assuming it was the responsibility of others, leading to a failure in communication.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to report an incident involving a missing resident in a timely manner to local law enforcement and the State Agency as required. The incident involved a resident with a history of stroke, frontal lobe deficit, and psychoactive substance abuse, who had moderately impaired cognition and required assistance for activities of daily living. The resident left the facility with a family member and did not return as expected. Despite the resident's absence being noted, there was a significant delay in notifying law enforcement and the State Agency, which hindered the opportunity for assistance in locating the resident. The nursing progress notes indicated that the resident left the facility at 4:30 PM, and it was not until 1:54 AM the following day that the resident's representative was contacted, who confirmed the resident was not with them. Law enforcement was only contacted at 7:02 AM, over 14 hours after the resident left the facility. The Director of Nursing Services and the Regional Nurse Consultant admitted to not reporting the incident to the State Agency and not considering the resident an elopement risk. They also acknowledged not utilizing the facility's guidelines, known as The Purple Book, during their investigation.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to complete the admission Minimum Data Sets (MDS) for two residents within the required timeframes, as mandated by the Resident Assessment Instrument (RAI) guidelines. Resident 293 was admitted with diagnoses including respiratory failure, bipolar disorder, Parkinson's Disease, and acute kidney failure. The admission MDS for this resident had an Assessment Reference Date (ARD) of 09/29/2024, but the assessment was not completed until 10/22/2024, which was 13 days late. Similarly, Resident 245, admitted with diagnoses of stroke, depression, and pain, had an ARD of 09/29/2024, but the assessment was completed on 10/29/2024, 20 days late. The delay in completing the MDS assessments was acknowledged by Staff E, the Licensed Practical Nurse/MDS Coordinator, who stated that they were the only staff member currently completing the assessments due to the recent loss of part-time help. Staff B, the Director of Nursing Services, was also aware of the issue and mentioned efforts to provide assistance to Staff E. The failure to complete these assessments within the required timeframes placed residents at risk for delayed identification of care needs and/or unmet care needs.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to implement a comprehensive care plan for Resident 73, who was identified as being at risk when drinking hot beverages. Despite the care plan specifying that lids were required on their coffee cups, an incident occurred where a nursing assistant served the resident coffee without a lid, resulting in the beverage spilling and causing a second-degree burn. This incident highlights the failure to adhere to the care plan, which was acknowledged by the Director of Nursing Services during an interview. Additionally, the facility did not adequately address the care needs of Resident 18, who was admitted with lymphedema, severe obesity, and high blood pressure. The resident's care plan did not include specific interventions for managing lymphedema, despite physician orders for diuretics and leg wraps. Observations revealed that the resident often did not have the prescribed leg wraps applied, and the care plan lacked goals and interventions for this condition. The Director of Nursing Services admitted that the care plan should have addressed the resident's lymphedema.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to prevent the development of a pressure ulcer for Resident 293, who was admitted with multiple diagnoses including respiratory failure, bipolar disorder, Parkinson's Disease, and acute kidney failure. Upon admission, the resident was assessed as being at risk for pressure ulcers, but the assessment did not document the presence of a sacral pressure ulcer noted at admission. A nursing admission assessment indicated a skin impairment, directing a wound assessment, which was not completed. Despite treatment orders to cleanse and dress the sacral area, there were no measurements or staging documentation found in the records. Observations revealed that Resident 293 was frequently positioned in bed with their heels on the mattress, which is contrary to pressure ulcer prevention practices. The resident reported heel pain, and staff observations noted a darker pink area on the right heel, but no immediate action was taken to address this. It was only after a fall that a dark purple area was observed on the resident's right heel, which was later assessed as a deep tissue injury caused by pressure. Interviews with staff revealed a lack of awareness regarding the sacral wound's measurement and staging, and the necessity of preventive measures such as heel boots and floating heels. The facility's failure to adhere to its own skin integrity policy and professional standards of practice resulted in the development of a deep tissue injury on the resident's heel, highlighting deficiencies in the assessment, documentation, and preventive care for pressure ulcers.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to provide appropriate care and services for a resident with limited range of motion (ROM), specifically Resident 51, who was diagnosed with quadriplegia, scoliosis, muscle weakness, and depression. Despite having a care plan that included a restorative program with passive range of motion exercises for both lower and upper extremities, the resident reported not receiving any therapy for months. Interviews with the resident and staff revealed that the facility lacked a fully staffed therapy department and did not have restorative staff to implement the care plan. The Therapy Director admitted to not being aware of the resident's contractures and confirmed that the resident was not on their caseload. Further investigation showed that the facility's restorative program was minimal, with staff acknowledging that it was a 'lost area' they were trying to address. Nursing assistants reported not being instructed to perform restorative programs or apply braces/splints for residents. The Director of Nursing Services and the Regional Nurse Consultant acknowledged the inadequacy of the restorative program, which was not robust due to minimal staffing. The lack of therapy and restorative care placed Resident 51 at risk for decreased mobility and worsening contractures, as evidenced by the resident's internally rotated feet and absence of braces or splints.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to ensure that dialysis services met professional standards of care for Resident 193, who required dialysis due to end-stage renal disease. The resident was admitted with multiple diagnoses, including diabetes, heart failure, and anxiety, and required substantial assistance with activities of daily living. Despite the facility's policy mandating collaboration and communication with the dialysis center, there was no documented communication between the facility and the dialysis center regarding the resident's dialysis treatments. The resident had attended 17 dialysis sessions, yet there was no evidence of pre- or post-dialysis communication or documentation in the medical record. Interviews with staff revealed a lack of communication and documentation regarding the resident's dialysis care. Staff members, including LPNs and RNs, acknowledged that they did not receive or seek post-dialysis reports from the dialysis center. The resident reported receiving minimal attention from nurses after returning from dialysis, and staff confirmed that they had not seen any documentation from the dialysis center. The Director of Nursing Services and the Regional Nurse Consultant acknowledged the communication issues, indicating that nurses should document the resident's dialysis visits and obtain necessary communications from the dialysis center.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to ensure that drugs and biologicals were labeled according to professional principles and discarded when expired, as observed in one of two medication carts and one of two medication rooms. During an observation at the Main Nurse's Station, expired medications were found, including glucagon shots, needles, Valproic Acid, hemorrhoidal suppositories, and Prevnar injections. Additionally, medications belonging to discharged residents were not removed, and some medications lacked proper labeling, such as opened dates. Staff J, a Licensed Practical Nurse/Unit Manager, acknowledged that medication destruction was not done timely and assumed the pharmacist monitored for expired medications. Further observations on Hall 1 and Hall 2 medication carts revealed additional expired medications, including Acidophilus supplements and glucagon pens. There were also medications without opened dates, such as Lantus and fluticasone bottles. Staff B, the Director of Nursing Services, stated that Unit Managers were responsible for ensuring discontinued or discharged resident medications were destroyed weekly and that medications should be rotated and checked for expiration upon stocking. Staff B also mentioned that the consulting pharmacy monitored expired medications bi-weekly.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to ensure that each resident's medical record was complete and accurately documented their Physician Orders for Life-Sustaining Treatment (POLST) for two residents reviewed for advanced directives. Resident 67, who had severe cognitive impairment and multiple diagnoses including chronic obstructive pulmonary disease and liver cirrhosis, had conflicting POLST documentation. The electronic medical record indicated a DNR status, while a scanned document showed an order to attempt CPR. Additionally, the POLST in the nurse's station binder matched the electronic record, indicating a DNR order. This inconsistency was confirmed during an interview with Staff V, who noted that the newest POLST might not have been scanned into the record, potentially causing staff confusion. Similarly, Resident 73, who also had severe cognitive impairment and was diagnosed with dementia and depression, had discrepancies in their POLST documentation. The electronic medical record showed a DNR status, but the scanned document indicated an order for CPR with full treatment. No POLST forms were found in the nurse's station binder for this resident. Staff V acknowledged a possible system issue after reviewing the records and noted that audits had been conducted to ensure each resident had a POLST, but the dates had not been matched. The Director of Nursing Service was unaware of the problem with the POLST forms until it was brought to their attention.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to protect the personal privacy of two residents during care activities. Resident 245, who was admitted with diagnoses including stroke, depression, and pain, was observed during incontinent care. The nursing assistant, Staff NN, left the resident exposed from the waist down after removing a soiled brief and cleaning the resident. This exposure occurred when Staff NN left the bedside to change gloves and wash hands, leaving the resident feeling cold. The resident had moderate cognitive impairment and was not continent of bowel or bladder, highlighting the need for careful and respectful handling during personal care. Resident 293, admitted with conditions such as respiratory failure, bipolar disorder, Parkinson's Disease, and acute kidney failure, was found on a fall mat between their bed and an open door, wearing only a brief. Staff Y, an NA, responded to the resident's call for help and found them exposed. The privacy curtain was open, and the resident was visible to anyone passing by. Staff P, an LPN, and other staff members entered the room without initially ensuring the resident's privacy. The Director of Nursing Service later instructed the staff to pull the privacy curtain, shut the door, and cover the resident with a blanket. This incident reflects a failure to maintain the resident's right to privacy during a vulnerable moment.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with dementia, insomnia, and kidney failure. The resident required substantial assistance with activities of daily living and had severely impaired cognition. An incident report indicated that the resident reported to a Nursing Assistant that another staff member was rude and rough during care. Although the staff member in question was suspended, the investigation was incomplete as it lacked additional resident or staff interviews to rule out abuse. The Director of Nursing Services acknowledged the investigation's incompleteness, citing challenges due to some residents having dementia. The facility's policy required a thorough investigation, including interviews, to rule out abuse, but this was not adhered to in this case. The failure to complete a comprehensive investigation placed the resident at risk for potential abuse and other negative health outcomes.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to complete a significant change assessment for Resident 79, who was reviewed for hospice and end-of-life care. According to the Resident Assessment Instrument Manual, a significant change assessment is required when a resident is placed on hospice with a terminal prognosis and a life expectancy of six months or less. Resident 79 was admitted to hospice services with diagnoses of malnutrition and an untreated urine infection, for which the Resident Representative chose not to receive additional treatment. Despite these conditions, a significant change assessment had not been completed as of 10/29/2024. Interviews with facility staff revealed that the MDS Coordinator acknowledged the oversight, stating they had not yet completed the assessment for Resident 79. Further discussions with the Administrator Designee, Director of Nursing Services, and Regional Nurse Consultant confirmed awareness of the backlog in MDS assessments and their efforts to address the issue. This deficiency placed Resident 79 at risk for unmet care needs due to their declining health.

Penalty

Inspection fine: $52,50729 days payment denial

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

Summary

The facility failed to consistently monitor or implement interventions per Registered Dietician (RD) recommendations for two residents, leading to significant weight loss and nutritional dissatisfaction. Resident 79, diagnosed with schizoaffective disorder and malnutrition, experienced a severe weight loss of 27.65% over six months. Despite recommendations for one-on-one assistance with meals and a Speech Language Pathologist (SLP) evaluation, these were not implemented. Observations showed Resident 79 was not assisted during meals, and their requests for diet changes were not addressed. The facility's failure to follow through with RD recommendations and obtain necessary evaluations contributed to the resident's continued weight loss. Resident 83, admitted with a fractured hip and malnutrition, also experienced significant weight loss, losing 17.24% of their body weight in less than four months. Observations revealed that Resident 83's meals were placed out of reach, and they received no assistance during mealtimes. Despite being identified as at risk for malnutrition, the facility did not consistently obtain weights or follow up on nutritional interventions. The lack of staff assistance and failure to monitor the resident's nutritional status contributed to their continued weight loss. Interviews with staff revealed systemic issues in processing RD recommendations and obtaining necessary evaluations. Staff members were unaware of the need for SLP evaluations, and there was a lack of communication regarding weight monitoring and nutritional interventions. The Director of Nursing Services acknowledged that RD recommendations should have been treated as orders, but the facility struggled with obtaining SLP services. These deficiencies in care and communication led to the residents' significant weight loss and nutritional dissatisfaction.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's right to be free from verbal and physical abuse. Resident 1, who had severe cognitive impairment and required extensive assistance for personal hygiene, was subjected to aggressive behavior by Staff D, a Nursing Assistant. On the evening of 04/28/2024, Staff D grabbed Resident 1's arm aggressively, causing pain, and screamed profanity at the resident while providing personal care. This incident was witnessed by Staff C, another Nursing Assistant, who reported the abuse immediately to the charge nurse. Resident 1 complained of wrist pain and received pain medication following the incident. An X-ray of the wrist was ordered, and the results were negative for any injury. During interviews, Resident 1 confirmed the abuse and expressed that it was not right for anyone to do that. Staff D denied the allegations, while Staff C corroborated the resident's account of the incident. The facility's policy on abuse, neglect, and exploitation, dated 09/20/2023, mandates the prohibition and prevention of abuse to protect the health, welfare, and rights of each resident. Despite this policy, the facility failed to prevent the abuse, leading to a deficiency in protecting the resident's rights.