Waters Edge Health And Rehabilitation 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 protect residents from verbal, physical, and sexual abuse, particularly on the dementia unit, where 12 separate incidents of resident-to-resident abuse were identified. Multiple residents with severe cognitive impairments and behavioral issues were involved in repeated altercations, including inappropriate sexual contact, physical aggression, and verbal threats. Despite documented histories of aggressive and inappropriate behaviors, the facility did not consistently implement or maintain effective supervision or interventions to prevent further incidents. For example, a resident with a known history of sexually inappropriate behavior and aggression was only placed on increased supervision temporarily after incidents, but this was not sustained, allowing further abuse to occur. Specific incidents included a resident being observed touching another resident inappropriately, repeated physical altercations resulting in injuries such as skin tears and scratches, and verbal abuse and threats. Staff interviews and record reviews revealed that the facility was aware of the risks posed by certain residents but failed to take adequate steps to separate residents or provide continuous supervision as required by their own policies. In several cases, staff reported escalating behaviors and prior warnings, but interventions such as one-to-one monitoring were either not implemented or not maintained, leading to repeated incidents. The facility's documentation and staff statements also showed inconsistencies and a lack of thorough investigation into reported incidents. Some staff statements were unsigned, and there were discrepancies between staff accounts and administrative conclusions. In several cases, administration minimized or dismissed the severity of incidents, citing brief durations or lack of direct observation, despite multiple staff and resident reports to the contrary. The failure to protect residents from abuse and to follow established policies resulted in a finding of immediate jeopardy, affecting all residents on the dementia unit.

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 timely report and thoroughly investigate multiple allegations of abuse, including sexual, physical, and verbal abuse, involving residents with severe cognitive impairments. Several incidents were not reported to the State Survey Agency within the required timeframes, and law enforcement was not notified in cases of alleged sexual assault. The facility also did not ensure that residents were protected from further potential abuse during the investigation period, as required by their own policies. Staff interviews and record reviews revealed that supervision and interventions for residents with known aggressive or inappropriate behaviors were inconsistently implemented and not maintained to prevent recurrence. One resident with a history of dementia, agitation, and aggressive behaviors was involved in repeated incidents of physical and sexual abuse toward other residents. Despite documented observations and staff reports of inappropriate touching and physical altercations, the facility administration often dismissed these allegations, citing insufficient evidence or the brevity of the incidents as reasons for not reporting or investigating further. Staff statements were inconsistently collected, often unsigned, and the cognitive status of the residents involved was not adequately considered during interviews. In some cases, care plans were not updated to reflect new risks or to implement protective measures for vulnerable residents. The facility's failure to act in accordance with its abuse prevention policies resulted in a pattern of unreported and uninvestigated abuse allegations, leaving residents at continued risk. The lack of immediate protective actions, incomplete documentation, and disregard for staff observations contributed to the finding of Immediate Jeopardy, affecting all residents on the dementia unit. The deficient practice persisted as the facility continued to implement its action plan, but the initial failures were not mitigated during the period under review.

Penalty

No penalty information released

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

Summary

The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration did not implement procedures based on the facility's Abuse, Neglect, and Exploitation policy, despite being aware of multiple residents with unpredictable and aggressive behaviors. Staff repeatedly informed administration about ongoing physical aggression, sexual behaviors, and escalating incidents among residents, but these reports were not acted upon appropriately. Several incidents of resident-to-resident altercations, physical assaults, and inappropriate sexual contact were not reported to the State Survey Agency within required timeframes and were not thoroughly investigated. Documentation and staff statements regarding these incidents were inconsistent, and administration often dismissed allegations based on their own review of camera footage or by questioning the validity of staff reports. Residents with significant behavioral health needs, including those with histories of physical and sexual assault, were not adequately protected. For example, a resident with severely impaired cognitive skills and limited mobility, who had a history of trauma, was subjected to inappropriate sexual contact by another resident known for sexually inappropriate and aggressive behaviors. Despite care plans and trauma assessments indicating the need for increased supervision and interventions, the facility did not implement or maintain adequate measures to prevent further abuse. Staff reported being unable to provide 1:1 supervision due to staffing shortages and felt unsupported by administration, who did not respond to or investigate incidents as required. A pervasive culture of fear and retaliation was reported among staff, who expressed concerns about being terminated or suspended for reporting abuse or cooperating with surveyors. Staff described the dementia unit as chaotic, with insufficient training and high turnover, and reported that administration discouraged open communication and reporting of incidents. Staff statements were often collected by administration in a manner that did not allow for verification or accuracy, and some staff were disciplined or terminated for not aligning with administration's narrative. These failures resulted in multiple deficiencies, including findings of Immediate Jeopardy, and affected the safety and well-being of all residents on the dementia unit.

Removal Plan

• Residents reviewed for proper placement on Dementia Unit. Residents identified as needing placement with active efforts for discharge to proper community placement.
• Admission team to conduct additional review for possible placement on Dementia Unit to ensure resident aligns with unit's goals and bed availability is appropriate.
• Employee Feedback form initiated to solicit feedback and solutions when staff see an opportunity and desire to remain anonymous or not.
• Facility initiated new tool from the Center of Excellence Post-Behavior Root Cause Analysis (RCA) form, providing additional insight to residents when behaviors occur. This tool utilizes a team approach (huddle) to gain knowledge of behaviors/events. Facility Staff completed this tool for those residents with known behaviors on the dementia unit to further care plan any additional interventions that may reduce resident to resident interactions and behaviors.
• Regional Human Resources Director initiated interviews with current staff.
• Administrator of Sister Facility, Social Services background, provided remote review of focused Dementia Unit residents to provide additional suggestions and feedback for interventions, and providing on-site support to assist efforts.
• Current Nursing Home Administrator was placed on administrative leave by Director of Operations.
• Re-Education by Director of Operations to Interdisciplinary Team (Dementia Unit focused) to include use of Post-Behavior Root Cause Analysis (RCA) Form.
• Re-Education by IDT to Facility Staff to include use of Employee Feedback Form. Facility Staff that have not yet received the re-education, and required to complete, will have these items completed prior to their next scheduled shift.
• Monitor: Review of Post-Behavior Root Cause (RCA) completion for behaviors.
• Use of Employee Feedback Form reviewed upon receipt.
• Ad Hoc QAPI held to discuss the above actions taken.

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 treatment and services to a resident diagnosed with unspecified dementia, agitation, depression, anxiety disorder, and visual hallucinations. The resident exhibited significant behavioral symptoms, including aggression, resistance to care, verbal and physical altercations with staff and other residents, and sexually inappropriate behaviors. Despite these ongoing issues, the facility did not conduct a comprehensive assessment to identify the root causes or triggers of the resident's behaviors, nor did it develop or implement a person-centered care plan with individualized, non-pharmacological interventions. The care plan lacked specific interventions tailored to the resident's needs, and staff were not provided with adequate guidance or training to manage the resident's complex behaviors. Documentation in the Treatment Administration Records (TAR) was inconsistent and incomplete, with staff failing to accurately monitor or record the resident's behaviors as required. Staff interviews revealed a lack of understanding regarding the resident's hallucinations and behavioral symptoms, and there was no evidence of a root cause analysis being performed to address the behavioral changes. The facility's approach to supervision was insufficient, as 1:1 supervision was expected to be provided by staff already assigned to the unit, rather than by a dedicated staff member, resulting in inadequate monitoring and intervention during behavioral incidents. Additionally, staff on the dementia unit had not received specialized dementia training, and there was high turnover among staff, further impacting the quality of care. Multiple staff members reported feeling unsupported and overwhelmed, with insufficient resources to provide the required supervision and care. The facility did not investigate incidents or provide staff with the necessary tools to implement person-centered interventions, and the care plan failed to identify or address environmental triggers that may have contributed to the resident's behavioral expressions.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective pest control program to address the presence of flies throughout the building, as evidenced by observations, interviews, and record reviews. Multiple residents with intact cognition reported ongoing issues with flies in their rooms and common areas, particularly when food was present or garbage was not promptly removed. Surveyors directly observed flies in resident rooms, hallways, and near the kitchen, as well as fly swatters kept by residents' beds for personal use. Staff interviews confirmed that the fly problem was persistent and had been reported to management multiple times, but staff were unsure if any effective action had been taken. The facility's pest control policy required the use of various methods, including engagement with an outside pest service, to control seasonal pests such as flies. However, maintenance staff indicated that the pest control company was not contacted regarding the current fly issue, as they believed the number of flies was typical for the facility. Instead, staff relied on manual methods such as using fly swatters and bug zappers at main exits. The issue was particularly pronounced in areas near exterior doors and dumpsters, and both residents and staff expressed frustration with the ongoing presence of flies despite repeated reports and 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

Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as required. Multiple residents reported that their rooms were not cleaned daily, and that garbage was not always emptied, resulting in unpleasant odors. Observations confirmed these reports, with surveyors noting a urine odor in one resident's room, a dried yellow stain on another resident's bed sheet, and full garbage containers. Residents stated that while they sometimes notified staff about the lack of cleaning, the response was inconsistent and did not ensure regular cleaning as per facility policy. Interviews with facility staff, including a housekeeper, LPN, and CNA, corroborated the residents' accounts. Staff acknowledged that housekeeping did not always clean resident rooms daily, and that nursing staff sometimes had to clean up messes themselves. The housekeeper explained that while daily cleaning should include emptying garbage, sweeping, and wiping down surfaces, this was not always completed. Deep cleaning was reportedly done monthly, but there were instances where rooms were not cleaned for several days. The housekeeper also noted that certain spills, such as body fluids over a certain amount, were not cleaned by housekeeping but left for facility staff, who could not always address them promptly. A review of facility grievance records from May to August revealed 11 grievances related to unclean rooms, with investigations confirming that rooms were not cleaned as required. The facility's housekeeping and laundry services were outsourced, and the district manager stated that daily cleaning should include disinfecting surfaces, sweeping, mopping, and cleaning bathrooms. However, there was no documentation or audit trail to verify that these tasks were consistently performed. The lack of regular cleaning and failure to maintain a homelike environment had the potential to affect all residents in the facility.

Penalty

No penalty information released

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

Summary

The facility failed to report multiple allegations of abuse, neglect, and resident-to-resident altercations to the State Survey Agency as required by its own policy and federal regulations. In several instances, staff immediately notified the Nursing Home Administrator (NHA) of alleged incidents, including physical and verbal abuse, sexual abuse, and physical threats among residents. Despite these reports, the NHA did not submit the required notifications to the State Survey Agency within the mandated timeframes, which are two hours for abuse or serious bodily injury and 24 hours for other incidents. In some cases, law enforcement was also not notified as required. Specific incidents included staff witnessing one resident repeatedly hitting another with a pillow, a resident making threatening statements, and a resident physically assaulting another, resulting in a skin tear. There were also allegations of sexual abuse, where staff observed inappropriate touching or situations suggestive of sexual misconduct. In each case, the NHA either determined that the incident did not occur as reported or relied on informal, unsigned staff statements, and therefore did not report the allegations to the State Survey Agency. The facility maintained informal 'soft files' with typed but unsigned staff statements for some incidents, while in other cases, no documentation was available. Additionally, there was an instance where the facility conducted an investigation into a resident-to-resident altercation but submitted the completed investigation to the State Agency late due to the NHA's personal emergency. The report also notes that some staff failed to immediately notify the NHA of an incident, and documentation in the electronic medical record reflected staff perceptions rather than objective facts. The NHA acknowledged responsibility for submitting facility-reported incidents but stated that, based on witness statements, the incidents did not warrant reporting.

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 incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and evaluation report into the assessment, care planning, and transitions of care for a resident with intellectual/developmental disabilities and mental illness. The PASARR Level II report specified that the resident required an intensive, continuous treatment program called specialized services, including a thorough assessment by a qualified intellectual disabilities professional (QIDP), physical/occupational therapy, monitoring for nonverbal communication, and person-centered interventions to address behavioral disturbances. Despite these recommendations, the facility's care plan did not reflect the specific person-centered interventions or specialized services outlined in the PASARR report. The resident had a complex medical history, including autistic disorder, intellectual disabilities, epilepsy, mood and anxiety disorders, and required a gastrostomy. The care plan included some general interventions for behaviors and mood but did not address the specialized services or recommendations from the PASARR Level II, such as involvement of a QIDP, targeted therapies, or specific behavioral supports. Staff interviews revealed a lack of awareness and training regarding specialized services, and key personnel, including the psychologist, occupational therapist, and social workers, were not involved in developing or implementing a specialized care plan for the resident. Additionally, the facility did not consistently monitor or document the resident's behaviors in relation to psychotropic medication use, and there was no evidence of ongoing psychiatric evaluation or review after the initial assessment. Staff reported challenges in managing the resident's behaviors, frequent disruptive incidents, and a lack of clear guidance or interventions. The absence of a coordinated, person-centered approach as recommended by the PASARR Level II report contributed to ongoing behavioral issues and a chaotic environment on the unit.

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

Three residents did not receive necessary care and treatment as ordered or according to their preferences and goals. One resident with a history of paraplegia and a chronic Foley catheter exhibited symptoms consistent with a urinary tract infection, including cold sweats, shivers, increased lethargy, and hypotension. Although a nurse practitioner ordered a urinalysis with culture, the sample was not processed, and the order was later cancelled by the Director of Nursing, who incorrectly determined the resident did not meet infection criteria. Review of the resident’s history and symptoms indicated that the criteria for catheter-associated urinary tract infection were met, and the urinalysis should not have been cancelled. Additionally, the same resident had a wound culture ordered for an infected wound, but the specimen was improperly stored in the refrigerator, resulting in the lab not processing it. A new specimen was not obtained until several days later, delaying appropriate treatment for the infection. Another resident was admitted with multiple surgical wounds to the left leg following a traumatic injury. Upon admission, there was no comprehensive assessment of the surgical incisions, and the care plan did not specify the locations or details of the wounds. Hospital discharge instructions required daily dressing changes and monitoring for drainage, but there were no corresponding orders or documentation of such care being provided until a week after admission. The first comprehensive wound assessment and appropriate treatment orders were not implemented until several days after admission, resulting in a lack of monitoring and treatment for the surgical wounds during that period. A third resident, who is severely cognitively impaired and dependent for all care, was observed during morning care to have two clean incontinent briefs placed on them by CNAs. Staff interviews revealed that double briefing is only to be done if it is part of the resident’s care plan or at the request of the resident or their representative, and this should be documented. Review of the care plan and Kardex showed no intervention directing staff to double brief this resident, indicating that care was not provided according to the resident’s plan or preferences.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice for three residents. One resident was admitted with a hospital-acquired stage 2 pressure injury to the sacrum, but did not receive a comprehensive assessment or treatment for the injury until several days after admission. Documentation was unclear regarding the staging of the wound, and there was no evidence of monitoring or treatment orders in place until days later. Staff interviews revealed a lack of awareness about the presence of the pressure injury, and the care plan and CNA care card did not specify the wound or interventions related to it. Another resident was admitted with a pressure injury that was incorrectly staged as a stage 2 when it was actually a stage 3. No treatment was initiated for three days after admission, and the care plan included incomplete instructions for interventions such as the use of barrier cream. When the wound worsened and increased in size, the treatment plan was not revised, and the same intervention was continued despite the lack of improvement. Documentation of wound care was also inconsistent, with several shifts lacking evidence that treatments were completed as ordered. A third resident developed a blister on the thumb that progressed to a stage 3 pressure injury, apparently related to the use of a palm guard. There were no interventions in place prior to the development of the injury, and after the injury occurred, the interventions implemented were not clearly defined. The care plan was not updated to reflect the new wound, and there was no documentation of a therapy referral or comprehensive assessment of the wound. These deficiencies were identified through interviews, record reviews, and observations, and were not addressed in a timely or systematic manner as required by facility policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that nursing staff had the appropriate competencies and skills to safely administer medications, as evidenced by an incident involving a newly graduated LPN who administered 15 units of lispro insulin to a resident with type II diabetes mellitus, instead of the prescribed 4 units. The resident's blood sugar was checked at 185, and the error was discovered after the medication was given. The resident did not experience any adverse effects during the monitoring period following the incident. Interviews revealed that the LPN was still in orientation and was supposed to be supervised by another nurse, but due to a staff call-off, she was assigned her own cart and responsibilities without documented evidence of completed orientation or skills check-off. Both the administrator and the orienting nurse confirmed that the facility did not have a formal process for documenting orientation or competency check-offs prior to allowing new nurses to work independently. Facility policies and assessments indicated that such check-offs were required, but these were not followed in practice.

Penalty

No penalty information released

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

Summary

A significant medication error occurred when a resident with type II diabetes mellitus, who was assessed as severely cognitively impaired, was administered an incorrect dose of insulin. The physician's orders specified that the resident should receive 15 units of insulin glargine at bedtime and a sliding scale dose of insulin lispro before meals and at bedtime, with 4 units indicated for a blood sugar reading of 185. However, the resident was mistakenly given 15 units of insulin lispro instead of the prescribed 4 units. The error was identified shortly after administration when the LPN realized the mistake upon returning to the medication cart. The incident was reported immediately to the night supervisor, and the responsible party and medical provider were contacted. The resident was monitored for adverse effects, but no negative outcomes were observed during the monitoring period. The deficiency was attributed to the failure to follow the physician's orders during insulin administration.

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

During wound care for a resident on Enhanced Barrier Precautions (EBP), two Licensed Practical Nurses (LPNs) failed to wear gowns as required by the facility's infection control policy. The policy specifies that gowns and gloves must be used during high-contact care activities, such as wound care, for residents with wounds or medical devices like feeding tubes, urinary catheters, or tracheostomy tubes. Despite an EBP sign posted on the resident's door and the resident's care plan indicating the need for EBP due to impaired immunity and multiple invasive devices, the LPNs only performed hand hygiene and donned gloves, omitting the use of gowns. The resident involved had chronic respiratory failure, peripheral vascular disease, severe cognitive impairment, and was dependent on multiple medical devices, including an indwelling urinary catheter, feeding tube, and tracheostomy. The LPNs acknowledged after the incident that they should have worn gowns, attributing the oversight to the location of the gowns being on the other side of the hall. The Director of Nursing confirmed that EBP protocols require gown and glove use for hands-on care involving wounds or invasive devices.

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 sufficient supply of clean linen was readily available for resident care in three of four linen closets observed across both floors. Multiple alert and oriented residents, including members of the Resident Council, reported that the facility was often low on linens such as towels and washcloths, resulting in delays for showers and personal care. Some residents resorted to stockpiling linens in their rooms to avoid running out. Observations confirmed that linen carts in several units contained only a small number of towels and washcloths, insufficient for the needs of the residents. Interviews with CNAs and an LPN corroborated the shortage, stating that they sometimes had to wait for laundry to deliver more linens, causing delays in resident care, particularly in the mornings and on weekends. The Laundry Manager was unaware of any ongoing issues and stated that linen was distributed twice daily based on census calculations. The DON confirmed there was no policy for maintaining sufficient laundry for resident use, and the Administrator noted that linens are counted daily and more can be ordered if needed, but acknowledged losses due to linens being thrown away or lost.

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 safe environment for a resident, identified as R1, who was at moderate risk for falls due to a history of traumatic brain injury and significant cognitive impairment. R1 was totally dependent on staff for all activities of daily living and required assistance from at least two staff members for bed mobility. Despite these needs, a certified nursing assistant (CNA1) provided care to R1 without the assistance of another staff member, contrary to the resident's care plan. During the provision of routine care, R1 fell from his bed, resulting in significant injuries, including a broken hip and a large laceration on his forehead that required nine staples. The facility's policy on accidents and supervision mandates that the resident environment should be as free of accident hazards as possible and that adequate supervision should be provided based on the resident's assessed needs. However, the failure to adhere to the care plan and provide the necessary supervision led to the accident. The facility's investigation confirmed that CNA1 did not follow R1's established plan of care, which required two staff members for bed mobility. This oversight directly contributed to the resident's fall and subsequent injuries. The incident highlights a lapse in following the care plan, which was acknowledged by the facility's administration 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 report an alleged violation concerning a resident's care to the State Agency within the required timeframe. A family member of a resident expressed concerns about the resident's incontinence care on a specific date. The facility was required to submit a report of the investigation to the State Agency within five working days of the initial allegation. However, the report was submitted late, on a date beyond the required timeframe. The Nursing Home Administrator acknowledged the delay and attributed it to technical issues with the submission process. The resident involved is an elderly individual with multiple diagnoses, including dysphagia, dementia, stroke, and muscle contracture. The resident is dependent on staff for various activities of daily living and is always incontinent of bowel and bladder. The care plan for the resident includes specific interventions for incontinence care, which were discussed with the resident's family. Despite the facility's documentation of care provided on the day in question, the family alleged that no care was given throughout the day. The facility's investigation found no concerns from staff or resident statements, and a skin check revealed no issues.

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 charge nurse was assigned for each shift, potentially affecting all 95 residents. During a review of staffing schedules from January to March 2024 and July 2024, it was found that the schedules did not indicate which nurse was assigned as the charge nurse for each shift, nor did they specify whether each nurse was a Registered Nurse or Licensed Practical Nurse. Scheduler-E, when interviewed, admitted to not knowing the requirement to indicate the charge nurse on the schedule, relying instead on personal knowledge of who it was for each shift. Director of Nurses (DON)-B also confirmed that each of the four wings had its own charge nurse, but this was not documented on the schedule. On a subsequent review of the schedule for 7/30/24, it was noted that the nurses' titles and the designation of a charge nurse per shift were included. The findings were discussed with the Nursing Home Administrator and DON, but no additional information was provided to explain the lack of identification of a charge nurse on the schedule.

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 prepared to conserve nutritive value and flavor for residents on a pureed diet. During an observation, Cook-C was seen preparing pureed Salisbury steak without following the standardized recipe. Cook-C added an unmeasured amount of water and instant potatoes to the pureed Salisbury steak, indicating it was too thin. Additionally, Cook-C pureed carrots without a recipe, using an unmeasured amount of liquid from a can. This preparation method was not in accordance with the facility's policy, which requires following standardized recipes for pureed diets. The Food Service Director (FSD)-D confirmed that Cook-C should have been following the recipes for pureed food. However, a recipe for pureed carrots was not available in the recipe book at the time of preparation, and Cook-C did not measure the ingredients. The facility's policy on Pureed Diet Preparation and Portion Control mandates the use of standardized recipes, which was not adhered to in this instance. The deficiency was discussed with the Nursing Home Administrator and Director of Nurses, but no additional information was provided to explain why the recipes were not followed.

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 complete a significant change in status assessment MDS for a resident who elected to receive hospice services. The resident, who was admitted with Alzheimer's Disease, Dementia, cognitive communication deficit, and unspecified psychosis, was rarely or never understood according to their annual MDS. On the date the resident began hospice services, the facility did not complete the required Significant Change MDS. A surveyor noted that the MDS was in progress but not completed or submitted over a month later. The MDS Coordinator acknowledged that significant changes are discussed in morning reports and stated that the MDS should be completed within 14 days of the change. However, the MDS for this resident was not completed in a timely manner, with different sections being completed on various dates, and the surveyor highlighted this concern to the Director of Nursing.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received proper treatment and assistive devices to maintain their hearing abilities. The resident, who was admitted with a primary diagnosis of dementia, was noted to have adequate hearing and did not use hearing aids according to their admission Minimum Data Set (MDS). However, during an interview, the surveyor observed that the resident had significant hearing difficulties and did not have hearing aids. An order for an audiology consult regarding hearing aids was placed on 01/17/2024, but there was no documentation of its completion. Another order dated 03/11/2024 indicated the need for an audiology setup due to hearing difficulty, yet the appointment remained pending as of 07/23/2024. Despite a progress note acknowledging the resident's hearing issues, the audiology consult was not arranged until a fax was sent on 07/31/2024, following the surveyor's request for 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 ensure that a resident with limited range of motion received appropriate treatment and equipment to prevent further decline. The resident, diagnosed with Huntington's disease, muscle wasting and atrophy, and muscle weakness, was observed multiple times without the prescribed hand splint, which was intended to be worn for 12 hours, twice a day. The care plan specified the use of hand splints for four hours at a time, but observations on several occasions revealed the resident's hand was not splinted and was clenched into a fist, indicating a lack of adherence to the care plan. Interviews with staff revealed confusion and miscommunication regarding the whereabouts and application of the hand splint. A CNA mentioned the splint was in the resident's drawer, while an LPN stated it had been sent to laundry due to a spill, yet the laundry manager could not locate it. The rehabilitation manager later confirmed the splint was in the resident's room. Despite these findings, no additional information was provided to explain why the resident did not receive the necessary treatment and equipment to maintain or improve range of motion.

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 an indwelling catheter received appropriate care to prevent urinary tract infections. The facility's policy on catheter care, revised on 10/16/2023, outlines specific steps for cleaning the genital area and catheter tubing. However, during an observation on 08/01/2024, a surveyor noted that a CNA did not follow these procedures correctly. The CNA used a washcloth to clean the resident's genitals, starting at the urethral meatus and moving down to the base of the penis. After obtaining a new washcloth, the CNA began cleaning from the base of the penis and in between the thighs, then used the same washcloth to clean the urethral meatus and catheter tubing, which is inconsistent with the facility's policy. The resident involved, who has a diagnosis of neuromuscular dysfunction of the bladder, acute cystitis, and dementia, was admitted to the facility with an indwelling catheter. The resident had a history of hospitalization for urosepsis and a recent positive urine culture requiring intravenous antibiotics. The surveyor intervened during the observation and later informed the Nursing Home Administrator and Director of Nursing about the improper catheter care provided to 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 ensure that residents receiving enteral feeding were provided with appropriate services to prevent complications. For one resident, there was a discrepancy between the enteral feeding orders and what was documented in the medical record, leading to a significant weight loss. The resident had orders for enteral feeding seven times a day, but the medical record showed it was administered five times a day. This discrepancy resulted in a reduction of water flushes, which are crucial for hydration, and there was no documentation or communication with the Registered Dietitian (RD) regarding the specific formula and water flushes provided. The RD's documentation did not accurately reflect the resident's actual feeding regimen, and the resident experienced a significant weight loss over two months without timely notification to the physician or dietitian. Another resident also experienced issues with enteral feeding orders not correlating with the RD's documentation. The resident's orders for water flushes did not match the feeding schedule, leading to potential dehydration. Observations revealed the resident had dry lips and a buildup around the mouth, indicating possible dehydration. The RD acknowledged the discrepancy in the orders and planned to update the medical record after physician approval. However, the resident continued to show signs of dehydration, and the facility's statement attributed the dryness to mouth breathing rather than addressing the incorrect fluid administration. Both cases highlight a lack of communication and coordination between nursing staff and the dietitian, resulting in residents not receiving the correct amount of nutrition and hydration. The facility's policies on feeding tubes and hydration were not followed, leading to discrepancies in feeding schedules and water flushes. The failure to accurately document and communicate the residents' feeding regimens and hydration needs contributed to the deficiencies observed by the surveyors.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident had bed linens in good condition that properly fit the bed, as observed by surveyors. During two separate observations, the resident was found lying on a bed with a fitted sheet that did not cover the entire mattress. On one occasion, the resident's head was directly on the mattress with the pillow off to the side, and on another occasion, the resident's lower body was directly on the mattress. The fitted sheet was not adequately covering the bolstered air mattress, indicating a deficiency in providing a safe and comfortable environment for the resident. Interviews with facility staff revealed that there were bariatric fitted sheets available, which should have fit the resident's mattress. However, the staff did not consistently keep the fitted sheets organized, leading to a mix-up between regular and bariatric sheets. The Laundry Manager confirmed that the bariatric sheets were marked with red stitching for identification, but the staff's failure to use the correct sheets resulted in the observed deficiency. The Nursing Home Administrator and Director of Nursing were informed of the issue, but no further information was provided at that time.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with pressure injuries. The resident, who had a history of traumatic brain injury, quadriplegia, and other significant medical conditions, developed two blisters on their left hand after staff removed a hand splint. The comprehensive care plan for the resident did not include interventions for the use of hand splints, and the treatment administration record (TAR) was not updated to document when the hand splint or palm guard should be applied. The facility's policy on pressure injury prevention and management emphasizes the importance of a systemic approach, including prompt assessment, treatment, and modification of interventions as needed. However, the resident's care plan and TAR were not revised after the blisters developed, and there was no order for the palm guard to be used when the splints were not in place. Staff continued to sign the TAR, indicating that the hand splints were being applied every four hours, despite the resident's left hand splint needing to be on hold until the blisters healed. Interviews with the wound doctor, wound nurse, and rehab manager revealed that the blisters were likely caused by the hand splints, and it was recommended that the left hand splint be held until the wounds healed. Despite these recommendations, the care plan and TAR were not promptly updated to reflect the necessary changes, leading to continued confusion among staff about the resident's current treatment plan. The lack of documentation and communication regarding the resident's care plan and TAR contributed to the deficiency identified 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 adequate supervision for a resident, identified as R37, during meal times to prevent choking. R37 has a diagnosis of schizophrenia and requires a pureed diet with close supervision due to dysphagia, as recommended by a speech therapist. The resident's care plan specifies the need for constant supervision while eating, to be seated upright, and to take small bites with liquid washes every 4-5 bites. Despite these requirements, R37 was observed eating breakfast alone in their room without staff supervision. Interviews with facility staff revealed a lack of consistent adherence to the supervision requirements for R37. A CNA mentioned that R37 typically eats breakfast in their room and is checked on periodically, indicating a misunderstanding of the need for constant supervision. The Director of Nurses acknowledged that R37 is usually supervised during meals, even in their room, but this was not the case during the surveyor's observation. The Unit Manager, new to the role, was unaware of R37's specific meal supervision needs and stated they would investigate further. This lack of supervision was communicated to the Nursing Home Administrator and Director of Nurses during the facility exit meeting.

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 assessments accurately reflected the residents' status concerning the Preadmission Screening and Resident Review (PASRR) for five residents. These residents, who had diagnoses of mental disorders such as schizophrenia, depression, bipolar disorder, anxiety, and unspecified psychosis, had completed PASRR Level I and Level II evaluations. However, this information was not correctly entered into the Minimum Data Set (MDS) comprehensive assessment, specifically in Section A1500, which asks if the resident has been evaluated by Level II PASRR and determined to have a serious mental illness or related condition. The MDS assessments for these residents incorrectly documented 'no' to this question, despite their diagnoses and completed PASRR evaluations. The issue was identified during a surveyor's interview with the MDS Coordinator (MDS-O), who stated that Social Services should handle Section A of the MDS due to their knowledge of PASRRs. MDS-O mentioned that the residents' Level I and Level II PASRRs might not have been scanned into their records, which is why they were not seen. However, the surveyor confirmed that all PASRRs were visible. The deficiency was further discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the incorrect coding of the MDS assessments and the need for accurate documentation of PASRR evaluations.

Penalty

Fine: $54,054

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

Summary

The facility failed to provide necessary treatment and services to prevent the development of pressure injuries and promote healing for three residents. One resident, who was admitted with no pressure areas, was identified as being at moderate risk for pressure injury development. However, the facility did not develop a skin integrity care plan until the resident developed an unstageable pressure injury on the sacrum. The care plan interventions were not person-centered, and there was a lack of monitoring of the resident's food, fluid intake, and repositioning. Additionally, upon the resident's return from hospitalization, the sacrum pressure injury was not comprehensively assessed until a week later. Another resident's pressure injury on the left buttock was not comprehensively assessed until five days after admission, and the care plan did not include individualized interventions to prevent the decline of the pressure injury. A third resident's air mattress was not set according to their weight, leading to the decline of a pressure injury from Stage 2 to Stage 3, which was identified as actual harm. The facility's policy on pressure injury prevention and management was not followed, as evidenced by the lack of prompt assessment and treatment, failure to monitor the impact of interventions, and failure to modify interventions as appropriate. The facility's failure to develop and update care plans, monitor residents' conditions, and provide individualized care contributed to the development and worsening of pressure injuries, resulting in a finding of Immediate Jeopardy.

Penalty

Fine: $54,054

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 catheter care and bowel management for a resident, leading to urinary tract infections and bowel incontinence. The resident, who was admitted with a Foley catheter for wound protection, did not have a comprehensive care plan or physician orders for catheter care and monitoring. Despite being assessed as continent of bowel and bladder upon admission, the resident became incontinent of bowel, and there was no toileting program or monitoring in place to address this change in condition. The facility's policies on indwelling catheter use and incontinence were not followed, as there were no documented assessments or care plans for the resident's catheter use. The resident developed two urinary tract infections, and there was a lack of documentation regarding catheter care, including the size of the catheter, catheter changes, and monitoring of the catheter insertion site. Additionally, the resident's bowel habits were inconsistently documented, and there was no care plan to address bowel continence or incontinence. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's bowel and catheter care. Certified Nursing Assistants (CNAs) did not consistently report the resident's bowel movements or catheter care, and the Director of Nursing (DON) was unaware of the resident's bowel habits. The facility did not have a bowel monitoring policy, and the resident's care plan did not include specific interventions for bowel or catheter care, contributing to the resident's decline in continence and the development of urinary tract infections.

Penalty

Fine: $54,054

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 grievances and recommendations discussed during Resident Council meetings were acted upon promptly and did not demonstrate their response and rationale for such requests. The grievance log generated from these meetings lacked essential details, including the name of the resident filing the grievance, grievance specifics, how the grievances were investigated, and the outcome of each investigation. This deficiency has the potential to affect all 98 residents residing at the facility. During the Resident Council meetings, several issues were raised by the residents, including administrative, nursing, maintenance, dietary, housekeeping, and activity department concerns. Residents reported delays in receiving food trays, staff using earbuds and personal phones during care, and issues with personal laundry and housekeeping practices. Additionally, residents expressed dissatisfaction with the timeliness of responses to their grievances and the lack of follow-up on previously raised concerns. Interviews with residents and staff revealed that the facility's grievance process was not effectively managed. Residents reported that grievances were not consistently addressed or resolved, and there was a lack of communication regarding the status of their complaints. The facility's grievance officer and other management staff were aware of the grievances but failed to ensure timely and appropriate responses, leading to ongoing dissatisfaction among residents.

Penalty

Fine: $54,054

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 notice of resident rights and services prior to or upon admission for all 40 residents reviewed. This deficiency was identified through interviews and record reviews conducted by the surveyor. The facility's policy requires that all residents have a signed and dated admission agreement on file, which includes a notice of rights and services. However, the surveyor found that none of the residents had a signed admission agreement at the time of admission. The surveyor's investigation revealed that the facility had transitioned from paper admission agreements to a digital CareFeed program, and it was unclear if the agreements were properly transferred. The Resident Care Coordinator (RCC) responsible for obtaining signatures admitted to the surveyor that there were issues with getting the agreements signed, especially for residents admitted after hours or on weekends. The RCC also mentioned that they had been trying to obtain signatures from residents and their families, but had not received responses. Specific cases highlighted in the report include a resident who was admitted with diagnoses such as hemiplegia, type 2 diabetes mellitus, and major depressive disorder, who did not have a signed admission agreement on file. Another resident's Power of Attorney for Healthcare was not provided with the admission agreement until the day before discharge, and the POA refused to sign it. The Nursing Home Administrator acknowledged the issue and stated that the facility was aware of the problem and working to correct it.

Penalty

Fine: $54,054

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 three out of four incidents to the State survey agency and/or Nursing Home Administrator within the required timeframe, potentially affecting several residents. One incident involved a resident with dementia, congestive heart failure, atrial fibrillation, anxiety, hypertension, and bipolar disorder, who was accused of inappropriate behavior towards another resident. The incident was not reported to the Nursing Home Administrator and State agency immediately, as required by the facility's policy, which mandates reporting within two hours if the allegation involves abuse. Another incident involved a possible drug diversion, where discrepancies with controlled substance medications were noted for several residents. The issue was not reported to the Nursing Home Administrator and State agency within 24 hours, as required. The delay in reporting was attributed to a staff member wanting more information before escalating the concern, which was against the facility's policy of reporting any concerns immediately. Additionally, a resident with a fully intact cognitive status accused staff of misappropriation and assault after an incident involving self-inflicted injury. The allegation was not reported to the State agency within the required 24-hour timeframe. The delay was due to the Nursing Home Administrator not being informed of the incident until two days later, resulting in a late report to the State agency.

Penalty

Fine: $54,054

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 confidential medical records were safeguarded against loss, destruction, or unauthorized use, potentially affecting up to 30 current residents. During a surveyor's tour of the medical records archive room, it was observed that ten cardboard boxes containing approximately 30 current and previous resident medical records were stored on the floor in the basement. These boxes were positioned directly below a water fire sprinkler, and the boxes were open without lids, leaving the records vulnerable to water damage. When questioned by the surveyor, Medical Records-OO acknowledged that if the fire sprinkler were activated, the records would be ruined. Medical Records-OO also confirmed that the medical records should be stored off the floor and secured in a covered metal cabinet to prevent such damage. During the exit meeting, the surveyor informed the Nursing Home Administrator and the Director of Nursing about these findings, but no additional information was provided to explain why the facility did not ensure the safeguarding of these confidential medical records.

Penalty

Fine: $54,054

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 the rights of two residents, R7 and R16, a married couple, to share a room despite both expressing their desire to do so. R7, who has moderate cognitive impairment due to dementia, and R16, who is cognitively intact, were living in separate rooms on different floors. R7 was placed on the dementia unit upstairs, while R16 was living downstairs. Both residents communicated their wish to share a room with each other to the surveyor, but the facility did not facilitate this arrangement. The facility's policy supports residents' rights to share a room with their spouse if both consent, yet this was not implemented in the case of R7 and R16. The Director of Social Services (DSS) and the Social Worker (SW) were aware of R7's request to live with her husband, but no action was taken to address this. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were also informed of the situation, but the facility cited R7's dementia and potential safety issues as reasons for not allowing the couple to share a room. However, there was no documentation in the residents' medical records regarding any discussions about room sharing. R16 expressed frustration to the surveyor about the facility's inaction, stating that he had spoken to various staff members, including the NHA, about the issue. Despite his efforts, the facility did not make arrangements for the couple to live together. The surveyor noted that the facility did not provide any additional information or documentation to justify their decision not to accommodate the couple's request, resulting in a deficiency in honoring the residents' rights.

Penalty

Fine: $54,054

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

Summary

The facility failed to promptly notify the state mental health authority after a significant change in a resident's mental health condition. The resident, who was diagnosed with bipolar disorder, began receiving Depakote Delayed Release Sprinkles 250 mg twice a day. Despite this significant change, the facility did not submit a Level 1 PASARR until several months later, and the submission did not include the new diagnosis or medication. This delay and omission were contrary to the facility's policy, which requires prompt referral to the state authority for a Level II resident review when a resident exhibits a newly evident serious mental disorder. The deficiency was identified during a surveyor's review of the resident's records and interviews with the Director of Social Services (DSS). The DSS acknowledged the oversight, noting that the initial PASARR form lacked a submission date and did not mention the bipolar disorder or Depakote medication. The DSS also indicated that the Level 1 PASARR should have been completed shortly after the diagnosis was made. The surveyor expressed concerns about the untimely submission and incomplete information on the PASARR form, highlighting the facility's failure to adhere to its own policy and regulatory requirements.

Penalty

Fine: $54,054

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 a resident who was dependent on staff for care. The resident, who was admitted with diagnoses including Anoxic Brain Damage and Coma, was observed multiple times with long fingernails pressing into her palms due to bilateral hand contractures. This condition was noted on several occasions over two days, with no protective measures in place to prevent skin injury. The resident's care plan specifically indicated that her nails should be kept short to prevent injury, yet this intervention was not followed. The Director of Nurses acknowledged the issue when brought into the resident's room, agreeing that the nails were too long and should be cut. Despite the care plan and CNA care sheet both documenting the need to keep the resident's nails short, the facility did not provide the necessary ADL services. The surveyor informed the Nursing Home Administrator and the Director of Nurses, but no additional information was provided to explain the failure to adhere to the care plan for this resident.

Penalty

Fine: $54,054

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 and appropriate treatment and care for two residents, R3 and R9, according to professional standards of practice and their comprehensive person-centered care plans. R3 was admitted with a right diabetic foot ulcer and a left below-knee amputation surgical incision, but treatments for these conditions were delayed by three days. Additionally, R3's blood pressure, heart rate, and fluid intake were not monitored as per physician orders, leading to a significant change in condition that was not adequately documented or addressed by the facility staff. R9 was admitted with a sacrum surgical wound covered by a wound vac, but the facility did not perform a comprehensive assessment of the wound until five days after admission. The initial assessment failed to include necessary measurements and descriptions, and the wound was not evaluated until the wound doctor conducted rounds. This delay in assessment and treatment was contrary to the facility's protocol, which required immediate evaluation and care planning for new admissions with wounds. The deficiencies in care for both residents were attributed to a lack of proper documentation and follow-through on physician orders. The facility's staff, including the Wound RN and DON, acknowledged the lapses in care and documentation, but no additional information was provided to explain why these failures occurred. The surveyor's findings highlighted significant gaps in the facility's ability to ensure residents received care in line with their medical needs and preferences.

Penalty

Fine: $54,054

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 necessary safety devices and supervision for two residents, R4 and R6, leading to deficiencies in preventing falls and inappropriate behaviors. R4, who was admitted with diagnoses including Anoxic Brain Damage and Coma, was observed multiple times without the required floor mats on either side of her bed, as stipulated in her care plan. This oversight occurred despite a previous incident where R4 slid off the bed, resulting in a hospital evaluation. The Director of Nurses and the assigned CNA were unaware of the requirement for floor mats, indicating a lack of communication and adherence to the care plan. R6, diagnosed with dementia and other conditions, exhibited agitated and sexually inappropriate behavior, which was not adequately supervised to prevent further incidents. Despite a history of resident-to-resident altercations and inappropriate behavior towards staff and other residents, there were no immediate revisions to R6's care plan to increase supervision. The facility's response to R6's behavior was delayed, with a behavior care plan only developed months after the initial incidents. Staff interviews revealed inconsistent awareness and management of R6's wandering and inappropriate behavior, further highlighting the lack of effective supervision. The facility's failure to provide adequate supervision and implement safety measures for R4 and R6 resulted in repeated incidents that could have been prevented. The lack of communication and timely updates to care plans contributed to the deficiencies observed by the surveyors. Despite being informed of these issues, the facility did not provide additional information or corrective actions to address the identified deficiencies.

Penalty

Fine: $54,054

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

Summary

The facility failed to ensure that two residents, R10 and R3, maintained acceptable parameters of nutritional status due to inadequate weight monitoring. R10, who was admitted with multiple diagnoses including chronic kidney disease and diabetes, did not have weights recorded for November 2023 and April 2024, despite the facility's policy requiring monthly weight checks. R10's weight at admission was 277 pounds, and the last recorded weight was 228 pounds, indicating a significant weight change without proper documentation or physician orders for weight monitoring. R3, with a history of conditions such as hypertension and diabetes, also experienced lapses in weight monitoring. The physician's orders required R3 to be weighed daily for three days, weekly for four weeks, and then monthly. However, there were no documented weights for the specified periods in January and February 2024, except for one weight recorded on January 29, 2024. The Director of Nursing acknowledged the absence of charting for R3's weights and confirmed that the licensed nurses should have followed the physician's orders. The facility's failure to adhere to its weight monitoring policy and physician orders resulted in a lack of documented weights for both residents, which could potentially impact their nutritional status. The Director of Nursing was unable to provide a satisfactory explanation for the missing weights, highlighting a deficiency in the facility's compliance with its own guidelines and procedures for monitoring residents' nutritional health.

Penalty

Fine: $54,054

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 administer oxygen to a resident according to the physician's orders. The resident, who was admitted with diagnoses including Anoxic Brain Damage and Coma, was observed multiple times over two days with oxygen running to her tracheostomy at 6 liters per minute, despite physician orders specifying oxygen should be administered at 1-5 liters per minute to maintain oxygen saturation above 90%. The resident's Treatment Administration Records indicated that her oxygen saturation was consistently above 93% during this period. The Director of Nurses confirmed the discrepancy between the observed oxygen administration and the physician's orders.