The Rehabilitation Center On Pico

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 individualized person-centered care plans for three sampled residents to address specific needs identified in their records and observed by surveyors. For Resident 21, the record showed an admission with diagnoses including metabolic encephalopathy, dementia, and HTN, and a physician order allowing out on pass for therapeutic services for four hours with family. The resident’s MDS showed moderately impaired cognition and independence with many activities of daily living. The resident’s leave-of-absence forms showed repeated outings with family, and during interviews on 3/16/2026, staff confirmed the resident frequently went out with her granddaughter. Staff also confirmed that Resident 21 did not have a care plan for being out on pass, even though they stated such a plan should have included review of physician orders, verification of family involvement, education on expected return time, medication, and emergency instructions. The DON also confirmed the absence of a care plan for out on pass, and the resident stated she had not been informed of any time limitation, had not received education about return times or emergencies, and did not take prescribed medications with her when she left the facility. For Resident 50, the record showed diagnoses including necrotizing fasciitis, an unspecified open wound of the left lower leg, generalized muscle weakness, bipolar disorder, and schizophrenia. The resident had an order allowing out on pass, not to exceed 4 hours, for therapeutic purposes. The MDS showed the resident was cognitively intact and able to walk at least 150 feet, and the wandering/elopement risk evaluation indicated the resident had the ability to walk or self-propel off the premise without assistance. During observation and interview, the resident stated he went out on pass every day. On 3/17/2026, LVN 1 reviewed the order summary and complete care plan report and confirmed there was no care plan for being out on pass. LVN 1 stated the resident should have had a care plan for safety and education, and the DON confirmed the absence of such a plan, stating it was part of the facility policy and that staff would not know how to care for the resident without it. For Resident 37, the record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysarthria, facial weakness, dysphagia, and muscle weakness. The order summary included a low air loss mattress with bolsters for skin maintenance. The physician progress note described the resident as bedbound and nodding to simple questions. The MDS showed severe cognitive impairment, unclear speech, dependence on staff for multiple ADLs, risk for pressure ulcers/injuries, and use of a pressure-reducing device and turning/repositioning program. On 3/19/2026, RN 1 reviewed the order summary and complete care plan report and confirmed there was no care plan for the low air loss mattress. RN 1 stated the resident should have had a care plan for the mattress, including maintenance, function, and correct settings according to the physician’s orders. The DON also confirmed there was no care plan for the low air loss mattress and stated it should have included interventions to prevent pressure injuries and mattress settings.

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 pressure ulcer prevention care consistent with professional standards and physician orders for two residents who were on low air loss mattresses (LALMs) for skin management. Resident 12 was readmitted with dementia, reduced mobility, dependence for personal care, contractures of both ankles, and flexion deformities of both hips. The resident had an active order for a LALM, was assessed as severely cognitively impaired and at risk for pressure ulcers, and the care plan directed staff to ensure the LALM was in place, plugged in, and functioning properly. During a concurrent observation and interview, Resident 12 was found lying on a Serene Air LALM that was off and deflated. The LVN stated the mattress should have been turned on and set to the second setting, did not know how long it had been off, and confirmed it had to be turned on to function properly. The mattress inflated after the LVN turned it on. The TN and DON later stated the resident was at high risk for pressure ulcers, that the LALM was being used for skin maintenance, and that there was potential for skin breakdown if the mattress remained off and not functioning for a long period of time. Resident 37 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, dysarthria, facial weakness, dysphagia, and generalized muscle weakness. The resident had an active order for a LALM with bolsters for skin maintenance, was bedbound, had severe cognitive impairment, was dependent for multiple activities of daily living, and was at risk for pressure ulcers. The resident weighed 97 pounds, but the microAir MA65 LALM was observed set to the 105 to 140 pound range. TN1 confirmed the setting was based on resident weight and stated the mattress should have been set to the 70 to 105 pound range. TN1 and the DON stated the incorrect setting placed the resident at risk for skin issues and pressure injury and did not provide the intended therapeutic benefit of the LALM.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the resident environment was free of accident hazards for one sampled resident who was identified as a high fall risk. The resident had multiple diagnoses including congestive heart failure, muscle weakness, anemia, morbid obesity, hemiplegia and hemiparesis following cerebrovascular disease, type 2 DM, dependence on supplemental oxygen, and dementia. The resident’s MDS showed dependence for multiple activities of daily living and substantial to maximal assistance needs for bed mobility. The resident’s fall risk evaluation identified the resident as high risk for falls, and the care plan included interventions to keep furniture locked in position and avoid repositioning furniture. During observation, the resident’s bed was found in a high position while the resident was in the room. The resident stated she did not put the bed in that position. CNA 5 stated the bed had been left high after therapy, and LVN 1 stated he had entered the room to give the roommate pain medication and should have lowered the resident’s bed afterward because the resident was a high fall risk. RN 1 later stated the resident was a high fall risk and the bed should have been placed in a low position to prevent injury from a potential fall. The bed was again observed in a raised position on a later date, and the DON acknowledged the bed was slightly high. The DON reviewed the facility’s Free of Accident Hazards/supervision/devices policy and stated incorrect bed height was a factor that could result in a fall. Facility policies also stated the facility strives to provide adequate supervision and an environment as free from accident hazards as possible, and identified incorrect bed height as a possible fall factor.

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 safe and sanitary food storage and preparation practices by leaving expired chlorine test strips in use for monitoring the dishwasher, and by failing to discard or properly date multiple food items. During a concurrent observation and interview in the kitchen, an opened bottle of chlorine test paper strips was found with an expiration date of 11/2025. Also observed were an opened container of pickle relish and an opened container of cherries without a use by or expiration date, an opened bottle of caramel sauce with a use by date of 12/17/2025 and an opened date of 3/8/2026, a turkey sandwich with a use by date of 3/14/2026, an opened bag of tortillas with a use by date of 2/28/2026, an opened plastic bag of chicken with a use by date of 3/9/2026, an opened plastic bag of gelatin with a use by date of 2/25/2026, and an opened plastic bag of white bread with an open date of 3/8/2026 and no use by date. During interview, the Dietary Supervisor stated expired chlorine test strips could give an inaccurate reading and could cause cross contamination, and that staff would not know whether the dishwasher was sanitizing dishes properly. The Dietary Supervisor also stated residents could get sick if they ate expired food items, that opened food items without a use by date should have been discarded, and that staff who opened food items should have checked the expiration date, use by date, and labeled the item with an open date and use by date. The Dietary Supervisor stated expired chicken could contain salmonella and could cause food poisoning, and that expired food items should have been thrown away. The DON stated expired chemical test strips would result in an incorrect reading and could potentially allow bacteria to remain on items washed in the dishwasher. The DON also stated residents could get sick and develop food poisoning if served expired food, and that kitchen staff were expected to check expiration dates before use. The DON stated chicken beyond the use by date could cause food poisoning and diarrhea because chicken contained salmonella, and that residents were not responsible for checking expiration dates on their 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 facility failed to ensure the Interdisciplinary Team (IDT) and the public patient representative were convened when Resident 42 did not have the capacity to provide informed consent for Quetiapine Fumarate (Seroquel). Resident 42 was readmitted from the hospital with diagnoses that included hepatic encephalopathy, schizophrenia, dementia, and psychosis. The admission record identified the resident as self-responsible and under the IDT, but later documentation and staff interviews indicated the resident was confused, oriented only to self, and not decisional. The Psychotherapeutic Drug Informed Consent Form for Seroquel 25 mg three times a day showed that the resident could not sign the form, yet the ADON signed and confirmed consent. The H&P stated the resident was not decisional. The physician order summary showed Seroquel was ordered for psychosis manifested by aggressive behavior, and the MAR showed the resident received multiple doses of the medication. The MDS also reflected severely impaired cognition and dependence for several activities of daily living, and it indicated the resident was taking an antipsychotic medication. During interviews, the LVN, SSD, ADON, and DON all stated the resident lacked decision-making capacity. They also stated that when a resident has no family and no capacity, the IDT should be involved, and the patient representative could be contacted. The SSD stated the patient representative hotline was not contacted regarding Seroquel. The ADON and DON stated an IDT for behavioral management was not done when the resident returned from the hospital, and both stated that the resident should have had an IDT discussion about the lack of capacity before the consent form was signed and before Seroquel was started. The facility policy required informed discussion of risks, benefits, and alternatives before initiating a psychotropic medication, and the informed consent policy stated that when a resident lacks capacity and has no surrogate, the IDT will review the resident’s condition, medication intervention, and alternatives before reaching a decision.

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 Resident 12 was free from the use of a physical restraint when the resident’s bed was placed against the wall without informed consent from the resident’s responsible party. Resident 12 was re-admitted with diagnoses including dementia, reduced mobility, need for assistance with personal care, contractures of both ankles, and flexion deformities of both hips. The resident’s MDS indicated severely impaired cognition and dependence for multiple activities of daily living, and it also indicated the resident did not use restraints. The order summary showed a physician order dated 1/26/2026 stating the resident may have the bed against the wall for safety every shift, and the care plan included keeping the bed low with the bed against the wall for safety due to fall risk. During observation, Resident 12 was seen lying in bed with the right side of the bed against the wall and a bed alarm in place. An LVN stated the bed was against the wall to prevent falls and acknowledged it could be considered a restraint, while an RN later stated there was no informed consent from the responsible party for the bed being against the wall. The responsible party stated she had not been informed before 3/18/2026 that the bed was placed against the wall and had not been told the reasoning, risks, or benefits.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the Minimum Data Set (MDS) for Resident 81 was accurately completed. Resident 81 was admitted on 2/9/2017 and readmitted on 11/5/2025 with diagnoses including other reduced mobility, muscle weakness, dementia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, and major depressive disorder, recurrent, unspecified. A review of the H&P dated 1/29/2026 indicated the resident could make needs known but could not make medical decisions. However, the MDS dated [DATE] indicated the resident usually could make herself understood and usually had the ability to understand others, and the facility did not check the box for Depression under Section I - Active Diagnosis. The record also included an Order Summary Report dated 3/19/2026 showing an order for Escitalopram Oxalate 5 mg daily for depressive disorder manifested by verbalization of sadness. During interviews and record review, the MDS LVN, ADON, and DON all stated the MDS was not accurate because the diagnosis of depression was missing. The DON reviewed the facility's Accuracy of Assessments policy and Resident Assessment policy, both of which stated the MDS must be accurate and include the resident's mood and behavior patterns, psychosocial well-being, and disease diagnosis and health conditions.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Resident 9 received assistance from the Restorative Nursing Assistants during meals as part of the RNA feeding program. Resident 9 was re-admitted with diagnoses including metabolic encephalopathy, UTI, pneumonitis, and BPH. The MDS dated 2/17/2026 indicated the resident had moderate cognitive impairment, required supervision or touching assistance with eating, and was on a mechanically altered diet. A physician order dated 3/12/2026 placed Resident 9 on the RNA feeding program for loss of appetite. During a concurrent observation and interview on 3/17/2026, CNA 3 was observed setting up Resident 9's meal tray and then leaving the resident to eat independently. CNA 3 stated Resident 9 was independent with feeding and could eat on his own. During an observation on 3/18/2026, Resident 9 was seen sitting up in bed with a breakfast tray in front of him, attempting to feed himself, and stating that he did not like the food and did not want to eat it. No staff were observed at the bedside. During interviews, CNA 4 stated she was assigned to Resident 9 but was not assisting him with meals because she believed he could eat on his own and did not know he was on the RNA feeding program. The DOR stated Resident 9 was placed on the RNA feeding program because he was not eating and had a loss of appetite, and that the expectation was for RNAs to sit at the bedside, assist during meals, and encourage the resident to eat. The RD stated the program was intended to provide supervision, cueing, and assistance to help Resident 9 consume more food, and the DON stated Resident 9 should have been assisted by nursing staff during meals. The facility's Restorative Feeding Program policy stated residents shall receive restorative feeding care as needed and that the RNA will provide cueing and assistance with feeding techniques and equipment as instructed.

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 LVN 4 verified the medication dosage before administering medication to one sampled resident, Resident 31. Resident 31 had an active order dated 2/18/2026 at 2:40 PM for ascorbic acid (vitamin C) 250 mg by mouth one time a day. During a medication administration observation on 3/18/2026 at 9:31 AM, LVN 4 prepared 9 medications for Resident 31, including a vitamin C tablet labeled 500 mg. During a concurrent observation and interview on 3/18/2026 at 11:06 AM, LVN 4 showed the vitamin C bottles in the medication cart and stated there was only vitamin C 500 mg available and no vitamin C 250 mg in the cart. During review of the medication order, LVN 4 stated Resident 31’s order was for vitamin C 250 mg and acknowledged there was no vitamin C 250 mg in the med cart. LVN 4 stated he should have cut the 500 mg tablet in half or checked the central supply closet for vitamin C 250 mg, and said he would contact the resident’s physician and notify the physician the wrong dose was given. The DON later stated the facility did not have vitamin C 250 mg in stock and only had vitamin C 500 mg, and that during medication administration the practice was to check against the order for the correct medication and dosage.

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 infection control practices for a resident who had been admitted on 3/3/2009 and readmitted on 6/23/2015, with diagnoses including right elbow contracture and dysphagia. The resident’s H&P dated 12/31/2025 indicated the resident did not have the capacity to make medical decisions, and the MDS dated 2/24/2026 indicated severely impaired cognitive functioning and dependence on mobility and ADLs. During an observation on 3/17/2026 at 9:06 AM in shower room [ROOM NUMBER], the SSA removed the trash and soiled linen carts from the room, and CNA 2 wheeled the resident directly into the shower room for a bath before the room was cleaned. At 9:16 AM, the resident completed the bath, and housekeeping entered afterward to clean the shower room. CNA 1 stated the trash and soiled linen carts should not be stored in the shower room and should be in the hallway. CNA 2 stated she did not consider infection control practices at the time and said she would have called environmental services to clean the shower room before the bath. The DON and IP stated the facility did not follow infection control practices because the shower room was not cleaned and disinfected prior to the resident’s bath, and the IP stated the shower room should have been decontaminated after the carts had been stored inside.

Penalty

No penalty information released

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

Summary

The facility failed to meet the requirement for no more than four residents per room in one residential room, room [ROOM NUMBER], which was documented as having 6 beds in 543.98 square feet. During review of the facility’s room waiver request letter dated 3/16/2026, the letter acknowledged that room [ROOM NUMBER] did not meet the 4-bed-per-room regulation. The letter also stated that the room had no projections or obstructions that would interfere with wheelchair movement and that it had enough space to provide each resident’s care, dignity, and privacy. During multiple observations in room [ROOM NUMBER] from 3/16/2026 to 3/19/2026, nursing staff were observed with adequate space to provide care to the residents in the room. Each resident in the room was observed to have curtains for privacy, working call lights, a dresser, television, and a bedside table. In interviews, LVN 5 stated he was assigned to care for the residents in the room, had no concerns with the amount of space, and said wheelchairs were easy to maneuver in and out of the room. Resident 16 stated he had no issues or complaints about the amount of space and said CNAs were able to change and help move him without problems.

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 16 of 38 resident rooms met the requirement for at least 80 square feet of usable living space per resident in multiple resident rooms. The affected rooms identified in the report were 101, 102, 103, 104, 110, 111, 112, 113, 214, 215, 216, 217, 219, 220, 221, and 222. The deficiency was identified during review of the facility’s room waiver request letter dated 3/16/2026, which showed that the facility requested a room variance for multiple resident rooms and listed room floor areas and capacities that resulted in less than 80 square feet per bed in the cited rooms. The waiver request letter stated that the rooms had no projections or other obstructions that would interfere with the free movement of wheelchairs or sitting devices, and that the rooms had enough space to provide for each resident’s care, dignity, and privacy. During an initial tour, nursing staff were observed with adequate space to provide care in each facility room, and residents were observed moving freely in their rooms and throughout the facility. In interviews, an LVN assigned to rooms 101 through 104 stated he had no concerns about the space and could easily maneuver around the rooms when caring for residents. A resident observed in one room stated she had no concerns about the space and was happy with it, and a CNA observed assisting a resident in another room stated she had no complaints and could move a wheelchair or shower chair easily in the room.

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 develop and update a comprehensive care plan (CP) for a resident’s urinary tract infection (UTI) following readmission from the hospital. The resident was initially admitted with metabolic encephalopathy and later readmitted with a diagnosis of UTI. A Minimum Data Set (MDS) dated 10/25/2025 documented that the resident had moderate to severe cognitive impairment, was independent with several ADLs such as eating and bed mobility, but required maximal assistance for toileting and showering, partial assistance for dressing and transfers, and was frequently incontinent. The Medication Administration Record dated 1/8/2026 showed the resident was receiving Ciprofloxacin 500 mg by mouth in the morning for seven days for treatment of the UTI. Record review revealed no care plan problem, goals, or interventions addressing the UTI, including no documented monitoring parameters, comfort measures, or physician notification requirements related to this condition. The MDS nurse reported that the resident’s CP had not been updated since 10/16/2025 and acknowledged that it should be updated quarterly and upon each admission or readmission, but stated she intended to update the CP upon the resident’s next admission due to frequent hospitalizations. The DON confirmed that there was no CP addressing the UTI after the resident’s return from the hospital and stated that a comprehensive care plan should have been initiated for the UTI diagnosis with appropriate interventions and goals. Review of the facility’s policy on Comprehensive Care Plans – Timing, dated 1/2025, indicated that the interdisciplinary team is responsible for reviewing and revising the comprehensive care plan after each assessment and completing it within seven days and no more than 21 days after admission, 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

A deficiency occurred when staff failed to ensure that a resident with significant physical limitations had access to their call light. The resident, who had hemiplegia and hemiparesis following a stroke affecting the left side, as well as other medical conditions such as diabetes, hypertension, and atrial fibrillation, was dependent on staff for activities of daily living. The resident's care plan specifically required that the call light be within reach and that the resident be encouraged to use it for assistance as needed. During two separate observations, the call light was found out of the resident's reach: once on the floor behind the head of the bed and again attached to the fitted sheet on the resident's left side, which the resident could not access. The resident confirmed that she would use the call light if she could find it. A CNA verified the call light was not within reach and repositioned it appropriately. Facility policies reviewed indicated that residents should have access to the call light when in bed or seated, and interventions should be consistent with the resident's needs and care plan.

Penalty

No penalty information released

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

Summary

A resident with diagnoses including dementia, fibromyalgia, hypertension, and muscle weakness, who was completely dependent on staff for personal care and had severely impaired cognition, was admitted with an order for routine oxygen therapy via nasal cannula at 2-4 liters per minute. During personal hygiene care, a Certified Nursing Assistant (CNA) removed the resident's oxygen tubing to prevent it from pulling while repositioning the resident and subsequently forgot to replace it. The resident was left without the ordered oxygen therapy following this care. Later, a Licensed Vocational Nurse (LVN) was informed that the resident's oxygen tubing was off. Upon assessment, the resident was not in visible distress or short of breath, but their oxygen saturation was found to be 77%, significantly below the normal range of 95%-100%. The LVN immediately reapplied the oxygen, resulting in the resident's oxygen saturation rising to 95%. The facility's policy required oxygen therapy to be administered via nasal cannula, but this was not followed during the incident.

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 medical records were accurately documented and complete for one of three sampled residents. Specifically, a resident was admitted with a history of dementia and a past episode of depression, but the face sheet incorrectly listed major depressive disorder as a current diagnosis. Review of the psychiatrist's progress notes and the history and physical indicated that the resident did not have an active diagnosis of depression and was not prescribed psychiatric medication at the time. The Minimum Data Set (MDS) assessment also did not indicate an active diagnosis of major depressive disorder. Interviews with the DON and review of documentation revealed that the depression diagnosis was historical and not current, and the listing of 'recurrent depression' was identified as a typographical error. The DON clarified that the resident only had a history of depression and was not currently exhibiting symptoms or receiving treatment for depression. The facility's documentation policy required relevant findings to be accurately recorded in the clinical record, but this was not followed in this instance, resulting in incomplete and inaccurate medical records for the resident.

Penalty

Fine: $40,94037 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 multiple residents were free from significant medication errors, as evidenced by the late administration and improper timing of critical medications for 11 out of 20 sampled residents. Several residents did not receive their prescribed medications, such as anticoagulants (Eliquis/apixaban), antihypertensives (Norvasc/amlodipine), aspirin, and antiepileptics (Depakote/valproic acid, Keppra/levetiracetam), in accordance with physician orders and facility policy. In many cases, medications were administered hours after the scheduled time, and in some instances, doses were given too close together, not maintaining the required interval between administrations. For example, one resident received apixaban and other medications up to six hours late, and subsequent doses were administered less than the ordered 12 hours apart. Another resident received Depakote doses within 39 minutes to less than two hours of the next scheduled dose, rather than at the prescribed intervals. The report details that the medication errors were not isolated incidents but occurred repeatedly over several days, affecting residents with complex medical histories, including those with atrial fibrillation, hypertension, diabetes, seizure disorders, and a history of stroke. Residents with cognitive impairments and those dependent on staff for medication administration were particularly affected. Staff interviews revealed that nurses were unable to administer medications on time due to heavy workloads, with some nurses responsible for up to 32 residents and multiple residents requiring time-intensive administration methods, such as gastrostomy tubes. Nurses reported that they often finished morning medication passes hours after the scheduled times and did not always notify physicians when medications were administered outside the prescribed window. The facility's own policies required medications to be administered within 60 minutes of the scheduled time, and for physicians to be notified if this could not be achieved. However, documentation showed that these protocols were not followed, and there was no evidence that physicians were contacted prior to late administration. The facility's pharmacist consultant had previously recommended additional support to prevent late medication passes, but this was not implemented prior to the survey. The cumulative effect of these actions and inactions resulted in significant medication errors for multiple residents, as confirmed by observation, interview, and record review.

Removal Plan

• The Licensed Nurse completed change in condition assessments and reported the medication errors for each resident affected with the related medications.
• The residents would be monitored every shift for adverse reactions.
• Affected residents were monitored by the DON.
• Licensed Nurses would be re-educated by the DON on the standard of practice and facility policy and procedure for administering medications and in accordance with the physician's ordered time to reduce the risk of medication error, serious injury, harm and or death.
• The DON evaluated the resident medication administration assignments, including evaluation of residents on antiseizure, anticoagulants, hypertensive and anticonvulsant medications, including gastrostomy tubes, dialysis, blood pressure parameter checks, diabetics with insulin administration, controlled pain medications and seizure protocol.
• The DON contacted the pharmacy consultant and requested an additional medication cart, which was verified. The cart would be delivered.
• The DON redistributed the resident assignment to ensure the load over four medication carts.
• The Interdisciplinary Team met and developed and implemented a plan of care to closely monitor affected residents for adverse effects related to receiving medications at the wrong time resulting in a medication error.
• The Medical Records staff generated an audit of all in house residents medication administration records including the time of administration for all shifts, identifying any residents who were affected by the medication error. A copy of the audit was provided to the DON for review.
• All licensed nurses in the oncoming shifts were prioritized with re-education with the objective to achieve 100% of the licensed nurses before the start of their shift.
• The Director of Staff Development / designee would complete a medication pass observation skill competency with LVN 1 and 2 prior to the start of their shift.

Penalty

Fine: $40,94037 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 revise and update care plans for three residents as required by both facility policy and regulatory standards. For one resident with a history of cognitive impairment and wandering, the elopement/wandering care plan was not updated quarterly, despite changes in the resident's wandering behavior as documented in assessments. The care plan continued to include interventions such as a Wander guard device and redirection, but was not revised to reflect the most current assessments, which indicated a change in the resident's wandering status. Another resident with diagnoses including congestive heart failure and chronic kidney disease had an activities care plan that was not updated to reflect current activity preferences. Although assessments indicated the resident participated in a sensory stimulation program, enjoyed wearing headphones, and refused group activities, the care plan did not include these updated preferences or interventions. The Activities Director confirmed that the care plan should have been revised to reflect the resident's current interests and participation. A third resident with paraplegia and a pressure ulcer on the ischium had a pressure ulcer care plan that had not been revised since its initial creation, despite ongoing wound care and changes in the resident's condition. Both the Treatment Nurse and the MDS Nurse confirmed that the care plan was not updated quarterly as required, and that without revision, staff would not know if the interventions were effective. The Director of Nursing also acknowledged that care plans were not being assessed or updated as needed, and that interventions were not revised to reflect the resident's current needs.

Penalty

Fine: $40,94037 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 residents did not receive care and services in accordance with professional standards of practice. One resident with Type II diabetes and morbid obesity received insulin injections without proper rotation of administration sites, as confirmed by review of the Medication Administration Record (MAR) and interviews with nursing staff. The facility's policy required rotation of injection sites to reduce the risk of skin tissue damage, but this was not followed on specific dates, as insulin was repeatedly administered in the same locations. Two other residents did not receive their prescribed medications in a timely manner. One resident with multiple diagnoses, including breast cancer, rheumatoid arthritis, asthma, and a history of stroke, reported not receiving morning medications at the scheduled time. The MAR confirmed that medications due at 9 AM were administered more than two hours late. Staff interviews acknowledged the delay and the lack of documentation or notification to the physician regarding the late administration, despite facility policy requiring timely administration and physician notification for missed or late doses. Another resident with diabetes, atrial fibrillation, and Alzheimer's disease experienced significant delays in receiving oral diabetic medications. The MAR showed that morning doses were administered six hours late, and subsequent doses were given too close together without physician orders to reschedule. Blood sugar monitoring was not performed as indicated in the care plan, and there was no documentation of physician notification regarding the late or closely timed medication administration. Facility policies required medications to be given within a specific time frame and blood glucose monitoring for diabetic residents, but these were not followed.

Penalty

Fine: $40,94037 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 maintain safe and sanitary food storage and preparation practices in the kitchen, as evidenced by multiple observations of unclean equipment and areas. Surveyors observed dust and food debris buildup on refrigerator and freezer vents and shelves, as well as in the dry storage area and walk-in refrigerator. Kitchen equipment and utensils, such as freezer gaskets, refrigerator racks, resident trays, and scoop drawers, were found to be damaged, rusted, cracked, or chipped, making them difficult to clean and potentially leading to contamination. Dented cans were stored alongside non-dented cans, contrary to facility policy and food safety standards. Staff did not consistently follow proper procedures to prevent cross-contamination during food preparation. The same whisk was used for multiple pureed foods without proper washing and sanitizing between uses, and the same chopping board and knife were used for both cooked chicken and vegetables without cleaning in between. Staff also failed to perform appropriate hand hygiene, such as washing hands after touching watches during food handling and after handling soiled dishes before touching clean ones. Additionally, staff were observed wearing jewelry, specifically wristwatches, while preparing and serving food, which is not permitted by food safety regulations. Other deficiencies included failure to properly monitor the cooling of potentially hazardous foods, as required by facility policy and food code, with missing temperature and time entries for cooked turkey sausage and breaded chicken. Pots and pans were stacked while still wet, rather than being air-dried as required. Staff did not accurately check the concentration of the quaternary ammonium compound (QUAT) sanitizer, as they did not follow the manufacturer's instructions for test strip use, potentially resulting in improper sanitization of kitchenware. These actions and inactions were confirmed through staff interviews and review of facility policies and relevant food safety codes.

Penalty

Fine: $40,94037 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 document and investigate a resident's grievance regarding missing personal items, including a pair of shorts, a gown, and a left leg brace. The resident, who was alert, oriented, and had diagnoses of severe obesity, hemiplegia, and gout, reported the missing items to the Social Services Assistant (SSA) but no formal documentation or investigation was initiated. The resident stated that the shorts went missing shortly after admission and the brace disappeared following a hospital stay, with both items not being found or recorded in the Theft and Loss Report Log. Interviews with facility staff revealed a lack of communication and adherence to established procedures for handling missing resident property. The Social Services Director (SSD) was unaware of the missing items and confirmed that there was no documentation of the loss, despite the facility's policy requiring such incidents to be logged and investigated. The SSA acknowledged being informed by the resident about the missing items and stated she searched the resident's closet but did not document the loss or escalate the issue as required by facility policy. Further review of the resident's records showed a prescription for a PRAFO boot, which was also reported missing after the resident's return from the hospital. The facility's policy mandates that missing items be described, valued, and actions taken be documented, but this process was not followed in this case. The lack of documentation and investigation resulted in the resident's grievance being dismissed and the missing items not being addressed in a timely manner.

Penalty

Fine: $40,94037 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 an individualized, person-centered care plan addressing a resident's repeated refusal of prescribed insulin. The resident, who was admitted with diagnoses including Type II diabetes and morbid obesity, had physician orders for Lispro Insulin to be administered per sliding scale before meals and at bedtime. Despite the resident's moderate cognitive impairment and a documented history of refusing insulin—66 refusals in one month and 41 refusals in the following month—there was no care plan created to address this pattern of refusal. The care plan did not include goals or interventions related to the resident's non-compliance with insulin therapy. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that a care plan should have been developed for the resident's refusal of insulin, as per facility policy. The facility's policies require that care plans be person-centered, comprehensive, and address situations where a resident declines care or treatment, including identifying the risk and documenting efforts to educate the resident and seek alternative interventions. The absence of such a care plan was acknowledged by staff and was not in accordance with the facility's established procedures.

Penalty

Fine: $40,94037 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

Facility staff failed to provide necessary respiratory care services for a resident by not ensuring that the resident's oxygen nasal cannula tubing was kept off the floor while in use. The resident, who had a history of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia and hypercapnia, and anemia, was observed sleeping in bed with the oxygen nasal cannula tubing resting on the floor. The care plan for this resident specifically indicated that staff should prevent the oxygen nasal cannula from touching the floor and should store it properly when not in use. However, during observation, the tubing was found on the floor and described as dirty by a Certified Nurse Assistant (CNA), who acknowledged the need to replace it with a clean one. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed that oxygen tubing left on the floor should be considered contaminated and must be exchanged for a new, dated one to prevent infection. The facility's policy and procedures for oxygen therapy also required changing visibly soiled oxygen tubing. Despite these protocols, the staff did not ensure the tubing was kept clean and off the floor, resulting in a failure to provide safe and appropriate respiratory care as required.

Penalty

Fine: $40,94037 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 safe and appropriate pain management for a resident with chronic pain conditions, including fibromyalgia, arthritis, and migraines. The resident's care plan required staff to administer analgesics as ordered, anticipate pain needs, respond immediately to complaints of pain, and evaluate the effectiveness of pain interventions every shift. Despite these interventions, documentation and interviews revealed that staff did not consistently reassess the resident's pain after administering pain medication, nor did they document or address episodes of uncontrolled pain. On one occasion, the resident reported a pain level of 10 after receiving Norco in the early morning, but there was no timely follow-up to assess the effectiveness of the medication. The Medication Administration Record (MAR) showed that the resident received various pain medications and non-pharmacological interventions, but not all prescribed interventions were provided, and there was a lack of documentation regarding the resident's ongoing pain and communication with the physician. Staff interviews confirmed uncertainty about the facility's policy for reassessing pain after medication administration, and there were discrepancies in pain assessments documented by different nurses. The facility's only pain management policy addressed general pain assessment but did not specify the required timeframe for reassessment after administering oral pain medication. The Director of Nursing acknowledged that the policy was inadequate for guiding staff on timely pain reassessment and that staff did not follow the standard of care for evaluating pain relief within an hour of medication administration. As a result, the resident experienced episodes of uncontrolled pain without appropriate follow-up or intervention.

Penalty

Fine: $40,94037 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 maintain a medication error rate below five percent, as required, resulting in a 20% error rate during a medication pass for one resident. During observation, six medication errors were identified out of 30 opportunities while a licensed vocational nurse was administering morning medications. The nurse prepared and attempted to administer seven medications, including both scheduled and as-needed drugs, but the resident refused two of them. The nurse did not notify the physician about the late administration of medications, which was outside the facility's policy of administering medications within one hour of the scheduled time. The resident involved had a complex medical history, including hemiplegia and hemiparesis following a stroke, hypertension, cardiomegaly, atrial fibrillation, and major depressive disorder. The resident required significant assistance with daily activities and had care plans in place for multiple conditions, including hypertension, anticoagulant therapy, and depression. The care plans specified that medications should be administered as ordered and at consistent times, with monitoring for side effects and interactions. Interviews with nursing staff revealed that heavy workloads and the need to administer medications to residents with gastrostomy tubes contributed to delays in medication administration. Both the nurse and the DON acknowledged that medications were not given within the required time frame and that the physician was not contacted as required by facility policy. The facility's policy and procedure on medication administration emphasized the need for sufficient staffing and timely administration of medications according to prescriber orders.

Penalty

Fine: $40,94037 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 kitchen staff were routinely trained and evaluated for competency in critical food safety procedures. During observations and interviews, staff were unable to accurately verbalize or demonstrate the correct process for cooling cooked foods, such as turkey sausage and breaded chicken. Review of the Cooling Monitoring Form revealed missing entries for time and temperature monitoring of these foods, and staff provided inconsistent and incorrect information regarding required cooling times and temperatures. The Dietary Supervisor confirmed that proper cooling procedures were not followed or documented, which is necessary to prevent bacterial growth in food. Additionally, staff demonstrated a lack of understanding and inconsistent practices regarding the use and testing of quaternary ammonium compound (QUAT) sanitizer solutions used for dishwashing. During demonstrations, a dietary aide and the Dietary Supervisor used different methods and times for testing the sanitizer concentration, and both provided incorrect information about acceptable concentration ranges. Review of manufacturer guidelines and facility policies indicated that the correct procedure was not being followed, and staff competency checklists showed areas needing improvement in these critical tasks. These failures were observed in the context of providing food and ice to 90 of 92 medically compromised residents. The facility's own policies, job descriptions, and competency checklists outlined the required procedures for food cooling and sanitizer testing, but staff were not consistently trained or evaluated to ensure compliance. The lack of proper training and competency assessment in these areas had the potential to result in harmful bacterial growth and cross-contamination.

Penalty

Fine: $40,94037 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 prepare and serve pureed foods in a form designed to meet the individual needs of residents on a puree diet. During food preparation, a staff member was observed adding thickener to pureed foods without measuring, and stated there was no guideline for the appearance or amount of thickener to use. This resulted in pureed yellow zucchini that did not hold its shape and pureed Spanish rice that contained chunks of rice, both of which were not consistent with the required smooth, pudding-like texture for pureed diets. The Dietary Supervisor confirmed that the pureed yellow zucchini was too flat and did not hold its shape, and that the pureed Spanish rice contained rice particles, which should not occur. The supervisor acknowledged that standardized recipes and portion sizes, including the amount of thickener, were available and should be followed to achieve the correct consistency. The Registered Dietitian also stated that the facility was using the outdated National Dysphagia Diet guidelines instead of the more current IDDSI standards, and confirmed that pureed foods should be smooth, homogenous, and free of lumps or particles. A review of facility policies, procedures, and recipes indicated that standardized recipes with specific instructions for consistency and thickener amounts were available and required for use. The diet manual and recipes specified that pureed foods must be smooth, moist, and free of chunks or particles. Despite these guidelines, the observed practices did not align with the facility's own standards, resulting in pureed foods that did not meet the required consistency for residents with dysphagia or chewing difficulties.

Penalty

Fine: $40,94037 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 properly dispose of garbage and refuse as evidenced by observations of three dumpsters that were not completely closed or covered when not actively in use. On multiple occasions, surveyors observed that two to three dumpsters were overflowing with trash and not fully covered, with one dumpster having a broken cover resulting in an uncovered gap, and another overflowing due to unbroken-down boxes. These conditions were confirmed during interviews with the Dietary Supervisor and Maintenance Director, who acknowledged that the dumpsters should be closed and not overfilled to prevent pest attraction and infection risks. A review of the facility's policies and procedures indicated that garbage and refuse containers are to be maintained in good condition, properly contained, and covered to prevent pest harborage. Additionally, the Food Code 2022 requires outside receptacles to have tight-fitting lids or covers to prevent the attraction and breeding of pests and to maintain sanitary conditions. The facility's failure to adhere to these standards was observed to have the potential to affect 90 of 92 residents.

Penalty

Fine: $40,94037 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 two of nine sampled employees, a Licensed Vocational Nurse and a Restorative Nurse Assistant, had documented evidence of tuberculosis (TB) screening and clearance as required by the facility's policy. Review of their employee files showed that both had completed the facility's TB symptom screening questionnaires, but there was no documentation of a PPD skin test or chest x-ray, nor any indication of previous positive TB tests. This lack of documentation meant there was no proof that these employees were negative for or free of TB symptoms. Interviews with facility leadership, including a Registered Nurse Consultant, the Administrator, and the Director of Nursing, confirmed that employees should not be allowed to work without proof of TB screening and clearance. The facility's policy required annual TB screening for healthcare workers, with a skin test or IGRA unless previously positive, in which case a questionnaire and chest x-ray if symptomatic were required. The absence of required documentation for these two employees constituted a failure to follow established infection prevention and control protocols.

Penalty

Fine: $40,94037 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

A deficiency was identified when a resident with Parkinson's disease, schizophrenia, muscle weakness, and mobility abnormalities was found to have a non-functioning call light in their bathroom and bathing area. The resident, who had moderate cognitive impairment and required assistance with toileting, personal hygiene, and bathing, attempted to use the call light, but there was no visual or audible signal to alert staff. A certified nursing assistant confirmed the call light was not working during the observation. The resident's care plan included interventions to keep the call light within reach and encourage its use for assistance. However, the maintenance director stated that although call lights were supposed to be checked monthly and as needed, he was unaware of the malfunction and there was no log documenting when the last check occurred. Facility policy required routine audits and maintenance of the call system, but this was not followed, resulting in the deficiency.

Penalty

Fine: $40,94037 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 17 out of 38 resident rooms met the required minimum square footage per resident, as specified by regulations. Multiple rooms designed for more than one resident did not provide at least 80 square feet of useable living space per resident, and single rooms did not provide at least 100 square feet. This was confirmed through observation, interviews, and a review of the Client Accommodations Analysis, which detailed the square footage and number of beds in each room. The analysis showed that several rooms, including those with three or more beds, were below the required space per resident. A review of the facility's Room Variance Waiver indicated that some rooms had been approved for a waiver due to their size, but these rooms still did not meet the standard requirements. During the survey, staff and residents reported that rooms were clean, free from clutter, and allowed for free movement, with no obstructions noted during care delivery. However, the documented measurements confirmed the deficiency in room size. The facility's policy and procedure stated that rooms should meet the minimum square footage requirements, but the actual room sizes in the affected rooms did not comply with these standards.

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 accurately assess the risk and condition of a pressure ulcer for a resident, leading to inaccurate documentation and potential adverse effects on treatment. The resident, who was admitted with multiple diagnoses including COPD, muscle weakness, and major depressive disorder, was identified as being at risk for pressure ulcers. Despite this, the facility's assessments were inconsistent and did not accurately reflect the resident's condition. During observations, it was noted that the resident had a red area on the left lateral heel, which was initially assessed as blanchable by a treatment nurse. However, a subsequent wound assessment inaccurately documented the area as non-blanchable, indicating a possible deep tissue injury. This discrepancy in assessment could have significant implications for the resident's care and treatment. The facility's policy on pressure ulcer prevention emphasizes the importance of accurate risk identification and individualized interventions. However, the resident's Braden Scale assessments were inconsistent, with inaccuracies in sensory perception, moisture, and mobility ratings. These inaccuracies resulted in the resident being assessed as moderate risk rather than high risk, potentially affecting the interventions implemented to prevent pressure ulcers.

Penalty

No penalty information released

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

Summary

The facility failed to implement measures to prevent pressure ulcers for a resident, leading to the development of a non-blanchable redness on the resident's left lateral heel, indicating a possible deep tissue injury. The resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disease, muscle weakness, and major depressive disorder, and was identified as being at risk for pressure ulcers due to immobility, incontinence, and other health conditions. The care plan included interventions such as encouraging frequent repositioning and floating the heels in bed, but these measures were not consistently followed. During an observation, a Certified Nursing Assistant (CNA) noted a red area on the resident's heel, which was confirmed by the Treatment Nurse (TXN) and the Director of Nursing (DON). The DON identified the area as non-blanchable, indicating an injury that required offloading the heels and notifying the doctor. The facility's policy on pressure ulcer prevention emphasized the importance of redistributing pressure and protecting the skin, but these guidelines were not adequately implemented for the resident. The failure to adhere to the care plan and facility policies resulted in the resident developing a pressure ulcer. The resident's care plan specifically called for interventions to prevent such injuries, but observations revealed that the resident's left leg and heel were not properly supported, contributing to the development of the ulcer. This deficiency highlights a lapse in the facility's adherence to established protocols for pressure ulcer prevention.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its policy and procedures for intravenous (IV) catheter care by not changing the IV site within the recommended 72 to 96-hour window for a resident. This oversight was identified during an observation and interview with the resident, who had an IV line on the left hand with a dressing dated 9/27/24, despite the last administration of IV medication being on 10/3/24. The Director of Nursing confirmed that the IV site had not been changed within the required timeframe, acknowledging the risk for infection. The resident involved had multiple diagnoses, including a urinary tract infection, diabetes mellitus, chronic obstructive pulmonary disease, quadriplegia, and muscle weakness, and required substantial assistance for daily activities. The facility's policy, aligned with CDC guidelines, mandates that peripheral IV sites be changed every 72 to 96 hours to prevent catheter-related infections. However, the facility did not follow these guidelines, as evidenced by the unchanged IV site, which posed a potential risk for infection.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate respiratory care for a resident who was experiencing a decrease in blood oxygen levels and difficulty breathing. The resident, who had a history of hemiplegia, hemiparesis, hypertension, diabetes mellitus, and pneumonia, was found to be desaturating with a blood oxygen saturation level of 78%. Despite the critical condition, the resident was administered oxygen via a simple mask, which delivers 40 to 60% oxygen, instead of a non-rebreather mask that delivers 100% oxygen, which is more appropriate for emergency situations. The deficiency was identified during a review of the resident's change of condition note, which lacked clarity on whether the correct oxygen delivery device was used. The Director of Nursing confirmed that the documentation did not specify the type of mask used, raising concerns about the adequacy of the treatment provided. The facility's policy on oxygen therapy was reviewed, which outlined the use of an oxygen mask but did not ensure the correct type of mask was used in this instance.

Penalty

Fine: $106,82136 days payment denial

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

Summary

The facility failed to protect a resident's right to be free from abuse, specifically involving two residents with complex mental health diagnoses. One resident, diagnosed with mood affective disorder and unspecified psychosis, was not adequately assessed or monitored, leading to an incident where another resident, who also had mood affective disorder and unspecified psychosis, became verbally and physically aggressive. The facility did not conduct a comprehensive assessment of the aggressive resident's cognitive patterns, mood, behaviors, and active diagnoses, nor did they review and reassess the care plan interventions as required by their policies. The aggressive resident had a history of verbal aggression and had been transferred to a General Acute Care Hospital for evaluation due to similar behaviors. Despite this history, the facility did not develop a comprehensive person-centered care plan for the resident's psychosis, nor did they provide adequate supervision or monitoring as outlined in their policies. This lack of action resulted in an incident where the aggressive resident threw a cup of juice at the other resident, causing fear and a sense of being unprotected. Interviews with staff and a review of the facility's policies revealed that the facility did not take reasonable precautions to prevent resident-to-resident altercations. The facility's policies required regular reassessment of interventions and adequate supervision for residents at risk of abusive behavior, which were not followed. Additionally, the facility's MDS assessments were incomplete, failing to capture the aggressive resident's cognitive skills and active diagnoses, further contributing to the deficiency.

Penalty

Fine: $106,82136 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 a comprehensive person-centered care plan for a resident diagnosed with psychosis, which is characterized by a disconnection from reality. The resident, who was admitted with multiple diagnoses including unspecified psychosis, had a psychology assessment indicating a need for emotional processing to achieve calmness. Despite this, the psychiatric intake note revealed the resident's refusal to continue medication and participation in interviews, showing signs of irritability and agitation. The Minimum Data Set (MDS) assessment did not document any symptoms of hallucinations or delusions, and the section for behavior was left incomplete. An incident occurred where the resident exhibited aggressive behavior by throwing objects at another resident and a Licensed Vocational Nurse (LVN). The Director of Nursing (DON) acknowledged the resident's refusal of medication and uncooperative behavior but did not see the need for a psychosis care plan due to the absence of psychotic behaviors. However, the MDS Coordinator emphasized the importance of such a care plan to establish a baseline, prevent decline, and improve behavioral and psychosocial outcomes. The facility's policy mandates the development of person-centered care plans that address medical, physical, mental, and psychosocial needs, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to protect Resident 5 from physical abuse when Resident 4 slapped Resident 5 with an open hand on the right side of her face. This incident occurred on 4/16/2024 and was witnessed by CNA 3, who heard a slap followed by Resident 5 crying loudly. Upon assessment, Resident 5's right cheek was noted to be red. Resident 5, who has severe cognitive impairments and multiple diagnoses including cerebral infarction, Down syndrome, and Alzheimer's Disease, required maximal assistance with daily activities and was feeling down, depressed, or hopeless according to her MDS dated 3/12/2024. Resident 4, who has intact cognitive skills and no prior behavioral issues, denied the incident but was educated that physical abuse is unacceptable in the facility. Following the incident, Resident 5 received cold packs and Tylenol for pain management. The facility's Director of Nursing confirmed that physical abuse had occurred and acknowledged that it should not have happened according to the facility's abuse policy and regulations. The facility's current policy, titled 'Abuse Prohibition and Prevention Program,' aims to provide an environment that prohibits and prevents abuse, but this policy was not effectively implemented 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 proper food handling practices by not maintaining a log for the temperatures of beverages on the snack cart. During an observation and interview with the Dietary Director (DD), it was noted that two thermoses of hot drinks intended for snack time in the activities room were checked for temperature, which was recorded as 142 degrees Fahrenheit. However, the DD admitted that there was no log maintained for these temperature checks. The facility's policy, revised on 9/1/21, mandates that food temperatures be recorded to ensure safety, with acceptable serving temperatures for coffee being above 140 degrees Fahrenheit. This lapse in documentation could potentially compromise food quality and safety, leading to foodborne illnesses.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a consult for a wound care specialist was ordered for one of the residents. The resident, who had severe impaired cognition and required substantial assistance for daily activities, accidentally spilled hot chocolate on their abdomen and inner thighs, resulting in redness and blisters. Although a topical burn treatment gel was ordered, the treatment nurse failed to obtain an order for a wound care specialist consult, which delayed the specialist's evaluation of the resident's wounds. During an interview and record review with the Director of Nursing (DON), it was revealed that the treatment nurse, who is no longer employed at the facility, did not secure the necessary order for the wound care specialist. As a result, the resident was not seen by the specialist until a week later than they should have been. This delay placed the resident at risk for worsening wounds.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a comprehensive, person-centered care plan for a resident who was at high risk for falls. The resident, who had a history of falls and various medical conditions including generalized anxiety disorder, major depressive disorder, and muscle weakness, did not have an updated and specific care plan addressing their fall risk. The care plan was not revised or updated in a timely manner, leading to an increased risk of falls for the resident. This deficiency was highlighted when the resident fell and sustained injuries, including a displaced fracture of the clavicle and a laceration to the forehead, after being found in another resident's room. The resident's care plan initially included interventions such as educating the resident, family, and caregivers about safety reminders, but it was not person-centered as the resident did not have family involved in their care. Additionally, the care plan was not updated to reflect the resident's current condition and needs, as evidenced by discrepancies in the resident's fall history and risk assessments. The facility's policy required care plans to be person-centered and updated within a specific timeframe, which was not adhered to in this case. Interviews with staff members, including CNAs and the RN Supervisor, revealed that the resident was known to be at high risk for falls but did not have a history of falls according to some staff members. The MDS Coordinator and DON acknowledged that the care plan was not person-centered and was not updated in a timely manner. The facility's policies on screening and care plan development emphasized the need for comprehensive and individualized care plans, which were not followed in this instance.

Penalty

Fine: $69,020

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 evaluate and analyze hazards and risks for Resident 1, who had multiple falls, and did not monitor the effectiveness of interventions for a non-compliant resident. Despite being educated to call for assistance, Resident 1 continued to perform activities beyond his ability, leading to several falls. On one occasion, Resident 1 fell from his wheelchair while attempting to transfer himself to his bed, resulting in a right ankle fracture. The facility did not develop care plans addressing Resident 1's non-compliance with care and calling for assistance, and there was no documentation that Resident 1's family was informed about his non-compliance. For Resident 2, who had severely impaired vision, the facility failed to complete an accurate Fall Risk Assessment and did not implement individualized, resident-centered interventions to reduce the risk of falls. Resident 2 had a history of falls and was legally blind, yet the fall risk assessments were completed inaccurately, and appropriate interventions were not implemented. As a result, Resident 2 fell from her bed, sustaining multiple rib fractures. The facility did not revise Resident 2's care plan quarterly or when there was a change in condition, and the necessary person-centered interventions for a blind resident were not included. Interviews with staff revealed that both residents were non-compliant with calling for assistance and wanted to be independent beyond their abilities. The facility's policies and procedures for post-fall evaluation and fall management were not followed, leading to inadequate supervision and failure to implement effective interventions. The deficiencies in care planning, risk assessment, and monitoring contributed to the falls and injuries sustained by both residents.