Abbotsford Health Care Center

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 did not ensure reasonable accommodation of resident needs and preferences for two residents. One resident had diagnoses including hemiplegia and hemiparesis following a stroke and a history of heart attack, and had a BIMS score of 15/15. The resident’s care plan required staff to push the resident in a manual wheelchair. The resident reported that the Broda chair used for mobility was broken and unavailable for about a week, during which staff borrowed another resident’s chair for use. The resident also reported being unable to get up for visits because a chair was not available, and staff confirmed the chair had been sent out for repair and that the resident and another resident shared the other resident’s Broda chair during that time. The same resident also reported that the nose piece of the glasses had been broken since shortly after admission, that staff had been told, and that nothing was done. The resident stated the glasses were rubbing the nose and causing sores, and the surveyor observed a sore/reddened area on the left side of the nose. Staff acknowledged the resident had a sore area from the glasses rubbing and that there had been a previous treatment, but they were unsure whether the facility was addressing the broken glasses. Family and facility staff discussed the need for an eye appointment to obtain new glasses, but the record review and interviews showed the issue remained unresolved at the time of the survey. A second resident, with diagnoses including type 2 diabetes, morbid obesity, anxiety disorder, and acute respiratory failure, and a BIMS score of 14/15, reported that the bariatric Hoyer lift had broken down multiple times since admission because of dead batteries and charger problems. The resident stated the lift was the only way to transfer and that the resident had to remain in bed when it was not working. Staff confirmed there had been issues with the special Hoyer lift, including a battery that would not charge, and stated that when the lift was not working the resident was unable to get out of bed. The administrator stated backup parts had been ordered, but also said the resident did not often get out of bed and it should not be a concern.

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 did not revise a comprehensive person-centered care plan for one resident to reflect the resident’s use of a Broda chair and the arrangement for sharing that chair with another resident. The resident was admitted with a personal motorized wheelchair and, on 02/15/26, was noted to be unsafe and recommended for placement in a Broda wheelchair for safety and positioning. The resident’s care plan did not indicate the resident was to use a Broda chair, and it did not include interventions related to sharing a Broda chair with another resident, including a schedule for use or instructions for what to do in an emergency. During interview, the resident stated the Broda chair being used had broken and had to be fixed, and that it was gone for about a week while staff obtained a different one. The resident stated being unaware that the chair was being shared with another resident. The NHA stated the chair had a hydraulic issue and was sent out for repair, and that the resident and another resident shared the other resident’s Broda chair during that time. The NHA also stated no care plan was made because it was only for a short time and the resident did not get out of bed often.

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 did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility's infection control surveillance was incomplete and missing pertinent information needed to help prevent the spread of infection. On 06/02/26, the infection surveillance line lists for residents, staff, and the most recent outbreak were reviewed and found to be incomplete because they did not include the dates symptoms resolved, making it impossible to determine whether staff returned to work on an appropriate date or whether residents were in isolation for the correct amount of time. On 05/31/26, a heavily saturated incontinence brief was observed on the nightstand next to R32's bed. R32 was on enhanced barrier precautions related to a wound on the buttock and a history of MDROs. During interviews, a CNA stated soiled briefs should immediately be placed in a garbage bag after removal from a resident and should never be placed on a nightstand. An LPN stated soiled briefs were expected to be placed into a garbage bag and disposed of properly, and acknowledged witnessing a similar situation on the same date. The LPN also stated the line list provided to the surveyor had been written in the day prior because there was no line list ready upon survey entrance, and acknowledged that some information was missing and the line lists were incomplete.

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 did not ensure its Infection Prevention and Control Program included an Antibiotic Stewardship Program that monitored antibiotic use. The facility policy titled, Antibiotic Stewardship Program, last revised November 2017, stated that the facility would implement an Antibiotic Stewardship Program as part of its overall infection prevention and control program, with the purpose of optimizing infection treatment while reducing adverse events associated with antibiotic use, and that the program included antibiotic use protocols and a system to monitor antibiotic use. During interview, an LPN stated the previous IP did not leave the information or complete the documentation for the facility's antibiotic stewardship monitoring upon termination, and acknowledged that contact would need to be made with the medical director regarding antibiotic use. The LPN also stated there was no current monitoring in place that could be located and that the facility would be working on it as soon as possible.

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 did not ensure that one or more individuals were designated as the Infection Preventionist with specialized infection prevention and control training. The facility policy titled, Infection Prevention and Control Program, stated that the designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations. During interviews, the NHA stated the previous Infection Preventionist had recently terminated and that the DON and an LPN would be working on the program together. The DON later stated they were not taking on the role of Infection Preventionist and that the LPN had recently started and would be assisting in the role. The LPN reported having completed training many years ago but could not obtain proof of completion, and later stated the certification was over 15 years old and that they would be taking the training in the upcoming days. The deficiency was identified for all 39 residents.

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 did not immediately notify the physician on call when R22’s groin wound worsened and increased in size. R22 was admitted with diagnoses including progressive multiple sclerosis, spinal stenosis of the lumbar region, and venous insufficiency, and the 04/16/26 MDS documented that R22 was independent with cognitive skills for daily decision making but dependent on staff for toileting hygiene, lower body dressing, transfers, personal hygiene, and bed mobility. On 05/23/26, the left groin wound was documented as a stage 3 pressure injury measuring 0.1 cm x 0.5 cm x 0.1 cm. On 05/29/26, the wound physician documented the area as a left inguinal wound measuring 2.1 cm x 5.5 cm x 0.1 cm, partial thickness, and the note did not document debridement to explain the increase in size. On 05/30/26, the facility documented the left groin wound as a stage 3 pressure injury measuring 3.5 cm x 6 cm x 0.2 cm with moderate serosanguineous exudate, 100% granulation tissue, and worsening status. The note stated the wound went from being almost closed the prior week to being open that day, with no signs or symptoms of infection, no pain, and no foul odor. The medical record did not document that the physician was notified of the continued increase in size. During interviews, the DON stated the wound physician was not documented as being notified of the increase and that the expectation was for the physician to be updated when there was a change in wound size.

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 one resident’s medication regimen was free from unnecessary psychotropic use and was reviewed for possible gradual dose reduction. The resident had diagnoses including dementia, muscle wasting, diabetes, cognitive impairment, traumatic brain injury, and dysphagia, and had a physician order for olanzapine, an antipsychotic medication, related to dementia and personal history of traumatic brain injury. The resident had been maintained on the same dose since 05/18/25, and a pharmacy review on 09/18/25 recommended a dose reduction. The physician responded by indicating that a previous dose reduction attempt in the facility had failed and that the current dose was required and clinically contraindicated for further reduction, but the medical record did not show a prior failed dose reduction or other patient-specific contraindication. Behavior monitoring for March, April, and May of 2026 showed no behaviors, and the resident’s record stated staff were to document suspiciousness, suicidal ideations, hallucinations, paranoia, or verbal/physical aggression. During interview on 06/02/26, the DON stated the resident had not had any behaviors since she had been at the facility and that the medication dose reduction had not been looked at. The DON also stated the medication administration time had been moved from morning to evening because the resident was always tired, and that the physician would be contacted about reducing the medication.

Penalty

No penalty information released

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

Summary

A Significant Change MDS assessment was not completed for one resident after hospice services were revoked. The resident was admitted on 05/23/25 and had diagnoses including orthopedic prosthetic devices, acute kidney failure, type 2 diabetes mellitus, depression, anxiety, and mood affective disorder. On 04/09/26, the resident’s MDS significant change assessment documented a BIMS score of 15/15, indicating intact cognition, and hospice care was elected the same day. The resident later signed a hospice revocation form on 04/22/26, effective that same day, with the stated reason for revoking hospice being hospice philosophy. The last completed MDS for the resident was the 04/09/26 assessment, and no Comprehensive Significant Change MDS was completed after the hospice revocation. During interviews on 06/02/26 and 06/03/26, the DON stated an MDS would be expected when hospice services ended and noted staffing changes and the absence of MDS personnel in the building, with oversight by corporate MDS staff. The MDS staff member stated they were not notified that the resident was coming off hospice services and would have expected notification and completion of a significant change MDS.

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 did not complete a resident’s quarterly assessment within the required 3-month timeframe for 1 of 17 residents, R7. R7’s quarterly MDS assessment had an ARD of 04/19/26 and was completed and locked on 05/24/26, but it had not been submitted to CMS at the time of survey. The facility policy titled Resident Assessments states the RAC is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments. During interview, the RMDS Coordinator stated that quarterly assessments are to be completed within every 92 days, acknowledged that R7’s assessment had been missed, and exported the assessment to CMS while speaking with the surveyor.

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 did not complete an accurate MDS assessment for one resident, R25, because the assessment in section A indicated the resident did not meet the federal definition of a serious mental illness even though the resident’s diagnoses and medications reflected otherwise. R25 was admitted with diagnoses including depression, anxiety, post-traumatic stress disorder, personality disorder, mood disorder, and altered mental status. The resident’s physician orders included multiple psychotropic medications, including amitriptyline, duloxetine, hydroxyzine, lamotrigine, olanzapine, prazosin, trazodone, and melatonin, and the care plan identified anxiety, depression, PTSD, mood and personality disorder, paranoia, and delirium. The resident’s preadmission Level I PASARR screen indicated a major mental disorder, symptoms suggesting a major mental illness, and psychotropic medication use to treat symptoms or behaviors of a major mental disorder. The surveyor reviewed the MDS and found section A was coded to indicate the resident did not meet the federal definition of serious mental illness, while section M showed regular antipsychotic use and section I listed depression, anxiety, PTSD, personality disorder, mood disorder, and altered mental status. During interview, Social Services E reviewed the MDS and confirmed the coding was inaccurate and stated the error occurred from the previous social worker.

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 did not ensure a Level II PASARR was completed for a resident with mental health diagnoses within 40 calendar days of admission. The resident was admitted with PTSD, anxiety, depression, personality disorder, and mood disorder, and the admission record showed a Level I PASARR completed shortly after admission that identified the resident as admitted under a 30-day exemption, with a major mental disorder, symptoms suggesting a major mental illness, and psychotropic medication use for symptoms or behaviors of a major mental disorder. No subsequent PASARR screens were found after admission. The resident’s BIMS score on admission was 15/15, indicating intact cognition, and the surveyor observed the resident walking, eating, toileting, and transferring independently during the survey. The record review showed no Level II PASARR completed by the required timeframe. During interview, the Social Services staff member confirmed that no follow-up PASARR II had been completed after the exemption and stated they were new to the role and had run an audit that identified the missing review.

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 did not develop or implement a person-centered dialysis care plan for R42, a resident admitted with end stage renal disease and assessed with intact cognition on the BIMS. The care plan dated 05/04/2026 identified alteration in kidney function due to ESRD and included general interventions for dialysis access care, bleeding precautions, and monitoring for thrill and bruit, but it did not identify the dialysis company, provider, nephrologist, or contact number. It also did not specify the days or times R42 attended dialysis, the type of dialysis access used, or which arm should not be used for blood pressure, blood draws, or IV insertion. Survey review found that the care plan lacked specific details about the access site, and progress notes since admission did not include thrill/bruit assessments or pre- and post-dialysis fistula assessments. During interview, an LPN stated R42’s dialysis access was in the left arm but could not locate documentation showing where this information was recorded, and was unsure which dialysis company, schedule, or physician managed dialysis concerns. The DON agreed the care plan needed to be more person centered and stated there was no information to show the assessments were being implemented.

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 did not review or revise R6’s person-centered comprehensive care plan after R6 revoked hospice services. R6 was admitted on 05/23/25 and had diagnoses including orthopedic prosthetic devices, acute kidney failure, type 2 diabetes mellitus, depression, anxiety, and mood affective disorder. The MDS significant change assessment on 04/09/26 documented a BIMS score of 15/15, indicating intact cognition, and hospice care was elected that same day with a signed hospice election form. On 04/22/26, R6 signed a hospice revocation form effective that day, with the stated reason of hospice philosophy. Surveyor review of the current care plan showed that the hospice care plan, initiated on 04/10/26 for end-of-life care with an intervention to coordinate the care plan with hospice, was not revised to reflect that R6 was no longer receiving hospice services and did not include new goals or interventions based on R6’s current status. During interview on 06/02/26, the DON stated the hospice care plan should not remain active and expected it to be updated when hospice ended.

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 did not ensure that treatment and care were provided according to orders, the resident’s preferences and goals, and the comprehensive person-centered care plan for one resident with moisture-associated skin damage (MASD) to the buttocks. The resident was admitted to the facility and had a physician order for zinc oxide to the buttock/groin area twice daily with cares and as needed for MASD, along with a care plan that included weekly skin inspection, monitoring for signs and symptoms of infection, thorough skin care after incontinent episodes, application of zinc oxide, and weekly wound evaluation. Record review showed the resident’s weekly skin assessments repeatedly documented MASD to the buttocks without evaluation on multiple dates, with only one assessment completed after the wound provider last evaluated the resident in March 2026 and noted the wound had worsened. The wound provider had previously documented the wounds as healed and ended services, after which the facility wound nurse assumed weekly monitoring. During interviews, staff stated weekly skin checks should include full skin evaluation and that worsening wounds should be reported to the provider, DON, and, if applicable, the POA; however, the DON acknowledged the resident’s weekly skin assessments did not show monitoring of MASD and the provider had not been updated on the changes.

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 did not ensure a resident with a severe hearing deficit received proper treatment and assistive devices to maintain hearing abilities. R47 stated the hearing aids stopped working after they remained in while showering and reported not having working hearing aids for a long period of time. During interview, R47 emphasized the need for the surveyor to speak very loudly and was observed without hearing aids in place. Staff interviews showed inconsistent awareness of the resident’s hearing aids: one LPN was unaware the resident had hearing aids, a CNA believed they were broken and had been so for quite some time, and another CNA was not aware the resident had any hearing aids at all. Record review showed the resident’s most recent MDS indicated minimal difficulty hearing and that the resident currently had hearing aids, which did not match the resident’s observed condition and staff reports. Audiology notes documented recommendations to check the hearing aids daily, charge them every night, visually inspect and clean them as needed, and assist with insertion. However, the physician order did not include care or monitoring of hearing aids, and the care plan stated the hearing aids were to be placed in the morning, removed at bedtime, and stored at the nurse’s station. The DON stated nursing staff had not completed a recent assessment and acknowledged the MDS was not accurate with the resident’s current condition.

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

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. The facility did not ensure a resident with limited ROM received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 1 of 5 residents reviewed. R32 had a restorative program that included passive ROM to bilateral lower extremities every shift, but the medical record showed the task was documented as not applicable on 14 days in March 2026, 17 days in April 2026, and 28 days in May 2026. The record also had no documentation on 19 days in March 2026, 16 days in April 2026, and 9 days in May 2026. During interviews, CNA J stated they believed therapy completes most restorative programs for residents. CNA D stated CNA F was the restorative CNA and completed the tasks, but was not sure who did them when CNA F was not working and thought it might be therapy. CNA F stated they were the restorative CNA, completed and charted the restorative tasks, but was unsure if anyone else did them when they were not working. CNA F was unsure when it would be appropriate to mark the task as not applicable and said maybe if the resident was sick. The DON stated CNA F was the restorative CNA, but if CNA F was not working, floor CNAs were to complete the tasks or the facility would assign someone. The DON was informed that R32's restorative documentation was incomplete and inaccurate.

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

Provide care or services that was trauma informed and/or culturally competent was not ensured for a resident diagnosed with PTSD. The resident was admitted with diagnoses including PTSD, anxiety, depression, personality disorder, mood disorder, and altered mental status, and was admitted for therapy and monitoring after frequent falls at home and a fire with smoke inhalation. A trauma informed care assessment identified traumatic events that caused nightmares and guilt, but the resident's care plan did not include those issues, did not identify the resident's trauma type(s) or triggers, and did not include interventions to prevent re-traumatization. During observation, the resident reacted visibly to loud noises and to another resident speaking from slightly behind her, stating that slamming doors and people approaching from behind were triggers because of PTSD. In interview, the resident described extensive trauma history, including abuse, a sibling's suicide, being struck on the head with farm equipment, childhood sexual abuse, loss of a pet after admission and the apartment fire, and feeling alone because family did not visit. The resident also reported prior counseling and grief group participation and said those services would still help. Social Services staff interviewed by the surveyor stated they did not know the resident's trauma history, triggers, or preferred services.

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 routine and emergency drugs and biologicals for one resident, R37, who was ordered Modafinil 100 mg by mouth twice daily for sleep apnea. The medication was ordered on 05/12/26, but the MAR showed it was not administered from 05/12/26 through 05/23/26. Nursing progress notes repeatedly documented that the medication was not available from the pharmacy, was on order, or was waiting for delivery during this period. The record also showed that on 05/23/26 staff called the pharmacy and were told the medication would be sent the next day if available, and the provider stated it was okay to hold until the medication was available. During interviews on 06/02/26, an LPN stated that when medications are unavailable, staff would check contingency supply, contact the pharmacy, and update the provider, with monitoring depending on the medication. Another LPN stated there had been concerns obtaining medications from the pharmacy. The DON acknowledged that R37 was without Modafinil from 05/12/26 through 05/23/26 without monitoring and appropriate notification and follow up.

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 thoroughly investigate an allegation of misappropriation of a resident’s money and did not ensure required interviews were completed. One cognitively intact resident (BIMS 15/15) reported that $200 was missing after returning from the hospital, while staff had previously observed a $50 bill in the resident’s room the day before. The facility’s investigation included an interview with the resident, a search for the missing money that was not found, contact with law enforcement, and staff interviews. However, the amount of money allegedly missing could not be confirmed beyond the $50 observed by staff, and the resident continued to state that $200 was missing. The facility’s abuse/neglect/exploitation policy required identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, as well as training staff on changes made and demonstrating staff competency after training. During the survey, the Social Services Director stated that resident interviews were conducted through daily “Angel Rounds” and provided a blank Angel Rounds form and a typed list of 26 residents with yes/no responses regarding missing items, with only the involved resident reporting missing money. Other interviewed residents did not recall being interviewed about missing items or money. A CNA familiar with the incident reported not remembering any staff education or training related to misappropriation after the money was reported missing. The surveyor determined the facility did not complete a thorough investigation due to lack of evidence of resident interviews and lack of timely staff training on misappropriation.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide a resident with required transfer/discharge notices, appeal rights information, Ombudsman contact information, and written bed-hold and return-rights information, as well as failure to document the admission, fall, and discharge. A resident (R7) was accepted for admission from a referring hospital with the understanding that she was a pivot transfer. Upon arrival, she traveled approximately two hours and was placed in a wheelchair that was too small. Shortly after arrival, while seated in the wheelchair, she reached down to pick something up and slid from the chair onto the floor. EMS was called because staff were unable to get her up from the floor, and she was transported to the emergency room. The facility’s electronic record for the resident contained only pre-admission documents such as advance directives, hospital discharge summary, and insurance information, but no admission documentation, progress notes, assessments, incident reports, or discharge documentation. The facility’s Admissions Coordinator stated that the resident was not admitted to the facility and reported that the resident could not transfer as reported by the hospital, slid from the wheelchair, and was sent to the hospital via EMS. The Nursing Home Administrator, however, stated that the facility had accepted the resident as an admission and that no admission paperwork had been completed. The Administrator reported that therapy was asked to assess the resident’s transfer status, but before that occurred, the resident had already fallen from the wheelchair. The Administrator stated that the facility did not have the appropriate equipment, such as a bariatric hoyer lift or sling, to care for the resident when it was determined she could not pivot transfer. The facility did not provide evidence that the resident was assessed at the facility to determine her transfer status, nor did it provide documentation that the resident’s needs could not be met in the facility as required by its transfer/discharge policy. The facility did not provide evidence that the required transfer/discharge process was followed. There was no documentation that the resident or her representative received written notice of transfer or discharge, including the specific reason for transfer, effective date, location of transfer, appeal rights, or the name, address, phone number, and email of the State Long-Term Care Ombudsman. There was also no evidence that the resident or representative received written information on the facility’s bed-hold duration, reserve bed payment policy, or the right to return to the facility. The facility did not provide evidence of communication with the receiving hospital explaining the reason for the resident’s discharge or documenting agreement to re-admit the resident. Although the Administrator reported being told that a correct hoyer sling would be ordered for the resident, the facility did not provide evidence that such a sling was ordered. The facility was unable to provide evidence that its own transfer and discharge policy requirements were met for this resident. The surveyor’s review of communications showed only an email chain in which the Admissions Coordinator initially accepted the resident for admission and later informed the referring hospital that there were issues when the resident arrived, that she could not transfer as reported, and that she slid to the floor and was taken to the hospital by ambulance. No further communication with the hospital after the resident’s transfer was provided. A discharge summary from the receiving hospital documented follow-up needs related to deconditioning, weakness, ankle and knee instability, bariatric management, and UTI, but the facility did not produce any pre-admission assessment indicating the resident’s transfer status or any documentation that the discharge process, including notices and appeal information, was followed. Overall, the facility failed to document the resident’s admission, fall, and discharge and failed to provide the required notices and information related to transfer/discharge, appeal rights, Ombudsman contacts, and bed-hold and return policies.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and use of assistance devices to prevent accidents for one resident identified as an elopement risk. The resident had diagnoses including altered mental status, history of falling, alcohol dependence with withdrawal delirium, age-related physical debility, and metabolic encephalopathy, and an MDS BIMS score of 00 indicating severe cognitive impairment. The baseline care plan identified the resident as at risk for elopement related to wandering and specified interventions including a Wanderguard on the right wrist and redirection from doors. Facility policies on elopement and accidents/supervision required elopement risk assessment at admission, development of an elopement prevention care plan, use of an alarm system to notify staff when exit doors are opened, and implementation of specific interventions to reduce risk from environmental hazards, including adequate supervision. On the survey date, the NHA identified the resident as one of two residents using the Wanderguard system, but the surveyor observed the resident alone in a wheelchair without any Wanderguard device in place and speaking incoherently about needing to meet family. A CNA confirmed the resident was supposed to always have a Wanderguard but could not locate it, and an RN then placed a Wanderguard on the resident’s ankle, stating the resident had fallen the previous night and been sent to the ED, with no ability to determine how long the resident had been without the device. The surveyor later observed the resident independently exit the room at a fast walk, cross the hall, and enter another resident’s room without a chair alarm in place, requiring immediate staff intervention and redirection. Record review showed prior documentation of wandering and attempts to go through doors looking for beer, with a Wanderguard previously placed due to elopement risk, but there was no documentation regarding whether the Wanderguard was in place before or after the fall and ED visit, no documentation of assessment upon return, and no CNA or nursing documentation of routine monitoring to ensure the Wanderguard was in place. Staff interviews indicated reliance on a binder listing residents requiring Wanderguards and a shared responsibility among all staff interacting with the resident to ensure the device was in place.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate skin assessments and treatment in accordance with professional standards of practice for two residents. For one resident with multiple traumatic injuries and a surgical incision on the left upper extremity, staff did not assess or document the condition of the surgical site, nor did they document the removal of steri strips as ordered. There was no evidence of ongoing assessments of the surgical incision, despite a physician's order for dressing changes and a noted incident of partial dehiscence and bleeding at the site. For another resident with a history of chronic ulcer, diabetes, peripheral vascular disease, and recent amputation, staff did not complete a comprehensive wound assessment when a new wound was first identified. The initial documentation lacked details such as wound size, and there was a delay in completing a full assessment. The resident was later found to have a pressure ulcer on the left heel, but the facility did not have documentation of an initial assessment with measurements when the wound was first discovered.

Penalty

No penalty information released

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

Summary

A deficiency occurred when staff failed to implement professional standards of practice for pressure injury (PI) care and prevention for a resident admitted with an unstageable PI to the left heel. Upon admission, the resident had multiple diagnoses including hemiplegia, hemiparesis, MRSA infection, deep tissue damage to the left heel, diabetes mellitus, protein-calorie malnutrition, atrial fibrillation, chronic kidney disease, anxiety disorder, and depression. The resident was assessed as having intact cognition but required moderate to maximum assistance with activities of daily living and was identified as being at risk for pressure injuries. Despite the presence of a pressure injury on admission, staff did not complete a comprehensive PI assessment that included measurements and a detailed description of the wound. The initial clinical assessment only noted the existence of an unstageable PI without further specifics. The first documented wound assessment with measurements and description was not completed until several days after admission by the wound clinic. During an interview, the DON confirmed that there was no documented comprehensive admission assessment of the PI, despite acknowledging that such an assessment was expected.

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 update a resident's care plan with new interventions or monitoring following an incident of unauthorized elopement. The resident, who was admitted under guardianship with diagnoses including benign neoplasm of meninges and mild cognitive impairment, had a BIMS score of 7, indicating moderate cognitive impairment, and a documented history of wandering and attempted elopement. The resident's care plan allowed for leaving the premises to smoke, as permitted by the guardian, but did not include specific interventions to address the risk of elopement despite the resident's known behaviors and history. On a specific date, the resident independently arranged for transportation and left the facility without staff authorization to attend an appointment that had been cancelled by the guardian. The facility's Director of Nursing confirmed that, although the guardian refused the use of a wander guard and Adult Protective Services were notified, no new interventions or monitoring were added to the care plan to prevent recurrence of such incidents. This lack of updated care planning was not in accordance with facility policy, which requires defining how care provision will be changed or improved to protect residents after such events.

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 adequate supervision and assistance devices to prevent accidents, resulting in a resident leaving the premises without staff knowledge or authorization. The resident, who was under guardianship and had diagnoses including mild cognitive impairment and a history of wandering and elopement, was permitted by their guardian to leave the facility to smoke, as the facility is smoke-free. Despite this, the resident's care plan required staff supervision due to confusion and altered mental status. On the day of the incident, the resident independently arranged for transport and left the facility to attend an appointment that had been previously canceled by the guardian, without signing out or informing staff. The facility's investigation into the incident was incomplete, as there was no documentation of resident or staff interviews, and no evidence that the resident had been signing out when leaving the premises. Staff members, including CNAs, reported not receiving education on elopement procedures following the incident, and the DON was unable to provide documentation of interventions implemented to prevent recurrence. The facility's policy required adequate supervision for residents at risk of elopement, but this was not followed in the case of this resident.

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 implement its policies and procedures regarding the screening of employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. Specifically, one of eight employees reviewed, identified as Intern D, was hired without the required Background Information Disclosure (BID), Department of Justice (DOJ) response, or Government Findings report being completed prior to starting work. The facility's policy mandates that all potential employees, including students affiliated with academic institutions, must undergo background, reference, and credential checks before employment. During the survey, it was discovered that both the facility and the corporate office assumed the other party was responsible for conducting Intern D's background check, resulting in the process not being completed. Despite this oversight, Intern D was observed in resident care areas obtaining paperwork for surveyors, even though the administrator stated that Intern D was being kept in the office. This failure to follow established screening procedures directly contravened the facility's abuse prevention policy.

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 care plan for a resident after the removal of side rails from her bed. The resident, who had diagnoses including congestive heart failure, morbid obesity, and anxiety disorder, was cognitively intact and had previously expressed a desire to have side rails to promote independence. The care plan, last updated in June, still listed side rails as an intervention for mobility impairment, despite their removal. Audits by the speech-language pathologist indicated the care plan had been updated, but the intervention remained unchanged in the documentation. Observations on July 8 confirmed that the resident's bed no longer had side rails, and the resident reported that the rails were removed during a hospitalization and not returned, with no alternative assistive device provided as promised. The DON confirmed the side rails were removed per protocol after the resident's hospital discharge and stated that side rails would not improve the resident's bed mobility. The failure to update the care plan to reflect the removal of side rails constituted the deficiency.

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 designate a director of food and nutrition services who met the minimum qualification requirements as outlined in their own policy. The current Dietary Manager (DM) is enrolled in a Nutrition & Food Service Professional Program but has not yet completed it, having received an extension to finish the program by a later date. The facility policy requires the director to have certification as a dietary manager, certification as a food service manager, an associate or higher degree in food service management or hospitality with relevant coursework, or at least two years of experience in the position along with completion or enrollment in a food safety management course. The DM does not currently meet these qualifications, as she is still in the process of completing her required program. Additionally, the facility does not have a full-time Registered Dietician (RD) on staff. The RD is only present in the facility one to two days per week, which does not fulfill the requirement for a full-time RD. This lack of appropriately qualified staff in the food and nutrition services department could potentially affect all 48 residents residing in the facility, as noted by the surveyor during interviews and record review.

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 prepare, store, and distribute food in a sanitary manner, as evidenced by multiple observations and staff interviews. A dietary aide was seen removing clean drinking glasses and plastic mixing containers from the dishwasher, stacking them together while still wet, and placing them in storage, causing water to drip on the floor and counter. The dietary aide acknowledged that dishes should be dry before being stacked and stored, and the dietary manager confirmed that this practice did not meet facility expectations or established food safety standards. Additionally, the kitchen's handwashing sink was observed to have heavy lime and dirt buildup on the faucet handles, drain, and basin. The dietary aide was unable to recall when the sink was last deep cleaned, and the dietary manager confirmed that the cleanliness of the sink did not meet expectations. The cleaning schedule was found to be lacking a specific task for deep cleaning the handwashing sink, which was only added after the surveyor's observation. Further deficiencies were noted in the storage of resident food brought in from outside sources. Refrigerators and freezers contained multiple opened food items without labels indicating the contents, resident names, or dates. Some food items prepared by the facility and not consumed during mealtimes were also stored without proper labeling. The dietary manager acknowledged that these practices did not meet facility policy and expressed concern about the potential for expired foods to cause foodborne illness.

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, functional, sanitary, and comfortable environment for all 48 residents, as evidenced by multiple observations of frayed carpeting, stained flooring, and damaged walls throughout the building. Surveyors noted frayed carpet in several hallways and common areas, with specific mention of fraying around metal circles in the floor and along seams. Numerous dark and white spots were observed on the carpets in various hallways, with some spots being large in size. Staff, including housekeeping, RN, and DON, were unable to identify the cause of the spots, and the DON confirmed that the spots had been present since her hire date in 2022. The Maintenance Director indicated that the carpets had been shampooed only a few times in the past six months and suggested that improper cleaning or treatment may have contributed to the stains. Additionally, a bathroom floor was found to be completely stained, and staff acknowledged the poor condition of the flooring. Further deficiencies were observed in the condition of the walls, including unfinished sheetrock, puncture marks, black marks, missing paint, and cracks. The Maintenance Director attributed some of the wall damage to wheelchairs or carts and acknowledged being unable to address all maintenance needs due to limited staffing. The DON stated that these issues had been reported to corporate but was unable to provide documentation of any follow-up. No specific residents were identified as being directly affected at the time of the survey, but the environmental deficiencies were present in areas accessible to all residents, staff, and the public.

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 develop and implement person-centered care plans that addressed all identified needs and preferences for two residents. For one resident, there was no activity care plan that included accommodations for vision and hearing deficits, despite the resident reporting difficulty hearing and seeing during activities such as bingo, and needing to sit close to the caller to participate effectively. The resident also stated that food preferences were not assessed or accommodated, and no alternatives were offered for foods she could not eat. Review of the care plan and interviews with staff revealed that vision and hearing accommodations, as well as specific food preferences, were not documented or implemented, and the process for assessing and updating these preferences was inconsistent or incomplete. For another resident with a history of spina bifida, pressure ulcers, osteomyelitis, and catheter-associated urinary tract infections, the care plan did not include a safe smoking plan, even though the resident was observed smoking outside without staff assistance and was unable to pick up a dropped lighter. Although a smoking safety assessment indicated the resident could smoke without supervision, the care plan lacked details on supervision requirements, safety measures, and storage of smoking materials. Staff interviews confirmed that the omission of a smoking care plan was an oversight.

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 with multiple chronic conditions, including diabetes, peripheral vascular disease, and a history of wounds, did not receive necessary wound care and related services as ordered. The resident had active wound treatment orders that lapsed for several days, leaving a period with no documented wound care provided. Orders from a wound clinic, including those for nutritional supplements and the use of a protective boot, were not transcribed or implemented in a timely manner. Additionally, recommendations from a registered dietician for a zinc supplement to promote wound healing were not addressed or documented as ordered. Observations and interviews revealed that wound care was not consistently performed according to the prescribed schedule, and the resident reported that dressing changes were missed for up to two days. The Prevalon boot, ordered to be worn at all times, was not consistently applied, with documentation showing it was only in use during certain shifts and not daily as required. There was no evidence of resident refusal or documentation of risks and benefits related to the boot in the care plan. The treatment administration record (TAR) did not reflect all required treatments, and staff interviews indicated confusion or lack of clarity regarding the implementation and monitoring of wound care orders. The facility's failure to ensure timely transcription and implementation of physician and wound clinic orders, as well as to follow through on dietician recommendations, resulted in gaps in care for the resident. Documentation and monitoring were inconsistent, and there was a lack of communication and follow-up regarding new orders and recommendations. These actions and inactions led to the resident not receiving the necessary treatment and services to promote wound healing as required by facility policy and physician directives.

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 infection prevention and control program for two of four sampled residents. For one resident with a urinary catheter, repeated observations showed the catheter urine collection bag was positioned on the lowest part of the wheelchair crossbars, causing it to rest on and drag across the floor as the resident moved throughout the facility. The facility's catheter care policy did not address proper positioning of the catheter bag, and the infection preventionist confirmed that catheter bags should be kept off the floor to prevent contamination. In a separate incident, during a dressing change for another resident with multiple pressure injuries and receiving hospice care, clean gauze intended for use between the toes was observed touching the floor and lying under the nurse's foot. Additionally, the measuring tool used for wound assessment was also in contact with the floor. The nurse acknowledged that items which had touched the floor should not have been used during the dressing change, and the Director of Nursing confirmed this expectation.

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 resident environment was free from accident hazards, specifically concerning the use of mechanical lifts for resident transfers. On one occasion, staff did not verify the proper sling size or the safe functioning of the mechanical lift before transferring a resident, resulting in the lift tipping over and causing the sling bar to strike the resident in the face. This incident led to a bruise and laceration below the resident's left eye, requiring hospital transfer and tissue adhesive repair. Observations revealed that staff were not aware of how to determine the proper sling size for residents, and the care plans did not specify the type or size of sling to be used. The maintenance staff lacked the necessary knowledge to inspect and ensure the safety of the mechanical lifts. The Maintenance Director admitted to not receiving specific training on the equipment and was unable to determine if the lifts were operating safely. A mechanical lift used in the incident had a defect that allowed its base legs to move to a closed position without using the foot lever, a condition that had been reported but not addressed. This lack of proper maintenance and inspection posed a safety risk to all residents using mechanical lifts. Additionally, the facility did not have a clear system for determining and labeling sling sizes. Staff relied on visual comparison to choose slings, as there were no labels or reference charts available to guide them in selecting the appropriate size based on residents' weight and height. The Nursing Home Administrator was unaware of the manufacturer's guidelines for sling size determination and the available sizes in the facility. This lack of knowledge and resources contributed to the potential for unsafe transfers, affecting all residents who required mechanical lifts.

Penalty

Inspection fine: $15,939

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 adequate supervision and assistance during a Hoyer lift transfer for a resident, leading to a serious accident. A Certified Nursing Assistant (CNA) transferred the resident using a Hoyer lift without the required assistance of another staff member, contrary to the facility's policy that mandates two people for all mechanical lift transfers. During the transfer, the resident slipped out of the sling and fell to the floor, resulting in a subarachnoid hemorrhage, subdural hematoma, and other injuries, necessitating hospitalization. The resident involved had a history of dementia and anxiety disorder and required total assistance with activities of daily living. The resident was identified as a fall risk, with a care plan that included the use of a Hoyer lift for transfers. On the day of the incident, the CNA did not request assistance from a nearby nurse and proceeded with the transfer alone, using an uncrossed sling, which was not specified in the care plan. This oversight led to the resident sliding out of the sling and sustaining severe head injuries. The incident was immediately investigated by the facility, revealing that the CNA was aware of the two-person policy but did not adhere to it. The facility had previously conducted education on Hoyer lift use, but the care plan lacked specific instructions on crossing the straps between the resident's legs. The failure to follow established procedures and ensure proper supervision during the transfer resulted in significant harm to the resident.

Removal Plan

• The facility completed resident care plan reviews for the residents who require mechanical lift transfers.
• The facility provided reeducation on mechanical lift use, requirement for 2 staff to be present during the entire transfer, and use walkie talkies to ask for assistance, and if unsure how to transfer a resident, staff is to seek clarification from a nurse.
• Licensed nursing staff educated on updating a resident care plan if the straps are to be crossed for the transfer.
• CNA C's employment with the facility was terminated.

Penalty

Inspection fine: $15,939

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 Bedrock corporation governing body failed to ensure adequate funds were available for the safe and efficient management of the facility, affecting all 51 residents. The governing body did not maintain current payment status with several service providers and vendors, leading to vendors refusing to provide services or issuing discontinuation notices until payment was received. This included the abrupt termination of the facility's pharmacy provider after a past due notice, and the potential disruption of services due to unpaid state bed taxes and civil money penalties. The facility's aging vendor report revealed significant outstanding balances with multiple vendors, some dating back over three years. The surveyor verified these balances with various service providers, confirming discrepancies between the amounts owed and those reported by the facility. For instance, the facility owed substantial amounts to a gas supplier, food supplier, and transportation services, with some services already halted due to non-payment. Additionally, the facility breached its contract with a garbage removal service, leading to legal action. The Nursing Home Administrator (NHA) was interviewed and stated that they only see invoices for services and supplies, which are then sent to corporate for payment. The NHA was not informed of past due amounts or when invoices were paid, and was unaware of the reasons behind the change in pharmacy service. Despite these financial issues, the NHA reported no disruptions in utilities, internet, or food services, although the facility's financial mismanagement posed a risk to the quality of care and life for residents.

Penalty

Inspection fine: $15,939

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 transportation services for a resident, identified as R2, who was sent to the hospital for an emergency evaluation due to chest pain and shortness of breath. R2, who has severe cognitive impairment and multiple medical conditions including atrial fibrillation and hepatocellular carcinoma, was discharged from the hospital on the same day but was unable to return to the facility until the following morning. This delay was due to confusion over transportation responsibilities between the facility and the managed care organization, resulting in R2 remaining at the hospital overnight. Interviews with facility staff and the managed care organization revealed a lack of clarity regarding who was responsible for arranging transportation for R2. The Assistant Director of Nursing and the Nursing Home Administrator both indicated that transportation is typically arranged by the managed care organization for residents under their care, but the facility also has a van service available during daytime hours. However, this service does not operate after hours, and alternative transportation options were not available. The facility's inability to secure transportation during off hours has been a recurring issue, particularly in rural areas where services are limited.

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 sufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. The staffing ratios did not align with the facility's assessment of staffing needs, particularly during the night shift, where the licensed nurse-to-resident ratio was higher than planned. This discrepancy resulted in delayed responses to call lights and unmet resident needs, as observed by surveyors and reported by residents and staff. Residents expressed dissatisfaction with the timeliness of care, with some waiting extended periods for assistance, leading to discomfort and unmet personal care needs. Multiple residents reported waiting for assistance with daily activities, such as getting ready for the day or being helped to the toilet, for extended periods. One resident, for example, had their call light on for nearly 45 minutes before receiving help. Staff interviews revealed that they were overwhelmed and unable to complete their tasks due to the high acuity of residents and insufficient staffing levels. The facility's staffing plan did not account for the increased needs of residents requiring two-person assistance or those with high acuity conditions, leading to rushed and incomplete care. The facility's failure to address staffing concerns was further highlighted by resident council minutes and grievance reports, which consistently noted issues with call light response times and inadequate staffing. Despite staff and resident complaints, the administration had not effectively addressed these concerns, resulting in ongoing deficiencies in care. The lack of agency staff and the facility's rural location compounded the staffing challenges, leaving the facility unable to meet the care needs of its residents adequately.