Evansville Manor Nursing And Rehab, Llc

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 protect a resident from sexual abuse by another resident with known sexually inappropriate behaviors. One resident (R2) had a documented history of making sexual comments, attempting to touch staff’s buttocks, and inappropriately touching female residents, including a prior incident of grabbing a female resident’s chest and using vulgar language toward staff and residents. R2’s comprehensive care plan specified that he must be escorted to and from activities, kept at least an arm’s length away from all female residents, monitored when in common areas, and kept out of arm’s reach from female residents. Staff interviews confirmed that, prior to the incident, R2 was to be in staff line of sight whenever out of his room and not left around female residents. The victim, R1, was a severely cognitively impaired, nonverbal resident with autism and metabolic encephalopathy, identified in her care plan as vulnerable due to limited speech and inability to call out for help or remove herself from unsafe situations. Her care plan included the need to provide a safe environment. On the date of the incident, R2 was observed in a lounge area with R1, with his hand on her in a way that appeared to be touching her private area. A CNA reported seeing R2 touching R1 in the abdomen area when returning from putting trays on the cart. Staff immediately separated the two residents and notified the RN on duty. Interviews and record review showed that R2 was left unsupervised in the lounge with R1 despite his care plan requirements for close supervision and restrictions around female residents. The CNA involved, who was agency staff, later reported she believed R2’s extra supervision was required only during mealtimes, indicating that she did not follow or was not aware of the full supervision requirements outlined in R2’s care plan and Kardex. The surveyors determined that the facility failed to provide adequate supervision and to follow R2’s care plan interventions to keep him out of arm’s reach of female residents and under monitoring in common areas, resulting in an incident of sexual touching of a nonverbal, severely cognitively impaired resident who could not consent or protect herself. This failure led to a finding of immediate jeopardy beginning on the date of the incident.

Removal Plan

• Separated R2 and R1
• Placed R2 on 1:1 staffing
• Completed a full head-to-toe assessment for R1
• Placed CNA G on administrative leave
• Ensured all residents in the facility were safe and expressed no concerns regarding safety
• Notified police, guardians, state agency, and Medical Director
• Sought Behavioral Care for R2 to review medications and increased sexual behavior
• Sent R1 to the emergency room for evaluation (no new orders)
• Provided training to nursing staff on supervision requirements and sexual behaviors requiring close monitoring, especially near vulnerable individuals
• Reinforced use of the Kardex every shift and CNA review of the binder for any additional changes to resident care
• Prohibited agency staff from being assigned to R2's hallway
• Completed education with staffing coordinator, nursing leadership, Human Resources, and NHA to ensure staffing expectations are followed
• Implemented documentation of 1:1 supervision every shift
• Educated the IDT to ensure non-verbal residents will not be placed on R2's hallway
• Implemented daily audits to ensure 1:1 is being done and documented
• Implemented daily audits to ensure R2's hallway does not have agency staff scheduled; if unavoidable, require documentation that the agency employee was educated

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 that a resident received treatment and care in accordance with professional standards of practice and the facility’s own change of condition policy. The Wisconsin Nurse Practice Act (N6.03) requires RNs to use the full nursing process—assessment, planning, intervention, and evaluation—while the facility’s Change of Condition policy requires prompt notification of the practitioner for uncontrolled pain or need for hospital transfer, and completion of an assessment with documentation of findings, including vital signs and pain. On one date, the resident reported increased abdominal and low back pain, was crying, and rated the pain as 10/10. The nurse contacted the NP, who ordered the resident sent to the hospital, but the resident refused transfer. Despite this significant change in condition and uncontrolled pain, there is no documentation that an RN assessment was completed or that nursing staff continued to monitor the resident’s condition. The resident had multiple chronic conditions, including bipolar disorder, other chronic pain, low back pain, fibromyalgia, schizoaffective disorder, generalized anxiety disorder, psychophysiologic insomnia, and adjustment disorder. The resident’s MDS showed a BIMS score of 15/15, indicating intact cognition. The comprehensive care plan identified altered respiratory status/difficulty breathing related to chronic respiratory failure, restrictive lung disease, and obstructive sleep apnea, with interventions including CPAP per MD orders, elevating the head of bed, and monitoring for and documenting changes in orientation, restlessness, anxiety, air hunger, and signs and symptoms of respiratory distress such as increased respirations, decreased pulse oximetry, tachycardia, restlessness, diaphoresis, headache, lethargy, confusion, hemoptysis, cough, pleuritic pain, and accessory muscle use. Despite these care plan directives, there is no evidence in the medical record that the resident was assessed or monitored after reporting severe pain on the first day. On the following day, a CNA summoned the nurse to the resident’s room at approximately 7:00 AM. The resident was unable to sit at the edge of the bed unassisted, had rapid respirations, increased pain, and altered mental status. The nurse confirmed with the resident that she now agreed to transfer to the ER, and 911 was called; the resident left via ambulance around 7:30 AM. The resident was admitted to the hospital ICU with diagnoses including pneumonia, acute on chronic respiratory failure, sepsis with acute hypoxic respiratory failure, and septic shock. Hospital documentation noted that the resident reported worsening dyspnea over the prior 24 hours, was in mild to moderate respiratory distress with increased work of breathing, low-grade fever, mild tachycardia, and later became hypotensive, requiring sepsis fluid bolus, IV fluids, IV pressors, and non-invasive ventilation. There is no evidence in the facility record that a nurse completed an assessment on the morning of transfer, beyond the resident’s report that only a temperature was taken and no other vital signs were obtained. In interviews, the resident stated she had been telling staff for about a week, multiple times per day, that she did not feel well and thought she had a urinary infection, and that staff did not listen. She reported that there was no assessment or monitoring on the day she first reported severe pain, and that on the following day she was "out of it" and unable to sit up, and that before transfer the nurse only took her temperature. The RN who worked on the first day stated she recalled the resident refusing to go to the ER and thought she might have done an abdominal assessment but could not remember and could not recall what she had documented. The DON confirmed that there was no documentation of further assessment or monitoring on either day and stated she would have expected the nurse to take vital signs, complete an assessment at least every shift, and enter a progress note. The lack of documented RN assessment, ongoing monitoring, and vital signs in response to the resident’s uncontrolled 10/10 pain and subsequent deterioration constitutes the cited failure to provide care in accordance with professional standards and facility 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 deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for multiple residents, as required by its own cleaning policies and checklists. The facility’s Cleaning Checklist for Elderly Home and Daily Cleaning Checklist require daily cleaning of resident rooms, including dusting, disinfecting high-touch surfaces, sweeping and mopping floors, and cleaning and sanitizing bathrooms. However, review of the Daily Cleaning Checklists for the hallway where the affected residents lived showed multiple days where required cleaning tasks were left blank, indicating that rooms and bathrooms were not consistently cleaned as specified. One resident reported that her room was not clean, and the surveyor observed dark, dried food spots on the floor, splatters of red/brown dried substances under the bedside table, a long piece of string on the floor, and an alcohol prep pad wrapper near the sink. Another resident stated that the facility was not kept clean, described her room as filthy and dusty, and said staff did not clean the sink counter or move items to clean under them. In that room, the surveyor observed dust on the over-bed light, a granola bar wrapper under the bed, dirty shoe prints on the floor, crushed white powder on the floor near the nightstand, a wall heater pulling away from the wall with paint ripping, and a cluttered, untidy sink counter. A third resident’s room was observed with dirty shoe prints on the floor, brown tube-feeding liquid splatters on the feeding pole, a wall heater that had fallen down the wall causing paint to rip, and paper debris under the head of the bed. The shared bathroom for two of the residents contained feces in the toilet bowl, dried brown drips on the toilet seat, and a graduated cylinder used for urine collection sitting upside down on a discolored disposable cloth with dried urine, along with tubigrip stockings on the same cloth. On a subsequent day, the surveyor found that these rooms and the shared bathroom remained in essentially the same unclean condition, with only a granola bar wrapper removed from one room, confirming that the facility did not ensure daily cleaning as required. Staff interviews further confirmed that rooms were not kept clean and that housekeeping did not move resident belongings to clean surfaces, while maintenance staff were unaware of the deteriorating wall heaters and relied on staff work orders rather than ongoing room audits during occupancy.

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 sufficient nursing staff to meet residents’ assessed needs and care plan interventions, resulting in unmet care needs and prolonged call light response times. The facility’s own “Sufficient Staffing” policy requires adequate nursing staff with appropriate competencies, daily review of staffing patterns, and adjustment of staffing based on census and resident acuity. Despite this, multiple residents and staff reported that there were not enough CNAs and that essential care tasks were not completed because staff were too busy. Surveyors directly observed long call light wait times on the unit, with call lights remaining unanswered for extended periods while staff were either not present on the hall or engaged in other activities. One cognitively intact resident reported waiting up to 45 minutes for call lights to be answered and described staff entering the room, stating they would return, and then not coming back for more than an hour, leaving needs unmet. Another cognitively intact resident with quadriplegia and physician orders and care plan interventions for daily active assisted ROM to the bilateral lower extremities stated that CNAs did not perform the ROM exercises as ordered because they were too busy. During a surveyor observation of this resident’s call light, staff entered the room within a few minutes, turned off the call light, told the resident they would notify a CNA about the need for incontinent care, and then left; incontinent care was not provided until approximately 24 minutes after the initial call light activation. CNAs later confirmed they had not completed the resident’s ROM exercises that day due to being too busy. Another resident with multiple sclerosis, paraplegia, a stage 4 sacral pressure injury, and a care plan requiring turning and repositioning at least every 1–2 hours was observed lying on her back in the same position over several hours, from early morning through early afternoon. CNAs assigned to her care acknowledged that she should be repositioned every 2 hours and admitted that she had not been repositioned during the shift until cares were provided around 2:00 PM, stating they did not always have time to reposition her. A different resident reported that there was one CNA for 20 residents and described waiting up to 1.5 hours for assistance to use the bathroom, resulting in an accident that made the resident feel terrible, humiliated, and disrespected. Surveyors also documented multiple call lights active for 10–32 minutes before being answered, including one instance where a nurse manager walked past a room with an active call light without responding. A further cognitively intact resident with lymphedema, fibromyalgia, chronic pain, morbid obesity, and a care plan requiring two staff for all cares and use of a Hoyer lift to and from the commode reported that there were not enough staff, especially on evening and night shifts. This resident stated she had to wait up to an hour for staff to answer her call light or assist her off the commode, and that prolonged time on the commode caused numbness in her right hip and leg and purple discoloration on the backs of her legs. She also reported sitting on a Hoyer sling all day, causing painful indentations, and stated that when she complained, staff became sarcastic, so she stopped voicing concerns. CNAs interviewed by surveyors stated there were not enough staff to complete all resident care needs, specifically citing that repositioning, ROM, and oral care often did not get done because there was too much to do, and that they were unable to take breaks due to workload, further confirming that staffing levels were insufficient to meet residents’ care plan requirements and daily needs.

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 pressure injury care and prevention consistent with its own policy and professional standards for two residents with existing pressure injuries. The facility’s Pressure Injury Prevention and Wound Care Management policy requires identification of risk factors, implementation of appropriate interventions, and individualized repositioning based on clinical condition, with the expectation that residents with pressure injuries receive care to promote healing and prevent additional ulcers. Despite this, staff did not follow the established care plans and interventions for the residents reviewed. One resident, admitted with multiple sclerosis, paraplegia, and a stage 4 sacral pressure injury, had a care plan that identified limited physical mobility and risk for altered skin integrity, with an intervention to turn and reposition the resident at least every 1–2 hours. On the survey date, the resident was repeatedly observed lying on her back in bed with the head of the bed elevated about 45 degrees at multiple times from 8:00 AM through 1:14 PM, without evidence of repositioning. Certified nursing assistants later confirmed they had not provided cares or repositioned the resident during that time, and one CNA stated she did not reposition the resident until about 2:00 PM. Nursing leadership, including the ADON and DON, stated that residents with pressure injuries should be repositioned every 1–2 hours and that this resident should have been repositioned per her care plan. Another resident, admitted with congestive heart failure, peripheral vascular disease, vascular dementia, and protein-calorie malnutrition, had a care plan identifying risk for altered skin integrity and a stage 4 pressure injury on the left great toe. Interventions included use of a foot cradle, a pressure-reducing air mattress, management of clinical conditions, and Prevlon boots to the feet while in bed, along with turning and repositioning every 2–3 hours. The wound care physician documented a stage 4 pressure wound of the left first toe with an etiology of pressure and an approach of close monitoring and off-loading. During an interview, the resident, who was cognitively intact, reported having a pressure injury on the foot and stated staff have them wear boots during the day and off at night; however, the surveyor observed the resident lying in bed with an air mattress and foot cradle in place, but the pressure-relieving boots were on the floor instead of on the resident’s feet. The DON later stated that the root cause of the pressure injury was pressure from blankets and that a foot cradle had been initiated to off-load the blankets, and confirmed the resident should be wearing the boots when in bed.

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 ordered and care-planned range of motion (ROM) services to a resident with significant mobility limitations. The facility’s ADL policy requires that, based on comprehensive assessment and care planning, residents receive necessary care and services to maintain or improve their abilities, with ADL needs communicated via the care plan and CNA Kardex. One resident with quadriplegia C5–C7 incomplete, cognitively intact with a BIMS score of 15, had a physician order for PT evaluation and treatment for ROM and pain/spasticity to the bilateral lower extremities (BLE). PT documentation indicated ROM to the BLE was provided, that the resident tolerated it well with improved comfort, and that a ROM program was posted in the room with updated staff recommendations. The comprehensive care plan and CNA Kardex both specified a daily active assisted ROM program to the BLE, referencing signs in the room that detailed specific leg and foot exercises and required a minimum of five repetitions once daily. Despite these orders and care plan interventions, the resident reported not receiving the prescribed daily ROM exercises to her legs, noting that the exercises decreased her edema and pain. During surveyor interviews, one CNA stated that staff use the CNA Kardex to determine resident care needs and acknowledged that the resident had a ROM program with exercises to be done in bed, but confirmed that ROM exercises were not performed that day while assisting with the resident’s care. A second CNA, who also provided care to the resident that day, similarly stated that CNAs assist the resident with ROM exercises but confirmed they did not assist with ROM that day. The DON stated that staff are expected to follow residents’ care plans. These observations and interviews showed that the resident did not receive the ordered and care-planned daily active assisted ROM to the BLE, resulting in a failure to provide appropriate treatment and services to maintain or improve ROM/mobility or prevent further decline.

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 pharmaceutical services that ensured timely administration of medications in accordance with physician orders and facility policy for one resident. The facility’s “Administering Medications” policy required medications to be administered per provider orders, with verification of the right medication, dose, route, time, and resident identity, and specified that medications should be administered within one hour of the prescribed time. The “Medication Error and Drug Interactions” policy defined a medication error as preparation or administration of medications not in accordance with the prescriber’s order. For the resident reviewed, physician orders for February 2026 included Potassium Citrate-Citric Acid oral solution via G-tube four times daily for kidney stones, Oxybutynin Chloride oral solution via G-tube three times daily for urinary leakage, and Gabapentin oral solution via G-tube three times daily for pain. Record review of the Medication Administration Audit Report showed that all three medications, scheduled for 8:00 AM on a specific date, were actually administered at 9:18 AM, which was outside the facility’s defined one-hour window (7:00 AM to 9:00 AM) for an 8:00 AM dose. During interviews, an LPN and the DON both confirmed that medications scheduled for 8:00 AM must be given between 7:00 AM and 9:00 AM, and that administration outside this timeframe constitutes a medication error. This late administration of the resident’s ordered medications, beyond the facility’s established administration window, resulted in a medication error and demonstrated that pharmaceutical services were not provided in accordance with the facility’s own policies and the prescriber’s orders.

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 abuse by a certified nursing assistant (CNA). An incident occurred in which a resident and a CNA engaged in a verbal altercation, with both parties yelling at each other. The CNA was reported to have antagonized the resident, and the resident accused the CNA of smelling like marijuana. The altercation was witnessed by a licensed practical nurse (LPN), who intervened and reported the incident to the nurse on call. Despite the altercation, the CNA continued to work the remainder of the shift on the same hallway as the resident, although did not provide direct care to the resident involved in the incident. The facility's policy requires that any staff member implicated in an alleged abuse event be immediately removed from resident care areas and suspended pending investigation. However, this procedure was not followed, as the CNA continued to work after the incident. Additionally, the incident was not reported to the Director of Nursing (DON) or Nursing Home Administrator (NHA) until several days later, and the state agency was not notified within the required timeframe. The facility's policy also mandates immediate assessment and protection of the resident, as well as timely reporting and investigation of abuse allegations, which did not occur in this case. Furthermore, the facility did not provide abuse education to all staff during the investigation of the incident. Only one LPN received education on abuse reporting and prevention following the event, while other staff members, including those directly involved or present during the incident, did not receive such education. This lack of comprehensive staff education and failure to follow established abuse prevention and investigation protocols contributed to 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 ensure that an allegation of abuse involving a resident and a certified nursing assistant (CNA) was reported to the State Agency within the required timeframe. The incident occurred when a resident, who was cognitively intact and had diagnoses including Type 2 Diabetes and depression, was involved in a verbal altercation with a CNA. The altercation included yelling and accusations, with the CNA being antagonistic and the resident making personal accusations against the CNA. The situation was witnessed by an LPN, who intervened and separated the individuals, ensuring the resident felt safe. The CNA was instructed not to interact with the resident further during the shift, but was not immediately suspended or removed from the care area as required by facility policy. The LPN who witnessed the incident reported it to the nurse on call later that night, but the nurse on call did not provide direction to remove the CNA from the facility or report the incident to the Director of Nursing (DON) or Nursing Home Administrator (NHA) until several days later. The incident was not reported to the State Agency until the following day, exceeding the facility's policy and federal requirements to report allegations of abuse immediately, but no later than two hours after the allegation is made. Interviews with staff confirmed that the incident was recognized as an allegation of abuse and that the reporting requirements were not met. Facility records and staff interviews indicated that the delay in reporting was due to a lack of immediate action by both the nurse on call and other supervisory staff. The facility's own policies require immediate notification of the administrator and State Agency in cases of alleged abuse, as well as immediate suspension of implicated staff. These procedures were not followed, resulting in a failure to timely report the suspected abuse 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 that all alleged violations of abuse were thoroughly investigated and that immediate steps were taken to protect residents from further abuse. On 9/27/25, the facility became aware of an abuse allegation involving a resident with diagnoses including Type 2 Diabetes and depression, who was cognitively intact. The incident involved a verbal altercation between the resident and a certified nursing assistant (CNA), during which both parties were observed yelling at each other, and the CNA was accused of antagonizing the resident. Despite the facility's policy requiring immediate suspension of implicated staff pending investigation, the CNA continued to provide direct care to residents after the incident occurred. Interviews and record reviews revealed that the facility did not provide evidence of protection for the resident involved or for other residents in the facility following the allegation. The CNA was not immediately removed from resident care areas and continued working the shift, although did not provide care to the specific resident involved. Nursing staff expressed discomfort with the CNA's continued presence, noting that the CNA would look into the resident's room and give looks, which contributed to an unsafe environment. The incident was not reported to the DON or NHA until days later, and the state agency was notified several hours after the event. Additionally, the facility did not provide abuse prevention education to all staff following the incident, as required by policy. Only one LPN received education on reporting allegations of abuse and the facility's abuse prevention policy, while other staff, including those directly involved, did not receive such education. The facility's failure to follow its own policies and federal guidelines regarding immediate protection, investigation, and staff education contributed to the deficiency.

Penalty

Fine: $40,74020 days payment denial

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

Summary

A resident with a history of schizoaffective disorder, chronic obstructive pulmonary disease, urinary tract infection, and chronic pain syndrome was admitted to the facility with specific medication titration orders for clozapine following a recent hospital stay. The hospital discharge instructions required a gradual titration of clozapine, starting at a low dose and increasing incrementally. However, the resident was mistakenly administered a 100mg dose of clozapine instead of the prescribed 12.5mg, constituting a medication error. Following the medication error, the resident exhibited significant changes in condition, including excessive sleepiness, difficulty staying awake, inability to use an inhaler, elevated blood pressure and heart rate, decreased oxygen saturation, and later, confusion and garbled speech. Despite these clear signs of a change in condition, the facility failed to conduct comprehensive RN assessments or provide detailed documentation of the resident's status. There was also a lack of timely and appropriate notification to the resident's provider, as required by facility policy and professional standards of nursing practice. The resident experienced a fall, continued to display altered mental status, and eventually required emergency transfer to the hospital, where an accidental overdose of clozapine was confirmed. Interviews with facility leadership and the nurse practitioner revealed that expected monitoring and provider communication did not occur, and documentation of assessments was lacking. The facility did not follow its own policy for change in condition, failed to notify the provider promptly, and did not ensure ongoing comprehensive assessments after the medication error.

Penalty

Fine: $40,74020 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 pharmaceutical services that ensured the accurate preparation and administration of medications for one resident. During medication administration, an LPN was observed crushing and administering several medications that, according to both manufacturer specifications and facility policy, should not be crushed. These included enteric-coated aspirin, extended-release bupropion, finasteride, and extended-release guaifenesin. Additionally, the LPN opened omeprazole and tamsulosin capsules and mixed their contents with the other crushed medications. The LPN stated that these actions were based on an order for crushed medications, but a review of the resident's physician orders revealed no such authorization. The orders specifically indicated that these medications should not be crushed, chewed, or opened, and in the case of aspirin, a chewable form was ordered but an enteric-coated tablet was administered instead. Interviews with other nursing staff, including another LPN, an RN, and the DON, confirmed that crushing extended-release or enteric-coated medications, or opening capsules that should be swallowed whole, constitutes a medication error. The facility's own policies and a reference list of medications not to be crushed were not followed in this instance. The incident was observed directly by the surveyor, and the staff interviewed acknowledged that the actions taken were medication errors according to both facility policy and professional standards.

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 complex medical conditions, including chronic diastolic congestive heart failure (CHF), chronic respiratory failure, morbid obesity, lymphedema, and schizoaffective disorder, experienced deficiencies in care related to both skin integrity and CHF monitoring. The resident, who was cognitively intact, reported developing soreness and potential skin breakdown on her buttocks from prolonged sitting on a Hoyer sling. Despite voicing these concerns, the registered nurse did not complete a timely assessment or promptly notify the provider of the potential skin breakdown. Interviews with staff revealed that the Hoyer sling was consistently left under the resident while she was seated, and staff cited difficulty and time constraints as reasons for not removing it. The facility's own policies required daily skin monitoring and immediate provider notification for new wounds, but these procedures were not followed. Further investigation showed that the facility failed to adequately monitor and document the resident's weight as ordered by the physician, which was critical for managing her CHF. The care plan and treatment administration record specified bi-weekly weights and provider notification for significant weight changes. However, weight documentation was inconsistent, with several weeks missing entries and no evidence of refusals by the resident, despite staff claims. The facility had a Hoyer lift capable of weighing the resident during transfers, but this feature was not utilized as required. Interviews with multiple CNAs confirmed that the resident did not refuse weight checks, contradicting the assumption that refusals were the reason for missing data. The director of nursing acknowledged that staff should have followed physician orders for weight monitoring and timely provider notification. The lack of regular weight monitoring and failure to notify the provider of significant weight fluctuations meant that symptoms of CHF exacerbation were not adequately tracked. Additionally, the facility did not perform a full assessment or timely provider notification regarding the resident's change in skin condition, as required by facility policy and professional standards of practice.

Penalty

No penalty information released

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

Summary

The facility failed to ensure adequate supervision and safety to prevent accidents for multiple residents, resulting in both actual harm and the potential for more than minimal harm. One resident with moderate cognitive impairment and total dependence on staff for all activities of daily living was left unattended in bed with the bed in a high position. This resident fell from the bed, sustaining a nasal fracture and facial lacerations that required sutures. Staff interviews confirmed that the resident was not capable of rolling over or transferring independently, and that the expectation was for the bed to be lowered when staff left the room. However, the bed was left at waist height, and the resident was left alone, directly leading to the fall and injuries. Several other residents who required Hoyer lift transfers with the assistance of two staff members were transferred with only one staff present. One cognitively intact resident sustained a skin tear to his toe during such a transfer. Interviews with staff revealed that, due to staffing shortages or time pressures, staff sometimes performed Hoyer transfers alone, contrary to facility policy and care plan requirements. Residents confirmed that transfers were sometimes performed by a single staff member, and staff acknowledged the deviation from policy. Another resident with severe cognitive impairment and total dependence on staff for mobility and transfers had care plan interventions that were not consistently followed. The care plan required the resident to be laid down after meals to prevent falls from sleeping in a wheelchair, but staff did not consistently document or communicate refusals to comply with this intervention. Observations showed the resident asleep in a wheelchair on multiple occasions, and staff interviews indicated a lack of consistent documentation and communication regarding the resident's refusals and the effectiveness of the intervention.

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 and drink were served to residents at palatable, attractive, and safe temperatures, as required by both facility policy and federal regulations. During the survey, a cognitively intact resident reported that her only concern was that the food was always cold, stating that it would be good if it wasn't consistently served at a low temperature. The surveyor confirmed this concern by receiving a test tray with scrambled eggs at 88.3°F, bacon at 77.5°F, toast with unmelted butter at 74.8°F, and oatmeal at 124°F, all of which were below the required serving temperatures. The milk was served at 34.5°F, which is within an acceptable range for cold beverages. The surveyor found the hot foods to be cold, tasteless, and unappetizing. Interviews with staff confirmed the expectation that hot foods should be served at appropriate temperatures, with the Dietary Manager acknowledging that the test tray foods were not at the required temperatures. The Dietary Manager noted that the facility uses insulated carts and heated plates but identified that the lack of warmers in the carts and delays in tray delivery by nursing staff contributed to the issue. The Dietary Manager was aware of ongoing complaints about cold food and had offered residents options to eat in the dining room or request replacement trays, but the deficiency persisted at the time of the survey.

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the administrator and other officials in accordance with State law and established procedures. Specifically, a dietary aide posted a photo of two residents on her personal Snapchat account with a caption, which was observed by a friend of a facility employee. The friend forwarded the photo to the employee, who did not immediately report the incident to facility administration as required by policy. The employee admitted to delaying the report until the following day while deciding what to do, despite facility policy mandating immediate reporting of all allegations or suspicions of abuse. The facility's policy clearly states that all allegations and/or suspicions of abuse must be reported to the administrator immediately, and to the State Agency within specified timeframes depending on the nature of the incident. In this case, the administrator was not made aware of the incident until the next day, and the timeline of when the employee became aware of the photo was not initially clear to the administrator. The delay in reporting the incident constituted a failure to follow the facility's abuse prevention and reporting 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 ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported and investigated according to policy and state law. Specifically, a dietary aide posted a photo of two residents on her personal Snapchat account with a caption, and this was brought to the attention of a facility employee by a friend. The employee did not immediately report the incident, instead waiting until the next day to notify the Nursing Home Administrator (NHA). Upon learning of the incident, the NHA did not interview other residents to determine if the issue was isolated or more widespread, nor was there education provided to staff regarding the importance of timely reporting of such incidents. The facility's policy requires immediate notification of the administrator and a thorough investigation, including interviews with all potentially involved or affected parties. However, the NHA assumed the incident was isolated and did not take steps to assess the broader scope of the concern. The failure to interview other residents and educate staff on timely reporting contributed to the deficiency, as the facility did not fully follow its own procedures for responding to alleged violations involving resident mistreatment.

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 was identified when a resident with diagnoses of hypertension and paroxysmal atrial fibrillation was administered Metoprolol Succinate ER 25 mg daily without consistent monitoring of blood pressure as required by physician orders. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 110, necessitating a blood pressure check prior to each administration. However, review of the Medication Administration Records (MAR) and the electronic health record (EHR) revealed that blood pressure readings were not documented daily, and there was no evidence that blood pressure was checked before each dose was given. During an interview, the Director of Nursing (DON) confirmed that blood pressure should have been checked daily prior to administering the medication, in accordance with the order. The DON also verified, upon review of the records, that the required monitoring was not performed. The facility's policy on medication administration emphasizes adherence to provider orders and safe medication practices, but these procedures were not followed in this instance, resulting in the administration of an antihypertensive medication without the necessary monitoring.

Penalty

Fine: $45,560

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 security measures for a resident identified as having a potential for wandering and elopement. This resident, who has dementia and mild intellectual disabilities, managed to elope from the facility without staff knowledge. The resident exited through a door at the rear of the facility, where the door alarm was disengaged, allowing the resident to leave the premises without alerting the staff. The facility's policy on elopement risk and prevention was not effectively implemented, as the resident was able to access various locations in the building and exit the facility. The resident had a history of wandering and had been previously identified as an elopement risk. Despite this, the facility did not reassess the resident's elopement risk after a prior incident where the resident was found outside the facility. The resident's care plan did not adequately address the risk of elopement, and the facility's Wanderguard system was not effectively monitored or maintained. Additionally, the facility allowed the use of magnets to disengage door alarms, which contributed to the resident's ability to leave the facility undetected. Interviews with staff and other residents revealed that the use of magnets to silence alarms was a known practice, and the facility did not provide adequate education or monitoring to prevent this. The resident's elopement was only discovered when a family member called to report the resident's whereabouts. The facility's failure to maintain proper security measures and supervision for the resident resulted in a deficiency finding of immediate jeopardy.

Removal Plan

• The facility is implementing a removal plan.
• Current alarm system and Wanderguard system being reviewed.
• Audits in place to ensure resident informs staff if he would like to go on a leave or have family bring snacks.
• Investigation to root cause initiated and audits/education implemented.
• Self-report submitted.
• Audits are continuing at least daily to ensure that alarms are engaged and working on all doors.
• A new Wanderguard system is being pursued.
• Separate magnet was taken away on 300 wing door so the alarm cannot be shut off without alarming and intervention.
• Staff educated on not disengaging alarm.
• Daily audits are being conducted to ensure all the exit door Wanderguard and alarm systems are working properly.
• R56 had updated SLUMS, MOCA, and MMSE cognitive tests.
• An updated elopement assessment will be conducted.
• The care plan for R56 was updated.
• Monitor for exit seeking and document episodes.
• Interventions for exit seeking behaviors: provide 1:1 and reassurance, offer distraction such as activity or snack.
• Facility is continuing to investigate to ensure no other processes or protocols were violated.
• Facility documented and reported to the state agency the incident.

Penalty

Fine: $45,560

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 stage 3 pressure injury in a resident who was admitted without any pressure injuries. The resident, who was cognitively intact, had a history of conditions such as acute and chronic respiratory failure, COPD, and CHF, and was at risk for skin integrity issues due to continuous oxygen use. Despite these risks, the facility did not implement pressure-relieving interventions prior to the development of the pressure injury behind the resident's left ear, which was attributed to the oxygen tubing. The facility's policy on pressure injury prevention and wound care management did not address device-related pressure injuries, which contributed to the oversight. The resident's care plan initially lacked interventions to prevent device-related pressure injuries, and it was only after the injury was noted that orders for skin prep and padding to the oxygen tubing were implemented. However, observations by the surveyor revealed that the padding was not consistently applied to the oxygen tubing, and there was a lack of documentation regarding the wound's characteristics, measurements, and drainage. Interviews with the facility's staff, including the DON and an LPN, highlighted a lack of awareness and documentation regarding the wound's development and characteristics. The DON confirmed that there was no documentation or assessments of the wound when it was first identified, and the LPN could not recall specific details about the wound or whether it was measured. The resident reported that the padding did not stay on well and that nurses did not always check behind his ears during skin assessments, indicating a gap in consistent care and monitoring.

Penalty

Fine: $45,560

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 items were stored and labeled according to professional standards, which could potentially affect the 59 residents in the facility. During an observation, it was noted that multiple food and beverage items in the kitchen refrigerator and dry storage room were not labeled with open or expiration dates, and some were beyond their labeled discard date. Items such as sandwiches, ham, meatballs, sliced tomatoes, pudding, orange juice, cranberry juice, potato salad, breadcrumbs, and flour were either past their use-by date or lacked proper labeling. The Dietary Manager acknowledged that these items could not be served due to their expired or unknown use-by dates. Additionally, the facility did not adhere to its own policies regarding dishwashing and sanitizing procedures. The dishwashing process was completed without testing the dishwasher temperature and concentration of the sanitizer before use, as required by the facility's policy. The Dietary Aide was observed using a sanitizing bucket without testing for temperature or concentration of the sanitizer, and there was no training provided for such testing. The Dietary Manager confirmed that the sanitizing bucket should be tested, but this was not being done. The facility's policies clearly state the importance of testing wash and rinse temperatures and sanitizer concentration before using the dishwashing machine. However, the Dietary Aide performed testing only after all dishes and utensils had been washed, contrary to the policy. The Dietary Manager was unsure if testing prior to washing would allow the machine to reach the required temperature, but acknowledged that without prior testing, the facility could not confirm if dishes were properly cleaned and sanitized. This lack of adherence to established procedures highlights a significant deficiency in the facility's food safety and sanitation practices.

Penalty

Fine: $45,560

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 residents, resulting in unmet care requirements for several residents. Residents R17, R13, R9, R45, R36, R7, and R27 were among those affected, with issues such as long call light wait times, missed showers, and inadequate assistance with activities of daily living (ADLs) being reported. The facility's staffing levels were insufficient, with only two CNAs available for night shifts to care for over 60 residents, leading to delays and incomplete care tasks. Interviews with residents and staff revealed widespread dissatisfaction with the staffing situation. Residents expressed concerns about safety and the quality of care, noting that agency staff were frequently used and not always respectful or invested in the facility. Staff members reported being unable to complete essential tasks such as bathing, making beds, and taking out garbage due to the lack of personnel. The facility's reliance on agency staff, who were often late or did not show up, exacerbated the problem. The facility's assessment and staffing policy did not align with the actual needs of the residents, as evidenced by the missed showers and unmet care needs. The Nursing Home Administrator acknowledged the staffing issues and indicated that the facility was attempting to address them by holding staff accountable for call-ins and offering incentives. However, these measures had not yet resolved the chronic understaffing problem, which continued to impact the residents' well-being.

Penalty

Fine: $45,560

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 standards, as observed in two medication carts. On the 300 Hall medication cart, three insulin pens were found without open dates, which is necessary to determine expiration. These pens were associated with three residents. Similarly, the 200 Hall medication cart contained an insulin pen without an open date for another resident. Both LPNs confirmed that insulin pens should be dated upon opening to track expiration. The Director of Nursing also stated that insulin pens should have the open date and resident information labeled. Additionally, the facility did not adhere to its policy regarding the preparation and storage of medications. A Registered Nurse repackaged Aspirin 81 milligrams at the start of her shift, placing them in a medication cup for later use, which is against the facility's policy that prohibits preparing medications in advance. The nurse reported a recurring issue of running out of aspirin due to limited stock, which had not been addressed by management. The Director of Nursing confirmed that transferring stock medication between carts in this manner is not acceptable.

Penalty

Fine: $45,560

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 and drink were served at palatable and safe temperatures, affecting all four hallways and the dining room, with a potential impact on all 59 residents. Observations and interviews revealed that residents frequently received hot foods cold and cold beverages warm. A test tray confirmed these findings, with sausage measured at 101.8°F, pancakes at 117°F, and milk at temperatures above the expected 40°F. The Dietary Manager acknowledged that the facility's policy required hot foods to be served hot and cold foods cold, but the test tray did not meet these standards. Multiple residents, all cognitively intact as per their Minimum Data Set (MDS) scores, reported similar issues. One resident mentioned receiving lukewarm food several times a week and expressed reluctance to reheat certain foods due to quality concerns. Another resident had to reheat meals in a microwave, and melted ice cream was a common issue. These concerns were reportedly discussed in Resident Council meetings. Other residents also expressed dissatisfaction with the temperature of their meals, indicating a consistent problem across the facility.

Penalty

Fine: $45,560

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 safe, clean, comfortable, and homelike environment for a resident, identified as R32, as observed by the surveyor. The surveyor noted that R32's room had a persistent smell of urine, a brown substance on the floor, a full garbage can, and white debris under the bed and on the floor on two separate occasions. The facility's cleaning policy, which includes using an EPA-approved cleaning agent and mopping the entire floor, was not adhered to, as evidenced by the unclean state of R32's room. The housekeeper, HK W, indicated that she was the only housekeeper available due to the absence and subsequent resignation of a second housekeeper, making it challenging to clean all resident rooms and common areas. There was no backup plan in place to address the shortage of housekeeping staff until the surveyor questioned the process. The Maintenance Director, MD Y, who oversees housekeeping, acknowledged the lack of a backup plan and the need to hire additional staff. The cleaning checklist provided showed no sign-off for R32's room on specific dates, further indicating a lapse in maintaining cleanliness standards.

Penalty

Fine: $45,560

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 a comprehensive person-centered care plan for a resident, identified as R32, to meet their medical, nursing, and psychosocial needs. R32 was admitted with multiple diagnoses, including Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, and other health issues. The resident's care plan did not reflect person-centered interventions, as evidenced by observations and interviews indicating that R32 often refused care and meals, particularly in the mornings, and was frequently found in bed in the same position throughout the day. The report highlights that R32's care plan lacked specific strategies to address their resistance to care and meals. The resident's power of attorney and a CNA noted that R32 was not a morning person and preferred to sleep in, often refusing breakfast but accepting snacks later in the day. The CNA also mentioned that R32 was more cooperative with care when their husband visited. Despite these observations, the care plan did not include these person-centered approaches, and there was no documentation of R32 receiving showers in September, despite a preference for Monday morning showers. Interviews with facility staff, including a social worker and the nursing home administrator, revealed that care plans were expected to be updated quarterly and as needed. However, there was no system in place to trigger updates based on residents' refusals of care, such as showers. The nursing home administrator and assistant director of nursing acknowledged that R32's care plan should have included person-centered approaches, such as allowing R32 to sleep in and offering care later in the day, but these were not reflected in the care plan.

Penalty

Fine: $45,560

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

Summary

The facility failed to ensure that a resident with congestive heart failure received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, who was admitted with a diagnosis of congestive heart failure, had a physician's order for daily weight monitoring due to the condition. The order specified that any weight gain or loss of 3 pounds in a day or 5 pounds in a week should be reported to the physician. However, the resident was not weighed on several consecutive days, and a significant weight gain was not reported to the physician as required. The Registered Dietician (RD) responsible for reviewing resident weights daily indicated that she notified facility nurses via email about the need for the resident's weight to be monitored. Despite these notifications, the resident was not weighed on the specified days, and the weight gain was not communicated to the physician. The Director of Nursing (DON) confirmed that the resident should have been weighed according to the physician's orders and that the weight increase should have been reported. The facility was unable to provide documentation showing that the physician was contacted regarding the resident's weight gain or that the resident was weighed during the specified period.

Penalty

Fine: $45,560

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, identified as R39, maintained acceptable parameters of nutritional status, specifically regarding fluid restriction and weight monitoring. R39, who has diagnoses including congestive heart failure (CHF), hypertension, and morbid obesity, was on a fluid restriction of 2000ml per 24 hours. However, the staff did not adequately monitor this restriction, as evidenced by inconsistent documentation of fluid intake and a lack of daily total calculations. Additionally, R39 experienced significant weight gains that were not reported to the medical provider, contrary to the facility's policy. The facility's policies on hydration and weight monitoring were not followed. The policy required fluid breakdowns for residents on restrictions to be documented in the Medication Administration Record (MAR) and the Point of Care (POC) task list, with intake and output monitored weekly by licensed nursing staff. Despite this, R39's fluid intake records for September showed numerous instances of missing documentation. Furthermore, the policy on weight changes stipulated that any weight change of 5 pounds or more within 30 days should be verified and communicated to the resident's physician and dietician. R39's weight increased by 14 pounds from April to May and by 20 pounds over six months, yet these changes were not communicated to the medical provider. Interviews with facility staff, including a CNA, LPN, NP, and the Director of Nursing (DON), revealed a lack of clarity and accountability regarding the monitoring of fluid intake and weight changes. The LPN was unsure who was responsible for monitoring daily fluid totals, and the DON acknowledged that nurses were supposed to do it daily. The NP was not updated about R39's weight gain or the lack of weight measurements in July and August. This lack of communication and adherence to policies contributed to the deficiency in maintaining R39's nutritional status and fluid balance.

Penalty

Fine: $45,560

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 misappropriation of a resident's property by a staff member at the facility. Resident R24 reported that he lent a Norro foot massager to RN L, a registered nurse, with the expectation that it would be returned shortly. However, R24 did not see the foot massager again and had to repeatedly ask RN L for its return. Despite these requests, RN L ignored R24, leading him to threaten to call the police before the item was finally returned. The facility's policy on abuse and neglect prevention clearly states that residents should be protected from misappropriation of their property. Misappropriation is defined as the intentional taking or withholding of a resident's belongings without consent. In this case, RN L's actions were considered misappropriation as she retained the foot massager despite R24's repeated requests for its return. The situation caused significant distress to R24, who had a history of a serious heart condition, adding to his stress and discomfort. Interviews with various staff members, including the Social Worker, LPN, Business Office Manager, and Director of Nursing, confirmed that the incident was recognized as misappropriation. The staff acknowledged that it is unacceptable for employees to borrow or withhold residents' belongings. Despite this understanding, the grievance process was not completed in a timely manner, and the issue was not addressed until R24 escalated the situation by threatening police involvement.

Penalty

Fine: $45,560

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 alleged misappropriation of a resident's property to the State Agency within the required timeframe. A resident, identified as R24, reported that a Registered Nurse (RN L) borrowed his Norro foot massager and did not return it despite multiple requests. The resident filled out a grievance form on 9/22/24, which was given to a Licensed Practical Nurse (LPN N) and subsequently forwarded to the Business Office Manager (BOM M), who was the Manager on Duty at the time. However, BOM M did not fully read the grievance nor report it to the Director of Nursing (DON B) or the Nursing Home Administrator (NHA A), leaving it for the Social Worker (SW C) to address the following day. The facility's policy requires that any allegations of abuse, mistreatment, neglect, or misappropriation be reported immediately to the Nursing Home Administrator or designee, and then to the State Agency as per State and Federal requirements. Despite this policy, the grievance was not reported to the appropriate authorities, and the police were not notified. The Social Worker, SW C, received the grievance on 9/23/24 but had not yet followed up on it. The Director of Nursing, DON B, stated that she was not aware of the grievance until later and acknowledged that it should have been reported immediately as it constituted an allegation of misappropriation, which is considered a form of abuse. Interviews with staff revealed a lack of communication and adherence to the facility's reporting procedures. BOM M admitted to not notifying the DON or NHA about the grievance, and DON B stated that she did not recall being informed by LPN N over the weekend. The failure to report the incident promptly resulted in a delay in addressing the resident's grievance and ensuring compliance with regulatory requirements. The incident highlights a breakdown in the facility's internal processes for handling and reporting allegations of misappropriation.

Penalty

Fine: $45,560

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 involving a resident's property. A resident, identified as R24, reported that they lent a Norro foot massager to a Registered Nurse (RN L) and did not receive it back for 2-3 weeks. Despite asking for its return multiple times, the resident only got the massager back after threatening to call the police. The grievance was filled out on 9/22/24 and given to a Licensed Practical Nurse (LPN N), who informed RN L to return the item. The Business Office Manager (BOM M) received the grievance but did not notify the Director of Nursing (DON B) or the Nursing Home Administrator (NHA A) as required by the facility's policy. The grievance was left for the Social Worker (SW C) instead. The DON B confirmed that allegations of misappropriation should be self-reported and investigated, with the accused staff member suspended pending investigation. However, this procedure was not followed, and the staff was not educated on the incident or the suspicion of a crime.

Penalty

Fine: $45,560

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

Summary

The facility staff failed to adequately assess and treat pain for a resident, identified as R45, who was experiencing significant pain levels. R45, who has a history of Multiple Sclerosis, Chronic Pain Syndrome, and other related conditions, reported a pain level of 8 out of 10 during consecutive shift assessments. Despite having physician orders for both scheduled and PRN pain medications, including Morphine ER and Morphine IR, the facility did not administer the PRN Morphine when the resident reported severe pain. The facility's policy on pain management requires that non-pharmacological interventions be attempted before administering PRN analgesics and that the effectiveness of any pain medication be evaluated post-administration. However, there was no documentation of reassessment of R45's pain after non-pharmacological interventions or after the administration of scheduled Morphine ER. Additionally, the facility had immediate release Morphine available in their contingency stock, but it was not utilized for R45's reported pain level of 8 out of 10. Interviews with facility staff, including LPNs and the DON, revealed a lack of adherence to the facility's procedures for managing pain and accessing contingency medications. Staff members indicated that they would assess pain and administer PRN medications if available, but there was no evidence that the PRN Morphine was administered or that the resident's pain was reassessed. The DON confirmed that staff should reassess pain after interventions and contact a provider if a medication script was unavailable, but these steps were not documented in R45's case.

Penalty

Fine: $45,560

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

Summary

The facility was found to have a medication error rate of 29.63%, significantly exceeding the acceptable threshold of 5%. This was observed during a medication pass task involving one sampled resident and two supplemental residents. The errors included medication timing errors, medication omission, and incorrect dosage administration. Specifically, medications for one resident were administered outside the prescribed time window, and one medication was omitted due to unavailability. Another resident received medications late, and the nurse failed to document the delay or consult the provider for guidance. Additionally, a third resident was given the wrong dose of a medication. The facility's policy on administering medications requires adherence to physician orders and state/federal regulations, including administering medications within one hour of the prescribed times. However, the surveyor observed multiple instances where this policy was not followed. For example, a resident's medications were administered more than two hours late, and another resident's medication was not available and thus omitted. The facility's Director of Nursing confirmed that medications should be administered within the specified time frame and that the provider should be updated if medications cannot be given as ordered. Interviews with the nursing staff and the Director of Nursing revealed a lack of adherence to the facility's medication administration policy. The staff acknowledged the errors and the need to update the provider and document any deviations from the prescribed medication schedule. The Director of Nursing also confirmed that medications should be available and administered as ordered, and that any unavailability should be promptly addressed with the provider and pharmacy. These deficiencies highlight a significant lapse in the facility's medication administration process, impacting the quality of care provided to the residents.

Penalty

Fine: $45,560

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, as observed during a survey. The deficiency involved a resident who had a physician's order for Entresto, a medication used to treat heart failure and high blood pressure, dated 8/30/24. However, the resident did not receive the medication since the order was placed. On 9/23/24, during a medication pass, a registered nurse confirmed that the Entresto was not available for administration, resulting in a significant medication omission error. Further investigation revealed that the facility's Director of Nursing (DON) acknowledged the expectation that medications should be administered per physician orders. The DON also confirmed that if a medication is not available, the nurse should update the provider and contact the pharmacy. Despite this expectation, there was no record of communication from the pharmacy regarding the unavailability of the resident's Entresto medication, indicating a lapse in the facility's medication administration process.