Woods Health Services

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 nursing staff demonstrated and maintained competency to safely provide care and services in accordance with professional standards. Review of CNA personnel files showed that 16 of 34 CNAs did not have current CPR certification, despite the facility’s CNA job description requiring CPR training after employment and maintenance of CPR certification. The Director of Staff Development (DSD) stated the facility did not require CNAs to maintain current CPR certification, acknowledged CNAs were hired with valid CPR that was allowed to expire, and confirmed there were no mock code drills documented in staff files. The DON stated she did not know if CNAs were required to be CPR certified but agreed they should be, and stated that the risk of CNAs not being CPR certified could lead to residents’ death. Record review further showed that CNA competency evaluations were not completed annually. CNA files indicated the last competency skills evaluations were done in 2024, and the DSD confirmed she had not completed annual competency evaluations since then, stating that annual skills competency was the method to determine if a CNA was competent to work. The DON stated the DSD was responsible for yearly CNA competency evaluations and that without these evaluations, CNAs might perform patient care not according to facility policies and procedures. For licensed nurses, review of Licensed Nurse Skill Evaluations revealed incomplete documentation for one RN and four LVNs, with missing evaluator initials, employee initials, and dates. The DON confirmed that these evaluations must be fully completed with initials and dates to be valid and stated she was not aware they were incomplete. Additional review of a Licensed Nurse Skill Evaluation for one RN showed that this RN was evaluated for IV therapy by an LVN, even though the DON stated LVNs were not allowed to work with IVs because it was outside their scope of practice. The DON reported she had an LVN assist her with yearly Licensed Nurse Skill Evaluations because she needed help, despite her job description stating she was responsible for ensuring all nursing personnel received annual competency training. In a separate resident emergency event, an RN and an LVN did not follow facility policy and expected emergency procedures. The RN, after being notified by an LVN that a resident had low oxygen saturation, did not assess the resident, did not obtain full vital signs, left the bedside to call 911, did not return to the resident’s room, and did not document vital signs or assessments before or after oxygen administration. The LVN reported the resident “did not look good,” obtained an oxygen saturation of 89%, left the resident alone twice (including to get the crash cart) instead of using the provided walkie talkie to call for help, administered oxygen at 2 L/min without increasing it, did not recall rechecking oxygen saturation, did not check blood pressure because she was busy, and did not document vital signs or assessments before or after oxygen therapy. The DON stated that during an emergency the RN’s role was to assess the resident and delegate tasks, that vital signs must be taken to determine stability, that residents should not be left alone because CPR might be needed, and that staff were expected to use walkie talkies in emergencies. Facility policies on CPR and oxygen administration required staff to be trained in CPR/BLS, participate in mock codes, assess residents before and during oxygen therapy, obtain and document vital signs and lung sounds, and document all assessment data and oxygen therapy details.

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 complete and document a thorough assessment and monitoring of a resident who experienced a change in condition and was found unresponsive. The resident had been admitted with diagnoses including traumatic subdural hemorrhage without loss of consciousness, repeated falls, diabetes mellitus, and muscle weakness, and was documented as lacking capacity to make decisions and being dependent on staff for most ADLs. On the night in question at approximately 11 pm, the charge nurse and other staff found the resident unresponsive but breathing, with an O2 saturation of 89%, a pulse of 61, and a temperature of 97.5°F. According to the incident note and SBAR, oxygen was administered for the low O2 saturation, and 911 was called. However, the resident’s BP and RR were not obtained at that time, and there was no documentation of the resident’s O2 saturation after oxygen was started. Staff instead obtained a blood sugar of 292 mg/dl. The records show that paramedics arrived at approximately 11:07 pm, assessed the resident, and initiated CPR, which was later discontinued when the resident was pronounced dead at 12 am. The SBAR later documented an O2 saturation of 96% on room air at 1:44 am and repeated the blood sugar of 292 mg/dl at 2:05 am, but these values did not reflect reassessment at the time of the initial change in condition. Interviews with the RN and the DON confirmed that when the resident was found unresponsive, staff focused on administering oxygen and calling 911 and did not obtain a BP or RR, and did not reassess or document the O2 saturation after oxygen was given. The DON acknowledged that it was important to obtain a full set of vital signs and finger stick glucose as part of the assessment during a change in condition, but that this was not done in this emergency. Review of the facility’s “Change in a Resident’s Condition or Status” policy and the SBAR Communication Form showed that nurses were expected to make detailed observations and gather relevant information, including BP, pulse, temperature, RR, oximetry, and finger stick glucose if indicated, prior to notifying the provider, which did not occur 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

Surveyors identified a deficiency in the implementation of a comprehensive person-centered care plan when staff did not follow the documented transfer assistance requirements for a resident. The resident had been admitted with diagnoses including type 2 diabetes mellitus, muscle wasting and atrophy, and dementia, and an MDS assessment showed the resident was severely impaired in cognitive skills and required substantial/maximal assistance for bathing, dressing, toileting hygiene, oral hygiene, and personal hygiene. The resident’s care plan, developed and later revised due to high fall risk related to confusion and balance problems, specified the intervention to use a 2-person assist for all transfers with an EZ stand. Despite this care plan intervention, a CNA reported, and the resident’s responsible party confirmed, that on a specified evening the CNA used the EZ stand alone to transfer the resident to the bathroom, without a second staff member assisting. The DON acknowledged that the purpose of the care plan was to communicate interventions staff should use to address resident needs and that interventions related to fall risk should be followed by staff. The facility’s policy on comprehensive person-centered care plans stated that a care plan with measurable objectives and timetables must be developed and implemented for each resident, but in this instance the intervention requiring two staff for EZ stand transfers was not implemented as written.

Penalty

No penalty information released

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

Summary

The facility failed to complete required annual performance reviews for four sampled CNAs, contrary to its policy and the Director of Staff Development’s (DSD) stated expectations. Review of CNA 1’s employment record showed hire on 4/25/2024 and a last performance review on 11/4/2024, with no review documented for 2025. CNA 2’s record showed a last performance review on 12/30/2024, with no review documented for 2025. CNA 4, hired on 7/19/2007, had a last performance review dated 12/28/2023, with no reviews documented for 2024 or 2025. CNA 5, hired on 10/16/2023, had a last performance review on 2/12/2024, with no review documented for 2025. In an interview on 2/10/2026, the DSD stated that performance reviews should be done annually and acknowledged that she had not completed any performance reviews for CNAs since starting in April 2025. Review of the facility’s September 2020 policy titled “Job Descriptions and Performance Evaluations” confirmed that annual performance reviews are required to be completed by the employee’s direct supervisor. This failure had the potential to result in CNAs providing improper care, making clinical errors, and causing resident injury, as identified by the surveyors based on the interview and record review.

Penalty

No penalty information released

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

Summary

Facility staff failed to notify a resident's physician of a significantly low blood pressure (BP) reading upon admission. The resident, who had a history of atrial fibrillation and hypertension, was admitted with an initial BP of 64/40 mm/Hg. Despite this abnormal finding, there was no documentation or evidence that the physician was informed of the low BP, as confirmed by interviews with nursing staff and review of progress notes. The facility's policy required that hypotension, defined as BP less than 100/60 mm/Hg, be reported to the physician. On the evening of admission, the resident was found on the floor after slipping off the bed while attempting to use a urinal. At the time of the fall, the resident's BP remained low at 65/41 mm/Hg. Subsequent BP readings taken every 15 minutes showed gradual improvement, but the initial hypotensive episode was not communicated to the physician. Interviews with staff indicated awareness that such low BP readings should be reported, but the responsible nurse did not do so, citing being overwhelmed by multiple admissions. The Director of Nursing confirmed that there was no documented communication with the physician regarding the resident's low BP and acknowledged that staff should have monitored and reported the abnormal vital sign. The lack of physician notification was not documented in the resident's records, and the facility's policy on BP measurement and reporting was not followed 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

Facility staff failed to implement necessary interventions to reduce the risk of falls for a resident who was identified as high risk upon admission. The resident had multiple diagnoses, including atrial fibrillation and hypertension, and was admitted with low blood pressure. Upon admission, the resident was wearing a yellow bracelet indicating fall risk, and the initial blood pressure reading was significantly below the facility's defined threshold for hypotension. Despite these indicators, there was no documentation that the resident's physician was notified of the low blood pressure, nor were additional interventions implemented to address the increased fall risk. On the day of the incident, the resident's Fall Risk Evaluation score was 13, confirming high risk status, and the resident required moderate to substantial assistance for mobility and toileting. Later that evening, the resident attempted to use a urinal located on the right side of the bed and slid off the bed onto the floor. At the time of the fall, the resident's blood pressure remained critically low, and subsequent monitoring showed persistently low readings. The resident reported occasional dizziness and spinning sensations when turning, although did not recall feeling dizzy immediately before the fall. Interviews with facility staff, including an LVN and the DON, confirmed awareness of the resident's fall risk and low blood pressure, but acknowledged that the physician was not notified and that monitoring and interventions were not initiated prior to the fall. Review of facility policies indicated that hypotension and fall risk should prompt evaluation and communication with the physician, but these steps were not documented or carried out 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 resident with multiple diagnoses, including disorders of bone density and muscle wasting, was admitted to the facility and later sustained an acute fracture of the left first toe, as confirmed by x-ray. The physician ordered the first toe to be taped to the second toe until an orthopedic consult, and the orthopedic specialist subsequently recommended buddy taping or splinting the toe for four to six weeks. However, there was no documentation indicating that the toe was taped as ordered, nor was there evidence that the orthopedic recommendations were transcribed into physician orders or followed after the consult. During observations and interviews, staff were unable to confirm if or when the resident's toes were taped, and the nurse did not transcribe the orthopedic recommendations into the resident's orders. The facility's policies required documentation of treatments and adherence to physician orders, but these were not followed in this case. The lack of documentation and failure to implement the prescribed treatment had the potential for the resident's injury to worsen.

Plan Of Correction

Immediate corrective action: Following observations on 6/20/2025, resident 1's toe was checked and buddy taped. Treatment records were updated, and staff in-serviced to ensure checking and taping were completed per the order summary report. Identifying other potentially affected: On 6/23/2025, the DON and Medical Records conducted a random review of three residents having treatment orders and observations. Audits and physical observation revealed successful evidence of completion. No additional concerns were noted. Measures for systemic change: Between the dates of 6/23/2025 and 6/27/2025, the DON provided in-services to licensed nurses regarding carrying out physician orders and proper completion of buddy taping and documentation of doing so for Resident 1's left toes. Monitoring for compliance: The DON and/or RN Supervisor will visually check Resident 1's toe for proper buddy taping regularly until follow-up physician orders discontinue the need. Successful completion of items above:

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 was admitted to the facility with a history of multiple left hip surgeries, including a recent procedure that resulted in a large surgical wound. Upon admission, the admitting RN failed to conduct a complete wound assessment and did not document the presence or condition of the surgical wound in the clinical admission record. Additionally, the RN did not obtain a treatment order for the wound at the time of admission, leaving the wound uncovered and without prescribed care for ten days. The facility's policies required a thorough admission assessment, including skin and wound evaluation, and prompt communication with the attending physician to obtain necessary treatment orders, but these steps were not followed. After a treatment order was eventually obtained, there were further lapses in care. On three consecutive days, the assigned LVNs did not implement the prescribed wound care treatment, as evidenced by blank entries in the medication administration record and confirmation from staff interviews. The wound dressing was not changed during this period, and the wound was left unattended, contrary to the treatment plan. The wound care specialist later confirmed that the wound had not been properly managed and that the dressing had not been changed for several days. As a result of these failures, the resident's surgical wound developed an infection, which was confirmed by laboratory testing and medical evaluation after the resident was transferred to an acute care hospital. The infection was attributed to inconsistent and inadequate wound care, including the lack of a timely treatment order and missed dressing changes. The facility's own staff, including the DON, wound care specialist, and infection preventionist, acknowledged that the required assessments and treatments were not performed according to policy, and that these omissions contributed to the resident's wound 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 maintain a complete and accurate medical record for a resident who was admitted with a surgical wound on the left hip. Upon admission, the responsible RN did not document the presence or description of the resident's left hip wound in the clinical admission record, despite the resident's history and physical indicating a healing wound and the Minimum Data Set noting the need for surgical wound care. The RN confirmed that wound assessments, including descriptions and measurements, should be documented at admission to allow for proper monitoring. Additionally, facility staff did not document the description or measurements of the resident's left hip wound in the long-term care evaluations on multiple subsequent dates. The Director of Nursing acknowledged that staff should have included this information in the evaluations. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, but this was not followed, resulting in incomplete and inaccurate records for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with a healing surgical wound on the left hip. The resident had diagnoses including acute osteomyelitis of the left femur, infection and inflammatory reaction due to an internal left hip prosthesis, and dysphagia. Upon review, it was found that the resident required surgical wound care and was dependent on staff for several activities of daily living. Despite these needs, the care plan did not include a treatment order for the left hip wound until nearly two months after admission. Interviews with nursing staff confirmed that a treatment order for the surgical wound was not obtained at the time of admission, and the care plan initially failed to address this critical intervention. The facility's policy required that care plans include measurable objectives and timetables to meet each resident's needs, and that all residents with wounds have a wound treatment order included in their care plan. The omission of the wound treatment order in the care plan was identified during record review and staff interviews.

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 from the responsible party prior to administering a psychoactive medication, Seroquel, to a resident with severe cognitive impairment. The resident, who had diagnoses including Parkinson's disease, dementia, and a history of falls, was unable to make medical decisions. Despite this, Seroquel was ordered and administered for psychosis manifested by visual hallucinations and aggression, without documented evidence that the responsible party was informed of the risks and benefits or that consent was obtained. Record reviews confirmed that the medication was given on multiple occasions, and both the LVN and DON acknowledged that informed consent was required for psychotropic medications, as per facility policy. The facility's policy specified that the physician must inform the resident or representative and obtain consent before use of such medications. The lack of documented consent meant the responsible party was not given the opportunity to make an informed decision regarding the resident's treatment.

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 irregularities identified during the Monthly Drug Regimen Review (MDRR) by the facility's pharmacist were acted upon for one resident. Specifically, the pharmacist made recommendations regarding the continued use of gastrointestinal medications (Famotidine and Pantoprazole), the reconsideration of Simvastatin, and a gradual dose reduction for the antipsychotic medication Seroquel. In each instance, there was no documentation that the resident's physician was informed of the pharmacist's recommendations or that any action was taken in response. Record reviews showed that the pharmacist's notes to the attending physician regarding these medications were left blank in the section for the physician's response, indicating no documented agreement or disagreement with the recommendations. Interviews with facility staff, including a hospice RN, RN supervisor, and the DON, confirmed that the pharmacist's recommendations were not communicated to the physician as required. The facility's policy states that such irregularities should be reported to the physician within a specified timeframe and that the physician should document their review and actions taken. The resident involved had significant cognitive impairment and multiple diagnoses, including dementia with psychotic disturbances, anxiety, and depression. The lack of follow-through on the pharmacist's recommendations resulted in the potential for unnecessary medication administration, as there was no evidence that the physician was made aware of or addressed the identified medication irregularities.

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 proper infection prevention and control practices in several instances involving two residents. For one resident with multiple diagnoses, including pressure-induced deep tissue damage and congestive heart failure, staff did not follow Enhanced Barrier Precautions (EBP) as required. Despite signage indicating the need for gloves and gowns during high-contact care activities, a certified nurse assistant was observed providing face hygiene care without wearing any personal protective equipment (PPE). Both the Infection Preventionist Nurse and the Director of Nursing confirmed that PPE should have been used for residents on isolation precautions. Additionally, the facility did not ensure that nasal cannula (NC) tubing used for oxygen delivery was kept off the floor for two residents. One resident, who was dependent for personal hygiene and had an order for continuous oxygen, was observed with their NC touching the floor while in bed. The attending licensed vocational nurse acknowledged that this was inappropriate for infection control. Similarly, another resident with intact cognition and an as-needed oxygen order was found with their NC tubing on the floor. The nurse present and the Director of Nursing both recognized this as an infection control risk and stated that the tubing should be replaced. A review of facility policies indicated that oxygen delivery devices must be kept clean and changed as needed, and that PPE is required during certain care activities to prevent exposure to bodily fluids. The facility's in-service training also emphasized the importance of proper storage of personal belongings to prevent contamination. These observations and interviews demonstrate lapses in adherence to established infection control protocols, specifically regarding the use of PPE and the handling of oxygen delivery equipment.

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 call light was within reach for a resident with severe visual impairment and failed to answer a call light in a timely manner for another resident. In the first instance, a resident who was legally blind and dependent on staff for activities such as toilet hygiene and bathing was observed sitting in a wheelchair beside the bed, with the call light placed in the middle of the bed and out of reach. The resident expressed difficulty in locating the call light due to blindness and stated a desire to have it within reach. Staff interviews confirmed the resident's blindness and the expectation that the call light should be accessible, especially for residents with visual impairments. Facility policy also indicated that call lights should be accessible to residents. In the second instance, a resident with diagnoses including a stage 3 pressure ulcer, diabetes, and dysphagia, and who had intact cognition, activated the call light for assistance with treatment. The call light outside the resident's room and at the nursing station remained lit and unanswered for approximately 11 minutes before being addressed by a nurse. The resident reported dissatisfaction with the wait time. Staff interviews confirmed that call lights should be answered within three to five minutes, with a maximum of ten minutes, and that both licensed and unlicensed staff are responsible for responding. Facility policy supported the expectation for prompt response to call lights.

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 code the Minimum Data Set (MDS) for a resident regarding the use of anticoagulant medication. The resident, who had a history of hemiplegia, hemiparesis following a cerebral infarction, diabetes mellitus, and generalized muscle weakness, was admitted and had an order for Plavix (clopidogrel), an antiplatelet medication, to be administered daily for a cerebrovascular accident. The MDS, dated shortly after admission, incorrectly indicated that the resident received anticoagulant medication. During interviews and record reviews, it was clarified by the MDS Nurse that Plavix is classified as an antiplatelet, not an anticoagulant, and should not have been coded under the anticoagulant section (N0415E) of the MDS. The DON confirmed that accurate medication documentation on the MDS is essential for proper care planning and that anticoagulant and antiplatelet medications are coded separately due to their different mechanisms and uses. The CMS RAI User's Manual also specifies that antiplatelet medications should be coded distinctly from anticoagulants.

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 Minimum Data Set (MDS) assessment accurately reflected a resident's hospice status. The resident was admitted with diagnoses including heart failure, depression, and anxiety disorder, and had an active physician order for hospice care from the time of admission. The resident's care plan and order summary both indicated hospice care, and interviews with the resident, a Licensed Vocational Nurse, and the MDS Coordinator confirmed that hospice services had been provided since admission. However, the MDS assessment did not indicate that the resident was on hospice care while residing in the facility. This discrepancy was identified during a review of the resident's records and confirmed through staff interviews. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, and federal regulations mandate that the assessment accurately reflect the resident's status. The inaccurate coding of the MDS assessment resulted in a failure to properly document the resident's hospice status.

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 medications, their purposes, and potential side effects were explained to a resident prior to administration. During an observation, an LVN administered multiple medications to a resident without providing explanations about the medications, their intended uses, or possible side effects. The resident, who had diagnoses including pulmonary embolism, diabetes mellitus, and dementia, was documented as lacking capacity to understand and make decisions, and required substantial to maximal assistance with activities of daily living and was dependent for mobility. Interviews with the LVN, the resident, and the Director of Nursing confirmed that the practice of explaining medications prior to administration was not followed in this instance. The resident expressed a desire to know what medications were being given and their purposes, stating it would have reduced confusion and provided a sense of choice. Facility policies reviewed indicated that residents have the right to be informed about their care and to participate in care planning and treatment, as well as to be treated with dignity and respect.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with diagnoses including heart failure, asthma, and dysphagia did not receive oxygen therapy in accordance with the physician's order. The resident was ordered to receive continuous oxygen at three liters per minute via nasal cannula, with the care plan specifying that the oxygen flow should be checked every four hours. However, during an observation, the resident was found to be receiving four liters per minute. The attending LVN confirmed the discrepancy and adjusted the oxygen flow to the ordered amount. Record reviews showed that documentation indicated the resident was receiving the correct amount of oxygen and that checks were being performed as required, but direct observation contradicted this. Interviews with nursing staff and the DON confirmed that oxygen administration should follow the physician's order and that only licensed nurses are permitted to adjust oxygen levels. Facility policies also required staff to verify and set oxygen delivery to the prescribed flow rate.

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 implement a physician's order for floor mats to be placed on both sides of a resident's bed. The resident, who had diagnoses including Alzheimer's disease, dementia, and a history of repeated falls, was assessed as having severely impaired cognitive skills and required substantial to maximal assistance with activities of daily living and was dependent for mobility. During observation, only one safety mat was found on the left side of the bed, despite the physician's order and care plan specifying floor mats on both sides to prevent injury in the event of a fall. Interviews with facility staff, including an LVN and the DON, confirmed that the physician's order for bilateral floor mats was not followed. The care plan and job descriptions for both LVNs and RNs indicated the requirement to comply with physician orders and implement care plans. The failure to place floor mats on both sides of the bed was directly observed and verified through record review and staff interviews.

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 post the actual nursing hours for all shifts on specified dates and did not ensure that the staffing information was displayed in a prominent location accessible to residents and visitors. Observations revealed that the staffing sheet was only posted at the nursing station and not in an area readily accessible to residents and visitors. Additionally, the posted staffing information did not include the total and actual hours worked per shift for both licensed and unlicensed staff responsible for resident care. Interviews with the Staffing Assistant and the Director of Nursing confirmed that the only nursing staffing postings were at the nursing station and that actual hours worked per shift were not posted as required. The facility's policy indicated that nurse staffing data, including actual hours worked, should be posted daily for each shift in a prominent location. However, this was not followed, resulting in nurse staffing information being inaccessible to visitors and lacking required details.

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 storage and maintain sanitary conditions in the kitchen. During an observation, five beef base containers labeled with a past best if used by date were found stored in a walk-in refrigerator. The dietary supervisor confirmed that food past its use-by date should not be stored and should be discarded to prevent potential foodborne illness, in accordance with the facility's policy and procedure. The policy specifically states that foods past the use by, sell-by, best-by, or enjoy by date should be discarded to maintain food safety and prevent contamination. Additionally, a review of kitchen logs revealed incomplete documentation for sanitation and equipment cleaning. The sanitation bucket log lacked records for several time points and was missing the manager's initials in the weekly review section. The ice machine cleaning log showed the ice machine was not cleaned as required, and the dish machine temperature record was missing checks and manager initials. The dietary supervisor acknowledged the importance of accurate and daily completion of these logs for regulatory compliance, infection control, and quality assurance, as outlined in the facility's 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 ensure accurate documentation of a resident's discharge disposition in the medical record. A review of the resident's records showed inconsistencies: the Admission Record indicated admission with diagnoses including atrial fibrillation, shortness of breath, and muscle weakness. The Discharge Planning Review noted the resident requested discharge to another LTC center, and the Discharge Instruction Form confirmed discharge to a LTC center. However, the Minimum Data Set (MDS) documented the resident as being discharged to a short-term general hospital. During interviews, the MDS Coordinator acknowledged incorrectly documenting the discharge destination in the MDS, while the Discharge Instruction Form reflected the correct LTC center destination. The Director of Nursing confirmed that accurate documentation in the medical record is essential for quality care and impacts the development of the care plan and post-discharge support. The facility's policy requires that documentation be objective, complete, and accurate. The discrepancy between the MDS and the Discharge Instruction Form resulted in incomplete and potentially misleading information regarding the resident's discharge status.

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 investigate and monitor healthcare personnel for signs and symptoms of Respiratory Syncytial Virus (RSV) after exposure to two residents who tested positive for RSV. Resident 1 was admitted with hypertensive heart disease and chronic kidney disease, and tested positive for RSV after exhibiting cough symptoms. Resident 2, admitted with dependence on supplemental oxygen and muscle weakness, also tested positive for RSV. Both residents were placed on isolation after their positive test results. However, the Infection Prevention Nurse (IPN) did not maintain a list of staff or residents who had close contact with the infected residents, and the Director of Nursing (DON) confirmed that there was no tracking of such contacts. The facility's policy and procedure for infection control lacked procedures for tracking close contacts or potential exposures. The IPN was unaware if two staff members who called off work due to not feeling well had close contact with the infected residents. The facility's failure to track and monitor close contacts of the infected residents was contrary to the CDC's guidelines, which recommend active surveillance to identify additional ill residents or healthcare personnel. This deficiency had the potential to spread RSV to other residents and staff within the facility.

Penalty

No penalty information released

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

Summary

The facility failed to maintain its infection prevention and control program for two sampled residents by not ensuring proper hand hygiene during meal service. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene before entering Resident 1's room, after assisting with the lunch tray, or after exiting the room. Subsequently, CNA 1 handled a coffee pot at a shared station without performing hand hygiene and then entered Resident 2's room to provide a coffee cup, again without performing hand hygiene. This sequence of actions had the potential to transmit infectious microorganisms between residents. Resident 1 was admitted with diagnoses including a left femur fracture, gastrointestinal hemorrhage, and muscle wasting, with moderately impaired cognition and dependency on assistance for activities of daily living. Resident 2 had a history of myocardial infarction, urinary tract infection, and difficulty walking, with decision-making capacity dependent on context. The facility's policy required handwashing before and after direct resident care and contact with potentially contaminated substances, which was not adhered to in this instance, as confirmed by interviews with CNA 1 and the Infection Preventionist Nurse.

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 complete the infection monitoring form during an influenza outbreak for a resident. The deficiency was identified during a review of the resident's Admission Record, which indicated that the resident was admitted on 12/16/2024 with diagnoses including influenza, pneumonia, and respiratory failure. However, the Infection Monitoring Forms dated 12/13/2024 and 12/14/2024 inaccurately indicated that the resident was already in the facility and showing symptoms of a cough, despite the resident not being admitted until 12/16/2024. During an interview with the Director of Nursing (DON), it was revealed that the infection monitoring in the facility was not initiated until 12/17/2024 for all residents, and the dates on the forms were inaccurately completed. The DON acknowledged the importance of ensuring that forms are accurately completed in healthcare, as they directly impact patient care, safety, compliance, and operational efficiency. The facility's policy and procedure on Charting and Documentation, dated 7/2017, emphasized that documentation in the medical record should be objective, complete, and accurate.

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 policies and procedures regarding falls management and care plan revisions, resulting in a deficiency. Specifically, the facility did not revise the care plans or implement new interventions for two residents after they experienced multiple falls. Resident 1, who was admitted with diagnoses including congestive heart failure, bradycardia, and Parkinson's disease, had several falls documented on SBAR Communication Forms. Despite these incidents, there were no revisions made to Resident 1's care plan to address the falls. Similarly, Resident 2, who was admitted with Parkinson's disease and dementia, also experienced multiple falls as documented on SBAR forms. The facility's records showed that no care plan revisions or new interventions were implemented following these falls. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that care plans should be revised after each fall, but this was not done for Residents 1 and 2. The facility's policies and procedures, including the Falls Management Program and Comprehensive Person-Centered Care Plans, emphasize the need for ongoing assessments and care plan revisions when there is a significant change in a resident's condition. The failure to revise care plans and implement new interventions after falls placed the residents at risk for further falls and injuries, as the facility did not follow its established protocols to mitigate these risks.

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 procedure titled 'Charting and Documentation,' resulting in incomplete documentation for a resident. The resident, who was admitted with diagnoses including congestive heart failure, bradycardia, and Parkinson's disease, had a scheduled urology consult that was not documented in the medical records. The absence of documentation regarding the cancellation of the urology consult appointment led to a lack of communication among facility staff about the resident's care. Interviews with facility staff revealed that the cancellation of the urology consult was known but not recorded in the resident's chart. Both a Licensed Vocational Nurse and Social Services staff acknowledged the importance of documenting such changes to ensure all staff are informed about the resident's care status. The facility's policy requires that all services, progress, and changes in a resident's condition be documented to facilitate communication among the interdisciplinary team, which was not followed 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 report a communicable disease, specifically Hepatitis A, to the California Department of Public Health (CDPH) for a resident who tested positive. The resident, who had been admitted to the facility with diagnoses including congestive heart failure, bradycardia, and Parkinson's disease, was found to have a high level of Hepatitis A antibodies during a test conducted at a general acute care hospital. The hospital's infection preventionist informed the facility of the positive test result, but the facility only reported the case to the County of Los Angeles Department of Public Health and not to the CDPH. The Director of Nursing (DON) admitted during interviews that they were unaware of the requirement to report the case to the CDPH. The facility's policy and procedure documents, which were reviewed, indicated that unusual occurrences, such as outbreaks of communicable diseases, should be reported to appropriate agencies within 24 hours. However, the facility did not follow this protocol in the case of the resident with Hepatitis A. The failure to report the disease to the CDPH had the potential to hinder proper and timely investigation of the communicable disease.

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 proper infection control practices to prevent the spread of Covid-19. A housekeeper entered a Covid-19 isolation room without wearing the required eye protection, such as a face shield or goggles, as indicated by the signage outside the room. This signage, provided by the County of Los Angeles Public Health, specified that personal protective equipment, including eye protection, must be worn before entering the room. The housekeeper acknowledged not wearing the necessary eye protection, which is a breach of the facility's policy on standard precautions. Additionally, three tumbler cups belonging to staff were found on the handrail in the red zone, an area designated for residents who tested positive for Covid-19. The Infection Preventionist Nurse confirmed that these cups should not be left on the handrails due to the risk of cross-contamination, which could potentially lead to the spread of infection throughout the facility. The facility's in-service training on infection control emphasized the importance of proper storage of personal belongings, indicating that items such as coffee cups and water bottles should not be left in hallways or resident 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 facility failed to answer call lights in a timely manner for seven residents, leading to frustration and potential psychosocial decline. Resident 2, who was dependent on staff for toileting, dressing, and bathing, reported waiting up to an hour for assistance, causing frustration and self-reliance for bathroom needs. Resident 15, who required substantial assistance, was observed waiting 15 minutes for help with a bedpan, and Resident 31 reported waiting more than 10 minutes for call light responses, which they considered too long. Resident 148, who was dependent on staff for various needs, reported waiting one to two hours for assistance, leading to prolonged periods in soiled briefs and concerns about skin health. Resident 149's representative stated that the resident, who had bowel issues, waited 15 minutes for call light responses, resulting in incontinence and the need for frequent clothing changes. Resident 150 also reported waiting up to an hour for assistance with soiled briefs, and Resident 30 mentioned that staff often promised quick returns but did not follow through. Interviews with staff, including CNA 1 and the DON, revealed that staffing shortages and increased resident assignments contributed to the delays. The DON acknowledged that call lights should be answered within 5 to 10 minutes and that longer waits could lead to urinary tract infections, skin breakdown, and negative impacts on residents' dignity and psychosocial well-being. Facility policies emphasized the importance of prompt call light responses to maintain resident dignity and care 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 develop and implement comprehensive care plans for three residents, leading to potential gaps in their care. For Resident 16, who was diagnosed with dementia and unspecified psychosis, the facility did not create a care plan to address the use of Depakote Sprinkles, a medication prescribed for bipolar mania. This omission was confirmed during an interview with an LVN, who acknowledged that a care plan was required to monitor the medication's effectiveness and potential adverse reactions. For Resident 25, who had diagnoses including Type 2 Diabetes and dysphagia, the facility did not individualize the care plan to address the resident's nutritional needs and difficulty chewing. Despite a recommendation from a Registered Dietician for a puree diet due to dental issues, the care plan remained generalized and did not reflect specific weight goals or interventions. Both the RD and an LVN confirmed that the care plan should have been tailored to meet the resident's specific needs. Resident 11, who had severe cognitive impairment and was dependent on assistance for daily activities, had a care plan for the risk of altered fluid balance that lacked measurable objectives and timeframes. The Director of Nursing acknowledged that the care plan needed to be individualized to help the resident maintain optimal functioning. The facility's policy and procedure on care plans emphasized the need for measurable objectives and timeframes, which were not met 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 Resident 46 received treatment and care in accordance with professional standards of practice by not following the physician's orders for the administration of antihypertensive medications. Specifically, the facility did not adhere to the prescribed parameters for holding medications based on the resident's blood pressure readings. On multiple occasions, Losartan and Metoprolol were administered despite the resident's blood pressure being below the threshold specified in the physician's orders, which could have adversely affected the resident's health status. Resident 46, who had a history of essential hypertension, hypertensive heart disease with unspecified congestive heart failure, and unspecified atrial fibrillation, was admitted to the facility with specific medication orders. The orders included holding Losartan if the systolic blood pressure (SBP) was less than 120 mmHg and holding Metoprolol if the SBP was less than 100 mmHg or the heart rate was less than 60 beats per minute. However, the Medication Administration Record (MAR) indicated that these medications were administered even when the resident's blood pressure readings were below the specified parameters. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the medications were given incorrectly on several dates, including 2/19/24, 2/24/24, 2/5/24, 2/23/24, and 2/26/24. The facility's policies and procedures for medication administration were not followed, as the staff did not check the physician's orders and parameters prior to administering the medications. This failure to follow the prescribed orders had the potential to result in harmful changes to the resident's blood pressure, compromising their health and safety.

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 sufficient staffing, resulting in delayed toileting and incontinence care for seven of 16 sampled residents. This deficiency was observed through multiple interviews, record reviews, and direct observations. Residents reported waiting times ranging from 10 minutes to over an hour for assistance with toileting and changing soiled briefs. These delays were corroborated by staff interviews, which revealed that staffing shortages and call-offs contributed to the prolonged response times. The Director of Nursing (DON) acknowledged that call lights should be answered within 5 to 10 minutes, and delays could lead to urinary tract infections (UTIs) and skin breakdowns. Resident 2, who was admitted with diagnoses including congestive heart failure and dysphagia, reported waiting up to an hour for assistance, leading to self-toileting despite fall risks. Resident 15, with hypertension and legal blindness, waited 15 minutes for help with a bedpan. Resident 30, diagnosed with Parkinson's disease and dementia, also experienced long waits for assistance. Resident 31, with a history of UTIs, reported similar delays. Resident 148, who had a lumbar vertebra fracture, waited up to two hours for help with changing wet briefs, causing discomfort and potential skin issues. Resident 149, with COPD and dementia, faced 15-minute waits, leading to incontinence incidents. Resident 150, admitted with enterocolitis due to C. diff, reported waiting up to an hour for brief changes, resulting in sore and irritated skin. Staff interviews confirmed the facility's staffing issues. CNA 1 and CNA 2 mentioned that call-offs and increased resident assignments led to longer wait times for residents. LVN 1 expressed emotional distress due to the staffing shortage, noting that new hires often did not stay. The facility's policies indicated that call lights should be answered within 3-5 minutes, with a maximum wait time of 10 minutes. The facility assessment highlighted the need for prompt response to bowel/bladder services to maintain continence and promote resident dignity. However, the observed delays and staff admissions indicated a failure to meet these standards, resulting in compromised resident care.

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 safe and proper food storage and preparation practices in the kitchen, as observed during a survey. Specifically, food items were found unlabeled and undated, including a jar of peanut butter, individual servings of chocolate pudding, containers of cut-up fresh fruits, dinner rolls, and bins of yellow and red onions. The Utility Worker (UW) acknowledged that the facility's practice was to label food items immediately upon opening to prevent serving spoiled food that could make residents sick. Additionally, cold foods such as macaroni salad were not maintained at the required temperature of 41 degrees Fahrenheit or below, with observed temperatures of 44 and 45 degrees Fahrenheit. The Executive Chef (EC) confirmed the importance of maintaining proper food temperatures to ensure food safety and quality for residents. The facility's policies and procedures (P&P) for food and supply storage, as well as refrigerated storage life of foods, were reviewed and indicated the necessity of labeling and dating food items and maintaining cold food temperatures at 41 degrees Fahrenheit or below. However, the facility's Temperature Log and Checklist (TLC) did not consistently document food items with corresponding temperatures, and cold items were not always placed on ice as required. The deficiencies observed in food labeling and temperature control had the potential to cause foodborne illness and affect the quality and palatability of food served to residents.

Penalty

No penalty information released

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

Summary

The facility failed to follow standard infection control practices by not safely and hygienically storing personal toiletries and belongings for two residents. Resident 9, who had diagnoses including myocardial infarction, type 2 diabetes mellitus, and end-stage renal disease, had an unlabeled electric toothbrush and other personal items stored improperly in a shared restroom. Similarly, Resident 98, who had heart failure, type 2 diabetes mellitus, and unspecified psychosis, also had personal items stored in an unhygienic manner. Certified Nursing Assistant 5 confirmed that the items should have been labeled and stored separately to prevent cross-contamination. The Infection Preventionist also emphasized the importance of labeling personal belongings to avoid confusion and potential cross-contamination. Additionally, the facility did not have a surveillance plan to monitor or track infections other than COVID-19. The Director of Nursing admitted that the facility did not track or monitor infections and relied on the public health nurse for advice when a resident had a communicable disease. This lack of tracking and monitoring could potentially lead to the spread of infections within the facility. The facility's policy indicated that the Infection Preventionist should maintain documentation of incidents, findings, and corrective actions, and report surveillance findings to the Quality Assessment and Assurance Committee.

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 call light was within reach for a resident, identified as Resident 28, as indicated in the resident's care plans. Resident 28, who had diagnoses including muscle weakness, unspecified glaucoma, and Alzheimer's disease, was observed sitting in a recliner chair with the call light device looped around the left side rail of the bed, out of reach. Certified Nursing Assistant 3 confirmed that Resident 28 could not reach the call light device and subsequently placed it within reach. Interviews with staff members, including the MDS Assistant and another CNA, emphasized the importance of having the call light within reach for resident safety and the ability to call for help. Resident 28's care plans, which addressed risks for falls, communication problems, and anxiety, all indicated the necessity of having the call light within reach. The facility's policy and procedure on call lights also required that the call light be available to residents and that staff respond promptly to requests. Despite these guidelines, the call light was not initially placed within reach, potentially compromising Resident 28's ability to alert staff for assistance in a timely manner.

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 had directions or instructions regarding treatment requests and wishes in the event of a medical emergency, as indicated in the facility's Policy and Procedure (P&P) and Resident 9's care plan. Resident 9's Admission Record indicated diagnoses including a subsequent non-ST elevation myocardial infarction, type 2 diabetes mellitus, and end-stage renal disease. Despite having an intact cognitive status, Resident 9 did not have a completed Physician Orders for Life-Sustaining Treatment (POLST) form or an advance directive (AD). The POLST form was incomplete and lacked signatures from both Resident 9 and a physician, which was confirmed during interviews with the Social Services Designee (SSD) and a Registered Nurse (RN). Both staff members acknowledged the importance of having a completed POLST or AD to ensure the resident's treatment wishes are honored in a medical emergency. Resident 9 stated that the facility did not discuss their treatment requests or wishes in the event of a medical emergency. The care plan for Resident 9, which indicated a Full Code status, required that the code status be signed by the resident or responsible party and be included in the active medical record. The facility's P&P on POLST forms, revised in 2018, also required that the form be signed by both the resident and a physician. The failure to complete the POLST form and discuss treatment wishes with Resident 9 had the potential for the resident to receive inappropriate or medically unnecessary care, treatment, and services.

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 35's Minimum Data Set (MDS) was completed accurately. Resident 35 was initially admitted with diagnoses including anxiety disorder, muscle weakness, and essential hypertension. The MDS dated [DATE] incorrectly indicated that Resident 35 was receiving oxygen therapy and tracheostomy care. However, during an observation and interview, it was confirmed that Resident 35 did not have a tracheostomy or a breathing tube. The MDS Assistant and the Director of Nursing (DON) both confirmed that the MDS was incorrect and not accurate, as Resident 35 did not have a tracheostomy and should not have been coded as such. The facility's undated Policy and Procedure (P&P) titled

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's bed was maintained in a low position, which is a critical intervention to prevent falls. Resident 40, who had a history of multiple falls and was at high risk for further falls, was observed on multiple occasions with their bed not in the lowest position. This failure occurred despite clear documentation in the resident's care plan and orders that the bed should be kept in the lowest position to minimize injury in case of a fall. The resident's medical history included cerebral infarction, muscle weakness, dementia, and severe cognitive impairment, all of which contributed to their high fall risk. On several documented instances, including an unwitnessed fall that resulted in a pneumothorax, the resident's bed was found to be elevated. Staff interviews confirmed that the bed should have been kept in the lowest position, and observations during the survey corroborated that this intervention was not consistently followed. The facility's policy on fall management also emphasized the importance of maintaining the bed in its lowest position as a preventive measure, yet this was not adhered to, placing the resident at risk for further falls and injuries.

Penalty

No penalty information released

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

Summary

The facility failed to follow the physician's order to check the colostomy site every shift and change the leaky colostomy bag in a timely manner for a resident who required colostomy care. The resident, who had no cognitive impairments and was dependent on staff for bathing and dressing, reported that the colostomy bag was leaking and that the facility did not have the necessary supplies to reattach a new colostomy bag. The resident expressed frustration, stating that they had been requesting the supplies for three weeks. An observation confirmed that the colostomy flange was not secured to the resident's skin and was soiled with stool, and the supplies were still en route to the facility at that time. The Registered Nurse (RN) confirmed that the colostomy bag needed to be changed on a previous date but could not be due to the lack of supplies. The Director of Nursing (DON) also stated that colostomy bags should be changed if they are leaking or soiled. The resident's care plan indicated that staff were to ensure appropriate wafer stoma size and adhesive and provide colostomy care every shift. The facility's policy and procedure for colostomy care outlined the necessary equipment and supplies, which were not available at the time of the incident, leading to the deficiency in care 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

The facility failed to ensure that Resident 10 received oxygen therapy consistent with professional standards of practice and in accordance with the physician's order. Resident 10, who was admitted with diagnoses including heart failure, unspecified dementia, and shortness of breath, had an order for continuous oxygen at three liters through a nasal cannula. However, during an observation, it was found that Resident 10 was receiving oxygen at 4 1/2 liters, contrary to the physician's order. This discrepancy was confirmed by both Resident 10's Responsible Party and a Registered Nurse, who acknowledged the importance of adhering to the prescribed oxygen flow rate. The facility's Policy and Procedure for Oxygen Administration, revised in October 2010, mandates verifying and reviewing the physician's orders for oxygen administration and ensuring the proper flow of oxygen is being administered. Despite this policy, the facility did not comply, as evidenced by the incorrect oxygen flow rate observed. This failure to follow the prescribed oxygen therapy could potentially compromise Resident 10's medical condition, highlighting a significant lapse in the facility's adherence to professional standards and physician orders.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was free from unnecessary psychotropic medication. Resident 30 had an order for Lorazepam without an end date within 14 days from the time it was ordered, which is against regulations. The resident was admitted with diagnoses including Parkinson's disease, dementia, and anxiety disorder. The Minimum Data Set indicated that the resident had mildly impaired cognition. Despite a recommendation from the Consultant Pharmacist to discontinue the Lorazepam order to comply with regulations, the order was not discontinued because the resident's family wanted to keep the medication available. The Medication Administration Record showed that Lorazepam was not administered during the review period, but the order remained active without proper re-evaluation for unnecessary medication use. During an interview, the Director of Nursing acknowledged that not following pharmacy recommendations would result in the resident not being re-evaluated for unnecessary medications. The facility's policy on Medication Monitoring and Management requires a documented clinical rationale if the prescriber deems the medication necessary, but this was not followed in Resident 30's case. This failure had the potential for the resident to receive unnecessary psychotropic medication, which could result in adverse consequences.

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 designated Infection Preventionist (IP) completed the specialized training required for the role, as indicated in the facility's job description. During an interview, the IP admitted to being on module five of 24 in the certification process and had not yet completed the necessary training. The Director of Nursing (DON) confirmed that the IP was still in training and that the DON was assisting with IP duties in the interim. The facility's job description for the IP role specified that the IP should have completed specialized training in infection prevention and control, which had not been fulfilled at the time of the survey.

Penalty

13 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 prevent a fall for a resident with a history of falls by not implementing the physician's order to place bilateral floor mats and a silent bed/chair alarm. The resident, who had muscle weakness, falls, and gait abnormalities, was admitted with an active order for these safety measures. Despite this, the resident fell and sustained a right femoral neck fracture, requiring surgical intervention and hospitalization. The resident's care plan and assessments indicated a high risk for falls, and the use of floor mats and bed/chair alarms were documented as necessary interventions. However, during the incident, these safety measures were not in place. The resident fell while attempting to use the restroom, resulting in a hip fracture. Staff interviews confirmed that the required safety devices were not present at the time of the fall. The facility's policies on silent pad alarms and fall management were not followed, as the ordered safety devices were not implemented. The failure to adhere to these orders and policies directly led to the resident's fall and subsequent injury. Staff members acknowledged the absence of the required safety measures, indicating a lapse in compliance with the physician's orders and facility protocols.