White Oak Post Acute Care

Penalty

Fine: $21,982

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 immediately notify a physician when there was a significant change in a resident’s skin condition, as required by its own skin program policy. The policy stated that when a resident develops a reddened area or wound, the licensed nurse must notify the resident, family, and physician of the reddened area or wound, with physician notification to occur during normal office hours unless a treatment order is needed. Resident #3 had a significant change in skin condition that was not promptly communicated to the physician, despite the facility’s policy and the resident’s risk factors. Resident #3 was admitted on 05/06/2024 and had a significant change MDS dated 01/22/2026 indicating the resident was always incontinent of bowel and bladder, dependent for bed mobility, and had no unhealed pressure ulcers at that time. On 02/14/2026, a CNA working day shift observed three dime-sized, fluid-filled blisters on the resident’s buttocks and reported this finding to the nurse. The LPN on duty acknowledged that it was reported to her that the resident had a skin condition on the buttocks, which she described as reddened and open, and she applied skin prep to the area. The LPN confirmed she did not notify the doctor or the resident’s responsible party and did not recall whether she documented her assessment. There was no documentation of a skin assessment for Resident #3 on 02/14/2026 in the medical record. On 02/18/2026, during a weekly body audit, a treatment nurse discovered a stage 3 pressure ulcer on the resident’s sacrum, measuring 8.1 cm in length, 9.2 cm in width, and 0.1 cm in depth, identified as an in-house acquired, new onset pressure ulcer with full-thickness skin loss. The nurse documented the wound, notified the nurse practitioner and responsible party, and obtained new treatment orders. The wound care nurse practitioner’s assessment on 02/19/2026 confirmed an acute stage 3 pressure injury with exposed adipose tissue and three open areas measured together as one wound. Interviews confirmed that the earlier skin changes reported on 02/14/2026 were not communicated to the physician at that time, resulting in a delay in physician notification until 02/18/2026.

Penalty

Fine: $21,982

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 implement and maintain its Enhanced Barrier Precautions (EBP) policy for residents requiring infection prevention measures. The facility’s written policy, dated January 2025, required the use of gown and gloves during high-contact resident care activities for residents with applicable conditions or devices, such as wounds and indwelling urinary catheters, even if multidrug-resistant organism (MDRO) status was unknown. High-contact activities were defined to include dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, urinary catheter care, and wound care. Resident #5 had a physician’s order for EBP related to a stage 3 pressure ulcer of the left buttock, and Resident #R1 had multiple non-pressure chronic ulcers of the left lower extremity, pressure ulcers of the left ankle and heel, and an indwelling urinary catheter documented in the care plan. On multiple observations, staff did not follow the EBP requirements for gown use during direct care of these residents. A treatment nurse provided wound care to Resident #5 wearing gloves but no gown, and there was no EBP signage on the resident’s door at that time. Later, a CNA was observed emptying Resident #R1’s indwelling catheter wearing gloves but no gown, despite EBP signage on the door, and confirmed she had not donned a gown. The same CNA was subsequently observed changing Resident #5’s brief while wearing gloves but no gown and acknowledged she had forgotten to wear a gown, even though an EBP sign was posted above the resident’s bed. The treatment nurse later confirmed she did not wear a gown for Resident #5’s wound care and stated she only used gowns for “big wounds or infections.” The DON stated that residents with infections, PEG tubes, wounds, colostomies, ostomies, urinary catheters, tube feedings, and pressure ulcers should be on EBP and confirmed staff should wear gown and gloves when emptying urinary catheters or providing wound 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 maintain accurate and complete medical records in accordance with accepted professional standards for one resident with pressure ulcers. Specifically, for a resident admitted with multiple pressure ulcers, including Stage 3 and Stage 4 wounds, physician orders required that the resident's heels be floated and that the resident be turned and repositioned every two hours. However, a review of the resident's ADL flowsheets revealed missing documentation for these interventions on several shifts. The assigned CNAs did not record whether the required care was provided during these periods. Interviews with staff confirmed that CNAs were responsible for documenting all ADL tasks, including pressure ulcer interventions such as turning and floating heels. One CNA acknowledged that documentation was not completed for the specified dates, citing lack of computer access at times, but stated that care was provided. The Director of Nursing also confirmed that the documentation was incomplete and that the required interventions were not accurately recorded in the resident's medical record.

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 were administered safely and in accordance with professional standards of quality. Specifically, a nurse left a cup containing 13 pills and two cups with liquid and supplement medications at the bedside of a resident without a physician's order for self-administration. The facility's policy requires that residents may only self-administer medications if the attending physician and the Interdisciplinary Care Planning Team have determined the resident has the capacity to do so safely. In this case, there was no such order in place for the resident. The resident, who was cognitively intact as indicated by a BIMS score of 15, confirmed that the medications left at her bedside were her morning medications, which she had not yet taken. The nurse admitted to leaving the medications at the bedside because the resident preferred to take them later, and acknowledged that this was not in accordance with facility policy or physician orders. The Director of Nursing also confirmed that there were no orders for self-administration and that medications should not have been left at the bedside without supervision.

Penalty

Fine: $179,1458 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 adequate supervision for a resident identified as a wanderer, unsafe smoker, and high fall risk. This resident, who was severely cognitively impaired, managed to enter the smoking patio unsupervised and subsequently fell when attempting to maneuver his wheelchair over uneven concrete. The incident occurred over a weekend when the assigned smoking aide was not present on the patio, leaving the resident without necessary supervision. The resident's clinical records indicated a history of cerebral infarction, hemiplegia, hemiparesis, and cognitive communication deficit. He was assessed to have a high fall risk and required frequent monitoring due to his tendency to wander and inability to remember to ask for assistance. Despite these assessments, there was no documented evidence that the required 30-minute checks were performed during the timeframe reviewed. Interviews with staff and other residents confirmed that the smoking aide was not present on the patio during the incident, and the resident was able to self-propel his wheelchair unsupervised. The facility's policies required a smoking aide to be present from 7 a.m. to 7 p.m. to monitor residents, but this was not adhered to, leading to the resident's fall and the immediate jeopardy situation.

Removal Plan

• The outside patio fence gate is to remain closed.
• Administrator/DON/Designee will monitor the smoke patio area by using a monitoring form to ensure adequate supervision provided to residents.
• Disciplinary action up to termination will take place if this occurs again.
• All staff will be in-serviced by Administrator/DON/Designee on providing supervision to resident while out on smoke patio, the smoke monitor will remain outside and must be relieved by other staff to leave that area.
• All staff members will be required to complete the training prior to working their shift.
• No employee will be allowed to begin their shift until the training has been received.
• Audit reports will be submitted to the Administrator and QAPI committee for review and new interventions implemented as needed.

Penalty

Fine: $179,1458 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 proper notification procedures were followed after a resident experienced a fall. The resident, who had a history of falling and was identified as a high fall risk, experienced an unwitnessed fall over a weekend. Despite the facility's policy requiring the charge nurse to notify the physician and family in the event of a fall, there was no documented evidence that this notification occurred. The resident's clinical record and nursing notes did not show any communication with the physician or family regarding the fall. Interviews with the nursing staff, including the charge nurse and LPN on duty during the incident, confirmed that the required notifications were not made. The charge nurse admitted to not completing an incident report or notifying the necessary parties. The Assistant Director of Nursing and the Director of Nursing both confirmed that the charge nurse should have followed the established protocol, which includes completing an incident report and notifying the family and nurse practitioner. The Director of Nursing was unaware of the fall until the interview, indicating a breakdown in communication and adherence to the facility's policies.

Penalty

Fine: $179,1458 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 complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for a resident, identified as R1, who was admitted to the facility. The resident's admission MDS assessment, with an Assessment Reference Date (ARD) of February 12, 2025, was still marked as 'in progress' beyond the required 14-day completion timeframe. Interviews with the MDS coordinator and the Director of Nursing confirmed that the admission MDS for R1 was not completed within the mandated period, indicating a lapse in adhering to regulatory requirements for timely assessments.

Penalty

Fine: $179,1458 days payment denial

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

Summary

The facility failed to implement fall prevention interventions as outlined in the care plan for a resident at risk for falls. The resident, who was admitted with diagnoses including paraplegia and an unspecified injury at the T7-T10 level of the thoracic spinal cord, was identified as cognitively intact with a BIMS score of 14. The care plan included the use of a fall mat as an intervention to minimize the risk of injury from falls. However, observations on two consecutive days revealed that the fall mat was not present at the resident's bedside as required. Interviews with the resident and staff confirmed the lack of consistent implementation of the fall mat intervention. The resident reported falling out of bed in previous months and stated that no ongoing safety interventions, including the fall mat, were in place post-accidents. Staff interviews revealed inconsistencies in the understanding and application of the fall mat intervention, with one CNA stating it was only used during transfers, contrary to the care plan's requirement for continuous use at the bedside. The MDS coordinator and DON confirmed the expectation for the fall mat to be in place at all times to reduce fall risk, highlighting a failure in adherence to the care plan.

Penalty

Fine: $179,1458 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 care plan for a resident within the required timeframe of 7 days following the completion of the comprehensive Minimum Data Set (MDS) assessment. The resident was admitted to the facility, and the Admission MDS assessment had an Assessment Reference Date (ARD) of January 10, 2025. However, by February 24, 2025, the resident's care plan only included a baseline care plan with no specific tasks or interventions listed for activities of daily living assistance, fall risk interventions, nutritional services, or skin care measures. Interviews with facility staff confirmed the oversight. The staff member responsible for completing MDS assessments and care plans acknowledged that the comprehensive care plan should have been completed by January 17, 2025, but was not. The Director of Nursing also verified the ARD and confirmed the absence of a comprehensive care plan by the required date, indicating a lapse in adhering to the facility's policy for timely care plan development.

Penalty

Fine: $179,1458 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 accurately document census checks for two residents identified as being at risk for elopement and wandering. Resident #5, who was admitted with cerebral infarction, hemiplegia, and hemiparesis, had a severe cognitive impairment with a BIMS score of 3. Physician's orders required census checks every 30 minutes due to the resident's risk of elopement. However, a review of the Task log from February 13 to February 15, 2025, showed no documentation of these checks. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the checks were not documented as required. Similarly, Resident #6, admitted with non-traumatic intracerebral hemorrhage and hemiplegia, also had severe cognitive impairment with a BIMS score of 5. The resident's physician's orders required hourly checks due to a history of wandering. However, the Task log from February 13 to February 24, 2025, lacked documentation of these checks. Interviews with the LPN and CNA assigned to Resident #6, as well as the DON, confirmed the absence of required documentation. Both residents' cases highlight a failure in maintaining accurate records of census checks, which are crucial for minimizing risks associated with elopement and wandering.

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 sufficient certified nursing assistant (CNA) staff to meet the needs of its residents, as required by its policy titled 'Sufficient Staff.' The policy mandates a specific staffing ratio of 8 CNAs for both the day and evening shifts, and 4 CNAs for the night shift. However, on multiple occasions, specifically on 12/22/2024, 12/29/2024, 01/11/2025, and 01/12/2025, the night shift was staffed with only 3 CNAs instead of the required 4. Interviews with several CNAs confirmed that the staffing levels on these dates were insufficient to provide adequate care. The facility's administrator acknowledged the staffing shortfall during an interview, confirming the deficiency in meeting the required staffing levels.

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 notify the Ombudsman of facility-initiated emergency transfers for two residents. The facility's policy requires that the Social Services Director or designee provide copies of notices for emergency transfers to the Ombudsman, which can be sent on a monthly basis. However, the facility did not document the emergency transfers of two residents on the Ombudsman Emergency Transfer Log, as required by their policy. Resident #5 was admitted with a history of cerebral infarction, hemiplegia, hemiparesis, history of falling, and cognitive communication deficit. On 12/26/2024, Resident #5 experienced a fall resulting in an emergency transfer to a local hospital for evaluation and treatment, but this transfer was not documented on the Ombudsman Emergency Transfer Log. Similarly, Resident #6, who was admitted with dementia, dysphagia, and cognitive communication deficit, was transferred to a local hospital on 11/05/2024, but this transfer was also not documented on the log. The Social Services Director confirmed the omissions during an interview.

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 three residents, leading to deficiencies in their care. Resident #3, who was admitted with hemiplegia and dementia, experienced a fall on January 1, 2025. Despite the care plan being updated to include a physical therapy (PT) screening, the therapy staff was not informed, and the screening was not completed as required. Interviews with the PT director and assistant confirmed that they were unaware of the fall and the need for a PT evaluation, which should have been conducted the day after the fall. Resident #4, who was severely cognitively impaired, exhibited wandering behaviors that were not reflected in his care plan. Although staff members, including CNAs and an LPN, observed the resident wandering into other residents' rooms and different halls, this behavior was not documented in the elopement risk assessment or care plan. The MDS coordinator confirmed that the resident's wandering should have been reported and included in the care plan, but it was not. Resident #5, who had a history of falls and cognitive impairment, had a physician's order for every 30-minute checks due to falls. However, the care plan did not include this order, and staff were unaware of the need for more frequent checks. Interviews with CNAs and an LPN revealed that they were performing checks every two hours instead. The MDS coordinator and DON confirmed the oversight, acknowledging that the order was not documented in the care plan or other records, leading to a failure in implementing the necessary checks.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary care and services to maintain good personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who was admitted with diagnoses including Morbid Obesity and Functional Quadriplegia, was assessed to require extensive assistance for ADL care and was always incontinent. On a specific day, the resident activated the call light at 7 p.m. requesting incontinent care, but did not receive assistance until the new shift arrived at 10 p.m., leaving her saturated in urine. Interviews with staff revealed that the CNA assigned to the resident's care was not aware of any missed care prior to shift change, despite the resident's report and the confirmation from another CNA who found the resident saturated. The Director of Nursing confirmed that incontinent care should be provided every two hours and before shift changes, indicating a lapse in the facility's adherence to its care protocols.

Penalty

No penalty information released

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

Summary

The facility failed to ensure accurate documentation of Activities of Daily Living (ADL) care for two residents, leading to a deficiency in maintaining proper medical records. Resident #8, who was admitted with unspecified thoracic spinal cord injury and acute pain due to trauma, required extensive assistance for ADL care. However, the bed bath log for Resident #8 showed missing documentation on multiple dates, indicating a lack of recorded care or refusals. Similarly, Resident #9, admitted with chronic obstructive pulmonary disease, morbid obesity, and hypertensive heart disease with heart failure, also required extensive assistance for ADL care. The bed bath log for Resident #9 also revealed several dates with no documentation of bed baths being given or refused. Interviews with facility staff confirmed the absence of documentation for the specified dates. An LPN stated that CNAs are responsible for charting bed baths, including any refusals, and upon review, confirmed the missing entries for Resident #9. Another staff member reviewed the charts for both residents and confirmed the lack of documentation for the mentioned dates. This failure to document ADL care accurately is a breach of the facility's policy on maintaining complete and legal records of 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 provide pharmaceutical services to meet the needs of a resident diagnosed with Bipolar Disorder. A handwritten telephone order for Ativan 1 mg IM was issued for the resident to address agitation and aggression. However, the medication was not administered as ordered. The nurse, S2RN, confirmed receiving the order but chose not to administer the medication because the resident had calmed down. S2RN did not contact the nurse practitioner to discontinue the order, which was a deviation from the facility's policy that requires medication to be administered in accordance with physician's orders. The Director of Nursing, S1DON, stated that staff are expected to follow physician's orders and should contact the ordering physician if a medication is not administered.

Penalty

Fine: $309,54027 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 nursing staff had the appropriate competencies and skills to provide safe care for residents, as evidenced by several incidents. One significant incident involved a resident who required a Hoyer lift and assistance from two staff members for transfers. However, a CNA attempted to transfer the resident independently without the lift, resulting in the resident falling and sustaining a laceration above the left eyebrow. Interviews with staff revealed a lack of knowledge on how to identify and implement residents' assessed transfer needs, indicating a systemic issue in training and competency verification. Another deficiency was observed in the facility's handling of residents who smoked. Several residents identified as unsafe smokers were found smoking unsupervised in non-designated areas, with some possessing smoking paraphernalia despite being assessed as requiring supervision. Staff interviews revealed a lack of awareness and training regarding their roles in implementing safe smoking interventions and monitoring residents' smoking behaviors. The facility did not have an effective system to assess and communicate smoking safety interventions, leading to unsafe conditions for residents who smoked. Additionally, the facility failed to document and verify the competency of its nursing staff. Personnel files reviewed showed no evidence of competency skills check-offs for several CNAs and LPNs. Interviews with staff and administration confirmed that competency checks were not consistently performed upon hire or annually, and there was no documentation to support that staff were competent in their roles. This lack of competency verification contributed to the unsafe practices observed in resident care and smoking interventions.

Penalty

Fine: $309,54027 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 administer its resources effectively and efficiently, leading to several deficiencies in resident care. One significant incident involved a resident who required a Hoyer lift and two staff members for transfers. However, a CNA attempted to transfer the resident independently without the lift, resulting in the resident falling and sustaining a laceration above her left eyebrow. The CNA and other nursing staff were unaware of how to identify and implement the resident's assessed transfer needs, as there was no documentation in the care plan or resident summary regarding the required assistance and devices for transfers. Another deficiency was observed in the facility's handling of residents who smoked. Several residents identified as unsafe smokers were found smoking unsupervised in unapproved areas without protective gear. The facility lacked an effective system to assess and implement safe smoking interventions, and staff were not informed of their roles in ensuring smoking safety. This led to residents possessing smoking paraphernalia and smoking in non-designated areas, posing a risk to their safety. Additionally, the facility failed to ensure that licensed nurses and CNAs were competent in the skills required to meet resident needs. There was no documented evidence of performance evaluations or competency skills check-offs for several staff members. Interviews revealed that competency checks were not conducted, and new hires were allowed to provide direct resident care without demonstrating their competency. This lack of oversight and training contributed to the deficiencies observed in resident care and safety.

Penalty

Fine: $309,54027 days payment denial

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

Summary

The facility failed to ensure that residents remained free from accident hazards and received adequate supervision and assistance to prevent accidents. Specifically, the facility did not have an effective system in place for nursing staff to identify and implement a resident's assessed transfer needs. This deficiency was highlighted when a resident, who required a Hoyer lift and two staff members for transfers, was independently transferred by a CNA without the lift, resulting in a fall and injury. Interviews with staff revealed a lack of knowledge on how to identify residents' transfer needs, and documentation did not clearly indicate the required assistance for transfers. Additionally, the facility failed to implement safe smoking interventions for residents identified as unsafe smokers. One resident, assessed as an unsafe smoker, was observed smoking unsupervised in an unapproved area, while another resident, not listed as a smoker, was found smoking unsupervised with smoking paraphernalia. A third resident, also assessed as an unsafe smoker, was observed with smoking materials in his possession at an undesignated time and area. Staff interviews indicated that the facility lacked an effective system to assess and implement interventions for smokers, and there was a reliance on verbal communication rather than documented procedures. The deficiencies in both transfer assistance and smoking safety were compounded by inadequate documentation and communication among staff. The facility's policies on safe lifting and smoking were not effectively implemented, leading to situations where residents were at risk of harm. Staff were often unaware of residents' specific needs and the appropriate interventions required, resulting in unsafe practices and potential harm to residents.

Penalty

Fine: $309,54027 days payment denial

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

Summary

The facility failed to ensure that residents with identified mental health diagnoses were referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. This deficiency was identified for four residents out of six sampled records reviewed for PASRR compliance. Specifically, residents with diagnoses such as Anxiety Disorder, Schizophrenia, Depression, Paranoid Personality Disorder, and Schizoaffective Disorder did not have the necessary PASRR Level II determinations on file. The absence of these determinations indicates a failure to submit the required Resident Review Forms to the appropriate state agency for evaluation. Interviews conducted with facility staff confirmed the oversight. S20SW, responsible for submitting PASRRs, acknowledged that new mental health diagnoses should prompt a submission for a PASRR Level II referral. However, she verified that the necessary forms for the affected residents were not sent. Similarly, S16CON confirmed that residents with approved mental health diagnoses should have had the forms submitted for PASRR Level II determinations, which were not completed for the residents in question.

Penalty

Fine: $309,54027 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 acceptable nutritional parameters for a resident with End Stage Renal Disease by not providing the ordered therapeutic diet. The resident, who was dependent on dialysis, was prescribed a liberal renal diet with a 1000 ml fluid restriction and was not to receive soups or broths. However, the resident reported frequently receiving soup and insufficient food portions that did not satisfy his hunger. An observation confirmed that the lunch tray lacked protein, consisting only of 1/2 cup of California blend vegetables and 1/2 cup of parslied noodles. Interviews with staff members corroborated the resident's claims. A dietary staff member confirmed the contents of the lunch and dinner trays, which included soup that the resident should not have received. The registered dietitian acknowledged that the resident should have received increased protein with his meals and confirmed the error in the meal provided. The Director of Nursing also confirmed that the resident should have been served the liberal renal diet as ordered, indicating a failure in adhering to the prescribed dietary plan.

Penalty

Fine: $309,54027 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 drugs and biologicals were stored according to accepted professional principles, as observed during a survey. Two medication carts, Med Cart A and Med Cart B, were found to contain loose pills, which were confirmed by the LPNs responsible for these carts. Additionally, Med Cart B contained an expired bottle of sterile water, which was also confirmed by the LPN. These findings indicate a lack of adherence to the facility's policy on medication storage, which requires that medication storage areas be maintained in a clean, safe, and sanitary manner, and that discontinued, outdated, or deteriorated drugs or biologicals not be used. Furthermore, the facility failed to maintain proper storage temperatures for medications in Med Frig D. The refrigerator was observed to have a temperature of 29 degrees Fahrenheit, which is below the required range of 36-45 degrees Fahrenheit. This refrigerator contained several insulin pens and vials of antibiotics. The temperature log for the refrigerator showed previous instances of temperatures being out of range, which were not reported or addressed. The DON confirmed that the responsibility for monitoring and reporting temperature logs lies with the nursing staff, and that the observed temperatures were inappropriate.

Penalty

Fine: $309,54027 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 all dietary staff hired were trained on how to test the chemical dishwasher for chlorine. During an observation, a staff member was seen placing various items through a low temperature dishwasher without testing for chlorine. In an interview, the staff member confirmed that he was not trained on how to test the dishwasher for chlorine. Additionally, a dietary manager confirmed that all kitchen staff should use the chemical rinse method to sanitize dishes and admitted that there was no documentation or proof of training for the five dietary staff hired to operate the dishwasher.

Penalty

Fine: $309,54027 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 store food in accordance with professional standards for food service safety, potentially affecting 81 residents served from the kitchen. During an initial tour of the kitchen, several items were found without proper labeling or dating, including containers of parsley flakes, onion powder, garlic powder, and a ground garlic and ginger mix. These items lacked labels indicating an open date or expiration date, which is against the facility's policy for food safety guidelines. Further observations in the refrigerator revealed additional items without proper labeling, such as sliced American cheese, shredded cheese, boiled eggs, concentrated liquid coffee, and fruit salad deluxe. Some items, like pepperoni, were past their expiration date. In the freezer, opened and unsealed boxes of premade pancakes, French fries, and white sheet cake were found without labels. The dry pantry also contained an opened, unsealed box of fish fry without a label. An interview with S7DEM confirmed that these items should have been labeled with open dates and/or expiration dates, which they were not.

Penalty

Fine: $309,54027 days payment denial

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

Summary

The facility failed to ensure that residents understood the binding arbitration agreement they signed upon admission. This deficiency was identified for two residents, who were admitted from the hospital and signed the Optional Binding Arbitration form without understanding its contents. Both residents stated during interviews that they were not aware of what an arbitration agreement was and confirmed that no one explained the agreement to them before they signed it. The staff member responsible for explaining the admissions process, S6CAC, confirmed that she reviewed the admissions packet and contractual agreements with the residents while they were in the hospital. However, she assumed the residents understood the arbitration agreement because they did not ask any questions. This assumption led to the residents signing the agreement without a clear understanding, resulting in the facility's failure to ensure informed consent for the arbitration agreement.

Penalty

Fine: $309,54027 days payment denial

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

Summary

The facility failed to develop and implement appropriate plans of action to correct and ensure ongoing compliance with identified quality deficiencies. This deficiency was observed through a review of the facility's Quality Assurance and Performance Improvement (QAPI) Team Meeting Notes, which indicated ongoing monitoring and audits for complaint surveys conducted between June and August 2024. Despite these notes, the facility continued to exhibit noncompliance in areas such as therapeutic diets, food storage, abuse reporting, and enhanced barrier precautions, as identified in both complaint and annual surveys. During an interview, the current administrator, who was not present during the last QAPI meeting, confirmed the lack of additional documentation to support the facility's compliance claims. The administrator acknowledged the ongoing deficiencies identified by the survey team, indicating that the facility's QA/QAPI process was ineffective in addressing and rectifying these issues. The deficiencies had the potential to affect the 88 residents residing in the facility.

Penalty

Fine: $309,54027 days payment denial

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

Summary

The facility failed to implement an effective infection prevention and control program, as evidenced by two main deficiencies. Firstly, staff did not adhere to the required use of Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). Specifically, an LPN was observed administering medications through a PEG tube to a resident with a gastrostomy infection without wearing a gown, despite the facility's policy requiring gown and gloves for high-contact care activities. Similarly, a CNA provided incontinence care to a resident with a stage 4 pressure ulcer without donning any PPE, contrary to the physician's order for EBP related to wounds. Secondly, the facility failed to maintain a sanitary environment by not promptly removing urine-soiled laundry from a resident's room. Observations revealed that urine-soiled laundry remained on the floor of a resident's room for an extended period, despite the responsibility of CNAs to remove such items. Interviews with staff confirmed that the laundry should have been picked up after each shift, and it was acknowledged that leaving urine-soiled laundry on the floor posed an infection control risk.

Penalty

Fine: $309,54027 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 safe, clean, comfortable, and homelike environment for its residents, as observed in multiple rooms and hallways. In Room A, issues included uncovered and broken fluorescent light fixtures with dead bugs, scuffed walls and baseboards, stained floor tiles, missing window blinds, dusty serving carts, rusted air conditioner vents, and deteriorating sheetrock on the ceiling. Similar conditions were noted in other areas, such as Room B, where a missing threshold transition piece and scuffed doors were observed, and Room C, which had scuffed walls with dried brown substances and rusted air conditioner vents. Room D had rotten sections of wood around the waterfall area, non-functioning recessed lights, and rusted air conditioner vents. Hallways E and F had scuffed walls, handrails, and baseboards, with broken blinds in resident rooms. In Room G, scuff marks, indentations, and missing paint were noted on the walls, while Room H had similar wall damage, a hole in the bathroom sheetrock, and broken blinds. Room I presented a safety hazard with a windowsill board propped up with exposed nails, which had been in this condition for about a month according to a resident. Interviews with staff confirmed the presence of these environmental concerns and acknowledged that the facility should be maintained in a safe and homelike manner, which it was not. The issues observed had the potential to affect the entire census of 88 residents residing in the facility.

Penalty

Fine: $309,54027 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 accurate assessments for two residents, leading to deficiencies in their Minimum Data Set (MDS) coding. For one resident, who had been diagnosed with Anxiety Disorder, Major Depressive Disorder, and Schizoaffective Disorder, the facility did not accurately code the annual MDS assessment regarding the Pre-Admission Screening and Resident Review (PASRR) Level II status. The resident's clinical record showed an approved Level II PASRR, but the MDS assessment did not reflect this, as it was incorrectly marked as 'no' for PASRR evaluation and left blank for serious mental illness. This discrepancy was confirmed during an interview with a staff member. Another resident, who had been diagnosed with Chronic Diastolic Congestive Heart Failure and had a cardiac pacemaker, was admitted to a hospice agency. However, the resident's quarterly MDS assessment did not indicate hospice care, as the relevant section was left unchecked. This oversight was confirmed by a staff member during an interview, who acknowledged that the resident was indeed receiving hospice services. The facility's policy on conducting accurate resident assessments was not effectively implemented, as evidenced by these inaccuracies in the MDS assessments.

Penalty

Fine: $309,54027 days payment denial

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. Resident #4's care plan did not reflect their hospice status, despite being admitted to a hospice agency. This oversight was confirmed by the MDS coordinator, who acknowledged the care plan should have included this information. Resident #14's ostomy care was not provided according to physician orders, as observed when an LPN failed to clean the ostomy site before applying a new bag, which was confirmed by the LPN and the Assistant Director of Nursing. Resident #32 missed a scheduled nephrology appointment due to a lack of staff available to accompany her, despite being ready and waiting for transportation. The facility's appointment log incorrectly indicated that she attended the appointment, which was later confirmed as a no-show by the nephrologist's office. Interviews with staff revealed a breakdown in communication and scheduling, resulting in the missed appointment. Resident #54's care plan did not document the necessary assistance and devices required for transfers, despite being dependent on staff and requiring a Hoyer lift. This was confirmed by an LPN. Additionally, Resident #75's care plan failed to address his smoking status, even though staff were aware of his smoking habits. The MDS coordinator confirmed that smoking status should be included in care plans, identifying residents as safe or non-safe smokers with appropriate interventions.

Penalty

Fine: $309,54027 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 a resident who was unable to carry out Activities of Daily Living (ADLs) without assistance received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #32, who was cognitively intact with a BIMS score of 15 and had a diagnosis of Type 2 Diabetes Mellitus with a foot ulcer, did not receive scheduled baths on several Saturdays over a four-month period. The facility's policy required residents to be assisted with bathing at least three times weekly, but there was no documentation of completed baths for Resident #32 on specified dates. Interviews with Resident #32 and staff confirmed the lack of documentation and the failure to provide the scheduled baths. Resident #32 stated she was supposed to receive baths on Tuesdays, Thursdays, and Saturdays but had not received them on Saturdays for the past four months, and she had never refused a bath. Staff interviews corroborated the resident's account, and it was acknowledged that there should have been documentation of the baths being performed or refused, which was not available.

Penalty

Fine: $309,54027 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 timely response to call lights, which is a critical aspect of accommodating resident needs and preferences. Specifically, Resident #192 experienced a significant delay in receiving assistance after activating the call light. On the morning of September 17, 2024, Resident #192, who was wet and needed changing, pressed the call light for help. Despite the call light being visibly lit in the hallway, multiple staff members passed by without entering the room to provide care. It was not until 9:42 a.m., nearly 43 minutes after the initial activation, that CNA staff entered the room to assist the resident. Interviews with staff revealed inconsistencies in the facility's call light response protocol. The ward clerk, S22WC, stated that the front desk is alerted when a call light is pressed, and after five minutes, a CNA is paged overhead. However, it was noted that a resident should not wait 30 minutes for a response. Both S3ADN and S2DON confirmed that any staff in the hallway should respond to a call light within 3-5 minutes, and acknowledged that a 30-minute wait is unacceptable. This incident highlights a breakdown in the facility's policy for timely call light response, resulting in a deficiency in accommodating resident needs effectively.

Penalty

Fine: $309,54027 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 report allegations of physical abuse and misappropriation of resident property to the facility administrator and the state survey agency in a timely manner. The incident involved a resident who was moderately cognitively impaired and had been given a bottle by a CNA, which was later found to contain a blue liquid with a strong smell resembling a cleaning agent. The resident experienced stomach upset and burning sensations after consuming a sip from the bottle. Despite attempts to contact the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the administrator, the incident was not reported to the state survey agency within the required timeframe. The resident also alleged that the same CNA had used her food stamp card for personal use, leaving only 12 cents on it. This was reported to a social worker, who confirmed that the administrator conducted an investigation into the allegations. However, the allegations of both physical and financial abuse were not reported to the state survey agency as required by the facility's policy, which mandates reporting within two hours for abuse allegations. Interviews with staff members revealed that the CNA who discovered the blue liquid reported the incident to an LPN, who then attempted to notify the DON and ADON via text messages. The ADON confirmed receiving a text about the incident the following morning and assessed the liquid as detergent. The administrator acknowledged being informed of the allegations the morning after the incident and admitted that the allegations should have been reported to the state survey agency within the required timeframe.

Penalty

Fine: $309,54027 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 a resident received enteral feedings as ordered by the physician. The resident, who had a history of Cerebral Vascular Infarction, Aphasia, and Dysphagia, was assessed with a BIMS of 0, indicating they were rarely or never understood. The physician's orders specified that the resident should receive continuous enteral feeding of Glucerna 1.2 at 70ml/hour for 22 hours daily, with a 2-hour break for routine care. However, observations on a specific day revealed that the resident's feeding tube was not running at multiple times throughout the day, and the pump displayed error messages indicating issues such as an empty bag, clog in line, and valve not loaded. Interviews with staff confirmed the deficiency. An LPN was observed attempting to restart the pump and hang a new bottle of Glucerna, acknowledging that the pump should have alarmed when empty. A registered dietitian and a consultant confirmed that the resident did not receive the continuous enteral feeding as ordered, as the feeding was not running from 8:45 a.m. to 4:00 p.m. on the day in question. This failure to administer the feeding as prescribed constituted a deficiency in the care provided to the resident.

Penalty

Fine: $309,54027 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 nurse staffing data was posted daily in a prominent location accessible to residents and visitors. On 09/19/2024, an observation at 9:45 a.m. revealed that no staffing data sheets were displayed. During an interview at 9:50 a.m., S3ADN, who was responsible for posting the staffing data, confirmed that the last staffing data sheet was completed on 09/18/2024. Another interview at 9:55 a.m. with S1ADM corroborated that the last daily staffing data sheet was completed on 09/18/2024.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary treatment and services to prevent the development of new pressure ulcers for a resident, resulting in actual harm. The resident, who is paraplegic with no sensation in the lower extremities, was observed multiple times with his feet resting directly on the footboard of the bed, contrary to the physician's order to float the heels. This oversight led to the development of new areas of discoloration on both heels, which were later assessed as a Deep Tissue Injury (DTI) on the left heel. The resident's clinical records indicated a history of spinal cord injury and osteomyelitis, with a Braden Scale assessment showing a risk for pressure ulcers. Despite this, the resident's care plan, which included floating the heels, was not followed. Observations and interviews revealed that the resident's heel boots were not applied, and his heels were not floated as required, leading to the development of pressure-related injuries. Interviews with staff, including CNAs and LPNs, confirmed that the resident required assistance with repositioning and that the responsibility for floating the heels and applying heel boots was not adequately fulfilled. The Director of Nursing acknowledged the deficiency, confirming that the resident's feet should not have been on the footboard and that the heels should have been floated at all times while in bed.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions for residents with wounds and indwelling medical devices. Specifically, staff members were observed not wearing gowns while providing care to two residents who were on Enhanced Barrier Precautions. This included activities such as transferring a resident and performing wound care, which are considered high-contact activities requiring the use of gowns and gloves. Additionally, the facility did not ensure proper handling of a urinary drainage bag for one of the residents. During a transfer, a staff member placed the urinary drainage bag above the level of the resident's bladder, which could potentially lead to backflow and increase the risk of infection. This action was confirmed by the staff involved, who acknowledged the mistake and the requirement to keep the drainage bag below the bladder level. Furthermore, the facility's staff failed to perform proper hand hygiene during the care of a resident. Observations revealed that staff members did not wash their hands after removing soiled gloves and before applying new ones, which is a critical step in preventing the spread of infection. Interviews with the staff confirmed their awareness of the hand hygiene policy, yet they did not adhere to it during the care of 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 accommodate the needs of a resident who requested to be transferred out of bed in a timely manner. The resident, who was admitted with diagnoses including Cerebral Infarction and Primary Disorders of Muscles, had a BIMS score of 15, indicating intact cognition, and was dependent on transfers. According to the resident's care plan, she required assistance with activities of daily living (ADLs) due to impaired mobility and needed a mechanical lift for transfers. On the morning of the incident, the resident requested to be transferred out of bed around 6:20 a.m., but the request was not fulfilled until after 9:45 a.m. Interviews conducted with the staff revealed that the CNA acknowledged the resident's request but did not transfer her until much later, citing the need for a two-person assist. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed that the delay in transferring the resident was unacceptable. The incident highlights a failure in the facility's ability to reasonably accommodate the resident's needs and preferences, as the resident was left in bed for an extended period despite her request to get up.

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 timely incontinence care for a resident who was unable to perform activities of daily living independently. The resident, who had diagnoses including Cerebral Infarction and Primary Disorders of Muscles, was dependent on staff for toileting hygiene and required substantial assistance with mobility in bed. Despite having intact cognition, the resident expressed frustration over being left in a wet gown and pillow, indicating a lack of timely care. Observations confirmed that the resident's under pad and brief were wet with urine, and staff acknowledged the delay in providing necessary care. Interviews with staff revealed that incontinence checks and care were not performed according to the facility's policy, which required checks every two hours and changes as needed. A CNA admitted to not changing the resident's brief within the required timeframe, and both the Assistant Director of Nursing and the Director of Nursing confirmed the expectation for two-hourly checks and care. The deficiency was identified through observations and interviews, highlighting a failure in adhering to the facility's incontinence care policy.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate medical records for a resident with diabetes, as required by professional standards. The resident, who was moderately cognitively impaired, had specific physician orders for insulin administration based on blood glucose levels. However, the Medication Administration Record (MAR) for July 2024 showed that insulin was documented as administered even when the resident's blood glucose levels were below the threshold of 200, contrary to the physician's orders. This discrepancy was confirmed by interviews with the Licensed Practical Nurses (LPNs) involved, who admitted to documentation errors, stating that insulin was not actually administered when the blood glucose levels were below 200. The Director of Nursing (DON) also reviewed the MAR and confirmed the findings, acknowledging that insulin should not have been documented as given if it was not administered. The resident himself confirmed that insulin was only supposed to be administered when his blood glucose was 200 or higher, aligning with the physician's orders. This documentation error indicates a failure in maintaining accurate medical records, which is a critical aspect of resident care management, especially for those with conditions like diabetes that require precise medication administration.

Penalty

Fine: $210,69131 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 residents with indwelling devices received appropriate treatment and care according to professional standards of practice. Resident #1 was admitted with a Percutaneous Endoscopic Gastrostomy (PEG) tube and a nephrostomy tube, but the facility did not obtain or enter orders for site monitoring and dressing changes. As a result, Resident #1 did not receive any dressing changes or site monitoring for these devices from admission until being transferred to the emergency room with sepsis and infections related to the PEG and nephrostomy tubes. Interviews with facility staff revealed a lack of clarity and responsibility regarding who was accountable for the dressing changes and site monitoring for residents with indwelling devices. Several staff members, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed that there were no orders entered for Resident #1's PEG and nephrostomy tube care, and as such, these tasks were not documented or performed. The absence of these orders meant that the necessary care did not populate in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), leading to a failure in providing essential care. Resident #3 also experienced a similar issue, where there were no documented orders or care provided for a nephrostomy tube. The resident reported that the dressing was not changed regularly, and the wound care nurse only changed it occasionally while attending to other wounds. The facility's failure to enter and follow through with necessary orders for site care and monitoring resulted in inadequate care for residents with indwelling devices, contributing to significant health issues.

Penalty

Fine: $210,69131 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 adequately supervise a cognitively impaired resident who exhibited exit-seeking behaviors, resulting in the resident's elopement. The resident, who had a severe cognitive impairment with a BIMS score of 4, was known to wander and had an elopement risk score of 11, indicating a high risk for elopement. Despite wearing a wander guard, the resident was able to remove it, and on the morning of the incident, the resident was found 1.1 miles away from the facility, having crossed a high-traffic highway. The resident's care plan had been updated to reflect the risk of elopement, and interventions such as hourly checks and the use of an electric monitoring device on the resident's wheelchair were implemented. However, these measures were insufficient as the resident was able to leave the facility unnoticed. Staff interviews revealed that the resident frequently expressed a desire to leave and had previously attempted to exit through a window and the front door, triggering alarms that were not adequately responded to. On the day of the incident, staff assumed the resident was heading to the dining room for breakfast and did not notice the resident's absence until alerted by a Good Samaritan. The facility's reliance on the wander guard and lack of sufficient supervision contributed to the resident's ability to leave the premises without detection, highlighting a significant lapse in monitoring and response to the resident's known behaviors.

Penalty

Fine: $210,69131 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 administer its resources effectively and efficiently by not ensuring that all admission orders were obtained, clarified, and entered into the resident's electronic medical record. This deficiency was highlighted when a resident was admitted with a Percutaneous Endoscopic Gastrostomy (PEG) tube and a nephrostomy tube, but the facility did not obtain or enter physician orders for site monitoring and dressing changes. As a result, the resident did not receive any dressing changes or site monitoring for these critical sites from the time of admission until they were transferred to the emergency room with an elevated temperature and altered mental status. Interviews with facility staff revealed a lack of clarity and responsibility regarding who was accountable for obtaining and entering these orders. The Director of Nursing (DON) and other staff members confirmed that orders for monitoring and dressing changes were not entered into the electronic medical record, which meant they did not appear in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for nurses to follow. This oversight led to the resident developing sepsis, a nephrostomy-associated urinary tract infection, and an infected PEG tube, as diagnosed in the hospital.

Penalty

Fine: $210,69131 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 the administrator was accountable to the governing body, which resulted in a deficiency related to the Quality Assurance and Performance Improvement (QAPI) program. The administrator, identified as S1ADM, did not participate in the QAPI program since assuming the position, leaving the responsibility to the Director of Nursing (S2DON). The facility's policy required the governing body and executive leadership to be responsible for the QAPI program, ensuring it is ongoing, defined, implemented, and maintained. However, the facility did not hold the required quarterly QAPI Committee Meetings with the Medical Director since the previous administrator's departure in February 2024. Interviews revealed that the Director of Nursing was expected to report to the governing body and that the management company, contracted by the governing body, expected the administrator to report to them. Despite these expectations, the administrator did not inform the management company that the facility was not conducting QAPI meetings as per company policy. The lack of communication and oversight led to the failure in maintaining the QAPI program, potentially affecting the care of 87 residents.

Penalty

Fine: $210,69131 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 complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified through a review of the facility's CMS 672 form and the Facility Assessment Tool. The CMS 672 form, dated June 10, 2024, indicated a census of 87 residents with various care needs, including those with indwelling catheters, incontinence, pressure ulcers, psychiatric diagnoses, and those requiring special care such as hospice, chemotherapy, and dialysis. Despite these documented needs, the Facility Assessment Tool, updated on May 14, 2024, was found to have numerous blank sections, failing to reflect the current resident population's needs accurately. The blank sections in the Facility Assessment Tool included critical areas such as psychiatric/mood disorders, heart/circulatory system, neurological system, and other medical conditions. Additionally, essential categories related to resident support and care needs, such as activities of daily living, mobility, skin integrity, mental health, and medication management, were also left uncompleted. Furthermore, the assessment failed to identify the facility resources needed for daily and emergency care, including nursing services, food and nutrition services, therapy services, and medical supplies. During an interview, the administrator confirmed responsibility for the assessment and acknowledged the incomplete documentation, which did not accurately reflect the facility's current population and their needs.

Penalty

Fine: $210,69131 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, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified during a review of the facility's undated QAPI policy, which stated that the facility should focus on indicators of the outcomes of care and quality of life. The policy required the Quality Assurance (QA) Committee to meet at least quarterly and maintain documentation of the ongoing QAPI program. However, during the review, no documentation of the QAPI plan or supporting documentation was produced for review. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for the QAPI program but was unable to provide any meeting minutes or evidence of quarterly QAPI Committee meetings with the Medical Director. The facility had not held these meetings since the previous administrator left in February 2024, and the DON was unsure of when the most recent meeting occurred or what was discussed. Additionally, the facility's monthly internal QAPI meetings with department heads had not occurred. The facility's management company was unaware that the facility was not conducting QAPI meetings per company policy, and the facility's Governing Body, consisting of the Owner/CEO and CFO, had contracted the management company to manage the facility's day-to-day operations.

Penalty

Fine: $210,69131 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 a resident was free from significant medication errors, specifically regarding the administration of Vimpat, a seizure medication. The resident, who was admitted with diagnoses including unspecified convulsions and traumatic brain injury, had a physician's order for Vimpat to be administered via PEG tube every 12 hours. However, the medication was not administered on multiple occasions from May 2, 2024, to May 10, 2024, due to its unavailability at the facility. Interviews with several LPNs revealed that although they were aware of the medication order, they did not administer the medication because it was not available during their shifts. Some LPNs mentioned sending faxes or making verbal requests to the pharmacy, but there was no documentation to confirm these actions before May 8, 2024. The facility's contracted pharmacists confirmed that the first request for Vimpat was made on May 8, 2024, and the medication was delivered on May 10, 2024. The Director of Nursing (DON) stated that the nurses should have notified her when the medication was not received by May 3, 2024, but she did not receive any notification. The DON confirmed that the process for requesting unavailable medication involved sending a fax to the pharmacy and placing the confirmation in a pharmacy binder, but there was no evidence of such requests for the resident's Vimpat. The failure to administer the prescribed medication was acknowledged as unacceptable by the DON.

Penalty

Fine: $210,69131 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 meet the nutritional needs of its residents by not adhering to the approved menu and failing to document menu substitutions. An observation on June 6, 2024, revealed that a resident received a meal that did not match the meal ticket, which listed pancakes, blueberry sauce, sausage patty, hot cereal, orange juice, 2% milk, and a beverage of choice. Instead, the resident was served a meal consisting of a sausage patty, grits, a boiled egg, 2% milk, a biscuit, grape jelly, and butter. The resident confirmed that meals often did not follow the menu on the meal ticket. Interviews with facility staff, including an LPN and the Dietary Manager (DM), confirmed the discrepancy. The DM admitted to substituting food items due to inconsistent food deliveries but failed to record these substitutions or provide a revised menu. The DM also acknowledged that the facility's Registered Dietician was not informed of these changes, which is against the facility's policy. The facility administrator confirmed that any meal substitutions should be documented and communicated to the Registered Dietician.

Penalty

Fine: $210,69131 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 store food in accordance with professional standards for food service safety, which had the potential to affect 77 residents who were served meals from the kitchen. During a tour of the kitchen, sprouted red beans with a large amount of mold were observed in a 5-gallon clear plastic container. Through an interview, S22DM stated that the red beans must have gotten wet and confirmed the observation, acknowledging that the red beans should have been discarded. The facility's undated policy on dry food storage indicated that dry foods, including dried beans, should be stored in a cool, dry place and noted that dry foods could be contaminated even if they do not require refrigeration.

Penalty

Fine: $210,69131 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 effective communication training was conducted as mandatory training for all direct care staff. This deficiency was identified during a review of personnel files and interviews, which revealed that three Certified Nursing Assistants (CNAs) did not attend the mandatory training on effective communication. The facility's Facility Assessment Tool and policy on in-service training indicated that all staff members are expected to be effective communicators, and ongoing education is required by federal and state laws. However, there was no documented evidence that the CNAs attended the training session held on April 17, 2024, which focused on customer service and effective communication. Interviews with the Director of Nursing (DON) confirmed that the training on effective communication was only provided once, and not all direct care staff attended. The DON acknowledged that no make-up training was offered for those who missed the session, including the three CNAs in question. Additionally, there were no additional training sessions scheduled to address this gap. The Administrator confirmed that the DON was responsible for providing all required trainings and expected the facility to comply with state and federal regulations.