Medilodge Of Southfield

Penalty

Fine: $239,380

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 and monitor residents experiencing changes in condition, did not notify physicians of continued decline, and did not transfer residents to higher levels of care in a timely manner. For four residents reviewed, these failures resulted in significant negative outcomes, including two deaths, one resident requiring intubation after hospital transfer, and another developing sepsis leading to shock. The surveyors found that physician-ordered interventions were not implemented, abnormal vital signs and lab results were not acted upon, and documentation and communication among staff and providers were lacking. One resident with a history of cardiac arrest and atrial fibrillation had physician orders for Cardizem and increased free water flushes that were never administered or transcribed. This resident exhibited persistent tachycardia and hypoxia over several days, with no follow-up or escalation of care until they were transferred to the hospital in respiratory distress and subsequently intubated. Another resident with end-stage renal disease and chronic anemia had a critically low hemoglobin level, but despite the facility's awareness and the resident's history of requiring hospital evaluation for low hemoglobin, there was a lack of timely notification and transfer. The resident ultimately expired in the hospital with a hemoglobin of 3.2, and documentation did not reflect any refusal of hospital transfer. A third resident, who was alert and oriented, requested to be sent to the hospital due to shortness of breath and refused dialysis, but there was no evidence of provider follow-up or reassessment. Orders for medication were not documented as given, and the resident was later found unresponsive and pronounced dead. The fourth resident, admitted with sepsis and toxic encephalopathy, had elevated heart rate and declining oxygen saturation, but vital signs were not consistently documented, and there was a lack of provider progress notes. The resident was eventually transferred to the hospital and diagnosed with septic shock. Facility policy required notification of significant changes, but this was not consistently followed, and documentation was incomplete or missing.

Removal Plan

• Assess current residents for a change in condition by reviewing labs and vital signs.
• Educate nursing staff on assessment, notifying the physician, implementing orders, and documentation.

Penalty

Fine: $239,380

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 food service equipment in accordance with professional standards, specifically regarding the routine maintenance and cleaning of the kitchen ice machine. During a kitchen tour, surveyors observed that the ice machine filter cover appeared brown in color and lacked any date labels. The Dietary Manager stated that an outside vendor was responsible for cleaning and that the unit was cleaned two weeks prior, but was unable to provide documentation for routine maintenance or filter changes beyond two records dated over 15 months apart. The ice machine had a service sticker with handwritten dates, but there was no consistent documentation of regular inspection, cleaning, or filter changes as required by the facility's Water Management Plan (WMP) and professional standards. Further interviews with the Dietary Manager and Maintenance Director revealed uncertainty about the frequency and documentation of ice machine maintenance prior to the current staff's tenure. The Maintenance Director was not aware of the previous monitoring schedule and indicated plans to begin quarterly monitoring. The facility's WMP specified daily visual monitoring and monthly cleaning and filter inspection, but these protocols were not being followed or documented. Additionally, the facility's policy document on ice storage did not provide specific maintenance protocols, and no additional guidelines were available at the time of the survey. These findings were confirmed through observation, interviews, and record review, indicating a failure to adhere to required food safety and equipment maintenance standards.

Penalty

Fine: $239,380

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 did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or a described process outlining how the facility carries out these required quality improvement and assessment activities.

Penalty

Fine: $239,380

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 purchase a surety bond in an amount equal to the current balance of personal funds held in the resident trust fund. At the time of the survey, documentation showed that 82 residents had personal funds managed by the facility, with a total balance of $63,240.36. However, the facility's surety bond was only for $45,000.00, which was significantly less than the current trust fund balance. The Business Office Manager confirmed the discrepancy and was unable to provide a clear explanation for why the bond amount did not match the current balance. Additionally, the facility did not have a policy regarding the surety bond. Interviews with the Business Office Manager revealed uncertainty regarding the timing of processing patient pay amounts, which contributed to fluctuations in the trust fund balance. The manager also acknowledged that at least one deceased resident was still listed as having funds in the trust account. Despite being informed of the concern, the facility did not provide documentation or a policy to address the issue of the insufficient surety bond coverage.

Penalty

Fine: $239,380

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 multiple failures in the proper storage and security of medications and biologicals. On one unit, an LPN was found to have placed an unlabeled and uncovered medicine cup of pills in a medication cart drawer after preparing them for a resident who was not present. The LPN could not recall which resident the medications were for, and the same drawer contained a bottle of Aspirin with an expired manufacturer date. In the medication room, staff food was found stored in the refrigerator alongside medication administration supplies, and a multidose vial of Aplisol was kept beyond the recommended 30-day use period after opening. The LPN present was unaware of the proper storage duration for the vial. Additional observations on the secured memory care unit revealed medication carts left unlocked and unattended in areas accessible to residents, with no nurse providing direct supervision. On two separate occasions, medication carts were found unlocked, and staff returned only after being prompted. Items not related to medication administration, such as applesauce, a gold watch, and a cell phone, were found stored in the medication cart drawers and narcotic box. Staff could not identify the owners of some of these items or explain why they were stored with medications and medical supplies. Interviews with the Director of Nursing confirmed that staff food should not be stored in medication room refrigerators, and that medication carts should always be locked when not directly supervised by nursing staff. The DON also stated that resident belongings should not be stored in medication carts except in specific circumstances, such as money being temporarily secured. The observations and staff interviews demonstrated a lack of adherence to facility policy and accepted professional standards for medication storage and security.

Penalty

Fine: $239,380

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 meals were maintained and served at a palatable and safe temperature, affecting multiple residents. During a Resident Council meeting, several residents reported that food was often served cold, particularly for those residing on the second floor or choosing to eat in their rooms, as they were served last. Residents also noted delays in being brought to the dining room, resulting in further cooling of their meals. Review of past Resident Council minutes revealed ongoing complaints over several months, including reports of cold breakfasts, melted ice cream, and meals served without adequate heat from the steamtable. These concerns were corroborated by both the Activity Director and Corporate Activity Director, who acknowledged awareness of the issue and attributed it to delays in food service rather than improper cooking temperatures. A temperature test conducted with the Dietary Manager confirmed that food items, including pork and potatoes, were served below the required temperature, with milk and dessert also not at appropriate temperatures. The Dietary Manager expressed uncertainty about why the food was not meeting temperature requirements despite the use of plate warmers and noted that staff workload and delays in tray service could be contributing factors. The Administrator, who was new to the facility, was aware of the ongoing concerns but could not confirm if the issues were current or historical. No corrective actions or follow-up measures were described in the report.

Penalty

Fine: $239,380

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

Summary

The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, specifically in the areas of oral hygiene, incontinence care, bathing, and nail care. One resident, who was admitted with severe cognitive impairment and required staff assistance for all ADLs, was observed with excessively long fingernails and reported that his nails had never been cut since admission. Documentation showed that he had only received two bed baths over a six-week period, despite requiring full assistance. Staff interviews confirmed that nail care was the responsibility of CNAs and should be performed when nails are long, but there was no evidence this was done until after surveyor intervention. Another resident, with severe cognitive impairment and multiple medical diagnoses, required partial to moderate assistance with oral hygiene. Documentation revealed that oral care was inconsistently provided, often only once daily or not at all, with several entries marked as 'No' or 'Resident Refused' without any follow-up or notification to nursing staff. The resident's legal guardian expressed concerns about neglect of oral care, noting a history of neglect prior to admission and poor oral hygiene since admission. Staff interviews indicated that refusals were simply documented without further action or escalation. A third resident, who was always incontinent and had intact cognition, reported receiving incontinence care only once per eight-hour shift, typically just before shift change, and expressed concerns about inadequate care given her use of diuretics. Review of documentation for bathing and incontinence care showed multiple blank or incomplete entries, supporting the resident's report of missed care. The facility's own policy required that residents unable to perform ADLs receive necessary services to maintain hygiene and grooming, but this was not consistently documented or provided.

Penalty

Fine: $239,380

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

Summary

A deficiency occurred when a certified nursing assistant (CNA) provided care to a resident without ensuring privacy. During the morning care, the CNA changed the resident in a shared room without drawing the privacy curtain, leaving the resident exposed to both another resident who was ambulating in the room and a surveyor who was present. The resident's call light was also found on the floor after the CNA left the room, making it inaccessible to the resident. The nurse on duty acknowledged that the privacy curtain was not used and stated that it was not functioning properly, but could not specify how long it had been out of order. The resident involved was legally blind and later expressed dissatisfaction with being exposed during care. The facility's policy requires staff to maintain resident privacy and dignity during care, but this protocol was not followed in this instance. The administrator was unaware of the incident at the time it occurred. The failure to use the privacy curtain and ensure the call light was accessible directly led to the resident's lack of privacy and dignity during personal care.

Penalty

Fine: $239,380

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 reasonably accommodate the needs and preferences of each resident. This deficiency was identified during the survey process, indicating that the facility did not take adequate steps to ensure that residents' individual needs and preferences were met as required by regulations.

Penalty

Fine: $239,380

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 honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident complaints in a timely and non-retaliatory manner.

Penalty

Fine: $239,380

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 pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.

Penalty

Fine: $239,380

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 cognitive communication deficit, Alzheimer's disease, and dementia was observed lying in bed with a Foley catheter resting directly on the ground and without a privacy bag. The resident was nonverbal and unable to participate in an interview. Review of the medical record revealed that upon readmission, there were no physician orders for the Foley catheter and no care plan addressing catheter care. The Director of Nursing confirmed that protocol requires a diagnosis, orders, privacy bag, anchoring device, care plan, and continuous monitoring for residents with a Foley catheter, none of which were in place for this resident at the time of observation.

Penalty

Fine: $239,380

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 and implement physician orders for respiratory care for two residents requiring specialized respiratory support. One resident with a tracheostomy and a speaking valve was observed without any documented physician orders for monitoring, cleaning, or checking the speaking valve, despite having a medical history of tracheostomy status, muscle weakness, and cough. The resident was alert and oriented, and the necessary supplies were present at the bedside, but there was no evidence in the medical record of orders or protocols for the care and maintenance of the speaking valve. Another resident, admitted for skilled rehabilitation following hospitalization for acute respiratory failure with hypoxia, COPD, morbid obesity, diabetes, and pulmonary embolism, did not have physician orders for the use of a BiPAP machine as indicated in their hospital discharge summary. Instead, the resident was provided with a CPAP machine, which is a different type of respiratory support, and there were no physician orders for either device in the facility's records. The resident expressed concern about not having the correct equipment and not receiving an explanation from the nursing staff regarding the change. Interviews with nursing staff and facility leadership confirmed that the process for obtaining and verifying physician orders for respiratory equipment was not followed. Staff acknowledged the absence of orders and the use of incorrect equipment, and there was no documentation or care plan reflecting the resident's prescribed BiPAP therapy. The facility's own policy required physician orders specifying the mode, settings, and frequency of use for positive airway pressure therapies, but these were not present in the residents' records.

Penalty

Fine: $239,380

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

Summary

A resident with diagnoses including dysphagia and heart failure, and a moderately impaired cognitive status, was observed to be edentulous and reported not having seen a dentist at the facility for examination or to obtain dentures. The resident expressed a desire for dentures to improve their ability to eat harder foods and reported difficulty eating anything hard due to the lack of teeth. Medical record review showed significant weight loss over several months, with documentation from dietary and psychiatry staff noting the need for new dentures and the impact on the resident's ability to eat. The resident's diet was adjusted, and the need for dental evaluation was noted in clinical documentation. Despite these documented needs and requests, there was no evidence of a dental examination or consult for the resident since March 2022. The Social Work Director was unaware of the resident's need for a dental referral and indicated that dental service issues had occurred previously. The lack of routine dental services and failure to address the resident's request for dentures contributed to the deficiency identified during the survey.

Penalty

Fine: $239,380

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 infection control protocols and practices for the implementation of Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP) for two residents. For one resident with a history of sepsis, urinary tract infection (UTI) with ESBL resistance, and ongoing antibiotic treatment, the facility did not implement the correct level of precautions upon admission. Despite hospital discharge orders specifying contact isolation for ESBL-positive urine, the resident was placed on EBP instead of contact precautions. This error was not identified until after staff interviews and review of the resident's medical record, during which it was acknowledged by both the interim infection preventionist and the RN that the resident should have been on contact precautions. Additionally, after the signage was corrected, therapy staff were observed entering and exiting the resident's room without donning any PPE, contrary to the required protocols for contact precautions. For another resident with a wound, the facility failed to implement EBP as ordered. The resident had a current order for EBP due to a wound, and PPE was available outside the room, but there was no signage indicating the need for precautions. Staff were observed entering and providing care to the resident without donning or doffing PPE, and there was no evidence of used gowns in the trash, indicating non-compliance with EBP protocols. Interviews with staff revealed confusion regarding the reason for EBP and a lack of awareness of the resident's current wound status and the need for precautions. The infection preventionist reported relying on communication from the wound care nurse to discontinue EBP orders, but the resident continued to have active wound care orders and wound documentation. The facility's own infection prevention and control policies require staff to follow established protocols for standard and transmission-based precautions, including the use of PPE and appropriate signage. However, observations and interviews demonstrated that staff did not consistently follow these protocols, leading to lapses in infection control practices for residents requiring EBP or TBP. These deficiencies were identified through direct observation, record review, and staff interviews, highlighting failures in both the implementation and communication of infection control measures.

Penalty

Fine: $239,380

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 medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated the required social services were not delivered to residents as needed. The lack of these services directly impacted the residents' ability to attain or maintain their optimal well-being.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of misappropriation of a resident's property and the results of its investigation to the State Agency within the required timeframe. A resident with moderately impaired cognition, who was alert and able to make her needs known, reported missing two pink wallets from her purse, one of which contained her state ID and Social Security card. The incident was initially reported to the facility's administrator by a CNA, and a search was conducted by the Housekeeping Supervisor in the laundry for two days, but the missing wallet was not found. The facility did not document any follow-up with the resident after the initial report, and the plan/actions section of the investigation form was left blank. The facility's investigation was limited in scope. Only the Housekeeping Supervisor and the CNA who received the initial report were involved in the search and documentation. The administrator did not interview the resident to obtain further information about the missing wallet, nor were other staff or residents interviewed to determine if there were additional missing items or witnesses. The administrator assumed the missing wallet was not stolen because the resident did not explicitly state it was stolen, and no further investigative steps were taken until the resident's sister later reported the wallet as stolen to the police. The facility reported the incident to the State Agency six days after the initial allegation, only after the resident's family became involved and contacted authorities. The investigation summary and witness statements did not indicate that the resident was interviewed beyond the initial report, nor that other potential witnesses or staff were questioned. The facility's policy required immediate investigation and thorough documentation, including interviews with all involved persons, but these steps were not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to thoroughly investigate an allegation of misappropriation of property for one resident. The resident, who had moderately impaired cognition and was alert and able to make her needs known, reported missing two pink wallets from her purse, one of which contained her state ID and Social Security card. The incident was initially reported to the facility's administrator by a CNA, and a search was conducted by the Housekeeping Supervisor, focusing on the laundry for two days. However, the investigation documentation was incomplete, with the plan/actions section left blank and no evidence that the resident was followed up with after the search. The facility did not report the allegation of misappropriation to the State Agency within the required timeframe. The initial report to the State Agency was made six days after the resident reported the missing wallet, and the investigation summary was submitted ten working days after the allegation was reported, exceeding the five working day requirement. The administrator stated that she did not initially report the missing wallet as misappropriation because the resident had multiple wallets and did not explicitly state it was stolen, only missing. The administrator also acknowledged that the five-day investigation report was not submitted timely. Facility policy required reporting alleged violations to the administrator and state agency within specific timeframes and submitting the results of the investigation within five working days. The facility's failure to follow these procedures resulted in a lack of timely and thorough investigation and reporting of the alleged misappropriation of the resident's property.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a dependent resident with severe cognitive impairment and quadriplegia did not receive timely incontinence care. The resident, who was fully dependent on staff for all activities of daily living, was left soiled after a Certified Nursing Assistant (CNA) failed to provide care as directed by the assigned nurse. The resident's care plan specifically required staff assistance with toileting and incontinence care due to the resident's medical conditions, including brain damage and muscle weakness. On the day of the incident, the nurse assigned to the resident instructed the CNA to perform a brief change and clean the resident, with additional instructions to notify the nurse once the task was completed. The CNA did not follow these directives and left the unit without informing the nurse or providing the required care. The resident's legal guardian arrived later and found the resident heavily soiled, with stool present on the resident's body, clothing, and medical equipment. The nurse confirmed that the care had not been provided and reported the incident to facility management. Documentation and interviews confirmed that this was not the first occurrence of the resident being left soiled, as noted by the legal guardian. The failure to provide timely incontinence care was substantiated by multiple sources, including the nurse, the legal guardian, and facility records. The incident was documented in a grievance form and a performance improvement form, both indicating that the CNA did not render care as instructed and failed to follow supervisor directives.

Penalty

No penalty information released

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

Summary

The facility failed to report multiple allegations of sexual abuse by a staff member to the Abuse Coordinator and/or State Survey Agency in a timely manner. This involved a resident, identified as R801, who exhibited signs of fear and distress when a male CNA continued working after the allegations were made. The allegations included inappropriate touching of R801's breasts and genital area by a male staff member, which were not promptly reported to the appropriate authorities, resulting in a delay in investigation. The report details that the complainant initially did not report the first incident, thinking R801 was confused. However, after a second incident where R801 mentioned the inappropriate touching in front of the alleged perpetrator, the complainant reported it to the Administrator. Despite this, the Administrator did not take immediate action, leading the complainant to contact the State Agency. The facility's failure to act promptly allowed the alleged perpetrator to continue working, causing further distress to R801. Interviews with various staff members revealed a lack of communication and failure to follow protocol in reporting the allegations. Staff members were aware of the allegations but did not ensure they were reported to the Administrator or Abuse Coordinator. The Administrator only became aware of the situation when the police arrived to investigate, prompted by an anonymous report to Adult Protective Services. The facility's policy required immediate reporting of such allegations, which was not adhered to, resulting in a significant delay in addressing the serious allegations of abuse.

Plan Of Correction

Element 1 - R801 no longer resides in the facility. - Facility unable to identify an allegation of abuse for the "unidentified resident." Element 2 - On 3/12/2025, all residents who are able to report abuse were queried about feeling safe and free from abuse by staff. No additional concerns and/or allegations noted. - For residents who are unable to report abuse, skin assessments were completed by a licensed nurse for any signs or symptoms of abuse. - This was completed on 3/12/2025. Root Cause: Facility did not follow the Abuse, Neglect, and Exploitation Policy. Element 3 - The Abuse, Neglect, and Exploitation Policy was reviewed by QAPI Committee on 3/12/25 and deemed appropriate. - Staff were re-educated on the Abuse, Neglect and Exploitation policy by management staff with emphasis on types of abuse, reporting abuse, and also included staff testing after education, and an in-service card being handed out. - This was completed by 3/17/2025 or prior to their next scheduled shift. Element 4 - Random weekly audits of staff will be conducted for 4 weeks, then monthly thereafter to ensure there are not any allegations of abuse until substantial compliance is obtained. - Results of the audits will be brought to the QAPI committee for monthly review and will only be discontinued with substantial compliance and the approval of the facility's QAPI committee. - Administrator is responsible to maintain 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 notify both legal guardians of a resident, R706, following an accident that resulted in an injury. The resident, who had full guardianship appointed to two individuals, sustained a hematoma on the right forehead during a transfer with a Hoyer lift. The facility's medical record indicated that only one of the two legal guardians was notified of the incident. The Director of Nursing (DON), who was newly hired and not present at the time of the incident, stated that their understanding was to notify one guardian, who would then inform the other. However, the facility policy required notification of all legal representatives in such cases. In another incident, the facility failed to notify the family of a resident, R707, after a fall. The resident, who had diagnoses including sepsis and end-stage renal disease, rolled out of bed and was found on the floor. Although the physician was informed, there was no documentation of family notification, and an Incident and Accident report was not provided for the fall. The facility's Fall Prevention Program policy required notification of both the physician and family in the event of a fall. The DON, who was not employed at the time of the incident, confirmed that the expectation was for staff to notify the family in such cases.

Penalty

No penalty information released

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

Summary

The facility failed to coordinate effective discharge planning for a resident, identified as R707, who was discharged on December 14th. The resident had complex medical needs, including a PEG tube, dialysis, and open wounds, and was supposed to receive home health care upon discharge. However, the necessary paperwork for home health services was not completed by the doctor, resulting in the resident not receiving the required care. The facility's Social Service Director (SSD) was aware of the issue but did not follow up adequately to ensure the problem was resolved, assuming it was handled after a conversation with the doctor. The discharge documentation for R707 was incomplete, lacking details on dietary, cognitive, communication, and psychosocial needs. Despite the facility's policy to ensure discharge planning addresses each resident's goals and needs, including caregiver support, these were not met in R707's case. The Director of Nursing and the Administrator were not aware of the issues with R707's discharge, indicating a lack of communication and oversight in the discharge process. The facility's discharge planning process was not effectively implemented, leading to a deficiency in meeting the resident's post-discharge care needs.

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 provide assistance with brief changes and toileting needs for a resident, leading to a deficiency. The incident involved a resident who was found by their family member lying in urine and feces, which had dried and stained the resident's gown, indicating that the resident had not been changed for several hours. The resident had a medical history that included acute respiratory failure with hypoxia, tracheostomy status, dependence on supplemental oxygen, quadriplegia, and anoxic brain damage. The family member reported the incident to the State Agency, and the facility's Nurse Unit Manager was informed but initially could not recall the incident. The Certified Nursing Assistant (CNA) assigned to the resident on the day of the incident stated that the resident had been experiencing loose bowel movements and required changing every two hours. The CNA also mentioned that the family had requested the resident's briefs remain open, and they had informed the nurse about the resident's condition. The CNA claimed to have changed the resident before the end of their shift, and the family found the resident in an unclean state approximately an hour and a half later. The facility's documentation indicated that the CNA was to receive performance counseling, but it was not completed due to the absence of a union representative.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the appropriate placement of a resident, identified as R702, on a locked, secured unit, which led to feelings of frustration and dissatisfaction. R702, who had diagnoses including bipolar schizoaffective disorder, dementia, and major depressive disorder, was moved to a secured unit despite having a moderately impaired cognition score and no documented evidence of exit-seeking behaviors. The decision to move R702 was made without a measurable assessment of elopement risk, and the facility did not attempt other interventions such as the use of a wander guard before the transfer. The resident and their legal guardian expressed dissatisfaction with the move, and there was no follow-up assessment after the wander guard was placed. Additionally, the facility failed to treat another resident, identified as R711, in a dignified manner. During an interaction with a housekeeper, R711 experienced rude and dismissive behavior when inquiring about missing socks. The housekeeper's response was witnessed by R711, who later expressed dissatisfaction with the staff's attitude, describing them as rude and cold. The housekeeping supervisor acknowledged the expectation for staff to assist residents or seek help from a nurse or aide if necessary. The facility's policies on resident dignity and memory care unit criteria were reviewed, but they did not adequately address the assessment or placement criteria for the secured unit. The lack of documentation and appropriate assessment contributed to the inappropriate placement of R702, while the interaction with R711 highlighted a failure to maintain a respectful and dignified 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 ensure adequate staffing and proper bed mobility assistance, leading to a fall incident involving a resident with severe cognitive impairment and multiple health issues, including end-stage renal failure and a sacral pressure ulcer. The resident required a two-person assist for bed mobility and transfers, as documented in their care plan. However, a CNA attempted to change the resident alone, resulting in the resident sliding out of bed. The CNA did not check the Kardex for proper assistance procedures and was not yet licensed, which contributed to the incident. The Director of Nursing confirmed that the CNA should have worked with another CNA due to their unlicensed status. Additionally, the facility failed to maintain an environment free from hazards, as evidenced by the presence of a long extension cord in a resident's room. The extension cord was used temporarily during a power outage but was not removed afterward, contrary to the facility's policy on electrical safety. The Maintenance Director acknowledged that the extension cord should have been removed once the power outage was resolved. The resident in the room was alert and reported previous issues with the extension cord and a bathroom flood, indicating ongoing environmental concerns.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of neglect and multiple resident-to-resident abuse incidents to the Administrator and the State Agency. This deficiency involved two residents, R507 and R501, and three unknown residents. For R507, the facility did not address a change in condition in a timely manner, failed to provide adequate tracheostomy care, and did not report the neglect allegations to the appropriate authorities. An anonymous individual reported witnessing a nurse yelling at a CNA for sleeping during the midnight shift and another nurse for not properly caring for R507's trach and not sending them to the hospital sooner. R507 was found in a soiled condition with a dirty trach and was eventually sent to the hospital. Interviews with staff revealed that LPN 'F' was concerned about R507's condition upon arriving late for their shift. They found R507 unstable, with abnormal vital signs, and in need of immediate hospital transfer. LPN 'F' reported the situation to other nurses in the building but did not inform the Administrator or Director of Nursing (DON) about the neglect concerns. The DON and Administrator were unaware of the allegations of neglect toward R507, and the facility's protocol for reporting such concerns was not followed. For R501, the facility failed to report multiple incidents of resident-to-resident abuse. R501 had several documented incidents of aggressive and threatening behavior towards other residents, including verbal abuse and threats of physical harm. Despite these incidents, the facility did not report them to the State Agency, and the Administrator only had an incident report from one of the dates. The DON and Administrator were not aware of these incidents, and the facility's policy for reporting abuse was 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 interact with a resident in a dignified and respectful manner, as observed during a survey. A nurse aide, identified as NA 'I', entered a resident's room and asked if the call light was within reach, which the resident noted was unusual and only done when the State Agency was present. The resident expressed that NA 'I' frequently acted unprofessionally. During the interaction, NA 'I' appeared irritated, did not respond to the resident's comment, and left the room, closing the door loudly. The resident, identified as R505, had intact cognition and was admitted with diagnoses including hyperlipidemia, chest pain, and rheumatoid arthritis. The incident was reported to the Director of Nursing, who acknowledged the conduct as unacceptable.

Penalty

No penalty information released

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

Summary

The facility failed to protect residents from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and two residents. The incident began when a resident, R501, reported that CNA 'J' verbally and physically abused him during an altercation over the air conditioning in his room. R501 accused CNA 'J' of pushing him in his wheelchair and shoving him onto his bed while exchanging derogatory language. The facility's investigation confirmed the verbal abuse by CNA 'J', who was subsequently terminated. Additionally, the facility failed to address ongoing aggressive behavior by R501 towards other residents, including R502. R502 reported feeling threatened and unsafe due to R501's verbal aggression, which included yelling and swearing. R502's brother also reported the threatening behavior to the nursing staff. The facility's investigation substantiated the verbal abuse by R501 towards R502, highlighting a pattern of aggressive behavior by R501 that was not adequately managed. The facility's records revealed multiple prior incidents of R501's aggressive behavior towards other residents and staff, including threats and derogatory language. Despite these documented behaviors, the facility did not take sufficient action to prevent further incidents, resulting in a failure to protect residents from abuse. The facility's administrator acknowledged the incidents of verbal abuse but was unaware of the extent of R501's aggressive behavior towards other 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 investigate multiple incidents of resident-to-resident abuse involving a resident with a diagnosis of bipolar disorder. This resident, who had intact cognition and exhibited verbal and other behaviors, was involved in several documented incidents of abuse, including yelling, threatening harm, and using derogatory language towards other residents. Despite these documented incidents, the facility did not conduct investigations or report these incidents to the State Agency. The acting Administrator at the time of the incidents was no longer employed at the facility, and the current Administrator was unaware of these incidents due to being on leave. The Director of Nursing (DON) also denied knowledge of the incidents and was unable to identify the other residents involved or provide evidence of any investigations. The facility's policy on abuse, neglect, and exploitation requires immediate investigation when there is suspicion or reports of abuse, but this was not followed. The lack of investigation and reporting resulted in the potential for continued and unidentified abuse, as well as the failure to ensure the safety and well-being of the victims.

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, as observed during an inspection. The handwashing sink near the dish machine room was blocked by three carts, making it inaccessible, and the trash can nearby lacked a liner, resulting in numerous gnats flying out when the lid was opened. Gnats were also observed near the steam table and in high concentration near the three-compartment sink, where standing water was present. The District Manager confirmed the presence of gnats and mentioned that pest control had been contacted approximately three weeks prior. In the chemical/mop room, a mop bucket with sludge and standing water was noted, with numerous gnats flying around. Additionally, clean pans on the dishware rack near the three-compartment sink were stacked with visible moisture inside, which was confirmed by the District Manager as improper. A steady leak from the discharge pipe under the dish machine resulted in standing water on the floor, and the District Manager stated that maintenance would be informed. Furthermore, a stack of milk crates was found across from the ice machine, containing a container of cottage cheese and an unopened milk carton, which the District Manager acknowledged should have been discarded.

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 pest control program, resulting in the presence of gnats and flies throughout the facility, which led to resident complaints. During an initial observation of the kitchen, numerous gnats were found in various locations, including the trash can near the handwashing sink, the steam table, and the area near the 3 compartment sink where standing water was present. Additionally, the chemical/mop room contained a mop bucket with wet sludge and standing water, attracting gnats. The District Manager confirmed the ongoing gnat problem and noted that a pest control company had visited the kitchen approximately three weeks prior. Pest control service reports from May and July indicated heavy gnat activity due to poor sanitation, including stagnant water and food debris. Two residents, one of whom was dependent on staff for mobility and had impaired range of motion, were directly affected by the pest issue. The first resident, who was receiving nutrition through a PEG tube, was observed with house flies on their gown and bedside, and expressed frustration over their inability to swat the flies due to limited mobility. The second resident, who shared a room with the first and had intact cognition, also reported the flies as a persistent nuisance and confirmed that staff were aware of the situation. House flies were additionally observed in the hallway between rooms, indicating a widespread issue within the facility.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment, affecting multiple residents. Observations revealed that a room with three residents had a warm air temperature, and the residents expressed discomfort due to the heat. One resident mentioned that their fan was taken for cleaning weeks ago and not returned. Additionally, flying insects were observed in the room. Another room lacked a privacy curtain, which had been missing for some time, and the room temperature was recorded at 80.8 degrees Fahrenheit. The 2-north unit had a missing end cap on a hallway handrail, exposing sharp edges, and a strong urine odor was detected in the lounge area. Soiled privacy curtains with a dark substance were also noted in one room, and trash cans lacked liners. Interviews with staff revealed that the facility was without a permanent Maintenance Director, and the interim staff confirmed the environmental issues. The Housekeeping & Laundry District Manager, also interim, acknowledged that housekeeping should address privacy curtain issues and confirmed the missing curtain in one room. The facility's policies on maintaining a safe and homelike environment and handrail maintenance were not adhered to, as evidenced by the unresolved environmental concerns and lack of communication among staff regarding these 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 a resident transfer was completed per the plan of care for a resident with paraplegia and muscle weakness. A Certified Nursing Assistant (CNA) was observed conducting a mechanical lift transfer alone, despite the care plan requiring a two-person assist for safety. The CNA acknowledged the protocol but proceeded alone due to the unavailability of additional staff. The resident's care plan clearly indicated the need for a two-person assist with a mechanical lift, which was not adhered to during the transfer. The facility also failed to implement appropriate interventions to reduce injury from falls for two residents. One resident was observed without a floor mat next to their bed, despite having a history of falls and a care plan that included the use of a low bed and floor mat. The Nurse Manager admitted that the care plan was not updated to include the floor mat, and an incident report was not completed for a previous fall. Another resident was found with a call light and Reacher on the floor, despite having fallen previously while trying to reach for items. The care plan included interventions for using a Reacher and call light, but these were not effectively implemented. Additionally, the facility failed to provide adequate supervision for a resident with cognitive impairment and a history of wandering and elopement. The resident was allowed to sign themselves out to smoke without staff supervision, leading to an elopement incident. The resident was later found at a hospital, having left the facility without staff knowledge. Despite the resident's cognitive impairments and history of elopement, the facility did not initially provide the necessary supervision, which was only implemented after the incident occurred.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Emgality, a medication prescribed for migraines linked to the resident's Multiple Sclerosis diagnosis. The resident reported not receiving their monthly dose of Emgality for several months, which was confirmed by a review of their clinical records. The records showed an order for Emgality to be administered every 28 days, but the medication was not given in April, May, and June. Progress notes indicated that the pharmacy required approval from the Director of Nursing (DON) due to the medication's high cost, but this approval was not obtained, resulting in missed doses. The DON was aware of a change in the pharmacy supplying the medication but did not provide a clear explanation for the missed doses. The DON confirmed that each missed dose should have been reported to the physician, which did not occur. The facility's policy on medication errors states that medications should be administered according to physician's orders, highlighting a failure in adhering to this policy. The lack of action to secure the necessary approval and communicate with the physician contributed to the medication error.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from the misappropriation of their social security income (SSI) funds. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 15, reported that their SSI funds were rerouted to the facility without their consent. This change occurred after the resident's payor source changed, and the facility filed a direct payee request with the Social Security Office to have the funds sent directly to them. The resident expressed frustration as they were unable to pay personal bills due to this unauthorized rerouting of funds. Interviews with the Business Office Manager (BOM) and the Administrator revealed that the facility believed they did not need the resident's consent to change the payee information, as they were acting on the direction of their corporate office. The BOM and Administrator stated that the resident had refused to pay the facility, which prompted the request for direct payment. However, they admitted that the resident never explicitly stated they would not pay their bill and had mentioned using funds from another source. The facility's actions were based on the assumption that the resident was unwilling to pay, rather than any explicit refusal, leading to the misappropriation of the resident's funds.

Penalty

No penalty information released

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

Summary

The facility failed to develop comprehensive care plans for two residents, R137 and R246, which resulted in deficiencies in addressing their specific needs. For R137, the facility did not identify or document mood, behavior, targeted symptoms, and the use of psychotropic medication. R137 had been diagnosed with Alzheimer's and seizures and was receiving multiple psychotropic medications, including Risperdal, Trazodone, Lexapro, and Zyprexa. Despite these medications and a history of behavioral disturbances, the care plans lacked specific details about the targeted behaviors and interventions necessary for the resident's condition. The facility's documentation for R137 was insufficient, as it did not reflect the resident's recent mood and behaviors, nor did it provide a clinical rationale for the use of psychotropic medications. The care plans initiated were generic and did not address the resident's specific needs or behaviors. Interviews with the Director of Social Services and the Director of Nursing revealed a lack of awareness and follow-up on the resident-specific care plans and interventions required for R137's condition. For R246, the facility failed to initiate a care plan for hospice care after the resident signed onto hospice. R246 had diagnoses including malignant neoplasm, malnutrition, diabetes, dysphagia, and heart failure. Despite a significant change in status, the facility did not complete a significant change MDS or develop a hospice care plan. The MDS Coordinator and the DON acknowledged the oversight but could not provide an explanation for the lack of a care plan for R246's hospice needs.

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 care plan reviews were completed with the required interdisciplinary team for two residents, and did not revise the care plan to reflect the current status of a resident's post-fall interventions. This resulted in a lack of opportunity for residents, their legal representatives, and/or family members to participate in discussions of treatment options and decisions related to their care. Additionally, direct care staff were unaware of changes in the resident's care needs following a fall. For one resident, R246, who was admitted to the facility and signed onto hospice, there was no documentation of a care planning review conference conducted with the resident, family, or required interdisciplinary team members. The MDS Coordinator acknowledged that a significant change MDS was completed due to the resident's decline but not since signing onto hospice. The facility's process for care planning reviews was questioned, and it was confirmed that no care conference was scheduled or completed for this resident. Another resident, R137, had a care planning review documented with their guardian by phone, but there was no evidence that all required members participated in this review, including the physician, CNA, activities, or dietary staff. Additionally, for resident R46, who was observed in their room with a floor mat not documented in their care plan, it was revealed that the nurse failed to update the care plan to include the floor mat intervention after a fall incident. The Nurse Manager confirmed that the direct care staff rely on the care plan for interventions, which was not updated in this case.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who required help. On two separate occasions, the resident was observed sitting in a wheelchair with a strong urine odor present, indicating they were in a soiled brief. The resident reported needing assistance to change and that a staff member was aware of their condition but did not return to help. Additionally, the resident's bed was stripped of linens and left unmade, further indicating neglect in care. The resident, who had intact cognition, expressed that they had to attend lunch in a soiled brief. The Director of Nursing (DON) was informed of the situation but could not provide an explanation for the oversight. The facility's policy on ADLs, updated in December 2023, states that residents unable to perform ADLs should receive necessary services to maintain hygiene, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the timely disposal of narcotic medication for a discharged resident, identified as R445. During a review of the medication cart, it was discovered that 38 tablets of Hydrocodone-APAP 5-325mg remained in the narcotic drawer, despite the resident having been discharged several weeks prior. LPN X indicated that it was the responsibility of the Director of Nursing (DON) to dispose of medications for discharged residents. Both Unit Manager Y and LPN X confirmed that the DON was aware of the discharge and the need for medication disposal. However, the medications were not disposed of until the surveyor's presence prompted action. The DON was unable to provide a clear explanation for the delay in medication disposal and was uncertain about the communication breakdown that led to the oversight. The facility's policy, updated in January 2024, requires that Schedule II, III, and IV controlled drugs be destroyed by the DON and another licensed nurse. Despite this policy, the narcotic medications were left in the medication cart for two months after the resident's discharge, indicating a lapse in following the established procedures.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a physician-ordered diagnostic test, specifically a duplex scan, was obtained for a resident as per the physician's order. The resident, who was admitted with diagnoses including congestive heart failure and acute embolism and thrombosis, required assistance with activities of daily living and had intact cognition. A physician's progress note indicated the need for a repeat venous Doppler scan to assess the progression of thrombosis, which was ordered to be completed by a specific date. However, the medical record review revealed that the repeat diagnostic test was not performed as ordered. During an interview, the Nurse Manager confirmed that the venous duplex diagnostic test was not conducted and had to be reordered. The facility's Laboratory and Diagnostic Guidelines outline procedures for tracking and completing diagnostic tests, including the use of tracking logs, electronic portals, and calendars to ensure timely completion. Despite these guidelines, the facility did not adhere to the physician's order for the repeat diagnostic test, resulting in a deficiency in providing timely and approved x-ray services or having an agreement with an approved provider to obtain them.

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 core infection control procedures for enhanced barrier precautions (EBP) for two residents, R93 and R297, who were under transmission-based precautions. On July 30, 2024, Certified Nursing Assistant P (CNA P) was observed transferring Resident #93 using a mechanical lift without wearing gloves or a protective gown, despite signage on the resident's door indicating the requirement for such protective equipment. Resident #93 had a comprehensive care plan that required enhanced barrier precautions due to a diabetic foot ulcer, dialysis, and a history of multidrug-resistant organisms (MDRO). The plan specified the use of gowns and gloves during high-contact activities, including transfers. Similarly, on the same day, CNA S was observed providing dressing care to Resident #297 without wearing a gown, contrary to the signage on the resident's door that indicated the need for enhanced barrier precautions. Resident #297 had a physician's order for enhanced barrier precautions due to pressure ulcers and surgical wounds, which required the use of gowns during high-contact care activities. Nurse T confirmed the requirement for a gown and acknowledged the need to educate CNA S on the precautions. The facility's policy on enhanced barrier precautions was reviewed and outlined the necessity for staff to use gowns and gloves during high-contact resident care activities to prevent the transmission of MDROs. The policy also emphasized the importance of staff training on enhanced barrier precautions and the availability of personal protective equipment (PPE) near or outside the resident's room. Despite these guidelines, the facility failed to ensure compliance with the policy, resulting in the observed deficiencies.

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 immunization program for influenza and pneumonia for two residents, resulting in the potential for infections. Resident R77, a long-term resident with multiple diagnoses including respiratory failure and quadriplegia, did not receive the necessary education or offer for the influenza vaccine in 2023. Additionally, there was no record of R77 or their legal guardian being offered a dose of PCV15 or PCV20, as recommended by the CDC for adults with immunocompromising conditions. Similarly, Resident R82, also a long-term resident with conditions such as respiratory failure and quadriplegia, did not receive the recommended pneumococcal vaccine. The clinical records showed that R82's last pneumococcal vaccine was administered in 2022, and there was no evidence that the resident or their legal guardian was offered a dose of PCV15 or PCV20, as per CDC guidelines. During an interview, the Director of Nursing confirmed that both residents did not receive their vaccinations and acknowledged the oversight. The facility's policies on influenza and pneumococcal vaccinations were reviewed, indicating that the facility aims to offer these vaccines in accordance with CDC guidelines. However, the failure to adhere to these policies for R77 and R82 led to the identified deficiency.

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 functional furniture for a resident, specifically a bed with a working remote control, which resulted in the resident being unable to adjust the bed's position. This deficiency was observed during multiple instances where the resident was seen attempting to eat meals while lying flat in bed. The resident reported that the bed remote control was broken, and they had not been offered an alternative bed despite the availability of open rooms. The resident's clinical record indicated they had intact cognition and were admitted with diagnoses including pressure ulcer, adult failure to thrive, and major depressive disorder. The facility's Maintenance Director from a sister facility confirmed that a new remote was ordered but was unsure of its arrival date. Despite the availability of open rooms, there was no consideration to swap the bed for a functioning one. The Director of Nursing acknowledged the lack of a specific policy for positioning during meals but stated that residents should be positioned comfortably. The deficiency was communicated to the Director of Nursing, who was informed of the ongoing concerns regarding the resident's poor positioning due to the broken bed 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 protect two residents from the misappropriation of their money and property by a staff member. One resident, who had intact cognition and was diagnosed with lupus, reported that a Certified Nursing Assistant (CNA) manipulated her mobile payment service application to transfer $129 to an unknown individual. The resident had initially asked the CNA to help her order lunch, during which he took her phone under the pretense of having an easier way to complete the transaction. The resident noticed the unauthorized transaction the following day and reported it to a nurse. Another resident, also with intact cognition and diagnosed with multiple sclerosis, reported her phone missing after returning from physical therapy. Surveillance footage showed the same CNA entering and exiting the resident's room during her absence, and he was observed acting suspiciously. The CNA was not assigned to the resident's unit, and staff confirmed he had no reason to be in her room. The facility's investigation substantiated the misappropriation of the resident's phone. The facility's policy on abuse, neglect, and exploitation was reviewed, which prohibits the misappropriation of resident property. The policy defines misappropriation as the wrongful use of a resident's belongings or money without consent. The facility's investigation confirmed the CNA's involvement in both incidents, leading to the substantiation of the misappropriation allegations.

Penalty

Fine: $15,593

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

Summary

The facility failed to implement measures and restrictions as directed by the County's Health Department after a resident was diagnosed with presumptive healthcare-associated Legionella. The facility did not conduct timely and accurate surveillance of infections and failed to ensure water management meetings were conducted as per their policy. This failure affected three residents reviewed for infection control and had the potential to impact all 140 residents in the facility. The Immediate Jeopardy was identified due to the facility's non-compliance with the Health Department's restrictions, which increased the risk of Legionella growth and spread. Observations revealed that the facility did not install 0.2-micron filters on faucets as recommended, and there were no signs alerting residents and staff not to use the water. Staff interviews indicated a lack of awareness and proper procedures for hand hygiene, with reliance on hand sanitizers and wipes instead of proper handwashing facilities. The facility's Director of Maintenance confirmed that filters were not installed in all necessary locations, and the facility management was aware of the situation but had not taken adequate action. The facility's infection control surveillance was incomplete and not up-to-date, with missing documentation for May and June 2024. Residents with symptoms of pneumonia were not tested for Legionella as directed by the Health Department. The facility's policy on infection surveillance was not followed, leading to a failure in identifying and managing potential Legionella cases. This lack of adherence to infection control measures and surveillance contributed to the deficiency identified by the surveyors.

Penalty

Fine: $15,593

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 cleanliness and repair in resident rooms, bathrooms, and common areas, particularly on the 1st floor South unit and the 2nd floor North and South units. During an initial observation, surveyors noted a dripping faucet, food crumbs, and a strong offensive odor in the dining room area on the 2nd floor North unit. The hallway floors were sticky with dried fluid stains, and a puddle of water was found next to a cart with a 5-gallon water container. Similar issues were observed on the 2nd floor South hallway, where floors were sticky, and debris and stains were present along the hallways. A broken bedside table was also noted in the hallway. Further observations revealed ongoing issues with cleanliness and maintenance. On the 1st floor South hallway, a shared bathroom had a leaking filter under the sink, resulting in a puddle of water on the floor. Another shared bathroom had a large puddle of unknown white fluid under the sink. These conditions persisted during multiple observations. On the 2nd floor, dried liquid stains and debris remained in the hallways, and food and debris were observed on the living room floor. A water cup with a date and room number was found over a bathroom sink, despite the facility following local health department guidance due to a presumptive Legionella positive, indicating the water was not safe to use. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities. A housekeeper stated they did not clean the hallways, which was the responsibility of floor care staff. The Assistant Administrator confirmed that housekeepers were responsible for cleaning resident rooms and hallways, while floor technicians worked after 7:00 PM. Despite these roles, the facility's environment did not meet the standards outlined in their policy for a safe and homelike environment, as evidenced by the persistent cleanliness and maintenance issues observed during the survey.

Penalty

Fine: $15,593

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 physician notification and follow-up for a resident, identified as R701, who experienced a change in condition. R701 was admitted with multiple diagnoses, including multiple sclerosis, asthma, and chronic kidney disease with heart failure. On the day of the incident, R701 reported feeling as though they had food poisoning, and the nurse attempted to contact the physician but received no response. Despite the resident's worsening condition, including symptoms of diarrhea and vomiting, there was no further documented attempt to reach the physician until the resident became unresponsive. The nursing notes indicated that the resident's daughter was informed of the situation and was told that the physician had been notified, but no response had been received. The evening shift nurse, identified as LPN K, was also unable to reach the physician and was occupied with another resident who required immediate attention. The facility's protocol for physician notification on weekends was not adequately followed, as there were multiple contacts available, including nurse practitioners and the medical director, which were not utilized. The Director of Nursing confirmed that there was no additional documentation or evidence of physician notification or response to the resident's change of condition. The lack of timely medical intervention and follow-up resulted in the resident being transferred to the hospital, where they expired shortly after arrival. The facility's failure to adhere to its protocol for physician notification and follow-up contributed to the deficiency identified in 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

The facility failed to ensure treatment in a dignified manner for two residents during a scheduled event for Nursing Home Week. The event, a Wheelchair Race, involved staff pretending to have various disabilities and racing in wheelchairs. This activity was observed to be offensive and insensitive by two residents, who expressed feelings of anger, embarrassment, and disgust. One resident overheard staff making light of disabilities and felt the event was in poor taste, while another resident, who uses a wheelchair due to amputations, found the event particularly offensive and requested both a public and written apology. Despite these complaints, the Admissions Director and the Administrator defended the event as a sensitivity training exercise and did not acknowledge the potential for offense. The first resident, R506, reported the incident to multiple staff members, including a nurse, the Business Office Manager, and the Assistant Administrator. They described the event as rude and insensitive, feeling that staff were making fun of people with disabilities. The second resident, R510, who has a left below-the-knee amputation and a right above-the-knee amputation, also found the event offensive and voiced their concerns to the Admissions Director. Both residents felt that the event was demeaning to those who require wheelchairs for mobility. Interviews with staff members, including the nurse, Business Office Manager, Admissions Director, and the Administrator, revealed that the event was intended as a learning tool for staff to better understand disabilities. However, the staff did not consider the potential for the event to be viewed as offensive by residents. The facility's policy on dignity was requested but only a general Resident Rights policy was provided, which did not directly address the right to be treated in a dignified manner.

Penalty

No penalty information released

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

Summary

The facility failed to obtain authorization to manage personal funds, properly manage a trust account, and follow its own policy on personal funds and trust accounts for a resident. The incident began when the resident reported that $50 was stolen from their wallet during the nighttime hours. The facility conducted an investigation but found no evidence to substantiate the missing money. The resident's durable power of attorney (DPOA) was notified, and a police report was made. The facility's investigation concluded that the money was not substantiated as missing, suggesting that the resident might have spent it on food or vending machines. However, the resident insisted that they had placed the money in their wallet under their pillow, as they did every night, and found it missing the next morning. The facility's records showed that the resident received money from their DPOA, which was held and distributed by the facility, but there was no official trust account in place as the DPOA had allegedly refused it. However, the signed contract did not indicate a refusal of a trust account. Further interviews revealed inconsistencies in the facility's handling of the resident's funds. The DPOA stated that they regularly gave money to the facility to be deposited into the resident's account and received receipts for these deposits. However, the DPOA did not receive monthly or quarterly statements of the account balance. The Assistant Administrator (AA) confirmed that the resident received money from the DPOA but could not provide a clear explanation of how the funds were managed without an official trust account. The AA also could not substantiate the missing money, suggesting that the resident might have spent it. The facility's failure to properly manage the resident's funds and maintain accurate records led to the deficiency cited 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 properly care for a resident's percutaneous endoscopic gastrostomy (PEG) tube. During an observation, it was noted that the resident's PEG tube site had a dressing but lacked an abdominal binder, which was required to prevent dislodgement. A review of the resident's clinical record revealed multiple hospital admissions due to PEG tube complications, including dislodgement and sepsis. Despite these incidents, there were no current orders for PEG tube site monitoring and care, and the previous orders had been discontinued and not re-ordered. The resident's care plans indicated the need for an abdominal binder and site care, but these interventions were not being followed at the time of the observation. Interviews with the facility's Director of Nursing confirmed that there should have been orders for PEG tube site care and the use of an abdominal binder for the resident. The facility's policy on feeding tubes, revised in June 2022, stated that feeding tubes should be maintained according to current clinical standards of practice to prevent complications. However, the facility failed to adhere to these standards, resulting in inadequate care for the resident's PEG tube.