Kith Haven

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect a resident from abuse by another resident, resulting in physical injury. Resident #101, who had a history of stroke, dementia, seizures, diabetes, cognitive communication deficit, anxiety, and hypertension, was assessed as having moderate cognitive decline with a BIMS score of 8/15 and needing some assistance with care. On the day of the incident, CNAs entered the shared room of Residents #101 and #102 and observed Resident #101 with blood on his face, a swollen right eye and lip, facial bruises, and blood on his teeth. When asked what happened, Resident #101 pointed to his roommate, Resident #102, and stated that they had been in a fight and that the other resident had assaulted him. Nursing staff documented that Resident #101 reported his roommate said he had “cut him off,” then assaulted him while he was lying down. Resident #102’s record showed extensive psychiatric and behavioral history, including traumatic brain injury, psychotic disorder with delusions and hallucinations, schizophrenia, depression, anxiety, adjustment disorder with mixed disturbance of emotions and conduct, frontotemporal neurocognitive disorder, dementia, and a history of alcohol abuse and domestic violence. Prior facility and in‑house documentation described increased behaviors since admission, including rejection of care, yelling, abusive language, threatening behaviors, strange and inappropriate behaviors, refusal of care, suspected drug‑seeking behavior, and episodes of psychosis with poor judgment, poor insight, and poor impulse control. On a prior date, staff documented that Resident #102 appeared intoxicated, was loud and obnoxious, talking to himself, making threats to harm other residents, and had disorganized, slurred, and rambling speech. Social services also documented that his guardian reported a history of domestic violence. Despite this, his initial care plan after admission did not address his history of violent and aggressive behavior toward others. On the day of the altercation, staff reported that Resident #102 had been verbally abusive and agitated all morning, refused care, and did not take his medications the night before. After the incident, nursing and NP documentation indicated that Resident #102 first denied involvement, then stated that his roommate had been scratching his genitals and that he hit him; assessment showed only pre‑existing moisture‑associated skin damage to his scrotum with no new injuries. Resident #101, by contrast, had multiple red, raised, abraded areas on his forehead, a nearly swollen‑shut right eye with abrasions and swelling, swollen and abraded lips, and later hospital documentation of a facial contusion and closed head injury, as well as an imprint of a hand on his chest. The facility’s own abuse prohibition and resident rights policies required a safe environment and freedom from physical abuse, including hitting and similar acts, but the care planning and monitoring for Resident #102 did not consistently reflect or operationalize his known risk for aggression toward others. Care plan review for Resident #102 showed fragmented and delayed behavioral interventions. A care plan for substance abuse was initiated with an intervention for close observation such as q15‑minute checks or 1:1 “as needed,” but this was not clearly dated in the Kardex and was only formally revised later. A separate care plan for mood and hostility did not include interventions to prevent hostility toward other residents and staff until weeks after the assault, and those interventions were tied to the resident verbalizing a desire to harm self or others, which he had not done prior to attacking his roommate. Another care plan addressing potential physical and verbal aggression, agitation, abusive language, and yelling outbursts included 15‑minute checks for 72 hours, which were discontinued well before the assault occurred, leaving Resident #102 without enhanced monitoring at the time he attacked Resident #101. The inconsistency between the care plan and the Kardex regarding close observation and 1:1 supervision, along with the absence of timely, targeted interventions addressing his documented aggressive and threatening behaviors, contributed to the failure to prevent the assault on Resident #101. The facility’s DON acknowledged that Resident #102 had several instances of appearing intoxicated from alcohol or drugs and that the facility became aware of his violent behavior history through his guardian. Staff interviews confirmed that Resident #102 had a pattern of cursing, using derogatory names, being vulgar and disrespectful, and refusing care, including on the morning of the incident. Despite these known behaviors and risk factors, Resident #102 remained in a shared room with a cognitively impaired roommate and without ongoing close observation or 1:1 supervision at the time of the event. This sequence of known behavioral risks, incomplete and inconsistently implemented care planning, and lack of sustained monitoring led to Resident #101 being assaulted by Resident #102 and sustaining documented injuries requiring hospital evaluation and treatment.

Penalty

No penalty information released

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

Summary

The facility failed to maintain sanitary conditions in the kitchen and failed to keep cold foods at proper temperatures during meal service. During a kitchen tour with the Certified Dietary Manager, the ice machine was observed with a partially detached bin seal/trim, orange residue on the inside white flap, and peeling interior surfaces that had turned white/translucent. The bottom of a dolly cart holding approximately 35 clean mugs was soiled with debris and unknown food particles, and a trash can was positioned against a clean cookware rack. In the deli cooler, the bottom vent grates had hardened substances and the door seals had black residue; the Certified Dietary Manager stated the bottom grates had been difficult to clean and that the facility had not noticed the soiled areas inside the ice machine. During meal service in the 2nd and 3rd floor dining rooms, resident beverages including milk, juice, and mighty shakes were observed sitting out without adequate cooling in place. The dietary aide stated the beverages were brought upstairs based on resident meal tickets, and the Certified Dietary Manager stated ice was supposed to be placed on top of the beverages to maintain temperature. Temperatures taken during service showed milk at 48 F and juice at 45 F on the 2nd floor, milk at 48 F and juice at 42.1 F on the 3rd floor, and juice at 43 F on the 1st floor. Review of temperature records showed multiple meal services on the kitchen, 2nd floor, and 3rd floor where beverage temperatures were not documented, and the facility policy required cold foods at point of service to be held at 41 F or below.

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 interdisciplinary review and revision of the comprehensive care plan for Resident #65. The resident was observed in their room on 3/18/26 and noted to have Enhanced Barrier Precautions in place, but not Transmission-based isolation precautions. When asked about recent illness or antibiotics, the resident did not know. Record review showed the resident had been admitted with diagnoses including dysphagia, left hemiplegia and hemiparesis following cerebral infarction, aphasia, gastrostomy, and dementia, and the MDS indicated the resident was rarely or never understood and was dependent on staff for ADLs. Review of the EMR showed a care plan titled that the resident was on isolation precautions related to cough, SOB, and COVID, initiated 12/31/25, but the care plan did not specify what type of isolation precautions were in place due to COVID. During interview, the MDS RN stated infection control handled and discontinued all care plans related to infections and isolation precautions. The IC nurse later reviewed the record and stated the care plan had not been closed because it was in a custom care plan, then acknowledged it should have been discontinued. Facility policy stated each resident will have a person-centered plan of care developed and implemented, and that the care plan will be updated with significant changes, including resolving items that are no longer applicable.

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 ADL care for multiple dependent residents, including grooming, oral care, bathing, and timely incontinence care. Surveyors observed residents with unshaven faces, long facial hair, greasy and uncombed hair, long and jagged fingernails with debris under the nails, disheveled appearances, and call lights not within reach. Documentation reviews also showed repeated blank entries for required ADL tasks and, in some cases, no documentation of refusal of care. One resident who was blind and cognitively impaired was observed in bed unshaven and disheveled, with a urinal containing dark yellow urine hanging beside the bed. The resident stated staff had only changed the brief and had not assisted with getting cleaned up or oral care, and said they preferred to be shaved but could not do it themselves. The resident’s care plan and MDS indicated moderate to maximum assistance was needed for ADLs, yet the documentation survey report contained multiple blank areas for ADL care and personal hygiene tasks with no refusal documented. Another resident with bilateral above-the-knee amputations, severe cognitive impairment, aphasia, and dependence for ADLs was observed in bed with a foul body odor, long jagged fingernails, and a call light on the floor. Staff acknowledged they had not provided morning ADL care. A resident with severe cognitive impairment and dependence for ADLs was observed with significant buildup and debris on the teeth and stated staff had not assisted with oral care that day. The LPN confirmed oral care still needed to be done, and the documentation report showed multiple blank entries for oral hygiene and personal hygiene tasks. A resident who was incontinent of bladder and bowel and dependent for toileting was observed with a strong odor of urine and a large brownish urine stain on the bed linens that was partially dry and partially wet. The resident later stated they had not been changed overnight and that sometimes staff did not get to it because they did not have enough people. The DON acknowledged staffing issues and that blank areas on daily care documentation meant the care task was not provided. Additional residents were observed with long chin and facial hair, greasy and uncombed hair, and missed shower documentation, with staff interviews confirming that some care was refused at times while other scheduled care was not completed as documented.

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 enteral tube care per professional standards of practice for four residents who had feeding tubes or PEG tubes. The deficiency involved improper management of tube feeding positioning, lack of appropriate monitoring of tube feeding administration, and failure to verify PEG tube placement before medication administration, as observed by surveyors and confirmed through interviews and record review. For one resident with a history of stroke, dysphagia, aphasia, hemiplegia, and a gastrostomy tube, surveyors observed tube feeding infusing while the head of the bed was positioned at 15 degrees and later at 24 degrees, despite the care plan directing that the head of the bed be elevated 45 degrees during tube feeding and for one hour afterward. A nurse later confirmed the bed was not elevated to 30 degrees. For another resident with dysphagia, hemiplegia, aphasia, gastrostomy, and dementia, surveyors observed the resident in bed with tube feeding equipment connected, the head of the bed at 20 degrees, and the pump displaying a feed error message while no staff were present in the hallway. A CNA who was questioned about the pump error did not know what it meant and could not state how high the head of the bed should be during tube feeding. The resident’s care plan directed head-of-bed elevation of 30 to 45 degrees during tube feeding. A third resident had a PEG tube in place but was also receiving a regular diet with thin liquids, and the record showed orders to flush the PEG tube and change the dressing, but the MDS did not indicate that the resident had a feeding tube or was receiving flushes through it. The NP stated the tube remained in place because the resident’s son wanted it kept until after a future craniotomy, but there was no documentation explaining the plan for the tube or routine monitoring of the insertion site. For a fourth resident with dysphagia and traumatic subdural hemorrhage, an LPN administered medications through the PEG tube without verifying placement first and did not properly flush the tube afterward. During interview, the LPN acknowledged not verifying placement, and the DON stated the resident was not supposed to have anything by mouth, while the medication orders included both oral and PEG administration. The facility policy required verifying tube placement before enteral medication administration and flushing the tube after medications.

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 consistently assess residents for Influenza and Pneumococcal vaccinations on admission, provide educational vaccination information sheets for each vaccination, and document vaccination information in the medical record, including consent or declination. During an interview, the Infection Control Practitioner stated that residents were usually assessed for vaccinations on admission and that vaccine history was reviewed with residents and responsible parties, but consent or declination was not provided at the initial care conference. She also stated that since a prior date through the survey date, she had not offered Flu, Pneumonia, or Covid vaccinations to residents because she had been busy with a large Covid-19 outbreak and often worked several days a week as a floor nurse, which prevented completion of her infection control duties. Record review showed deficiencies in the vaccination documentation for multiple residents. One resident with heart disease, diabetes, and arthritis had Flu, Pneumonia, and Covid vaccinations documented as received, but there was no additional consent or declination after that. Another resident with cancer, heart disease, stroke history, and peripheral vascular disease had Flu, Pneumonia, and Covid vaccinations refused in the electronic record, but no consent or declination form with educational information was identified. A third resident with heart disease, diabetes, and respiratory failure had Flu, Pneumonia, and Covid refused, but only the Covid declination was documented; there was no indication that Flu or Pneumonia vaccinations had been reoffered. A fourth resident with hypertension, dementia, and schizophrenia had Flu, Pneumonia, and Covid refused, but no consent or declination forms were present. The record review also noted that consent or declination forms for vaccinations that included information on risks and benefits were not identified for the residents reviewed, and the residents or representatives were not able to make an informed decision on whether they wanted to receive the vaccinations. The facility policy stated that immunizations are to be offered as appropriate to residents and staff to decrease the incidence of preventable infectious 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 specify the indication for use and provide a clinical rationale for duplicate antipsychotic therapy for one resident. Resident #88 was admitted with diagnoses including Adjustment Disorder, Anxiety Disorder, Dementia, Psychotic Disorder with Delusions, and Psychophysiologic Insomnia. Her medication record showed Paliperidone (Invega) ER 1.5 mg daily, ordered on 3/7/2025 for antipsychotic use, and Quetiapine (Seroquel) 25 mg twice daily, ordered on 4/9/2025 for psychotic disorder; both medications are classified as antipsychotics. Review of Mental Health Provider progress notes from June 2025 through March 2026 found no documentation of a clinical rationale for the dual antipsychotic therapy. During interview, the Social Worker reviewed the chart and stated that antipsychotic was not an appropriate indication for Invega and that the resident’s behaviors had decreased as she stabilized on her current medication regimen, but she did not believe the practitioner’s charting explicitly addressed the rationale for the duplicate antipsychotic therapy. The facility policy stated that when pharmacological interventions are indicated, licensed staff will verify that the physician order includes the appropriate clinically supported diagnosis.

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 timely completion of a significant change MDS assessment for a resident who was admitted with dysphagia, left hemiplegia and hemiparesis following cerebral infarction, aphasia, and dementia. The resident’s MDS documented that the resident was rarely or never understood, was dependent on staff for ADLs, and was receiving hospice care. The resident’s HCP ordered hospice admission and the EMR showed the payor source changed to hospice on 6/23/25, but the significant change MDS related to decline and hospice admission was not completed until 8/11/25. The resident’s care plan related to hospice services was initiated on 6/23/25 and revised on 8/13/25. During interview, the DON stated that a significant change MDS should be completed when a resident is admitted to hospice services and acknowledged concern that the assessment had not been completed when the resident entered hospice in June 2025. The MDS RN later confirmed, after speaking with the Regional MDS Nurse, that a significant change MDS should have been done and was not completed, and no further explanation was provided for the delay.

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 and services to ensure communication was completed in an understandable language for a resident who did not speak English. Resident #88 had diagnoses including heart disease, diabetes mellitus, psychotic disorder with delusions, and dementia, and the MDS identified Romanian as the resident’s preferred language and indicated that an interpreter was needed to communicate with staff. The resident was also documented as severely cognitively impaired and required supervision to moderate assistance with ADLs, with set-up assistance for eating. During observation, the resident was seen in the room without any communication or translation boards/devices present. When asked how they were doing, the resident responded, “No English.” Staff interviews showed inconsistent understanding of the resident’s language needs. One LPN stated the resident only spoke Romanian and said staff used communication boards and a translator device, while a CNA stated the resident spoke Russian and reported using a translator app on a personal phone because no other way to communicate was available. The CNA also stated the translator box was missing and that a communication board had not been seen in the room. Record review showed care plans that included use of a pocket talker, a talk box translator, a picture board, gestures, and staff encouragement to use a communication board. However, the resident’s room did not have a communication board or translation device present during survey observations. Staff later stated the translator device had been taken away by the DON because it was no longer working due to the resident’s advancing dementia, but there was no documentation in the EMR showing discontinuation of the device. The DON also stated staff were not allowed to use personal devices, yet staff reported using translation apps on their phones to communicate with the resident. The DON and unit staff were unable to explain how complex communication was being completed without the translator device, and the unit manager stated the resident could understand English, while also acknowledging the resident had progressed to communicating only in Romanian.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Resident #81’s skin was assessed and monitored beneath a soft helmet. The resident had a history of stroke, left-sided weakness, cranial surgery with skull flap, heart disease, neuropathy, frontotemporal neurocognitive disorder, and hypertension. The physician order required the head helmet to be worn at all times and directed nursing to inspect the skin around the helmet each shift, every day and night shift, starting 12/13/2025. On 3/18/2026, the resident was observed lying in bed awake and wearing the soft helmet. She stated the helmet made her head feel hot, itchy, and sweaty at times, and she removed it to show her hair underneath. She also reported having another soft helmet with holes for aeration that she wore in warm weather. Review of the MAR/TAR showed the helmet order and the instruction for nursing to inspect skin around the helmet each shift, but the Kardex did not mention a soft helmet or monitoring the skin beneath it. Review of the progress notes, skin checks, and care plans showed no documentation of assessing or monitoring the skin underneath the helmet. The fall care plan noted that the resident was supposed to wear her helmet at all times and frequently chose to remove it, but it did not include monitoring the skin under the helmet. The wound nurse confirmed that nurses should assess under the helmet each shift, yet the record contained no such documentation. The facility also failed to ensure timely laboratory monitoring for Resident #139 while receiving IV vancomycin. The resident was admitted with diagnoses including sepsis due to MRSA and pneumonia and returned to the facility with a PICC line for IV therapy. The hospital discharge prescription ordered vancomycin 1.25 grams IV every 24 hours for 35 days and specified weekly labs including CBC with differential, BUN, creatinine, WSR, C-reactive protein, and vancomycin trough. The record showed the last vancomycin peak and trough lab collection was on 03/09/2026, with the next weekly lab due on 03/16/2026. However, no vancomycin peak and trough order was placed in the facility chart on readmission. The readmission order set included only CBC, CMP, vitamin D, and lipid panel labs, and the contracted lab order produced by the ICP nurse also did not include vancomycin peak and trough monitoring. Staff interviews confirmed that the admission nurse sought help with orders, that the ICP nurse handled the vancomycin and labs, and that the DON placed batch orders, but the required vancomycin monitoring order was not present in the chart. The resident initially refused a stat blood draw on 03/18/2026, and the labs were obtained later after the NP spoke with him and explained why they were needed. The NP acknowledged that the discharge instructions from the ID physician had been missed and that vancomycin should have been monitored. The chart later showed an order for weekly labs including a vancomycin trough and to hold vancomycin until the lab was drawn.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to consistently implement an existing behavior care plan for a resident with a known history of poor impulse control and aggression. The resident was an adult, alert and able to make their own decisions, with multiple diagnoses including end stage 5 kidney disease, alcohol use, PTSD, anxiety disorder, schizoaffective disorder, chronic migraine, diabetes, depression disorder, and heart failure. The resident required assistance with ADLs, had a left below-knee amputation, was wheelchair-bound, and received dialysis. The resident’s care plan for potential aggression, dated 1/14/25, directed staff to avoid confrontation and adjust the plan of care to reduce incidents of aggression where possible. The facility’s care plan policy required that care plans be specific, resident-centered, and address management of risk factors, including aggressive behaviors. On 1/7/26, an argument occurred between this resident and another resident regarding an accusation of theft, leading the facility to initiate 15-minute checks for the aggressive resident. Despite this known conflict and the active aggression care plan, on 1/8/26 staff allowed the resident to sign out for a smoking LOA at a time when they were aware the other involved resident was already outside. Video and documentation showed that as the resident wheeled past the other resident, the other resident struck them with a grabber, and both residents then hit each other, with the aggressive resident striking the other resident’s face and causing a cut. The 15-minute check sheet documented observation of the resident at 11:45 a.m. while outside, during the period of the altercation. In interviews, the Administrator and DON acknowledged that they did not follow the aggression care plan directive to avoid confrontation and adjust the plan of care to reduce incidents of aggression when possible, and confirmed that the facility did not prevent the two residents from being outside together despite the prior conflict.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. As a result, the resident was not properly prepared for a safe transition to the next care setting.

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 adequate supervision for three residents with varying degrees of cognitive impairment and behavioral health diagnoses, resulting in multiple resident-to-resident altercations. One resident with Huntington's disease and schizoaffective disorder, who had a history of poor impulse control and previous physical aggression, was involved in two separate altercations on the same day. In the first incident, this resident was redirected from the front door by a receptionist, became upset after an interaction with another resident, and physically pushed that resident, who then retaliated. A third resident was present during this event. Shortly after the first altercation, the same resident re-entered the building from the back patio and was involved in a second altercation with another resident. This second incident escalated to physical violence, with the resident striking the other multiple times in the face, resulting in a small abrasion. Interviews revealed that staff were aware of the resident's behavioral triggers and history, but supervision was limited to 15-minute checks, and there was no continuous monitoring or documentation of these checks in the electronic medical record. Staff interviews indicated a lack of clear communication regarding the resident's supervision needs and the reasons for increased monitoring. The facility's policy required monitoring and interventions to prevent escalation of aggression, but staff actions did not align with these procedures. The activity director, who was responsible for the resident during part of the monitoring period, was not fully informed of the prior incident or the specific reasons for the increased supervision. Other staff members acknowledged that the resident should have been accompanied when re-entering the building, especially given the recent altercation and known behavioral risks. The lack of adequate supervision and failure to follow established protocols directly contributed to the repeated altercations among residents.

Plan Of Correction

F 689 Free of Accidents/Hazards Element 1 Resident #702 continues to reside within the facility. Resident continues to have a 1:1 for supervision. Resident care plans were reviewed and revised as appropriate. Resident #6 continues to reside in the facility. Resident care plans were reviewed and revised as appropriate. Resident #7 continues to reside in the facility. Resident care plans were reviewed and revised as appropriate. Element 2 Like residents are identified as residents that reside within the facility involved in a resident-to-resident incident. The IDT made rounds on the like residents to ensure care planned interventions were in place in accordance with the plan of care, and any concerns were addressed. Element 3 The procedure to implement the plan of correction included: 1. IDT reviewed F 689 2. IDT reviewed the "Abuse Policy" and deemed it appropriate. 3. IDT were reeducated on the "Abuse" policy with emphasis on ensuring interventions of supervision are in place and the care plans have meaningful interventions in place and have been implemented timely. All staff were reeducated to ensure they accompany the resident away from the environment in which the behavior has occurred. Element 4 The process to ensure that the specific citation remains corrected includes: 1. The Director of Nursing or designee will review with the IDT interventions to ensure adequate supervision is in place for resident incidents. 2. The Admin will conduct rounds to ensure there is adequate supervision for residents involved in an incident. 3. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. 4. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. 5. Any area of non-compliance will be addressed. 6. The Admin will be responsible for sustained compliance.

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 services provided met professional standards of quality by not following hospital discharge recommendations for blood glucose monitoring and insulin administration for two residents with diabetes. One resident, who had a history of end stage renal disease, dependence on dialysis, and type 2 diabetes with ketoacidosis, was readmitted to the facility after a hospitalization for diabetic ketoacidosis (DKA). Hospital discharge instructions included a specific sliding scale insulin regimen to be administered three times daily before meals. However, the facility did not implement these orders upon readmission, with a delay in ordering the sliding scale insulin and a lack of documentation explaining the deviation from the hospital's recommendations. Additionally, on days when the resident returned from dialysis, blood glucose monitoring and insulin administration were not performed as ordered, and the medication schedule was not adjusted to accommodate the resident's dialysis schedule. Interviews with nursing staff and the DON revealed uncertainty about why the hospital discharge orders were not followed and confirmed that there was no documentation of any rationale for not adhering to the recommendations or of any discussion with the practitioner regarding these changes. The facility's own diabetic management policy required that orders be received and implemented accurately, with blood glucose monitoring and anti-diabetic agents administered per physician order, but this was not done in this case. The lack of adherence to the prescribed regimen was evident in both the medical record and staff interviews. A second resident with type 2 diabetes had a physician's order for insulin glargine to be held if blood glucose was less than 100. Despite this, the medication administration record showed that insulin was administered on three occasions when the resident's blood glucose was below the specified threshold. The facility's policy required that results outside of ordered parameters be communicated to the physician immediately, but there was no documentation that this occurred. These failures demonstrate that the facility did not ensure that care and services were provided in accordance with professional standards and physician orders for diabetic management.

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 update care plans and implement appropriate interventions to prevent repeated falls for a resident with severe cognitive impairment and multiple medical conditions, including an above-the-knee amputation, dementia, anemia, and chronic obstructive pulmonary disease. The resident experienced several falls, some of which were unwitnessed, and after each incident, the care plan was either not updated or interventions were not properly documented or implemented. For example, after one fall, a three-day sleep study was ordered, but the results were not found in the electronic medical record. On other occasions, the care plan was not updated at all, or interventions such as 15-minute checks were added but not documented as completed. Interviews and record reviews revealed that the facility's process for updating care plans and documenting interventions after falls was inconsistent and incomplete. The Director of Nursing acknowledged that interventions should be meaningful and relevant to the specific fall, and that documentation and follow-up were lacking. Facility policy requires that incidents and accidents be documented in the medical record, including clinical information, observations, and follow-up care, but this was not consistently done for the resident in question.

Penalty

No penalty information released

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

Summary

The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. During a tour of the kitchen, several unsanitary conditions were observed, including spills and sticky floors in the walk-in cooler, expired food items, and dirty fan covers with debris buildup. The walk-in freezer contained items without expiration dates and expired products, while the dry storage area had expired canned goods and other food items. The kitchen area had dried substances under the pop machine spigots and inside the toaster, and the dishwashing area had observable debris and buildup around the dishwasher. The Dietary Manager, who started in the facility in a recent month, acknowledged the issues and noted that cleaning logs were often incomplete, with many daily tasks left blank. The facility's policies on food storage and dish machine sanitation were not adhered to, as evidenced by the expired food items and the lack of regular cleaning of the dish machine. The manager admitted that the cleaning logs from the previous month were similarly incomplete, indicating a systemic issue with maintaining cleanliness and proper food storage practices in the kitchen.

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 residents' rights and dignity, as evidenced by multiple observations and interviews. Resident #6 was observed in a wheelchair with a towel over his lap due to missing pants, which he had reported to staff without resolution. The resident expressed frustration over the missing clothing and lack of assistance from staff. Additionally, Resident #60 was found with long fingernails that were not trimmed by staff, despite the resident's need for assistance with personal hygiene. Several residents, including Residents #38, #81, and #82, reported receiving cold meals, with food trays often left in the hallway before being served. This resulted in meals being served at unpalatable temperatures, and residents expressed dissatisfaction with the quality of food service. The Dietary Manager acknowledged complaints about cold food but had not conducted audits to address the issue. Furthermore, Resident #97 reported missed showers and long call light wait times, leading to incontinence incidents and further dissatisfaction with care. The facility's failure to provide timely hydration was also noted, with observations of water dated from previous shifts and call lights left on the floor, making them inaccessible to residents. Interviews with residents revealed complaints of staff rudeness and disrespect, with reports of staff ignoring residents' needs and failing to address concerns. The facility's policies on resident rights and hydration were not adequately followed, contributing to the overall deficiency in maintaining a dignified and respectful environment for 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 provide consistent pre and post dialysis weights for two residents and did not ensure that two other residents received their medications post dialysis. This resulted in potential health risks due to the lack of medication therapy and monitoring of fluid retention. The facility's 'Hemodialysis' policy and 'Medication Administration' policy were not adhered to, leading to these deficiencies. Resident #107 did not receive several medications on multiple dialysis days in December 2024 and January 2025, including medications for blood pressure, GERD, and dialysis-related needs. The Director of Nursing (DON) was unable to explain why the medications were not administered as per the physician's orders. Similarly, Resident #22's medication regimen was not adjusted to accommodate dialysis treatments, resulting in missed doses of medications for hypertension, depression, and other conditions on dialysis days. Resident #21 and Resident #83 experienced inconsistencies in obtaining pre and post dialysis weights. Resident #21's Dialysis Communication Forms were often incomplete, missing crucial weight information, which is essential for assessing nutritional status and fluid retention. Resident #83's weights were not consistently obtained, and the dialysis center did not always provide the necessary weight documentation. This lack of documentation and monitoring could lead to complications related to fluid retention and other dialysis-related issues.

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 pharmacist medication regimen reviews (MRR) were properly reviewed, acted upon, and documented in the residents' clinical records for five residents. This resulted in medications not being adjusted with physician responses to accept or decline the pharmacy recommendations. The deficiency was identified through interviews and record reviews, revealing that the facility did not maintain signed copies of pharmacy recommendations within the medical charts or in a subsequent binder for other residents' MRR. For Resident #27, the pharmacist noted an irregularity on 9/24/2024, but the specifics were not documented in the resident's medical record. The Director of Nursing (DON) stated that the recommendation was addressed timely in early October 2024, but signed copies were not available. Similarly, for Resident #86, pharmacy consultation reports were provided but were unsigned by the physician and DON, and specifics of recommendations from March, May, and October 2024 were not located in the resident's medical record. Resident #40 had four MRR recommendations over the past year, but only one recommendation from 10/30/2024 was located. The recommendations from March and May 2024 were missing, and it was unclear if they were reviewed or acted upon. For Resident #42, two MRR recommendations were identified, but only one was found, and the recommended bloodwork was not located in the medical record. Resident #102's pharmacy reviews for June and August 2024 were missing, and the DON could not confirm if there were any recommendations for those months.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper storage and labeling of medications across multiple medication carts and a treatment cart. Observations revealed that medications were not dated when opened, including insulin, Valproic acid, oxcarbazepine, Risperidone, and inhalers, which could affect their efficacy and potency. Loose tablets were found in medication carts and on the floor, indicating a lack of proper handling and storage procedures. Additionally, the facility did not consistently monitor refrigerator temperatures where temperature-sensitive medications were stored. The 'Vaccine Storage Temperature Log' showed several instances where temperature checks were missed, potentially compromising the integrity of the medications stored within. This lack of consistent monitoring could lead to medications being stored at incorrect temperatures, further affecting their effectiveness. The treatment cart was found unlocked and unattended in a common area, accessible to residents. This posed a risk as the cart contained dressing supplies and prescribed treatments. The nurse responsible for the cart acknowledged that it should have been secured, highlighting a lapse in protocol adherence. These deficiencies collectively indicate a failure in maintaining medication safety and security within the facility.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to infection prevention and control standards in two key areas: the safe handling of ice and the proper storage of personal items. An Activity Aide was observed transporting uncovered basins filled with ice in an elevator, which was intended for resident activities. This practice was contrary to the facility's protocol, which required the use of covered pitchers for ice transport. The Infection Prevention and Control Nurse confirmed that the aide should have used the covered pitchers, as per the facility's infection control practices. Additionally, multiple observations were made regarding the improper storage of personal items such as urinals and bedpans in resident rooms. In several instances, urinals and bedpans were found without proper identification, making it unclear which resident they belonged to. Some items were stored inappropriately, such as a bedpan placed upside down on a bedside table over personal and food items, and a denture cup without a lid positioned under a soap dispenser. The Director of Nursing acknowledged that these items should have been marked with identification to prevent contamination and ensure proper infection control.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unclean and cluttered conditions in resident rooms. In one instance, a bathroom was found to be very soiled with brown smears on the toilet seat and discolored stains on the floor. Another room was observed to be cluttered with bags and boxes, obstructing a clear path. These conditions were noted despite the residents having full cognitive abilities and being independent or requiring minimal assistance with care. Additionally, a resident complained about a malfunctioning sink that overflowed before the water could get warm, causing inconvenience and potential hazards. Another resident's area was cluttered with overflowing bags of pop cans and bottles under the bed. These observations indicate a failure by the facility to ensure a clean and safe environment, as required by the care plans and resident rights to a homelike setting.

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 review and revise care plans for two residents, leading to potential missed interventions and unmet needs. Resident #64, who experienced significant weight loss, was observed struggling to eat due to shaky hands and was not receiving assistance with meals. Despite a 5.6% weight loss over 33 days, the care plan was not updated to reflect necessary interventions such as increased protein intake and assistance with feeding. The resident's nutritional care plan lacked updates for recent changes, and the Registered Dietitian was unaware of the resident's pressure ulcers, which required additional protein for healing. Resident #39, who has a tracheostomy and a feeding tube, was observed refusing enteral nutrition and water flushes, yet his care plan did not reflect these refusals or the fact that he was consuming food orally. The resident was scheduled for a swallow evaluation, but this was not documented in the care plan. Despite being observed eating food, including a hamburger, the care plan did not mention the resident's oral intake or the lack of current speech therapy services. The facility's failure to update and revise care plans for these residents indicates a lack of adherence to their own policies, which require care plans to be updated with significant changes. This oversight could lead to inadequate care and unmet needs for residents with complex medical conditions.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate care for two residents, leading to deficiencies in their treatment. Resident #383 was observed with a bandage on his left forearm that had not been changed since 1/27/2025, and there were no current orders for wound care on his Treatment Administration Record (TAR). The Director of Nursing (DON) confirmed the absence of an appropriate order and noted that the dressing was loose and not covering the injuries. This oversight in wound care management highlights a lapse in ensuring timely and documented treatment for the resident. Resident #115, who was admitted with multiple diagnoses including heart failure and was prescribed to wear a Life Vest, was found not to be using the device correctly. On 1/27/2025, it was noted that the Life Vest was not connected to the battery, and the resident refused to plug it in despite being educated on its importance. There was no documentation of this issue being reported to the physician or nurse practitioner. Additionally, after an unwitnessed fall on 1/29/2025, there was no mention of the Life Vest in the subsequent documentation, indicating a lack of monitoring and intervention related to the device. The facility's care plans and documentation for Resident #115 did not include specific interventions or instructions for the Life Vest, and there was no staff education on its use. The facility's policy on wearable cardioverter-defibrillators was not effectively implemented, as evidenced by the lack of documentation and staff awareness regarding the Life Vest. These deficiencies in care and documentation for both residents reflect a failure to adhere to standards of practice and ensure the safety and well-being of the 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 prevent the development of facility-acquired pressure ulcers for a resident, resulting in two new pressure ulcers. The resident, who had a history of impaired cognitive ability and was dependent on assistance for most activities, developed these ulcers due to poor nutritional intake, including a low protein diet, and subsequent weight loss. The facility's 'Skin Management' policy required a nutritional evaluation for residents with skin impairments, but this was not adequately implemented for the resident. Observations and interviews revealed that the resident had sores on the right foot, with one wound on the heel progressing to a Stage IV ulcer with exposed bone and tendons. The resident's care plan included interventions for offloading pressure, but these were not effectively executed, as the resident was noted to kick off the soft boot meant to relieve pressure. Additionally, the resident's nutritional care plan was not updated to address the significant weight loss and inadequate protein intake, which was only 58% of the required amount for wound healing. The Registered Dietitian was unaware of the resident's pressure ulcers and the recent significant weight loss. The resident's protein intake was insufficient, and the care plan did not reflect necessary interventions to address this deficiency. The lack of timely and appropriate nutritional interventions, combined with inadequate pressure relief measures, contributed to the development and worsening of the resident's pressure ulcers.

Penalty

No penalty information released

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

Summary

The facility failed to implement a restorative therapy program and develop a care plan for a resident, resulting in the potential for functional decline. The resident, who had diagnoses including anxiety disorder, depression, lymphedema, and an open wound of the lower leg, was admitted to the facility and required substantial assistance with daily activities. Despite having intact cognition, the resident reported that therapy had stopped prematurely and that the facility staff did not follow through with the planned restorative therapy, which included walking exercises and the use of weights. The resident's electronic medical record indicated a task for nursing rehab to maintain the ability to walk, but documentation showed inconsistent implementation, with many days marked as 'Not Applicable' and no care plan developed for restorative therapy. The Director of Nursing acknowledged the lack of a restorative therapy plan and was unable to find instructions from therapy in the electronic medical record. The facility's policy on restorative nursing emphasized the importance of maintaining residents' physical well-being, but the resident's care did not align with these guidelines.

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 prevent significant weight loss and provide adequate nutritional support for a resident, resulting in a 5.6% weight loss over 33 days and the development of pressure ulcers. The resident, who had a history of shaky hands, was observed with uneaten meals and reported difficulty feeding himself without assistance. Despite the resident's nutritional care plan indicating the need for health shakes and Med Pass supplements, these interventions were not effectively implemented or documented in the care plan. The resident's protein intake was significantly below the required amount to promote healing of pressure wounds, and the dietary staff was unaware of the resident's pressure ulcers. The facility's policies on nutritional services and weight management were not adequately followed, as the resident's significant weight loss was not promptly addressed with appropriate interventions. The Registered Dietitian (RD) was not aware of the resident's pressure ulcers and did not adjust the care plan to meet the resident's increased protein needs. Observations revealed that the resident was not receiving assistance with meals, contributing to inadequate nutritional intake. The lack of timely and effective interventions led to the resident's continued weight loss and inadequate protein intake, which are critical for healing pressure ulcers.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that oxygen was provided as ordered for a resident with chronic obstructive pulmonary disease (COPD), among other diagnoses. The resident, who had severely impaired cognition and required assistance with daily activities, had an order for 2 liters of oxygen via nasal cannula to maintain oxygen saturation above 90%. However, during an observation, it was noted that the oxygen tubing was not properly connected to the concentrator, resulting in the resident not receiving the prescribed oxygen. The resident's oxygen saturation was initially recorded at 85% before the tubing was reconnected, after which it increased to 95%. The deficiency was identified when a nurse was summoned to the resident's room and observed the incorrect connection of the oxygen tubing. The nurse acknowledged that the staff responsible for changing the oxygen tubing had not connected it correctly. The Director of Nursing was aware of the issue and indicated that the staff had been informed about the importance of proper tubing connection. This incident highlights a lapse in ensuring the correct delivery of respiratory care as per the resident's medical orders.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that suicide precautions were ordered and documented for a resident who was on suicide watch. The resident, who had a history of major depressive disorder and other significant health issues, was observed without a call light, which had been replaced with a bell as a precautionary measure. Despite the resident's threats of self-harm and the initiation of 15-minute checks by the staff, there was no formal order for suicide precautions in the resident's care plan or medical record. Interviews with staff revealed that the resident had been sent to the hospital for suicidal ideation and returned without changes in medication. The staff were aware of the resident's condition and had attempted to implement suicide precautions, but these were not documented in the care plan. The Director of Nursing confirmed that the resident had been on suicide precautions previously, but there was no documentation of the 15-minute checks in the medical record, as they were recorded on paper at the nurse's desk. The facility's policy on suicide/self-harm attempts required immediate 1:1 supervision and updates to the care plan when warning signs were exhibited. However, the staff had not received education on suicide precautions, and the necessary orders for suicide precautions were not placed until more than 24 hours after the resident's initial threat of self-harm. This lack of documentation and formal orders resulted in a deficiency in the continuity of care for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to obtain informed consent prior to administering psychotropic medications to three residents, which is a requirement to ensure that residents or their representatives are fully aware of the potential effects and reasons for the medication. Resident #27 was prescribed Risperidone for psychotic disorder without a documented diagnosis of psychosis, and the facility was unable to provide a consent form for this medication. Similarly, Resident #90 was receiving Latuda and Zoloft for delusional disorder and depression, respectively, without the facility obtaining consent forms for these medications. The facility's social worker confirmed that consents were not used for anti-depressants or anxiety medications, despite their potential impact on residents' behaviors and moods. Additionally, Resident #102 was receiving multiple psychotropic medications, including Ativan, Depakote, and Zyprexa, for various psychological conditions. However, the facility failed to conduct pharmacy reviews for this resident's medication regimen in June and August 2024, as required. The Director of Nursing acknowledged the absence of these reviews and was unable to confirm if any pharmacy recommendations were made during those months. This oversight indicates a lapse in the facility's medication management and review processes, which are critical for ensuring the safe and appropriate use of psychotropic medications.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to standards of practice and physician orders regarding medication administration for a resident, leading to potential adverse medication reactions. The resident, who had chronic kidney disease, dementia, bradycardia, and other conditions, was administered medications outside the prescribed parameters. Specifically, Nifedipine was given despite the resident's heart rate being below the ordered threshold, and Doxazosin was administered without applying the necessary parameters after the resident's return from the hospital. The resident's medical records indicated multiple instances where medications were administered despite vital signs being outside the prescribed parameters. For example, Nifedipine was given when the resident's heart rate was below 50, and Doxazosin was administered when the systolic blood pressure was below 100. Additionally, Midodrine was given when the blood pressure was above the hold parameter of 110. These actions were contrary to the physician's orders and the facility's medication administration policy. Interviews with the Director of Nursing revealed that the nursing staff did not follow the parameters and failed to contact the physician for clarification when vital signs were inconsistent with the medication orders. The facility's policy required that medications be administered according to the physician's written orders and that any inconsistencies be addressed with the physician before administration. The failure to adhere to these protocols resulted in the potential for adverse medication reactions and re-hospitalization 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 ensure timely dental services for a resident, resulting in a broken tooth not being repaired or extracted, causing pain and infection. The resident, who had intact cognition and required assistance with daily activities, reported breaking a tooth around Thanksgiving and expressed frustration over not knowing when it would be addressed. An observation confirmed the presence of a broken tooth on the upper left side, which was painful and infected. The resident was unaware of the plan for dental care, and the facility did not communicate effectively with the dental service provider. The resident's medical record indicated that a dental hygienist had assessed the resident on December 2nd, noting a deep fracture in the tooth that was painful. The dentist was scheduled to visit the facility on January 29th, but the visit was canceled and rescheduled for February 5th. The facility was not informed that x-rays were needed before further treatment, and there was no hygienist available to perform the x-rays. The lack of communication and coordination between the facility and the dental service provider led to a delay in treatment, leaving the resident in pain and without a clear plan for 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 adaptive eating equipment and utensils for a resident, resulting in difficulties during meal times. The resident, who had moderately impaired cognition and required assistance with eating, was observed struggling to manage a Styrofoam cup and utensils due to poor hand control. The resident expressed frustration and was unable to eat or drink without spilling, as the adaptive equipment specified in the meal ticket, such as a two-handled spouted cup and built-up utensils, was not provided. Staff interviews revealed that the adaptive equipment was available but not consistently provided to the resident. The Dietary Manager confirmed that the equipment should have been included with every meal, and the Director of Nursing acknowledged that the resident should have received a two-handled cup for hydration. The resident's care plan and therapy communication documents also indicated the need for specific adaptive equipment to assist with eating, which was not adhered to during the observed meal.