Mesa Glen 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 deficiency involves the facility’s failure to maintain a complete medical record for one resident when documentation of assistance with eating and oral hygiene was missing for specified shifts. The resident, who had diagnoses including primary arthritis, dementia, and gastro-esophageal reflux disease, was severely cognitively impaired and dependent or requiring substantial/maximal assistance for multiple ADLs, including eating and oral hygiene, per the 2/28/2026 MDS. The resident’s orders included a regular diet, minced and moist, with RNA assistance for feeding at all meals. The care plan documented swallowing problems and required staff to check the resident’s mouth after meals for pocketed food and debris, report findings to the nurse, and provide oral care to remove debris. Another care plan for ADL self-care deficits indicated the resident required staff assistance to eat, had their own teeth, and required oral inspection every shift for oral care. Record review of the Documentation Survey Report for ADLs in February 2026 showed no entries for eating and oral hygiene on the evening shift of 2/2/2026 and the night shift of 2/3/2026. Further review of the medical record found no RNA or CNA documentation that the resident was assisted with dinner and provided oral hygiene on the 2/2/2026 evening shift, or that oral hygiene was provided on the 2/3/2026 night shift. During interviews, a CNA and an LVN stated that staff who assisted the resident with eating were required to document assistance with eating and oral hygiene on the ADL charting every shift or every time care was provided, including meal consumption percentages and related details. In a concurrent interview and record review, the DON confirmed that the ADL documentation for eating and oral hygiene was incomplete for the identified shifts and stated that accurate completion of documentation was important to verify the resident’s health condition and reflect the care provided. The facility’s policy on assisting residents with in-room meals required detailed documentation of meal assistance, including date and time, staff identity, amount consumed, resident participation, special requests, difficulties with feeding, chewing or swallowing, refusals, and interventions, which was not present for the resident on the cited shifts.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to follow infection prevention and control practices related to a clogged shower drain and the handling of bedside urinals. Two residents, one with anorexia nervosa, schizophrenia, and anxiety disorder and another with cellulitis of both legs, lack of coordination, and hypertension, required staff assistance with bathing and toileting. One resident reported taking a shower in the shower room next to the dining room while seated in a shower chair, during which the water did not drain and formed a puddle that the assisting CNA stood in. Another resident, observed in the same shower room on a different day, stated they had to stand in pooled water over a clogged drain during showers and expressed feeling disgusted and concerned about infection. On observation with the Maintenance Director, there was a pool of water over the shower drain, and the Maintenance Director confirmed the drain was clogged. The facility also failed to properly manage and empty bedside urinals for one resident. During observation in the resident’s room, three urinals full of urine were hanging on the foot of the bed, and the resident stated staff had not emptied the urinals all day and that this occurred frequently. The CNA assigned to the resident that shift acknowledged not having emptied the urinals and stated their practice was not to enter the resident’s room when the resident was present unless the call light was activated. The Infection Preventionist stated staff were expected to round on residents every two hours and that the resident’s urinals should be emptied at least every two hours, noting that failure to empty them could result in urine being spilled on the resident or floor. Facility policies indicated that bathrooms, including showers, were to be cleaned and disinfected daily and that if a resident preferred to keep a urinal at bedside, it should be checked frequently and emptied and cleaned as necessary.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that resident-accessible call systems were functional and appropriately configured in shower and bathing areas. During observation of a resident in the shower room next to the dining room, the call light did not activate when the pull cord was used. The resident reported taking showers independently in that shower room and stated that if he fell to the ground, he would be unable to call for help because the call light did not work. Review of this resident’s assessment records showed admission and readmission with diagnoses including cellulitis of both legs, lack of coordination, and hypertension, and a Minimum Data Set (MDS) indicating moderate cognitive impairment. The MDS further documented that the resident required substantial/maximal assistance for bathing, lower body dressing, and toileting hygiene, and partial/moderate assistance for oral hygiene and upper body dressing. On a separate observation in the shower room across from the South Nurses’ Station, the call light pull cord did not extend to the floor. The Maintenance Director confirmed in both shower rooms that the call light in one did not activate when pulled and that the pull cord in the other was too short to reach the ground, acknowledging that the call light needed to function and be reachable in case a resident fell and needed assistance. In an interview, the DON stated that the facility did not have a policy and procedure regarding the call light system. These observations, interviews, and record reviews demonstrated that the facility was not adequately equipped to allow residents in general to call for staff assistance in bathroom and bathing areas.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain a safe, clean, and sanitary environment and to follow infection control practices for two residents using a shower room and for one resident’s bedside urinals. One resident, admitted with anorexia nervosa, schizophrenia, and anxiety disorder and assessed as needing substantial/maximal assistance with bathing and toileting hygiene, reported taking a shower in the shower room next to the dining room while seated in a shower chair when the water was not draining, resulting in a puddle of water that the resident described as disgusting. The resident stated that the CNA assisting with the shower was also standing in the puddle of water. Another resident, admitted with cellulitis of both legs, lack of coordination, and hypertension and assessed as moderately cognitively impaired and needing substantial/maximal assistance with bathing and toileting hygiene, was observed in the same shower room standing in a pool of water over the shower drain and stated having to stand in the pooled water during showers, feeling disgusted and dirty because the drain was clogged. During a concurrent observation and interview with the Maintenance Director in the shower room next to the dining room, there was a visible pool of water over the shower drain, and the Maintenance Director confirmed the shower drain was clogged. In addition, staff failed to empty three full urinals that were hanging on the foot of the first resident’s bed. The facility’s policy titled “Quality of Life - Homelike Environment” indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment. The observed clogged shower drain with standing water and the unemptied, full urinals at the bedside were inconsistent with this policy and represented failures in maintaining infection control and environmental cleanliness.

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 a physician-ordered topical medication as prescribed for one resident. The resident was admitted with diagnoses including anorexia nervosa, schizophrenia, and anxiety disorder, and had no cognitive impairment per the MDS dated 2/6/2026. The MDS also documented that the resident required varying levels of staff assistance with ADLs such as footwear, bathing, toileting hygiene, oral hygiene, and lower body dressing. The Order Summary Report dated 3/27/2026 showed a physician order, dated 3/3/2026, for Clotrimazole 1% external solution to be applied to the resident’s face every day shift for eczema. In an interview, the resident reported having an order for a topical solution for itching and eczema and stated that staff did not provide the medication for 5 days beginning on 3/11/2026. Review of the March 2026 Treatment Administration Record revealed that staff did not apply the ordered Clotrimazole solution on 3/13/2026 and 3/15/2026. Progress notes indicated the medication was not given on 3/13/2026 because it was not on hand. The treatment nurse confirmed not administering the Clotrimazole on 3/13/2026 due to the medication being unavailable, and further stated that they did not contact the pharmacy to determine why the medication was not available and did not notify the resident’s physician that the ordered medication was not given. In an interview, the DON stated that when a resident’s medication is not available, the nurse is expected to follow up with the pharmacy and notify the prescriber, and also stated that the facility did not have a policy and procedure for medication 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

The facility failed to ensure staff complied with state regulations and its own policy requiring employees to wear identification name badges at all times while on duty. Surveyors observed multiple staff members either not wearing ID badges or wearing them improperly. One LVN had an ID badge clipped to a pants pocket below the waist and stated this was their usual practice. A care coordinator working with a resident in the lobby to sign documents was not wearing an ID badge and stated they did not have it with them. The hairdresser was observed going from room to room without an ID badge and stated they did not have one. A treatment nurse, identified as a newly hired staff member, was not wearing an ID badge and stated they had not yet been given one. Another LVN at the nurses’ station was not wearing an ID badge and stated they had forgotten to put it on after returning from lunch. Resident records showed that one resident admitted with anorexia nervosa, schizophrenia, and anxiety disorder had no cognitive impairment and required varying levels of assistance with ADLs such as bathing, toileting hygiene, oral hygiene, and dressing. Another resident, admitted with a right arm fracture, type 2 diabetes mellitus, and lack of coordination, had moderately impaired cognitive skills and required substantial to partial assistance with ADLs including bathing, dressing, toileting hygiene, and oral hygiene. During an interview, the cognitively intact resident stated that multiple staff did not wear ID badges while working and expressed a need for staff to wear badges so the resident would know who was providing their care. Review of the facility’s “Identification Name Badges” policy indicated that each employee must wear an identification name badge at all times while on duty, and state regulation (California Code of Regulations, Title 22, Section 72501(h)) requires all employees serving patients or the public to wear name and title badges unless contraindicated.

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 a deficiency in the facility’s failure to maintain hot foods at or above 140°F during meal service, as required by facility policy for time/temperature control for safety (TCS) foods. During a test tray observation conducted with the Dietary Supervisor (DS) at 12:25 PM, food temperatures were recorded as pasta at 105°F, turkey and sauce at 105°F, and green beans at 120°F. A repeat test tray observation at 12:35 PM, again in the presence of the DS, showed that the temperatures remained below required levels, with pasta at 105°F, turkey at 105°F, and green beans at 110°F. In a concurrent interview, the DS reported that the facility had been experiencing issues with a malfunctioning plate warmer, which the DS believed may have contributed to food being served at inadequate temperatures, particularly during the morning meal service. The DS also stated that if residents request reheating, staff reheat food for approximately 15 seconds to reach about 160°F, not exceeding that temperature. Review of the facility’s policy and procedure on cooling and reheating of potentially hazardous or TCS food during meal service confirmed that hot foods are to be maintained at temperatures greater than 140°F during meal service. This deficient practice was documented as having the potential to result in rapid growth of bacteria that can cause foodborne illness and can lead to insufficient meal intake and weight loss due to cold or improperly heated food.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to follow physician orders and care plan interventions for 1:1 supervision and continuous observation for two residents, resulting in both residents being left unattended at various times. Resident 1 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and contractures of the right upper arm and right knee. Assessment documents showed Resident 1 required substantial/maximal assistance with most ADLs and had a high fall risk score of 19 on the facility’s fall risk evaluation, with a care plan identifying risk for falls related to confusion and a history of attempting to get out of bed unassisted. The care plan and physician orders required 1:1 supervision, maintenance of 1:1 observation at all times, and that Resident 1 not be left unattended. Resident 2 was admitted with dementia, Alzheimer’s disease, and an anxiety disorder, and had moderately impaired cognition. The MDS indicated Resident 2 required supervision or touching assistance for toileting, bathing, dressing, footwear, and personal hygiene. Physician orders and care plans dated 1/30/26 documented 1:1 supervision for Resident 2 due to episodes of aggression toward staff, exit-seeking behavior, unprovoked agitation, crying, and aggression, with interventions specifying that a 1:1 sitter be placed with the resident for safety, that the resident not be left unattended, that a reliever be requested before the sitter went on break, and that 1:1 observation be maintained at all times. Despite these orders and care plan directives, the facility’s sitter schedule for the night shift on 2/1/26 showed a single sitter (S1) assigned simultaneously to both residents. Observations and staff interviews confirmed that the 1:1 supervision orders were not implemented as written. During an early morning observation in Resident 1’s room, S1 was present with Resident 1, whose bed was positioned against a wall with a Geri chair wedged tightly against the bed frame on the other side, creating a physical barrier. S1 reported having permission from the DON to place the Geri chair next to the bed. LVN 1 stated that S1 was assigned as a 1:1 sitter for both residents and had to go back and forth between their rooms every 15–20 minutes, even though a 1:1 order meant one sitter should be dedicated to one resident for the entire shift. LVN 1, CNA 1, CNA 2, the RN supervisor, the DON, and the Administrator all acknowledged that each resident with a 1:1 order should have continuous supervision, should not be left alone, and that another staff member should cover when the sitter left the room. Direct observation showed S1 leaving Resident 1 alone to walk down the hallway and around a corner to briefly check on Resident 2, then leaving Resident 2 alone to return to Resident 1, while S1 also described Resident 2 as unpredictable, with a history of hitting other residents and staff and throwing objects. These observations and interviews demonstrated that both residents, each with a physician’s order and care plan for continuous 1:1 supervision and not to be left unattended, were in fact left alone at times, and that one sitter was inappropriately assigned to cover both 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

Surveyors identified that a resident was not kept free from physical restraints when the resident’s bed was positioned against a wall on one side and a Geri chair was wedged tightly against the bed frame on the other side, creating a physical barrier that restricted the resident’s ability to get out of bed. The resident had been admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, as well as contractures of the right upper arm and right knee. The resident’s history and physical documented that the resident had the capacity to understand and make decisions. The Minimum Data Set showed the resident required substantial/maximal assistance for multiple ADLs, and a fall risk evaluation identified the resident as high risk for falls. The care plan documented the resident was at risk for falls related to confusion and a history of attempting to get out of bed unassisted, with interventions including 1:1 supervision and maintaining constant observation without leaving the resident unattended. During an early-morning observation in the resident’s room, the bed was seen placed against the wall on the left side and the Geri chair was placed directly against the right side of the bed, wedged against the bed frame. The resident was lying in the center of the bed in a fetal position, wrapped in a blanket from head to toe. Interview with the sitter assigned to the resident revealed that the DON had given permission to place the Geri chair next to the bed. An LVN confirmed awareness that the Geri chair was placed against the bed and stated it was being used as a restraint to prevent the resident from rising from the bed because the resident tended to “wiggle out” of bed. The LVN reported that the Geri chair had been in that position since the day shift two days earlier and that both the Administrator and the DON were aware of its use in this manner. Record review showed there was no physician’s order for the use of a Geri chair for this resident, despite its use as a device that restricted the resident’s movement and access to getting out of bed. The facility’s policies on restraint use stated that restraints were to be used only to treat medical symptoms and never for discipline, staff convenience, or fall prevention, and policies on safety and supervision emphasized maintaining an environment free from accident hazards and promoting resident dignity and well-being. In interviews, the RN supervisor, DON, and Administrator each acknowledged that placing the Geri chair against the bed in this way constituted a restraint, could result in entrapment, and was not acceptable, and that other alternatives should have been used instead of using the Geri chair as a restraint for this 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 deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in accordance with its Abuse Prevention/Prohibition and Resident Rights policies. One resident (Resident 3) had a history of aggressive behavior, including an SBAR on 8/8/2025 documenting attempts to hit others in the hallway and a transfer to a general acute care hospital on 8/11/2025 for aggressive behavior, shouting, screaming, and attempting to hit others. Resident 3’s MDS dated 11/3/2025 showed severely impaired cognition and a need for partial/moderate assistance with ADLs and mobility. After a psychiatric hospitalization and readmission on 9/23/2025, the facility initiated a care plan for aggressive behavior, but the DON later acknowledged that the interventions in this care plan were vague, not individualized, and not behavior-specific, despite Resident 3’s known history of aggression. Resident 4 was admitted on 12/5/2025 with diagnoses including pneumonia and anxiety disorder, with an MDS indicating moderately impaired cognition and a need for substantial/maximal assistance with ADLs and mobility. On 1/19/2026, an SBAR documented that Resident 4 was sitting by the time clock on the North Station when Resident 3 hit Resident 4 on the back of the head. Resident 4 reported head pain rated 7/10 and was transferred to a general acute care hospital for further evaluation and treatment. In an interview, Resident 4 stated they were seated in the lobby watching the clock when Resident 3 approached in a wheelchair; Resident 4 attempted to move out of the way but was struck in the back of the head before they could reposition, describing the contact as sudden and unexpected and reporting emotional distress and feeling shaken by the incident. In interviews, Resident 3 demonstrated a fist motion as if punching Resident 4 and stated being angry because Resident 4 was blocking the way, though did not verbally admit to striking the other resident. RN 2 reported being at the North Nursing Station, hearing someone yell, “Ow, he hit me,” and immediately separating the two residents; RN 2 did not witness the actual strike but saw Resident 3 making a fist-like motion. RN 2 stated that when a resident has a known history of aggressive behavior, the care plan must be individualized and include specific, measurable interventions such as defined supervision levels, identification of triggers, early intervention strategies, de-escalation techniques, environmental modifications, redirection methods, staff approach guidelines, and escalation criteria, and that vague, generalized interventions without behavior-specific guidance leave staff without clear direction to prevent escalation. The DON similarly stated that without detailed individualized interventions for a resident with a known history of aggressive behavior, staff lack clear direction to proactively prevent escalation, increasing the risk for resident-to-resident altercations, even when aggressive behaviors have been dormant for months. The facility’s policies defined abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish and guaranteed residents the right to be free from abuse and neglect.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to timely develop and implement a comprehensive, individualized, person-centered care plan to address a resident’s known aggressive behaviors. The resident was admitted with diagnoses including paranoid schizophrenia and diabetes mellitus, and had documented episodes of aggression. On one occasion, an SBAR Communication Form recorded that the resident was in the hallway attempting to hit others. A subsequent Skilled Nursing Facility to Hospital Transfer Form documented that the resident was transferred to a general acute care hospital for aggressive behavior, shouting, screaming, and attempting to hit others. Following a 5150 psychiatric hold for being physically aggressive to staff, the resident was readmitted, and a care plan addressing aggressive behavior was initiated on 9/26/2025. However, this care plan was not individualized or resident-specific. It lacked documented monitoring parameters, did not identify behavioral triggers, and did not provide staff guidance on how to approach, redirect, and manage the resident’s aggressive behaviors. Although the care plan problem was opened on 9/26/2025, the specific interventions were not added or implemented until 11/5/2025, resulting in a significant delay in putting any concrete strategies into practice. The resident’s MDS dated 11/3/2025 indicated severely impaired cognition and a need for partial/moderate assistance with ADLs and mobility, underscoring the need for clear, structured behavioral interventions. During interviews, an RN and the DON both acknowledged that the care plan did not reflect a comprehensive, individualized, person-centered approach and was missing resident-specific guidance related to monitoring, triggers, and staff direction for managing aggressive behaviors. The facility’s own policy on comprehensive, person-centered care plans requires measurable objectives, timeframes, and services derived from thorough assessment and ongoing review, including after hospital readmission, which was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that current nurse staffing information was posted daily in a prominent location accessible to residents, staff, and visitors, as required by its policy. On 1/2/26 at 12:08 PM, surveyors observed a posting titled "Census and Direct Service Hours Per Patient Day" in front of Nursing Station 1 near the entrance lobby with a date of 12/31/25, indicating the information was not current. During an interview at 12:10 PM, the DON acknowledged the posting was not current and explained that the Director of Staff Development had resigned and the staff member responsible for posting the staffing information did not come to work due to personal circumstances. At 1:00 PM the same day, CNA 1 stated that CNA 1 had been responsible for creating the posting by entering licensed nurse and CNA hours into a computer program that generated the daily nursing hours for posting, and that a personal circumstance had prevented CNA 1 from reporting on time to print and post the information. On 1/5/26 at 8:50 AM, surveyors again observed the same type of staffing posting in front of Nursing Station 1 near the entrance lobby, now dated 1/2/26, showing that the information still had not been updated daily. In a concurrent observation and interview at 9:10 AM, the DON stated that the posting needed to be updated every day. At 10:00 AM, CNA 1 reported that projected nursing hours for posting had been prepared and placed in a bin in front of the staffing office, and that nurses working the weekend were expected to retrieve these projected hours and post the staffing information near the two nursing stations. CNA 1 stated that the nursing hours needed to be posted so staff, residents, and families would have staffing information. Review of the facility’s July 2016 policy "Posting Direct Care Daily Staffing Numbers" confirmed that within two hours of the beginning of each shift, the numbers of licensed nurses and unlicensed nursing personnel directly responsible for resident care must be posted in a prominent, accessible, clear, and readable format, which was not done as observed on multiple days.

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 reevaluate and update the care plan interventions for a resident exhibiting hoarding behavior, despite ongoing issues with clutter and refusal of assistance. The resident, who had diagnoses including bilateral primary osteoarthritis of the knee, COPD, anxiety disorder, and personality disorder, was observed to have intact cognition and the capacity to make medical decisions. The resident required setup or clean-up assistance with several activities of daily living. Observations revealed significant clutter in the resident's room, including boxes, clothing, personal items, and food scattered around the bed, with the call light cord not within reach. Interviews and record reviews indicated that the Social Services Director had discussed the hazards of the clutter with the resident in early September, but there were no further documented interventions or encouragement to address the issue in the following months. Nursing notes showed that the resident refused deep cleaning and continued to decline assistance, despite being educated on proper cleaning and hygiene. The care plan for hoarding, initiated in late July and last revised in early August, included interventions such as encouraging the resident to organize belongings, offering to clean and organize, explaining risks, and assisting with expired food, but these interventions were not updated or revised after the resident's continued refusal and persistent clutter. The facility's policy required ongoing assessment and revision of care plans when desired outcomes were not met or when there was a significant change in the resident's condition. However, the care plan for this resident was not reevaluated or updated in response to the lack of progress and continued safety hazards, resulting in a deficiency related to the failure to maintain a safe and clean environment 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 was identified when a resident's room was observed to be excessively cluttered, with multiple boxes, clothing, bags, food, drinks, and personal grooming items scattered around the bed and on the floor. The call light cord was found on the floor and not within the resident's reach. These conditions were noted during an observation and interview, where the resident stated that the facility would not assist with moving boxes to storage or provide additional boxes for organizing belongings. The resident had a history of bilateral primary osteoarthritis of the knees, COPD, anxiety disorder, and personality disorder, but was assessed as having intact cognition and the capacity to make medical decisions. The Minimum Data Set indicated the resident required setup or clean-up assistance with several activities of daily living. Despite this, the room remained cluttered, and the resident had refused deep cleaning services, as documented in housekeeping and nursing progress notes. Social services had previously discussed the hazards of the clutter with the resident, but there were no further documented interventions or encouragement to address the issue in the following months. The resident's care plan included goals to maintain a safe and clean living area and interventions such as encouraging the resident to organize belongings and offering staff assistance with cleaning. However, the care plan interventions were not effectively implemented, as the clutter persisted and the environment remained hazardous. Facility policies required a safe, clean, and homelike environment, but these standards were not met in this instance.

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 safe and sanitary practices for ice and water handling by not replacing an expired water filter connected to the icemaker in the kitchen. During an observation, the expired filter was noted, and the Dietary Manager (DM), who was new to the position, was unsure of the replacement schedule for the filter. A log sheet attached to the icemaker was reviewed, but it only indicated the month of December without specifying the year, making it unclear when the last replacement occurred. The manufacturer's specifications for the water filter recommend replacing the cartridge at least once per year or when the flow rate becomes inconveniently slow. A review of the facility's policy and procedure for maintenance service indicated that the Maintenance Department is responsible for ensuring all equipment, including the icemaker, is maintained in a safe and operable manner according to manufacturer recommendations. The policy also assigns the Maintenance Director the responsibility of developing and maintaining a maintenance schedule. However, the observation and interviews revealed that these procedures were not followed, resulting in the use of an expired water filter and a lack of clear documentation regarding maintenance activities.

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 a care plan addressing the use of a rollator walker for a resident with end-stage renal disease on hemodialysis and diabetes mellitus type 2. Despite the resident being at risk for falls due to gait and balance problems, psychoactive drug use, and weakness, there was no individualized care plan in place for the safe use of the rollator walker. The resident's care plan only generally addressed fall risk but did not include specific interventions or measurable objectives related to the assistive device, as required by facility policy. On the day of the incident, the resident attempted to get up from the rollator walker on the outside patio, lost balance, and fell, resulting in an acute humeral neck fracture that required hospitalization. Documentation revealed that the physical therapy department had discharged the resident from services without completing an assessment or evaluation for rollator walker use, and there was no communication of recommendations to the nursing staff. The lack of a care plan and communication between therapy and nursing staff contributed to the resident's fall and injury. Interviews with the DON and occupational therapist confirmed that there was no care plan for the use of the rollator walker and that nurses were not made aware of the resident's needs regarding the device. Facility policies required comprehensive, person-centered care plans and documentation of assistive device use based on assessment, but these were not followed. The deficiency was further compounded by the absence of interdisciplinary communication and failure to adhere to established policies and procedures.

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 exited the facility without staff knowledge or supervision. The resident had a history of elopement at home, wandering behavior, and an elopement risk score of 6.0 upon admission. The resident was admitted with diagnoses including seizures and depression, and had fluctuating capacity to make medical decisions. The Minimum Data Set assessment indicated the resident was cognitively intact and required limited assistance for activities of daily living. Despite these risk factors, the resident was last observed in bed early in the morning, and staff were unable to locate the resident during subsequent checks, prompting a facility-wide search. Interviews with staff revealed that the resident was ambulatory and frequently walked around the facility. The Director of Nursing stated that the elopement was unexpected, as the resident had not previously shown signs of wanting to leave. The facility's policy on safety and supervision emphasized the importance of targeting interventions to reduce individual risks and providing adequate supervision. However, the lack of effective supervision allowed the resident to leave the premises unnoticed, constituting a failure to prevent accidents 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

Facility staff failed to promptly respond to call lights and requests for toileting assistance for three of five sampled residents, as required by the facility's policy on dignity. One resident with severe cognitive impairment and significant assistance needs for toileting and hygiene was reported by a family member to experience long delays in staff response, often requiring the family member to seek help directly from the nurses' station. Another resident, who was incontinent and at risk for skin breakdown, reported waiting up to 30 minutes or more for assistance after activating the call light, including a specific incident where the resident waited a total of three hours to be changed after an incontinent episode. This resident described feeling ignored and demeaned by the delays. Observations confirmed that call lights remained on for extended periods before staff responded. In one instance, a resident waited 30 minutes for help with a soiled brief, and in another, a resident waited for assistance after an episode of incontinence, with staff not returning as promised. Interviews with residents revealed that these delays were not isolated incidents, with reports of waiting hours for assistance, particularly during nighttime hours. Residents expressed feelings of frustration and a lack of dignity due to these prolonged waits. Staff interviews corroborated that residents should not have to wait long for assistance, especially when in need of changing soiled briefs. The Director of Nursing stated that residents should not wait longer than five minutes for such assistance to maintain their dignity, as outlined in the facility's policy. The policy specifically prohibits practices that compromise dignity and requires prompt response to toileting requests, which was not consistently followed in these cases.

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 informed consent was properly obtained for psychotropic medications prescribed to a resident with severe cognitive impairment. The resident, who had diagnoses including dementia, anxiety disorder, and hypertension, was readmitted to the facility with orders for multiple psychotropic medications. Documentation indicated that the resident was severely impaired in cognitive skills and required substantial assistance with daily activities. Upon review, it was found that the facility continued the psychotropic medication regimen initiated during a recent hospital stay without verifying or obtaining new informed consent from the resident's representative. Interviews with the resident's daughter revealed that medication changes, specifically an increase in depression medication dosage, were made without her notification. The Social Service Director and MDS Nurse confirmed that the medication changes occurred during the resident's hospital stay and were continued upon readmission to the facility. However, there was uncertainty about whether proper notification or consent had been obtained for these changes. The facility's records included informed consent forms for the psychotropic medications, but the psychiatric nurse practitioner stated that they did not actually obtain consent from the resident's representative as indicated on the forms. The facility's policy required verification of prior informed consent for psychoactive medications upon admission or readmission, and if such documentation was not present, the admitting physician was responsible for obtaining consent. In this case, there was no verified documentation from the discharging hospital, and the admitting provider did not obtain informed consent from the resident's representative. This resulted in the resident receiving psychotropic medications without the required informed consent process being completed.

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) engaged in physical abuse against a resident with severe cognitive impairment and multiple psychiatric diagnoses, including intellectual disability, schizoaffective disorder, and anxiety disorder. The resident, who required substantial assistance with daily activities and had a history of verbal aggression but not physical aggression, was subjected to an incident where the RN threw a cup of juice in the resident's face and chest. This action was in response to the resident having thrown juice at the RN and a certified nursing assistant (CNA) during a period of agitation. The RN later admitted to 'mirroring' the resident's behavior by intentionally throwing juice back at the resident, believing it might discourage future incidents, despite recognizing afterward that this was not permitted. Observations and interviews confirmed that the resident was left visibly distressed, crying intermittently and unable to articulate their feelings following the incident. The care plan for the resident included interventions for staff to use calm approaches, provide cues, and allow the resident time to adjust when agitated, but these were not followed during the event. Staff interviews indicated that the resident's aggressive behaviors were typically managed through verbal de-escalation, medication, or giving the resident time alone, and that the resident was not considered a physical threat. The facility's policies on abuse prevention and resident rights explicitly prohibit willful infliction of injury or punishment and require staff to treat residents with kindness, respect, and dignity. Despite these policies and staff education on abuse, the RN's actions constituted physical abuse, as confirmed by both facility leadership and the abuse coordinator. The incident was reported internally after another RN received a text message confession from the involved RN, which was then escalated to the administrator.

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 physical abuse involving a resident with severe cognitive impairment and multiple psychiatric diagnoses within the required two-hour timeframe to the California Department of Public Health. The resident, who had a history of behavioral issues and required significant assistance with daily activities, was involved in an altercation where a registered nurse (RN) threw juice at the resident after the resident had thrown juice at the nurse. This incident was witnessed by a certified nursing assistant (CNA), who did not report the event as required due to being occupied with other duties. The facility's policies and procedures, as well as staff interviews, confirmed that all staff are mandated reporters and are required to report any suspected abuse, neglect, or mistreatment immediately, and no later than two hours after the incident. Despite this, the CNA failed to report the incident to the Abuse Coordinator or Administrator. The RN involved in the incident later sent a text message to another RN describing the event, but this message was not seen until the following day, further delaying the reporting process. Record reviews and staff interviews indicated that the facility's abuse prevention and reporting policies were not followed in this case. The delay in reporting the incident resulted in a violation of the resident's rights and had the potential to delay the investigation of abuse and expose the resident to further harm. The deficiency was identified through interviews, record reviews, and examination of facility policies.

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 treat two residents with dignity during daily care activities. For one resident with severe cognitive impairment and multiple diagnoses, an Activity Assistant referred to the individual as a "feeder" while the resident was seated in the dining room. This terminology was used in the presence of the resident and was confirmed during an interview with the staff member. The resident's records indicated a high level of dependence on staff for daily activities, including eating and personal hygiene. In a separate incident, another resident with Huntington's disease, dysphagia, and moderate cognitive impairment was assisted with eating by a staff member who stood over the resident at the bedside. The resident later stated that being assisted at eye level would have maintained their dignity. The staff member involved acknowledged standing while assisting and confirmed awareness that sitting at the same level is the appropriate practice. Facility policies reviewed indicated that residents should be treated with dignity and respect, specifically noting that staff should not stand over residents while assisting with meals and should avoid using labels such as "feeder."

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 environment free from accident hazards and did not provide adequate supervision for three residents. One resident, who was severely cognitively impaired and required a 1:1 sitter due to aggressive behaviors and a history of losing balance, was left unsupervised on the patio while the assigned sitter was inside the facility using a personal phone for four minutes. The sitter acknowledged being distracted by personal emails and not observing the resident as required by facility policy, which prohibits personal phone use during supervision duties. Additionally, two other residents with significant cognitive impairments and histories of falls experienced multiple unwitnessed and witnessed falls. Despite these incidents, the facility did not conduct required interdisciplinary team (IDT) meetings after each fall, as outlined in their policies. Record reviews confirmed that no post-fall IDT meetings were held for these residents following their falls in July and August, even though the facility's procedures mandate such reviews within 24 hours to analyze causes and update care plans. The lack of supervision and failure to follow post-fall protocols were confirmed through staff interviews, record reviews, and direct observation. The Director of Nursing and other staff acknowledged that the facility's policies require constant supervision for high-risk residents and timely IDT meetings after falls, but these procedures were not followed for the residents in question.

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

Nursing staff failed to follow the facility's medication administration policy and procedure in several instances, resulting in deficiencies related to timely medication administration and proper documentation. For one resident with a history of seizures, hypotension, and acute kidney failure, scheduled medications including antipsychotics and anticonvulsants were not administered as ordered on one evening, and there were multiple instances where medications were given late or documentation was delayed. The Director of Nursing confirmed that the resident did not receive the scheduled medications and that the responsible nurse could not provide a reason for the omission. Additionally, two nurses admitted to documenting medication administration after completing medication passes for multiple residents, citing issues such as unreliable Wi-Fi, rather than immediately after each administration as required by policy. Another resident with metabolic encephalopathy, dementia, UTI, and arthritis had six medications scheduled for administration at a specific time in the morning. Observation revealed that these medications were administered more than one and a half hours late. The nurse involved acknowledged the delay and confirmed that medications should be administered on time according to physician orders to ensure effectiveness. A third resident with Parkinsonism, epilepsy, and COPD had multiple instances where scheduled medications for seizure control were documented as being administered late. Interviews with nursing staff revealed that documentation was not completed immediately after each medication was given, contrary to facility policy. Staff acknowledged that they should have documented each administration before proceeding to the next medication, but this was not consistently done.

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 the doorknob and door of a resident room, occupied by three residents, were cleaned daily as required by facility policy. Observations on two separate occasions revealed visible brown specks and smudges on the doorknob and surrounding door area, which remained uncleaned over several days. The infection preventionist confirmed that these areas were dirty and acknowledged that the doorknob is considered a high-touch surface that should be cleaned daily to prevent the spread of infection. The three residents involved had various medical conditions, including metabolic encephalopathy, chronic kidney disease, bipolar disorder, pneumonia, dementia, anxiety disorder, hypertensive heart disease with heart failure, and paranoid schizophrenia. Their levels of cognitive and physical functioning varied, with some requiring supervision or assistance for activities of daily living. Review of facility records and policies indicated that environmental surfaces are to be cleaned regularly and when visibly soiled, but this was not followed for the doorknob and door in question.

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 follow its policy and procedure regarding notification of a change in a resident's condition or status. Specifically, staff did not notify a resident's physician of a significant unintentional weight loss, as required by facility policy. The resident experienced a weight decrease from 144 pounds to 127 pounds over a 30-day period, which was documented in the progress notes. Despite this significant weight loss, there was no Change in Condition Evaluation created for June, July, or August, and the physician was not notified of the change. The resident involved had multiple medical diagnoses, including multiple rib fractures, hypertensive heart disease, urinary tract infection, and protein-calorie malnutrition. The resident was assessed as having moderate cognitive impairment and required varying levels of assistance with activities of daily living. Facility policies required staff to report significant weight changes to the physician, but review of records and interviews with nursing staff and the DON confirmed that this notification did not occur for the resident's significant weight loss.

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 Certified Nursing Assistant (CNA) was recorded sitting in a resident's room by a Licensed Vocational Nurse (LVN), and the video was subsequently posted to TikTok. The video included identifiable personal property and pictures belonging to the resident, as well as a view into four other resident rooms. The resident involved had a history of hereditary and idiopathic neuropathy and dementia, with fluctuating capacity to understand and make decisions. The facility's policies and employee handbook explicitly prohibit recording and sharing videos of residents or their personal spaces on social media, and require safeguarding resident privacy and confidentiality. Interviews with the CNA and the Director of Nursing (DON) confirmed that the video was recorded in the facility and that such actions were not permitted, as they violate residents' rights to privacy and confidentiality. Review of facility policies further supported that employees are required to treat residents with respect and protect their personal information, including video and audio recordings. The posting of the video to a public social media platform constituted a failure to honor these rights and maintain confidentiality 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 provide an accurate and comprehensive admission assessment for one resident with multiple diagnoses, including unspecified dementia and legal blindness. Upon admission, documentation inconsistencies were noted across various records, including the care plan, admission notes, and progress notes. The resident's care plan indicated the need for a wanderguard for safety, but other records failed to accurately reflect the resident's cognitive impairment, visual impairment, and safety concerns. Additionally, the baseline care plan and progress notes did not document the presence of pain or injury, despite the resident having a red and swollen right hand and forearm, and a physician's order for immobilization of the right forearm with a splint and ACE wrap. Observations and interviews revealed that staff did not perform necessary assessments, such as vision and pain assessments, nor did they follow physician orders for immobilizing the resident's right forearm. The resident was observed to have visible swelling and redness in the right hand and forearm, and demonstrated difficulty lifting the affected arm. Despite these findings, there was no documentation of a right arm injury in the resident's hard chart, and the medication administration record showed that the resident did not receive a pain assessment or pain medication until several days after admission. Further interviews with staff indicated a lack of awareness and documentation regarding the resident's impairments and needs. The activities director did not engage with the resident during the initial interdisciplinary team meeting, and there was no documentation of activities provided. Facility policies required comprehensive admission assessments, including pain and functional assessments, but these were not completed as required, resulting in delayed interventions for the resident's pain and inadequate accommodation of the resident's cognitive and visual impairments.

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 each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents with behavioral health needs did not receive the appropriate care and services as required by regulations.

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 identify and monitor signs and symptoms of a urinary tract infection (UTI) for one resident, as required by the resident's care plan. The care plan, dated 1/23/2025, specified that the resident, who had a history of UTI and was at risk for further complications, should have vital signs monitored every shift. However, records and interviews confirmed that staff only checked the resident's vital signs once a week, with the last recorded check occurring on 5/28/2025, prior to a significant change in the resident's condition on 6/4/2025. The Director of Nursing acknowledged that the care plan was not followed and that the facility's policy for care plans was not implemented as required. The resident, who had diagnoses including encephalopathy, dementia, and anxiety, and was severely cognitively impaired and incontinent, experienced a rapid decline. On 6/4/2025, the resident developed severe shortness of breath, high fever, and low oxygen saturation, leading to emergency transfer to a general acute hospital, where the resident was diagnosed with UTI and sepsis. The failure to monitor vital signs as outlined in the care plan resulted in delayed identification of the resident's deteriorating condition.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from verbal and mental abuse, as evidenced by an incident involving a certified nurse assistant (CNA) and a resident with diagnoses including hyperlipidemia and mood disorder, who lacked the mental capacity to make medical decisions. During the incident, a CNA was observed by another staff member yelling at the resident and threatening physical harm, stating, "If you hit me I'm gonna F . you up," while picking up a chair. The resident acknowledged a loud verbal exchange but reported feeling safe and voiced no complaints at the time of the interview. No visible injuries or signs of distress were observed during the assessment. The facility's policies clearly prohibit verbal abuse, intimidation, or threats from staff and require immediate reporting of such incidents. Despite these policies, the incident occurred, and the facility's internal investigation substantiated the occurrence of verbal and mental abuse. The deficiency was identified through staff interviews, resident interviews, and review of facility records and policies.

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 obtain informed consent for the administration of Ativan (lorazepam), a psychoactive medication, for a resident with severe cognitive impairment. The resident was admitted with diagnoses including dementia, anxiety disorder, and psychosis, and was determined by a physician to lack the capacity to understand and make decisions. The resident's Minimum Data Set assessment confirmed severe cognitive impairment and indicated the use of antianxiety medication. A physician order was present for Ativan to be administered as needed for inconsolable yelling. However, upon review of the resident's medical record, the Social Services Director was unable to locate a signed informed consent for the use of Ativan. Further investigation confirmed that the resident's responsible party had not provided documented consent for the medication. Interviews with facility staff, including the Director of Nursing, confirmed that facility policy requires informed consent to be obtained and documented prior to administering psychoactive medications, especially when the resident is unable to provide consent. The policy specifies that consent must be obtained from the resident's representative if the resident is not capable. Despite this, there was no evidence that informed consent was obtained or documented for the use of Ativan in this case.

Plan Of Correction

Corrective Action: Resident 77's informed consent for use of Ativan was obtained and verified by a licensed nurse from RP1 on 4/16/25. Other Residents Affected Identification: All residents taking Psychotropic Medications are at risk for deficient practice. On 4/17/25, all residents on Psychotropic Medications were reviewed for completion of Informed Consents. No other residents were affected by the deficient practice. Measures and Systemic Changes: On 04/17/2025, the DON initiated in-service to Licensed Nurses and SSD to ensure that consents are obtained prior to giving psychotropic medication. Upon admission, any residents receiving psychotropic medications shall be audited by the Medical Records to verify if the informed consent has been completed. During weekly Behavior Management Meetings, the IDT shall monitor and audit the compliance of informed consent verification, and the copy of the audit will be provided to the administrator, DON, and the IDT. Findings on the audit will be addressed by the SSD and IDT immediately. MONITORING PERFORMANCE: Medical Records will audit psychotropic medications once weekly for 3 months or until substantial compliance is achieved, reporting any deficits to the DON for follow-up. Issues and trends, along with a copy of the report, will be forwarded to the DON/Administrator for further review and immediate corrective action as necessary. The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved. Upon admission, any residents receiving psychotropic medications shall be audited by the Medical Records to verify if the informed consent has been completed. During weekly Behavior Management Meetings, the IDT shall monitor and audit the compliance of informed consent verification, and the copy of the audit will be provided to the administrator, DON, and the IDT. Findings on the audit will be addressed by the SSD and IDT immediately. MONITORING PERFORMANCE: Medical Records will audit psychotropic medications once weekly for 3 months or until substantial compliance is achieved, reporting any deficits to the DON for follow-up. Issues and trends, along with a copy of the report, will be forwarded to the DON/Administrator for further review and immediate corrective action as necessary. The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.

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 licensed vocational nurse administered cetirizine 10 mg to a resident instead of the physician-ordered loratadine 10 mg. The resident, who had diagnoses including Type 2 Diabetes Mellitus, acute osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb, was admitted and readmitted to the facility with intact cognition. The physician's order specifically required loratadine 10 mg by mouth once daily for skin allergy, but during a medication pass, the nurse gave cetirizine, which was not ordered for the resident. The nurse explained that cetirizine was administered because it was the house supply provided by the pharmacy, despite the absence of a physician's order for cetirizine. The Director of Nursing confirmed that the order was for loratadine and that cetirizine should not have been given. Facility policy required medications to be administered as prescribed and for staff to verify the correct medication, dose, and resident before administration. The error resulted in a medication error and had the potential to cause adverse side effects for the resident.

Plan Of Correction

F755: Pharmacy Services/Procedure/Pharmacist/Records CORRECTIVE ACTION: On 4/17/25, Resident 27 was assessed by a licensed nurse and no adverse reaction was noted. Change of Condition for the Medication Error was initiated and MD was made aware with no new order but to continue to monitor resident. Resident was monitored for 3 consecutive days with no adverse reaction noted related to medication error. On 04/17/25, Medication Cart was supplied with Loratadine. LVN 4 is no longer working at the facility. OTHER RESIDENTS AFFECTED IDENTIFICATION All Residents had the potential to be affected by the deficient practice. On 04/17/25, an audit of all Medication Carts for availability of over-the-counter medications for residents with orders for its use was conducted. All over-the-counter medications were available and none were identified to be affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES Inservice was initiated on 04/17/2025 by DON regarding proper medication administration as ordered by MD. On 04/17/2025, DON/Designee initiated a weekly medication administration observation to 2 random nurses to ensure administration of correct medication as ordered by MD. Medical record will include in the daily audit the MAR for any missed dose of medications ordered by MD. MONITORING PERFORMANCE DON/Designee will report findings from weekly medication administration observation and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.

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 compliance with federal regulations regarding the administration of psychotropic medications, specifically Ativan (lorazepam), for a resident diagnosed with dementia, anxiety disorder, and psychosis. The resident, who had severe cognitive impairment and lacked decision-making capacity, had a physician order for Ativan 0.5 mg to be given orally every eight hours as needed for inconsolable yelling. The order, dated 4/8/2025, did not include a required 14-day limitation for PRN (as needed) use, nor was there documentation of the prescriber's rationale or specified duration for extending the order beyond 14 days, as mandated by both federal regulation and the facility's own policy. During interviews and record reviews, it was confirmed that the Ativan PRN order remained active without an end date or appropriate documentation to justify its continuation past 14 days. The Director of Nursing acknowledged that the order should have been limited to 14 days and that the necessary documentation for extension was missing. The facility's policy, consistent with federal requirements, clearly states that PRN orders for psychotropic medications must be limited to 14 days unless properly justified and documented by the prescriber.

Plan Of Correction

F758: Free from Unnecessary Psychotropic Meds/PRN Use {F 758) CORRECTIVE ACTIONS: On 04/16/2025, Resident 77's Ativan order was followed up with MD and a new order was obtained with a duration of 14 days. OTHER RESIDENTS AFFECTED IDENTIFICATION: On 4/16/2025, all residents with PRN orders of psychotropics were audited and no other residents were noted to be affected by the deficient practice. All other residents with PRN psychotropics are noted with a 14-day stop date. Measures and Systemic Changes: The DON/Designee initiated education to licensed staff on 4/17/25 to ensure that any residents receiving PRN psychotropics must have a 14-day stop date initially upon ordering, and MD has to have a documentation of the rationale on the resident's medical records if MD wishes to continue its PRN use. The DON/DSD will monitor daily all new orders for PRN psychotropics prescribed to ensure the order is limited to 14 days. This will be followed by bimonthly reviews for 2 months, then monthly reviews for 3 months, and quarterly thereafter. MONITORING PERFORMANCE: The DON/SSD will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a licensed vocational nurse (LVN) failed to perform hand hygiene during medication administration for two residents. The LVN was observed handing medications and water to one resident, then documenting the administration without performing hand hygiene after handling the medications and after the medication pass. In a separate instance, the same LVN prepared medications for another resident without performing hand hygiene before or after handling the medications. The two residents involved had significant medical histories. One resident had end stage renal disease, was dependent on renal dialysis, and had Type 2 diabetes mellitus, requiring supervision or assistance with several activities of daily living. The other resident had Type 2 diabetes mellitus, acute osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb, requiring substantial or maximal assistance with personal care tasks. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that facility policy and standard infection control practices require hand hygiene before and after medication administration and resident contact. Review of the facility's hand hygiene policy further supported these requirements, stating that hand hygiene is the primary means to prevent the spread of infections and must be performed before and after direct contact with residents and before preparing and handling medications.

Plan Of Correction

F880: Infection Prevention and Control Corrective Action: On 04/17/25, Resident 27 and Resident 62 were assessed by a licensed nurse. Both residents did not show any adverse reaction or signs of infection caused by the deficient practice. LVN 4 is no longer working in the facility. In-service initiated on 04/17/2025 by DON regarding infection control with an emphasis on hand hygiene during medication pass and also before and after care with residents. Other Resident Affected Identification: All residents have the potential to be affected by the deficient practice. On 04/17/25, DON/Designee conducted a random observation of 4 licensed nurses during medication pass. All licensed nurses observed performed hand hygiene appropriately. No other residents were affected by the deficient practice. On 05/02/2025, IP nurse/Designee initiated a weekly random medpass observation to 2 random licensed nurses to ensure proper hand hygiene is performed. PERFORMANCE MONITORING: DON/designee will report any findings/trends during monthly QAA meeting for review x90 days or until substantial compliance has been achieved.

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 facility failed to ensure a resident was able to communicate with persons outside the facility, specifically when the receptionist did not notify the resident of incoming phone calls from a family member. The resident, who had diagnoses of hypertensive heart disease without heart failure and depression, was admitted with a responsible party listed as a family member. Although the resident's history and physical indicated a lack of capacity to make decisions, the Minimum Data Set assessment showed the resident was cognitively intact. The family member reported that the receptionist would not notify the resident of calls if the resident was not visible in the lobby, and messages left with the receptionist were not relayed to the resident. The family member noted that when another receptionist was on duty, communication with the resident was facilitated promptly. The receptionist admitted that if the resident was not in the lobby, she would only page the assigned CNA, and if the CNA was unavailable, she would not notify anyone else, nor would she page the LVN, citing their busyness. The receptionist acknowledged that it was the resident's right to have access to phone calls. The Director of Nursing confirmed that the facility's expectation was for the receptionist to notify the CNA, LVN, or RN supervisor when a family member called for a resident. Facility policies reviewed indicated that residents should be given telephone messages when unable to take incoming calls and that residents have the right to communication with people and services both inside and outside the facility. The failure to notify the resident of incoming calls resulted in the resident not receiving important communication from their family member.

Plan Of Correction

F 550 Resident Rights Corrective Action: One-on-one in-service was provided to Receptionist 1 on 05/02/2025 and 05/07/25 by DON/Designee regarding the proper transferring of calls when residents have a phone call. DON/DSD initiated in-service on 05/02/2025 and 05/07/25 to all receptionists and staff regarding residents' rights to receive calls from outside the facility and properly communicate residents' concerns. Corrective Action Continued: Resident 1 is no longer in the facility. Other Residents Affected Identification: All residents have the potential to be affected by the deficient practice. Random residents who frequently received phone calls were interviewed on 04/30/25 and 05/07/25 by SSD/Designee to determine if there were any concerns about making or receiving phone calls. No other residents were affected by the deficient practice. Measures and Systemic Changes: Department Head room round form was updated on 05/07/2025 to include asking residents if they have any issues receiving calls. Any findings will be reported during stand-up to Admin and DON 5 times per week. Monitoring Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.

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 a comprehensive care plan for a resident diagnosed with hypertensive heart disease without heart failure. Although the resident was admitted with this diagnosis and had a physician's order to monitor for orthostatic hypotension by checking blood pressure once a week, the care plan did not address hypertensive heart disease or include the required blood pressure monitoring. Instead, the care plan only referenced coronary artery disease related to atrial fibrillation, which was not supported by the resident's Minimum Data Set or medical records. Record reviews showed that the resident's Minimum Data Set listed active diagnoses of hypertension and depression, and the physician order summary specifically required monitoring for orthostatic hypotension. The Director of Nursing confirmed that the care plan was not updated to reflect the physician's order for blood pressure monitoring. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and services to meet residents' needs, but this was not followed for the resident in question.

Plan Of Correction

F 656 Develop/ Implement Comprehensive Care plan Corrective Action: Resident was discharged on 04/03/2025. Corrective Action Continued: DON initiated in-services to licensed nurses on 05/02/2025 regarding the importance of developing accurate care plans based on diagnosis and ensuring they reflect the related interventions. Other Residents Affected Identification: All residents have the potential to be affected by the deficient practice. On 05/02/25, all residents with a diagnosis of Hypertension were audited by DON/Designee to ensure a care plan is present and reflects current interventions that might include Blood Pressure Monitoring. No other residents were affected by the deficient practice. Measures and Systemic Changes: DON provided an in-service to MDS nurse on 05/02/25 to ensure care plans reflect residents' diagnoses with their corresponding interventions. Care plans will be reviewed by the MDS nurse upon admission and quarterly at minimum thereafter for accuracy. The DON initiated an in-service to Licensed Nurses on 05/02/25 regarding quality of care, with an emphasis on the importance of monitoring BP and updating care plans based on physician's orders. Monitoring Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved. Date: 05/07/25

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 monitor and document a resident's blood pressure as ordered by the primary physician. The resident, who was admitted with diagnoses including hypertensive heart disease without heart failure and depression, had a physician's order to be monitored for orthostatic hypotension once a week on Saturdays. On the specified date, there was no documentation in the Medication Administration Record (MAR) that the blood pressure monitoring was completed. An interview with a licensed vocational nurse confirmed that the assigned nurse did not assess or document the resident's blood pressure, and that if documentation was missing, the assessment was not performed. The resident's care plan did not address hypertensive heart disease or the required blood pressure monitoring, despite the resident having an active diagnosis of hypertension. The facility's policy required nurses to assess and document vital signs, including blood pressure, as part of baseline information for acute condition changes. The lack of documentation and assessment was confirmed through record review and staff interview, indicating the ordered monitoring was not carried out as required.

Plan Of Correction

F6841 Quality of Care Corrective Action: Resident 1 was discharged on 04/03/2025. LVN 4 is no longer employed at the facility. Other Residents Affected Identification: On 5/2/2025, IP Nurse reviewed residents with Blood Pressure monitoring orders. All Blood Pressure Monitoring reflecting on MAR are all being done and documented as ordered by MD. There are no other residents affected by the deficient practice. Measures and Systemic Change: MRD/Designee will initiate a weekly audit on 05/02/25 of all residents with Blood Pressure Monitoring to ensure it is done and documented on the MAR per MD's order. Monitoring Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.

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, specifically an LVN and RNs, demonstrated the necessary competencies and skills to follow physician orders for blood pressure assessment for a resident. The resident in question was admitted with diagnoses including toxic encephalopathy and depression, and was determined by a physician to lack capacity for decision-making, though the Minimum Data Set indicated cognitive intactness. The resident's care plan did not address the diagnosis of hypotension, despite a physician order to monitor for orthostatic hypotension once weekly. Review of the Medication Administration Record showed that the required monitoring for orthostatic hypotension was not documented on the specified date. During interviews, it was confirmed that the LVN did not follow the facility's job description, which requires accurate and timely documentation of resident assessments and care. The absence of documentation was interpreted by staff as evidence that the assessment was not performed. Further interviews with the DON and review of job descriptions for both LVNs and RNs revealed that the nursing staff did not fulfill their responsibilities for documentation and implementation of physician orders. The DON acknowledged that the RNs did not complete the required documentation or provide the ordered care, and stated that additional training was needed for the involved staff.

Plan Of Correction

F 726 Competent Nursing Staff Corrective Action: LVN 4 is no longer employed at facility. Other Residents Affected Identification: There are no other residents affected by this deficient practice. Measures and Systemic Change: DON/Designee initiated skills competency (on 05/02/25) regarding accurate blood pressure monitoring for all Licensed Nurses on 05/02/2025. DSD to ensure all new hires have a skills competency prior to starting. Monitor Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.

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 was physically assaulted by their roommate, resulting in significant injuries. The incident involved two residents, both with complex psychiatric and cognitive diagnoses, including schizophrenia, major depressive disorder, and dementia. On the day of the incident, one resident approached the other's bed and began making the bed while the other was still sleeping. This led to a confrontation where one resident grabbed the other's hair, and the other responded by hitting and scratching, resulting in a closed head injury and a nasal bone fracture for one of the residents. Both residents sustained visible injuries, including scratches, bleeding, and pain. Staff, including a CNA and an LVN, responded to the altercation after hearing yelling and screaming from the room. Upon entering, they observed the residents physically engaged and separated them. The injured resident was subsequently transferred to a hospital for evaluation and treatment, where imaging confirmed a nasal bone fracture and a closed head injury. The other resident was later transferred to another hospital on a psychiatric hold due to ongoing aggressive behavior. The report details that both residents had a history of mental health and cognitive impairments, and staff interviews indicated that residents with aggressive behaviors should be closely monitored to prevent such incidents. The facility's policy emphasized the commitment to protecting residents from abuse by anyone, including other residents. However, the actions and inactions leading up to the event, including the lack of effective monitoring or intervention prior to the altercation, resulted in a failure to ensure the right of residents to be free from abuse and physical harm.

Plan Of Correction

CORRECTIVE ACTION: On 3/20/25, Resident 4 was assessed by the licensed nurse, initial treatment was provided, Analgesic was provided for pain and was transferred to a General Acute Care Hospital for further evaluation. Resident 4 returned the same day and room change was initiated. Treatment for scratches to face continued until resolved on 3/31/25. Resident did not have any complaints of pain upon return and throughout the stay at the facility. On 3/21/25 and 3/24/25, Social Services Director conducted a room visit to Resident 4 and Resident 4 had no concerns regarding care or safety. On 3/21/25, Psychiatrist consult was conducted and Resident 4 had no new onset of any Psychiatric concern and stated she feels safe in the facility. On 4/9/25, x-ray of nose was ordered but resident refused. On 4/10/25, x-ray was re-offered but resident still refused stating she does not have any pain. Risks and benefits explained but still refused. Primary Physician and Responsible Party was notified. On 3/20/25, Resident 5 was assessed by the licensed nurse, initial treatment was provided, Analgesic was provided for pain, one-on-one sitter was initiated and was transferred to a General Acute Care Hospital for further evaluation. Resident 5 returned to the facility the same day with no major injuries noted. On 3/20/25 and 3/21/25, Social Services Director conducted a room visit to Resident 5 and Resident 5 had no concerns regarding care or safety after she was separated from Resident 4. Resident 5 continued to have one-on-one sitter until transferred to another facility per Resident 5's request. Resident 5 will not return to the facility. On 3/21 and 3/24, all staff was provided in-servicing on Resident-to-resident altercation/abuse prevention, reporting and investigation. On 4/10/2025, an All Staff meeting was conducted with outside resources to in-service on behavior management of residents. **IDENTIFYING OTHER RESIDENTS AT RISK** All residents had potential for harm due to the deficient practice. On 4/10/25, facility audited residents with a history of aggressive behavior and 16 residents were identified. 2 of 16 identified residents had an altercation on 3/30/25 that was immediately de-escalated by staff with no negative outcome. On 4/10/25, SSD/designee interviewed 48 residents with capacity to make decisions and make needs known to ensure resident safety and roommate compatibility. 2 residents who verbalized concerns with roommates were moved to another room per resident's request. **SYSTEMIC CHANGES** Hallway Monitor Program (24/7 monitoring) was initiated on 3/29/25. All Hallway Monitoring Aides have undergone Skills Competency conducted by DSD/Designee. Monitoring aides will do rounds every two hours to identify residents with potential escalating behaviors that could lead to aggression. Findings will be logged onto a Hallway Monitor Form and will be reported and addressed accordingly. A certified Management Assaultive Behavior trainer resource initiated an in-person training on 4/10/25 to staff regarding preventing resident-to-staff and resident-to-resident altercation by identifying potential behaviors and how to de-escalate situations that may lead to altercation. Psychology visits will be increased to weekly at minimum for all residents with a history of aggressive behavior and will be referred to a Psychiatrist as needed. **MONITORING EFFECTIVENESS** The SSD/designee will report concerns or issues related to the deficient practice to the DON and/or Administrator for follow-up. Staff will also be encouraged to identify trends and vocalize concerns related to the deficient practice by utilizing the Administrator's open door policy and by participating in providing feedback at the mandatory monthly All Staff Meeting. Reports and findings will be submitted to the QAA Committee for further review and recommendations. Submissions to the committee will be monthly for a period of 3 months or until full compliance is achieved.

Penalty

Fine: $100,16033 days payment denial

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

Summary

The facility failed to provide a safe environment and adequate supervision for two residents, resulting in preventable injuries. For one resident with Huntington's Disease and dementia, staff did not implement care plan interventions designed to reduce self-injurious behavior, such as anticipating needs and providing positive interaction. Additionally, staff failed to follow a physician's order for hourly monitoring of this resident's aggressive behavior. As a result, the resident sustained a self-inflicted scalp laceration and contusion after banging their head on a door, requiring hospital treatment. Subsequently, the same resident was involved in a physical altercation with a roommate, resulting in a nasal fracture, scalp hematoma, and severe facial pain, again necessitating hospital evaluation. Interviews with staff and review of records confirmed that the required hourly monitoring was not performed prior to these incidents, and staff were unaware of the monitoring order. Another resident, who was dependent on staff for eating due to severe cognitive impairment and upper extremity dysfunction, was left unsupervised with a lunch tray placed within reach. Despite being assessed as a moderate fall risk and requiring total assistance for eating, staff delivered the meal tray to the resident's room before being ready to assist. The resident attempted to reach for the tray independently and fell. Staff interviews confirmed that the tray should not have been delivered until assistance was available, and the DON acknowledged that the resident's confusion and inability to recognize hazards contributed to the fall. Facility policy required individualized supervision and environmental adjustments based on resident risk factors, including cognitive status and physical limitations. However, in both cases, staff failed to adhere to these requirements, resulting in injuries. Documentation and interviews revealed that staff were either unaware of or did not follow care plans and physician orders for supervision and monitoring, directly leading to the incidents described.

Plan Of Correction

F 689: FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CORRECTIVE ACTION Resident #37 was transferred to a General Acute Hospital on 3/2/25 for evaluation following self-inflicted injuries. On 3/4/25, the resident was placed under 1:1 sitter supervision for close monitoring. A healthcare provider ordered a helmet for the resident to wear while out of bed to prevent further self-inflicted harm. The IDT convened on (date) to review and update Resident #37's comprehensive care plan. On 3/24/2025, the DSD/Designee provided nursing staff with education on the importance of hourly monitoring for Resident #37, emphasizing behavioral observations and self-inflicted injuries. Resident #294 attempted to retrieve his lunch tray from the bedside table independently and was found on the floor on 3/5/25. The resident was assessed for injuries and placed under Close Observation and Care (COC) monitoring from 3/5/25 to 3/8/25. No injuries were noted from the fall. CORRECTIVE ACTION (CONTINUED) On 3/25/2025, the DON/Designee conducted an in-service training for licensed staff covering: - Comprehensive care planning for managing residents with self-inflicted injuries and aggressive behaviors - Abuse and neglect prevention and prohibition On 3/25/2025, the DSD/Designee provided CNAs with education on: - Abuse and neglect prevention and prohibition - Close supervision of residents during behavioral escalations and the immediate reporting of any behavioral changes to licensed staff - Safety and supervision during mealtimes, with a focus on residents requiring total assistance with eating OTHER RESIDENTS AFFECTED IDENTIFICATION All residents had the potential to be affected by the alleged deficient practice. From 3/21/25 to 3/25/25, licensed staff and the IDT conducted facility rounds to observe residents for any behaviors indicating self-inflicted injuries. No additional residents were observed with self-inflicted injuries. CORRECTIVE ACTION (CONTINUED) On 3/25/2025, the DON/Designee conducted an in-service training for licensed staff covering: - Comprehensive care planning for managing residents with self-inflicted injuries and aggressive behaviors - Abuse and neglect prevention and prohibition On 3/25/2025, the DSD/Designee provided CNAs with education on: - Abuse and neglect prevention and prohibition - Close supervision of residents during behavioral escalations and the immediate reporting of any behavioral changes to licensed staff - Safety and supervision during mealtimes, with a focus on residents requiring total assistance with eating OTHER RESIDENT AFFECTED (CONTINUED) On 3/28/25, the DSD/Designee monitored meal times to assess whether residents requiring total assistance with eating had their meal trays left on the bedside table before receiving assistance. No residents were observed experiencing the alleged deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/21/25, the Director of Nursing (DON) or designee conducted an additional in-service training session for licensed staff, focusing on the following topics: - Comprehensive care planning for residents with self-inflicted injuries and aggressive behaviors - Strategies for preventing and prohibiting abuse and neglect - Licensed staff rounds during mealtimes to ensure resident safety and supervision From 3/21/25 to 3/25/25, the Director of Staff Development (DSD) or designee provided training to CNA staff, which included: - Close supervision during behavioral escalations, along with immediate reporting of concerns to licensed staff - Accurate documentation for residents requiring close monitoring - Safety and supervision during mealtimes, specifically for residents who need total assistance with eating On 3/29/25, facility will initiate a hallway monitoring program where a monitoring aide will do rounds every two hours to identify residents with potential escalating or self-inflicting injuries behaviors. Findings will be logged on a Hallway Monitor Form and will be reported and addressed accordingly. As part of new hire orientation and annual performance evaluation, the DSD/Designee shall provide ongoing staff training and competency development in safety, supervision, and abuse prevention. PERFORMANCE MONITORING The safety committee will perform monthly audits of behavioral incident reports, staff training compliance, and the effectiveness of the hallway monitor program. Findings will be received during monthly safety QAPI meetings, where necessary adjustments to training and monitoring programs will be made based on recommendations. The Administrator/Designee will oversee the continued effectiveness of these systemic interventions and allocate additional resources as needed.

Penalty

Fine: $100,16033 days payment denial

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

Summary

The facility failed to ensure that residents and/or their responsible parties were properly informed about their rights to formulate an Advance Directive (AD) and that documentation regarding ADs and Physician Orders for Life-Sustaining Treatment (POLST) was accurate and complete. In several cases, forms were either incomplete, not signed by the appropriate party, or not filled out at all. For example, one resident's POLST and AD Acknowledgement Form were signed by an individual who was not the documented responsible party, and the facility's records did not clarify the authority of the signer. In another instance, a resident's AD Acknowledgement Form was missed entirely during the admission process, which was later acknowledged by the Social Services Designee (SSD) as an oversight. Multiple residents with varying degrees of cognitive impairment and medical complexity were affected by these documentation failures. Some residents were cognitively intact and able to make their own medical decisions, while others were severely or moderately impaired and dependent on staff or responsible parties for decision-making. In several cases, the AD Acknowledgement Forms were not fully completed, with key sections left unchecked regarding whether the resident had executed an AD. Additionally, some POLST forms were not signed and dated by the resident, and in at least one case, the responsible party was incorrectly identified and allowed to sign critical documents. Interviews with facility staff, including the SSD, RNs, LVNs, and the Director of Nursing (DON), confirmed that these omissions and inaccuracies were due to lapses in the admission and documentation process. Staff acknowledged that the forms should be completed upon admission and that incomplete or missing documentation could result in staff not knowing the resident's wishes in emergency situations. The facility's own policy required inquiry about advance directives prior to or upon admission, but this was not consistently followed, as evidenced by the incomplete or missing forms for several residents.

Plan Of Correction

F578: Request/Refuse/Discontinue Treatment; Formulate Adv Dir CORRECTIVE ACTION From 3/21/25 to 3/25/25, the SSD and SSA added an accurately completed copy of the Advance Directive Acknowledgement Form (ADAF) and Physician Orders for Life-Sustaining Treatment (POLST) to the medical records of Residents 5, 6, 11, 35, 37, 41, and 75 signed by residents or appropriate Responsible Party depending on residents' capacity to make decisions. On 3/21/25 the DON conducted an in-service for Licensed Staff, SSD, Medical Records regarding the importance of completing the Advance Directive Acknowledgement Form and Physician Orders for Life-Sustaining Treatment (POLST) accurately signed by resident or appropriate Responsible Party depending on residents' capacity to make decisions upon admission. OTHER RESIDENTS AFFECTED IDENTIFICATION From 3/21/25 to 3/25/25, the SSD and SSA conducted a comprehensive review of all active residents to ensure they had been provided with information on formulating an Advance Directive and that any completed POLST forms were accurate. Upon completion of the review, no additional residents were found to be affected by this deficient practice. MEASURES AND SYSTEMIC CHANGES Upon admission, new residents will be provided with information on how to formulate an Advance Directive. If an Advance Directive is already in place, a copy will be obtained from the resident or their representative and promptly placed in the resident's medical record upon receipt. The SSD/SSA, in coordination with the Medical Records (MR) department, will ensure that all residents receive information on Advance Directives and that a copy is obtained from the resident or their representative, if applicable, and placed in their medical record. The SSD/SSA, in coordination with the Medical Records Director (MRD), will ensure that the Advance Directive Acknowledgment Form (ADAF) is completed and that residents' POLST forms are accurately completed upon admission. MONITORING PERFORMANCE The Social Service Director (SSD) and Administrator will ensure that the above process is consistently maintained. The SSD or designee will report any trends or issues related to providing residents with information on creating an Advance Directive and completing a POLST, as well as confirming whether a copy of the ADAF and POLST is included in the resident's medical record. These reports will be submitted to the QAA Committee monthly for a period of three months or until compliance is achieved, for further review and any additional recommendations.

Penalty

Fine: $100,16033 days payment denial

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

Summary

Three deficiencies were identified regarding the facility's failure to provide a safe, clean, and homelike environment for three residents. One resident's personal wheelchair went missing two to three weeks prior and was not reported to the Social Services Director as required. The resident, who had moderate cognitive impairment and relied on the wheelchair for mobility, reported the loss to a CNA, but no theft and loss report was initiated. The absence of the wheelchair limited the resident's ability to move freely and participate in activities such as going outside to smoke. Another resident, who had severe cognitive impairment and required assistance for toileting, was found to have a broken toilet seat in their bathroom. The seat was loose and missing a screw, leaving it detached from the toilet rim. The issue was reported by the resident's responsible party to staff, but the seat remained unrepaired at the time of observation. The resident's care plan indicated a risk for injury due to falls, and the broken seat presented a potential hazard during transfers. A third resident, who was dependent for all activities of daily living and had severe cognitive impairment, was found in a room where the patio sliding door could not be fully closed. Cold air was entering the room, and the maintenance supervisor was unable to close the door due to dirt in the track. The door had no screen, and it was noted that it was going to rain that day. The DON confirmed that such conditions were not homelike and could lead to discomfort or illness for the resident. Facility policies required prompt investigation of missing property, maintenance of equipment in good repair, and provision of a homelike environment, but these were not followed in the cited instances.

Plan Of Correction

F 584: Safe/Clean/Comfortable/Homelike Environment CORRECTIVE ACTION Resident 11's personal wheelchair was reported missing to the Social Services Director (SSD), and on 3/7/2025, a replacement wheelchair was provided for Resident 11. On 3/7/2025, Maintenance Director secured and fully attached the toilet seat in Resident 63's bathroom. On 3/10/2025, Maintenance Director repaired Resident 68's patio door to ensure it could be fully closed. OTHER RESIDENT AFFECTED IDENTIFICATION On 3/7/2025, the administrator and maintenance supervisor conducted environmental rounds to ensure all residents had a clean and safe environment. They confirmed that all patio doors could be fully closed and toilet seats were securely attached. No other residents were found to be impacted by the alleged deficiencies. On 3/7/2025, the SSD performed an inventory of residents with personal wheelchairs. No other residents were found to be affected by the alleged deficiency. MEASURES AND SYSTEMIC CHANGES Department heads will perform daily room rounds from Monday to Friday, ensuring that equipment in residents' rooms is in good working condition. Findings will be communicated to the leadership team during the daily standup. Maintenance staff will conduct monthly room rounds for all residents' rooms to verify that doors and toilet seats are in proper working condition. Upon a resident's new admission or issuance of a personal wheelchair, licensed staff must inventory the wheelchair and ensure it is marked for the resident's use only. Any missing or lost personal wheelchairs must be documented in the theft and loss log by the SSD/SSA for resolution. MONITORING PERFORMANCE The Maintenance Supervisor will present the findings from maintenance logs, specifically regarding the environmental inspections of patio doors and toilet seats, to the monthly Safety Committee for three months or until compliance is achieved for further review and recommendations. The Administrator is responsible for ensuring the continuity and sustainability of this process. The SSD will report any instances of lost or missing personal wheelchairs to the monthly QAA Committee for monitoring. 3/28/2025

Penalty

Fine: $100,16033 days payment denial

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

Summary

The facility failed to develop and implement comprehensive, individualized care plans for four residents, as required by federal regulations. For one resident with end stage renal disease, Type 1 diabetes mellitus, and a history of myocardial infarction, there was no care plan addressing the administration of an anti-psychotropic medication (Olanzapine). The resident was cognitively intact and able to make medical decisions, but the absence of a care plan meant that staff did not have documented goals or interventions related to the use of this medication. The facility's own policy required individualized care plans with measurable objectives and timetables to be developed within seven days of the comprehensive assessment, but this was not followed. Another resident, with a history of hyperlipidemia, dementia, and cerebral infarct, was involved in a resident-to-resident altercation and attempted to elope from the facility. Despite these significant events, there was no care plan created to address the altercation or the risk of elopement. Staff interviews confirmed that the lack of care plans for these incidents placed the resident at risk for recurrence, as interventions to prevent future incidents were not implemented and the care team was not made aware of the resident's history. A third resident, admitted with respiratory failure, a gastrostomy, and dementia, did not have a care plan for dementia upon admission, despite severe cognitive impairment and total dependence for activities of daily living. Staff and the DON acknowledged that a care plan should have been created at admission to guide care. Similarly, another resident with sickle-cell disease, bipolar disorder, and PTSD did not have a care plan addressing PTSD. Staff were unaware of the diagnosis, and both nursing staff and the DON stated that a care plan was necessary to ensure consistent, individualized care and to address the resident's specific psychological needs. The facility's policy required comprehensive, person-centered care plans for all residents, but this was not consistently implemented.

Plan Of Correction

F656: DEVELOP/ IMPLEMENT COMPREHENSIVE CARE PLAN CORRECTIVE ACTIONS Resident 5 was reassessed on 3/13/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident's current status. Resident 196 was transferred to an acute hospital on 3/6/25 for evaluation and treatment per MD order. Resident readmitted to the facility, and the comprehensive care plan was updated reflecting the resident's current status. Resident 37 was reassessed on 3/4/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident to resident altercation and the resident's current status. Resident 68 was reassessed on 3/5/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident's current status. Resident 47 was reassessed on 3/5/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident's current status. OTHER RESIDENTS AFFECTED IDENTIFICATION IDT conducted chart review on 3/25/25 and 3/28 to all active residents, including newly admitted residents, to ensure that the plan of care is current and updated to meet the resident needs. Two other residents were found to have been affected by the deficient practice. The comprehensive care plan was reviewed and updated for the affected residents on 3/28/25. DON and/or designee provided in-service to the RNs and LVNs on 3/21/25 about the importance of initiating care plans timely upon admission and updating the resident's care plan for any change of conditions. MEASURES AND SYSTEMIC CHANGES Resident's clinical records will be reviewed by the IDT within 48 hours of admission to check for care plan completion and if special care issues reported by the endorsing hospital are addressed in the care plan. MDS staff will complete the comprehensive care plan within 7 days of a resident's comprehensive assessment to outline the resident's needs, goals, and interventions to promote their well-being. OTHER RESIDENTS AFFECTED IDENTIFICATION IDT conducted chart review on 3/25/25 and 3/28 to all active residents, including newly admitted residents, to ensure that the plan of care is current and updated to meet the resident needs. Two other residents were found to have been affected by the deficient practice. The comprehensive care plan was reviewed and updated for the affected residents on 3/28/25. DON and/or designee provided in-service to the RNs and LVNs on 3/21/25 about the importance of initiating care plans timely upon admission and updating the resident's care plan for any change of conditions. MEASURES AND SYSTEMIC CHANGES Resident's clinical records will be reviewed by the IDT within 48 hours of admission to check for care plan completion and if special care issues reported by the endorsing hospital are addressed in the care plan. MDS staff will complete the comprehensive care plan within 7 days of a resident's comprehensive assessment to outline the resident's needs, goals, and interventions to promote their well-being. MEASURES AND SYSTEMIC CHANGES (CONTINUED) Licensed nurse will update the resident's plan of care within 24 hours for any resident’s COC and special needs lists. PERFORMANCE MONITORING The IDT will conduct care plan meetings within 7 days after admission to discuss the resident's overall care and level of assistance required, then quarterly and as needed for any unusual occurrence. The DON/designee will review the special needs list for accuracy and completeness weekly and as needed. The DON/designee will monitor the corrective action for continuous compliance. Findings will be reviewed by the Director of Nursing/Designees weekly for the first three months and will be presented to the QA committee monthly for three months for further evaluation and recommendations. 3/28/2025

Penalty

Fine: $100,16033 days payment denial

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

Summary

The facility failed to provide care in accordance with professional standards of practice for two residents. For one resident, who had diagnoses including acute osteomyelitis and cellulitis, there were medical orders to flush a Peripherally Inserted Central Catheter (PICC) and a Midline catheter with normal saline before and after medication administration and at regular intervals for maintenance. Review of the Treatment Administration Record (TAR) revealed multiple blank entries on specific dates, indicating that the required flushing was not performed or not documented. Both the RN Supervisor and the Director of Nursing confirmed that if the procedure was not documented, it was considered not done, and that failure to flush the lines could compromise the patency of the intravenous access. For another resident, who was severely cognitively impaired and dependent for activities of daily living, there was a failure to perform and document weekly skin assessments as required by facility policy. The resident reported having a sore, and observation confirmed the resident was in bed. Interviews with the DON and the treatment nurse revealed that the last documented skin assessment was shortly after the resident's readmission, with no subsequent weekly assessments found in the records. The treatment nurse acknowledged the importance of regular skin assessments and was unable to provide documentation of ongoing monitoring for the resident's skin condition. These deficiencies were identified through interviews, record reviews, and observations, and were confirmed by facility staff. The lack of adherence to medical orders for catheter care and the absence of required skin assessments represented failures to provide care in accordance with professional standards and facility policy.

Plan Of Correction

F684: Quality of Care CORRECTIVE ACTION On 3/27/2025, review of Resident 27 MAR regarding IV flushing showed that flushing is rendered by RN before and after IV medication administration per MD's order. On 3/19/2025 and 3/25/2025, Treatment Nurse with the Nurse Practitioner assessed the skin of Resident 49, and the skin is improving with no complications noted. OTHER RESIDENTS AFFECTED IDENTIFICATION All residents with IV orders were reviewed on 3/10/2025, and no other residents were affected by the deficient practice identified. On 3/27/2025, all residents with skin conditions were reviewed for appropriate assessment and documentation. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, in-service was provided by the DON to Licensed Nurses regarding the importance of flushing pre- and post-medication administration per MD's order for prevention of complications such as clotting and maintaining patency of the access site. On 3/25/2025, in-service was provided by the DON/Designee to Licensed Nurses regarding the importance of weekly skin assessments for residents with skin conditions. DON, ADON, RN Supervisor/Designee will monitor three times weekly the IV MAR to ensure flushing before and after medication administration is rendered per MD's order and is documented promptly in the IV MAR. OTHER RESIDENTS AFFECTED IDENTIFICATION All residents with IV orders were reviewed on 3/10/2025, and no other residents were affected by the deficient practice identified. On 3/27/2025, all residents with skin conditions were reviewed for appropriate assessment and documentation. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, in-service was provided by the DON to Licensed Nurses regarding the importance of flushing pre- and post-medication administration per MD's order for prevention of complications such as clotting and maintaining patency of the access site. On 3/25/2025, in-service was provided by the DON/Designee to Licensed Nurses regarding the importance of weekly skin assessments for residents with skin conditions. DON, ADON, RN Supervisor/Designee will monitor three times weekly the IV MAR to ensure flushing before and after medication administration is rendered per MD's order and is documented promptly in the IV MAR. MEASURES AND SYSTEMIC CHANGES (CONTINUED) DON/Wound IDT, during a weekly wound meeting, will conduct an audit ensuring all residents with skin conditions have skin assessments completed and documented on residents' medical records. MONITORING PERFORMANCE ADON/RN Supervisor will conduct weekly monitoring for four weeks, then monthly thereafter, of IV flushing and skin assessments until 100% compliance is obtained. These reports will be submitted to the QAA committee monthly for a period of three months or until compliance is achieved, for further review and any additional recommendations. MEASURES AND SYSTEMIC CHANGES (CONTINUED) DON/Wound IDT, during a weekly wound meeting, will conduct an audit ensuring all residents with skin conditions have skin assessments completed and documented on residents' medical records. MONITORING PERFORMANCE ADON/RN Supervisor will do weekly monitoring for four weeks, then monthly thereafter, of IV flushing and skin assessments until 100% compliance is obtained. These reports will be submitted to the QAA committee monthly for a period of three months or until compliance is achieved, for further review and any additional recommendations.

Penalty

Fine: $100,16033 days payment denial

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

Summary

The facility failed to provide appropriate treatments and services to prevent the development and promote the healing of pressure ulcers for four residents. For two residents, the low air loss mattresses (LALM) intended for wound management and prevention were found to be set on static pressure rather than alternating pressure, contrary to physician orders and manufacturer instructions. Observations confirmed that the static mode was engaged during times when the residents were not receiving care, and documentation of LALM settings was missing for certain shifts. Staff interviews confirmed that leaving the mattress on static mode could prevent wound healing and increase the risk of skin breakdown, especially for residents unable to reposition themselves. Another resident, who was dependent for activities of daily living and mobility, did not have prescribed heel boots in place for offloading purposes as ordered by the physician. The absence of heel protectors was observed during a room check, and staff acknowledged the importance of following physician orders to prevent pressure ulcers, particularly for residents with limited mobility and increased risk of skin breakdown. Facility policy also emphasized the need to "float heels" or use protective devices as recommended by clinical staff or the physician. Additionally, a fourth resident was found lying on a bariatric LALM that was set at a weight significantly higher than the resident's actual weight. Staff interviews indicated that incorrect mattress settings could compromise the effectiveness of pressure redistribution, increasing the risk of skin breakdown. The resident's physician order required monitoring of proper mattress functioning and placement every shift, but the observed setting did not match the resident's documented weight. Facility policy and the user manual for the mattress system both highlighted the importance of correct settings for optimal support and pressure relief.

Plan Of Correction

F686: Treatment/Service to prevent/heal Pressure ulcer CORRECTIVE ACTION On 3/7/2025, LALM setting was corrected for residents 36, 20, and 16. On 3/7/2025, offloading boots were put on resident 1's feet. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/7/2025, the treatment nurse and licensed nurses checked all residents with LALM and offloading boots to verify that they are being utilized as ordered. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/21/2025, DON/Treatment nurse provided an in-service training to licensed nurses on how to operate air loss mattress for correct setting. DON/designee will randomly check residents' LALM setting weekly to verify that they are correctly set per MD orders. DON/designee will randomly check residents with offloading boots orders if they are properly carried out. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.

Penalty

Fine: $100,16033 days payment denial

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

Summary

The facility failed to implement its pain assessment and management policy for two residents by not communicating pain specialist recommendations to the medical doctor and by not notifying a physician when a resident's pain management was ineffective. For one resident with major depressive disorder and neuropathy pain, the pain specialist recommended attempting nonpharmacological interventions before administering medications and discontinuing Gabapentin. These recommendations were documented in progress notes but were not communicated to the attending physician, and there were no orders or documentation of nonpharmacological interventions being attempted. The resident reported that staff did not try any nonpharmacological interventions for their bilateral leg pain, and the nurse confirmed that the recommendations were not relayed to the physician as required. For another resident with end stage renal disease, Type 1 diabetes, and a recent myocardial infarction, pain management orders included Hydrocodone-Acetaminophen and Gabapentin. Despite ongoing reports of significant pain, with pain scores ranging from 6 to 9 out of 10 over several days, the resident stated that the pain medication was not effective and had informed nurses of this. The medication administration record showed persistent high pain levels, and there was no evidence that the physician was notified about the lack of pain control. A nurse acknowledged not contacting the physician due to being busy, despite recognizing that the pain management was not effective. Both cases demonstrated a failure to follow the facility's policy, which requires a multidisciplinary approach to pain management, including communication of recommendations and monitoring the effectiveness of interventions. The director of nursing confirmed that the pain specialist's recommendations and the resident's complaints should have been communicated to the attending physician, and that these omissions placed the residents at risk of not achieving optimal pain relief.

Plan Of Correction

F 697: Pain Management CORRECTIVE ACTION On 3/6/25, Resident 25 pain medication was reviewed, and non-pharmacologic intervention prior to administering pain medication ordered was given by MD. On 3/27/25, Resident 5 returned to the facility and pain assessment was reviewed and completed. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/27/2025, DON reviewed all orders for residents with pain management to ensure pain medications and non-pharmacologic intervention were performed prior to pain medication administration. No other resident was affected. 3/28/2025

Penalty

Fine: $100,16033 days payment denial

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

Summary

The facility failed to provide sufficient nursing staff with the appropriate competencies and skills to meet the needs of three residents, as evidenced by multiple delays in care and unmet resident needs. Resident 5, who was cognitively intact and required assistance with personal hygiene and dressing, reported waiting up to an hour for staff to assist with her nasal cannula for oxygen, both at night and during the day. Resident 6, who was severely cognitively impaired, legally blind, and required substantial assistance with toileting, stated she often waited an hour or more for staff to change her incontinence pad, and had developed a sore on her bottom. Resident 41, who was moderately cognitively impaired and required maximal assistance with bathing and toileting, was observed calling for help from her bed and reported waiting up to two hours for restroom assistance. Staff interviews revealed that CNAs did not consistently follow facility policy regarding the endorsement of resident care when leaving their assigned areas for breaks or lunch. One CNA admitted to not informing another CNA upon returning from lunch, resulting in a lack of coverage for assigned residents. Other CNAs confirmed that the policy required them to endorse care to another CNA when leaving the unit, but this was not always practiced. The DON stated that all staff, including housekeeping, were trained to answer call lights and that call lights should be answered within ten minutes, but observations and resident reports indicated this standard was not consistently met. Resident council feedback and direct resident interviews further corroborated the staffing issues, with residents reporting frequent and prolonged waits for assistance. Facility policies reviewed indicated a requirement for sufficient and competent nursing staff and prompt response to call lights, but these procedures were not consistently followed, resulting in unmet care needs for multiple residents.

Plan Of Correction

CORRECTIVE ACTION On 3/6/2025, staff answered the call lights timely. On 3/21/25, staff were provided in-service by the DON regarding the importance of answering call lights timely and the importance of endorsing resident care before going on breaks and/or leaving for the day. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/24/25, the SSD interviewed 7 alert residents to ask if the call lights are being answered timely. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES During the shift huddle, staff will be reminded to answer call lights promptly and to endorse resident care before going on breaks and/or leaving for the day by the RN supervisor/designee. DON/designee will interview 5 random residents weekly to check if their lights are being answered timely. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.

Penalty

Fine: $100,16033 days payment denial

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

Summary

The facility failed to ensure that intravenous antibiotics, Zosyn and Daptomycin, were administered according to the physician's orders for a resident diagnosed with acute osteomyelitis of the left foot and ankle and cellulitis. The resident was admitted and readmitted with these diagnoses and had intact cognitive abilities. Physician orders specified Zosyn IV every eight hours and Daptomycin IV once daily for a set period. Review of the resident's Intravenous Medication Administration Record (IMAR) revealed blank spaces on multiple dates for both medications, indicating missed doses. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that blank spaces on the IMAR meant the medications were not administered as ordered. The facility's policy required that the individual administering the medication document the administration in the resident's Medication Administration Record immediately after giving the dose. The failure to document and administer the antibiotics as ordered was confirmed through interviews and record reviews, with staff acknowledging that the missed doses could impact the resident's treatment for infection. The deficiency was identified through direct review of medical records and staff interviews, which established that the resident did not receive prescribed antibiotics on several occasions.

Plan Of Correction

F755: Pharmacy Services/ Procedure/ Pharmacist/ Records CORRECTIVE ACTION MD notified on the missed dosage of Daptomycin and Zosyn on 3/10/25 on Resident 27. MD's recommendation was to monitor adverse reaction and complication of the missed medication. Resident was assessed by RN on 3/10/25 and no new onset of acute distress noted. OTHER RESIDENTS AFFECTED IDENTIFICATION Review of the residents with IV medication orders was conducted on 3/10/2025 and no other deficient practice was noted. All IV medication orders were being administered as ordered. MEASURES AND SYSTEMIC CHANGES DON/Designee to monitor IV documentation QD x2 weeks then 2x/week x 2 weeks then monthly thereafter to ensure all IV medications are being administered as ordered by MD. Medical record will include in the daily audit the IV MAR for any missed dose of IV medications ordered by MD. DON conducted an in-service on 3/25/2025 to Registered Nurses regarding the importance of administration of IV Medication as ordered by MD. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met. DON conducted an in-service on 3/25/2025 to Registered Nurses regarding the importance of administration of IV Medication as ordered by MD. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.

Penalty

Fine: $100,16033 days payment denial

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

Summary

The facility failed to follow its own policy and federal regulations regarding the use of psychotropic medications for two residents. For one resident, an order for Ativan (lorazepam) 0.5 mg every six hours as needed for anxiety did not include a required 14-day end date. Both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that PRN psychotropic medications must have a 14-day limit, and the absence of an end date was acknowledged as a risk for unnecessary medication use. The facility's policy also specified this 14-day limitation for PRN psychotropic orders. For another resident, the facility did not obtain a signed informed consent for the use of Olanzapine (an antipsychotic) and Lorazepam. The resident was cognitively intact and had the capacity to make medical decisions, as documented in the medical record. The resident reported refusing the medication and stated that no consent had been signed. Review of the resident's records confirmed that the informed consent forms for these medications were not signed by the resident. The DON and LVN both stated the importance of informed consent, and the facility's policy required written informed consent before initiating psychotropic medications. Additionally, the resident prescribed Olanzapine did not have a documented diagnosis supporting the use of this medication in the admission record, as confirmed by the DON. The facility's policy required that psychotropic medications be prescribed only after a personal examination and with a specific diagnosis documented. The lack of a supporting diagnosis and missing informed consent for psychotropic medication use were direct violations of both facility policy and federal requirements.

Plan Of Correction

F758: Free from Unnecessary Psychotropic Meds/ PRN Use CORRECTIVE ACTIONS Resident 197's Ativan was discontinued on 3/18/25 as ordered by MD. No reports of new onset of acute distress noted related to previously not having a 14-day stop date. On 3/21/25, the SSD validated that the informed consent for Resident's 5 the use of Olanzapine and Lorazepam has been obtained. The informed consent verification was done on 3/21/25. OTHER RESIDENTS AFFECTED IDENTIFICATION The DON/Designee audited all residents on 3/21/25 to 3/28/25 receiving Psychotropic medications if a valid informed consent has been verified. There are 72 residents receiving Psychotropic medications - all informed consents for residents on Psychotropics have been verified from 3/21/25 to 3/28/25. All other residents with PRN psychotropics are noted with a 14-day stop date. MEASURE AND SYSTEMIC CHANGES The DON/Designee initiated education to licensed staff on 3/21/25 to ensure that any residents receiving psychotropic medications shall have an informed consent verified prior to initial administration and all PRN Psychotropics must have a 14-day stop date initially upon ordering. DON/DSD to monitor all PRN medication prescribed to ensure order is limited to 14 days. Bimonthly for 2 months, then monthly for 3 months, then quarterly thereafter. MONITORING PERFORMANCE The DON/SSD will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.