Lake Country Health Services

Penalty

Fine: $26,130

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 honor a resident's Do Not Resuscitate (DNR) advanced directive, resulting in staff performing cardiopulmonary resuscitation (CPR) on a resident who had a clearly documented DNR order. The resident had multiple signed state DNR forms in the electronic medical record, an active medical doctor order for DNR, and a care plan indicating DNR status. The resident was also wearing a DNR bracelet at the time of the incident. Despite these clear indications, when the resident became unresponsive and pulseless, the registered nurse on duty initiated CPR without verifying the resident's code status. The nurse reported being unable to ascertain the resident's code status at the time of the emergency, stating that the only way to check would have been to leave the resident alone to access a computer. The nurse did not notice the DNR bracelet on the resident's wrist before starting compressions and was not aware of a process for calling a code or obtaining assistance to verify code status. Other staff members confirmed that the resident's DNR status was documented in the electronic medical record and that the resident wore a DNR bracelet. The nurse performed between 12 and 16 chest compressions, which resulted in the resident being revived. Following the administration of CPR, the resident experienced extreme pain, particularly in the chest and ribs, requiring narcotic pain medication for management. The pain persisted until the resident's death. Documentation showed that the resident's pain was rated as high as 10 out of 10, and the resident required both as-needed and scheduled morphine. The incident was identified as immediate jeopardy due to the facility's failure to follow the resident's advanced directive, resulting in unnecessary resuscitation and significant pain.

Removal Plan

• Primary Care Physician, Hospice MD, and POA notified.
• Hospice in person visit.
• Skin evaluation.
• Pain evaluation.
• Change of Condition evaluation with vital signs.
• Nursing evaluation.
• Morphine as needed ordered.
• Current residents reviewed for code status orders/documentation.
• Code status verified on PCC ribbon banner.
• Care plans updated appropriately.
• Reeducation to licensed nurses on need to verify code status prior to initiating CPR.
• If DNR-do not initiate CPR.
• If full code, initiate CPR and activate 911.
• DON/designee will conduct Code drills on each shift.
• Interviews of nurses will be conducted on various shifts using case studies and 'what if' scenarios to validate understanding and expectations required during a code situation.
• Scenarios will include situations where resident is a DNR, and others where resident is a full code.
• Results of the above audits will be brought to the Quality Assurance and Performance Improvement (QAPI) committee.
• QAPI committee met to review above plan.

Penalty

Fine: $26,130

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 and procedure in place to ensure that residents' code status, as indicated in their advance directives, was followed. This deficiency was observed when a resident with a documented Do Not Resuscitate (DNR) order and a signed state DNR form was given cardiopulmonary resuscitation (CPR) compressions by staff without first verifying the resident's code status. The nurse involved was unable to ascertain the resident's code status at the time of the event and initiated CPR based on nursing judgment, despite the presence of a DNR bracelet on the resident, which was only noticed after compressions had been administered. The nurse reported not receiving specific training from the facility on code procedures and stated that there was no clear process for calling a code or determining code status in an emergency, especially when alone with a resident experiencing a rapid change in condition. The facility's phone paging system, which is intended to alert staff to a code blue, was observed to be non-functional during the survey. Portable phones, which could also be used to call a code blue, were not available or functional on all units, and staff reported that the reception for these phones was poor and unreliable. The facility's overhead paging system, which could serve as an additional method for alerting staff, had not been functional for years. During the survey, multiple attempts to use the phone paging system failed, and it took over 20 minutes before a test page was successfully heard, after troubleshooting and adjustments to phone settings. Staff interviews revealed inconsistent knowledge and practices regarding the use of portable phones and the process for calling a code blue. Some staff were unaware that portable phones should be carried or could be used to call a code, and the education provided to staff did not clearly address this. Additionally, the facility did not have a dedicated Code Blue policy, and the documents provided to guide staff during a code event contained discrepancies about the steps to take when a staff member is alone with an unresponsive resident. These deficiencies affected residents designated as full code and had the potential to impact a significant portion of the facility's population.

Penalty

Fine: $26,130

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 cerebrovascular disease, dementia, hypertension, atrial fibrillation, and diabetes, was admitted to the facility and later placed on hospice care with a focus on comfort measures. The resident had a physician's order for Morphine Sulfate (Concentrate) Oral Solution, 100 mg/5 mL, to be administered at a dosage of 0.5 mL by mouth every two hours for pain management. However, for four consecutive scheduled doses, the resident was only administered 0.25 mL per dose, which was half of the prescribed amount. This medication variance was identified through a review of the resident's controlled substance records and confirmed by the Director of Nursing. The surveyor's review of the resident's medical record, including the EMAR, physician's orders, and care plans, confirmed that the resident was severely cognitively impaired and required significant assistance with daily activities. Pain level assessments were documented, and the resident was noted to be on a DNR (Do Not Resuscitate) status with advanced directives in place. The incorrect administration of morphine was not in accordance with the physician's orders, and the responsible LPN was no longer employed at the facility at the time of the survey. No additional information was provided by the facility regarding the incident during the survey.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to protect a resident from exploitation and mental abuse by a Certified Nursing Assistant (CNA). The CNA and the resident exchanged phone numbers and developed a relationship that included intimate and sexual interactions. The resident believed the CNA was his girlfriend and that they would eventually live together outside the facility. The CNA visited the resident in his room, even when not assigned to his care, and purchased gifts for him. The relationship ended with the CNA sending humiliating and degrading text messages to the resident, causing him emotional distress. Facility staff were aware of the relationship and the exchange of gifts but failed to report it to the administration in a timely manner. The administration, upon becoming aware of the exchanged phone numbers, did not conduct a thorough investigation into the possibility of exploitation or abuse. This lack of action allowed the CNA continued access to the resident, creating a situation of immediate jeopardy. The facility's policy on abuse, neglect, and exploitation required immediate investigation of such allegations, but this was not followed. The resident, who had intact cognition and was responsible for his own decision-making, expressed feelings of disappointment, sadness, and loneliness after the relationship ended. Despite staff awareness of the situation, including rumors and direct observations of inappropriate interactions, the administration did not intervene effectively. The failure to investigate and address the relationship in a timely manner led to a finding of immediate jeopardy, indicating a serious risk of harm to the resident.

Removal Plan

• Facility completed interviews of residents and staff by Executive Director or designee to determine any further concerns of actual or suspected abuse.
• Facility staff reeducated by Executive Director or designee on Abuse, Neglect, and Exploitation policy. This reeducation included information on types of abuse, obligation to report abuse, abuse of power, and need to safeguard residents. This education included how abuse can affect a staff member's licensure or ability to be employed in facility.
• Director of Nursing Executive Director and President of Success reviewed established Abuse, Neglect and Exploitation policy. No changes were necessary to this policy.
• Executive Director or Designee will interview a sampling of no less than 3 staff and 3 residents daily including review of grievances to ensure proper recognition, reporting, and notification of suspected/potential or actual abuse. These audits will be completed daily for 2 weeks, then 5 days per week for 10 weeks or until substantial compliance is maintained. Results of these audits will be brought to QAPI for review and recommendation.
• ADHOC QAPI review of this plan was completed with Medical Director, VP of Success, Director of Nursing, and Executive Director.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to ensure that residents received treatment and care consistent with the Wisconsin Nurse Practice Act, resulting in deficiencies for three residents. One resident, who had a history of chronic kidney disease, COPD, diabetes, dementia, and anxiety disorder, experienced a change in condition during the night shift. The resident was found by a CNA yelling for help and unable to breathe. The RN on duty observed the resident with agonal breathing and cyanotic lips and fingers but did not perform a comprehensive assessment, contact the resident's physician, or call 911. Instead, the RN contacted the resident's daughter, who was the second POA, to inquire about the family's wishes. The resident was later found pulseless and not breathing by another RN. Another resident had weeping blisters on their arms that were not addressed in weekly skin assessments. The resident was admitted with multiple diagnoses, including liver disease, muscle weakness, and diabetes. Despite having fragile skin and blisters, the facility's skin care plan did not include person-centered interventions to address these issues. The facility's weekly head-to-toe skin checks failed to document the skin areas identified by the physician, and there was no documentation of nursing assessments for the blisters. A third resident was injured during a Hoyer lift transfer when a bar hit their head, causing pain. The facility did not document an initial neurological check after the incident, and the resident was sent to the ER, where they were diagnosed with a mild concussion. Upon returning to the facility, the resident was not placed on the 24-hour board for close monitoring, and no neuro-checks were documented. The facility's fall prevention policy required neuro-checks for any fall where a resident hits their head, but this was not followed in the resident's case.

Removal Plan

• Director of Nursing/designee completed an audit of residents requiring transfer from facility to higher level of care to verify appropriate assessment and notification, including Emergency Medical Services Activation.
• Facility Licensed Nursing staff to be reeducated by Director of Nursing or designee on Change of Condition of the Resident policy. This reeducation includes information on assessment/evaluation (regardless of code status), provider notification of findings, and documentation requirements. Reeducation includes use of the INTERACT 4.5 Change in Condition Guidelines for when to immediately notify the physician/provider and activate emergency medical services.
• Director of Nursing, Executive Director, and President of Success reviewed established Change in Condition of the Resident policy. No changes were necessary to this policy.
• Director of Nursing or Designee will review facility charting to identify resident change in condition to ensure proper documentation of assessment/evaluation and timely provider notification. These audits will be completed daily for 2 weeks, then with morning clinical 5 days per week for 10 more weeks or until substantial compliance is maintained. Results of these audits will be brought to QAPI for review and recommendation.
• ADHOC QAPI review of this plan was completed with Medical Director, VP of Success, Director of Nursing, and Executive Director.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, leading to significant injuries. One resident, admitted with a fracture and a history of falls, did not have a person-centered falls care plan that addressed self-transferring. Despite being assessed as requiring assistance for transfers, the resident attempted to self-transfer, resulting in a fall and a new sacral fracture. The care plan interventions were generic and did not specifically address the resident's tendency to self-transfer, which was known to the staff but not documented or adequately managed. Another resident was injured during a Hoyer lift transfer conducted by two CNAs, one of whom had not received formal training on the use of the lift. During the transfer, the bar of the Hoyer lift struck the resident's head, causing a mild concussion. The incident revealed a lack of proper training and competency verification for staff using mechanical lifts, as the CNA involved did not have documented training or competency in safe patient handling or Hoyer lift use. The facility's policies on fall prevention and safe resident handling were not effectively implemented, as evidenced by the lack of individualized care planning and inadequate staff training. The deficiencies in care planning and staff training contributed to the accidents and injuries sustained by the residents, highlighting a failure to adhere to established safety protocols and guidelines.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to report allegations of sexual abuse and exploitation involving a resident and a Certified Nursing Assistant (CNA) to the Nursing Home Administrator (NHA) and the State Survey Agency in a timely manner. The relationship between the resident and the CNA included months of communication through phone calls, text messages, and in-person visits, which were not reported by staff despite being aware of the situation. This lack of reporting allowed the alleged perpetrator continued access to the resident. The facility's policy requires immediate reporting of alleged violations to the NHA, state agency, and other required agencies within specified timeframes. However, the facility did not adhere to these requirements, as the allegations were not reported until October, despite staff being aware of the situation as early as July. Interviews with staff revealed that rumors and observations of the inappropriate relationship were known among staff members, but these were not formally reported to administration or investigated until much later. The investigation revealed that the CNA had inappropriate interactions with the resident, including exchanging text messages with intimate content and physical contact. Despite multiple staff members being aware of the situation, it was not until a staff member reported a concerning text message to the NHA in October that a formal investigation was initiated. The facility also failed to notify the state survey agency within the required timeframe, as the investigation was not conducted until October, well after the initial awareness of the situation.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to ensure thorough investigations of allegations of abuse and exploitation for two residents. In the first case, a relationship between a resident and a CNA was not properly investigated despite staff awareness of inappropriate communications and visits. The CNA had access to the resident's room and exchanged text messages with the resident, which included inappropriate content. Staff members were aware of the situation but did not report it to the Nursing Home Administrator in a timely manner, allowing the CNA continued access to the resident. When the Administrator became aware, they did not conduct a thorough investigation by interviewing all relevant staff and residents. In the second case, a resident's family member reported concerns about a CNA being rough during care. The facility did not document or thoroughly investigate this allegation. Although the Assistant Director of Nursing spoke to the CNA and provided training, there was no documentation of a grievance or investigation. The facility's grievance log did not contain any record of the incident, and the current Nursing Home Administrator could not find any documentation regarding the concern. The facility's failure to conduct thorough investigations and document allegations of abuse and exploitation resulted in deficiencies. Staff members did not follow the facility's policy for investigating allegations, which requires immediate investigation and protection of residents. The lack of documentation and follow-up on these allegations highlights a significant oversight in the facility's handling of potential abuse and exploitation cases.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of low staffing levels during night shifts. On specific dates, the facility had only one nurse and one or two CNAs for multiple units, despite having a resident census of over 70. This staffing shortage led to extended call light response times, with some residents waiting over an hour for assistance. The Director of Nursing and other staff members acknowledged the staffing issues, which were exacerbated by call-ins and no-shows. Residents expressed concerns about the lack of timely care, with one resident having to rely on a family member to contact the facility for assistance. The facility's grievance log documented complaints about long call light times, which were attributed to insufficient staffing. Staff interviews revealed that CNAs were often responsible for 13-15 residents per shift, and in some cases, one CNA was responsible for 20 residents, making it difficult to provide necessary care such as bathing and toileting. One resident, who had chronic kidney disease, COPD, diabetes, and dementia, did not receive scheduled showers due to low staffing. The resident's medical records indicated that showers were missed on specific dates, and staff notes confirmed that the lack of staff was the reason. The facility's management was informed of these issues, but no additional information or corrective actions were provided to address the deficiencies.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to notify the resident's Power of Attorney (POA) when there was a significant change in the resident's pain medication. The resident, identified as R2, was admitted with multiple diagnoses including chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and dementia. The POA for healthcare was activated in November 2021. On September 26, 2024, the resident's pain medication was changed from Hydromorphone to Hydrocodone-Acetaminophen due to worsening behaviors and confusion. However, the facility did not inform the POA of this change, despite the requirement to do so as per the facility's policy. The deficiency was identified during a surveyor's interview with the POA, who confirmed they were not informed of the medication change. The surveyor also reviewed the resident's records and found no documentation indicating that the POA was notified. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were informed of the oversight, and they confirmed the lack of notification in the resident's electronic medical record. The facility's policy mandates immediate notification of the resident's representative when there is a need to alter treatment significantly, which was not adhered to in this case.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to adequately address and resolve grievances for two residents, R9 and R12, as observed by the surveyor. R9, who is cognitively intact and requires substantial assistance with toileting, expressed ongoing concerns about not being checked on during the night and being double briefed, leading to waking up in urine-soaked conditions. Despite a grievance being initiated on R9's behalf, the surveyor observed R9 in a saturated state on multiple occasions, indicating the issue was not resolved. The facility's grievance log did not contain a record for R9, and the documentation provided by the DON lacked a detailed resolution. R12, who has moderately impaired cognition and a preference to get up before 6:00 AM, reported dissatisfaction with not being assisted out of bed in a timely manner and a lack of follow-up on a room change request. R12 had been self-transferring, which led to a fall, and expressed feeling ignored by the Social Services Coordinator regarding the room change. The surveyor noted that R12's care plan documented the preference for early rising, yet the facility did not address this grievance effectively, as R12 continued to wait for assistance. The facility's grievance policy requires timely resolution and documentation of grievances, but the surveyor found deficiencies in both the handling and documentation of grievances for R9 and R12. The staff interviews revealed inconsistencies in the grievance process, with some grievances being verbally relayed rather than formally documented. The facility's failure to resolve these grievances in a timely and documented manner led to the surveyor's findings of non-compliance with the grievance policy.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to adhere to its admissions policy for a resident, identified as R16, who was admitted with multiple medical conditions including liver disease, muscle weakness, hypertensive heart disease with heart failure, asthma, psoriasis, immunodeficiency, type 2 diabetes mellitus, and adjustment disorder. The deficiency was identified when it was found that R16 did not sign the admission agreement within the required 48-hour timeframe, which includes consent to treat, financial agreement, and acknowledgment of resident rights. During the survey, it was revealed that the Admissions Director was on medical leave at the time of R16's admission, and the Social Services Coordinator was responsible for completing the admission paperwork. The coordinator believed that R16 had signed the necessary documents electronically, but the admission file was not found in the electronic medical record. The facility later acknowledged that the admission paperwork was somehow deleted and was in the process of being retrieved. The Nursing Home Administrator confirmed that the admission paperwork, including the consent to treat and financial agreement, was not reviewed with R16 or their representative, nor was it acknowledged with a signature. The administrator admitted that several aspects of the admission process were overlooked during this period, leading to the deficiency. No additional information was provided by the facility regarding the missing documentation.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to ensure that a comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team according to the resident's assessed needs. The resident, who was initially cognitively intact, experienced a decline in cognitive skills and continence during their stay. Despite these changes, the care plan was not updated to reflect the resident's increased risk for pressure areas and skin impairments, the need for a toileting plan, and appropriate discharge planning interventions. The resident's care plan initially included interventions for discharge planning and urinary incontinence, but these were not revised to incorporate person-centered approaches or address the resident's continence decline and skin issues. The resident's admission and subsequent assessments documented changes in their condition, including increased incontinence and the presence of skin issues such as shearing and blisters. However, the care plan did not include specific interventions to address these issues, such as pressure-relieving devices or a detailed toileting plan. The Director of Nursing acknowledged that the care plan was not person-centered and lacked appropriate interventions, and the facility had no additional information to provide to address these deficiencies.

Penalty

Fine: $159,8208 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 develop and implement an effective discharge planning process for a resident, leading to inadequate preparation for the resident's transition from the facility. The resident, who had multiple medical conditions including liver disease, heart failure, and diabetes, was admitted to the facility with the goal of discharging to the community once clinical and rehabilitation goals were met. However, the facility did not complete the admission process properly, failing to inform the resident and their representative about the insurance benefits and the need for private pay or discharge after 30 days of coverage. Discharge planning for the resident was not initiated until the day before the discharge, and the necessary durable medical equipment (DME) was not ordered during the resident's stay. The interdisciplinary team (IDT) did not update the resident's discharge care plan to reflect their current needs and did not conduct a home evaluation, despite the resident's significant assistance requirements for activities of daily living. The resident was informed of the need to discharge or privately pay only one day before the insurance coverage ended, leaving insufficient time for proper discharge planning. As a result, the resident was discharged home without the necessary support and equipment, leading to a readmission to the hospital less than 24 hours later due to sepsis and a urinary tract infection. The facility's lack of communication and coordination among the IDT, as well as the failure to inform the resident of their insurance options, contributed to the inadequate discharge planning and subsequent hospital readmission.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to provide necessary ADL services for three residents who were dependent on staff for care. One resident, R7, who was dependent on staff for bathing, did not receive showers on two specific dates in September 2024. The surveyor found no documentation indicating that R7 declined showers on those dates. Another resident, R11, also dependent on staff for bathing, received only two showers during the entire month of September 2024, with no documentation of declined showers on several other dates. The Director of Nursing (DON) acknowledged the lack of documentation and mentioned that R11 might have received bed baths, which were not documented. Resident R13, who was dependent on staff for continence care, reported multiple instances in July 2024 where she did not receive the necessary care. R13 mentioned being left on a bedpan for two hours and not receiving continence care during specific shifts on various dates in July. The surveyor's review of R13's records confirmed the absence of documentation for continence care on those dates. R13 also reported that the situation had improved since moving to a different room, but there were still concerns about the consistency of care provided. The surveyor interviewed staff members, including CNAs and the DON, to understand the facility's procedures for documenting and providing ADL care. The DON stated that staff should follow care plans and document continence care if the task is activated. However, the surveyor found multiple instances where documentation was missing, indicating a failure to provide and record the necessary care for the residents. The Nursing Home Administrator was informed of these deficiencies, but no additional information was provided to address the concerns raised by the surveyor.

Penalty

Fine: $159,8208 days payment denial

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

Summary

The facility failed to ensure that a resident with urinary incontinence was comprehensively assessed and provided with appropriate treatment and services to prevent complications and restore continence. The resident, identified as R16, was initially documented as occasionally incontinent of bladder and always continent of bowel upon admission. However, during their stay, the resident's continence declined to frequently incontinent of both bladder and bowel. Despite this change, the facility did not update the resident's care plan with person-centered interventions or a formal toileting program to address the decline in continence. The resident's care plan included general interventions such as administering medication, applying skin moisturizers/barrier creams, and providing assistance with toileting. However, these interventions were not tailored to the resident's specific needs following the decline in continence. A grievance was filed by the resident regarding incontinence care, and although a toileting plan was mentioned, it was not documented in the care plan. Interviews with facility staff, including the Director of Nursing and a Certified Nursing Assistant, revealed a lack of awareness and documentation of a specific toileting plan for the resident. The facility's Director of Nursing acknowledged that the comprehensive care plan was not person-centered and lacked specific interventions for the resident's continence decline. Additionally, it was noted that the facility did not conduct formal bladder assessments on all residents, and continence was only assessed at admission. The Nursing Home Administrator confirmed that the facility did not have a policy and procedure for a bowel/bladder program, and the resident's continence status change was not addressed in their care plan.

Penalty

Fine: $159,8208 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 timely therapy services for two residents, R4 and R16, as required by their medical conditions and physician orders. R4, who had a history of stroke, type 2 diabetes, and bilateral knee arthritis, returned to the facility after receiving cortisone injections in both knees. Despite the orthopedic doctor's order for physical therapy (PT) to begin on July 25, 2024, R4 did not start PT until September 5, 2024, resulting in a 42-day delay. This delay was attributed to a lack of communication between the staff and the therapy department, as the PT order was not promptly communicated to the therapy team. R16, who was admitted with multiple diagnoses including liver disease, muscle weakness, and heart failure, was discharged from the facility without a home evaluation. The facility did not acknowledge that R16 only had 30 days of benefits, which led to inadequate discharge planning. The therapy department was unaware of the limited benefits and did not conduct a home evaluation, which could have identified necessary recommendations and safety issues for R16's discharge. Consequently, R16 was readmitted to the hospital less than 24 hours after discharge due to the inability to be cared for at home. Interviews with facility staff, including the Nursing Home Administrator, Director of Nursing, and Director of Rehabilitation, revealed systemic issues in communication and process adherence. The facility lacked a policy for the communication process between staff and the therapy department, which contributed to the delays and oversight in therapy services for both residents. Despite the acknowledgment of these issues by the staff, no further information was provided to explain why the facility did not ensure timely therapy services for R4 and R16.

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 written notices of transfer, including reasons for transfer and appeal rights, to residents and their representatives at the time of transfer to the hospital. This deficiency was observed in seven residents who were transferred due to changes in their medical conditions. The facility lacked a policy and procedure for written transfer requirements, and the necessary information was not sent with the residents at the time of transfer. For instance, Resident 49 was transferred to the hospital twice without receiving the required transfer notice. Similarly, Resident 51 was transferred without documentation of the transfer notice being provided. Resident 58, who had not returned to the facility at the time of the survey, also did not have evidence of receiving the required transfer notice. The facility's Admission Director admitted that they only verbally reviewed the Bed-Hold form with the resident's Power of Attorney, which did not include the full transfer notice information. Other residents, such as Resident 55, Resident 3, Resident 4, and Resident 75, also did not receive the necessary written transfer notices. In some cases, the facility attempted to communicate via phone or voicemail, but there was no evidence of written notices being provided. The Director of Nursing acknowledged the lack of documentation and the absence of a formal process for ensuring that transfer notices were completed and provided to residents or their representatives.

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 written bed-hold notifications to residents or their representatives at the time of transfer to a hospital, as required by regulations. This deficiency was identified in five out of seven resident transfers reviewed during the survey. The Director of Nursing (DON) acknowledged that the facility did not have a policy or procedure in place for providing written bed-hold notifications, and the Bed-Hold form was not sent with residents at the time of transfer. Resident 49 was transferred to the hospital for a change in condition and returned to the facility, but there was no documentation of the required bed-hold information being provided. Similarly, Resident 51 was transferred and returned without evidence of bed-hold notification. Resident 58 was transferred and had not returned at the time of the survey, with no documentation of the bed-hold information being provided. The Admission Director mentioned verbally reviewing the Bed-Hold form with the resident's Power of Attorney but did not send the form with the resident. Resident 55, who is cognitively intact and responsible for themselves, was hospitalized and readmitted without evidence of a bed-hold notice in their medical record. Resident 75 was transferred to the hospital after a misunderstanding during a phone call with their daughter, and no bed-hold notice was provided. The Nursing Home Administrator and DON were informed of these findings, but no additional information was provided as to why the notices were not given.

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's medical record accurately reflected their resuscitation code status. The resident, who was admitted with chronic conditions including dementia and had moderate cognitive impairment, initially elected a full code status upon hospital discharge. However, upon admission to the facility, the resident signed a CPR consent form indicating a DNR status without the involvement or notification of their activated Power of Attorney (POA). This discrepancy was not identified by the facility staff, including the Physician Assistant, who documented conflicting code statuses in the resident's progress notes. The inconsistency in the resident's code status persisted, with documentation showing both DNR and full code orders at different times. The facility's Director of Nursing and Social Services Director acknowledged that a care conference was held with the resident's POA, during which the code status was discussed and changed to full code per the POA's wishes. However, there was no documentation provided to confirm the date or details of this conference. The surveyor noted these inconsistencies and the lack of proper documentation and communication regarding the resident's code status, which led to the deficiency finding.

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 with pressure injuries received necessary treatment and services consistent with professional standards of practice. The resident, who was readmitted to the facility from the hospital on multiple occasions, had a stage 2 pressure injury to the coccyx that was not comprehensively assessed upon re-admission. The facility did not document measurements or a description of the wound bed during these re-admissions, which is contrary to their policy requiring a comprehensive assessment upon admission or readmission. The resident, identified as having multiple medical conditions including discitis, type 2 diabetes, atrial fibrillation with a pacemaker, prostate cancer, and heart failure, was at high risk for developing pressure injuries. Despite this, the facility did not perform comprehensive assessments of the resident's pressure injury upon re-admissions on three separate occasions. The resident's Braden Scale scores indicated a high to moderate risk for pressure injuries, yet the necessary documentation and assessments were not completed as required. Interviews with facility staff, including the Assistant Director of Nursing who also served as the wound nurse, confirmed that the comprehensive assessments were not documented. The staff acknowledged the oversight but did not provide additional information as to why the necessary treatment and services were not provided to promote healing of the resident's pressure injury. This lack of comprehensive assessment and documentation upon re-admission led to the deficiency noted by the surveyor.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the environment was free from accident hazards, leading to a fall incident involving a resident, R3. R3, who was admitted with multiple diagnoses including chronic diastolic heart failure and Parkinson's disease, fell from their bed while receiving care. The fall was attributed to the bed frame not being extended to accommodate the mattress size, causing the mattress to hang over the side. This incident resulted in R3 sustaining a laceration to the bridge of the nose. The facility's policies on bed maintenance and inspections were not adequately followed. The Maintenance Director was responsible for keeping records of bed inspections and maintenance, but there was no routine maintenance schedule for long-term residents. The bed frame extenders were not locked, which led to the mattress not being secured properly. Additionally, there was no maintenance plan in place for inspecting bed rails after installation, which contributed to the unsafe environment. Interviews with facility staff revealed that there was no formal process for regular maintenance checks on beds. The Maintenance Director stated that bed issues were brought to their attention by nursing staff, but there was no routine schedule for inspections. The Director of Nursing and Assistant Director of Nursing confirmed that they relied on housekeeping or nurses to report issues, and no formal checks were set up. This lack of a structured maintenance process contributed to the accident involving R3.

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 R69, maintained acceptable nutritional status, resulting in severe weight loss over a period of less than two months. R69, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, and diabetes, was not weighed as ordered by the physician. The facility's policy required weights to be taken on admission, the next two days, weekly for three weeks, and then monthly. However, after the initial weight on admission, R69 was not weighed again until nearly two months later, revealing a significant weight loss of 24.5 pounds and 13.03%. Despite this, there was no evidence that the physician or dietician was notified, and no new interventions were implemented. The deficiency was further compounded by continued inaction as R69's weight continued to decline. By April, R69 had lost a total of 32 pounds, equating to a 17.02% weight loss since admission, yet there was still no notification to the physician or dietician, nor were any new interventions put in place. The dietician's notes inaccurately stated that the weight loss occurred outside the facility, which was not the case. Additionally, the resident expressed a desire for a G-tube due to poor intake and depression, but there was no documentation that this request was communicated to the physician or dietician. Throughout this period, the facility's interdisciplinary team failed to address the resident's nutritional needs adequately. Despite the resident's significant weight loss and voiced concerns, the facility did not implement timely or effective interventions. The lack of communication and documentation regarding the resident's condition and requests further exacerbated the situation, leading to continued weight loss and deterioration of the resident's health.

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, identified as R27, who experienced a significant worsening of pain. R27, who has chronic conditions including chronic obstructive pulmonary disease, osteoarthritis, and osteoporosis, reported being in constant pain. Despite this, the facility did not adjust R27's pain management plan following a hospitalization. The resident's pain assessment showed a marked increase in pain from February to May, affecting sleep and daily activities, yet the facility did not address this change. Upon readmission to the facility after hospitalization for pneumonia, R27 did not have a scheduled order for Tylenol for pain management, only a PRN order for fever. Additionally, Tramadol, which R27 was taking prior to hospitalization, was not reordered due to a drug interaction, and no alternative pain management was provided. The Director of Nursing was unaware of the significant change in R27's pain assessment and the discontinuation of Tramadol, indicating a lack of communication and oversight in managing R27's pain. Furthermore, although the Physician Assistant's documentation suggested that physical and occupational therapy were part of R27's pain management plan, these therapies were not provided. Orders for PT and OT evaluations were placed but not followed up on, leaving R27 without the intended supportive care. This oversight contributed to the facility's failure to manage R27's pain effectively, as highlighted by the surveyor's findings.

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 Registered Pharmacist (RPH) consult recommendations were promptly acted upon and communicated to the necessary staff, as observed in the cases of two residents, R58 and R3. For R58, a medication review was completed by the RPH, recommending the discontinuation of Rivaroxaban due to the resident's medical condition and potential side effects, and its replacement with Apixaban. However, the Clinical Pharmacy Report containing these recommendations was not available in the resident's medical record until nine days later, when it was signed by the physician. The Director of Nursing (DON) was unaware that the Medical Director and physician were required to receive these reports promptly. In the case of R3, pharmacy medication regimen reviews were conducted in February and March, with recommendations made. However, the February recommendations were not communicated to the facility for review due to a transition period with a new pharmacist. As a result, the same recommendations were reissued in March and signed off by the physician. The DON acknowledged the concern that the February recommendations were not followed up on in a timely manner by the Medical Director and physician.

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 drugs and biologicals, specifically insulin pens, were labeled in accordance with currently accepted professional principles. During an observation and interview, it was found that two residents, R45 and R55, had insulin pens in their respective medication carts that were not labeled with an open or use-by date. The facility's policy on medication administration for subcutaneous insulin requires that vials or devices be dated after first use. However, the surveyor observed that insulin pens for insulin glargine, latanoprost, Novolin NPH, and insulin lispro were not labeled with the necessary dates, indicating a lapse in adherence to the facility's medication labeling policy. This deficiency was communicated to the facility during the end-of-day meeting.