Heritage Lakeside

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 submit an initial report of an allegation of misappropriation of a resident's property to the state survey agency within the required 24-hour timeframe and did not notify law enforcement as required. The incident involved a resident with a history of Alzheimer's disease, unspecified psychosis, and hallucinations, who had a moderately impaired cognitive status as indicated by a BIMS score of 12. The resident's responsible party reported via email that the resident's wallet and social security card were missing, and the resident had expressed concerns about people entering rooms and taking items. Facility records showed that a formal grievance was filed regarding the missing items, and the facility conducted interviews with the resident, who at times denied having the wallet at the facility and suggested another family member had possession of it. Despite these interviews and ongoing communication with the responsible party, the facility did not submit the required report to the state agency until several days after the initial allegation was made. Additionally, the facility's documentation and staff interviews confirmed that law enforcement was not contacted regarding the missing wallet and identification cards. The facility's Abuse Prevention Policy required immediate reporting of all alleged violations involving misappropriation of resident property to the state agency and law enforcement, depending on the circumstances. However, the administrator initially determined that the missing wallet, which did not contain money but did include identification cards, did not rise to the level of misappropriation and therefore did not report it promptly. The delay in reporting and failure to notify law enforcement were confirmed through interviews with facility staff and review of facility documentation.

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 conduct a thorough investigation into an allegation of misappropriation involving a resident's missing wallet and identification cards. The resident, who had a history of Alzheimer's disease, unspecified psychosis, and hallucinations, was reported by a responsible party to be missing a wallet containing a state identification card and social security card. The resident's cognitive status was moderately impaired, as indicated by a BIMS score of 12. The responsible party notified the Social Services Director (SSD) via email, and a formal grievance was filed, with the facility offering to assist in replacing the missing items. Despite the facility's policy requiring timely and thorough investigations of all reports and allegations of abuse or misappropriation, the investigation did not include interviews or statements from staff who cared for the resident. The investigation consisted of interviewing the resident, searching for the wallet, and interviewing other residents, but omitted staff interviews. Multiple staff members, including LPNs, CNAs, and a Trained Medication Aide, confirmed during subsequent interviews that they had not been asked about the missing wallet and were unaware of the incident. Facility documentation, including the Monthly Grievance Log, Complaint/Grievance Report, and state agency reports, confirmed that the investigation was incomplete. The SSD and Administrator both acknowledged that investigating such allegations was a group effort, but the Administrator stated that she expected the investigation to include staff interviews, which did not occur. This failure to follow investigative protocols resulted in an incomplete investigation of the alleged 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 facility failed to ensure that a comprehensive care plan was developed and implemented to address all of a resident's medical needs and preferences. Specifically, after a resident with a history of stroke and morbid obesity experienced a fall from a wheelchair during van transport, no fall incident report was completed, and no new interventions were added to the care plan. The Director of Nursing acknowledged that the event was initially considered a motor vehicle accident rather than a fall, resulting in the omission of required post-fall assessments and care plan updates. Additionally, the care plan did not reflect the resident's preference for sitting on multiple items in the wheelchair, such as a dycem, various cushions, sheepskin, and a bath blanket, nor did it mention the use of a lumbar back support, despite these being regularly used and observed by staff and confirmed by the resident. Further, a physician's order for the resident to bear weight on the right foot in a CAM boot was not incorporated into the care plan or the CNA Kardex. These omissions demonstrate that the facility did not update the care plan to include new medical orders or the resident's specific needs and preferences, as required by facility policy and standard care protocols. The lack of documentation and care plan updates following the fall and the introduction of new medical equipment contributed to the deficiency identified during 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

A deficiency occurred when a resident, who had a history of stroke with right-sided weakness and morbid obesity, was transported in a wheelchair while sitting on multiple items, including a dycem, cushion, and bath blanket. The wheelchair was not equipped with only manufacturer-approved cushioning, and these additional items were not removed prior to transport. During the van ride, the driver applied the brakes suddenly to avoid a deer, causing the resident to slide under the safety belts and fall onto the wheelchair foot pedals. The resident's right foot became pinned between the wheelchair wheel and the seat belt device on the van floor, resulting in a right ankle fracture that required hospital treatment. Observation, interview, and record review confirmed that the environment was not free from accident hazards, as the use of multiple non-standard items in the wheelchair contributed to the resident's fall and injury. The CNA accompanying the resident and the van driver were unable to assist the resident after the fall, necessitating emergency services to extricate and transport the resident to the hospital. The Director of Nursing acknowledged that the presence of multiple items in the wheelchair could have contributed to the hazard.

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 licensed nurses possessed the specific competencies and skill sets necessary to meet residents' needs, affecting all 42 residents. One incident involved a male resident admitted for rehabilitation after abdominal surgery, where an LPN performed a venous blood draw from the resident's foot without documented evidence of appropriate training or competency in this procedure. The facility did not have a policy or procedure in place regarding venipuncture from non-standard sites, and staff interviews revealed uncertainty about proper protocols and training requirements for blood draws from locations other than the arms or hands. Review of staff records showed that the LPN involved had not received documented training in venipuncture, and her most recent education did not cover this skill. Other nursing staff hired since February of the same year also lacked evidence of training or competency evaluations. Interviews with RNs and the DON confirmed that there was no standard policy or procedure for venipuncture, and that training and competency documentation was missing for several staff members. Staff expressed varying understandings of which anatomical sites were appropriate for blood draws and what training was required. The facility was unable to provide requested policies, procedures, or documentation of training and competency evaluations for licensed nurses, both upon hire and annually. The DON acknowledged the absence of such documentation and stated that, at the time, there was no evidence of licensed nurse training or competency evaluation since February. This lack of a system to evaluate and document nurse competencies contributed to the deficiency identified by surveyors.

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 addressing anticoagulant use and risk for bleeding for two residents. One resident, a female with a history of atrial fibrillation and anemia, was prescribed anticoagulants (Xarelto and later Pradaxa) following hospitalization for post-surgical knee sepsis. Despite her diagnoses and medication changes, there was no care plan in place to address her anticoagulant therapy or associated bleeding risks, even after a hospital readmission for anemia and complications related to anticoagulant use. Similarly, another resident with a history of stroke, peripheral vascular disease, and blood clots was admitted with an order for Pradaxa, but also lacked a care plan for anticoagulant use or bleeding risk. Interviews with nursing staff and the Director of Nursing revealed that care plans are typically initiated by the MDS Coordinator and updated by various departments, with information communicated to CNAs through reports, Kardex, or other documentation. However, there was no evidence that care plans specific to anticoagulant use or bleeding risk were created or maintained for these residents. Staff were unable to explain the absence of these care plans, and there was inconsistency in how updates were communicated to CNAs, with no set routine for reviewing the Kardex. The facility's own policies require comprehensive care plans based on thorough assessments and incorporation of risk factors, including monitoring for complications related to anticoagulation, but these were not followed for the affected 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 failed to protect residents from sexual abuse by not implementing effective interventions to prevent a resident from exposing his genital area to others. Despite being aware of the resident's ongoing behavior of inappropriate nudity and sexual comments, staff interventions were limited to placing a blanket on his lap, which was repeatedly reported as ineffective. Multiple staff members acknowledged that the blanket did not consistently cover the resident, and there were no new or alternative interventions put in place after the incident where the resident exposed himself in a common area in proximity to two other residents, both of whom had severe cognitive impairment. The resident with a history of inappropriate display of nudity and sexual comments had diagnoses including Alzheimer's dementia, enlarged prostate, stroke, overactive bladder, urinary retention, and cognitive communication deficit. The care plan had not been updated with effective strategies since the last modification several months prior to the incident. Staff interviews confirmed awareness of the behavior and the ineffectiveness of current interventions, yet no additional measures were implemented to prevent recurrence, resulting in continued exposure of other vulnerable residents to inappropriate conduct.

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 adhere to professional standards for food safety by not labeling and dating perishable items in the refrigerator. During an initial tour of the kitchen, a surveyor observed several food items that were not labeled correctly. These included an open bag of cherry jam with an open date of December 2nd, chopped onions in an unlabeled container, an open milk jug without an open date, a V8 juice with only a received date and visibly separated contents, and a tub of leftover pulled pork that was neither labeled nor dated. Interviews with the interim Kitchen Supervisor and the Registered Dietitian revealed that the facility's policy required all leftovers and opened items to be labeled with open dates and discarded if not used within seven days, in accordance with the federal food code. The interim Kitchen Supervisor acknowledged the oversight and confirmed that the staff should have labeled the items and discarded those past the seven-day limit. The Registered Dietitian also confirmed the policy and noted that education had been provided to staff to ensure compliance.

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 proper storage and labeling of drugs and biologicals, specifically insulin, which had the potential to affect several residents. During an observation, a surveyor found 16 unopened insulin pens and one bottle of Humalog stored in a refrigerator that was out of the acceptable temperature range, with the thermometer reading 28°F, below the required 36°F-46°F range. The temperature logs for the refrigerator were incomplete, with missing entries for November and December 2024, and several days in January 2025 showing temperatures below freezing. The Director of Nursing (DON) acknowledged that the nursing staff is responsible for maintaining the refrigerators and temperature logs. Additionally, a resident with diabetes mellitus II had an insulin pen with a pharmacy label that did not match the physician's orders. The label indicated administration at bedtime, while there were two orders for daily administration. The Registered Nurse (RN) confirmed the discrepancy and stated that the medication should have been sent back to the pharmacy for correct labeling. The DON recognized the potential harm of incorrect labeling and stated the expectation for medications to be correctly labeled according to 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 facility failed to reasonably accommodate the personal needs of a resident, identified as R21, who was unable to access or use the sink in his room. R21, who has Parkinson's disease and uses a wheelchair and a walker for mobility, was observed by a surveyor attempting to brush his teeth and wash his hands without success due to the sink's location in a corner, which was inaccessible with his wheelchair or walker. Despite his efforts to reach the sink, R21 was unable to do so and attempted to stand, risking his safety, without any staff assistance present. Interviews with the resident, his family member, and facility staff revealed that the issue was known but unaddressed. The Certified Nursing Assistant (CNA) acknowledged that R21 could not reach the sink, and the Director of Nursing (DON) was unaware of the problem. This lack of awareness and action from the facility staff contributed to the deficiency, as R21 was unable to perform basic hygiene tasks independently or with assistance, compromising his personal care 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 facility failed to ensure that a resident, identified as R21, received necessary assistance with hand hygiene after toileting and during personal care activities. R21, who has diagnoses including Parkinson's disease and non-Alzheimer's dementia, requires substantial assistance with activities of daily living, including personal hygiene. Observations by the surveyor revealed that R21 was not offered hand hygiene services after using the bathroom or during other personal care activities. This was despite the facility's policy emphasizing hand hygiene as a primary means to prevent infection spread. Interviews with staff and family members highlighted the issue further. R21's family member reported difficulties accessing the sink due to space constraints, which R21 confirmed, stating that his wheelchair and walker could not fit in front of the sink. Staff members, including CNA J, acknowledged the oversight in not assisting R21 with hand hygiene, despite knowing the resident's limitations. The Director of Nursing expressed expectations for staff to assist residents with hand hygiene, indicating a gap between policy and practice in the facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident 137, who was admitted with a foot wound, did not receive the necessary treatment as per the orders received upon admission. The facility's policy on the prevention of skin breakdown was not followed, as the resident's wound on the right big toe was not treated despite being identified during an initial skin evaluation. The wound was categorized as a vascular wound, but there was no indication of a venous wound in the diagnosis or treatment orders. The Director of Nursing (DON) admitted that an order from the Nurse Practitioner to apply a mepilex to the wound was not entered into the system, resulting in a lack of treatment for the resident's wound. The surveyor observed the resident's untreated wound on multiple occasions, and the DON acknowledged that the order should have been implemented upon admission. Despite the oversight, there were no changes in the condition of the wound during the resident's stay at the facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the safety of residents R21 and R30 through adequate supervision and the use of safety devices. For R21, who has Parkinson's disease, encephalopathy, and non-Alzheimer's dementia, the staff did not use a gait belt during transfers, despite the facility's policy requiring it for residents needing assistance. Observations showed that R21 was left unsupervised while brushing his teeth and was transferred without a gait belt during showering and toileting, contrary to the care plan and staff expectations. For R30, who has dementia and a history of falls, the facility did not update the care plan with new interventions following a fall on 12/30/24. Despite having a moderate fall risk score, the care plan lacked documentation of the intervention to toilet the resident before supper, which was noted after the fall. The Director of Nursing acknowledged the oversight in updating the care plan, which is crucial for preventing further falls and potential injuries. These deficiencies highlight the facility's failure to adhere to its policies and care plans, resulting in inadequate supervision and safety measures for residents at risk of falls. The lack of proper documentation and implementation of interventions for R30's fall risk and the failure to use gait belts for R21's transfers demonstrate a significant lapse in ensuring resident safety.

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 a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The deficiency was identified when the facility was unable to provide a medical justification for changing a resident's indwelling Foley catheter on a monthly basis. The Centers for Disease Control and Prevention (CDC) guidelines suggest that catheters should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised, rather than at routine, fixed intervals. However, the facility's policy did not include standards for the frequency of catheter removal, and the Treatment Administration Record indicated that the resident's catheter was being changed monthly without documented clinical justification. The resident involved, identified as R24, was admitted to the facility with diagnoses including respiratory failure, severe protein-calorie malnutrition, cognitive communication deficit, abnormal weight loss, and dysphagia. The resident had an order for an indwelling Foley catheter to be changed every 23 days and as needed for urinary retention. During the survey, the Director of Nursing was unable to provide a physician's justification for the monthly catheter changes and indicated that they would need to reach out to urology for records. Despite efforts to obtain medical records from a urology visit, the facility was unable to provide a medical reason for the monthly catheter changes before the survey concluded.

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 respiratory care for a resident with chronic obstructive pulmonary disorder (COPD), specifically in the administration of nebulizer treatments. The resident, who was admitted with a diagnosis of COPD, was observed receiving a nebulizer treatment without a lung assessment being conducted before and after the treatment. The Registered Nurse (RN) involved only measured the resident's pulse and oxygen saturation prior to the treatment and did not perform a lung assessment, which is a standard of nursing care for nebulizer treatments according to the National Library of Medicine. Interviews with the RN and the Director of Nursing (DON) revealed a lack of awareness and training regarding the necessity of lung assessments in conjunction with nebulizer treatments. The RN admitted to not performing lung assessments unless specifically ordered by a doctor, and the DON confirmed that the facility did not have a policy requiring such assessments unless ordered. The resident also confirmed that lung assessments were never conducted before or after treatments, nor were they instructed to rinse their mouth or expectorate post-treatment, which are part of the standard care practices for nebulizer treatments.

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 trauma-informed and culturally competent care for a resident identified as a trauma survivor. The resident, who was admitted with diagnoses including PTSD and major depression, was not comprehensively assessed for their history of trauma, potential triggers for re-traumatization, or specific approaches to mitigate these triggers. The resident's care plan lacked documentation of trauma-informed care strategies and did not include personal cultural preferences or resident-specific interventions to prevent re-traumatization. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's trauma history and care needs. A Certified Nursing Assistant was unaware of the resident's past trauma, and the Director of Nursing indicated that the Social Services Director had not completed the necessary care planning for PTSD. The facility did not conduct ongoing assessments or monitor the effectiveness of interventions to ensure they met the resident's goals, leading to a deficiency in providing appropriate care for the resident's trauma-related 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 facility failed to have a policy identifying the circumstances under which the loss or damage of dentures would be the facility's responsibility. This deficiency was observed in the case of a resident, referred to as R5, who lost their partial upper denture on November 1, 2024. Despite the resident's intact cognitive status and ability to communicate effectively, the facility did not provide a policy specific to missing dentures, nor did they promptly refer the resident for dental services within three days of the dentures being reported missing. R5, who was admitted with diagnoses including diabetes mellitus II, anemia, anxiety, and a cognitive communication deficit, reported the missing dentures to various staff members, including CNAs, nurses, the Social Services Director (SSD), and the Nursing Home Administrator (NHA). The resident expressed that the missing dentures affected their ability to eat and made them self-conscious, yet no dental services were provided after the dentures were reported missing. The facility's investigation into the missing dentures, led by the SSD, concluded without locating the dentures or offering to replace them, citing that the facility was not responsible unless negligence could be proven. The facility's NHA confirmed the absence of a specific policy for lost or missing dentures and stated that the facility was not responsible for replacing the dentures as they were not proven to be lost due to staff negligence. The resident handbook, which was provided to all residents upon admission, was referenced as outlining the facility's policy on missing items, indicating that the facility is not responsible for lost or missing personal items. Despite the resident's grievance being documented, no follow-up actions were taken to assist the resident in obtaining new dentures or scheduling a dental appointment.

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, as evidenced by multiple deficiencies observed during care for two residents. For one resident, a Certified Nursing Assistant (CNA) did not perform hand hygiene between different care tasks. The CNA assisted the resident with personal hygiene, changed the lift sheet, and handled personal items without removing gloves or performing hand hygiene until the end of the care session. This action was contrary to the facility's hand hygiene policy, which emphasizes hand hygiene as a primary means to prevent infection spread. Additionally, a Registered Nurse (RN) failed to disinfect reusable medical equipment after use. The RN used a blood pressure cuff and pulse oximeter to assess a resident's vitals and returned the equipment to the medication cart without disinfecting it. This was against the facility's policy, which requires disinfection of reusable items between residents to prevent infection transmission. Another deficiency involved a resident who required enhanced barrier precautions due to an indwelling medical device. The facility did not have the necessary signage or personal protective equipment (PPE) cart outside the resident's room, as required by the facility's policy. This oversight was discovered during a surveyor's observation, and the Director of Nursing was surprised to find the absence of the required precautions, which are essential for infection control in residents with specific medical conditions.

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 its admission packet did not require residents to waive potential facility liability for losses of personal property. This deficiency was identified during a policy review and interview with the Nursing Home Administrator (NHA). The facility's Resident Handbook, dated 2023, states that while the facility aims to keep residents' items safe, it is not responsible for replacing misplaced items. During an interview, NHA A confirmed that the handbook is provided to all residents and reiterated that the facility does not reimburse or replace missing items unless the loss is directly linked to staff negligence. This policy potentially affects all 33 residents residing in the facility.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely written notification of transfer or discharge to residents and their representatives, as well as the ombudsman, for four residents who were hospitalized. This deficiency was identified through interviews and record reviews conducted by surveyors. The facility did not ensure that the residents and their representatives were informed in writing about the transfer or discharge and the reasons for the move in a language and manner they could understand. Resident R24 was admitted with diagnoses including non-ST elevation myocardial infarction and unspecified psychosis. R24 was sent to the emergency room for a suspected rib fracture and returned to the facility without receiving a written notice of transfer. Similarly, Resident R22, who had diagnoses such as respiratory failure and severe protein-calorie malnutrition, was transferred to a hospital due to respiratory distress but did not receive a written notice of transfer. Resident R20, with conditions including osteomyelitis and atrial fibrillation, was transferred to the hospital for an infection requiring antibiotic therapy, yet no documentation of a written notice of transfer was found. Resident R21, diagnosed with Parkinson's disease and non-Alzheimer's dementia, was hospitalized due to altered mental status. Despite the presence of R21's wife during the transfer and the facility's communication with the physician, no written notice of discharge or transfer was documented. Interviews with facility staff, including the Social Services Director and Director of Nursing, revealed confusion and inconsistency in the process of providing written notifications of transfer, contributing 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 post the required daily nurse staffing information correctly, as observed by surveyors. Over a 30-day period, the facility did not consistently include the resident census and the facility name on the daily postings. Specifically, on two separate occasions, surveyors observed that the daily postings near the elevator were missing both the daily resident census and the facility name. A review of the last 30 daily postings revealed that 17 postings were missing the daily resident census, and six postings were missing the facility name. Additionally, six postings were missing both the facility name and the resident census. During an interview, the Director of Nursing (DON) acknowledged the expectation that all required information should be present on each daily posting and recognized the need for a better system to ensure compliance.

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 report an allegation of abuse to the State Agency within the required timeframe. A family member of a resident reported that a Certified Nursing Assistant (CNA) allegedly bent the resident's fingers back to cause pain in an attempt to make the resident stand up. This incident resulted in bruising to the resident's knuckles and hand. Despite the facility's policy requiring immediate reporting of such allegations to various authorities, including the State Agency, the incident was not reported as required. The resident involved had a range of medical conditions, including moderate cognitive impairment, and required assistance with activities of daily living. During the investigation, the Nursing Home Administrator stated that the facility followed a flowchart for determining reporting requirements, which incorrectly indicated that the incident was not reportable. However, upon review, it was noted that the flowchart was not applicable to nursing homes. Both the Director of Nursing and the Facility Owner acknowledged that the incident should have been reported to the State Agency, as it involved allegations of abuse and injury.

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 a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. The resident, who had a history of Alzheimer's disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, and atherosclerotic heart disease, experienced a change in condition that was not properly assessed by the staff. Despite showing signs of a stroke, comprehensive neurological assessments were not completed, and a Registered Nurse did not assess the resident as the condition continued to deteriorate. Throughout the day, various staff members, including LPNs and RNs, noted the resident's unusual sleepiness and lack of responsiveness. However, the necessary neurological assessments were not conducted, and the resident's condition was not promptly reported to a physician. The resident's family was not informed in a timely manner, and the resident was not transferred to the emergency room until several hours later, by which time the resident had suffered a stroke and was subsequently placed on hospice care. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition. The staff failed to follow the facility's neurological assessment policy, and documentation was completed the following day, rather than at the time of the events. The failure to assess and provide appropriate interventions for the resident led to serious harm, resulting in a finding of immediate jeopardy.

Removal Plan

• All nursing staff to be educated on change of condition policy and when to notify MD.
• Facility will do a house sweep to identify any other residents with a change of condition, with appropriate MD notification.
• Nursing staff will be educated on symptoms of a stroke by using the FAST (face, arms, speech, time) assessment.
• Nursing staff will be educated on proper neurological assessment.

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 fluid and food intake for three residents, leading to severe dehydration and malnutrition. One resident, admitted with multiple health issues including chronic kidney disease and morbid obesity, was not properly assessed for hydration needs. Despite having a documented fluid requirement of 2,400 ml, the resident's daily fluid intake was significantly below this level, often less than 500 ml. The facility did not develop a care plan to address the resident's hydration needs, failed to monitor fluid intake accurately, and did not communicate the resident's inadequate fluid intake to the physician. This neglect resulted in the resident being hospitalized with severe dehydration and eventually passing away. Another resident, who was readmitted after a stroke, did not have an updated nutritional assessment or care plan to address their hydration and nutritional needs. The resident was observed to be totally dependent on staff for care, yet there was no documentation of intake or output monitoring. The family expressed concerns about the resident's NPO status and requested that the resident be offered pleasurable foods, but the facility did not address these requests or assess the resident's ability to safely consume food and fluids. A third resident, with a history of stroke and malnutrition, was identified as being at high risk for dehydration. However, the resident's care plan did not include any interventions or revisions to address this risk. The facility failed to monitor the resident's fluid intake adequately, and there was no evidence of a comprehensive care plan to prevent dehydration. Despite being on a list for monitoring, the resident's hydration status was not fully addressed, leaving them vulnerable to potential harm.

Removal Plan

• All nursing staff educated on facility policy for tracking fluids/hydration at the facility, including reviewing hydration, notifying MD, and new hydration assessments.
• Facility completed a house sweep for all residents at risk for dehydration, using a dehydration assessment to determine who is at risk.
• All at risk residents with less than 1500ml daily intake will be reviewed weekly at Resident at Risk Meetings.
• All residents at risk for dehydration will have updated care plans.
• Facility reviewed the dehydration procedures in coordination with Nursing, IDT, and Dietitian, including how the facility tracks hydration, reviews dehydration, and follows up on residents at risk.
• Facility updated the hydration assessment and follows residents who scored an 8 or higher.
• All residents at risk who consume less than 1500ml will be reviewed and physician will be notified.
• Hydration policy updated related to required components on dehydration being available for nurses to use/follow.
• Facility will review dehydration assessments/update care plans on admission, quarterly, and as needed.

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 adequate pressure ulcer care and prevention for two residents, leading to deficiencies in treatment and documentation. One resident, who was readmitted with multiple diagnoses including Alzheimer's disease and a recent stroke, developed a deep tissue injury on the left heel due to inadequate repositioning and lack of protective measures. Despite being identified as high risk for pressure injuries, the resident's care plan did not include interventions for pressure injury prevention, and staff failed to reposition the resident every two hours as required. Observations revealed that the resident's heels were not off-loaded, and staff did not implement necessary protective measures even after the injury was noted. Another resident developed a stage 4 pressure injury on the lumbar spine, which required surgical intervention and subsequent hospitalization. Upon return to the facility, the resident's wound care was inadequately documented, with no weekly assessments or detailed descriptions of the wound's condition. The wound continued to drain, indicating it was not healed, yet the facility's wound nurse was unaware of the need for continued documentation and mistakenly believed the wound was a surgical wound rather than a pressure injury. This lack of documentation and awareness led to a delay in identifying an infection, which was only addressed after a culture was taken by an external wound clinic. The deficiencies in care and documentation for both residents highlight a failure to adhere to established guidelines for pressure injury prevention and treatment. The facility did not ensure that residents at risk for pressure injuries received appropriate interventions, nor did it maintain accurate and timely records of wound assessments. These oversights resulted in actual harm to the residents, as evidenced by the development and progression of pressure injuries.

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 two out of five Certified Nursing Assistants (CNAs), who have been employed for more than one year, received the required minimum of 12 hours of in-service training annually. This deficiency was identified during a survey conducted on 09/23/24, where the surveyor requested documentation of in-service training hours for CNAs BB and DD. CNA BB, hired on 09/16/22, and CNA DD, hired on 12/22/15, did not receive the necessary training in areas such as communication, behavioral health, and dementia care. Despite multiple requests from the surveyor, the facility was unable to provide the required documentation. The Nursing Home Administrator (NHA) admitted that there was no current process in place to ensure CNAs completed the annual training requirement, which was under review for correction.

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 adhere to professional standards for food service safety, specifically in the area of hand hygiene during meal distribution. Dietary Aide (DA) S was observed handling meal tickets, which are not cleanable surfaces, and then directly touching ready-to-eat foods without changing gloves or performing hand hygiene. This improper practice was noted during the serving of meals to five residents, where DA S touched various food items such as buns and pizza after handling meal tickets. The facility's policy, dated April 2019, clearly states that bare hand contact with food is prohibited and that gloves should be changed between tasks. However, DA S did not follow these guidelines, leading to potential contamination of the food served to the 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 failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper hygiene and personal protective equipment (PPE) protocols. In one instance, a Certified Nursing Assistant (CNA) used a mechanical lift to transfer a resident without sanitizing it after prior use in another resident's room. Additionally, staff did not perform hand hygiene with glove changes during incontinent care for residents, and failed to wear gloves when obtaining a blood sample for blood glucose monitoring. Further deficiencies were noted when staff entered a resident's room labeled for Droplet Precautions without wearing the required PPE, such as masks and eye protection. This was compounded by a lack of awareness among staff about the transmission-based precautions in place, as evidenced by a CNA's admission of not knowing the necessary PPE requirements and a Licensed Practical Nurse (LPN) initially being unsure of the resident's precautionary status. Additional observations included staff not wearing gowns during high-contact care activities for residents on enhanced barrier precautions, and failing to sanitize hands or change gloves appropriately during care procedures. These lapses in protocol were observed across multiple staff members and residents, indicating a systemic issue with adherence to infection control policies within the facility.

Penalty

No penalty information released

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

Summary

The facility failed to promptly notify and consult with a resident's physician when there was a deterioration in the resident's clinical condition. The resident, identified as R12, exhibited symptoms of low blood pressure on multiple occasions, with readings below 100/60 mm/hg. Despite the facility's policy requiring that hypotension be reported to the physician, the physician was only notified on two out of fourteen instances of low blood pressure. This lack of notification was contrary to the orders that required the monitoring of blood pressure every shift and updating the physician with any concerns. R12 was admitted with several diagnoses, including cellulitis, morbid obesity, muscle weakness, hypertension, atrial fibrillation, heart failure, diabetes with neuropathy, and atherosclerotic heart disease. The facility's failure to notify the physician of the low blood pressure readings was confirmed through record reviews and interviews with the Director of Nursing and the resident's physician. The physician indicated that staff should follow the set parameters for blood pressure and notify them immediately of any irregularities, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure privacy for a resident during personal care, as observed by a surveyor. The resident, who was readmitted with Alzheimer's disease and other medical conditions, was noted to have impaired cognition and was dependent on staff for personal care. The surveyor observed multiple instances where the resident's privacy was compromised, including the resident's breast being exposed to the hallway due to the room door being open and the privacy curtain not being used. Additionally, the resident's care plan had not been updated since 2021, despite a significant change in the resident's status. During personal care, staff members were observed leaving window blinds open and not using the privacy curtain, resulting in the resident's breasts and genital area being exposed. The surveyor noted that staff did not attempt to cover the resident or ensure privacy during these care activities. Family members and a Licensed Practical Nurse expressed concern about the lack of privacy, and the Director of Nursing acknowledged that the expectation was to provide privacy by closing blinds and using privacy curtains during care.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary care and assistance for a resident, identified as R1, who was unable to perform activities of daily living. R1 was readmitted with multiple diagnoses, including Alzheimer's disease and atherosclerotic heart disease, and was assessed as having impaired cognition. Despite being dependent on staff for most personal care activities, the facility did not update R1's care plan since 2021, and the Minimum Data Set (MDS) was not completed to reflect R1's current physical functionality. Surveyors observed R1 in a state of neglect over several days. R1 was found lying in bed with disheveled hair, a dried substance on the face, and a strong smell of urine in the room. The catheter bag was observed lying on the floor, and R1's sheets were bunched up and soaked with a dark brown liquid. Despite these conditions, staff did not provide adequate care, such as repositioning, grooming, or oral hygiene. Family members expressed concern about R1's condition, noting that R1 was often left in a hospital gown with bunched-up sheets and a persistent urine odor. Interviews with staff, including CNAs and the Director of Nursing, revealed a lack of adherence to care protocols. CNAs admitted to not performing necessary hygiene tasks, such as offering mouth swabs for oral care. The Director of Nursing acknowledged that staff were expected to provide comprehensive personal care to R1, who was entirely dependent on them. However, observations and interviews indicated that these expectations were not met, leading to the deficiency in care for R1.

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 proper care and assessment for a resident with an indwelling Foley catheter, as there was no physician order directing the care and treatment for the catheter. The resident, who was readmitted with multiple diagnoses including Alzheimer's disease and atherosclerotic heart disease, was observed to have impaired cognition and was dependent on staff for all care. Despite these needs, the facility did not update the resident's care plan since 2021, and the Minimum Data Set (MDS) assessment was not completed to reflect the resident's current physical functionality. Surveyors observed several instances where the resident's catheter care was inadequate. The catheter bag was found lying on the floor with very little output, and the urine was reddish dark brown with sediment. Staff failed to report or address these issues adequately, as evidenced by the lack of communication between CNAs and LPNs regarding the catheter's condition. The resident was observed to be in pain, moaning, and holding their abdomen, yet staff did not assess for abdominal distention or other complications associated with the catheter. The Director of Nursing acknowledged that staff should have been checking for abdominal distention and ensuring the catheter was draining properly. However, observations showed that staff did not follow the facility's catheter policy, leading to the resident's discomfort and potential complications. The lack of proper assessment and communication among staff contributed to the deficiency in care for the resident with the indwelling Foley catheter.

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 proper procedures were followed for the administration of insulin using insulin pens, as observed by a surveyor. Specifically, a Licensed Practical Nurse (LPN) did not perform the necessary safety check of priming the needle on insulin pens before administering insulin to two residents, R8 and R11. The manufacturer's instructions for insulin pens clearly state that priming is essential to remove air from the needle and cartridge, ensuring the correct dose is administered. However, during the administration of insulin to R8 and R11, the LPN did not prime the needle with 2 units before dialing the pen to the prescribed dose, which is a critical step to verify the pen's functionality and ensure the residents received the correct insulin dosage. Upon inquiry, the LPN incorrectly stated that priming the needles on insulin pens was not required, indicating a lack of adherence to the facility's policy and procedure. The Director of Nursing (DON) confirmed that the facility's policy mandates priming the needle with 2 units before administering the prescribed dose. The surveyor's observations and subsequent interviews revealed that the LPN's actions were not in compliance with the established procedures, leading to the deficiency in the administration of pharmaceutical services to meet the needs of the 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 failed to ensure that all drugs and biologicals were stored and labeled according to accepted professional principles, as observed in the case of a resident's room. Insulin pens were found unattended on a bedside table in the resident's room while the resident was away for dialysis. The insulin pens, including a Humalog pen with 140 units left and an Insulin Glulisine pen with 60 units left, were not stored in a locked compartment as required. Additionally, the Humalog pen was expired and lacked an open date, and neither pen was capped. The resident expressed a desire to self-administer medications and had a lock box in the room for insulin storage. However, the lock box was not easily accessible from the bed, leading the resident to keep the insulin pens on the bedside table for convenience. The resident was unaware of the expired status of the Humalog pen, as they had not needed it recently due to dietary management. The Director of Nursing was unaware of the resident's practice of storing insulin in their room and acknowledged that expired medications should not be available to 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 failed to provide necessary treatment and services to prevent the development and worsening of pressure injuries for a resident identified as high risk. The resident, who had diagnoses including osteomyelitis, type 2 diabetes, venous insufficiency, and a heel fracture, developed an unstageable pressure injury on the right foot and a stage II pressure injury on the right buttock. The facility did not conduct weekly comprehensive assessments of these injuries, nor did they implement preventative pressure-relieving measures as required by their policy and national guidelines. The resident's care plan lacked specific interventions to address the pressure injuries and the risk of skin breakdown. Although the care plan included general interventions related to diabetes management, it did not address the specific needs for preventing friction and shearing that contributed to the pressure injuries. Observations during the survey revealed that the resident's feet were not properly elevated, and the prescribed heel riser and pool noodle were not in use, leading to the resident's foot resting against the bed's footboard, potentially exacerbating the injury. Interviews with facility staff, including the Director of Nursing and nursing staff, revealed a lack of clarity and responsibility for completing weekly wound assessments after the departure of an employee who previously handled these tasks. The facility's failure to conduct timely and comprehensive skin assessments and implement effective interventions resulted in actual harm to the resident, as evidenced by the worsening of the pressure injuries.

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 report an incident of potential misconduct involving a resident's feeding tube in a timely manner. The incident occurred when a Certified Nursing Assistant (CNA) flushed a resident's PEG/G-tube with warm water, which was outside the scope of her practice. This action was identified as potential abuse, neglect, or mistreatment by the facility. The incident was discovered on June 28, 2024, but was not reported to the state agency until July 10, 2024, which was beyond the required reporting timeline. The facility's policy mandates that all alleged violations involving neglect must be reported immediately, but not later than 2 hours after the allegation is made, or not later than 24 hours, to the administrator, who must then report to the state survey agency within 5 working days. The Director of Nursing (DON), who was responsible for preparing the misconduct incident report, was new to her position and unfamiliar with the state-required timeline and submission process. The DON was guided by the facility's corporate nurse in the investigation process and submission to the state. Despite the completion of most of the investigation by the DON, the initial report was not submitted promptly, resulting in a delay. The incident report noted that the CNA's actions were outside her scope of practice, and the resident questioned when the CNA became a nurse, indicating a lack of proper role understanding and execution.

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 conduct a thorough investigation and take appropriate corrective actions regarding an alleged violation involving a resident's feeding tube. A Certified Nursing Assistant (CNA) flushed a resident's feeding tube with warm water, which was outside her scope of practice. The incident was reported by a Therapeutic Medication Aide (TMA) who witnessed the CNA's actions and expressed concern. The facility's investigation was limited, with insufficient staff interviews and no resident interviews conducted to determine if similar incidents had occurred. The Director of Nursing (DON) acknowledged that the investigation was incomplete, as not all nursing staff were interviewed, and there was no evidence of post-incident education provided to staff regarding the scope of practice for CNAs. The report noted that the CNA claimed she was instructed by a Registered Nurse to perform the task, but the RN and other nurses denied giving such instructions. The facility's policy requires thorough investigations of alleged violations, but the evidence showed that this was not achieved in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that services were provided by a qualified person in accordance with a resident's written plan of care. A Certified Nursing Assistant (CNA) improperly flushed a resident's feeding tube with warm water, which was outside her scope of practice. The resident, who required tube feeding due to a swallowing problem, had specific orders for the feeding tube to be flushed four times daily. However, the CNA, who was not qualified to perform this task, took it upon herself to flush the tube after finding it unattached, claiming she had seen others do it and was instructed by a Registered Nurse (RN) to do so. The RN denied giving such instructions, and the CNA could not recall who else might have asked her to perform tasks outside her scope. The incident was reported, and an investigation was conducted by the Director of Nursing (DON). Despite the investigation confirming the CNA's actions were outside her scope of practice, there was no evidence that the facility provided post-incident education to the nursing staff regarding the scope of practice for CNAs. The lack of documented education following the incident highlights a gap in ensuring that all staff are aware of their professional boundaries and responsibilities.

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 residents received necessary treatment and services consistent with professional standards of practice, specifically for two residents with non-pressure injuries. Resident R4, who had diagnoses including diabetes mellitus, end-stage renal disease, and weakness, developed a facility-acquired non-pressure injury on his left heel. Despite documentation indicating that staff were checking R4's heels and feet twice daily, a weekly wound assessment inaccurately reported no skin concerns. By 07/16/24, R4 had developed two additional non-pressure injuries on his feet, and the initial injury had worsened, yet these were not documented in the weekly wound assessment. The facility's records showed multiple instances where required documentation and treatment were not completed as ordered. Physician orders for weekly skin assessments and daily checks of R4's feet and heels were not consistently documented. Additionally, treatment orders for R4's left heel were not followed on several occasions. Interviews with R4 and the Director of Nursing confirmed that staff were not checking R4's feet and heels as ordered, which contributed to the lack of timely intervention and documentation of R4's skin conditions.

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 necessary supervision to prevent accidents for two residents, R6 and R11, during meal times. Both residents had specific care plans and caregiver instructions indicating the need for supervision while eating due to swallowing difficulties and other related issues. Despite these instructions, on the morning of July 23, 2024, both residents were observed eating breakfast without any staff supervision in the small lounge/dining area. R6 was noted to be eating without alternating food and drink, contrary to the swallowing strategies outlined in her care plan. Similarly, R11 was eating without supervision, despite her care plan indicating the need for a supervised setting during meals. The lack of supervision was confirmed through interviews with CNA D, who acknowledged that residents in the small dining room require supervision while eating. CNA D admitted that the current procedure involved serving residents in the dining room first and then leaving to serve room trays, which resulted in a lack of supervision for those in the dining room. The Director of Nursing, DON B, also confirmed that staff are expected to remain present to supervise residents who require it. This oversight in supervision led to the deficiency noted by the surveyors.

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 adequate pain management for a resident (R1) who was under hospice care with a terminal diagnosis. R1 had multiple serious health conditions, including vertebral osteomyelitis, lumbar fractures, and blood clots, and was admitted to the facility after hospitalization. Despite having a care plan that included administering medications as ordered and monitoring their effectiveness, the facility did not consistently follow these directives. R1 expressed increased pain using a pain scale, but the facility did not administer as-needed medications when R1's pain was elevated, nor did they document the effectiveness of these medications when used. The Medication Administration Record (MAR) indicated several instances where as-needed pain medications were administered without documenting their effectiveness. There were also periods where R1 experienced high pain levels for extended hours without receiving as-needed medications. For example, on one occasion, R1 had a high pain rating for approximately 3.25 hours without administration of as-needed pain medications. Additionally, there were instances where the effectiveness of administered medications was unknown or not documented, leaving gaps in the management of R1's pain. Interviews with facility staff, including an LPN, revealed that there were delays in receiving medications from the pharmacy, which contributed to the inadequate pain management. The LPN reported that R1 was physically uncomfortable and expressed symptoms of anxiety, and despite administering medications when they arrived, the LPN felt that R1's pain was not managed adequately. This lack of timely and effective pain management, along with insufficient documentation, highlights the facility's failure to adhere to R1's care plan and provide the necessary care to maintain R1's highest practicable physical well-being.

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 licensed nurses had the necessary competencies and skills to manage a resident's negative pressure wound therapy (NPWT). The resident, who was admitted after a surgical procedure on the right lower leg, required NPWT as part of their care plan to promote healing and prevent complications such as infection and sepsis. However, the NPWT malfunctioned, and staff were unable to continue the therapy effectively. The resident reported that the staff seemed unfamiliar with the NPWT equipment, and there was a lack of proper training and orientation for the staff regarding NPWT. The surveyor's investigation revealed that the facility did not provide specific training related to NPWT for its staff, despite having a resident population that required wound care and treatment. Interviews with various staff members, including LPNs, RNs, and the Director of Nursing (DON), confirmed the absence of NPWT training. The facility's assessment included wound care but did not specifically address NPWT. The Nursing Home Administrator acknowledged the lack of documentation to support employee education related to NPWT and stated that education was provided through manufacturer videos or pamphlets, but not consistently before resident admissions. The deficiency was further highlighted by the termination of the facility's certified wound care nurse around the time of the incident, leaving the staff without adequate support or guidance. The DON, who had been employed for approximately eight weeks, also lacked orientation and was unable to provide additional information on NPWT training. The resident's wound was eventually managed with alternative dressing treatments, and the wound care clinic noted that the wound was healing well without the need for NPWT.

Penalty

Fine: $113,298105 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 adequate pressure ulcer care and prevention for three residents, resulting in the development and worsening of pressure injuries. Resident 7 developed multiple pressure injuries, including a stage 3 pressure injury on the left heel that became unstageable. The facility did not implement preventative measures, conduct weekly comprehensive assessments, or notify the physician of changes in the pressure injuries. Additionally, there was a significant weight loss in Resident 7, and dietary needs to promote wound healing were not addressed. Resident 1 was readmitted with multiple pressure injuries, including a stage 2 pressure injury on the right heel acquired in the facility. The facility did not perform weekly comprehensive assessments, update treatment orders, or notify the physician. There was also a lack of documentation regarding the development and treatment of pressure injuries on the right heel and ischial tuberosity, and no interventions were in place to relieve heel pressure. Resident 5 acquired a pressure injury from friction and shearing, but the facility did not complete a comprehensive assessment or implement preventative measures until after the injury developed. The facility's documentation was inadequate, with missing details on wound characteristics, drainage, and depth. The facility's wound care policy was not followed, and there was a lack of communication with the physician regarding changes in wound conditions.

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 staff performed proper handwashing during personal care for one of the sampled residents. Specifically, two CNAs failed to perform hand hygiene after assisting one resident with a Hoyer lift transfer and before entering another resident's room to assist with incontinence care. The CNAs did not sanitize their hands or don gloves before providing care, which included handling a clean brief and assisting with bowel incontinence care. One CNA acknowledged the oversight, while the other admitted to not sanitizing hands or wearing gloves during the care process. Additionally, the RN involved in the care of the second resident did follow proper hand hygiene protocols, including washing hands and changing gloves multiple times during wound care. However, the initial failure of the CNAs to perform hand hygiene before entering the room and during the incontinence care process was a significant lapse in infection control practices. The facility's policy on hand hygiene was not adhered to, leading to this deficiency.