Montello Care Center

Penalty

No penalty information released

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

Summary

The facility failed to thoroughly investigate a potential allegation of abuse involving one resident who was found between the wall and the bed with injuries including a swollen right eye, facial swelling, and abrasions on the right shoulder and arm. The resident, who had significant medical conditions such as anoxic brain damage, epilepsy, and hemiplegia, was dependent on staff for care, transfers, and mobility. Staff interviews revealed inconsistent accounts regarding the presence and extent of the resident's injuries. One LPN reported finding the resident without injuries or bleeding and only cleaned sputum from the face, while a CNA described the resident as having a swollen, bloodied face and observed bloody washcloths nearby. The LPN did not document the incident in the medical record, and the discrepancy between staff statements was not investigated further by facility administration. The facility's administration was notified of the incident and initiated an investigation, but failed to address or reconcile the conflicting staff statements regarding the resident's injuries. The Nursing Home Administrator confirmed that there was no follow-up to investigate the discrepancy between the LPN and CNA accounts. As a result, the facility did not ensure a thorough investigation of a potential abuse allegation, as required, and did not document or clarify the circumstances surrounding the resident's injuries.

Penalty

Fine: $15,935

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

Summary

A resident with a diagnosis of Alzheimer's disease and other forms of dementia was admitted for a short-term respite stay. The resident had a known history of wandering but no prior physically aggressive behavior. On the evening in question, staff attempted to assist the resident with bedtime care, which the resident resisted, stating that only their spouse performed such care. The resident became increasingly agitated, expressed a desire to leave the facility, and attempted to exit through multiple doors. In response to the resident's attempts to leave, multiple staff members pursued the resident throughout the facility, physically blocked exit doors from both inside and outside, and put hands on the resident to prevent elopement. These actions escalated the resident's agitation and resulted in the resident becoming physically aggressive, injuring several staff members. Law enforcement was called, and upon arrival, the resident reported feeling attacked by numerous individuals. Staff interviews and record reviews revealed that staff did not follow the facility's own policies and training regarding the management of agitated or wandering residents, which emphasize the use of least restrictive measures, avoiding physical restraint, and not blocking exits. The facility's care plan for the resident included specific interventions for wandering and agitation, such as approaching from the front, avoiding overstimulation, providing reassurance, and maintaining a calm environment. However, these interventions were not followed during the incident. Staff actions, including physically restraining the resident and blocking exits, were inconsistent with both the care plan and facility policies. Post-incident interviews indicated that some staff were not adequately trained on managing severe agitation or elopement, and there was a lack of immediate post-incident education for all involved staff.

Penalty

Fine: $15,935

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 allegations of abuse were reported to the State Agency (SA) for one resident who was admitted for a 5-day respite stay and had a diagnosis of Alzheimer's disease, among other conditions. On the evening in question, the resident became agitated and attempted to leave the facility through multiple doors. Staff responded by holding the doors shut and physically restraining the resident to prevent elopement, including holding the resident in a chair. Law enforcement was called to assist, and a police report documented that the resident alleged being attacked by numerous individuals. The police also observed staff who appeared distressed and noted that staff were holding the resident in a chair upon arrival. Despite these events and the facility's own policy requiring immediate reporting of suspected abuse to the SA, the Nursing Home Administrator (NHA) did not report the incident, citing the absence of resident injuries and attributing the situation to behavioral issues. The NHA also did not conduct interviews with staff involved in the incident and relied solely on statements obtained by law enforcement. Additionally, the NHA had not reviewed all relevant documentation, including the police and crisis reports that contained allegations of abuse. The failure to report the incident to the SA constituted a deficiency in the facility's abuse reporting procedures.

Penalty

Fine: $15,935

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

Summary

The facility failed to thoroughly investigate an allegation of abuse involving a resident admitted for a 5-day respite stay with diagnoses including Alzheimer's disease, dementia, and anxiety disorder. On the evening of the incident, the resident became agitated and attempted to leave the facility through multiple exits. Staff responded by holding doors shut and physically restraining the resident in a chair to prevent elopement. A crisis report and police report documented that staff held the resident in a chair and that the resident later stated to police that they had been attacked by numerous individuals. The facility did not ensure that all staff involved in the incident were interviewed as part of the investigation. Several staff members who were present or directly involved, including CNAs and an LPN, were not asked for statements by facility administration. Some staff indicated they were not approached for statements by the facility, and their accounts were not included in the facility's investigation documentation. Additionally, the facility did not obtain or review the police report or county crisis documentation, both of which contained relevant information about the incident and the resident's allegations. The facility's policy required that all allegations of abuse be thoroughly investigated, including interviewing all witnesses and reviewing all events leading up to the incident. However, the investigation was incomplete, as key staff interviews were not conducted, and external reports were not obtained or reviewed. This failure to follow policy resulted in an incomplete investigation of the abuse allegation involving the resident.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement adequate policies and procedures to ensure the timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. Specifically, the facility's policy on reporting abuse, neglect, exploitation, or misappropriation did not include examples of crimes that should be reported, such as assault and battery, nor did it indicate that the facility had consulted with local law enforcement to clarify reporting requirements. On one occasion, a resident struck another resident in the face, an incident witnessed by a medication technician. Despite the policy stating that law enforcement officials should be notified, the facility did not report the incident to local law enforcement. Both residents involved in the incident had severe cognitive impairment, as indicated by their low BIMS scores and diagnoses of dementia, and were unable to recall the event during subsequent interviews. The administrator stated that the incident was not considered malicious and, based on the residents' inability to recount the event, decided not to report the abuse to law enforcement. The facility did conduct internal assessments and interviews following the incident, but the required external notification was not made.

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 a safe, functional, and sanitary environment for residents in the area outside the building. Observations made by the surveyor revealed that the front of the facility was unkempt, with long weeds present along the building, under residents' windows, along fencing, and around trees. The area also contained an open dumpster with garbage bags, lacking a complete privacy fence on one side facing the main parking lot and public roadway. Additional items observed included two plastic chairs, one holding dried cardboard, a garbage can labeled for laundry without a lid and containing items, and a pile of dry dirt and landscaping bark along the path to the front doors. Three garbage cans were present at the entrance, one with a stained lid, and exposed wires were seen where a doorbell was missing near the main entrance. During staff interviews, it was confirmed that the front doors, which were supposed to be locked during the night shift for safety, were not locked within the required timeframe. The Nursing Home Administrator acknowledged that staff were aware of the need to lock the doors, but the process for auditing door security had not yet been implemented. The administrator also confirmed that the dumpster should have been closed. These conditions had the potential to affect more than 4 of the 28 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

A deficiency occurred when a resident with multiple complex medical conditions, including quadriplegia, diabetes, and a history of osteomyelitis, did not receive appropriate care and services to prevent pressure injuries and promote healing. The resident had a wound vac (negative pressure wound therapy) placed by a wound provider, with orders for dressing changes per protocol. On one occasion, staff reported to the Director of Nursing (DON) that the wound vac dressing was not adhered properly, but the DON did not assess the dressing or ensure the wound vac was functioning as intended. Certified Nursing Assistants (CNAs) observed that the dressing was bunched up and not suctioning, and communicated this to the DON, who stated the dressing was fine and did not further assess the situation. Subsequent nursing assessments documented worsening maceration and a deteriorating wound condition, with the wound vac dressing being replaced and noted to be running correctly at one point. However, later documentation and interviews revealed that the wound vac dressing was not intact, the foam was not suctioning, and there was a strong odor at the wound site. The resident developed a low-grade fever and redness, and alternative wound care was provided after the wound vac was removed. Staff interviews indicated that some nurses were uncomfortable with wound vac dressing changes, and alternative dressing orders were provided for such situations. Despite these measures, there was a lack of consistent assessment and intervention when concerns about the wound vac's function were raised. The facility's policies required ongoing review of interventions and adherence to clinical guidelines for negative pressure wound therapy. However, the failure to promptly assess and address the malfunctioning wound vac, as well as the lack of comprehensive staff education on wound vac management, contributed to the resident not receiving the necessary care to prevent further deterioration of the pressure 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

A deficiency occurred when the facility failed to provide adequate supervision and assistance to prevent accidents and did not conduct a thorough investigation following a resident's fall. The resident, who had a history of cervical laminectomy, Parkinson's disease, diabetes, and recent vertigo, fell out of bed after a CNA left the room to assist another resident. The resident was unable to reach the call light and, after calling for help without response, used the phone to call 911. Law enforcement and EMS responded, assisted the resident, and transported them to the emergency department for evaluation. The facility's policies required staff to identify interventions based on resident-specific risks and to conduct a root cause analysis within 24 hours of a fall, including documentation of the circumstances, assessment data, and interviews. However, the event report for the incident lacked nursing documentation, staff or resident interviews, and a root cause analysis. There was also no documentation of the resident's condition immediately after the fall, including the status of the surgical neck wound or a description of the initial fall after returning from the bathroom. Interviews with facility staff confirmed that the investigation was incomplete and did not include the required elements. The DON could not recall the root cause analysis or the reason for the fall, and the event report was closed without these critical components. The resident's medical record and event report did not meet the facility's own policy requirements for post-fall assessment and 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

A resident with multiple diagnoses, including osteomyelitis of the thoracic vertebra, was admitted to the facility and prescribed a continuous 24-hour intravenous (IV) antibiotic (cefazolin) administered via a CADD pump. The resident was cognitively intact and made their own medical decisions. On one occasion, the scheduled change of the antibiotic cartridge was not performed as ordered, resulting in the resident missing a dose of the IV antibiotic. The missed dose was confirmed by both the resident and multiple staff members, who noted that the cartridge was found dry and unchanged the following day, and an unused cartridge was left over and subsequently discarded. The Director of Nursing (DON) was responsible for the shift when the cartridge should have been changed but did not perform the task. The medication administration record indicated the dose was given, but staff interviews and the presence of an unused cartridge confirmed the dose was missed. The incident was reported to the Nursing Home Administrator (NHA), who initially did not investigate further based on the DON's assurance that the dose was not missed. The deficiency was identified through staff and resident interviews, as well as review of medical records and medication supplies.

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 the Director of Nursing (DON) failed to document an assessment and observation of a resident with severe cognitive impairment and multiple complex medical diagnoses, including pneumonitis, dysphagia, and respiratory failure. The facility's policy required that all services, changes in condition, and objective observations be documented in the resident's medical record to ensure complete and accurate communication among the interdisciplinary team. On the date in question, therapy staff expressed concerns about the resident's respiratory status and swelling, prompting the DON to assess the resident. The DON verbally reported the assessment findings to the registered nurse (RN) but did not enter any documentation of the assessment or observations into the resident's medical record. Subsequent interviews confirmed that the DON acknowledged the lack of documentation and that the assessment was only communicated verbally. The resident's medical record was missing this critical information, despite the facility's policy and the need for accurate records to reflect changes in the resident's condition. The omission was identified during a surveyor's review of the medical record and staff interviews, which also revealed that the resident was later sent to the hospital and passed away. The failure to document the DON's assessment constituted a lack of complete and accurate medical records for the resident.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a registered nurse (RN) failed to follow proper infection prevention and control protocols during wound care for a resident with multiple complex medical conditions, including traumatic spinal cord injury, diabetes, quadriplegia, and an ESBL-resistant infection. During the wound care procedure, the RN did not perform hand hygiene between glove changes and wore two pairs of gloves simultaneously, contrary to facility policy. Additionally, the RN used scissors that had been used to cut a soiled dressing to then cut a clean dressing, without sanitizing the scissors in between uses. These actions were observed during wound care on the resident's left heel and buttock, both of which had significant wounds, including a stage 4 pressure injury. Facility policies required hand hygiene immediately after glove removal and the use of clean, sanitized equipment during wound care. The RN acknowledged not performing hand hygiene between glove changes and not sanitizing the scissors before using them on a clean dressing. The Assistant Director of Nursing confirmed that the RN's actions were not in accordance with facility protocols, specifically regarding glove use and the need for clean equipment during wound care.

Penalty

Fine: $203,500

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

Summary

The facility failed to ensure a safe environment free from abuse for two residents, both of whom had dementia and activated Powers of Attorney for Healthcare. One resident had a documented history of sexually inappropriate behavior, verbal and physical aggression, and wandering. Despite multiple incidents where this resident made sexual comments, was verbally and physically aggressive, and entered other residents' rooms, the facility did not consistently implement or revise interventions to address these behaviors or ensure the safety of other residents. Progress notes documented several incidents, including inappropriate sexual comments and altercations with other residents, but there was a lack of corresponding care plan updates or incident reports for these events. On one occasion, a resident was observed touching another cognitively impaired resident's breasts under her shirt. The incident was witnessed by another resident, who intervened and notified staff. Both the victim and the perpetrator had severe cognitive impairment and activated POAHCs. Prior to this event, the resident with a history of inappropriate behavior had previously been involved in similar incidents, including a prior sexual interaction with another resident and multiple episodes of aggression and boundary violations. Staff interviews revealed that these behaviors were known among staff, but documentation and communication regarding specific incidents and follow-up actions were inconsistent or lacking. The facility's policies required prompt reporting, investigation, and care plan revision following resident-to-resident altercations, especially those involving abuse or aggressive behavior. However, the facility was unable to provide evidence of investigations, incident reports, or care plan revisions for several documented incidents involving the resident with a history of inappropriate behavior. Staff and administration interviews confirmed gaps in communication, documentation, and follow-up, contributing to the failure to prevent the sexual abuse of a cognitively impaired resident by another resident with known high-risk behaviors.

Removal Plan

• Placed R2 on 1:1 supervision.
• Reviewed medical records and interviewed staff to identify other residents who may exhibit high-risk behavior.
• Developed care plans for residents identified with the potential for high-risk behavior.
• Reviewed the Abuse policy and playbook.
• Completed staff education on resident rights, abuse, reporting responsibilities, and willful/intentional acts.
• Initiated audits to ensure compliance.

Penalty

Fine: $203,500

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 timely reporting of suspected abuse involving two residents, as required by both facility policy and regulatory standards. Specifically, one resident with dementia and moderate cognitive impairment exhibited sexually inappropriate, verbally, and physically aggressive behaviors toward other residents on multiple occasions. Another incident involved a verbal altercation between this resident and another resident with no cognitive impairment. Despite these events, there was no evidence that the facility reported the allegations of abuse to the State Agency as required. Documentation in the medical records indicated that the resident with dementia made inappropriate sexual and combative comments to other residents and was involved in aggressive behavior on several dates. Staff documented these behaviors in progress notes but did not specify the exact nature of the comments or identify the recipients. Additionally, a verbal altercation between the two residents was documented, and staff intervened to separate them. However, there was no documentation of these incidents being reported to facility leadership or the State Agency, nor was there evidence of an investigation or follow-up as required by facility policy. Interviews with staff revealed uncertainty about whether the incidents were reported, and the Director of Nursing was unable to provide documentation of any investigation or reporting for the incidents in question. The Nursing Home Administrator, who was not employed at the time of the initial incidents, confirmed that the facility's policies require such events to be reported and that staff should notify leadership when incidents occur. The lack of timely reporting and investigation of these incidents constituted a deficiency in the facility's abuse reporting practices.

Penalty

Fine: $203,500

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

Summary

The facility failed to thoroughly investigate allegations of abuse involving two residents, as required by its own policies and regulatory standards. Progress notes documented that one resident, who had dementia with psychosis and moderate cognitive impairment, exhibited sexually inappropriate, verbally, and physically aggressive behaviors toward other residents on multiple occasions. Another incident involved a verbal altercation between this resident and another resident with a history of stroke and no cognitive impairment, after the first resident took the other's hat, leading to an argument that staff had to intervene to stop. Despite these documented incidents, the facility was unable to provide evidence of any investigations into the alleged abuse or altercations. The Director of Nursing (DON) acknowledged awareness of some of the incidents but could not provide details about the specific behaviors, the individuals involved, or any investigative actions taken. There was also no documentation to show that the incidents were reviewed or that appropriate actions were implemented in response to the behaviors. The facility's policies require that all allegations of abuse and resident-to-resident altercations be promptly reported, thoroughly investigated, and documented, with findings reported to appropriate leadership. However, the lack of investigation records and incomplete knowledge of the incidents by facility leadership demonstrate that these procedures were not followed for the incidents in question.

Penalty

Fine: $203,500

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 care plans for three residents at high risk for falls were reviewed, revised, or updated in a timely manner following fall incidents, as required by facility policy. For one resident with severe cognitive impairment and multiple diagnoses, including chronic pain syndrome and dementia, the care plan was not updated after two falls, one of which resulted in significant injuries including a femur fracture and scalp laceration. Although staff reportedly implemented new interventions such as placing a fall mat and lowering the bed, these changes were not documented in the resident's care plan. Another resident, also with severe cognitive impairment and a history of falls, experienced multiple falls over several months. The care plan interventions were not consistently updated after each fall. In some cases, interventions were added to the care plan days or weeks after the fall occurred, and in other cases, interventions were already listed in the care plan prior to the fall, indicating a lack of timely review and revision. Documentation did not always reflect the implementation of new or different interventions following each incident. A third resident with dementia and a history of falls also had multiple falls, with care plan interventions not being updated promptly. For some falls, interventions were documented as being added to the care plan weeks after the incident, and in other cases, no new interventions were documented at all. Interviews with facility staff, including the DON and LPN, confirmed that changes to care plans should be documented at the time interventions are implemented, but this was not consistently done for these 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 adequate supervision to prevent resident-to-resident altercations involving four residents. On multiple occasions, a resident with severe cognitive impairment engaged in aggressive behavior towards other residents. These incidents included rolling a wheelchair into another resident's foot, yelling, and physical altercations. Despite being placed on 15-minute checks and later 1:1 supervision, the resident continued to have altercations, indicating a lack of effective supervision. The facility's staff did not consistently implement the required interventions for the resident. Although the resident was supposed to be on 1:1 supervision when outside their room, this was not always provided. During one incident, the resident was not supervised, leading to a physical altercation with another resident. Additionally, the motion sensor and audio monitoring devices intended to assist in supervision were not properly managed, as staff were unaware of their locations or how to use them effectively. Interviews with staff and the nursing home administrator revealed gaps in communication and training regarding the supervision and monitoring of the resident. The education provided to staff about the monitoring interventions was insufficient, with only a small portion of the nursing staff having signed the education sheet. Furthermore, there was no specific assignment of staff to provide 1:1 supervision, leaving it to the discretion of the nurse on duty, which contributed to the failure in supervision.

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 resident-to-resident altercation to the State Agency as required by their Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy. The incident involved two residents, R1 and R5, who were involved in a physical altercation on 9/7/24. R1, who had severe cognitive impairment and required 1:1 supervision, was not being supervised at the time of the incident. R5, who had moderate cognitive impairment, became upset with R1 and a physical altercation ensued. The altercation was not reported to the State Agency because neither resident incurred physical injuries. R1 was admitted to the facility with diagnoses including a fall with a fracture and dementia, and had a BIMS score indicating severe cognitive impairment. R5 was admitted with diagnoses including dementia and depression, with a BIMS score indicating moderate cognitive impairment. The facility's policy requires immediate reporting of suspected abuse to the administrator and state authorities, but this was not followed. The Nursing Home Administrator confirmed that the incident was not reported due to the absence of physical 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 food was stored and prepared in a sanitary manner, which had the potential to affect all 30 residents. During an initial tour of the kitchen, the surveyor observed that cooling logs were not completed for leftover foods, including meatballs, chili, hard-boiled eggs, and cooked carrots. These items were not listed on the cooling log, and the Dietary Manager (DM) acknowledged that they should have been discarded. The facility's policy requires logging food temperatures for cooling foods within acceptable times, but this was not adhered to. Additionally, the surveyor noted cleanliness issues in the resident snack refrigerator, which contained dry sticky debris and layers of cardboard food packaging stuck to the shelves. The Nursing Home Administrator (NHA) stated that dietary staff were responsible for cleaning the refrigerator, but there was no cleaning log available, and the NHA was unaware of the last cleaning date. The DM confirmed the absence of a cleaning log and stated that the refrigerator had been cleaned within the last month. The facility also failed to monitor and document food holding temperatures. The Dietary Manager in Training (DMT) was observed serving lunch and checking food temperatures only once, without verifying holding temperatures before or after serving. Furthermore, food items for resident consumption were not labeled with open or expiration dates, and some were beyond the labeled discard date. The surveyor found icy pops and cottage cheese without proper labeling, and the DM could not confirm if the icy pops were for resident consumption.

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 establish and maintain an effective infection prevention and control program, which is crucial for preventing the development and transmission of communicable diseases and infections. The facility's Infection Control Manual, dated 2019, requires the creation of monthly and quarterly infection summary reports, but the facility did not maintain these reports. This was confirmed by the Director of Nursing (DON), who also serves as the Infection Preventionist, during an interview with the surveyor. The absence of these reports indicates a lack of ongoing infection surveillance, which is a fundamental component of an effective infection control program. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for three residents with a history of multi-drug resistant organisms (MDROs). These residents, identified as having conditions such as MRSA infection and ESBL resistance, did not have orders for EBP, nor were there signs posted in their rooms indicating the need for such precautions. The DON confirmed that these residents were not on EBP, despite having indwelling lines and MDRO colonization, which are conditions that typically require such precautions. This oversight in implementing EBP further highlights the deficiencies in the facility's infection control practices.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a clean, comfortable, and homelike environment for its residents, as evidenced by a persistent urine odor noted by surveyors during observations on two consecutive days. The odor was detected upon entering the facility, in the dining room during lunch service, and in resident hallways and common areas, with the strongest odor on the 100 wing. Interviews with housekeeping staff confirmed the presence of the odor, and they suggested that the lack of air fresheners and issues with caulk around toilets might be contributing factors. Additionally, social services staff indicated that unsealed resident trash cans might also be contributing to the odor, and staff had been instructed to empty them more frequently. A resident, identified as R15, and their family member both confirmed the presence of the urine odor, with the family member noting that the 100 wing had a stronger odor than the 200 wing. R15, who had intact cognition as per their most recent Minimum Data Set assessment, expressed dissatisfaction with the facility's smell. The nursing home administrator also verified the presence of the odor, acknowledging the issue during an interview with the surveyor.

Penalty

No penalty information released

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

Summary

The facility failed to thoroughly investigate incidents involving potential abuse for five residents, leading to deficiencies in their abuse prevention program. One resident, with moderate cognitive impairment, was found with an injury of unknown origin, specifically a bruise near the left eye, which was not investigated by the facility. The Regional Director of Operations was unaware of the incident until questioned by the surveyor, and there was no documentation of an investigation, indicating a lapse in the facility's protocol to rule out abuse. In another incident, two residents with severe cognitive impairments were involved in a resident-to-resident altercation, where one resident made contact with the other's face. Although the facility initiated an investigation and placed the residents on 15-minute checks, the investigation was incomplete as it did not include interviews with other staff or residents to ensure no further abuse concerns existed. The current Nursing Home Administrator confirmed that important documentation from the previous administration was missing, contributing to the incomplete investigation. A third incident involved a resident with intact cognition and another with severe cognitive impairment, where the latter attempted to hit the former. The facility did not conduct an investigation into this altercation, and the Regional Director of Operations was not aware of the physical contact involved. The lack of investigation into these incidents highlights a significant deficiency in the facility's ability to protect residents from potential abuse and ensure thorough investigations are conducted.

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 assistance with activities of daily living (ADLs) for five residents, as observed by surveyors. Resident 19, who was diagnosed with dementia and failure to thrive, required partial assistance with meals according to their care plan. However, during a meal observation, the resident was not consistently assisted with eating, as the CNA responsible for feeding was attending to multiple residents simultaneously. The CNA did not sit at eye level with Resident 19, which is considered best practice, and the resident did not attempt to eat independently during the observation period. Additionally, the facility did not consistently provide scheduled weekly showers for Residents 15, 4, 6, and 31. Resident 15 reported missing showers due to short staffing, and documentation confirmed the absence of shower records for several weeks. Resident 4 also reported irregular shower schedules, which was corroborated by resident council meeting minutes and grievance forms. Resident 6 experienced similar issues, with documentation showing missed showers over a sixteen-week period. Resident 31, who was discharged, received only one shower in the documented period without any recorded refusals. The Director of Nursing confirmed the lack of documentation indicated showers were not provided and acknowledged the residents' preferences and care plans were not followed. The facility's failure to adhere to care plans and provide necessary assistance and hygiene care highlights deficiencies in staffing and adherence to established care protocols.

Penalty

No penalty information released

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

Summary

The facility failed to implement its abuse policy by not completing timely and thorough background checks for four out of eight sampled staff members. The facility's policy, revised in April 2021, mandates conducting employee background checks to ensure that no individual with a history of abuse, neglect, exploitation, or related disciplinary actions is employed. However, the facility did not obtain Integrative Background Information System (IBIS) or Department of Justice (DOJ) reports for a Certified Nursing Assistant (CNA)-T and a Dietary Aide (DA)-S. Additionally, the facility obtained the IBIS and DOJ reports for a Physical Therapist (PT)-R only after the individual had already been hired. Furthermore, a background check for CNA-U had not been completed within the last four years, and no IBIS or DOJ reports were provided for this individual. The deficiency was identified during a caregiver program compliance check conducted by a surveyor. The Regional Director of Operations (RDO)-D acknowledged the issue, attributing the missing background check information to the absence of a current Human Resources (HR) Director. The previous HR Director may have discarded some of the necessary documents, and the facility was in the process of recruiting a new HR Director. In the meantime, all background checks were being processed through the company's HR headquarters. The RDO-D recognized the concern and indicated that the issue would be addressed once a new HR Director was hired.

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 address a grievance raised by a resident, identified as R15, regarding the lack of response to their call light. R15, who has intact cognition as indicated by a BIMS score of 15 out of 15, reported that when staff did not respond to their call light, they contacted a family member, FM-L, to call the facility for assistance. FM-L attempted to contact the facility multiple times but was unable to reach anyone or leave a message due to the absence of a voicemail system. Despite R15 informing the staff about the issue, the facility did not follow up with R15 or FM-L to resolve the grievance in a timely manner. The surveyor's investigation confirmed the communication issues, as calls made to the facility's listed numbers resulted in no answer and no voicemail option. Interviews with the Nursing Home Administrator and Social Services staff verified the facility's phone system problems, including the lack of a separate line for staff and the absence of a voicemail system. The grievance was not documented in the facility's grievance file, indicating a failure to adhere to the grievance policy and promptly resolve the issue.

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 incidents involving potential abuse to the Nursing Home Administrator (NHA) and the State Agency (SA) for three residents. On April 2, 2024, a resident with moderate cognitive impairment was found with a bruise of unknown origin on the left eye area. The facility did not report this injury to the NHA or the SA, and there was no documentation other than what was in the resident's medical record. The Regional Director of Operations (RDO) was unaware of the incident until questioned by the surveyor, indicating a lapse in the facility's reporting protocol. Additionally, on July 20, 2024, a physical altercation occurred between two residents, one with intact cognition and the other with severe cognitive impairment. The altercation involved one resident making fists and hitting the other in the chest. Despite the incident being documented in a nursing progress note, the facility failed to notify the SA or the family member of the resident who was attacked. The RDO was aware of the altercation but not of the physical contact, further highlighting the facility's failure to adhere to its abuse prevention policy.

Penalty

No penalty information released

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

Summary

The facility failed to provide a written notification of transfer, including the reason for the transfer, location, appeal rights, and contact information for the State Long-Term Care Ombudsman, for a resident who was transferred to the hospital. The resident, who had intact cognition and no activated Power of Attorney for Health Care, was transferred to the hospital following an unwitnessed fall. However, the medical record did not contain the required written notification or documentation of the reason for the transfer, nor was there evidence that this information was conveyed to the receiving provider. The surveyor's review of the resident's medical record and an event report revealed that the transfer details, such as the reason for the transfer, date and time, mode of transportation, and communication with the receiving provider, were not documented. The resident returned to the facility with a hematoma requiring staples and a diagnosis of a urinary tract infection. Interviews with the Regional Director of Operations and the Director of Nursing confirmed the absence of the required transfer notice and 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 provide a written bed hold notice to a resident, identified as R6, who was transferred to the hospital. According to the facility's Bed-Holds and Returns policy, revised in October 2022, all residents or their representatives should receive written information regarding the bed-hold policy at the time of transfer, or within 24 hours if the transfer was an emergency. This notice should include details about the duration of the bed-hold policy, the reserve bed payment policy, and the right to return to the facility. However, R6, who was transferred to the hospital on May 12, 2024, did not receive such a notice, and the facility was unable to locate a copy of the signed bed hold policy. R6 was admitted to the facility with diagnoses including metabolic encephalopathy, diabetes mellitus type 2, chronic kidney disease stage 3, and neuropathic bladder with urinary retention. The Minimum Data Set (MDS) assessment indicated that R6 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Despite this, the facility did not provide the required written bed hold notice upon R6's transfer to the hospital. This deficiency was confirmed during an interview with the Regional Director of Operations, who acknowledged the oversight.

Penalty

No penalty information released

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

Summary

The facility failed to meet the Pre-Admission Screen and Resident Review (PASRR) requirements for a resident with a history of mental illness or mental disorder. The resident was admitted with diagnoses including dementia, insomnia, and depression, and was prescribed psychotropic medications. Despite these indicators, the PASRR Level I Screen incorrectly marked 'no' for major mental disorder and did not trigger a Level II Screen. The resident's medical record also lacked documentation of a county exemption, which is necessary when a resident remains in the facility for long-term care beyond the initial 30-day exemption period. The deficiency was identified during a survey when the resident's medical record was reviewed, revealing that the facility did not complete a PASRR Level II Screen after the resident stayed beyond 30 days. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the oversight. The facility's policy requires a Level I PASRR Screen for all admissions and a referral for a Level II Screen if criteria for mental disorder or intellectual disability are met, 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 develop a comprehensive care plan for a resident following a smoking assessment. The resident, who was admitted with diagnoses including ataxia, alcohol dependence, nicotine dependence, diabetes, debility, and glaucoma, had a Minimum Data Set (MDS) assessment indicating severely impaired cognition. A smoking risk assessment identified the resident as a potential unsafe smoker with moderate problems in areas such as carelessness with smoking materials, general awareness, and capability to follow the facility's safe smoking policy. Despite these findings, the resident's medical record did not contain a smoking care plan until it was requested by the surveyor. The Director of Nursing (DON) stated that the resident did not smoke upon admission, but when the resident expressed a desire to smoke, a smoking assessment was completed. However, the nurse responsible for the assessment did not follow through with creating a care plan, which was only completed on the day it was requested by the surveyor. This oversight resulted in the facility not having a documented plan to address the resident's smoking needs and risks, as required by their own smoking 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 provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections (UTIs). During an observation, it was noted that the staff did not maintain the catheter drainage bag below the level of the resident's bladder, which is necessary to ensure unobstructed urine flow. The facility's policy, revised in April 2022, clearly states that the drainage bag should be positioned lower than the bladder at all times to prevent urine from flowing back into the bladder. The resident involved, identified as R14, had multiple diagnoses, including quadriplegia, pressure injury, osteomyelitis, neurogenic bowel, diabetes mellitus, ESBL resistance, UTIs, and neuromuscular dysfunction of the bladder. On the day of the observation, the surveyor noted that the catheter drainage bag was placed on the bed at the level of the resident's bladder, preventing urine flow. This was confirmed by both a CNA and an LPN, who acknowledged that the bag should be kept below the bladder level. The Director of Nursing also stated that the bag should not remain at the bladder level for extended periods during care and dressing changes.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident, identified as R20, was offered fluid intake between meals, as required by the facility's Resident Hydration and Prevention of Dehydration policy. R20, who was admitted with multiple diagnoses including aphasia, dysphagia, neurocognitive disorder with Lewy body dementia, epilepsy, and Parkinson's disease, was at risk for weight loss and aspiration. The care plan indicated that R20 was on a general diet with nectar-thick liquids. However, during the survey period from July 29 to July 31, 2024, the surveyor observed that R20 did not have thickened liquids available in their room, and staff interviews confirmed that fluids were not provided between breakfast and lunch. The surveyor's interviews with R20's Power of Attorney for Healthcare (POAHC) and Certified Nursing Assistants (CNAs) revealed that unless the POAHC was present, R20 did not receive fluids in the morning. The CNAs confirmed the absence of thickened liquids in R20's room, and the Director of Nursing (DON) stated that staff were expected to provide fluids between meals. Despite these expectations, the facility did not adhere to its policy, resulting in a deficiency in providing adequate hydration to R20.

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 monitoring of high-risk medications for two residents, leading to deficiencies in their care plans. Resident 6 was prescribed insulin and bumetanide, but their care plan lacked interventions for monitoring potential side effects or adverse reactions to these medications. This oversight was confirmed by interviews with the LPN and the Director of Nursing, who acknowledged the absence of necessary monitoring interventions in the resident's plan of care. Similarly, Resident 19, who had diagnoses including hypertension, syncope, and dementia, was prescribed apixaban and furosemide. The care plan for this resident did not include monitoring for bleeding or other potential side effects related to apixaban use. Additionally, although there was an order to weigh the resident weekly due to diuretic use, the resident had not been weighed for ten out of the preceding twenty-two weeks. The Director of Nursing confirmed these deficiencies, acknowledging the lack of monitoring for side effects and the failure to adhere to the weekly weighing order.

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 assessment and documentation for the use of psychotropic medications for three residents, leading to a deficiency in medication management. Specifically, residents were prescribed lorazepam, an anti-anxiety medication, on a PRN basis without a documented rationale for its continued use beyond the 14-day limit as required by the facility's policy. The policy mandates that PRN orders for psychotropic medications should not exceed 14 days unless a specific rationale and duration are documented by the prescriber. However, for the residents in question, there was no such documentation, and the orders lacked an end date. Resident 1, diagnosed with conditions including dementia and anxiety disorder, had a PRN order for lorazepam without a rationale for its use beyond 14 days. Similarly, Resident 22, with diagnoses of dementia and anxiety, and Resident 19, with dementia and generalized anxiety disorder, also had PRN orders for lorazepam without the necessary documentation. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the absence of required documentation and acknowledged that the orders should have included a rationale or been discontinued.

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 of medications for a resident, identified as R4, during a medication administration observation. On the morning of July 31, 2024, a surveyor observed two bottles of eye drops and a container of topical lotion prescribed to R4, along with a scopolamine transdermal patch not prescribed to R4, left on R4's bedside table. The scopolamine patch was found by RN-N on the floor near the medication cart and was placed on the bedside table along with the other medications when RN-N became distracted and left the room. Interviews with LPN-G and RN-N confirmed that the scopolamine patch did not belong to R4 and that medications should not have been left at the resident's bedside. The Director of Nursing, DON-B, also verified that medications should be stored appropriately and confirmed that R4 was not self-administering medication. This incident highlights a lapse in the facility's medication storage protocol, as medications were not secured in locked compartments as required.

Penalty

No penalty information released

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

Summary

The facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment, which had the potential to affect all 29 residents. The facility failed to appropriately monitor for infections and outbreaks, as evidenced by the incomplete COVID-19 line list that did not identify symptoms, monitor symptoms, or include the date of the last symptom for residents and staff. The Director of Nursing (DON) acknowledged that the facility did not maintain a line list for monitoring symptoms and was in the process of hiring a new Infection Preventionist (IP) to address this issue. During incontinence care for two residents, staff did not perform appropriate hand hygiene. For one resident, a Certified Nursing Assistant (CNA) did not remove soiled gloves or complete hand hygiene after cleansing stool from a colostomy bag, and continued to provide care with the same gloves. The CNA acknowledged the failure to follow proper hand hygiene protocols. The DON confirmed that staff are expected to remove soiled gloves, perform hand hygiene, and don clean gloves when continuing care. For another resident, a Medication Technician (MT) did not remove soiled gloves or complete hand hygiene after providing rear perineal care and continued to assist with repositioning and other tasks with the same gloves. The MT acknowledged the failure to follow proper hand hygiene protocols. The DON confirmed that staff are expected to remove soiled gloves, perform hand hygiene, and don clean gloves when moving from dirty to clean tasks.

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 medications were properly secured in a medication cart, which had the potential to affect multiple residents. The facility's policy required that medication carts be locked and parked at the nurses' station or inside the medication room when not in use. However, on 4/9/24, a surveyor observed a resident with severe cognitive impairment, as indicated by a BIMS score of 0 out of 15, open an unlocked medication cart in the lobby and remove two medication cards. There were no staff present in the immediate area, although four staff members were observed talking in a group down a resident wing. A resident in the lobby noticed the incident and told the resident to stop, after which the surveyor motioned for staff to intervene. The staff then removed the medication cards from the resident's hand and pushed the resident back to their room. The Medication Technician (MT) responsible for the cart confirmed that it was unlocked and admitted to being distracted by other duties, including assisting administration and talking with staff. The Director of Nursing (DON) later confirmed that the expectation was for staff to lock the medication cart at all times when not in use. This lapse in protocol led to the observed deficiency, as the medication cart was left unsecured, allowing a resident with severe cognitive impairment to access it unsupervised.

Penalty

No penalty information released

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

Summary

The facility failed to implement policies and procedures for reporting suspected abuse, neglect, or theft in accordance with section 1150B of the Act for two residents. Resident 16, who had intact cognition, reported during a resident council meeting that a staff member had kicked their foot off a chair and was rough with them. This allegation of abuse was not reported to the State Agency or local law enforcement. The Nursing Home Administrator (NHA) was unaware of the incident and did not review the resident council meeting minutes where the allegation was documented. Resident 17, who had severe cognitive impairment, reported that money was taken from their purse. The grievance noted that the resident was agitated and kept their purse with them at all times. Despite the resident's agitation and the grievance documentation, the allegation of misappropriation was not reported to the State Agency or local law enforcement. The NHA, who was not employed at the facility at the time of the incident, confirmed that the allegation was not reported due to the resident's memory issues and age.

Penalty

No penalty information released

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

Summary

The facility failed to thoroughly investigate allegations of abuse and misappropriation for two residents. Resident 16, who had intact cognition, reported during a resident council meeting that a Medication Technician had kicked their foot off a chair on purpose and was rough with them. The Nursing Home Administrator (NHA) was unaware of this allegation and did not see the minutes from the resident council meeting, resulting in no investigation being conducted. The facility's policy requires a thorough investigation of all allegations, including interviewing the alleged victims, witnesses, and staff, which was not done in this case. Resident 17, who had severe cognitive impairment, reported that money was taken from their purse. The grievance noted that the resident was agitated and kept their purse with them at all times. The investigation section of the grievance indicated that staff needed to search the purse when the resident was unaware, but the resolution section stated that the Activity Director looked in the purse and found nothing missing. The NHA confirmed that no further investigation was conducted, including obtaining statements from residents and staff to determine if money was indeed missing or if other residents had similar complaints.

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 services to promote healing and prevent pressure injuries for one resident (R6). R6's medical record indicated the presence of open areas on the buttocks on two separate occasions, but there were no assessments or proof of monitoring for the effectiveness of treatments. The facility's protocol required detailed documentation and regular assessments of pressure sores, which were not followed. R6's care plan did not address the resident's risk for pressure injuries or impaired skin integrity, despite R6 being at high risk according to a Skin Risk Assessment. Additionally, the facility could not locate documentation from the previous Director of Nursing (DON) regarding R6's wound assessments, and the current interim DON confirmed the lack of weekly wound assessments and conflicting documentation in R6's medical record. On observation, a scabbed area was noted on R6's right buttock, which was verified by an LPN. The interim DON confirmed that a scabbed area should not be considered healed and acknowledged the deficiencies in documentation and care planning. The facility's failure to adhere to its own protocols and ensure consistent and accurate documentation contributed to the deficiency in providing appropriate pressure ulcer care and prevention for R6.