Regency At Jackson

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 prepare and serve food under sanitary conditions while major plumbing repairs and floor excavation were occurring in the kitchen. After an underground water line break affecting the kitchen and laundry, contractors began digging a large hole in the kitchen floor near the steamer and tray line. Temporary plastic barrier walls were placed, but they were unsecured and had open areas. Surveyors observed garden hoses running from the kitchen across the dining room floor and out an open window, with hoses duct-taped to the floor. The kitchen floors were heavily soiled with boot prints, and contractors walked through the food prep area, tracking dirt. Large piles of dirt, broken tile, concrete, rocks, and wastewater were present near the tray line, stovetop, and three-compartment sink. Despite these conditions, the facility continued to prep and serve meals from the kitchen. Dietary staff were observed serving food from a steam table located directly next to the unsecured plastic barrier and large open holes in the floor with exposed dirt and debris. Prepped and wrapped silverware was stored on the steam table within about two feet of the large hole and dirt piles. Cardboard boxes of disposable meal service items were placed directly on the kitchen floor near the tray line. A soiled blender was observed on a dining room table next to personal drinks and a soiled towel. The Certified Dietary Manager (CDM) stated that after the first hole was dug following breakfast, all subsequent meals continued to be prepped and served in the kitchen next to the excavation area, and that food had been taken back and forth from refrigerators located beyond the barrier and past the large hole. Multiple staff interviews confirmed that the barrier was not effectively monitored or verified as secure. The Maintenance Director acknowledged that he did not verify that the plastic barrier wall was secured or check it frequently, and that a wet saw was used to cut through floor tiles, which created dust. The DON stated that if the barrier was broken open there was a risk of pathogens contaminating the food and that, because the barrier was not sealed, food should not have been prepared in the kitchen. The previous DON reported she knew digging was occurring in the kitchen but did not enter the kitchen initially, assumed there was a barrier, and believed food preparation had been moved out of the kitchen without confirming this. The Administrator stated she saw the barrier closed but did not order food preparation to be removed from the kitchen and did not assign anyone to monitor the barrier. From the time the hole was dug until surveyor intervention, 10 meals were served out of the kitchen under these unsanitary conditions, affecting all residents who ate meals prepared there.

Removal Plan

• Facility plans to use prepared food from a US food vendor for upcoming meals as a back-up plan.
• Facility is using disposable paper products immediately as a back-up plan.
• Facility discarded all lunch that was ordered for residents and stopped lunch trays enroute to the units; lunch was catered in for the residents.
• Dietician and Medical Director were notified of the Immediate Jeopardy.
• The kitchen immediately closed for services.
• The dining room next to the kitchen is being set up as the temporary kitchen until pipe work and construction are completed.
• The juice machine, coffee maker, steamer, steam table, tray line, prep area, 3-compartment area, and handwashing station are being utilized in the temporary kitchen.
• All residents who eat meals were immediately assessed for food borne illness.
• All residents at risk for food borne illness.
• A temporary refrigeration truck is providing both freezer and refrigeration.
• An electrician inspected for the correct plug for the steamer, rewired to accommodate the steamer in the temporary kitchen, and cleared it for use.
• The steam table was disinfected after removal from the construction zone.
• A handwashing station was delivered and set up in the temporary 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 deficiency involves the facility’s failure to promptly document, investigate, track, and resolve resident grievances, including allegations of neglect, as required by its grievance policy. The Nursing Home Administrator (NHA) reported that a resident had recently alleged receiving no care for 14 hours, but this allegation was not reported because it was determined it did not occur within a two-hour window. A concern form dated 2/16/26 documented that this resident reported being left 14 hours without staff checking on her, not enough staff, and being told she had to go to bed. The form indicated that management spoke with staff who claimed they had gotten the resident up multiple times and changed her when needed, and it was marked as investigation complete with staff education, but there was no evidence that the allegation of neglect was reported to the State and no supporting documentation in the medical record to show the neglect did not occur. The report further describes multiple residents with care concerns that were not effectively captured or addressed through the grievance process. One resident with a history of stroke, moderate cognitive impairment, and dependence on staff for all ADLs had multiple undocumented care tasks, including hygiene, ADLs, toileting, and missed showers over nearly a month. This resident’s daughter reported that every time she visited, she found care problems such as soiled sheets and the resident leaning in bed almost falling out, and that she repeatedly voiced concerns to staff without any change and was not aware of a concern form process. Another resident, cognitively intact and requiring significant assistance for toileting and bathing, reported not receiving a shower for two weeks and only one shower in the past two months, despite having reported several complaints and having a concern form completed without follow-up or improvement. The NHA later verified there were no care concern forms for these residents in the past 30 days. Additional deficiencies in grievance handling are linked to staffing-related neglect concerns for several other residents. A CNA reported that on a specific weekend night there were no CNA staff on one floor, only two nurses, and that three residents were left up in chairs all night, with one resident heavily soiled with urine and stool and requiring a shower after being left in a chair for the entire 12-hour night shift. The CNA stated a grievance form was completed and given to the NHA, and that potential allegations of neglect were reported to nursing staff. An LPN confirmed that no CNA worked that night, that three residents were left in chairs and remained in the same clothing when day shift arrived, and that management was informed because resident care needs were not met. Despite this, the NHA reported having no knowledge of the three residents who remained up all shift and no concern forms for the involved residents in the past 30 days. A former scheduler reported being unable to fill CNA staffing on multiple occasions, being instructed to add non-CNA staff to the schedule, and stated that concern forms related to unmet care needs and staffing were completed at least twice weekly and provided to the NHA and DON, but these were not reflected in the grievance tracking or resolution process.

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 implement policies and procedures to ensure timely reporting of reasonable suspicions of a crime, including abuse and neglect, as required by section 1150B of the Act. The Nursing Home Administrator (NHA) reported that a cognitively intact resident with severe morbid obesity, cervical disc degeneration, muscle wasting, depression, and anxiety alleged she had received no care for 14 hours. The NHA stated this allegation was not reported because it was determined the event did not occur within the prior two hours. A concern form documented that the resident reported being left 14 hours without staff checking on her, not enough staff, and being told she had to go to bed, but there was no evidence that this allegation of neglect was reported to the State. The form was signed by the NHA, and staff witness statements lacked dates and times. Review of the resident’s electronic medical record for the date in question showed no evidence to support that the allegation of neglect did not occur. During an interview, the same resident, who was calm and able to answer questions, reported that staff often tried to put her to bed earlier than she wanted due to staffing issues and that one night she was transferred to bed late at night and not gotten up until after mid-afternoon the next day because two staff were needed for a mechanical lift. She reported being unhappy about the long period she remained soiled and mentioned recent skin breakdown with no follow-up. Additional residents with intact decision-making abilities and significant physical care needs, including multiple sclerosis with functional quadriplegia, dementia with repeat falls, and Alzheimer’s disease with dependence for transfers and toileting, were also involved in care concerns related to staffing and potential neglect. A CNA reported that on a weekend night there were no CNA staff on one floor for the entire night shift, and that two residents were left up in chairs all night, with one remaining in the chair into the following morning, and another resident found heavily soiled with urine and stool and requiring a shower after being left in a chair for the entire 12-hour shift. The CNA stated that potential allegations of abuse related to these care concerns were reported to nursing staff. An LPN confirmed that no CNA staff worked that night on the floor, that three residents were left up in chairs and remained in the same clothing when she returned for the day shift, and that management was informed because resident care needs were not met. The NHA reported having no knowledge of these three residents remaining up all night and stated there were no concern forms or additional allegations of abuse over that weekend, while the scheduler reported frequently being unable to fill CNA shifts, documenting care concerns and staffing issues on concern forms, and providing them to the NHA and DON. The report reflects that these multiple allegations and observations of potential neglect and unmet care needs were not consistently recognized, documented, or reported as required.

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 thoroughly investigate and report multiple allegations of neglect and abuse, as required by its abuse prohibition policy. One cognitively intact resident with severe morbid obesity, cervical disc degeneration, muscle wasting, depression, and anxiety alleged that she received no care for 14 hours, including being left in bed soiled and experiencing skin breakdown. This concern was documented on a care concern form indicating she was left 14 hours without staff checking on her, that there was not enough staff, and that she was told she had to go to bed. The Nursing Home Administrator acknowledged that this allegation was not reported externally because it was determined the event did not occur as alleged, and the concern form showed the facility marked the investigation as complete without evidence that the allegation of neglect was reported to the state or that a thorough investigation with supporting documentation was conducted. Additional allegations of neglect involved three other cognitively intact or partially impaired residents who required extensive assistance with transfers, toileting, and hygiene. A CNA reported that on a weekend night there were no CNA staff on the second floor for the entire 12‑hour night shift, and that two nurses were present, one of whom was called in as CNA coverage but continued to function as a nurse passing medications. According to this CNA, two residents were left up in chairs all night and remained in the chairs when day shift arrived, and another resident was found heavily soiled with urine and stool and required a shower after being left in a chair the entire shift. An LPN corroborated that no CNA staff worked that night on the second floor, that a CNA had stayed over late to get most residents to bed but left three residents up in chairs, and that these three residents were still in the same chairs and clothing at the start of the next day shift. Despite these reports, the NHA stated there were no concern forms for these residents in the past 30 days and denied knowledge of three residents remaining up all night on the referenced night shift. The scheduler reported chronic difficulty filling CNA positions, being instructed to add non‑CNA staff such as transportation and medical records staff to the schedule, and having repeatedly completed concern forms related to unmet care needs and staffing issues and provided them to the NHA and DON. The facility’s own abuse prohibition policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be immediately reported, thoroughly investigated, and documented by the Administrator, and reported to appropriate state agencies and others. The documented failure to initiate and complete thorough investigations, to document them adequately, and to report allegations as required constitutes the cited 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 deficiency involves the facility’s failure to provide activities of daily living (ADL) care, including toileting, hygiene, transfers, and showers, as outlined in residents’ care plans and reflected in their MDS assessments. Multiple residents who were dependent on staff for ADLs reported not receiving timely or adequate care, and task documentation showed numerous missing entries for required care. One cognitively intact resident with severe morbid obesity, muscle wasting, and depression reported being put to bed early due to staffing issues and described an incident where she was transferred to bed late at night and not gotten out of bed until after mid-afternoon the next day, remaining in a soiled brief and reporting skin breakdown with no follow-up. A concern form documented her allegation of being left 14 hours without staff checking on her and being told she had to go to bed, but the facility’s internal form only reflected staff statements that she had been gotten up and changed, with no supporting evidence in the medical record and no documentation that the allegation of neglect was reported to the state. Another resident with a history of stroke, right-sided weakness, and depression, who was dependent on staff for transfers, bed mobility, hygiene, dressing, showering, and toileting, had multiple undocumented ADL and hygiene tasks and missed showers on task reports over several weeks. During observation, this resident was found in bed with a family member expressing upset that the sheets were soiled and the resident was leaning in bed almost falling out. The family member stated that every visit resulted in complaints to staff about care concerns, including staffing, call light response times, and lack of dignity and respect, and that she was not aware of any formal concern form process. Another cognitively intact resident requiring moderate to maximum assistance for toileting and bathing reported not having received a shower for two weeks and only one shower in the prior two months, despite multiple complaints and completion of a concern form, with task reports showing multiple undocumented ADL and toileting tasks and several missed showers. Additional residents with significant physical impairments and dementia, who required two-person assistance for transfers and toileting and staff assistance for showering and personal hygiene, were not provided ADL care as planned during a night shift when no CNA staff were present on one floor. A CNA reported that on that night, one resident was not laid down the entire night, another remained in a chair all night and into the next morning, and a third was found heavily soiled with urine and stool and required a shower after being left in a chair for the entire 12-hour shift. An LPN confirmed that no CNAs worked that night on the affected floor, that a CNA had stayed over late to get most residents to bed but left three residents up in chairs who remained in the same clothing until morning, and that management was informed because resident care needs were not met and there was a potential allegation of neglect. The scheduler reported chronic inability to fill CNA positions on multiple shifts, being instructed to add non-CNA staff to the schedule, and submitting concern forms about unmet care needs and staffing at least twice weekly. Another resident with severe cognitive impairment, pneumonitis, severe protein-calorie malnutrition, non-pressure ulcers, dementia, and peripheral vascular disease required substantial assistance with showering and personal care and was dependent on staff for toileting and perineal hygiene. Family members reported that during a three-week stay, this resident received only one shower, wore a pull-up that he manipulated to urinate into a urinal, and was given a bedpan despite his inability to use it and his stated need for a commode. They described an incident where he was placed on a toilet with the call light behind him and out of reach, leaving him to yell repeatedly for help until someone responded. Task sheets showed that scheduled showers on multiple dates were not provided, with no reasons documented, one refusal documented without evidence of additional attempts, and no documentation that CNAs notified a nurse when showers were not completed. The DON stated that her expectation was that CNAs would re-approach residents and notify the nurse if showers could not be given, but the record contained no such documentation, further demonstrating the failure to provide and document ADL care as required. Across these residents, interviews with CNAs and nursing staff indicated that staffing shortages forced staff to choose between passing meal trays and providing hands-on care, and that routine two-hour checks and changes could not be completed for all residents. The NHA reported no knowledge of the three residents left up all night and stated there were no concern forms for several of the affected residents in the prior 30 days, despite staff and scheduler reports that concerns and potential neglect had been reported. These observations, interviews, and record reviews collectively show that seven residents did not receive ADL care per their care plans and MDS-identified needs, including missed showers, prolonged periods without toileting or repositioning, remaining in soiled conditions, and lack of timely assistance with transfers and toileting, in the context of documented and reported staffing shortages and incomplete documentation of 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 deficiency involves the facility’s failure to provide adequate nursing staff to meet residents’ needs and to ensure that resident care was consistently delivered as required. One cognitively intact resident with severe morbid obesity, cervical disc degeneration, muscle wasting, depression, and anxiety reported being left in bed from approximately 11:00–11:30 p.m. until after 3:00 p.m. the next day because two staff were needed for a mechanical lift transfer and staff were not available. This resident also reported being left soiled for a long period and having recent skin breakdown, and stated that staff tried to put residents to bed early due to staffing issues, particularly on night shift. A concern form documented allegations that the resident was left 14 hours without staff checking on her, that there was not enough staff, and that she was told she had to go to bed, with no supporting documentation in the medical record to refute the allegation. Another resident with a history of stroke affecting the right dominant side and depression, who was dependent on staff for transfers, bed mobility, hygiene, dressing, showering, and toileting, reported concerns about insufficient staffing, delayed call light response, and lack of dignity and respect. Review of this resident’s task reports over nearly a month showed multiple gaps in documentation of hygiene, ADLs, toileting, and several missed showers. During an observation, the resident’s family member found the resident’s sheets soiled and the resident leaning in bed almost falling out, and stated that every visit involved raising care concerns to staff without change, and that she was not aware of the concern form process. A third resident, cognitively intact and requiring moderate to maximum assistance for toileting and bathing, reported not having received a shower for two weeks and only one shower in the past two months, with multiple holes in task documentation for hygiene, ADLs, toileting, and showers, despite having previously reported complaints and concern forms without improvement. Additional residents with multiple sclerosis and functional quadriplegia, dementia with repeat falls, and Alzheimer’s disease with chronic spinal pain, anxiety, and depression, all requiring significant staff assistance for transfers, toileting, and showers, were affected by staffing shortages on a specific weekend night shift. A CNA reported that on one night there were no CNA staff on the second floor night shift, only two nurses, and that one nurse who was called in as CNA coverage instead passed medications as a nurse. According to this CNA, three residents were left up in chairs all night, with two of them remaining in the same chairs and clothing when day shift arrived, and one resident was heavily soiled with urine and stool and required a shower after being left in a chair for the entire 12‑hour shift. An LPN confirmed that no CNA staff worked that night on the second floor, that a CNA had stayed over late to get most residents to bed but left three residents up in chairs, and that those three residents were still up and in the same clothing at 7:00 a.m. the next morning. The scheduler reported being unable to consistently fill CNA and nurse positions on the schedule, being instructed to add non‑nursing staff to the schedule, and completing concern forms about unmet care needs and staffing at least twice weekly, while the NHA reported having no concern forms for several of the affected residents and no knowledge of the three residents who remained up all shift. The DON reported that 12 residents required assistance of two staff with care needs, underscoring the level of dependency among the resident population. Despite this, there were documented instances where no CNA coverage was present on a unit for an entire night shift, and where residents dependent on staff for basic ADLs, toileting, and transfers experienced prolonged periods without appropriate care, remained in chairs overnight, or were found soiled. Multiple staff interviews described chronic difficulty filling schedules, lack of support from management when staffing could not be secured, and repeated but unaddressed concern forms related to staffing and unmet resident care needs. These observations, interviews, and record reviews collectively demonstrate that the facility did not ensure sufficient nursing staff each day to meet the needs of residents and did not consistently provide the level of care required by residents’ conditions and care plans.

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 notify a resident’s family and the on-call provider of a significant change in condition that resulted in the resident being sent to the hospital. The resident had multiple serious diagnoses, including pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure ulcers of the lower extremities, dementia, and peripheral vascular disease. The most recent MDS showed severe cognitive impairment with a BIMS score of 3/15 and dependence on staff for toileting and perineal hygiene. The resident’s wife had previously expressed concerns about his safety and care, including that his call light did not work and that the bell provided as an alternative could not be heard because he was at the end of the hall. A nursing progress note documented the wife’s complaint that it was neglectful that no one could hear when he needed help and that she believed he had received the worst care there. On the day of the change in condition, the resident’s family member noticed he was responding differently and questioned a decline in his condition. She reported that the LPN caring for him told her he was not dying and, when asked if he should go to the hospital, stated that the hospital would not do anything but send him back. The family member requested that staff check his vital signs, and when the resident appeared to perk up somewhat, she left for the day. Later, the hospital contacted her to inform her that the resident had been there for several hours. The family member reported that the facility had not called her about this change in condition and that there were no missed calls or messages on her cell phone or home landline. She was very upset that she was not notified, particularly after having earlier asked the LPN whether he should be sent to the hospital.

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 cognitively impaired female resident from sexual abuse by another resident. The resident who was abused had a history of cerebral infarct, anxiety, depression, altered mental status, substance use disorder, and aphasia, and required assistance with personal care, including one-person assist for transfers, dressing, hygiene, and bathing, and two-person assist for toileting. Her MDS reflected moderately impaired decision-making, and the Nursing Home Administrator (NHA) confirmed she was not able to consent and that her responsible party did not want her to have contact with the male resident involved. Despite this, the male resident, who was cognitively intact and independent with care needs, was observed engaging in physical contact with her. Prior to the incident that led to the citation, the abused resident’s mother, who was her DPOA, had observed her daughter holding hands with the male resident in his room and reported feeling uncomfortable. She communicated to the NHA that she did not want the male resident touching her daughter for any reason. The facility’s own investigation documented that the male resident had been counseled that the female resident was unable to consent to physical touching and that her mother did not want physical contact between them. The male resident verbalized understanding. There were also prior documented behaviors by the male resident involving inappropriate touching of other residents, including touching another resident’s dorsal hand and arm, requiring redirection and behavioral monitoring. On the date of the incident, a CNA reported rounding on the unit and observing the cognitively impaired female resident in the male resident’s room. The CNA witnessed the male resident standing over her, kissing her neck, with his hand on her inner thigh by the vaginal area over her pants, groping her. The CNA immediately intervened, separated the residents, and removed the female resident from the room while telling the male resident he could not engage in that behavior. The male resident laughed, became angry, raised his voice, and began slamming items in the room. Nursing staff were notified, and documentation reflected that the contact left a red mark on the female resident’s neck. The facility’s investigation concluded that non-consensual physical contact occurred with a resident who lacked capacity to consent, and that the male resident had previously been educated not to touch her, yet still engaged in the behavior, resulting in substantiated sexual abuse. Additional documentation and interviews highlighted inconsistencies in staffing records related to who was present on the unit at the time of the incident. The CNA who reported witnessing and intervening in the abuse was not listed on the facility’s working schedule for that shift, even though both the CNA and an LPN described that CNA as being on the floor and directly involved in responding to the event. The facility schedule showed only two CNAs scheduled for the shift on the second floor, and the NHA initially stated the schedules provided were accurate. This discrepancy in staffing records was identified during the surveyor’s review of the incident and related interviews.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide required bed-hold policy and transfer/discharge documentation, and to document that these were given, when a resident was transferred to the hospital with a change in condition. The resident had been admitted with diagnoses including pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure ulcers of the lower extremities, dementia, and peripheral vascular disease. The most recent MDS showed a BIMS score of 3/15, indicating severe cognitive impairment, and the resident required substantial assistance with ADLs and was dependent for toileting and perineal hygiene. Despite these needs, the record did not contain evidence that the resident or representative received the bed-hold policy or transfer/discharge paperwork at the time of the emergency transfer. Interviews and record review showed multiple communication and documentation gaps surrounding the resident’s change in condition and transfer. The resident’s family member reported concerns about his care, including a non-functioning call light that led the facility to provide a bell that staff could not hear, and she stated she was unsure the resident knew how to use it. A nursing progress note documented the wife’s complaint that the call light did not work and that the bell was not loud enough, her statement that he had received the worst care and that it was neglectful that no one could hear when he needed help, and that the resident was moved to a different room with a working call light. The prior DON acknowledged being informed of concerns about the call light, including that it had been placed in a dresser drawer out of the resident’s reach at some point, and also acknowledged not completing a grievance or concern form. On the day of the hospital transfer, the family member noticed a change in the resident’s responsiveness and questioned whether he should go to the hospital; she reported that an LPN told her he was not dying and that the hospital would not do anything but send him back. Later, the hospital notified her that the resident had been there for several hours, and she stated the facility had not called her about this change in condition. The LPN reported that the resident was initially fine but became unstable around dinner, that she obtained vital signs, placed him on oxygen, and called 911, and that she believed she called the wife and sent transfer/discharge paperwork, but then stated she was unsure and that it had been “kind of crazy” at the end of her shift. Record review confirmed there was no documentation that the provider was notified of the change in condition before transfer, no documentation that the resident or representative received the bed-hold policy or transfer/discharge paperwork, and no documentation that the wife was notified of the transfer. The unit manager and social worker both indicated that such paperwork should be completed and documented, but acknowledged that it was not evident in the record for this 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 deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing leave of absence (LOA) and leaving against medical advice (AMA) for two residents. For one resident, the record included a signed "Determination to Leave the Facility Against Medical Advice" form, which stated the resident was not cleared by the physician to leave due to being at high risk for accidents, falls, or other acute illness/conditions when outside the facility unsupervised, potentially resulting in serious negative health outcomes. The form documented that the resident was their own responsible party, not deemed incompetent, and that they had participated in care planning related to the decision to leave unsupervised and agreed to abide by the plan of care, with plans to be reviewed and revised as needed. However, review of the resident’s care plans showed no care plan addressing the decision to leave AMA or go on LOA, and there was no documentation that the resident had actually participated in care planning related to this decision. For the second resident, the face sheet showed admission to the facility and an MDS with a BIMS score of 13/15, indicating intact cognition. LOA sign-out sheets showed this resident frequently left the facility on LOA. Despite this, review of IDT notes revealed no discussion regarding the resident’s LOA or evaluation of safety, and review of the resident’s care plans showed no care plan addressing LOA, safety interventions, or assessments. In an interview, the DON stated she did not find an evaluation of this resident’s ability to go on LOA or any IDT documentation regarding LOA ability, and she stated her expectation was that evaluation and care planning be completed for a resident who goes on LOA. The facility’s policy dated 11/16/2022 required that a corresponding care plan be developed and initiated for LOA, addressing clinical issues such as medication needs during leaves, education on medication administration, dietary issues, and any other potential concerns or problems, which was not done for these residents.

Penalty

No penalty information released

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

Summary

Failure to complete and document an evaluation of a resident’s ability to take a leave of absence (LOA) occurred when a cognitively intact resident with known visual impairment was allowed to sign out on LOA without an assessment of safety. The resident had a BIMS score of 13/15, indicating intact cognition, and a care plan identifying impaired visual function related to stroke, but the care plan did not include any interventions addressing LOA safety in light of the visual impairment. Progress notes documented that the resident signed out on LOA with another resident and, upon return, did not use the crosswalk to cross the street and was struck by a speeding vehicle, resulting in a fractured spleen, rib fracture, and scalp laceration. The facility’s LOA policy required that affected residents be evaluated regarding their abilities at admission, quarterly, upon significant change in condition, and after any new developments that might warrant a change in the evaluation. The social worker reported she had heard that staff needed to know if a resident was safe to go out on LOA as their own responsible person and assumed there was an assessment form, but she had never seen or completed such an assessment. Review of the electronic medical record showed only one IDT meeting, which did not address LOA or evaluate the resident’s LOA safety, and the DON confirmed she could not find any LOA ability evaluation for the resident. No IDT meeting or LOA ability evaluation was conducted or documented after the accident.

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 ordered immunizations were administered for a resident who had consented to receive them. The resident, identified as Resident #108, had an original admission date noted on the face sheet and a most recent admission date of 2/14/2026. Review of consent forms showed that the resident signed consents on 10/28/2025 and again on 10/28/2026 to receive the Pneumococcal (PCV20) and Respiratory Syncytial Virus (RSV) vaccinations. In the electronic medical record, both RSV and PCV20 immunizations were listed as pending with a confirmation date of 10/28/2025. However, review of the physician orders from October 2025 through 2/26/2026 revealed that no physician orders were ever written for either vaccination. Further review of the Medication Administration Records (MARs) for October, November, and December 2025, and January and February 2026 showed no documentation that the PCV20 or RSV vaccines were administered to the resident. The DON confirmed during interview that, despite the signed consents, the resident never received the vaccinations. The DON also reviewed the resident’s progress notes for October and November 2025 and found no documentation that the vaccinations were given or any notation explaining why they were not administered. The DON stated that the vaccinations should have been administered because the resident requested them and signed consent.

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 ensure that nurses and CNAs possessed and demonstrated required competencies and that hiring, background checks, and orientation processes were completed as required by state and federal regulations. Surveyors’ interviews and personnel file reviews showed that a CNA hired and later terminated within a two‑month period had no completed orientation plan or new hire paperwork in her file, including no background check, certification verification, I‑9, fingerprinting, drug screening, or pre‑hire physical. When asked, the DON initially produced only a freshly printed, blank general orientation form and could not provide completed orientation, competency check‑offs, or required CNA‑specific training documentation for this CNA. The Human Resource Coordinator (HRC) confirmed that this CNA’s new hire process and CNA‑specific trainings were not completed and that she had not been checked off on any required competencies such as abuse/neglect, transfers, ADLs, infection control, residents’ rights, dementia care, change in condition, skin assessments, behavior management, elopement risk, bowel and bladder, hospice, hemodialysis program, bed mobility, body mechanics, gait belts, CNA documentation, cleaning equipment, respiratory care, emergency care, abdominal thrusts, code status, and unit orientation. Further review of personnel files for a sample of 19 CNAs hired over a six‑month period revealed widespread omissions in required hiring and orientation documentation. Multiple CNAs had incomplete or unsigned new hire checklists, no reference checks, no I‑9 forms, no I‑CHAT background checks, no sex offender registry checks, no eligibility letters, no certification verifications, no TB tests, no documentation of active driver’s licenses, and no evidence of completed facility general orientation. CNA‑specific competency evaluations were consistently missing, and there was no verification that orientation was completed before CNAs were scheduled to work on the units. One rehired CNA had only an I‑CHAT background check completed at rehire, with no updated competencies, no certification verification, and no clinical oversight to determine training needs, yet was placed on the schedule. Another CNA completed her own competency skills check‑off and signed it as passed without any nurse or management validation or signature. Interviews with leadership and staff confirmed that unvalidated staff were working independently with residents. The HRC stated he was unaware of federal regulations in the State Operations Manual and was learning CNA education and training requirements during the survey. He described a process in which he conducted a one‑day general orientation and then sent new hires to the DON or ADON for job‑specific orientation and unit shadowing, but there was no documentation that competencies were actually completed before staff were released to work. The DON acknowledged that CNA competencies had not been done prior to her arrival, that she had no log or proof of completed competencies, and that she was aware CNAs were working with residents without required training and competencies but could not remove them from the floor due to staffing needs. A CNA reported she went from shadowing other CNAs directly to being scheduled on the floor without a nurse checking her use of equipment or transfers. The scheduler confirmed she had no checklist to verify completion of orientation or competencies and simply scheduled CNAs once they stated they were done orienting, and she reported receiving no training on competency requirements. Similar deficiencies were identified in the hiring and orientation of licensed nurses. Personnel files for several RNs and LPNs hired in the same six‑month period showed new hire checklists either blank or minimally completed, with missing I‑CHAT background checks, eligibility letters, sex offender registry checks, nursing license verifications, I‑9 forms, TB tests, physicals, and drug screenings. There was no evidence of completed facility general orientation or nursing‑specific competency evaluations, and no verification that orientation was completed before these nurses were scheduled to work on the units. In one case, only the nursing license verification, I‑CHAT background check, and sex offender list verification were present, with no orientation plan or health screening documentation. Overall, the survey findings document that both CNAs and nurses were hired and placed on the schedule without completed regulatory hiring elements, orientation, or validated competencies necessary to safely meet residents’ assessed needs and care plans.

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 provide required activities of daily living (ADL) care, including bed baths and personal care, to a dependent hospice resident. The resident was admitted with multiple serious diagnoses, including congestive heart failure, COPD, major depression, chronic pain syndrome, multiple vertebral fractures, and generalized weakness, and the most recent MDS documented that the resident was cognitively intact but dependent on staff for all personal care. During observation, the resident was found asleep in bed with oxygen at 2.5 L/min with no date on the tubing, wearing a white T‑shirt soiled with crumbs and spilled coffee from lunch, and positioned with bare feet pressed against the hard footboard without socks or a cushion. The resident’s water glass on the overbed table was empty and undated at that time. On a subsequent observation and interview, the resident was coughing while trying to eat breakfast, and the water glass was dated from the previous day, indicating it had not been refreshed. The resident reported that hospice aides provided baths when they came in and stated he could no longer perform personal care independently. The resident was still wearing the same soiled T‑shirt from the prior day. Review of the hospice binder showed hospice CNA bath/shower visits scheduled twice weekly, with the last shower/bed bath documented on 12/30/25, indicating no bath for approximately 30 days. CNAs interviewed stated they believed hospice was responsible for the resident’s showers and that the showers listed on their task sheets corresponded to hospice visit days; they also stated they were not told to provide the scheduled showers themselves. The NHA stated that floor CNAs were expected to provide baths or showers in addition to any provided by hospice, and record review showed no documented coordination of care between the facility and the hospice agency regarding who was responsible for personal 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 deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistance were provided during care, resulting in a fall from bed with injury. The resident, identified as R7, experienced an incident in which she fell or rolled out of bed while being assisted with a bedpan, landing on her face, splitting her lip, and breaking a tooth. The incident summary notes that the bed was in a low position and that the resident stated something slipped and she fell. Emergency room evaluation confirmed no fractures but documented the need for sutures to the upper lip and a broken front tooth. Prior to the incident, facility records contained inconsistent and incomplete assessments and directions regarding the resident’s functional status and required level of assistance. The care plan and Kardex documented that the resident required assistance from two staff for bed mobility (turning and repositioning in bed) and for transfers with a hoyer/mechanical lift, and that she required assistance from one staff to use the bedpan. However, the MDS functional status section showed multiple mobility and transfer items as “not assessed” as of the day before the incident, including chair/bed transfers, lying to sitting, sit to lying, toilet transfer, toileting, and transferring. A transfer report also documented that the resident only needed assistance with toileting and transfers and was not dependent on care, which conflicted with the care plan and Kardex indicating two-person assistance for certain tasks. On the night of the incident, the CNA assigned to the resident (CNA K) assisted her with the bedpan without a second staff member present. In an interview typed by the Nursing Home Administrator (NHA), the resident reported that she wanted to get up, that the CNA was helping her off the bedpan, and that she felt herself sliding before she rolled out of bed; she stated the CNA was not being mean and that she believed the CNA had not hooked her up correctly. In a separate typed interview, CNA K stated that the resident wanted to use the bedpan, that she placed the resident on it and checked on her multiple times, and that when she attempted to remove the bedpan, the resident began yelling and then threw herself on the floor. CNA K acknowledged she had not reviewed the Kardex that night and did not know the resident was a two-person assist, and she did not ask anyone for assistance. The facility’s own incident summary later stated that the allegations were substantiated due to the CNA not following the plan of care. Additional record review revealed broader deficiencies related to staff preparation and documentation that contributed to the unsafe situation. The personnel file for CNA K, who had been hired approximately two months before the incident, lacked a completed new hire checklist, reference checks, I-9, background checks, eligibility letter, sex offender registry check, certification verification, pre-hire drug screen and physical, TB test, driver’s license verification, general orientation checklist, CNA-specific competency evaluations, and verification of orientation completion before working on the units. There was also no evidence that CNA K’s competency in performing two-person transfers or other required CNA skills had been assessed. Interviews with staff on first and third shifts indicated they were aware the resident was a two-person assist for care, and nursing staff reported that the resident had been exhibiting behaviors and yelling at staff during care in the evenings. Despite this, there was no documented investigation into the competencies of CNAs providing two-person transfers on the day or unit of the incident, and no hands-on demonstrations or return demonstrations were recorded for staff performing two-person transfers.

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 enforce its infection prevention and control program related to COVID-19 by not ensuring mandated mask use for staff. During an observation in the kitchen while breakfast was being served, the surveyor observed the Dietary Manager not wearing a mask, despite a mandate from the Infection Preventionist that all staff wear masks following two other staff members testing positive for COVID-19. When the Dietary Manager noticed the surveyor, the manager smiled, giggled, and stated they were just going to put a mask on. In a subsequent interview, the DON reported that when staff reported they had COVID, the management team requested a second COVID test and, if positive, tested all staff and residents according to CDC guidelines on the first, third, and fifth days. The DON also stated that, in this context, mask-wearing was mandated for all staff working, confirming that the Dietary Manager’s failure to wear a mask occurred while a universal staff masking requirement was in effect.

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 nursing staff to meet the needs of residents for 14 out of 30 days reviewed. Staffing records and interviews revealed that on multiple days, the number of aides and nurses scheduled was below the required levels based on the facility's census and acuity assessments. The Nursing Scheduler explained that staffing is determined by average daily census and adjusted for resident acuity, but when vacancies occurred, efforts to fill shifts with other staff or managers were not always successful. Specific dates were identified where the facility was short by one or more aides or nurses on both day and afternoon shifts. The Nursing Home Administrator confirmed during the review that there were 14 days within the review period where the necessary nursing staff was not present to provide care to residents as required. No information was provided regarding the specific impact on individual residents or their medical conditions at the time of the 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 thoroughly and accurately investigate two falls experienced by a resident with moderate cognitive impairment, resulting in a left hip fracture that required hospitalization and surgery. The resident, who had diagnoses including dementia, schizophrenia, and difficulty walking, experienced two falls on the same day. Documentation of both incidents was incomplete, with missing entries for pain assessment, level of consciousness, mental status, and mobility. The incident reports lacked essential details, such as staff involved, witness statements, and accurate timing, and there was no comprehensive summary or root-cause analysis to determine how the falls led to the fracture. Direct care staff, including CNAs assigned to the resident, were not interviewed or asked to provide statements at the time of the incidents. The DON considered the nurse's incident report as the only required statement and did not obtain additional narratives from other staff. The investigation process was inconsistent, with the DON unable to identify which CNAs were assigned to the resident and no summary of the investigation available. The facility's fall program and incident reporting policies were not followed, as evidenced by the lack of risk analysis, monitoring for pain or neurological changes, and implementation of interventions to prevent further injury. Additionally, the facility did not report the incident as required by its abuse and neglect policy, despite the resident sustaining a serious injury of unknown origin. The documentation was further compromised by altered dates and times on post-fall forms, and the DON admitted that certain documentation was omitted if no abnormal findings were observed. The lack of a thorough investigation and failure to follow established protocols resulted in an incomplete response to a significant injury event.

Penalty

No penalty information released

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

Summary

A resident with a history of dementia, difficulty walking, schizophrenia, and diabetes experienced two falls within a short period, one of which was unwitnessed. Following the unwitnessed fall, required neurological assessments and pain evaluations were not performed as per facility protocol. The incident report for the first fall was incomplete, with critical assessment fields left blank, and neurovital sign monitoring was not initiated immediately. The nurse responsible did not communicate the details of the falls, including the unwitnessed nature of one, to the oncoming nurse, resulting in a lack of timely monitoring and assessment. Throughout the night and into the following day, there were no documented neurological or pain assessments for the resident, despite observable signs of distress and confusion. The resident was later found to have a swollen, painful, and displaced left leg, with a pain level of 8/10, only after a nurse aide alerted the day shift nurse. The resident's pain was not addressed with medication until the following day, and the neurological assessment was only started at that time. The nurse practitioner, upon assessment, observed significant changes in the resident's condition and arranged for immediate transfer to the hospital, where a left hip fracture was diagnosed. Documentation in the medical record and medication administration record was inconsistent and incomplete, with unclear codes and missing entries regarding pain management. The facility failed to provide its neurological assessment and pain management policies when requested. The lack of thorough assessment, monitoring, and documentation after the falls led to a delay in treatment, increased physical distress, and worsening pain 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 timely revise and update care plans for a resident following significant changes in condition, specifically after a fall resulting in a left femur fracture and subsequent surgery. The resident, who had diagnoses including dementia, schizophrenia, and diabetes, experienced two falls and was hospitalized for surgical repair of a displaced intertrochanteric fracture. Upon readmission, new pain management orders were implemented, but the pain care plan was not revised to reflect the increased pain level or the new medication regimen. The last update to the pain care plan occurred prior to the falls and surgery. Additionally, the resident's skin care plan was not updated to address post-surgical site care or infection prevention measures following the hospital readmission. The last revision to the skin care plan predated the surgical event, and no new interventions were documented for the surgical site. During an interview, the DON acknowledged that the care plans had not been revised to address the resident's current needs. The facility was unable to provide a policy for care plan updates and revisions when requested.

Penalty

No penalty information released

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

Summary

Surveyors observed multiple failures to maintain food safety and sanitation standards in the facility's kitchen and food service areas. During a kitchen tour, it was found that potentially hazardous foods, such as hot dogs and ham, were not consistently date-marked according to FDA Food Code requirements, and staff were still being trained on proper procedures. Additionally, leftover breakfast items, including ham chunks, scrambled eggs, and sausage links, were stored in the walk-in cooler at unsafe temperatures (ham measured at 88°F) without proper cooling logs, indicating a lack of adherence to required cooling methods and documentation. Further inspection revealed unsanitary conditions and improper maintenance of food contact surfaces and equipment. Accumulations of food debris were found in the two-door arctic air unit, utensil drawers, on the underside of coffee spouts, around the can opener blade, and on a plate drying on the clean side of the dish machine. The dish machine itself failed to produce the required chlorine sanitizer residual, as confirmed by repeated testing with facility-provided test strips. Additionally, a spray bottle containing a yellow solution was not labeled with its common name, and the Certified Dietary Manager was unsure of its contents. Plumbing and facility maintenance issues were also identified. The air gap on the ice machine was found to be sunken into the drain, and the sanitizer compartment of the three-compartment sink was directly connected to the wastewater drain without an air gap, both of which violate backflow prevention standards. Large openings were present in the walls under sinks in the second and third-floor pantries, increasing the risk of pest entry. These findings collectively demonstrate a failure to procure, store, prepare, and serve food in accordance with professional standards and regulatory requirements.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in its plumbing system. During a tour, surveyors observed that on the third floor, the soiled utility room had active water lines remaining after the removal of a hopper basin, and the Maintenance Director (MD) was unsure if these lines were being flushed. On the second floor, a tub room was found full of equipment with the tub removed, but water lines previously connected to the tub were still active and connected to the domestic water supply, despite being believed inactive by the MD. The surveyor confirmed the lines were still active after moving equipment to access the shut-off valves. Further interviews with the MD revealed that while vacant rooms are flushed weekly, only a couple of free chlorine samples are taken each year, and there was uncertainty regarding the facility's control limits for free chlorine. A review of the facility's Water Management Program policy indicated requirements for preventing water stagnation, ensuring adequate disinfection, and monitoring controls, but the observed practices did not align with these policy requirements.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary care and services to ensure that two residents did not experience a decline in their ability to perform activities of daily living (ADLs) without a medical reason. For one resident with diagnoses including spinal stenosis, muscle weakness, and chronic pain, documentation showed that scheduled showers or baths were not consistently provided as planned. The resident reported receiving fewer showers than scheduled, and there was no documentation to support that showers or baths were offered, refused, or that refusals were reported to nursing staff. The Director of Nursing confirmed that CNAs were not documenting the completion of showers or baths, and there was no supporting evidence in the electronic medical record for care provided. Another resident with a history of stroke, mild cognitive impairment, and mobility issues also did not receive scheduled showers or baths as planned. The resident expressed a preference for daily showers and reported not receiving even the scheduled twice-weekly showers, with no refusals documented. Record review confirmed only three showers or bed baths were provided in the last month, with no documentation explaining missed care or refusals. Staff interviews indicated a lack of knowledge about the resident's care schedule, and the Director of Nursing acknowledged that required documentation was missing.

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 care and services to prevent the development and worsening of pressure ulcers for a resident with significant medical complexities, including cerebral atherosclerosis, diabetes with neuropathy, a history of stroke, and existing pressure ulcers. The resident was dependent on staff for all activities of daily living, including repositioning, and required specialized equipment such as a low air loss mattress and heel protectors. Despite care plans and policies indicating the need for frequent repositioning and use of pressure-relieving devices, the resident was observed multiple times without heel protectors and was not consistently repositioned as required. Documentation and interviews confirmed that repositioning occurred only 1-2 times per shift, rather than every two hours as specified in the care plan. Wound care documentation revealed inconsistent and incomplete assessment and measurement of the resident's pressure ulcers, with several instances where wounds were not measured or assessed weekly as required by facility policy. The resident developed new pressure ulcers, including a deep tissue injury to the right heel and a new open area near the left hip, which were not promptly identified or reported to nursing leadership. Observations showed that the resident was left in the same position for extended periods, and staff failed to implement or document non-pharmacological interventions for pressure ulcer prevention. Additionally, the resident was found sitting in a geri chair without a specialty cushion, only a pillow, further increasing the risk for pressure injury. Interviews with staff indicated a lack of communication and follow-through regarding new wounds, with one CNA stating she did not report a new pressure ulcer because a nurse was present. The hospice nurse was also unaware of the new wound, and wound assessments from hospice were not available in the facility's records. The facility's own skin management policy required weekly evaluation, measurement, and staging of pressure ulcers, but this was not consistently done. The cumulative effect of these failures resulted in the worsening of existing wounds and the development of new pressure ulcers for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the attending physician documented the rationale for not implementing a pharmacy recommendation regarding medication monitoring for a resident. The resident, who had vascular dementia and catatonic schizophrenia, was prescribed carbamazepine as a mood stabilizer. The consultant pharmacist recommended obtaining a baseline carbamazepine level and periodic monitoring to optimize efficacy and reduce toxicity, as well as other laboratory tests. While the physician responded to the pharmacist's recommendation by ordering CBC, CMP, and ophthalmology follow-up, there was no documentation or explanation in the medical record as to why the carbamazepine level was not obtained as recommended. Record review and interviews confirmed that the rationale for not following the pharmacy's recommendation was not documented by the attending physician at the time. The DON reported that the nurse practitioner stated carbamazepine levels were not necessary since the medication was being used for catatonic schizophrenia rather than seizures, but this explanation was not entered into the medical record until an addendum was made after the issue was identified. The lack of timely documentation of the physician's rationale constituted the 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

A deficiency was identified when a resident admitted with diagnoses including borderline personality disorder, post-traumatic stress disorder, anxiety, and depression was prescribed Depakote 125 mg twice daily for mood stabilization. The consultant pharmacist recommended routine laboratory monitoring, specifically valproic acid (VPA) and ammonia levels every six months, which was acknowledged and signed by the physician. However, a review of the resident's medical record and laboratory results for the past 12 months revealed that no VPA or ammonia levels had been obtained. During an interview, the Director of Nursing confirmed that there were no records of these laboratory tests being completed 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 serve food at the appropriate and preferred temperatures for a resident who was reviewed for food palatability. The resident, who had multiple medical diagnoses including dysphagia, COPD, and mood disorders, reported that meals were frequently cold. During observation, the resident received a lunch tray with ground turkey and gravy, stuffing, and carrots, all of which were measured below the expected serving temperatures (131°F for turkey and gravy, 123°F for stuffing, and 115°F for carrots). The resident sampled the food and expressed dissatisfaction, stating that the food was not hot enough and that the carrots were cold. The Certified Dietary Manager confirmed that the food should have been served at 140°F or above for the main items and 135°F for the vegetables, but could not explain the temperature discrepancy. Further observations during meal service revealed that the plates in the plate warmer were only at 90°F, and a test tray delivered to the second floor also had food items below the required temperatures (116°F for carrots and peas, 108°F for ham and potato casserole). The process involved food being delivered to the units via a food cart, with nursing staff distributing trays to residents. These findings indicate that the facility did not ensure that food was served at safe and appetizing temperatures, resulting in resident dissatisfaction during meals.

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 medication cart was locked while unattended, as observed on the second floor next to a specific room. The cart was left unlocked and unattended from 12:17 PM to 12:35 PM, during which time no staff were present in the vicinity. The Assistant Director of Nursing (ADON) eventually locked the cart at 12:35 PM. Interviews with the ADON and the Registered Nurse (RN) responsible for the cart confirmed that the facility's policy required the cart to be locked when not in use or when the nurse was not in attendance. The RN admitted to being distracted, which led to the oversight. The Director of Nursing (DON) reiterated the facility's policy that medication carts must be locked when unattended or kept in view of the nurse at all times. A review of the facility's policy on medication storage, dated October 2024, confirmed that unlocked medication carts should not be left unattended.

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 timely identify the formation of pressure ulcers and consistently implement ordered wound care treatments for two residents, resulting in the development of a facility-acquired unstageable pressure ulcer for one resident and a deep tissue injury for another. Resident #3, who had severe cognitive impairment and was at high risk for pressure ulcers, developed an unstageable pressure ulcer on the right iliac crest and a deep tissue injury on the left gluteus. Despite having a low-air loss mattress and other pressure reduction measures in place, the facility did not consistently complete the ordered treatments, and there was no documentation of new pressure reduction measures being implemented after the ulcers were identified. Resident #5, who had severe cognitive impairment and was dependent on staff for all care, developed a deep tissue injury on the right heel. The facility had previously implemented pressure reduction measures, including a low-air loss mattress and offloading boots, but did not consistently document the application of these measures. The deep tissue injury was identified by the assigned nurse, and although a treatment was initiated, no new pressure reduction measures were implemented post-ulcer identification. The Director of Nursing (DON) confirmed that the facility's skin management program included weekly skin assessments and that any newly identified breakdown should prompt a progress note and treatment order. However, the facility's documentation and implementation of these measures were inconsistent, leading to the development and worsening of pressure ulcers in both residents. The facility's failure to consistently implement and document ordered treatments and pressure reduction measures contributed to the residents' deteriorating skin 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 prevent a fall with major injury for a resident, resulting in the resident falling out of bed during care and sustaining a femur fracture. The resident, who had a history of hemiplegia and hemiparesis following a stroke, required extensive assistance by two staff members to turn and reposition in bed. However, on the day of the incident, a CNA provided care alone, contrary to the care plan, leading to the resident sliding out of bed and being lowered to the floor mat by the CNA. The resident later reported pain, and an X-ray confirmed a right distal femur fracture, necessitating hospital transfer for further evaluation and treatment. Interviews with staff confirmed that the CNA did not use the appropriate number of staff required for bed mobility, as per the resident's care plan. The incident resulted in increased pain, anxiety, and depression for the resident, who also required changes in pain and anxiety medication regimens. The resident's mobility was further impacted, necessitating the use of a Hoyer lift for transfers instead of a sit-to-stand mechanical lift previously used. The facility's past non-compliance worksheet identified the root cause as the CNA's failure to follow the care plan's staffing requirements for bed mobility.

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 effectively clean and maintain the physical plant, impacting 53 residents. Observations included extremely tacky and sticky flooring in a resident room, numerous dead insect carcasses in a restroom bathtub, and human feces in a shower stall. Additionally, loose window screens, stained ceiling tiles, and damaged window screens were noted. Several resident rooms had issues such as slow-draining sinks, malodorous conditions, and corroded faucets. The Director of Environmental Services acknowledged these issues and indicated that maintenance would be contacted, but no specific work orders were found addressing these concerns in the last 60 days. The facility's policies on cleaning and disinfection, as well as maintenance services, were reviewed and found to be in place. However, the implementation of these policies was lacking, as evidenced by the numerous maintenance and cleanliness issues observed. The Director of Environmental Services confirmed the use of the TELS system for work orders, but the system did not reflect any entries related to the identified maintenance concerns. This failure to maintain a clean and safe environment increased the likelihood of cross-contamination, bacterial harborage, and decreased air quality for 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 ensure that call lights in resident rooms were answered in a timely manner, as observed in multiple instances. On 5/14/2024, the call light for a specific room was observed to be on for an extended period, with several staff members, including nurses, walking past without responding. This pattern continued with the call light remaining on for over 20 minutes while staff members were present in the hallway but did not respond. The nurses' station had a board that lit up and made an audible sound when a call light was turned on, indicating the room number. On 5/15/2024, the same issue was observed with staff members walking past the call light without responding. The administrator confirmed that it was the expectation for all staff to answer call lights and get the appropriate staff member if they could not fulfill the resident's need.

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's right to be free from verbal abuse by staff. Resident #359, who is cognitively intact and has a history of chronic respiratory failure, depression, anxiety, and cerebral palsy, reported an incident where a Certified Nursing Assistant (CNA) used inappropriate language towards her. The resident stated that the CNA used the f-word and was verbally abusive when the resident did not get out of bed to go to the bathroom. The resident's roommate, who has moderate cognitive impairment, confirmed overhearing the CNA using inappropriate language during the incident. The incident was reported to the Director of Nursing (DON) and a grievance form was filled out. The DON and Nursing Home Administrator (NHA) interviewed the CNA involved, who denied swearing but acknowledged a loud argument with the resident. The facility did not report the incident to the State Agency, considering it a customer service issue rather than abuse. The resident expressed feeling downgraded and tearful when recalling the incident, indicating emotional distress caused by the CNA's behavior. The facility's investigation included interviews with the resident, the CNA, and the resident's roommate. The DON and NHA concluded that the incident did not constitute abuse, as the resident did not explicitly state she felt abused. However, the resident's grievance and the roommate's confirmation of the inappropriate language used by the CNA highlight a failure to protect the resident from verbal abuse, as required by regulations.

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 abuse to the State Agency involving a resident who reported verbal abuse by a Certified Nursing Assistant (CNA). The resident, who was cognitively intact, reported that the CNA used inappropriate language and swore at her when she was unable to get out of bed. The incident was reported to the Director of Nursing (DON) and a grievance form was filled out, but the facility did not consider the incident reportable to the State Agency, treating it instead as a customer service issue. The resident's medical record revealed she had chronic respiratory failure, depression, a history of wedge compression fracture of the thoracic vertebra, anxiety, and cerebral palsy. The resident reported the incident to the DON, who discussed it with the Nursing Home Administrator (NHA). The resident's roommate, who had moderate cognitive impairment, confirmed the CNA's inappropriate language. Despite this, the facility did not report the incident to the State Agency, as they did not perceive it as abuse. Interviews with the NHA, DON, and the CNA involved revealed that the facility considered the incident a matter of poor etiquette rather than abuse. The CNA denied swearing at the resident but acknowledged a loud argument. The facility's grievance summary indicated that the resident felt safe and did not allege abuse, leading the facility to provide customer service training to the CNA rather than reporting the incident as abuse.

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 further potential abuse for a resident who reported inappropriate behavior by a Certified Nursing Assistant (CNA). The resident, who has chronic respiratory failure, depression, a history of wedge compression fracture of the thoracic vertebra, anxiety, and cerebral palsy, reported that the CNA used inappropriate language and was rude when the resident needed assistance. The resident's call light was not within reach, leading her to transfer herself to the bathroom and back to bed, which was unmade. The CNA then demanded the resident get out of bed to make it, using offensive language in the process. The resident reported the incident to the Director of Nursing (DON), who filled out a grievance form and discussed the matter with the Nursing Home Administrator (NHA). The CNA was subsequently educated on proper approach and etiquette but was not immediately removed from resident care duties. The resident's roommate, who has moderate cognitive impairment and a history of stroke, confirmed overhearing the argument and the use of inappropriate language by the CNA. Despite the resident's emotional distress and the roommate's confirmation, the facility did not report the incident to the State Agency, considering it a customer service issue rather than abuse. The NHA and DON did not provide a clear answer when asked if the CNA's behavior constituted abuse. The facility's grievance report indicated that the resident felt safe and did not perceive the incident as intentional abuse, but the CNA was still educated on proper etiquette. The facility's procedural guidelines state that any employee alleged to have committed abuse should be immediately suspended pending investigation. However, the CNA continued to work her shift and was only reassigned from caring for the resident involved. The facility's response did not align with its own guidelines, as the CNA was not immediately removed from contact with residents, and the incident was not reported to the State Agency as required for potential abuse 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 develop and implement comprehensive care plans for Resident #14, resulting in potential safety risks and unmet care needs. Resident #14 was readmitted to the facility with multiple diagnoses, including vascular dementia and catatonic schizophrenia, and had a severe cognitive impairment. The resident required assistance for various activities of daily living (ADLs) and was at risk for falls. Despite this, observations revealed that the resident's bed was not consistently maintained in the lowest position as required by the care plan, increasing the risk of falls and injury. The resident was observed multiple times with the bed elevated to knee height, contrary to the care plan's directive to keep the bed in a low position for safety. Interviews with staff confirmed that the bed was not always kept in the lowest position, and the CNA acknowledged maintaining the bed at knee height during breakfast, despite knowing it should be lower. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were aware of the care plan intervention to keep the bed in a low position but believed it might no longer be necessary, despite the care plan indicating otherwise. The interdisciplinary team (IDT) reviewed the fall care plan and deemed it appropriate, indicating the ongoing need for the low bed for safety. However, the failure to consistently implement this intervention resulted in a deficiency in the resident's care plan, potentially compromising the resident's safety and 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 ensure blood glucose values were documented in the medical record for one resident and failed to implement assessment/intervention for bowel constipation for another resident. Resident #22, who has severe cognitive impairment and is always incontinent for bowels, did not have a bowel movement documented from 5/8/24 to 5/12/24. Despite the facility's protocol requiring intervention after three days without a bowel movement, the necessary medications were not administered, and the bowel protocol was not implemented until five days had passed. This was confirmed by both the Unit Manager and the Director of Nursing, who acknowledged the lapse in following the bowel protocol. Resident #408, who has diagnoses including type two diabetes with hyperglycemia, had an order for twice-daily blood glucose checks. However, the medical record only contained three blood glucose readings over four days. The Unit Manager verified that the blood glucose values should have been documented in the medical record but were not due to a failure in the system to prompt for documentation. The Director of Nursing confirmed that the expectation was for blood glucose values to be documented in the medical record, which did not occur. Both deficiencies were identified through observations, interviews, and record reviews. The facility's failure to follow its own protocols for bowel management and blood glucose monitoring resulted in lapses in care for the residents involved. These deficiencies highlight issues in the facility's documentation and adherence to medical orders, as confirmed by the staff interviews and record reviews.

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 two residents had water available at their bedside, resulting in the potential for dehydration. Resident #6, who was diagnosed with dysphasia and required nectar thick liquids, was observed multiple times without appropriate thickened water in his room. Despite having a physician's order and care plan indicating the need for thickened liquids, Resident #6 was provided with non-thickened water, which he could not drink. Interviews with staff confirmed that Resident #6 did not like the taste of thickened water and would sometimes ask for non-thickened water, which he was not allowed to have for safety reasons. Resident #32 was also observed without adequate water in her room. She reported that staff did not bring her fresh water daily or each shift, leading her to fill her cup from the bathroom sink. Observations confirmed that her water cup was often empty or only partially filled. Interviews with staff indicated that CNAs were responsible for passing water to residents each shift, but this was not consistently done. The facility administrator stated that it was her expectation that each resident would receive fresh water each shift, which was not being met in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a medication was administered within the prescribed parameters and not in an excessive dose for one resident. Resident #38, who has a history of a right femur fracture and hemiplegia following a stroke, was observed to have received 4000 mg of acetaminophen daily from April 4, 2024, through May 14, 2024. This dosage exceeded the physician's order, which specified that the resident should not receive more than 3000 mg in 24 hours. The Director of Nursing reviewed the order and confirmed that the administered doses exceeded the prescribed limit.

Penalty

No penalty information released

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

Summary

The facility failed to ensure appropriate infection control practices during wound care for two residents, resulting in the potential for cross-contamination and the spread of infection. During multiple wound care observations, Licensed Practical Nurses (LPNs) were observed washing their hands with soap and water for significantly less than the recommended 20 seconds. Specifically, handwashing durations ranged from four to six seconds, which is below the standard set by the Centers for Disease Control and Prevention (CDC) and the facility's own policy. In interviews, both the MDS Coordinator and the Nursing Home Administrator confirmed that the expectation for handwashing duration is at least 20 seconds. The observations of inadequate handwashing were consistent across different times and residents, indicating a systemic issue with adherence to proper infection control protocols. This deficiency was identified through direct observation, interviews, and record reviews, highlighting a failure in maintaining appropriate hygiene practices during wound care procedures.