The Estates At Chateau Llc

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 prevent an unintentional fire and to control smoking materials for a resident who used continuous oxygen and had documented dementia with moderate cognitive impairment. The resident’s diagnoses included pulmonary fibrosis, COPD, depression, nicotine dependence, and dementia. A smoking evaluation dated 12/19/25 identified the resident as safe to smoke independently, with no cognitive loss, no visual or dexterity problems, and allowed her to store and handle her own cigarettes and lighter. This evaluation did not address whether the resident understood safety measures related to removing or positioning oxygen equipment prior to smoking. The initial smoking care plan, initiated 12/23/25, set a goal for the resident to smoke safely and independently, noted education on the dangers of oxygen and smoking, and stated she was independent with smoking per evaluation, but did not include specific interventions regarding oxygen placement or removal before or during smoking. On 12/24/25, the resident was found smoking in her room, contrary to facility expectations. The incident analysis identified that she was a new admission and independent with smoking per her admission form. She was re-educated, and the plan was to remove smoking materials and keep them at the nursing station. A smoking evaluation dated 12/24/25 again documented no cognitive loss despite the MDS showing moderate cognitive impairment and a dementia diagnosis, and it specified that the resident could light her own cigarette but could not store her own smoking materials, which were to be kept at the nursing station. However, the smoking care plan was not revised until 12/29/25 to add the intervention to store smoking materials at the nurse station. A Risk vs Benefits form dated 12/30/25 identified the concern of the resident smoking in her room while on oxygen and described the dangers of oxygen-related fires, but it did not list any benefits, was not signed by the resident or representative, and there was no documentation of monitoring or evaluation of the effectiveness of the intervention to store smoking materials at the nurse’s station. On 1/29/26 at 8:39 a.m., progress notes documented that the resident was smoking in her room and caused a fire, indicating that the 12/29/25 intervention to keep smoking materials at the nurse’s station was not followed. The resident denied smoking and refused a respiratory assessment and skin check. An incident analysis for 1/29/26 stated that staff heard the roommate yelling for help and found a fire on the resident’s oxygen tank in her room while the resident was smoking, though she denied it. The fire was extinguished, and both residents were assessed with no injuries found. A search of the room revealed a pack of cigarettes, which was taken to the nurse’s station. The smoking evaluation dated 1/29/26 again documented no cognitive loss despite the MDS and dementia diagnosis, noted that the resident smoked 5–10 times per day, could light her own cigarette, could not store her own smoking materials, and that smoking materials were supposed to be kept at the nurse’s station. It also stated that daily room checks were to be done, that the resident used oxygen, had been educated to remove and store oxygen prior to smoking, and had a wanderguard on her portable oxygen tank. Following the fire, the care plan was updated on 1/29/26 with interventions such as daily room searches with the resident’s permission, safety checks, posting signs in Spanish about no smoking and oxygen being flammable, visualizing the room every shift to remove visible smoking materials, and using a wanderguard on the portable oxygen tank. However, between 1/29/26 and 2/2/26, the record did not include a comprehensive assessment or analysis supporting that 15-minute checks were appropriate or sufficient to prevent the resident from smoking, nor did the care plan provide instructions for staff if the resident was non-compliant with surrendering smoking materials. There was no documented assessment of the resident’s task-specific decisional capacity to safely engage in smoking while using oxygen, despite her dementia, moderate cognitive impairment on the MDS, and prior non-compliance on 12/24/25 and 1/29/26. On 2/2/26, the resident told an interviewer she did not trust staff with her smoking materials and admitted refusing to give them up when asked. She produced a box of cigarettes and a lighter from her coat pocket while wearing a nasal cannula connected to oxygen at 2 LPM. A nursing assistant reported that the resident often refused to give up her smoking materials after returning from smoking outside and that staff did not always have time to check residents after smoking to ensure materials were turned in. Another nursing assistant and an RN stated the resident was non-compliant with smoking rules, hid smoking materials, and that residents sometimes shared supplies, but these refusals and hiding behaviors were not documented in the record between 12/23/25 and 2/2/26. An LPN showed that the drawer designated for smoking materials at the nurse’s station contained only office supplies and confirmed there was no log to track smoking supplies. The DON acknowledged that family brought in smoking materials without first bringing them to the nursing station and that it was difficult to take items from the resident. These observations and interviews demonstrated that the resident remained in possession of cigarettes and a lighter after the fire, that staff were aware of ongoing non-compliance and family involvement in supplying materials, and that there was no effective system or documentation to ensure smoking materials were secured as care planned, resulting in continued risk of fire.

Removal Plan

• Reviewed smoking policies with the medical director and ombudsman input.
• Developed and implemented a comprehensive system to prevent accidents, hazards, and fires related to smoking inside the facility, including a plan for residents who fail to comply with safe smoking practices.
• Reassessed R1's capacity to make safe decisions regarding smoking.
• Revised R1's care plan with individualized interventions.
• Identified residents with similar smoking risks and their level of compliance with facility smoking policy.
• Implemented individualized interventions for residents with similar smoking risks to prevent unsafe smoking.
• Re-educated residents on safe smoking policies and administered a knowledge check quiz.
• Educated all staff on smoking policies and administered a knowledge check quiz to demonstrate understanding.

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 procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an adequate discharge planning process to ensure a resident's preference for discharge was met. The resident, who had intact cognition and no behavioral or psychiatric issues, expressed a desire to move closer to family in a neighboring state. Although the care plan indicated that the resident and family were seeking a skilled nursing facility (SNF) in the desired area and that referrals had been initiated, there was a lack of documentation regarding where referrals were sent, updates on the status of those referrals, or outcomes from the MNchoice assessment. Progress notes showed some referrals and assessments were made, but did not include follow-up information or communication with the resident or family about the discharge process after certain dates. Interviews with staff revealed that there was no evidence of follow-up on discharge plans or referrals in the electronic medical record since the last care conference, despite the resident's ongoing wish to discharge. The social services director acknowledged the absence of follow-up, and the director of nursing stated that the expectation was for social services to remain involved and for resources to be set up for a safe discharge in a timely manner. The facility's own discharge planning policy required continuous evaluation and implementation of interventions to address discharge goals, which was not reflected in the documentation or actions taken 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 facility failed to ensure that routine personal hygiene, including showers, hair care, and shaving, was completed for two residents who were dependent on staff for activities of daily living (ADLs). One resident, who was cognitively intact but had significant physical impairments and was dependent on staff for all personal hygiene, was observed with a two-inch long beard despite expressing a preference to be clean-shaven. Documentation and care plans lacked specific instructions or preferences regarding shaving, and staff interviews confirmed that the resident had been requesting to be shaved for several weeks without the request being fulfilled due to staff being too busy. Another resident, also cognitively intact but with multiple medical diagnoses and a self-care deficit, required staff assistance for bathing, dressing, grooming, and oral hygiene. The care plan did not include the resident's preferences or evidence of refusals for bathing or assistance. Weekly skin assessments and progress notes showed repeated refusals of baths, but there was no documentation of staff offering additional opportunities for bathing or partial baths, nor was there evidence of staff reapproaching the resident or documenting interventions. Observations revealed the resident appeared disheveled with a large, matted clump of hair, and staff interviews confirmed the lack of recent bathing and grooming. The facility's policy required that care and services be provided based on comprehensive assessment and resident needs and choices, to ensure that abilities in ADLs do not diminish unless unavoidable. However, the lack of documentation, failure to follow up on resident requests and preferences, and insufficient attempts to provide or document personal hygiene care led to the deficiency identified during the survey.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and record review, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency were not provided in the report.

Penalty

No penalty information released

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

Summary

A resident with a history of smoking violations was not adequately protected from potential smoking-related accidents. The resident was assessed as having adequate memory and cognitive function and was care planned to smoke independently, with interventions including smoking in her room, no smoking signs, and not allowing removal of cigarettes. Despite these interventions, documentation and staff interviews confirmed that the resident repeatedly smoked in her room, in violation of facility policy, and kept all smoking materials in her possession. Observations revealed evidence of smoking in the resident's bathroom, including a plastic cup with tar-colored liquid, coffee grounds, a strong odor of smoke, loose tobacco on the floor, and a bag of loose tobacco on the resident's wheelchair. Staff interviews indicated that the resident would not allow staff into her room without knocking and waiting for a response, making supervision difficult. The resident refused to have her smoking materials stored at the nursing station, despite being assessed as unsafe with her own smoking materials. The facility's policy required residents to smoke only in designated areas and allowed for revocation of smoking privileges for non-compliance, but the resident continued to smoke in her room. The administrator and DON confirmed the facility's policy and the ongoing non-compliance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure appropriate clinical decision-making and documentation regarding the use of an indwelling urinary catheter for one resident. The resident, who was cognitively intact and independent with activities of daily living, had a history of urethral stricture and obstructive and reflux uropathy. Despite these diagnoses, the medical record did not contain documentation of the reason for the catheter's insertion, justification for its continued use, or evidence of periodic reassessment. There was also no documentation of any attempt to remove the catheter or a referral to urology for further management until recently, even though the resident had experienced multiple urinary tract infections (UTIs) associated with the catheter, including one that resulted in hospitalization for sepsis. Interviews with staff confirmed that no trial removal of the catheter had been attempted since the resident's admission, and the care plan only referenced long-term catheter use without further detail. The resident reported a history of frequent UTIs and expressed that the catheter was intended to remain until he could stand and care for himself, based on previous medical advice. The facility's electronic medical record lacked evidence of ongoing assessment or a clear plan for catheter management, and no relevant policy was provided upon request.

Penalty

No penalty information released

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

Summary

The facility failed to follow established nutritional interventions and dietary orders for several residents, resulting in deficiencies in the provision of adequate food and fluids. Three residents with specific dietary needs, including large portions for wound healing and malnutrition, and the addition of yogurt or cottage cheese for weight gain, did not consistently receive the prescribed food portions or supplements. Observations and interviews revealed that residents who were supposed to receive double or large portions were served meals of the same size as other residents, and one resident did not receive the ordered yogurt or cottage cheese with meals. Staff interviews confirmed that the intended larger portions were not being provided, and the dietary staff did not consistently follow meal tickets or care plans specifying these interventions. Additionally, the facility failed to ensure that a fluid restriction order was followed for a resident with hyponatremia. The resident was observed drinking fluids freely from large containers, and staff reported that they were unable to monitor her intake because she was independent in obtaining fluids. There was no documentation of education or risk versus benefit discussions with the resident regarding the importance of adhering to the fluid restriction. The resident herself stated that she had not received any education from facility staff about her fluid restriction or its significance. Facility policies were reviewed and indicated that food and nutritional needs should be met according to physician orders, and that therapeutic diets should be prepared and served as prescribed. However, the observed practices did not align with these policies, as residents did not receive the prescribed diets or fluid restrictions. The lack of adherence to dietary and fluid orders was confirmed through staff interviews, resident statements, and direct observation of meal service and resident behavior.

Penalty

No penalty information released

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

Summary

A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such treatment. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.

Penalty

No penalty information released

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

Summary

The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or incorporate trauma-informed approaches or cultural competence in the delivery of care or services to residents, as required. The report does not specify the number of residents affected or provide details about their medical history or condition 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

A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.

Penalty

No penalty information released

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

Summary

A resident with central spinal cord syndrome and a history of receiving physical, occupational, and speech therapy did not receive specialized rehabilitative services as ordered. The resident's care plan was updated to include passive range of motion (PROM) and instructions to follow physical therapy (PT) orders. During a care conference, the resident and family requested additional PT due to observed movement in the resident's lower extremities. A provider subsequently ordered a PT evaluation, but the evaluation was not completed after the order was written. Interviews with staff revealed that the PT order was not acted upon, with the LPN confirming that the order "fell through the cracks." The director of nursing stated that the expectation was for therapy to evaluate residents within 72 hours of a new order and to communicate the therapy plan to nursing staff within one week. Despite these expectations, the resident was not evaluated by PT after the new order, and the facility was unable to provide a policy for therapy services 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

A resident with a BIMS score of 15/15 and diagnoses including weakness, schizophrenia, anxiety disorder, depression, and chronic pain syndrome was involved in a verbal altercation with a dietary aide at the kitchen door. The incident occurred when the resident requested two chicken sandwiches and was told only one was available. Both the resident and the dietary aide admitted to yelling and calling each other derogatory names, specifically 'bitch.' Another dietary aide intervened and asked the resident to leave, which he did. There was no physical interaction, but the exchange was loud and disrespectful. Facility camera footage partially captured the incident but lacked audio and did not cover the entire altercation. The facility's leadership was unaware of the event until informed by surveyors. The facility's policy emphasizes protecting residents from all forms of abuse, including verbal abuse by staff. The incident demonstrated a failure to protect the resident from staff-to-resident verbal abuse as required by facility policy.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of staff-to-resident abuse to the State Agency and the facility administrator after a verbal altercation occurred between a resident and a dietary aide. The resident, who was cognitively intact with a BIMS score of 15/15 and had diagnoses including schizophrenia, anxiety disorder, depression, and chronic pain syndrome, reported that he and a staff member engaged in a heated exchange involving yelling and name-calling over a request for two sandwiches. Another staff member intervened to de-escalate the situation, but neither staff member nor the resident reported the incident to facility management. Interviews revealed that both staff involved in the incident acknowledged the altercation and the use of inappropriate language, but did not notify management as required by facility policy. The administrator confirmed that leadership was unaware of the incident until it was brought to their attention during the survey. Facility policy mandates immediate reporting of any situation considered abuse or neglect, but this procedure was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure resident safety by allowing a former resident, who had been discharged and issued a no-trespass order, to repeatedly gain unauthorized entry into the building through an unsecured door without staff awareness. This resulted in non-consensual contact when the former resident entered a female resident's room at night and kissed her on the forehead, causing her mental anguish and difficulty sleeping. The former resident also misappropriated property from another resident and was observed in multiple areas of the facility after discharge, including attempting to sleep in his old room and interacting with residents on various floors. Staff interviews revealed that the former resident was able to enter the building undetected on several occasions, often due to the front door being propped open by residents, and that staff were not always aware of his presence or the trespass order in place. The report documents that the former resident had a history of behavioral issues, including increased aggression towards staff and residents, frequent intoxication, and providing alcohol to other residents. Despite being discharged against medical advice and given a trespass order, the former resident continued to return to the facility, sometimes entering the building and resident rooms, and at other times remaining just outside the property. Police were called multiple times, but the former resident often left before their arrival. Staff and residents reported feeling unsafe, and some residents expressed a desire to file restraining orders due to the former resident's threats and inappropriate behavior. The facility's front door was identified as a key vulnerability, as it was often left propped open, allowing unauthorized access. Additionally, the facility failed to protect two residents from abuse when another resident engaged in a verbal and physical altercation with one resident, which escalated to a physical incident with a second resident later the same day. Documentation and interviews confirmed that staff were aware of the altercations but did not implement effective interventions to prevent further incidents. The affected residents had various medical and behavioral diagnoses, including alcohol dependence, depression, and physical disabilities, but were generally independent in their self-care. The facility's lack of effective monitoring and response to both the unauthorized entries and resident-to-resident altercations resulted in a finding of Immediate Jeopardy, placing all residents at risk.

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 immediately report an allegation of stolen money to the State Agency (SA) and law enforcement, as required by policy and regulation. A cognitively intact resident with a history of multiple fractures and depression reported that $80 was taken from her purse overnight while she was asleep. The resident discovered the theft the following morning and filed a grievance with the facility. The grievance form indicated that the resident herself made a police report, but facility staff did not assist her in this process. Interviews revealed that the social worker informed the resident she would need to file her own police report and did not offer assistance. The incident was not reported to the SA within the required 24-hour timeframe, nor was it reported to law enforcement by the facility. Staff interviews indicated a misunderstanding of reporting requirements, with some staff believing that confirmation of the theft or proof that the resident had the money was necessary before reporting to the SA. The director of nursing acknowledged that taking a resident's money could be considered financial abuse and should have been reported. The facility's policy required reporting any suspicion of misappropriation of resident property to the SA within 24 hours, regardless of whether the incident resulted in serious bodily injury. Despite this, the facility did not follow its own policy or state law, resulting in a failure to report the suspected theft in a timely manner.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a process was in place for timely prior authorization (PA) of medications, resulting in a resident missing multiple doses of a prescribed diabetes medication, Rybelsus. The resident, who was cognitively intact and had diagnoses including diabetes and heart disease, had a care plan directing staff to administer medications as ordered. However, medication administration records showed repeated missed doses of Rybelsus over several months, with gaps in March, April, and May. The missed doses were due to delays in completing and returning the required PA forms to the pharmacy, which prevented the pharmacy from dispensing the medication. Interviews with staff revealed a lack of clarity and knowledge regarding the PA process. The pharmacist confirmed that the facility did not return PA forms in a timely manner, and staff, including medication aides and nurses, were unsure of their roles in ordering and authorizing medications requiring PA. The medication aide reported notifying nurses about the need for refills but did not escalate the issue promptly when the medication did not arrive. Nurses and nurse managers were also unaware of the extent of missed doses, and documentation in progress notes did not consistently reflect the missing medication. The resident reported missing Rybelsus doses for about a month in March and April, as well as some in May, and stated that nurses attributed the delay to the need for administrative approval. The facility's medication orders policy did not include guidance on the PA process, contributing to the confusion and failure to ensure timely medication administration as ordered by the provider.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its policy of removing alcohol from a resident's room and did not adequately analyze the underlying causes of increased aggression in a resident with a history of substance abuse. The resident, who had diagnoses of alcohol dependence, cocaine dependence, and major depressive disorder, exhibited physical and verbal aggression towards others, particularly after consuming alcohol. Despite the facility's policy allowing for the confiscation of substances posing risks to residents' health and safety, staff did not remove alcohol from the resident's room without explicit permission from the resident. The resident's care plan included interventions such as monitoring for intoxication, offering community resources, and notifying providers of substance use. However, the resident repeatedly declined treatment and harm reduction approaches. The facility documented several incidents where the resident became aggressive after consuming alcohol, including altercations with other residents and staff. Despite these incidents, alcohol was not removed from the resident's room, as staff believed they needed the resident's consent to do so. Interviews with facility staff revealed a lack of consistent action in addressing the resident's alcohol use and aggression. Staff were aware of the resident's behavior changes and the presence of alcohol in the resident's room but did not take steps to remove it, citing the resident's right to refuse. The facility's administrator acknowledged that the facility's policy was not followed, and the resident's aggression was a new behavior that had not been assessed for root causes.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a consistent care plan for a resident, identified as R4, who was reviewed for care plans. R4's care plan contained conflicting information regarding the number of staff required to assist with personal care tasks. While one part of the care plan indicated that two staff members were needed, another section stated that only one staff member was required for bathing, dressing, and personal hygiene. This inconsistency was observed during a visit when a nursing assistant changed R4's incontinent brief alone, despite the care plan's indication of needing two caregivers. R4 was admitted with a primary diagnosis of cerebral infarction and additional conditions such as hemiplegia, repeated falls, and anxiety disorders. The resident's care plan was not updated to reflect current needs, as noted by various staff members during interviews. The nurse manager and director of nursing both expressed expectations that care plans should be regularly updated and consistent. However, the intervention requiring two caregivers was not removed from the care plan, despite it no longer being applicable. This oversight was acknowledged by the social services staff who initially added the intervention following reports of 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 maintain aseptic technique during perineal care for residents, as observed in multiple instances. Nursing assistants were seen wiping residents' perineal areas from back to front, which is contrary to the expected front-to-back method. This improper technique was noted during the care of residents R1, R2, and R4, with the same washcloth being reused without changing sides or using a new cloth for each stroke, as required by aseptic standards. Additionally, the facility did not provide timely incontinent care for residents R1 and R4. R4's brief was found saturated with urine, and the linens were soaked, indicating a lack of regular checks and changes. The care plan for R4 specified that incontinent briefs should be checked every two to three hours, but this was not adhered to, as evidenced by the delay in changing R4's brief until several hours later. R1 also reported that staff did not regularly check or change her incontinent brief, and she often had to use her call light to request assistance. The facility also failed to provide weekly showers for R1, who expressed a preference for showers. Despite this preference being documented, R1 did not receive a shower as expected, and her family member reported having to bathe her during visits. The facility's policy on activities of daily living was not followed, as residents did not receive the necessary care to maintain their abilities in these areas, leading to deficiencies in personal hygiene and comfort.

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 licensed staff were adequately trained on wound vacuum-assisted closure (VAC) procedures, which affected five out of sixteen licensed staff. A resident was admitted with a wound VAC due to an open fracture and required regular dressing changes as per the care plan. However, the facility's records showed inconsistencies in the treatment administration record, with multiple registered nurses and licensed practical nurses checking off completed treatments without proper training. The resident reported that staff were unable to manage the wound VAC alerts, indicating a lack of competency in handling the device. Interviews with staff and family members revealed that the wound VAC alarm frequently went off, and staff were unsure how to address the issues. The Director of Nursing admitted uncertainty about whether staff had been educated on wound VACs and acknowledged the absence of a formal policy or procedure for wound VAC management. The facility could only provide wound VAC education competencies for a limited number of staff, and the administrator confirmed the lack of comprehensive training documentation for all licensed nurses.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper monitoring and timely removal of food stored in refrigerators and freezers, which could potentially affect all 65 residents consuming food from the facility kitchen. During an observation, several undated and improperly stored food items were found in the kitchen's refrigerator and freezer, including undated corn, peas, carrots, turkey lunch meat, and caramel sauce, as well as expired items like carrots and apple sauce. The dietary manager acknowledged that these items should have been dated and discarded, indicating a lapse in the facility's food safety practices. Additionally, the facility did not adhere to proper food storage practices, as observed in the dry storage room where a Styrofoam cup was used to scoop flour, and food items like sweet potatoes and onions were stored on the floor. The dietary manager admitted that storing food on the floor was unacceptable and that the cup should not have been left in the flour container. Furthermore, the third-floor unit refrigerator temperatures were not properly monitored, with recorded temperatures exceeding safe levels, leading to spoiled food. Staff members, including a registered nurse and a licensed practical nurse, were unsure of the appropriate refrigerator temperatures, highlighting a lack of knowledge and oversight in maintaining food safety. The facility also failed to cover food items properly when serving residents, as observed with uncovered food trays in the third-floor hallway. A fly was seen around the serving area, and the dietary manager confirmed that all food should be covered during tray pass to prevent contamination. The facility's policies on refrigerator temperatures and food storage were not followed, contributing to these deficiencies in food safety and handling practices.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper food storage and handling practices in its main production kitchen and unit-based refrigerators, as identified during a recertification survey. The Quality Assurance and Assessment (QAA) program did not effectively identify or implement actions to address these ongoing issues, despite repeated non-compliance with federal regulations over multiple years. The deficiencies included undated food items in the kitchen refrigerators and freezers, and over-packed unit refrigerators that were not maintaining appropriate temperatures. The dietary manager (DM), who had been in the role for nearly a year, acknowledged the issues with kitchen safety and food storage. The DM noted that there had been significant staff turnover, making it challenging to maintain consistent practices. Although the DM attended routine QA meetings, no formal audits or ongoing monitoring were conducted outside of their manual checks. A recent corporate mock survey had identified similar concerns, but only partial education had been provided to staff, and no Performance Improvement Project (PIP) was in place to address the kitchen issues. The facility administrator confirmed that the QA team met monthly and was aware of the kitchen concerns, which had been discussed previously. However, despite recognizing the need for staff coaching and accountability, no PIP or documented audits were in place for the kitchen issues. The administrator mentioned that a new plating system had been introduced to address food temperature concerns, but the lack of labeling, dating, and proper storage in refrigerators remained unaddressed. The most recent QAPI meeting minutes were requested but not provided.

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 meals were served in a warm and palatable manner, affecting the quality of life and nutritional intake for three residents. These residents, who had intact cognition and no delusional thinking, reported that their meals were consistently served cold. Observations confirmed that food trays were transported on non-enclosed carts without insulated plate bases, leading to meals being served at room temperature. The dietary manager acknowledged that the food was not hot and expressed that trays should have been passed within approximately 15 minutes to maintain appropriate temperatures. The facility's Meal Tray Service policy did not specify a time frame for meal tray passes or methods to ensure meals remained at a palatable temperature. The administrator expected staff to use a heated plate system with both an insulated lid and bottom, and anticipated that management and additional staff would assist in timely tray passing. However, the observed delay in tray distribution contributed to the deficiency, as the last tray was passed significantly later than expected, resulting in cold meals for residents.

Penalty

No penalty information released

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

Summary

The facility failed to maintain personal dignity for a resident, identified as R16, who was reviewed for dignity with personal care. R16, who had intact cognition, required maximal staff assistance for various activities of daily living due to multiple diagnoses, including osteoarthritis, heart failure, diabetes, and chronic pain. Despite these needs, R16's care plan lacked evidence of his preference to wear a hospital gown versus personal clothing, and there was no documentation of the facility's efforts to obtain personal clothing for him. Observations and interviews revealed that R16 was often seen wearing a hospital gown, although he expressed a preference for wearing shorts and a shirt. R16 stated that he had requested clothing from his family, but due to his wife's health and living situation, she was unable to provide them. Staff interviews confirmed that R16 did not have personal clothing at the facility and that he seemed more comfortable in shorts and a shirt, which was his preference. However, there was no follow-up to ensure R16 received clothing, and the facility's staff had not discussed his clothing preferences with him. The facility's policy on Activities of Daily Living (ADLs) emphasized honoring and supporting each resident's preferences, choices, values, and beliefs. Despite this policy, the facility did not adequately address R16's clothing needs or preferences, as evidenced by the lack of documentation and follow-up actions. The assistant director of nursing and social worker acknowledged the facility's responsibility to assist residents in obtaining clothing, yet R16's situation remained unresolved, highlighting a deficiency in maintaining his personal dignity.

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 necessary maintenance services were performed to provide a homelike environment for a resident with a broken overhead light. The resident, who had intact cognition and required supervision for oral and personal hygiene, reported that the overhead light in her room had not worked since she moved in several weeks ago. Despite requests to the maintenance staff, the issue remained unresolved. The facility's Closed Work Order report indicated a request for a correctly fitting mattress and noted the non-functional light, but the maintenance director was unaware of the broken light until it was brought to his attention during the survey. During observations, the resident's room was found to be dimly lit, with the bed positioned against the far wall and a privacy curtain drawn, further reducing light from the working entrance light. The maintenance director acknowledged that the facility was transitioning to LED lights and had recently received a shipment that could be used to fix the light. However, he admitted to accidentally closing the maintenance request for the light, as it was combined with the mattress request. The facility's maintenance policy did not specify a timeline for completing requests, contributing to the oversight.

Penalty

No penalty information released

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

Summary

The facility failed to implement and document care-planned interventions for substance use for two residents, R44 and R1, leading to a lack of continuity in their care. R44, who had a history of substance abuse and was a current smoker, was found intoxicated on multiple occasions. Despite the care plan's directive to monitor vital signs when intoxicated, there was no evidence of such monitoring in R44's medical records. Interviews with staff, including a registered nurse and the assistant director of nursing, confirmed the absence of recorded vital signs and highlighted inconsistencies in documentation practices. Similarly, R1, who had a history of cocaine and alcohol abuse, displayed signs of intoxication on several occasions as documented in the Medication Administration Records (MAR). However, there was no indication that medications were held or that vital signs were checked as per the care plan's instructions. Interviews with a licensed practical nurse and a nurse practitioner revealed that vital signs were not consistently monitored, and the nurse practitioner was unaware of the frequency of R1's substance use. Additionally, the facility failed to individualize the care plan for R48, who was on psychotropic medications, by not including target behaviors for the use of these medications. The care plan lacked specific documentation of pharmacological and non-pharmacological interventions, as well as potential side effects of the medication olanzapine. The interim director of nursing and the administrator acknowledged the absence of specific behavior charting and target symptoms in the care plan, which was contrary to the facility's care planning policy.

Penalty

No penalty information released

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

Summary

The facility failed to accurately and comprehensively assess a resident's smoking practices, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, who has intact cognition and medical conditions including paraplegia and diabetes, was admitted with a care plan indicating they could smoke safely and independently. However, the initial smoking evaluation inaccurately stated that the resident was not a smoker, leaving several assessment questions unanswered. This oversight meant that the resident's ability to smoke safely, including their need for supervision or adaptive equipment, was not properly evaluated. Interviews with staff revealed inconsistencies in the smoking assessment process. A licensed practical nurse (LPN) familiar with the resident confirmed that the resident was a smoker and had been smoking since their arrival at the facility. Despite this, the smoking evaluation in the electronic medical record incorrectly indicated the resident was a non-smoker. Another LPN was unsure of the resident's smoking status, further highlighting the lack of a comprehensive assessment. The assistant director of nursing (ADON) acknowledged the discrepancy and noted that smoking assessments are intended to ensure resident safety. Observations of the resident smoking independently outside the facility confirmed their smoking status. The resident was seen using a lighter and cigarettes stored in a pouch around their neck, demonstrating their ability to smoke without assistance. Despite the resident's safe smoking practices, the facility's failure to conduct a thorough initial assessment and update the care plan accordingly constituted a deficiency in providing adequate supervision and ensuring a safe environment 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 comprehensively assess and manage pain for a resident, identified as R11, who developed new back pain. R11's quarterly Minimum Data Set (MDS) indicated moderate cognitive impairment and frequent pain that interfered with daily activities, yet no scheduled or as-needed pain medication was recorded. The MHM Pain Evaluations noted non-pharmacological interventions like warm towels were used, but lacked detailed information on the pain's location or characteristics. R11's care plan mentioned non-medicinal pain relief and monitoring for medication side effects but did not specify current pain issues or management goals. Observations and interviews revealed that R11 experienced significant pain, particularly in the arms and lower back, and expressed dissatisfaction with the current pain management, stating a need for different interventions. The Medication Administration Record (MAR) showed limited use of PRN Bio Freeze, with recorded pain levels reaching up to 4, but lacked detailed documentation of pain characteristics. Nursing staff, including a nursing assistant and a registered nurse, acknowledged R11's recent increase in back pain complaints, yet there was no comprehensive assessment or update to the care plan. The assistant director of nursing confirmed that the newly reported back pain was not evaluated or recorded in the medical record, as it was not communicated to them. The facility's Pain Management Protocol mandates assessment of new or worsening pain, but this was not followed for R11. The lack of communication and documentation resulted in inadequate pain management for the resident, contrary to the facility's policy aimed at ensuring effective pain management for residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely reordering of physician-ordered medications, resulting in a delay in administration for a resident diagnosed with asthma. The resident, who had intact cognition and required maximal assistance with eating and oral hygiene, had an order for two puffs of Dulera inhaler twice a day. However, on one occasion, the medication was not administered in the morning because it was out of stock, and the nurse had to order a new inhaler. The medication was not expected to arrive until later in the day, causing the resident to miss the scheduled dose. The issue was identified during an observation and interview with an LPN, who acknowledged the delay and noted that the medication should have been reordered when about 15 doses were left. The LPN mentioned that while she routinely reorders medications when they are low, there have been problems with other nurses not reordering in a timely manner. The interim DON confirmed that nursing staff should reorder medications when they are running low to prevent missed doses. The facility's policy indicated that medications should be reordered three to five days in advance to maintain an adequate supply.

Penalty

No penalty information released

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

Summary

The facility failed to ensure adequate blood sugar monitoring for a resident diagnosed with diabetes, depression, and schizophrenia, leading to potential unnecessary administration of insulin. The resident's Medication Administration Record (MAR) showed orders for insulin glargine and insulin aspart, but there were no corresponding blood sugar level tests documented. The resident's blood sugar was only recorded twice over a period of several weeks, despite an increase in insulin dosage due to previously high blood sugar levels. Interviews with facility staff, including a nurse practitioner, registered nurse, assistant director of nursing, and regional nurse consultant, revealed that the order for blood sugar checks was inadvertently discontinued when the insulin orders were updated. This oversight resulted in inconsistent monitoring of the resident's blood sugar levels, which was not aligned with the facility's Blood Glucose Monitoring Procedure that required documentation after each test.

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 have a qualifying diagnosis for the routine use of an antipsychotic medication and did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident reviewed for unnecessary medications. The resident, who was cognitively intact and had no behaviors, was prescribed olanzapine, an antipsychotic medication, for anxiety, which is not an appropriate indication for its use. The resident's medical record lacked a baseline AIMS assessment before the initiation of olanzapine, and the care plan did not include individualized documentation of pharmacological and non-pharmacological interventions or potential side effects of the medication. The facility's policy required an AIMS assessment to screen for tardive dyskinesia at baseline, semi-annually, and after discontinuation every month for three months. However, the interim Director of Nursing admitted that the initial AIMS assessment was only completed after the survey visit. Additionally, a pharmacy recommendation indicated that a gradual dose reduction was necessary, but there was no evidence of a timeline for this reduction or a referral to the Associated Clinic of Psychology. The facility's failure to adhere to its policy and the lack of appropriate documentation and assessments contributed to 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 ensure the accuracy of the posted nurse staffing information, which had the potential to affect all 65 residents and visitors who may wish to view the information. The staff postings for the period from August 5 to August 14, 2024, indicated that the facility had six nursing assistants (NAs) on the day and evening shifts and three NAs on the night shifts. However, the actual staffing reports for the same period showed discrepancies, with fewer NAs present than what was posted. For instance, on August 5, 2024, the day shift had three NAs, the evening shift had four NAs, and the night shift had two NAs, contrary to the posted information. During an interview on August 15, 2024, the staffing coordinator revealed that the facility used a computer program to generate the staffing information for the postings. The coordinator noted that the computer program was erroneously pulling unfilled NA slots as if they were filled, leading to inaccurate staff postings. The facility's Nursing Hours Posting policy, dated October 2022, mandates that the total number of NAs directly responsible for resident care during each shift must be posted, which was not adhered to in this instance.

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 residents' right to be free from abuse, provide adequate supervision, and develop a comprehensive care plan for two residents with a history of alcohol abuse and altercations. Both residents, R1 and R2, were involved in a physical altercation while intoxicated, resulting in injuries. R1's care plan indicated a need for monitoring while intoxicated, but this was not effectively implemented, leading to the incident where R2 struck R1 on the face, causing a scratch, and R1 retaliated by hitting R2 on the cheek, causing redness and warmth. Interviews with staff and other residents revealed that intoxicated residents frequently return to the facility and are not adequately monitored, leading to safety concerns. Staff members, including trained medication aides and registered nurses, confirmed that both R1 and R2 were intoxicated during the altercation and that there was no history of resident-to-resident altercations noted in their care plans. Despite the altercation, no reeducation was provided to staff regarding the monitoring of intoxicated residents, and there was a lack of awareness about the residents' history of assaulting others. The director of nursing and the facility administrator acknowledged the incident and the failure to provide adequate supervision and monitoring. The administrator confirmed that R2 is alcohol-dependent and resistant to treatment, and both residents were placed on 15-minute checks for 24 hours following the assault. However, no root cause analysis was completed, and no reeducation was provided to staff, highlighting a significant gap in the facility's approach to managing residents with a history of alcohol abuse and altercations.