Christian Care Nursing Center

Penalty

22 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 timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.

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 care in a dignified manner for two residents who were cognitively intact and had specific care needs. One resident, with a history of congestive heart failure and muscle weakness, was observed to have repeated delays in response to call lights, with documented wait times ranging from 29 to 57 minutes on multiple occasions. The resident reported frequent long waits for assistance, particularly when needing to be changed due to a wet brief, leading to discomfort and embarrassment. Staff interviews revealed that call light notifications were only accessible via electronic tablets or a monitor at the nursing station, and not all staff consistently carried the required tablets, further contributing to delayed responses. Another resident, diagnosed with muscle weakness and chronic obstructive pulmonary disease, reported that staff often used their personal cell phones to text while providing care in the resident's room. The resident expressed feeling ignored and that staff attention was diverted away from her needs during care interactions. The facility had a policy prohibiting the use of personal cell phones in resident care areas, but the resident's account and staff behavior indicated this policy was not consistently followed. These deficiencies were identified through direct observation, resident interviews, staff interviews, and review of facility records and policies. The events described demonstrate a lack of respect for resident dignity and failure to maintain an environment that promotes quality of life, as required by federal regulations. The issues included both delayed response to resident needs and inappropriate staff conduct during care provision.

Plan Of Correction

F550 1. Residents #401 and #10 still currently reside in the facility. The cited residents did not sustain harm from the deficient practice and are at their psychosocial baseline. Their call lights have been evaluated and are working appropriately. 2. Current residents have the potential to be affected by this deficient practice; a sweep was completed on both units to assess the working order of every resident's call light on 6/6/2025. Residents were interviewed regarding observing staff on cell phones in resident rooms on 6/6/2025. Any resident with a concern had a resident concern form filled out on their behalf. 3. Policies on call lights and use of personal cell phones were reviewed and deemed appropriate. Clinical staff have been educated on these policies by 6/6/2025 by the DON/designee. Facility charge nurses were provided with call light receivers to ensure proper notification of call lights. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure call lights are answered timely and staff are not utilizing their personal cell phones in care areas. The Admin/designee will perform a 3x weekly audit on call light receivers to ensure receivers are functioning and audible. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to follow its own grievance policy in addressing two documented grievances submitted by a cognitively intact resident with diagnoses including weakness and Parkinson's disease. The grievances, both recorded on designated forms, described concerns about nursing staff behavior during mealtimes, including inattentiveness and rudeness, as well as issues with delayed or missing condiments resulting in cold food. Both grievances were assigned to the DON with a specified resolution date, but there was no evidence that the concerns were addressed or communicated to the resident. During an interview conducted more than three weeks after the grievances were filed, the resident reported that no one had discussed the concerns with her since she raised them. She expressed a lack of expectation that her issues would be resolved, indicating a breakdown in the facility's process for acknowledging and resolving grievances as outlined in their policy. The policy requires prompt efforts to resolve grievances, keeping the resident informed of progress, and issuing a written decision, none of which occurred in this case. Further interviews with facility leadership revealed confusion regarding responsibility for grievance management. The DON stated that the NHA handled grievances, while the NHA, identified as the Grievance Official, was unaware of the specific grievance forms and had not seen the paperwork. This lack of communication and adherence to policy resulted in the resident's grievances not being addressed in a timely or effective manner.

Plan Of Correction

F585 1. Resident #29 still currently resides in the facility. The cited resident did not sustain harm from the deficient practice and is at their psychosocial baseline. Resident #29's grievances were resolved. 2. All residents were interviewed during guardian angel rounds to ensure for potential resident concerns by 6/6/2025. Those residents with concerns were provided with a resident concern form and resolved according to the facility grievance policy. 3. The facility IDT was reeducated on the facility grievance policy including grievance documentation, follow-up, and resolution by 6/6/2025. Facility grievance monitoring was added to the morning meeting template for follow-up. 4. The QAPI committee has directed the NHA/designee to perform random weekly audits of the facility grievance log to ensure grievance is resolved according to the grievance policy. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and 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

Surveyors observed that in the Faith Unit medication room, a multidose vial of opened tuberculin solution did not have an opened date on the vial, box, or packaging. The Registered Nurse (RN) Unit Manager confirmed that staff were required to date multidose vials when opened to ensure timely disposal. In a subsequent observation in the same medication room, another opened tuberculin vial was found without an opened date on the vial, though the box was dated. The RN Unit Manager stated that both the vial and the box should be dated in case they become separated. Manufacturer instructions indicated that vials in use for 30 days should be discarded, highlighting the importance of proper dating. Additionally, in the Love Unit, an unlocked and unattended medication cart was observed. The cart was left unattended while the LPN responsible for it was distracted at the nurse's station and did not lock the cart before leaving. Facility policy requires that medications and biologicals be stored securely and only accessible to authorized personnel, with specific requirements for expiration dating and storage. These observations demonstrate failures in medication labeling and secure storage practices as required by federal regulations and facility policy.

Plan Of Correction

F761 1. No specific residents were identified in this citation, both undated TB vaccine vials were discarded immediately upon discovery and the nurse who left the med cart unlocked and unattended was provided on the spot education. 2. The facility provided a sweep of the medication rooms and medication carts by 6/6/2025 to identify improperly dated medications, any found were immediately discarded. 3. The policy on labeling, dating and storage of medications was reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on proper procedure, including the importance of securing unattended medication carts by 6/6/2025. Labels were requested from pharmacy for the purpose of ensuring vials are dated appropriately. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of medication rooms and carts to ensure appropriate labeling is done and unattended carts are properly secured. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to prepare and handle food in accordance with professional standards for food service safety, as evidenced by multiple observations during a kitchen tour and interviews with the Certified Dietary Manager (CDM). During the inspection, a pan of gravy stored in the walk-in cooler was found at 42°F, and the facility's cooling log showed incomplete entries and improper cooling of roast beef and turkey, which did not reach the required temperatures within the specified time frames. The CDM was unable to confirm whether any improperly cooled food had been served to residents. Additionally, a sanitizer bucket was found to have a concentration well above the required 200-400 ppm, and the chemical dispenser had not been serviced to address this issue. Further observations revealed that clean pans were stored with food debris, and the juice gun spout had an accumulation of debris, with uncertainty from the CDM about whether the spout was properly cleaned. The meat slicer had dried meat shavings, and the mixer had dried cake debris and splatter. The refrigeration unit in the kitchenette had a gasket with black spotted accumulation, and an open container of soy sauce requiring refrigeration was found stored at room temperature in the dry storage room. These findings indicate a lack of adherence to cleaning protocols and proper food storage practices. The report references specific sections of the 2022 FDA Food Code, highlighting the facility's failure to meet standards for cooling, sanitizing, cleaning, and storing food and equipment. The deficiencies observed have the potential to result in foodborne illness among all residents consuming food from the kitchen, as the facility did not consistently follow required food safety procedures.

Plan Of Correction

1. No residents were negatively impacted by this deficient practice. 2. The CDM has re-implemented a food cooling log in accordance with 2022 FDA Food Code section 3-501.15 cooling methods. The facility has repaired the quat sanitizer dispenser to ensure proper concentration of 200-400 ppm. The CDM has implemented a quat sanitizer log to ensure proper concentration under the Code by 4/25/2025. The clean pots and pans under the preparation table were recleaned. The juice gun was recleaned, including removing and disassembling the spout and wiping out the inside. The meat slicer was removed from operation. The mixer was thoroughly cleaned. The top gasket on the refrigerator in the Love Kitchenette was cleaned. The soy sauce identified as half opened was discarded from use. 3. The CDM was educated by the NHA on the Food Safety Requirements Policy and Procedure. All dietary staff were educated on the Food Safety Requirements Policy and Procedure including proper food cooling, proper testing of quat sanitizer, clean food prep surfaces, proper juice gun cleaning, non-food surface cleaning, and proper food refrigeration after opening. These items were added to the daily cleaning log. 4. The QAPI Committee has directed the CDM to perform random weekly audits of proper refrigeration of food items, food cooling temperatures, and cleanliness of food/nonfood contact surface. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program as required by federal regulations. The Infection Preventionist did not track or monitor employee illnesses, which limited the facility's ability to identify and respond to outbreaks, as evidenced by the lack of data on employee sick calls during a COVID outbreak. Infection control policies, including those for influenza and pneumococcal vaccinations, were outdated, with some not reviewed or revised for several years. The facility's infection surveillance policy required tracking of staff infections, but this was not being implemented. Additionally, the facility's infection control policies were not updated annually as required. Direct care observations revealed multiple failures in hand hygiene and infection control practices. During wound care for three residents, staff did not clean bedside tables or use barriers for supplies, did not change gloves or perform hand hygiene between dirty and clean tasks, and used the same gloves for wound care and peri care. Supplies and equipment, such as wound care scissors, were not properly cleaned or were returned to common carts after being contaminated. Staff interviews indicated a lack of understanding of proper hand hygiene protocols, with some staff and the DON stating that gloves only needed to be changed if visibly soiled, and that urine was not considered a contaminant requiring glove changes. These practices were inconsistent with both facility policy and CDC guidelines. Additional deficiencies were identified in the handling of medications and water management. A urine sample was found stored in a medication refrigerator, contrary to policy requiring separation of potentially harmful substances from medications. The facility also lacked an active and ongoing water management plan to reduce the risk of Legionella and other waterborne pathogens. The Maintenance Director was unaware of key aspects of the water management program, including team membership, control limits for chlorine, and the requirement for annual review and team meetings. The facility's water management policy called for an interdisciplinary team and regular reviews, but these were not being conducted.

Plan Of Correction

1. Resident #1, #4, and #25 continue to reside at the facility and no negative outcomes were identified related to the deficient practice. DPS B A digital testing unit was purchased, and levels remain at acceptable levels as of 4/25/2025. 2. All residents may be impacted by this deficient practice. The facility completed an infection screening evaluation on all residents as of 4/30/2025. Any resident identified with an additional wound or signs/symptoms of an infection will be treated accordingly, and their care plans will be updated. Current residents can be impacted by Legionella. Water levels will continue to be monitored as required. 3. The facility has reviewed the facility Infection Control Plan; this policy is deemed appropriate. The facility's Regional Nurse Consultant educated the DON on proper infection control policies, including hand hygiene. Clinical staff were provided with education on the Infection Control Plan by the DON/designee after the DON educated them, including proper hand hygiene, maintaining a clean work environment, and employee illness management. The ICP has been appropriately educated on infection tracking and trending. 4. The facility has incorporated the Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. The Water Management Plan has been updated using the CDC Toolkit, including establishing core members. The Director of Plant Operations educated the members of the WMP on understanding what Legionella is and understanding the facility's water system by 4/30/2025. 5. The QAPI Committee has directed the DON/Designee to perform random weekly audits of proper infection control procedures and tracking and trending. The Committee has also directed the Director of Plant Operations to perform weekly tests for Legionella. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to provide care in a dignified manner for several residents, as evidenced by the experience of one resident with multiple medical conditions, including diabetes, stage 4 kidney disease, diverticulosis, irritable bowel syndrome with diarrhea, and urine retention. This resident, who is her own responsible party, reported significant delays in staff response to her requests for assistance, particularly when using the call light system. She stated that the call light system was ineffective, with no visible indicator in the hallway when activated, and that staff relied on portable devices to receive alerts. However, staff were required to remove these devices during care, preventing them from noticing new calls for assistance during that time. The resident described waiting 20 to 30 minutes for staff to respond, which caused her pain and frustration, especially when she needed to use the bathroom. She resorted to using a metal call bell to get attention when her initial call was not answered within 15 minutes. The resident also reported that staff attempted to take away her call bell, but she refused to give it up. These actions and inactions resulted in the resident feeling undignified and dissatisfied with the care provided, as her needs for timely assistance were not met.

Plan Of Correction

F550 1. Residents #5, 30, 35, and 40 still currently reside in the facility. The cited residents did not sustain harm from the deficient practice and are at their psychosocial baseline. Weekly Guardian Angel Rounds have been initiated. 2. Current residents have the potential to be affected by the deficient practice. Residents were interviewed by 4/25/2025 during Guardian Angel Rounds to ensure resident rights were being met and any issues/concerns were addressed and reported. A weekly resident council will be held x 4 weeks to ensure the current residents' needs are addressed. 3. Policy on Resident Rights was reviewed and deemed appropriate, all staff were in-serviced by the Admin/designee by 4/25/2025. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of staff providing care to ensure that resident rights are being observed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to follow policies and procedures to accurately assess, monitor, and treat pressure ulcers for two residents. For one resident, the initial skin assessment upon admission documented only a stage 1 ulcer on the gluteal cleft, with no mention of other skin issues. However, subsequent assessments revealed a stage 3 pressure ulcer on the coccyx and multiple open, weeping areas on the buttocks and inner thighs. The resident was observed to be left in the same position for extended periods, was not on a turning schedule despite being unable to reposition herself, and experienced prolonged exposure to moisture and soiled briefs. Staff were unaware of or did not follow a turning schedule, and there was a lack of timely wound care orders and documentation for the identified wounds. The DON could not provide consistent or complete documentation of the resident's wounds or treatments, and excoriated areas were not measured or tracked for improvement or decline. For another resident with a history of a stage III/IV sacral pressure ulcer and high risk for pressure ulcers, deficiencies were observed in wound care practices and documentation. During a dressing change, an LPN failed to use a barrier or clean the table for wound care supplies, did not change gloves or perform hand hygiene between removing the old dressing and applying the new one, and packed the wound with a soiled glove. The resident's brief was saturated with urine and not cleaned prior to the dressing change. There was also a lack of clear documentation of wound care visits and assessments in the medical record, and the care plan did not include meaningful interventions or revisions for the resident's stage III/IV pressure ulcer, such as frequent repositioning or offloading. Interviews with staff revealed inconsistent knowledge and application of infection control and wound care protocols, including hand hygiene, glove changes, and proper handling of wound care supplies. The facility's own policies required full body skin assessments upon admission and weekly, clear documentation of pressure injuries, and clean technique for dressing changes, including cleaning the work surface and changing gloves. These policies were not consistently followed, leading to deficiencies in the prevention, assessment, and treatment of pressure ulcers for the affected residents.

Plan Of Correction

1. Resident #350 no longer resides at facility. The nurse was instructed to complete a wound assessment but failed to do so. This nurse was coached by DON. Resident #1 still currently resides in the facility; no negative outcome was identified due to this deficient practice. Her plan of care has been reviewed to reflect her status. She was assessed and is comfortable. Her wound care documentation is up to date. 2. Like residents are identified as those with pressure injuries. The plans of care for all like residents were reviewed by 4/25/2025 and updated to reflect the residents' current needs and treatment. 3. The policy and procedure on skin management, along with dressing change policies, have been reviewed and revised. Consultant Nurse educated the DON on assessments and documentation on skin management. Nurses were educated by DON/designee by 4/25/2025 on appropriate management/documentation/care. An admission wound assessment was activated in the EMR. Licensed Nursing staff were educated on completing this assessment on admission. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents currently in the facility with wound injuries to ensure their wounds are properly cared for and documented, and their plan of care/orders addresses their needs. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to comply with federal requirements for posting daily nurse staffing information. Observations revealed that the daily nurse staffing data sheets for both Faith's Terrace and Love's Garden were posted on bulletin boards facing the nurse's station, making them inaccessible and not visible to residents or visitors passing by. The staffing data sheets were placed alongside other staff-only postings, such as on-call schedules and thank-you cards, further indicating that the information was intended for staff use rather than public access. During interviews, a CNA confirmed that the staffing data sheets were only posted where staff could see them and not where residents or visitors could access them. A review of historic daily nurse staffing data sheets showed that the facility did not consistently record the daily resident census or the actual hours worked by nursing staff by category. Instead, the sheets listed only the scheduled hours and staff names, with inaccuracies such as all nurse hours being entered under the RN category, even when most scheduled nurses were LPNs. The Nursing Home Administrator acknowledged that census numbers and actual working hours were not always recorded on the daily nurse staffing data sheets, and that he kept track of actual hours worked separately.

Plan Of Correction

1. No residents were negatively impacted by this deficient practice. 2. Clear wall paper holders were purchased and mounted in a location on the unit consistent with this requirement and visibility. 3. The Staffing Coordinator was educated on Posted Nurse Staffing Information by the NHA and its requirements including posting the total number of hours worked in real time. The Staffing Coordinator was educated on posting staffing sheets with documented census and updating hours worked upon shift change by the NHA. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of posting nurse staff information including the number of actual hours worked. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and 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

A deficiency was identified when a resident, who was cognitively intact and their own responsible party, was administered aripiprazole, an antipsychotic medication, without being informed of the reason for its use or the associated risks and benefits. The resident's medical record, including the Medication Administration Record and electronic documentation, did not contain any evidence that this information was provided prior to the administration of the medication. The resident had diagnoses including dementia and cerebral infarction, and had been receiving aripiprazole since admission. During the survey, the Nursing Home Administrator was unable to provide documentation that the resident had been informed about the medication's purpose or its risks and benefits. Although the administrator indicated that the physician would speak to the resident about the medication, no documentation of such a discussion was available by the time the survey concluded. As a result, the facility failed to meet the requirement to inform the resident in advance about their treatment, including the risks and benefits of the prescribed psychotropic medication.

Plan Of Correction

1. Residents #350 still currently resides in the facility. She was educated on and consented to the use of Abilify on 3/28/2025. 2. Like residents are identified as those who are ordered antipsychotic medications. They have the potential to be affected by this deficient practice. A sweep was completed by 4/23/2025 to ensure all like residents have the appropriate education and consent documented and their plan of care updated as needed. 3. Policy on the use of antipsychotic medications was reviewed and deemed appropriate. Licensed nurses and social work staff were in-serviced between by 4/25/2025 on appropriate procedures. 4. The QAPI committee has directed the DON/designee to perform random weekly audits on residents who are ordered antipsychotic medications to ensure the proper procedure is followed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to respond in a timely manner to grievances raised by two residents, as evidenced by interviews, observations, and record reviews. One resident, a 90-year-old female with diagnoses including vascular dementia, kidney disease, and major depressive disorder, was not her own responsible party and served as the resident council president. She reported ongoing issues with wheelchair comfort and meal quality, specifically noting a decrease in fresh fruit offerings and dissatisfaction with bread options. Despite her participation in resident council meetings, she was unaware of any formal written grievance forms and expressed that discussions during meetings did not lead to resolutions, stating, "nothing gets done." Review of resident council minutes from several months revealed repeated dietary complaints, including concerns about dessert amounts, meat quality, bread variety, and the availability of fresh fruit and vegetables. These concerns were documented in meeting minutes and a grievance/complaint report was submitted to the Nursing Home Administrator on behalf of the resident council, indicating that concerns were not being fully communicated or resolved. The administrator acknowledged receipt of the grievance but did not provide evidence of prompt resolution or written decisions to the residents as required. Additionally, the occupational therapist confirmed that while a low back cushion had been provided to the resident for wheelchair comfort, there was no documentation or communication to nursing staff regarding its use after therapy ended. The resident continued to experience discomfort and improper positioning in her wheelchair, and nursing staff had not been instructed to perform frequent positioning checks until prompted by the therapist during the survey. These findings demonstrate a lack of timely and effective response to resident grievances and insufficient communication among staff regarding resident care needs.

Plan Of Correction

F585 1. Residents #10 and #40 still currently reside in the facility. Their grievances were immediately documented and addressed between by 4/23/2025. 2. Current residents have the potential to be affected by this deficient practice. A resident council meeting will be held on 4/22/2025, to ensure current residents can express their concerns. A weekly resident council will be held x 4 weeks to ensure the current residents' needs are addressed. 3. Resident Council policy was reviewed and revised. Department heads and facility managers were educated by the Admin/designee between by 4/23/2025 on proper procedures. 4. The QAPI committee has directed the DON/designee to perform random weekly audits on 20% of current residents in the facility, to ensure their concerns are being addressed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to document the reason for a resident's transfer to the hospital emergency department in the resident's medical record, as required by federal regulations. The resident in question was a 72-year-old individual with multiple diagnoses, including liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. The resident was cognitively intact, as indicated by a BIMS score of 13. On the date of the incident, the resident requested to be sent to the emergency department for evaluation, and the facility arranged for transport after obtaining an order from the on-call healthcare provider. A review of the resident's electronic medical record revealed that, aside from a progress note stating the resident requested to go to the emergency department, there was no documentation indicating the specific reason for the transfer. There was no transfer form, physical assessment, physician communication note, or physician note explaining the medical necessity or rationale for the transfer. The facility's documentation did not provide any further details beyond the resident's request. During interviews, the DON confirmed that a transfer form was not completed for this resident, as the form was a recent addition to their processes. The DON also stated that no assessment was performed prior to the transfer because the resident requested to go, and it was the facility's practice to send residents to the emergency department upon request, regardless of medical necessity. This lack of documentation and assessment led to the deficiency cited by surveyors.

Plan Of Correction

F623 1. Resident #47 no longer resides in the facility, an investigation of the event was completed and the licensed nurse involved received education on appropriate assessment, notification, and documentation of transfers. 2. Like residents are identified as those who are emergently transferred to the hospital. A sweep of like residents for the last 2 weeks was completed by 4/23/2025 to ensure appropriate documentation of the reason for transfer was in place. A Transfer form was added to the facility's EMR system to guide the licensed nurses in appropriate documentation. 3. Licensed nurses were educated on the use of the new Transfer form in PCC to complete which includes, appropriate assessment, notifications, and documentation for all residents who require emergent transfer to a hospital. 4. The QAPI Committee has directed the DON and/or designee to ensure that weekly audits are completed on residents who are transferred out emergently, to ensure the appropriate assessment, notifications, and documentation is completed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and 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

A deficiency occurred when the facility failed to provide a resident or their representative with written notice specifying the duration of the bed-hold policy prior to or immediately following the resident's transfer to the hospital. The resident in question was a 72-year-old individual with multiple diagnoses, including liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. The resident was cognitively intact at the time of transfer, as indicated by a BIMS score of 13. Documentation showed that the resident requested to go to the emergency department and was transferred accordingly, but there was no evidence in the medical record that the required bed-hold policy notice was given. Interviews with facility staff, including the Nursing Home Administrator and the Director of Nursing, confirmed that they could not locate any documentation showing that the bed-hold policy had been presented to the resident or their representative. The DON initially stated that the Admissions Coordinator had discussed the policy with the resident and family, but later clarified that there was no documentation of such a discussion. The only related communication found was an email indicating the resident would not be returning to the facility, as they were being transferred to hospice care. A review of the facility's own policy confirmed that written notice of the bed-hold policy should be provided at the time of transfer and a signed copy kept in the resident's file. However, in this case, there was no evidence that the policy was communicated or documented as required, resulting in noncompliance with federal regulations regarding notice of bed-hold policy upon transfer.

Plan Of Correction

Resident #47 no longer resides in the facility. An investigation of the event was completed, and the admissions director received education on appropriate notification and documentation of Bed Hold policy notifications. Like residents are identified as those who have been transferred emergently from the facility. A facility sweep was completed by 4/30/2025 of transferred residents from the last 2 weeks to ensure proper notification of the Bed Hold policy was provided and documentation made in their EMR. The policy for Bed Hold has been reviewed and deemed appropriate. The Business Office Manager has been educated on appropriate processes on 4/23/2025. The QAPI Committee has directed the NHA and/or designee to ensure that weekly audits are completed on 100% of residents who are transferred out emergently to ensure the proper process is followed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to adequately assess, monitor, and provide care for a resident with significant dental needs. The resident, who has Alzheimer's disease, dementia, abnormal posture, and is nonverbal with limited movement, was observed exhibiting behaviors such as clenching her shirt and teeth, which her husband identified as signs of pain. Despite a dental consultation indicating the need for diagnostics and oral surgery for a tooth extraction under sedation, there was no documented follow-up by the facility after the initial referral. Nursing progress notes indicated a dental appointment occurred, but no procedures were performed, and there was no evidence of further follow-up or communication with the physician regarding ongoing dental concerns. The resident's care plan did not address dental issues, and pain assessments consistently recorded a pain level of 0/10, despite ongoing reports of pain-related behaviors. Staff interviews revealed uncertainty about monitoring for pain and infection, especially given the resident's inability to express discomfort verbally. There was also a lack of documentation regarding monitoring for infection or updating the physician about the resident's dental needs. The facility did not have a system in place to ensure ongoing assessment and intervention for the resident's dental pain and potential infection, as required by professional standards of practice and the resident's care plan.

Plan Of Correction

F684 1. Resident #30 still currently resides in the facility; Ultram has been ordered for her pain and she is being monitored daily for any s/sx of dental infections. Her plan of care has been updated to reflect her status. Resident #30 is scheduled for tooth extraction. 2. Like residents are identified as those requiring dental services outside the facility. The plans of care for all like residents were reviewed by 4/30/2025 and updated to reflect the residents' current needs and treatment. Follow-up appointments and responsible party notification were documented by 4/23/2025. 3. Policy on Ancillary Services has been reviewed and revised. Social worker was educated by the DON/designee by 4/23/2025 on appropriate process. Licensed nurses were educated on identification, notification, and treatment of dental pain. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents currently in the facility receiving offsite dental services to ensure they are being monitored for their dental issues and their plan of care addresses their needs. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and 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

A deficiency was identified regarding the facility's failure to provide appropriate care for contractures in a resident with a history of spastic hemiplegia, contractures, and brain injury. The resident, who is moderately cognitively impaired and dependent on staff for mobility, was observed with contractures in both upper extremities and no splints in place. The resident reported that staff had not applied his hand splints for some time and did not ask if he wanted to wear them. One splint was found across the room, not in use. The care plan indicated the resident should wear a right hand splint for up to four hours at night, but there was no documentation in the electronic medical record task list for staff to chart the application of splints. Interviews with therapy staff revealed uncertainty about whether the resident was wearing the splint as scheduled or if it still fit. Occupational therapy documentation from previous periods indicated a splint wear schedule was in place, but current staff were unsure of its implementation. The lack of documentation and inconsistent application of the splint as per the care plan led to the deficiency in providing appropriate treatment and services to prevent further decrease in range of motion for the resident.

Plan Of Correction

F688 1. Resident #3 still currently resides in the facility; His care plan was reviewed, and orders were entered in order for staff can document the application and removal of his splint. 2. Like residents are identified as those with limited contractures. The plans of care for all like residents were reviewed by 4/25/2025 and updated to reflect the residents' current needs and treatment. Therapy referrals have been made if indicated, and documentation verification entered for any residents using a positioning device. 3. Policies for ROM and applying splints have been reviewed and revised. Nursing staff and therapy staff were educated by the DON/designee by 4/25/2025 on appropriate process related to this policy. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of residents currently in the facility receiving care for contractures. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and 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

A deficiency was identified when a resident with a history of unsteadiness, vascular dementia, and impaired memory experienced an unwitnessed fall in her room. The incident report noted that the resident was confused, incontinent, and had impaired memory, all of which are predisposing factors for falls. The root cause analysis indicated that the anti-rollback mechanism on the resident's wheelchair was not functioning properly at the time of the fall. Maintenance reportedly fixed the anti-rollbacks after the incident, but there was no documentation provided to confirm this repair or any inspection of other wheelchairs in the facility. Staff interviews revealed that certified nurse aides who cared for the resident before and after the fall were unaware of the incident and did not have knowledge of the anti-rollback malfunction. They stated that a malfunctioning chair would be obvious and that they would not use it if it was not working correctly. The staff also expressed concern that the resident was left unattended in her room, as she had a known history of attempting to self-transfer. The care plan for the resident included multiple fall prevention interventions, but there was no documentation of care or supervision provided immediately prior to the fall. The facility failed to provide a complete investigation of the fall, including staff statements, details of the resident's care and supervision before the incident, and records of wheelchair repairs or inspections. Despite requests from the surveyor, the Director of Nursing did not supply the full investigation or documentation related to the wheelchair's repair or the assessment of other wheelchairs. The lack of thorough investigation and documentation contributed to the deficiency cited under the requirement to ensure the resident environment is as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents.

Plan Of Correction

1. Resident #17 still currently resides in the facility. Her plan of care has been reviewed and she has not had any additional falls. 2. Like residents are identified as those who have experienced a fall within the last two weeks. The plans of care for all like residents were reviewed by 4/30/2025 and updated to reflect the residents' current needs and treatment. 3. The Policy regarding fall management has been reviewed and deemed appropriate. The NHA and DON were educated on fall investigations, documentation, and follow-up by the Nurse Consultant. Licensed nursing staff were educated by the DON/designee by 4/25/2025 on fall management. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents that experienced a fall in the facility to ensure their intervention was appropriate and the plan of care addresses their needs. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper accountability and documentation for controlled substances, specifically fentanyl transdermal patches, for one resident. According to facility policy, all controlled substances must be accurately recorded on designated usage forms, with each dose administered and destroyed being witnessed and signed by two licensed staff members. However, review of the Controlled Drug Record sheets revealed multiple discrepancies, including missing documentation of quantities received, incomplete or missing nurse signatures for patch destruction, and instances where patches were signed out twice on the same day or with undated entries. In several cases, only one nurse signed for the destruction of used patches, contrary to policy requirements. Further review of the resident's medication administration records and related documentation showed inconsistent and incomplete entries regarding the placement and verification of fentanyl patches. There were instances where the same nurse signed as both the oncoming and off-going nurse, missing signatures, and lack of clear documentation of patch location or verification that the patch was in place. These documentation lapses made it difficult to accurately reconcile the number of patches dispensed, administered, and destroyed, resulting in a lack of clear accountability for the controlled substance. During an interview, the Director of Nursing was unable to provide a satisfactory explanation for the discrepancies in the documentation and could not account for the missing or improperly documented patches. The facility's failure to follow its own policies and federal regulations regarding controlled substance accountability led to this deficiency, as evidenced by the incomplete and inconsistent records for the resident receiving fentanyl patches.

Plan Of Correction

1. Resident #4 still currently resides in the facility. Her pain levels for the dates in question were reviewed and her pain levels were 0. She is comfortable and denies pain on her assessment. Her patch is in place and signed out appropriately. 2. Like residents are identified as those requiring controlled substance patches. The orders, and documentation of application and removal was reviewed for those like residents. 3. The revised and approved the Destruction of Narcotics policy and procedure. This policy identifies fully used narcotic vs. a narcotic that still has use. This policy further outlines destruction protocols for both. Licensed nurses were educated by the DON/designee by 4/25/2025 on appropriate process. 4. The QAPI committee has directed the DON/designee to perform random weekly audits of all residents currently in the facility receiving controlled pain patches to ensure they are in place and documented appropriately. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and 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

Surveyors observed that the Love Unit Medication Room contained a refrigerator with an opened multidose tuberculin vial that was not dated at the time it was opened. When questioned, an LPN was unable to provide information on when the vial was opened and acknowledged that it should have been dated upon opening. This failure to date the medication vial is not in accordance with the facility's policy and accepted professional standards for medication labeling and storage. Additionally, the same refrigerator contained a urine sample belonging to a newly admitted resident. The LPN confirmed that the refrigerator is designated solely for medication storage and that storing a urine sample in this location was inappropriate. The facility's pharmacy policy specifies that potentially harmful substances and non-medication items must be stored separately from medications, and that outdated or improperly labeled medications should be immediately removed from inventory.

Plan Of Correction

F761 1. The Love unit med room refrigerator was immediately audited, all non-medications were removed, and medications/vaccines that were not dated were removed and discarded. 2. A sweep of all med room refrigerators was performed by 4/25/2025 to ensure they are used only for medications and/or vaccines, and all vaccines are labeled appropriately. 3. The policy on Medication labeling and storage was reviewed and deemed appropriate. Licensed nurses were educated on proper procedure by 4/25/2025 by the DON/designee. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure medications are stored appropriately and expired medications are discarded. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and 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

Certified Nurse Aides (CNAs) were observed transferring a resident from a wheelchair to bed using a full body electronic lift without communicating with the resident at any point during the process. The CNAs did not inform the resident when they were going to lift, turn, or remove her brief. The resident was awake with eyes open but did not speak during the observation. Upon transfer, a wet spot approximately 3 to 4 inches in diameter was noted on the center of the resident's buttock, and her wheelchair had a strong urine odor. After the cushion cover was removed, the wheelchair and cushions continued to emit a strong urine smell.

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

Two residents with significant cognitive and physical impairments, including Alzheimer's disease, chronic pain, hemiplegia, and psychotic disorder, reported issues with the quality of incontinence briefs provided by the facility. One resident expressed distress about the need for staff to use two briefs at a time to prevent bed soiling, stating that all staff were aware of the problem but no action was being taken. The same resident also voiced concerns about the declining quality of food and the lack of staff response to complaints, indicating that concerns were not being documented or addressed. Another resident's responsible party reported that the new, lower-quality briefs frequently leaked, resulting in increased laundry, more frequent changes, and urine soaking through to clothing and wheelchair cushions. Observations confirmed a strong urine odor on the resident's wheelchair. Both staff and responsible parties indicated that management was aware of the concerns but had not taken effective action to resolve them. Interviews with the DON and NHA revealed awareness of the issues, but no solutions or interventions had been implemented at the time of the survey.

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 medical diagnoses, including Alzheimer's disease, hemiplegia, heart disease, and psychotic disorder, was admitted to the facility and is not her own responsible party. Her responsible party expressed ongoing concerns about the high sodium content in the resident's meals, noting that the food provided is primarily canned or processed and tastes very salty. Despite repeated complaints and participation in meetings, the responsible party reported that his concerns about the resident's sodium intake, given her medical conditions, were not addressed. The Dietary Manager confirmed that the facility does not offer low sodium diets, only 'no added salt' options, and does not calculate or monitor the resident's daily sodium intake. The DON was aware of general concerns but could not recall specifics or confirm if concern forms were completed, and the NHA was not fully aware of the responsible party's concerns, indicating a lack of effective communication and follow-up regarding dietary grievances.

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 safe emergency food to meet the requirements of its emergency menu. During a tour of the dry storage room, it was observed that the shelf labeled 'Emergency Food' contained minimal entrée items and mostly canned vegetables, which are typically used to accompany entrée meals. An interview with the Certified Dietary Manager revealed that some of the emergency food had been used to supplement regular menu items before expiration, and the facility was in the process of transitioning between different menus with the assistance of a culinary vendor. A review of the emergency menu showed that items such as Beef Stew, Chili with Beans, Chicken and Dumplings, and Corn Beef Hash were listed, but none of these entrée items were found onsite during the evaluation. This lack of required emergency food provisions was identified through observation, interview, and record review, indicating a failure to maintain adequate subsistence supplies as mandated by emergency preparedness regulations.

Plan Of Correction

E015 1. No residents were harmed as a result of this deficient practice. 2. An emergency food supply was purchased and in the facility by 4/30/2025. 3. The CDM was educated by the NHA by 4/25/2025 on the Emergency Food Supply Policy and Procedure. An emergency food agreement was obtained by the food. 4. The QAPI Committee has directed the CDM/Designee to perform random weekly audits of emergency food supply in the facility. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to provide automatic emergency lighting in accordance with regulatory requirements, specifically at the emergency generator transfer switches located in the electrical room. During an observation on March 26, 2025, it was noted that there was no battery pack powered emergency light installed at these transfer switches. This deficiency was confirmed through an interview with the facility Maintenance Director at the time of the observation. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.

Plan Of Correction

K291 1. No residents were harmed as a result of this deficient practice. 2. An emergency battery pack powered light has been installed in the electrical room. 3. The QAPI Committee has directed the Director of Plant Operations/designee to perform random audits of facility emergency lighting x 4 weeks to ensure operations. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to maintain and test its automatic sprinkler system in accordance with NFPA 25 requirements. During an observation on March 26, 2025, it was found that ceiling tiles were missing from the ceiling grid in the data room located in the service hall. This absence of ceiling tiles was confirmed by the facility Maintenance Director at the time of observation. The missing ceiling tiles could interfere with the proper operation of the sprinkler system, as required by the relevant fire protection standards.

Plan Of Correction

K3531. No residents were harmed as a result of this deficient practice. Ceiling tiles in the IT storage closet have been properly installed. Any protrusions through the ceiling tiles have been properly sealed with fire resistant material. The QAPI Committee has directed the Director of Plant Operations/designee to perform random audits of facility x 4 weeks to ensure ceiling tiles are in place according to NFPA 25. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to maintain its emergency generator system in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards. During a record review conducted on March 26, 2025, it was found that the facility did not provide the required annual generator preventative maintenance report. The last available report was dated 3/20/24, indicating that the annual maintenance had not been documented for the current year. This deficiency was confirmed through an interview with the facility Maintenance Director at the time of the record review. The absence of the current annual preventative maintenance report means the facility could not demonstrate compliance with required generator maintenance protocols, which are essential for ensuring the emergency power system's reliability in the event of a main utility power loss.

Plan Of Correction

K918 1. No residents were harmed as a result of this deficient practice. 2. The annual generator preventative maintenance and testing has been completed on 4/3/2025. 3. The QAPI Committee has directed the Director of Plant Operations/designee to perform weekly generator load tests as scheduled and submit the results of those tests to QAPI. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to comply with NFPA 99 requirements for the storage of nonflammable gases, specifically oxygen cylinders. During an observation, surveyors found that the oxygen storage closet in the main hall contained both full and non-full cylinders mixed together, rather than segregating empty cylinders from full ones as required. This was confirmed through an interview with the facility Maintenance Director at the time of observation. Additionally, the same oxygen storage closet was found to have combustibles stored within five feet of the oxygen cylinders, which is not permitted under the relevant fire safety standards. These deficiencies were identified during a survey and could potentially affect 17 occupants if the cylinders were needed during an emergency event. The report cites specific violations of NFPA 99 standards 11.6.5.2 and 11.3.2.3(2).

Plan Of Correction

K923 1. No residents were harmed as a result of this deficient practice. 2. The oxygen storage room has been appropriately organized and labeled in accordance with NFPA 99. All cardboard has been removed from the closet and signage has been introduced to keep the area clear. Proper storage racks and locations have clearly been labeled as to the placement of the oxygen containers. All clinical staff will be educated by 4/25/2025 regarding oxygen storage. 3. The QAPI Committee has directed the Director of Plant Operations/designee to perform weekly audits of the oxygen room to ensure compliance. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.

Penalty

No penalty information released

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

Summary

The facility failed to ensure appropriate treatment and care for Resident #49 due to multiple oversights and failures in following admission orders and addressing changes in the resident's condition promptly. Upon admission, R49 had a complex medical history including diagnoses of sepsis, atrial fibrillation, pulmonary hypertension, and a history of recurrent deep vein thrombosis. Despite clear instructions from the hospital regarding the need for daily INR monitoring and adjustments to medications like warfarin and Lasix, the facility did not consistently follow through with these orders. This lack of adherence to crucial medication and monitoring protocols resulted in missed opportunities to address R49's changing condition in a timely manner. The facility's failure to accurately transcribe and implement admission orders is evident in the discrepancies between the hospital discharge instructions and the facility's documentation. Despite recommendations for daily weights, strict intake and output monitoring, and daily PT/INR checks, these orders were not consistently carried out for R49. Additionally, the facility did not adequately monitor R49's weight, leading to a significant 24.4-pound weight gain in just 13 days, indicating a potential worsening of his condition that went unaddressed.

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 properly date mark and discard food products, as well as store them correctly. During an inspection, several items in the walk-in cooler were found without dates, including honey ham, ham roll-ups, beef tips and gravy, turkey, hot dogs, and a strawberry smoothie. Additionally, some items were kept beyond their safe consumption dates, such as puréed deviled eggs, French onion dip, BBQ pork, pizza sauce, and butternut soup. In the Faith and Love kitchenettes, thickened beverages were found either undated or past their safe consumption period. These actions are in violation of the 2017 FDA Food Code sections 3-501.17 and 3-501.18, which mandate proper date marking and timely disposal of ready-to-eat, time/temperature control for safety food items. The facility also failed to store food products properly. During the initial tour, boxes of food were observed stored on the floor of the walk-in freezer. This is against the 2017 FDA Food Code section 3-305.11, which requires food to be stored at least six inches above the floor to prevent contamination. Additionally, the facility did not ensure the cleanliness of food and non-food contact surfaces. The inspection revealed an accumulation of debris in a utensil drawer, on the inside top of a microwave, and on clean pots and pans. The microwaves in the kitchenettes also showed significant debris, with one microwave having pitted and chipping surfaces. These conditions violate the 2017 FDA Food Code section 4-601.11, which requires equipment and utensils to be clean to sight and touch. Furthermore, the facility did not adhere to proper procedures for air-drying pots and pans. Several pans were found stacked and stored wet, which is against the 2017 FDA Food Code section 4-901.11 that mandates air-drying of equipment and utensils after cleaning and sanitizing. Additionally, during a meal observation, a Certified Nurse Aide (CNA) was seen using bare hands to fold soft shell tortillas for two residents, which is a direct violation of the 2017 FDA Food Code section 3-301.11. This section prohibits food employees from contacting ready-to-eat food with bare hands and requires the use of suitable utensils or gloves to prevent contamination.

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 and maintain an effective Infection Control Program, particularly in the areas of comprehensive surveillance of facility infections and education on infection control measures. The designated Infection Preventionist (IP) reported not receiving memos from CMS or CDC and had not reviewed new Enhanced Barrier Precautions (EBP) updates. The IP also failed to document staff education on EBP and did not conduct an all-staff in-service on the new information. Additionally, the IP was unable to clearly articulate the facility's surveillance process and inconsistencies were found in the infection logs, including missing symptoms and culture results for residents with infections. Mapping of infections was also incomplete or missing for certain months, which hindered the facility's ability to track and manage infections effectively. Resident #9, who was admitted with diagnoses including an infection due to an indwelling urethral catheter and chronic ulcers, was placed on Enhanced Barrier Precautions. However, during an observation, a Certified Nurse Aide (CNA) failed to don a gown while providing direct care, despite the requirement for gown and gloves under EBP. The resident reported that staff never used the PPE and was unaware of the reasons for the precautions. This indicates a lack of proper implementation and adherence to the facility's infection control policies. The facility's policies on infection surveillance and Enhanced Barrier Precautions were not consistently followed. The Infection Preventionist did not maintain accurate documentation of infections, symptoms, and culture results, and failed to map infections properly. Staff education on EBP was not documented, and the resident involved was not informed about the precautions. These deficiencies highlight significant gaps in the facility's infection control program, putting residents at risk of infection and transmission of communicable diseases.

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 and maintain a process to ensure pharmacy monthly medication reviews and recommendations were reviewed and acted upon by the attending physician for five residents. The medical records for these residents showed that the consultant pharmacist made non-significant recommendations, but there was no documentation indicating that these recommendations were conveyed to or reviewed by the physician. This lack of follow-up was confirmed through interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who admitted that the recommendations were not available and had not been reviewed by the physicians. The DON also revealed that the pharmacy recommendations had been going to a spam folder and that there was no system in place to review them. For Resident #2, the pharmacy notes from 12/20/23 and 1/24/24 contained recommendations that were not reviewed by the physician. Similarly, for Resident #24, the pharmacy note from 3/13/24 was not reviewed. Resident #30 and Resident #42 had pharmacy notes with recommendations on multiple dates, none of which were followed up by the physician. Resident #9 had pharmacy notes with recommendations on 1/24/24 and 3/13/24, but there was no evidence of physician follow-up. The failure to review and act upon these recommendations resulted in the potential for unnecessary medication to be administered to these 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 ensure that certified nursing assistants (CNAs) completed the required 12 hours of in-service training annually. A review of the Employee Online Inservice Training competencies report revealed that out of 30 CNAs, 27 had not completed any of the assigned training modules. These modules included essential topics such as body mechanics, fire safety, HIPAA privacy, infection control, pressure ulcers risk control, resident rights, abuse prevention, and dementia care, among others. Interviews with the Human Resources (HR) Director, a CNA, the Director of Nursing (DON), and the Nursing Home Administrator (NHA) confirmed that the staff were behind on their mandatory training and that efforts were being made to address this issue. The facility's policy on the Nurse Aide Training Program, revised in December 2022, mandates that each nurse aide must complete at least 12 hours of in-service training annually. This training is crucial for ensuring the continuing competence of nurse aides and includes topics such as effective communication, dementia management, abuse prevention, infection control, and safety procedures. Despite this policy, the facility did not ensure compliance, resulting in a potential for inadequate and substandard quality of care for residents. The HR Director acknowledged the issue and reported that she was working with staff to get them caught up on their training requirements.

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 Advanced Directives were properly documented and communicated for one resident, resulting in the potential failure to carry out the resident's medical treatment decisions. Resident #19, who had vascular dementia, was readmitted to the facility after a hospitalization. The Medical Treatment Decisions of Resident form, signed by the resident's responsible party and the Medical Director, indicated that the resident did not wish to have cardiopulmonary resuscitation (CPR). However, this code status was not reflected in the Electronic Medical Record (EMR) or on the resident's profile. During an interview, the Director of Nursing (DON) confirmed that there was no order reflecting the resident's Advanced Directives and wish to be a Do Not Resuscitate (DNR). The DON acknowledged that without such an order, staff would not be able to quickly identify the appropriate actions to take in the event of cardiac arrest. The DON also mentioned that the facility had recently conducted an audit of each resident's code status, but Resident #19 had been missed.

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 notification of planned discontinuation of coverage for Medicare Part A services for two residents, resulting in the loss of the right to appeal the determination and the potential for unforeseen obligation and hardship. Resident #1 received Medicare Part A Skilled Services from February 8, 2024, through March 27, 2024, and Resident #40 received these services from March 26, 2024, through April 9, 2024. In both cases, the facility initiated the discharge from Medicare Part A Services before benefit days were exhausted, but the required notification forms (CMS-10055 and CMS-10123) were not completed or provided to the residents. This omission was confirmed through a review of the SNF Beneficiary Notification Review forms and interviews with facility staff. The Admissions Director reported that the MDS nurse responsible for completing the notification forms had recently quit, and the task was not reassigned to another staff member. The Director of Nursing confirmed that the required forms were not being completed by the outside agency MDS nurse covering the facility. The Nursing Home Administrator also acknowledged the lapse in completing the required notifications. This failure to provide proper notification resulted in the residents losing their right to appeal the discontinuation of Medicare Part A services and potentially facing unforeseen financial obligations.

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 revise the Plan of Care for a resident (R10) who displayed behaviors affecting others. R10, admitted with a history of stroke, hemiplegia, and dementia, was observed during multiple meal services engaging in loud, gregarious, and teasing conversations with staff and another resident (R12). Despite R12's lack of engagement and occasional complaints about R10's rude remarks, the facility did not update R10's care plan to address these behaviors. Staff acknowledged R10's behavior and mentioned using humor to manage it, but no formal guidance was found in the care plan or medical record on how to handle the behavior while preserving R10's dignity and ensuring a pleasant dining experience for other residents. Interviews with the Assistant Director of Nursing (ADON) and Social Worker (SW) revealed that R10's behavior was known but not documented in the care plan. The ADON mentioned that R10's daughter had informed them about his different sense of humor, which was not appreciated by other residents. However, no information was found in the medical record or care plan addressing this behavior. The lack of documentation and guidance on managing R10's behavior led to the deficiency noted in the report.

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 professional standards of quality for Resident #38, who was admitted with diagnoses including chronic obstructive pulmonary disease and heart failure. The resident, who was cognitively intact with a BIMS score of 15, had a physician's order for a Lidocaine External Patch to be applied to the right upper back. However, an LPN placed the patch on the resident's right upper arm instead, following the resident's request, without consulting the physician or obtaining an updated order. This action was confirmed through interviews with the LPN, the Director of Nursing, and the Nursing Home Administrator, all of whom acknowledged that the patch should have been placed according to the physician's order on the right upper back. The deficiency was further documented in an Employee Coaching report, which detailed the LPN's deviation from the physician's order and the facility's policy on medication administration. The facility's policy, revised on 3/31/2022, mandates that medications must be administered in accordance with orders. The failure to follow the physician's order for the Lidocaine patch placement resulted in a potential risk for the resident's well-being, as the professional standards of quality were not adhered to.

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 appropriate bowel monitoring and protocols for a resident, resulting in severe diarrhea followed by constipation. The resident, who had a history of having only half a colon and did not use laxatives prior to admission, was administered a daily laxative for over a week, leading to severe diarrhea. Despite the resident's Power of Attorney (POA) informing the facility that the resident used Imodium instead of laxatives, the facility continued with the laxative administration. Subsequently, the resident was given too much Imodium, causing severe constipation. The facility's records showed that the resident did not have a bowel movement for 11 days, despite having multiple loose stools in one morning, which was not documented properly. Interviews with staff revealed that the facility's bowel protocol was not followed consistently, and there were issues with the documentation and implementation of bowel monitoring. The Director of Nursing (DON) acknowledged that the Imodium order was incorrectly entered and that some nurses failed to run the bowel report, leading to the resident's prolonged constipation.

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 attempt gradual dose reductions (GDR) of psychotropic medications and ensure PRN psychotropic medications were limited to 14 days for two residents. Resident #30, who was admitted with Alzheimer's disease, anxiety, and depression, was prescribed sertraline, trazodone, and quetiapine fumarate. Monthly pharmacist reviews recommended dose reductions, but there was no documentation of GDR attempts or risk versus benefit considerations in the resident's medical record. The Director of Nursing (DON) admitted that pharmacist recommendations had not been followed up due to a lack of a system or process in place, and the recommendations were going to a spam folder. Resident #42, admitted with Alzheimer's disease, anxiety, and right-sided hemiplegia, had an order for Ativan with no end date. Monthly pharmacist reviews recommended evaluating the necessity of the PRN medication and providing a risk versus benefit statement, but there was no follow-up documentation. The DON confirmed that Ativan should not be ordered PRN with no stop date and acknowledged the lack of a system to review pharmacist recommendations.

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 antibiotic use protocols and a system to monitor antibiotic use for a resident diagnosed with a urinary tract infection (UTI). The resident was admitted with multiple diagnoses, including dementia and COPD, and was prescribed Cephalexin for a UTI diagnosed in the hospital emergency department. Despite the resident showing no signs or symptoms of a UTI, the facility proceeded with the antibiotic treatment without completing a UTI protocol form or obtaining necessary laboratory results in a timely manner. The creatinine clearance, which is essential for adjusting antibiotic dosage, was calculated only on the fifth day of antibiotic administration, and the pharmacy faced difficulties in obtaining the required laboratory and patient values from the facility. This delay in obtaining and acting on critical information led to the inappropriate administration of antibiotics to the resident. The facility's policy on antibiotic stewardship was not followed, as evidenced by the lack of adherence to established protocols and the failure to monitor antibiotic use effectively. The medical director and nursing staff did not ensure that antibiotics were prescribed and administered appropriately, resulting in potential risks to the resident's health.

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 appropriate neurological assessments were completed for a resident who experienced two unwitnessed falls within a short period. The resident, who had a history of stroke, high blood pressure, osteoporosis, and a traumatic fracture, was on anticoagulant medications. After the first unwitnessed fall, neurological exams were performed as per the facility's policy. However, after the second unwitnessed fall, no incident report was filed, and the neurological assessments were not restarted as required by the facility's protocol. During interviews, a Registered Nurse confirmed the absence of an incident report and neurological assessments for the second fall. The Director of Nursing also acknowledged that the expectation was to restart neurological exams after any unwitnessed fall with a known or suspected head injury. The failure to follow these protocols resulted in the potential for a delay in treatment after an unrecognized acute change in the resident's condition.