The Villas At Brookview

Penalty

No penalty information released

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

Summary

The facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles and did not take timely action when temperatures were not within the required range. During observation, the dishwasher log for April showed wash temperatures recorded at 150 degrees F and rinse temperatures at 180 degrees F, while the low-temperature dishwasher itself was later observed with a wash temperature of 140 degrees F and a rinse temperature of 108 degrees F. Staff gave conflicting statements about the required temperatures, with one dietary aide stating the wash cycle should be 160 degrees F and the rinse cycle 180 degrees F, while another stated the machine was supposed to be 180 degrees F. The log used for April did not include a place to record rinse temperatures, and one meal entry was missing from the log. Review of the dishwasher documentation showed additional inconsistencies. January through March logs were titled as high-temperature dishwashing records and each entry listed 150 degrees F for wash and 180 degrees F for rinse, with no variation. In April, the log reflected wash temperatures between 119 and 130 degrees F and chemical sanitizer readings between 99 and 101 PPM, including an outlier of 120 on one breakfast entry. The facility’s own staff and administrator acknowledged that 99 and 101 were not options on the test strips, and the assistant administrator stated she would have recorded 100 PPM. The service technician’s manual later identified the machine as a low-temperature dishwasher requiring a wash temperature of 140 degrees F and a rinse temperature of 120 degrees F. The facility also failed to ensure food items were properly labeled, dated, and stored in the walk-in freezer. During the freezer tour, a half-full 20-pound bag of ice was stored on the floor, and multiple food items were found undated or unlabeled, including pancakes, breadsticks, chicken patties, sugar cookies, chocolate chip cookies, fruit, and patties in tied or open bags. A sealed bag of freezer-burnt berries with an unclear date was also present. The culinary service director stated food items were supposed to be checked routinely and that items should be dated so staff would know when they were placed in the freezer and when they should be used or discarded. The facility further failed to assure that proper hair and beard restraints were used by staff preparing food in the kitchen. During the initial tour, two dietary assistants were observed wearing hair bonnets, but their hair was not properly constrained. The culinary service director stated all dietary staff should wear hairnets or bonnets and beard masks to prevent hair from contacting exposed food, clean equipment, utensils, and linens.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident was informed of and consented to medications prescribed and administered for mental health intervention. The resident had diagnoses including schizoaffective disorder, bipolar disorder, anxiety disorder, and insomnia, and the admission MDS indicated the resident was cognitively intact with moderate depression. The resident’s CAA for psychotropic drug use showed use of an antipsychotic, antidepressant, and antianxiety medication within the prior seven days. The hospital discharge summary listed clonazepam, divalproex ER, olanzapine, and trazodone to continue at the facility, and the physician orders in the electronic record reflected these medications and their related diagnoses. The informed consent form for required medications, signed by the care manager and the resident, listed only clonazepam and trazodone as medications the resident was educated on for consent. Although check marks were present for anti-anxiety, antidepressant, and antiepileptics, the form did not document divalproex sodium ER after the antiepileptic box was checked and did not identify olanzapine or check the antipsychotic box. During interview, the care manager stated she should have listed Depakote ER and olanzapine and acknowledged forgetting to mark the antipsychotic box. The DON reviewed the form and physician orders and stated the form lacked documentation that the resident received olanzapine and Depakote ER, and that staff were expected to review physician orders, match medications to the classifications on the form, educate the resident, and document 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 facility failed to comprehensively assess a resident with signs and symptoms of moderate depression after the resident scored 17 on the PHQ-9, which indicated moderately severe depression. The resident’s diagnoses included schizoaffective disorder, bipolar disorder, anxiety disorder, and insomnia. The admission MDS indicated the resident was cognitively intact, had moderate depression, and required assistance with activities of daily living, including substantial assistance with lower extremity dressing and care. The resident’s CAA for psychosocial well-being documented “yes” to little interest or pleasure in doing things, and the CAA for mood state documented “yes” to thoughts that the resident would be better off dead or hurting himself in some way. No further information was documented on the mood state CAA. During multiple observations, the resident was not seen out of the room, and the room door was either cracked open or closed while the resident sat in a wheelchair watching TV with the volume low. The resident’s electronic medical record lacked evidence that the facility comprehensively assessed the resident’s history of suicidal thoughts. The comprehensive care plan noted alteration in mood and behavior related to loss of independence, a history of suicidal thoughts, that talking with staff helped the resident, and agreement to see Associated Clinic of Psychology. However, the record lacked evidence that the resident was offered ACP services. The social worker stated the facility should have completed a suicide prevention assessment with a PHQ-9 score of 17 and could not find documentation that ACP had been offered. The DON also reviewed the record and stated the facility expected a suicide prevention assessment at that score and expected ACP to be offered to all residents on admission, but could not find documentation that it had been offered to 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 request a follow-up PASRR screening after a new mental health diagnosis was identified for one resident. The resident’s admission record listed diabetes mellitus, anemia, hyperlipidemia, history of transient ischemic attacks, cerebral infarction without residual deficits, and symptoms and signs involving cognitive functioning and awareness, and the initial PASRR completed before admission identified no major mental disorder and an anticipated stay of less than 30 days. The resident later received a diagnosis of unspecified schizophrenia on 2/17/22, and a psych treatment plan dated 2/4/22 listed adjustment disorder, unspecified. Subsequent documentation showed diagnostic impressions updated to other specified schizophrenia spectrum and other psychotic disorder, with treatment notes referencing delusions, paranoia, scattered thought processes, and changes in discharge planning from assisted living to remaining in a long-term care setting. Review of the record through 4/1/22 found no indication that a follow-up PASRR was requested after the new mental health diagnosis, and the medical record lacked documentation of a referral for a subsequent screen. During interviews, the LSW acknowledged an updated Level II screen had not been completed and should have been, and the DON stated that newly diagnosed mental health illnesses after admission were expected to be followed up by social services for necessary screening.

Penalty

No penalty information released

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

Summary

The facility failed to coordinate services for a resident enrolled in hospice who had multiple diagnoses including Alzheimer’s disease, chronic kidney disease stage four, pneumonitis due to inhalation of food and vomit, and oropharyngeal dysphagia. The resident’s hospice plan of care identified skilled nursing visits for symptom management twice weekly, home health aide visits three times weekly, and additional hospice services including social work, chaplain, and music therapy. The resident was observed resting in bed with the head elevated while being assisted with eating by a visiting agency worker and with family present at the bedside. Family members stated they had contracted with a support agency to provide 14 hours per day of care for the resident, including personal care assistance. Facility documentation dated 4/9/26 identified the visiting agency was present, but it did not state the agency’s role, qualifications, frequency of visits, length of visits, or whether the services were contracted and by whom. During subsequent observations, visiting agency staff were present in the resident’s room while the resident rested in bed, and family and agency staff described the agency as providing bedside sitting, oral care, turning, repositioning, and incontinent care. Facility staff were unaware of the scope of the visiting agency’s services and the qualifications of its staff. An LPN stated the agency had been present all week and assisted with turning, positioning, oral care, and safety, while also stating she did not know the agency staff’s training. A CNA and RN stated the agency provided personal care and sought facility assistance as needed, and the RN acknowledged the care plan lacked any indication of this service. The DON stated she believed the agency was present for companionship, was unaware the agency staff were providing personal care or feeding the resident, and had not spoken with the family about implementation of the services. The facility policy for coordination of care was requested but was unavailable.

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 medication error rates remained below 5% for 1 of 3 residents observed during medication administration, resulting in an 8% error rate. During an observed medication pass, RN-A prepared and administered oral medications for R66, including gabapentin 100 mg, but review of the resident’s EMR did not show an active order for gabapentin at that time. RN-A later stated the resident had previously taken gabapentin 200 mg and had been decreased to 100 mg, but after reviewing the EMR, RN-A found an order for pregabalin 100 mg by mouth three times daily instead. The resident did not receive the ordered pregabalin during the observed medication pass. Further review showed gabapentin 200 mg three times daily had been discontinued on 2/3/26, while pregabalin 100 mg twice daily was ordered on 4/2/26 and changed to three times daily on 4/7/26. Staff stated the discontinued gabapentin remained in the medication cart, and the DON said the expectation was for overnight nurses to audit medication carts weekly and remove discontinued medications. The DON also reviewed the resident’s medication cards and sign-out pages and stated it appeared the resident had received several doses of gabapentin instead of the ordered pregabalin between 2/3/26 and 4/15/26.

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 complete and accurate medical records for one resident who was reviewed for mental health practitioner visits. The resident’s quarterly MDS indicated the resident was independent in decision making, could understand others, and could make self-understood, and diagnoses included anxiety, depression, schizophrenia, and PTSD. A facility progress note documented that social work met with the resident to discuss barriers and goals of care and noted that the resident had a therapist he worked with, but no therapist name or appointment details were included. The resident’s EMR did not contain the therapist’s name, dates of appointments, after-visit summaries, or other information regarding mental health care. During interviews, the HUC stated after-visit summaries were kept in the hard chart if not scanned into the EMR, but there was no record in either location. The DON stated the resident’s guardian assisted with appointments and had not always brought back after-visit summaries, and the facility should have followed up with the therapist, though she was unsure whether that had been done. The HUC later stated the facility did not currently have access to the therapist notes and had requested after-visit notes from the providing facility.

Penalty

No penalty information released

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

Summary

The facility failed to implement proper infection prevention and control precautions for two residents reviewed for contact precautions. R16 had diagnoses including multidrug-resistant organism (MDRO) and staphylococcal infection, and the care plan identified use of isolation precautions per protocol. During observation, R16 had a sign indicating enhanced barrier precautions (EBP) outside the room. The infection preventionist later confirmed R16 had MRSA and should have been on contact precautions, and also confirmed the EBP sign was incorrect for R16. The facility policy for contact precautions stated MDRO infections should be considered for residents who have them and proper PPE should be used when entering the resident's room. R64's care plan identified multiple conditions including type 1 diabetes mellitus, malignant neoplasm of the tongue, dysphagia, moderate protein calorie malnutrition, gastrostomy status, altered elimination related to a Foley catheter, and EBP. During observation, two nursing assistants provided personal care while wearing gloves but no gowns, despite EBP signage outside the room. They assisted with dressing, handled the urinary bag and tubing, adjusted clothing over the feeding tube site, repositioned the resident, and placed the catheter bag into the bed bag for privacy. During interview, both nursing assistants stated they should have worn gowns, and the infection preventionist confirmed that EBP requires gown and glove use during high-contact resident care activities.

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 were offered and kept up to date on flu and pneumonia immunizations for 2 of 5 residents reviewed. Facility policy stated influenza vaccination was the primary method for managing influenza and that the facility would follow CDC and Minnesota Department of Health recommendations, and the pneumococcal policy stated the facility would identify residents at risk and offer pneumococcal vaccination according to the current CDC schedule. A CDC pneumococcal timing reference dated 3/15/2023 was reviewed as part of the findings. R60’s EMR showed an admission date of 1/29/26, a diagnosis of Parkinson’s disease, anxiety, and depression, and immunization history including PCV13 on 11/10/16, PPSV23 on 6/20/14, and influenza on 10/20/22. During interview, the IP stated immunization status was reviewed on admission and necessary immunizations were offered, and confirmed R60 should have been offered PCV20 and influenza vaccines. The IP also confirmed there was no documentation in R60’s EMR showing he refused PCV20 or influenza. R69’s quarterly MDS showed an admission date of 12/17/25 and diagnoses of debility, heart failure, respiratory failure, and malnutrition, but the EMR contained no documentation of immunizations received or signed declinations. The IP confirmed R69 had no record of immunizations or declinations and was unsure why R69 had not received immunizations or education regarding immunizations.

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 timely report potential neglect related to a medication error and subsequent hypoglycemic event to the State Agency within 24 hours. A resident with diagnoses including cancer, cardiorespiratory conditions, diabetes, anxiety, depression, asthma, and respiratory failure was discharged from the hospital with orders for insulin Aspart 1–15 units SQ three times daily with meals, dosed according to blood glucose levels. On one day, the resident’s eMAR showed a blood glucose of 355 mg/dl at noon with documentation indicating the insulin was administered, a refusal code, and a notation of 15 units given, and later that day at 5:00 p.m. a blood glucose of 356 mg/dl with 15 units of Aspart administered. That night, nursing notes documented that around 8:00 p.m. the resident was found with cold, clammy hands, weakness, a blood glucose of 52 mg/dl, and was conscious but incoherent and confused, leading to transfer to the hospital. In an interview, an RN stated that at about 2:15 p.m. she heard the resident hysterically crying, checked a blood glucose that was above 200 mg/dl, and immediately administered 15 units of Aspart insulin. She noticed that the day nurse had not recorded the noon insulin dose and instructed that nurse to chart the insulin as given at noon but not to administer it, while she herself documented the insulin as given at 5:00 p.m. even though it was administered around 2:30 p.m. The RN reported that she called the DON around 3:00 p.m. and explained the medication error, and later that evening found the resident incoherent, cold, and clammy with a low blood glucose, treated with juice, and then sent to the hospital. The resident’s IDT note later documented rehospitalization for low blood glucose, including a blood glucose of 33 mg/dl despite facility interventions, and that the resident was unresponsive in the hospital. The DON confirmed being notified by the RN that afternoon that the resident’s blood glucose was over 400 mg/dl and that Aspart had been given at 2:15 p.m., and stated she instructed the RN to document the insulin but gave no further instructions. During the survey, the DON observed that both nurses appeared to have charted the insulin and was uncertain what dose had been given, and acknowledged she did not complete a medication error form, investigate the error, or re-educate the RN. The LPN on duty that day reported he was aware of the resident’s hospitalization for low glucose but was not informed of the incorrect timing of the rapid-acting insulin, was unaware of any medication error report or re-education, and only speculated that the DON might have investigated. The Administrator stated she was not aware of the medication error, confirmed the incident was not reported, and was unsure whether any medication error documentation, investigation, or re-education had occurred. No investigation policy was provided when requested. The facility did not report this potential neglect related to the medication error and resulting hypoglycemia to the State Agency within the required 24-hour timeframe.

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 initiate an investigation into a potential neglect situation after a medication error involving rapid-acting insulin administration to one resident. The resident had multiple pertinent diagnoses including cancer, cardiorespiratory conditions, diabetes, anxiety, depression, asthma, and respiratory failure, and had a BIMS score of 99 indicating non-participation in the assessment. Hospital discharge orders dated 2/24/26 directed that the resident receive insulin Aspart 1–15 units subcutaneously three times daily with meals, with specific sliding-scale doses based on blood glucose levels. On 3/13/26 at 12:00 p.m., the eMAR showed a blood glucose of 355 mg/dl with documentation indicating the medication was administered, a code for refusal, and an entry of 15 units of Aspart insulin given, and at 5:00 p.m. the eMAR showed a blood glucose of 356 mg/dl with 15 units of Aspart insulin administered. According to nursing documentation, around 8:00 p.m. on 3/13/26 the resident was found with cold, clammy hands, weakness, and a blood glucose of 52 mg/dl, with mental status described as conscious but incoherent and confused. Vital signs at that time included blood pressure 139/78, pulse 61, and oxygen saturation 22. The resident was given juice, and blood glucose rose sequentially to 74 mg/dl and then 92 mg/dl, but the resident remained weak and was hospitalized. An IDT note dated 3/16/26 recorded that the team met to review the rehospitalization for low blood glucose, noting a blood glucose of 33 mg/dl despite facility interventions and that the resident was transferred to the hospital for further evaluation and was currently unresponsive there. In an interview, the resident stated she did not recall the events leading up to the hospitalization. In interviews, RN-A reported that on 3/13/26 at about 2:15 p.m. she heard the resident hysterically crying, checked a blood glucose over 200 mg/dl, and immediately administered 15 units of Aspart insulin. RN-A stated she saw that RN-B had not recorded the noon insulin, told RN-B to chart the insulin as given at noon but not to administer it, and that RN-B did so. RN-A also documented the insulin on the eMAR as given at 5:00 p.m., although she administered it around 2:30 p.m. RN-A stated she called the DON around 3:00 p.m. and explained the medication error and was told the DON would correct the eMAR and write a progress note, but she was unsure if this occurred, and she reported that the facility had not addressed the medication error or charting with her. LPN-A, who was on site that day, reported being aware only of the hospitalization for low glucose and denied knowledge of the incorrect timing of the rapid-acting insulin or any medication error report or re-education. The DON acknowledged being informed by RN-A that the resident’s blood glucose was over 400 mg/dl and that Aspart had been given at 2:15 p.m., stated she instructed RN-A to document the insulin, and, upon reviewing the eMAR during the survey, noted it appeared both RN-A and RN-B had charted the insulin and she was uncertain of the dose given. The DON denied completing a medication error form, conducting an investigation, or re-educating RN-A, and the Administrator stated she was not aware of the medication error, that the incident was not reported, and was unsure if any investigation or re-education occurred. No investigation policy was provided 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

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to insulin administration timing and late medication passes. One resident with multiple comorbidities, including diabetes, cancer, cardiorespiratory conditions, anxiety, depression, asthma, and respiratory failure, had orders for insulin aspart on a sliding scale to be given three times daily with meals, and insulin glargine twice daily. On one occasion, a nurse administered 15 units of rapid-acting insulin aspart at approximately 2:15 p.m. in response to a blood glucose level above 200 mg/dl, even though this insulin was ordered to be given with meals and no meal was provided at that time. The nurse did not contact the provider before giving the insulin at this off-schedule time. Documentation on the electronic MAR for that day showed conflicting entries: at 12:00 p.m. the blood glucose was 355 mg/dl with indications that the insulin was both refused and 15 units given, and at 5:00 p.m. the blood glucose was 356 mg/dl with 15 units of insulin aspart documented as administered. The nurse later stated she had instructed the day nurse to chart the insulin as given at noon, even though it was not, and she herself documented the 2:15 p.m. dose under the 5:00 p.m. slot. The DON acknowledged being informed that the insulin had been given at 2:15 p.m. and instructed the nurse to document the dose, but no further instructions were given, and during the survey the DON was unsure what dose had actually been administered due to the conflicting documentation. The nurse manager (LPN) reported he was unaware that the insulin had been given at 2:15 p.m. and stated that the nurse should have contacted him, as giving rapid-acting insulin between meals was a medication error. Later that same day, around 8:00 p.m., the resident was found incoherent, cold, and clammy with a blood glucose in the low 50s mg/dl, and facility documentation noted that the resident required juice to raise the blood glucose and was subsequently sent to the hospital. An IDT note later recorded that the resident had a blood glucose of 33 mg/dl despite facility interventions and was transferred to the hospital, where the resident was unresponsive. The resident later reported not recalling the incident but stated she had been told her blood glucose was very low and that she was glad the hospital discontinued her rapid-acting insulin and kept her on scheduled insulin only. In addition to the insulin timing error, surveyors observed that the same resident’s scheduled 8:00 a.m. medications were administered nearly three hours late. On the survey date, the resident finished breakfast and was still waiting for her morning medications, which included multiple cardiac, anticoagulant, pain, respiratory, and diabetic medications, as well as other routine drugs. At 10:40 a.m., an RN was observed setting up the medications, and at 10:51 a.m. the RN entered the room to administer them, waking the resident to do so. The resident stated that her medications were late again and that she had to be awakened to take them. The RN acknowledged to the resident that the medications were late and proceeded with administration. The resident reported that her medications were given late a few times a week and that when medications such as insulin, pain medication, and Mucinex were more than an hour late, it affected her pain control and breathing. The resident’s NP stated that rapid-acting insulin aspart should not be given between meals because it can significantly lower blood glucose without accompanying food, and that the nurse should have called the provider if there was a need or request to administer insulin at an off-schedule time. The NP also stated the expectation that medications be administered within one hour before or after the scheduled time, or that times be changed if this could not be met. The pharmacist stated that the resident’s glargine insulin and Mucinex should be given as close to 12 hours apart as possible for optimal diabetic and COPD control, and that keeping pain medications on schedule helps prevent pain from becoming severe and harder to manage. The DON and Administrator both acknowledged that giving the insulin at the incorrect time and administering the morning medications almost three hours late constituted medication errors. The facility’s standing orders document did not include an intervention for hyperglycemia treatment related to sliding scale insulin.

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 maintain accurate medical records for one resident when documenting administration of insulin aspart. The resident had hospital discharge orders for rapid-acting insulin aspart 1–15 units SQ three times daily with meals, with a sliding scale based on blood glucose levels. On a specified date, the resident’s eMAR at 12:00 p.m. showed a blood glucose of 355 mg/dl, a check mark indicating the insulin was administered, a code indicating the resident refused the insulin, and an entry that 15 units were given. The same day at 5:00 p.m., the eMAR documented a blood glucose of 356 mg/dl and administration of 15 units of insulin aspart. The resident’s diagnoses included cancer, cardiorespiratory conditions, diabetes, anxiety, depression, asthma, and respiratory failure, and the MDS indicated the resident did not participate in the BIMS assessment. During interview, an RN stated that around 2:15 p.m. that day she administered 15 units of insulin aspart, knew the timing was not as ordered, and told another nurse to document that it had been given at noon because the resident had refused it at that time. That second nurse documented at 12:00 p.m. that the insulin was refused but also that 15 units were administered, while the first RN documented 15 units as given at 5:00 p.m. A LPN denied knowledge that the insulin had actually been given at 2:15 p.m. and that the eMAR showed administration at 12:00 p.m. and 5:00 p.m. The DON reported being called between 2:30 p.m. and 3:00 p.m. and informed that the resident’s blood glucose was over 400 mg/dl and that insulin had been given at that time, and upon later review of the eMAR, the DON stated both nurses had charted the insulin as administered and was uncertain of the actual dose. The Administrator stated she was not aware that the insulin was administered at 2:15 p.m. but documented as given at 12:00 p.m. and 5:00 p.m. A medical records policy was 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 deficiency involves failure to keep medications stored securely in a medication cart on the 400 unit. During an observation, an employee identified as E-I walked away from a medication cart in the hallway between resident rooms, leaving it unlocked and unattended from 12:27 p.m. to 12:37 p.m. During this time, one resident wheeled by the cart and two nursing assistants walked past it. The Director of Social Services checked only the narcotics drawer, confirmed it was locked, and then left, while the rest of the cart remained unlocked. E-I later acknowledged that the cart was unlocked when she left and stated it should have been locked to prevent other staff and residents from taking medications from the cart, which could make them sick. In a separate observation the same day at 2:27 p.m., the same medication cart on the 400 unit was again found unlocked and unattended in the hallway between resident rooms. From 2:27 p.m. to 2:47 p.m., nursing assistants walked by the unlocked cart five times. At 2:47 p.m., the DON walked by, pushed the lock to secure the cart, and stated it was not good that the cart was unlocked, that medications could go missing, and that the cart was supposed to be locked when staff walked away. The facility’s Storage of Medications policy dated May 2022 stated that the medication supply was accessible only to licensed nursing personnel or staff lawfully authorized to administer medications, and that medication carts were to be locked when not attended by authorized personnel.

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 found that the facility failed to develop and implement an adequate baseline (48-hour) care plan for a newly admitted resident with significant pain and a chronic pressure ulcer, and failed to provide a summary of that plan to the resident or representative. On admission, nursing assessment documented that the resident had frequent moderate pain over the prior five days, rated 5/10, which made it hard to sleep and limited day-to-day activities. The assessment also identified a wound on the coccyx, described as an opening on the right buttock, and progress notes documented admission with a chronic Stage IV sacral ulcer. A PT evaluation noted that pain interfered with functional activity and sleep and indicated that nursing would address the pain. A provider progress note and subsequent pain ratings showed ongoing pain scores ranging from 5/10 to 8/10 over the first several days after admission. Despite these findings, the 48-hour baseline care plan dated two days after admission only indicated that the resident experienced pain, without including any interventions to relieve that pain. The baseline care plan also noted the resident was on Enhanced Barrier Precautions related to wounds but did not document that the resident had skin issues or specify interventions to treat the wounds. The care plan further failed to indicate whether the resident or the resident’s family/representative was offered a copy of the 48-hour care plan or given the opportunity to sign it. Staff interviews confirmed that pain, pressure ulcers, and related interventions should be included on the baseline care plan and that residents should be offered a copy and the opportunity to sign. The facility’s own baseline care plan policy stated that the baseline care plan should include any services and treatments to be administered by the facility until a comprehensive assessment and person-centered care plan are developed.

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 comprehensively develop and implement a care plan for a resident with a diagnosis of malnutrition and poor nutritional intake. The resident’s admission MDS showed intact cognition, a need for set-up assistance with meals, and diagnoses including pneumonia and malnutrition. The care plan dated 2/2/26 identified a potential nutritional problem related to moderate malnutrition and included interventions such as assisting with meal set-up, recording nutritional intakes, taking orders at meals, and offering alternatives. However, the care plan did not include specific interventions for when the resident did not eat meals, nor did it provide direction on when to offer the ordered nutritional supplement. The care plan also lacked documentation of the resident’s food preferences. On observation, the resident was seen eating only a small portion of a noon meal, using fingers to eat a few bites of fish, drinking fluids, and not consuming the pasta and vegetables, stating she did not like the meal. One staff member removed the tray after confirming the resident was done, estimated intake at about 10%, and acknowledged knowing the resident disliked the facility food but did not offer an alternative or assistance, and had not reviewed the care plan. Another staff member charted that the resident ate 50% of the meal without having seen the resident eat or removed the tray, later admitting this was inaccurate and that actual intake was about 25%. This staff member also acknowledged not offering assistance or an alternative food choice despite typical practice to do so. Review of the care plan days later confirmed it had not been updated with interventions for poor intake or food preferences, and the resident reported staff had not asked about her food preferences. The DON stated that documentation showed 50–75% intake for that meal and described expectations that staff offer alternatives, notify appropriate clinical staff, and increase monitoring when a resident does not eat well, but acknowledged this was not done and that such interventions were expected to be in the care plan.

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 ordered pressure ulcer prevention interventions for residents identified as at risk. One resident with severe cognitive impairment, right-sided paralysis, diabetes, and a brain tumor was care planned to have heels floated with a pillow and to be turned and repositioned every two to three hours and as needed, and had provider orders for weekly skin inspections and an air mattress to prevent skin breakdown. Progress notes documented that this resident could only make slight body position changes and had friction and shear identified as a potential problem, but the care plan did not include precautions for friction and shear despite this documented risk. Hospice notes described poor skin turgor and anasarca, and the resident’s family reported that staff’s method of turning consisted of placing a towel under the shoulder, which hospice staff considered inadequate, while an employee stated a towel alone could not properly position a resident and that pillows should be used. Another resident, admitted with intact cognition but at risk for pressure ulcers, had diagnoses including malnutrition, pneumonia, and respiratory failure, and was ordered to receive TED hose daily and ACE wraps in the morning and off at bedtime for edema management, along with a care plan for turning, repositioning, and offloading every two to three hours and as needed. Provider documentation noted significant lower extremity edema and weight gain related to fluid retention. During an extended observation period, this resident remained on her back with the head of the bed elevated, feet resting directly on a pillow, and another pillow placed on top of her feet, which she described as feeling heavy. At that time, she was not wearing the ordered TED hose or ACE wraps, her socks were leaving indentations in her swollen feet, and her heels were on the pillow rather than floated off the bed. The nurse acknowledged the resident’s edema, the risk of sores from tight socks, that the heels were not properly floated, and that the resident was not wearing TED hose as ordered, and admitted having placed the pillow on the feet earlier and forgetting to remove it. The facility’s policy required implementation of appropriate preventive skin measures, including mobility, repositioning, and pressure redistribution plans, and updating the care plan to identify risks for skin breakdown.

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 safe transfers and adequate supervision when a nursing assistant (NA-A) transferred a resident (R5) alone using an EZ Stand mechanical lift, despite the resident’s care plan and facility practice requiring two staff for all mechanical lift transfers. R5’s annual MDS indicated intact cognition, dependence on staff for all transfers, and diagnoses including heart failure and morbid obesity. R5’s care plan dated 6/3/24 documented the need for assistance of two staff with the EZ Stand and identified a risk for falls related to impaired mobility, and a subsequent care plan dated 9/3/24, as well as orders dated 2/10/26, specified “care in pairs.” Provider notes documented that R5 weighed 543 pounds. During an observation, surveyors saw NA-A exit R5’s room alone with the EZ Stand after R5 thanked her for helping her out of bed, with no other staff present in or near the room. In interviews, R5 confirmed that only NA-A assisted with the EZ Stand transfer and reported that staff sometimes used one person instead of two when another staff member could not be found. Staff member E-J stated that R5 required two staff for EZ Stand transfers and that all residents using mechanical lifts required two staff. NA-A acknowledged transferring R5 without a second staff member, stated she was aware R5 was supposed to have care in pairs due to past allegations against staff, and admitted she should have waited for help and that she knew she could get in trouble and that injury could occur without another staff present. Another employee, E-D, stated R5 always transferred with two staff for safety and that if she observed a one-person EZ Stand transfer, she would educate the staff on safe transfer procedures. The DON confirmed that all mechanical lifts in the facility required two staff for safe transfers and that staff could seek assistance from various nursing personnel or wait for help. The facility’s Fall Prevention and Management policy indicated staff would identify and implement relevant interventions to minimize serious consequences of falling.

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 sufficiently manage pain and implement or document non-pharmacological pain interventions for a resident admitted with frequent, moderate pain. On admission, the resident’s nursing assessment documented pain rated 5/10 over the prior five days, interfering with sleep and daily activities, and the PT evaluation and provider notes also identified pain that interfered with function and sleep. The resident had a diagnosis of transverse myelitis and a history of long-term opioid use, but arrived without an order for her usual Percocet. Initial documentation on the day of admission noted pain rated 5/10 but did not indicate what pain interventions were provided. Over the following days, the resident’s pain scores ranged from 5/10 to 9/10, with multiple documented assessments showing moderate to severe pain. Provider orders were obtained for a lidocaine 4% patch and PRN oxycodone-acetaminophen 10-325 mg every six hours, with the first Percocet dose administered two days after admission. Nursing progress notes and the MAR showed administration of Percocet for pain scores of 6/10 and 9/10, and one note indicated the medication was effective, but the records consistently lacked documentation of non-medication pain interventions attempted before or along with opioid use. The resident’s 48-hour baseline care plan noted admission with pain but did not include specific interventions to relieve pain, while the subsequent care plan listed non-medicinal interventions such as positioning, rest, and massage without evidence in the notes that these were implemented or documented. Interviews with staff, including the DON, confirmed that facility expectations and the written Pain Management Protocol required pain assessment on admission, use and documentation of non-pharmacological interventions, and obtaining alternative medications or interventions if there was a delay in pain medication. Staff acknowledged that non-medication interventions and thorough pain assessments, as well as documentation of interventions and resident responses, were not carried out or recorded for this resident 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 facility failed to ensure nurses were timely and competently trained on the administration of oral and sublingual medications for a resident with complex needs. The resident had frontal lobe brain cancer, was significantly cognitively impaired, dependent for ADLs, had difficulty or pain with swallowing, and was receiving scheduled and PRN pain medications. Hospice notes documented that during the early morning hours, a facility nurse contacted hospice to request discontinuation of all medications because the resident was having difficulty swallowing, including Synthroid and morphine. Hospice staff educated the nurse that lorazepam and morphine were comfort medications and could still be administered. Later that morning, hospice documented that the resident’s family requested morphine and lorazepam be given as a slurry, and provider orders were written for lorazepam soluble and morphine solutab, including an order allowing the medications to be slurried in a small amount of water and given sublingually. Despite these orders, hospice documentation and interviews showed that facility staff did not understand how to properly administer solutab and sublingual medications or slurries. Hospice reported that staff were providing solutab comfort medications mixed with applesauce, which drained out of the resident’s mouth when the resident was unable to swallow, and that staff had requested discontinuation of comfort medications because they did not know the medications dissolved in the mouth without swallowing. The resident’s family member reported witnessing staff trying repeatedly to get the resident to swallow morphine solutabs, during which the resident coughed and gurgled. Multiple licensed nurses interviewed later stated they did not know what sublingual medication was, confused it with liquid medication, and did not know what a slurry was. One nurse stated that for hospice patients she had them swallow medications ordered to be slurried and given sublingually. The DON described how a slurry should be prepared and administered but the facility’s pain management policy did not contain instructions on sublingual or slurried pain medication administration, and a medication administration policy was 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

A significant medication error occurred when a resident was administered 40 mg of methadone, which was 16 times the prescribed dose of 2.5 mg. The error originated from a handwritten order by a hospice RN, which incorrectly indicated the volume to be administered and did not comply with Board of Pharmacy requirements for prescription clarity. The order was then transcribed into the electronic health record as 4 mL instead of the correct 0.25 mL, due to misinterpretation of the handwriting and lack of a leading zero. The medication bottle from the pharmacy had a different instruction, indicating a dose of 0.5 mL (5 mg), further adding to the confusion. The resident, who had no cognitive impairment but was dependent on staff for activities of daily living and had diagnoses including a femur fracture and COPD, received the incorrect dose via g-tube. The nurse administering the medication noticed the discrepancy between the MAR and the medication bottle but proceeded to give the dose listed in the MAR, believing it to be the most current order. The nurse did not seek clarification despite the mismatch. The double-check process for new orders was not completed, as the order sheet was left next to the computer without verification by another nurse, contrary to facility protocol. Following administration, the resident exhibited symptoms of opioid overdose, including lethargy, low respiratory rate, low oxygen saturation, and unresponsiveness. Narcan was administered at the facility, and the resident was transferred to the hospital, where they required intensive care and a continuous Narcan infusion due to persistent symptoms of methadone overdose. Interviews with staff confirmed that the medication should not have been administered when discrepancies were noted, and that the double-check process was not followed due to a busy shift.

Removal Plan

• Suspend the nurse who administered the incorrect dose and educate all nurses.
• Educate the nurse manager on clarification of any orders that are scribbled, dose increase that is too high or the handwriting is not legible.
• Educate the nurse who administered the incorrect dose that whenever a discrepancy on the MAR and the medication bottle or bubble pack, the order must be clarified, and the medication should not be administered.
• Educate hospice agency nurse related to transcription error and conflicting orders from the hospice doctor and the nurse.
• Revise hospice agency procedure for ordering medications.
• Audit all hospice residents' provider orders and correct any errors. Audit all new orders.
• Educate all licensed nursing staff/contracted agency nurses on the rights of medication administration, transcription of medications, processing of medications, narcotic administration and side effects, and what to do when a med error occurs. Ensure all staff receive education before their next shift.
• Develop a system to ensure appropriate transcription and order double check. Nurses confirm knowledge of the new transcription procedure into the electronic health record system. Add triple check of all new orders to the night shift nurse duty list.
• Review policies and procedures related to medication administration, transcription, and transcription errors.
• Review hospice contracts for medication management.

Penalty

No penalty information released

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

Summary

The facility failed to revise the care plan for a resident with multiple diagnoses, including Down syndrome, right shoulder dislocation, Alzheimer's, dementia, intellectual disabilities, and epilepsy, to include an individualized intervention—a fall mat—despite its use at the bedside. The resident was identified as a fall risk due to her medical conditions and history of a fall prior to admission. The care plan, developed after admission, included general fall prevention interventions such as following therapy instructions, monitoring safety, and reviewing past falls, but did not specify the use of a fall mat as an intervention. Observations confirmed that a fall mat was present by the resident's bed, and staff interviews revealed that the mat was used as a precaution because the resident was known to roll out of bed, although she had not fallen since admission. Multiple staff members, including a nursing assistant and registered nurses, acknowledged the presence and purpose of the fall mat but confirmed that it was not documented in the resident's care plan. The facility's care planning policy requires individualized, person-centered care plans developed by the interdisciplinary team, but this intervention was omitted from the written plan.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was comprehensively assessed for self-administration of medications. The resident, who had diagnoses including Type 2 diabetes mellitus, dermatitis, prurigo, and bipolar disorder, was noted to have intact cognition and required staff assistance with activities of daily living. The resident's care plan directed staff to administer medications per orders but did not include any direction or assessment for self-administration of medication. There was no provider order for lidocaine 4% gel or for self-administration, and the electronic health record did not contain an assessment for self-administration of medication. Observations revealed that a container of Tylenol lidocaine 4% was present and accessible in the resident's room, and the resident reported self-applying the medication for shoulder pain. Nursing staff observed the medication in the room on multiple occasions but did not remove it or address its presence. Interviews with staff confirmed that an assessment and provider order are required for self-administration, and that the medication should be documented in the medication administration record. The nurse manager and regional nurse consultant were unaware of the medication's presence and stated that staff are expected to act if such medications are found. The facility was unable to provide a policy for self-administration of medication.

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

Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.

Penalty

No penalty information released

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

Summary

The facility failed to adequately assess and monitor non-pressure related skin abrasions for a resident with a history of Type 2 diabetes mellitus, dermatitis, prurigo, bipolar disorder, and previous MRSA skin infection. Despite the resident's care plan instructing staff to monitor skin integrity and report concerns, documentation and observation revealed that open and scabbed lesions on the resident's right lower extremity (knee to thigh) were not identified, assessed, or documented in a timely manner. Weekly skin inspection records and nursing progress notes did not reflect the presence of these lesions, and staff interviews confirmed that the lesions had been present for several days without being reported to the provider or nurse manager. Nursing assistants and registered nurses were unaware of the new and existing lesions until prompted by surveyor observation and interviews. The nurse manager confirmed that there was no documentation or provider notification regarding the new and scabbed lesions, despite the resident's history of skin infections. The facility's process for monitoring and reporting non-pressure related skin concerns was not followed, as evidenced by the lack of timely assessment, documentation, and communication among staff regarding the resident's skin condition.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to ensure that a resident received recommended dental services. The resident, who was cognitively intact and independent with activities of daily living, was identified as edentulous and at risk for nutritional deficits. Despite being aware of his need for dentures and expressing dissatisfaction with having no teeth, the resident had not received dentures and was not informed about the status of obtaining them. Documentation showed that the dental group initially did not proceed with denture fabrication because the resident was expected to be discharged soon, as communicated by the social worker. However, when the resident remained in the facility beyond the anticipated discharge date, there was no evidence that the dental group was updated about the change in the resident's status. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's dental needs. The social services staff did not have direct contact with the dental service and did not notify them when the resident's discharge plans changed. The medical records director was unaware if the upcoming dental exam would address the denture issue and could not find documentation of any update to the dental group. The LPN confirmed that the resident had repeatedly expressed his desire for dentures. Additionally, the facility was unable to provide a policy or procedure regarding dental 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

The facility failed to ensure that nail care was completed for a resident who was dependent on staff for activities of daily living (ADLs). The resident had multiple diagnoses, including Type 2 diabetes mellitus, dermatitis, prurigo, and a history of MRSA skin infection, and required staff assistance with ADLs. Observations over several days revealed that the resident's fingernails were excessively long, with a dark, brown substance underneath, and the resident had open lesions from scratching. Documentation showed no evidence that the resident refused nail care or assistance with cleaning under the nails during the review period, and there was a lack of progress notes indicating refusals or attempts to provide nail care. Interviews with nursing staff and nursing assistants confirmed that nail care for diabetic residents was the responsibility of licensed staff, while cleaning under the nails was to be performed by nursing assistants. Both groups acknowledged the importance of maintaining clean and trimmed nails, especially given the resident's history of skin infections and scratching. However, staff were unable to recall recent attempts to clean the resident's nails, and there was no documentation of refusals or completed care. The facility's policy for nail care was 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 notify a resident's physician of the deterioration of a non-pressure related skin wound. The resident, who was admitted with multiple diagnoses including a non-pressure chronic ulcer of the left heel, diabetes, and morbid obesity, had a care plan and treatment orders in place for a diabetic foot ulcer. Over the course of several weeks, wound care documentation and photographs showed that the resident's left heel ulcer increased in size, developed additional open areas, and exhibited worsening periwound erythema. Despite these changes, there was no documented notification to the resident's primary care physician or nurse practitioner regarding the wound's deterioration. Interviews with facility staff, including a nurse manager (LPN), a registered nurse, and the DON, confirmed that the wound had worsened and that the primary care provider should have been notified. The LPN acknowledged that the wound was no longer improving and appeared worse compared to previous evaluations, but could not provide documentation that the physician had been informed. The nurse practitioner covering for the resident's usual provider also confirmed there was no documentation of notification and stated that such notification would be expected when a wound increases in size or develops new open areas. Facility policy required that changes in a resident's condition, including wound deterioration, be promptly reported to the attending physician and documented. However, the review of records and staff interviews indicated that this notification did not occur, and there was no evidence of updated treatment orders or changes to the plan of care in response to the wound's decline.

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 professional standards of practice for treatment orders were followed for two residents with non-pressure related skin wounds. In the first case, a resident with a surgical wound and wound VAC therapy was discharged from the hospital with detailed wound care orders, including specific instructions for dressing changes and the application of an alginate dressing to protect the periwound area. These orders were not transcribed into the facility's electronic health record (EHR), and the wound care provided did not follow the hospital's instructions. Observations confirmed that the required dressing components were missing, and the nurse responsible was unaware of the detailed orders. The nurse manager and DON both confirmed that the orders had not been transcribed and that the wound care provided was not in accordance with the physician's instructions. In the second case, another resident with a surgical incision following orthopedic surgery was seen by an orthopedic provider, who gave specific wound care orders, including allowing Steri-Strips to fall off naturally and permitting the incision to get wet in the shower. These orders were documented in the resident's paper chart but were not transcribed into the EHR. The nurse manager confirmed that only monitoring orders were present in the EHR and that the specific wound care instructions from the orthopedic provider were missing. The DON acknowledged that the facility was reviewing charts to ensure all post-appointment orders were transcribed. Facility policy required that treatment orders be transcribed accurately and in a timely manner and that ongoing treatments for skin issues follow provider orders. Despite these policies, the failure to transcribe and implement the detailed wound care orders for both residents resulted in care that did not meet professional standards. Interviews with nursing staff and management confirmed that the lack of transcription could disrupt the continuous plan of care and lead to inappropriate wound management.

Penalty

No penalty information released

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

Summary

The facility failed to comprehensively assess non-pressure related skin wounds for two of three residents reviewed, and did not administer wound treatments in accordance with physician orders for one resident. One resident with a surgical wound and wound VAC to the right buttock experienced a malfunction of the wound VAC device, resulting in the application of a wet-to-dry dressing without a corresponding physician order or documented provider notification. After hospital readmission, this resident returned with a suction burn injury to the periwound area, but the facility did not complete a comprehensive assessment of this new wound, nor did they transcribe or follow the detailed hospital discharge wound care orders, including specific dressing change instructions and use of alginate dressing. Documentation of wound assessments repeatedly lacked details about the new suction injury, and wound care was not performed as ordered. Another resident with a surgical incision to the right hip following orthopedic surgery was not comprehensively assessed upon admission or during subsequent wound evaluations. Initial and weekly wound assessments lacked measurements and did not include required details such as wound bed description, periwound condition, or evidence of infection. The nurse manager confirmed that the wound assessments were incomplete and did not meet the standard for a comprehensive evaluation. A third resident with a diabetic foot ulcer had weekly wound care provider notes and corresponding evaluations that included wound measurements and progress, but the documentation consistently omitted required details in the wound bed, exudate, periwound, pain, and treatment sections. Additionally, there was a failure to identify deterioration of the wound, as the wound size increased over time without documentation of this change or a comprehensive assessment of the wound's status. These deficiencies were identified through observation, interview, and document review.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete, accurate, and up-to-date medical records for a resident who was receiving wound care for a non-pressure related skin injury. The resident had a history of a non-pressure chronic ulcer of the buttock, recent major surgery for repair of a deep ulcer, and required a wound VAC with specific dressing change orders. Documentation was missing for several wound care treatments, including a wound VAC dressing change performed by a wound care provider, a wet-to-dry dressing change performed by an LPN after the wound VAC device failed, and a subsequent wound VAC dressing change performed by an RN prior to the resident's transfer to the hospital. Additionally, there was no physician order documented for the wet-to-dry dressing that was applied when the wound VAC failed. Interviews with nursing staff and the nurse manager confirmed that these treatments were not documented in the resident's medical record or treatment administration record (TAR), and that the medical record was therefore incomplete and inaccurate. The nurse manager and interim DON both acknowledged the importance of accurate documentation for continuity of care and confirmed that the expected documentation was missing. The facility's policy regarding the contents of medical records was 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 develop and implement a comprehensive discharge plan for a resident, resulting in the resident being discharged without necessary services and medications. The resident, who was cognitively intact and required moderate assistance for daily activities, was discharged without a personal care assistant (PCA) due to an incomplete waiver evaluation. Additionally, the facility incorrectly transcribed orders, providing a home health aide instead of a skilled nurse, and failed to correctly order the resident's medications and dialysis. The resident's community case manager repeatedly communicated with the facility's social worker to ensure the necessary services were in place for the resident's discharge. However, the facility did not complete the CADI waiver assessment, leading to the resident being discharged without PCA services. The resident also missed a dialysis appointment and a primary care physician appointment due to the lack of assistance and incorrect scheduling by the facility. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's discharge needs. The social worker admitted to faxing medication orders to an incorrect pharmacy and did not verify the completion of the orders. The nurse practitioner intended for the resident to receive skilled nursing services, but this was not communicated effectively, resulting in the resident receiving inadequate care upon discharge. The facility's discharge planning policy was not followed, leading to significant gaps in the resident's post-discharge care.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a current Clinical Laboratory Improvement Amendments (CLIA) waiver, which is necessary for performing blood testing. This deficiency was identified during a review of the facility's certifications, which revealed that the CLIA waiver had expired and there was no updated certificate on file. The administrator confirmed that the facility was in the process of renewal but lacked documentation of the application for renewal. This oversight had the potential to affect residents who required routine blood glucose monitoring. The report specifically identified numerous residents who were receiving blood glucose monitoring for conditions such as Diabetes Mellitus Type II and other diabetes-related diagnoses. These residents had varying frequencies of blood glucose monitoring, ranging from daily to four times a day. The absence of a current CLIA waiver could impact the quality and reliability of the blood testing services provided to these residents. Additionally, the facility did not have a policy available for the maintenance of the CLIA waiver, as confirmed by the administrator.

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 physician orders for a resident with end-stage renal disease and diabetes, leading to inadequate nutritional intake. The resident, who was cognitively intact and had a complex medical history including anemia, peripheral vascular disease, and a history of skin integrity issues, was supposed to receive a regular diet with double meat/protein portions. However, during an observation, the resident was served a single sandwich without the prescribed double portion of meat, and the tray ticket did not indicate the need for double meat/protein. The resident expressed dissatisfaction with the meal portions and mentioned having to purchase additional food independently to meet his nutritional needs. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's dietary orders. The nutritional consultant stated that residents with orders for double meat/protein should automatically receive double portions, but this was not reflected on the resident's tray ticket. The clinical manager and assistant director of nursing confirmed the oversight and acknowledged the need for staff education to ensure dietary orders are accurately documented and followed. The registered dietitian amended the resident's tray ticket after being informed of the issue, but also noted that the resident frequently consumed outside food, which was not always in line with his dietary restrictions.

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 community-use glucometer was properly cleaned and disinfected between resident uses. During an observation, an LPN used an alcohol wipe to clean the glucometer after performing a blood sugar reading for a resident. The LPN then placed the glucometer back in the medication cart without using the appropriate disinfectant. The RN and DON later confirmed that the correct procedure involved using a purple top Sani wipe with a two-minute kill time, not an alcohol wipe, to clean the glucometer. The deficiency was identified when the LPN was observed using the glucometer for a resident and then cleaning it improperly. The RN and DON both stated that the facility's protocol required the use of a specific disinfectant wipe, which was not followed in this instance. The instruction manual for the blood glucose monitoring system also indicated that an EPA-registered disinfectant should be used, and if blood was visible, two wipes should be used—one for cleaning and one for disinfecting.