Chariton Park Health Care Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide protective oversight and complete ordered 15‑minute safety checks for a known elopement‑risk resident, resulting in an undetected elopement through the resident’s room window. The resident had multiple psychiatric and behavioral diagnoses, including schizoaffective disorder, psychoactive substance abuse, suicidal ideations, mood disorder, ADHD, opioid abuse, anxiety disorder, and insomnia due to another mental disorder. The resident’s PASRR and care plan documented a long history of mental health issues, substance use, homelessness, prior overdoses, abuse history, and a need for ongoing psychiatric care, low‑stimulation environment, consistent routines, and environmental supports to prevent elopement. Facility assessments, including elopement risk evaluations, identified the resident as at risk for elopement, with a documented history of elopement from prior secured facilities and from home, as well as prior elopement from this facility shortly after admission. The facility’s own elopement and intensive monitoring policies required systematic identification and monitoring of residents at risk for elopement, including intensive monitoring and 15‑minute checks for residents with poor impulse control or elopement ideation. The resident’s elopement risk evaluation showed an increasing risk score over time, and nursing notes documented the resident’s agitation, drug‑seeking behavior, difficulty with redirection, and multiple attempts to get out the door. Staff documented that the resident was on intensive monitoring with every 15‑minute face checks, and the care plan called for completion of elopement risk assessments and face checks/intensive monitoring. On the day of the incident, staff recognized that the resident was “spiraling,” irritated, and had verbalized intent to run away and had attempted to open a door earlier in the day. Despite this, the 15‑minute checks were not consistently or timely completed as ordered, and staff responsible for the checks acknowledged being behind on face checks due to a busy day and documenting checks when they had time rather than at the required intervals. During the period when the resident was supposed to be under 15‑minute face checks, the resident used a metal watch band to loosen and remove the screws from a rubber security block in the windowsill, slid open the side window, pushed out the screen, and exited into a fenced courtyard. The resident reported that it took about an hour to remove the block and open the window and that he closed the curtain when staff entered the room so they would not notice his actions. Staff performing checks reported that they completed face checks by opening the door and seeing if the resident was in the room, without observing what the resident was doing. After exiting into the courtyard, the resident moved a picnic table next to the building, stood on it, climbed onto the roof, crossed the roof, jumped down into an open area outside the fenced courtyard, and walked several blocks down city streets. Facility staff were unaware the resident had eloped until an off‑duty employee saw the resident walking in pajamas and a coat and notified the facility, and a police officer subsequently made contact with the resident, who admitted leaving the facility through the window and walking away.

Removal Plan

• Transferred Resident #1 to the hospital by ambulance per the resident's request after the elopement event
• Placed Resident #1 on one-on-one observation for safety upon return to the facility
• Notified the resident's guardian and physician of the elopement
• Arranged psychiatric services evaluation for Resident #1
• Implemented additional interventions to ensure the security of Resident #1's window as well as all windows in the facility
• Secured the courtyard picnic table to the concrete patio
• Educated all staff regarding the resident elopement policy, residents at risk for elopement, and intensive monitoring procedures
• Educated staff on documentation requirements for face checks and window security

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services to a resident with serious mental illness, a history of trauma, and known coping mechanisms, resulting in multiple self-harm incidents. The resident had diagnoses including schizoaffective disorder, mood disorder, ADHD, PTSD, opioid abuse, anxiety disorder, and insomnia, with a documented history of severe bullying, sibling suicide, homelessness, substance abuse, and the death of a child. The PASRR and care plan identified the need for a low-stimulation environment, consistent routines, psychotherapy, ongoing psychiatric care, and person-centered, trauma-informed interventions. The care plan also directed staff to monitor for anxiety, avoid power struggles, provide opportunities for healthy energy release, and use non-invasive coping mechanisms before behavioral outbursts. Staff were aware that the resident’s coping mechanisms included watching calming television programs (especially Animal Planet), gaming, music, and writing in notebooks. On one occasion, the resident’s guardian reported that the resident had voiced self-harm ideations, after which the resident was placed on one-on-one supervision and staff were instructed to search the room and remove harmful objects. Items with cords, including the television, gaming system, power cords, shoelaces, and hoodies with strings, were removed from the room. Two days later, while on one-on-one observation, the resident repeatedly requested the return of the television to watch Animal Planet, a known coping mechanism, and repeatedly asked to see the Environmental Services Supervisor to help get the television back. The one-on-one staff member assigned that day had never previously provided one-on-one observation and understood their role as only to prevent the resident from hurting self or others. The staff member did not provide additional interventions or access to the television, and the Social Services Designee later stated there was no reason to keep the television and personal items from the resident while on one-on-one observation and was not aware of the resident’s repeated requests or escalating distress. As the resident’s requests for the television went unmet and the Environmental Services Supervisor was unavailable, the resident became increasingly agitated, knocked over linen carts, threw items in the hallway, and then went to the room and broke the inside pane of the double-pane window. The resident sat on the bed surrounded by glass, picked up a shard, and cut the left forearm from elbow to wrist, requiring emergency transport for medical and psychiatric evaluation. After the resident’s return from the hospital, staff failed to ensure the room was free of remaining glass shards. The resident later found glass in the windowsill and under the bed on separate occasions, cutting the same forearm multiple times while alone in the room. Staff documentation and interviews confirmed that shards remained in the windowsill and curtain area and that the room had not been thoroughly cleared of glass before the resident’s return. Although the care plan was updated to include high suicide risk and the need for a written safety plan and specific self-harm interventions, the record showed no evidence that staff collaborated with the resident to develop the written safety plan as directed. These actions and inactions demonstrate the facility’s failure to implement care-planned, person-centered behavioral health interventions, to maintain a safe environment free of known hazards, and to provide necessary services to support the resident’s highest practicable mental and psychosocial well-being. The deficiency is further supported by staff and resident interviews describing the mismatch between the resident’s identified needs and the care actually provided. Staff acknowledged that the resident’s coping mechanisms included watching calming animal shows and gaming, and that removal of personal items, including the television, increased the resident’s agitation. The resident reported feeling that staff had taken away all coping mechanisms, leaving nothing to do while on one-on-one observation, and stated that close proximity and talkative staff increased anxiety. The resident described breaking the window with a metal cup, cutting the left forearm to obtain transfer to the hospital, and later intentionally searching the windowsill and under the bed for glass shards to cut the arm again. The Social Services Designee confirmed that glass shards from the initial incident remained in the room and that staff did not thoroughly clean the room before the resident’s return. Additionally, although the care plan called for development of a written safety plan and teaching alternative coping skills, the record contained no documentation that such a written safety plan was created with the resident, indicating a failure to implement the care-planned intervention for managing self-directed violence 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 follow proper immediate discharge procedures for a resident who exhibited increased aggressive behaviors, including multiple physical assaults on staff. After a series of incidents involving physical aggression, law enforcement intervention, and psychiatric evaluation, the resident was sent to a hospital. The facility then determined it could not meet the resident's needs and issued an immediate discharge notice while the resident was at the hospital. However, the discharge notice identified the psychiatric hospital as the discharge location, which did not meet regulatory requirements for specifying an appropriate discharge location. The facility's policy required that, in cases of emergency transfer and subsequent discharge, the discharge location must be properly identified and the resident's status must be evaluated based on their condition at the time of transfer. Despite this, the facility did not amend the immediate discharge notice to reflect an appropriate discharge location after being informed of the error. The discharge letter was also improperly dated, and there was no documentation explaining why the resident was taken into custody on one of the dates in question. The resident, who had a guardian, remained in the hospital pending a hearing after the discharge was appealed. The facility had attempted to find an alternative placement for the resident for several months but was unsuccessful due to the resident's aggressive behaviors. The failure to properly identify a discharge location and to amend the discharge notice as required constituted the deficiency cited in the report.

Penalty

Fine: $47,740

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 documented history of serious mental illness, including schizophrenia, bipolar disorder, and intermittent explosive disorder, was admitted to the facility with known aggressive and assaultive behaviors. The resident's PASRR and care plan indicated a need for 24-hour protective oversight and specific environmental and supervision interventions to prevent harm to self or others. Despite these documented needs, the resident was on 15-minute face checks rather than continuous supervision at the time of the incident. On the day of the event, the resident entered a vending room where two other residents were present. Without provocation, the resident forcefully slammed another resident's head against a vending machine and struck the resident multiple times in the face with a closed fist. The assaulted resident sustained lacerations to the right eyebrow and upper lip, both requiring sutures. Multiple witness statements and progress notes confirmed the unprovoked nature of the attack and the injuries sustained. The facility's abuse and neglect policy required assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as sufficient staff deployment and supervision to prevent abuse. However, the interventions in place at the time did not prevent the resident with a known history of violence from attacking another resident, resulting in physical harm that met the facility's definition of abuse.

Penalty

Fine: $47,740

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 resident dignity on the secured unit by providing only plastic forks and spoons for meal service, with no knives available for residents to use. Observations showed that residents were served meals such as meatballs and pork chops, which could not be easily cut with the provided utensils, resulting in residents having to use their hands to eat meat. Multiple residents expressed dissatisfaction with the use of plastic utensils, stating it was difficult to eat certain foods and that they did not like using plastic silverware. Staff interviews confirmed that plastic utensils were routinely used for safety reasons and to avoid delays in residents' smoke breaks, which occurred if metal silverware was unaccounted for after meals. Although butter knives were reportedly available upon request, staff did not routinely provide them, and residents were not always aware they could request them. The facility's policy on promoting and maintaining dignity emphasized treating residents with respect and considering their preferences and former lifestyles. However, the practice of serving meals without appropriate utensils, particularly knives, did not align with this policy. Staff and residents indicated that the use of plastic utensils was primarily to prevent issues with accounting for metal silverware and to avoid delaying smoke breaks, rather than based on individual resident needs or preferences. The deficiency affected all 57 residents on the secured unit, as observed and confirmed through interviews and record review.

Penalty

Fine: $47,740

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

Staff failed to follow facility policy regarding the search and inventory of a resident's personal belongings upon admission, resulting in the resident bringing prohibited and illegal substances into the facility. The policy required the admission coordinator or designee to complete an initial inventory and ensure no contraband entered the facility, with floor staff under the charge nurse responsible for addressing and removing any items not allowed. On the night of admission, staff did not complete the required search due to being occupied with other incidents, including a resident attempting to elope and multiple admissions, and subsequently did not want to disturb the new resident who had fallen asleep. The resident, who had a documented history of polysubstance abuse, later reported bringing a dab pen containing cannabis concentrate, 20 tablets of Adderall, and bath salts (an illegal synthetic stimulant) into the facility. The resident stated that none of the staff searched their belongings, which were kept in a duffle bag. The resident admitted to consuming some of the substances and sharing them with other residents. Drug testing confirmed that multiple residents tested positive for methamphetamines and THC, and the resident did not have a physician's order for Adderall. Interviews with staff revealed that the required inventory and search process was not completed at the time of admission, and the Director of Nursing and Administrator were unaware that the search had not occurred. Staff acknowledged that belongings should have been kept at the nurse's station until a search could be completed, but this protocol was not followed. As a result, illegal and controlled substances were introduced and distributed within the facility, directly violating facility policy and federal regulations.

Penalty

Fine: $47,740

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

Facility staff failed to document the rationale for administering as needed (PRN) antipsychotic medications to a resident, as required by facility policy. The policy mandates that staff must assess and document the clinical rationale, including the resident's behaviors or symptoms that justify the use of PRN psychotropic medications, and record the effectiveness of the intervention. However, multiple reviews of the resident's Medication Administration Record (MAR) and progress notes revealed that staff consistently administered PRN antipsychotic and antianxiety medications without documenting the specific behaviors or evidence of anxiety that warranted their use. The resident involved had a complex psychiatric history, including diagnoses of schizophrenia, bipolar disorder, schizoaffective disorder, intermittent explosive disorder, and generalized anxiety disorder. The care plan and physician orders indicated the use of several scheduled and PRN psychotropic medications to manage behavioral symptoms such as aggression, agitation, and anxiety. Despite these directives, staff did not provide the required documentation in the progress notes to support the administration of PRN medications, even though the MAR indicated the medications were given and noted as effective. Interviews with staff, including an LPN, the DON, the Administrator, and the psychiatric provider, confirmed that documentation practices did not align with facility policy. Staff acknowledged that PRN medications were sometimes given based on the resident's request or non-verbal cues, but the necessary behavioral documentation was missing. The psychiatric provider also expected staff to document the resident's behaviors when PRN medications were administered to inform ongoing treatment decisions, but this was not consistently done.

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

Facility staff failed to notify a resident's physician, nurse practitioner (NP), and guardian of significant changes in the resident's condition, including refusal of ordered diagnostic procedures, ongoing weight loss, and low blood pressure readings. The facility's policies required prompt notification of the resident, physician, and representative when there were changes in condition or treatment, but documentation and interviews revealed that these notifications did not consistently occur. Specifically, there was no evidence that the guardian, NP, or physician were informed when the resident refused a CT/Urogram, experienced notable weight loss over several months, or had low blood pressure readings while on antihypertensive medications. The resident involved had a history of severe cognitive impairment, bipolar disorder, and benign prostatic hypertrophy, and was under the care of a guardian due to impaired decision-making capacity. The resident's care plan and assessments indicated the need for involvement of the guardian in care decisions and highlighted the importance of notifying the physician and NP of changes in health status. Despite this, the medical record lacked documentation of notifications to the guardian or providers regarding the resident's refusal of diagnostic tests, significant and ongoing weight loss, and episodes of low blood pressure. The Registered Dietitian's notes also did not prompt documented communication with the NP or guardian regarding the resident's nutritional decline. Interviews with staff, the NP, and the resident's guardian confirmed that required notifications were not made. The NP stated he was not informed of the resident's refusal of an abdominal X-ray or of the low blood pressure readings, and the guardian reported not being notified of the resident's weight loss, low blood pressure, or refusal of procedures. Staff interviews revealed uncertainty or lack of recall regarding whether notifications were made, and the administrator acknowledged that staff should have communicated these changes to the NP and guardian. The deficiency centers on the facility's failure to follow its own policies for timely and appropriate notification of significant changes in a resident's 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

The facility failed to follow physician orders to provide double portions or double entrees at meals for five residents who had documented orders for such diets. Observations during meal service showed that dietary staff did not serve double portions or entrees to these residents, despite their orders being clearly listed on the Diet Type Report and physician order sheets. Interviews with the affected residents revealed that they were not receiving the prescribed amounts of food, with some reporting ongoing hunger and concerns about weight stabilization. Care plans for these residents also indicated the need for double portions, particularly in cases of past significant weight loss. The Dietary Manager stated that the practice of serving double portions had been discontinued due to budget cuts, under the belief that it was a matter of resident preference rather than a medical necessity. However, the Director of Nursing, Administrator, and Consultant Dietitian all indicated that they were unaware of this change and affirmed that staff should follow physician orders for diet. The failure to provide double portions as ordered was observed consistently during the lunch meal service, and staff interviews confirmed the deviation from prescribed dietary plans.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision and oversight following an altercation between two residents, leading to a second altercation involving another resident. Initially, Residents #1 and #3 were placed on one-on-one supervision after an altercation where Resident #1 was pushed down by Resident #3. Despite this measure, staff did not effectively separate the residents or intervene to prevent further incidents. Resident #1, who had moderately impaired cognition and a history of mental health issues, was involved in a subsequent altercation with Resident #2, who was cognitively intact but had a history of hallucinations and delusions. The facility's Behavioral Emergency Policy outlines that staff should recognize when a resident poses a danger and utilize de-escalation techniques as a first resort. However, during the incident, staff failed to adequately monitor and redirect the residents involved. Resident #1, while under one-on-one supervision, approached Resident #3 and Resident #2 in the dining room, leading to Resident #2 striking Resident #1. The staff member providing supervision to Resident #1 did not intervene effectively, citing concerns about personal safety and the speed of the incident. Interviews with staff, including the Director of Nursing and the Interim Administrator, revealed expectations for immediate response to de-escalate situations and protect residents from harm. However, the staff's actions did not align with these expectations, as they failed to prevent the second altercation. The report highlights a lack of effective communication and intervention strategies among staff, contributing to the deficiency in resident supervision and safety.

Penalty

Fine: $37,950

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

Summary

The facility failed to protect a resident from physical abuse by another resident with a known history of aggressive behaviors. The incident involved a resident who was verbally assaulted by another resident in the hallway, which escalated to a physical altercation in the dining area. The staff did not adequately separate the residents or monitor the aggressive resident after the initial verbal assault, allowing the situation to escalate to physical violence. The aggressive resident had a documented history of aggression and required 24-hour supervision due to safety concerns. Despite this, the resident's care plan did not include interventions or recommendations to address these behaviors. The staff's failure to implement a 1:1 monitoring system or to separate the residents after the initial verbal altercation contributed to the physical assault, resulting in the victim sustaining scratches and hair loss. Interviews with staff and administration revealed a lack of awareness and communication regarding the incident and the aggressive resident's history. The director of nurses and the administrator acknowledged that the residents should have been separated and that closer monitoring could have prevented the physical assault. The facility's policies on abuse and neglect were not effectively followed, leading to the deficiency.

Penalty

Fine: $37,950

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 resident-to-resident abuse involving two residents to the state agency as required. The incident involved a verbal and physical altercation between two residents, where one resident became frustrated with the other for using the phone for an extended period. This led to a confrontation where the resident on the phone became aggressive, resulting in physical harm to the other resident, including a scratch on the neck and hair being pulled out. The facility's policy mandates immediate reporting of such incidents to the administrator and appropriate agencies, but this was not followed. The incident was not documented in the medical records, and the resident's legal guardian, physician, or medical director were not notified. Interviews with staff revealed a lack of awareness and communication about the incident, with some staff members not recalling the event or their involvement in it. The director of nurses and the administrator were unaware of the physical altercation and the need for reporting. The administrator acknowledged awareness of a verbal altercation but not the physical attack. The failure to report and document the incident as per the facility's policy resulted in a deficiency in handling and reporting abuse allegations.

Penalty

Fine: $37,950

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

Summary

The facility failed to investigate an allegation of verbal and physical resident-to-resident abuse involving two residents. Resident #1, who was cognitively intact, reported that Resident #3 became angry after being asked to get off the phone, leading to a verbal altercation. Resident #3 then physically attacked Resident #1 by shoving, scratching, and pulling out a clump of hair. The activity director and another staff member intervened, but no investigation was initiated following the incident. The activity director witnessed the altercation and attempted to separate the residents, calling a code green for additional staff assistance. Despite the administrator being present in the facility at the time, there was no follow-up investigation or documentation of the incident. The activity director believed that witness statements were collected, but the Director of Nurses and the administrator were unaware of any such documentation. The administrator acknowledged awareness of a verbal altercation but was not informed of the physical attack until later. The Director of Nurses stated that she would have initiated an investigation had she been informed. The lack of communication and failure to investigate the incident resulted in a deficiency in the facility's handling of resident-to-resident abuse allegations.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from abuse when an LPN engaged in inappropriate text communication of a sexual nature with the resident. The resident, who had diagnoses of physical and mental health disorders, resided on a secured unit for residents with behavioral issues and was under guardianship. The incident involved the LPN responding to the resident's requests for a sexual relationship through social media, which is against the facility's policies. The resident was cognitively intact but had hallucinations and delusions, as noted in their quarterly Minimum Data Set. The inappropriate communication was discovered when the Director of Nursing (DON) reviewed the resident's phone messages with permission. The messages included sexual content initiated by the resident and responded to by the LPN, which violated the facility's abuse and social media policies. The facility's policies clearly state that staff should not engage in social media contact with residents or suggest any form of sexual relationship. The DON and interim administrator confirmed that such behavior is against the facility's policies and should not occur at any time. The incident was uncovered during an investigation into a different matter, highlighting a breach in the facility's protocol for protecting residents from abuse.

Penalty

Fine: $44,50012 days payment denial

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 assess three residents (#19, #47, and #115) for the ability to consent prior to engaging in sexual relations, leading to a failure to protect Resident #47 from sexual abuse by Resident #115. Resident #47, with a history of mood disorders, impulse control disorder, bipolar disorder, and mild mental retardation, reported feeling worthless, experiencing flashbacks, and fearing contracting STDs after being forced into oral sex by Resident #115. Despite Resident #47's limited intellectual capacity and the presence of a guardian, there was no assessment for consent to sexual activity in the medical records. Resident #115, diagnosed with oppositional defiant disorder, ADHD, bipolar disorder, and moderate intellectual disabilities, engaged in sexual activities with Resident #19 without the capacity to understand the purpose, risks, and consequences of such actions. The facility's failure to assess and monitor residents' abilities to consent to sexual activity resulted in abusive situations and violations of residents' rights. The facility's policies regarding sexual activity and abuse were not effectively implemented in the cases of Residents #47 and #115. Despite clear guidelines on assessing residents' capacity to consent to sexual activity, documenting such assessments, and prohibiting non-consensual sexual activities, the facility did not conduct proper evaluations for Residents #47 and #115. Resident #47's care plan indicated the need for structured plans to address inappropriate behaviors and mood stabilization, highlighting the importance of monitoring and intervention in cases of vulnerability. Similarly, Resident #115's care plan identified behavioral challenges and the need for supervision to prevent harm to self and others, indicating the necessity for strict adherence to facility guidelines. The failure to follow established protocols and assess residents' abilities to consent led to instances of sexual abuse and inappropriate behavior within the facility. The lack of oversight and monitoring by facility staff, as evidenced by Resident #115's unauthorized presence on another hall and the failure to intervene in inappropriate behaviors, contributed to the deficiencies in protecting residents from abuse. Staff members, such as CNA E, were aware of residents engaging in sexual activities but did not take appropriate actions to prevent or address such incidents. Additionally, the residents' legal guardians expressed concerns about their wards' capacity to engage in relationships and the potential risks of harm or suicidal ideations following relationship issues. The facility's failure to enforce guardian directives and ensure residents' safety highlights systemic issues in supervision, monitoring, and adherence to established guidelines, ultimately resulting in instances of sexual abuse and misconduct among vulnerable residents.

Penalty

Fine: $44,50012 days payment denial

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 store, prepare, and serve food in accordance with professional standards for food service safety and sanitation. Observations revealed that opened food items in the walk-in freezer and dry storage room were not sealed properly, and dented cans were not segregated from active use. Additionally, resident food items in a unit refrigerator were stored under unsanitary conditions, with visible residues and splatters. Trash cans in the kitchen were left uncovered when not in use, and ice and water dispensing machines were found to be dirty and lacking proper air gaps to prevent potential backflow of liquids. Food preparation surfaces were not appropriately cleaned and sanitized, and staff were not knowledgeable about sanitization procedures or the use of the dishwashing machine. Utensils and food containers were found to be in poor condition and not protected from contaminants. Kitchen surfaces and equipment, including floors, ceilings, vents, shelves, drawers, and cooking appliances, were not maintained in a clean state. Staff also failed to practice proper hygienic practices, such as gloving, handwashing, and avoiding the consumption of personal food and beverages while preparing and serving food to residents. The facility census was 116.

Penalty

Fine: $44,50012 days payment denial

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 residents were treated with dignity and respect, as evidenced by multiple incidents involving staff behavior towards residents. During a group resident council, various residents expressed fear of retaliation if they filed grievances or complaints. They reported that night shift staff had a bad attitude and yelled at residents, with specific mention of a CNA who belittled residents. This was corroborated by individual interviews with residents who described instances of staff being rude, dismissive, and using inappropriate language towards them. One resident with schizoaffective disorder and other mental health diagnoses reported feeling ignored and mistreated by specific staff members, including a CNA who raised their voice when the resident requested extra food. Another resident with a hearing deficit and mental health issues stated that the same CNA yelled at residents who asked for meal alternatives. A third resident with behavioral challenges and mental illness described being yelled at and cursed by the CNA when requesting additional juice. Additional interviews revealed that other residents felt belittled and disrespected by staff, including a resident with multiple sclerosis who reported being cursed at by a nursing aide. Another resident with anxiety and personality disorders felt dismissed by staff when asking questions. A resident with major depressive disorder and schizophrenia reported that staff, particularly on the night shift, were hateful and delayed providing medications while engaging in personal activities. Observations confirmed that a CNA took a chair from a resident without returning it, leaving the resident standing. The DON and administrator acknowledged these issues and stated that they had previously addressed similar complaints with the staff involved.

Penalty

Fine: $44,50012 days payment denial

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

Summary

The facility failed to protect the residents' right to retain and use personal possessions, specifically instant coffee, by keeping it locked up in the medication room and controlling the times residents could access it. This affected eight residents, including those with guardians and those who were cognitively intact. The facility's policy on Resident's Rights, revised on 07/05/23, states that residents have the right to retain and use personal possessions unless it infringes on the rights or health and safety of others. However, the facility enforced a policy where residents could only access their coffee at 1:00 P.M. and 6:30 P.M., and only in limited quantities, which was signed by the administrator but undated. Observations on multiple occasions showed that the coffee was kept in a large tote in the locked medication room, with each container marked with the resident's name. Interviews with residents revealed that they were unhappy with this arrangement, as they had purchased the coffee with their own money and did not understand why they could not keep it in their rooms. Some residents mentioned that they had no restrictions from their guardians or physicians regarding coffee consumption. They also expressed frustration over having to wait for staff to access their coffee, especially when staff were busy with other duties. The Director of Nursing (DON) and the Administrator acknowledged that residents should have access to their own property but cited issues with coffee being used as currency among residents, leading to trading, stealing, and overuse. The Administrator mentioned that residents had verbally agreed to the limited access policy during activities to make the coffee last longer, but nothing was documented in writing. Despite these explanations, there was no documented reason in the residents' medical records to justify why they could not keep their coffee in their rooms.

Penalty

Fine: $44,50012 days payment denial

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 reasonable accommodation for Resident #81, who required a Hoyer lift and two staff members to get out of bed. Despite the resident's requests to get out of bed more frequently, staff often cited a lack of time or help and did not return to assist. The resident's custom electric wheelchair had been broken for over a month, and although it could still be used manually, staff found it difficult to push. The resident expressed a desire to participate in meals in the cafeteria and go outside but was often left in bed due to the broken wheelchair and lack of alternative seating options that were comfortable for extended periods. Additionally, the facility failed to provide adequate seating in the Station 2 common/dining area, affecting all residents residing in that unit. Observations showed that seven residents had to eat their meals with trays on their laps or on the arms of high-back chairs due to insufficient dining room chairs and table space. Residents expressed dissatisfaction with this arrangement, noting the difficulty and discomfort of balancing meal trays on their laps. Interviews with staff, including CNAs, the Activity Director, the Therapy Director, and the DON, revealed a lack of communication and coordination in addressing the broken wheelchair and seating issues. The Therapy Director was unaware of the resident's discomfort with the alternative wheelchair, and the Maintenance Supervisor was not informed about the shortage of dining room chairs. The facility's failure to ensure appropriate and comfortable seating for Resident #81 and adequate dining arrangements for Station 2 residents led to the identified deficiencies.

Penalty

Fine: $44,50012 days payment denial

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 act promptly and follow up with a response to residents' concerns voiced in resident council meetings. Additionally, the facility did not hold monthly resident council meetings as required. The review of the resident council meeting minutes from December 2023 showed various concerns, including missing clothing, dietary requests, and maintenance issues, with no documentation of these concerns being communicated to staff or resolved. The facility did not provide minutes for a January 2024 resident council meeting, and only one meeting was held in February 2024 for station two, with no indication of a meeting for station one. Residents reported that resident council meetings were held sporadically without a specific schedule or agenda, making it difficult to address their concerns effectively. Interviews with the Activity Director (AD), Social Services Director (SSD), Director of Nursing (DON), and the Administrator revealed a lack of clarity and consistency in the process for addressing concerns raised during resident council meetings. The AD, who was new to the position, was unaware of the specific process to follow and admitted that some meetings and minutes fell through the cracks during the transition period. The DON stated that concerns should be emailed to department managers and followed up by the next day, but there was no documentation to support this process. The Administrator acknowledged that the AD was responsible for reporting concerns but admitted that the transition period led to lapses in holding meetings and documenting minutes.

Penalty

Fine: $44,50012 days payment denial

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 housekeeping and maintenance services to maintain a clean, sanitary, and orderly environment. Observations revealed multiple deficiencies in various resident rooms and common areas, including torn drywall, missing paint, water stains, and black scuff marks. Additionally, several rooms had issues with missing or damaged furniture, such as bed frames without mattresses, privacy curtains pulled out of the wall, and dresser drawers with missing paint. Bathrooms were found to be in poor condition, with stained floors, peeling ceiling texture, and black discoloration around the base of toilets. In one instance, a resident reported that the cold-water faucet in their sink did not work, and they could only get hot water. This issue had persisted since staff attempted to fix a leak. The resident also mentioned that their TV had been removed by staff, and despite requesting a replacement, they had not received one. The resident expressed frustration over the lack of cold water and the absence of a TV in their room. Interviews with staff members, including housekeepers and the maintenance supervisor, revealed a lack of clarity regarding responsibilities for cleaning certain areas, such as bathroom vents and common areas. The maintenance supervisor admitted that it took a long time to patch and paint walls and that he was running out of paint. He also acknowledged that he had not had time to address all the areas in need of repair, including dining rooms and furniture. The administrator confirmed that maintenance was responsible for ensuring that walls, doors, floors, ceilings, and furniture were in good repair, but the observations indicated that this was not being adequately managed.

Penalty

Fine: $44,50012 days payment denial

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 knew how to file a grievance, where grievance forms were located, or how to complete a grievance form. During a resident council group interview, multiple residents expressed that they did not know how to file a grievance and feared retaliation from staff if they did. Specific residents reported missing clothing and stated that they had informed staff but had not received any follow-up or resolution. These residents were also unaware of the grievance process or where to find the necessary forms to file a grievance. The facility's policies on resident rights and grievance procedures were reviewed and found to be comprehensive. However, the implementation of these policies was lacking. The Social Services Director (SSD), who was new to the position, was unaware of her role in the grievance process, and no grievances had been filed since she assumed the role. The Director of Nursing (DON) confirmed that grievances were to be filed using a form that residents or visitors had to request from staff, and there was a 24-48 hour turnaround time for resolution. The administrator acknowledged that residents should be able to file grievances without fear of retaliation and that grievance forms should be readily available without needing to ask staff. The SSD's lack of awareness of the grievance process and the residents' fear of retaliation contributed to the deficiency in ensuring residents' rights to voice grievances were upheld.

Penalty

Fine: $44,50012 days payment denial

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 complete required pre-employment screenings for four of eight sampled employees hired since the previous survey. Specifically, the facility did not request a criminal background check (CBC) for two employees, did not check the Employee Disqualification List (EDL) for three employees, and did not check the Nurse Aide (NA) Registry for three employees prior to hire, as directed by facility policy. The facility's policy mandates that the Human Resources (HR) department conduct pre-employment screenings, including Criminal History, Federal Exclusion Lists, Licensure, Family Care Safety Registry (FCSR), EDL, NA Registry, and I-9 verification, prior to hiring any staff. However, these checks were either not completed or were conducted after the employees had already started working, which is against the facility's policy. The deficiencies were identified through a review of employee files and interviews with HR staff and the Administrator. For instance, the Maintenance Supervisor's file lacked documentation of an NA Registry check, CNA K's file lacked an EDL check, and Hall Monitor L's file showed that the FCSR and NA Registry checks were conducted 19 days after the hire date. Additionally, NA M's file had no documentation of a CBC, EDL, or NA Registry check either before or after the hire date. HR staff confirmed that these checks should be completed before the employee's first paid day, but this was not consistently done. The Administrator also confirmed that he expected all new employees to have these checks completed prior to their first paid day.

Penalty

Fine: $44,50012 days payment denial

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 staff prepared and safely administered medications to five residents. Certified Medication Technician (CMT) I prepared the medications, but Certified Nurse Aide (CNA)/CMT/Team Lead G administered them without observing the preparation process. This practice was observed during a medication pass, where medications for residents with various diagnoses, including schizoaffective disorder, anxiety, diabetes, and mood disorder, were involved. The facility's policy mandates that the person who prepares the medication must also administer it, which was not followed in these instances. Additionally, the facility failed to obtain a physician order for a resident to self-administer eye drops. During the medication pass, the resident self-administered the eye drops without a proper order, which is against the facility's policy. The facility's Resident's Rights Policy requires an interdisciplinary team to determine if a resident can safely self-administer medications, which was not done in this case. The facility also failed to complete accuchecks as ordered for a resident with diabetes and did not obtain a urinalysis when ordered for another resident. The resident's care plan indicated the need for daily blood glucose monitoring, but there was no documentation of these checks being performed. Similarly, a urinalysis ordered for a resident with urinary issues was not obtained in a timely manner. Furthermore, the facility did not document the narcotic counts being completed by two staff members, as required by their policy, on multiple occasions.

Penalty

Fine: $44,50012 days payment denial

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 an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of each resident. This deficiency was observed in five residents out of 34 sampled residents. The facility census was 116. During a resident council meeting, residents reported that there were not many activities on the unit, the activity calendar was not followed, and there were no activities on weekends or after supper. Observations and record reviews confirmed that several residents did not participate in any documented activities for extended periods, and there was a lack of staff interaction and engagement with the residents. Resident #48's care plan indicated a need for cognitive stimulation and social activities, but there was no documentation of activity participation for several months. Observations showed the resident in their room with no staff interaction or activities provided. Similarly, Resident #96, who had dementia and other mental health diagnoses, was observed lying in bed or standing in the hallway with no staff interaction or activities. The resident's activity progress notes indicated minimal participation in activities, and there was no documentation of activity engagement for several months. Resident #110, who had dementia, anxiety, and depression, had no care plan for activities and no documented participation in activities for several months. Observations showed the resident pacing in their room or standing in the hallway with no activities provided. Resident #25, who had a traumatic brain injury and other mental health disorders, was observed sleeping in bed most of the time due to boredom. The resident expressed a desire for more activities but reported that there had not been an activity director for several months. Resident #116, who had schizophrenia and insomnia, participated in a craft activity but expressed a desire for more activities, especially in the evenings. The Activity Director confirmed the lack of scheduled activities on weekends and evenings and acknowledged the need for more one-on-one programming for certain residents.

Penalty

Fine: $44,50012 days payment denial

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 safety of Resident #102, who expressed suicidal ideations and threatened self-harm by placing a bag over their head. Despite the resident's high risk for suicide as indicated by the Columbia Suicide Severity Rating Scale, the care plan was inconsistent, and the resident's room contained plastic liner bags in trash cans, which could be used for self-harm. Staff interviews revealed a lack of awareness and documentation regarding the resident's increased monitoring, and the resident continued to express suicidal thoughts without appropriate intervention or documentation of face checks and room safety measures. The facility also failed to ensure the safety of Resident #48 by not placing their feet on wheelchair foot pedals while being propelled by staff. Observations showed the resident's feet were unsupported, which could lead to accidents or injuries. Staff interviews confirmed that wheelchair pedals should be used for resident safety, but this practice was not followed. Additionally, the facility did not implement effective interventions to prevent Resident #21 from being transported in their rollator walker by another resident. Despite staff and resident awareness that this practice was unsafe, it continued to occur. The DON and other staff members acknowledged the issue but failed to implement successful interventions to stop the behavior, putting Resident #21 at risk of injury.

Penalty

Fine: $44,50012 days payment denial

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 offer sufficient fluids to maintain proper hydration and health for three residents. Observations over several days showed that Residents #48, #96, and #110 did not have water pitchers or glasses of fluids in their rooms. This was despite the facility's policy that fluids should be passed every two hours, with additional fluids provided during meals. Staff interviews confirmed that water pitchers were either broken or not replaced, and fluids were not consistently offered as required by the policy. Resident #48, who has diagnoses including dementia and schizophrenia, was observed without water pitchers or glasses of fluids in their room over multiple days. The resident's care plan emphasized the need to encourage fluids to promote prompted voiding responses. Similarly, Resident #96, who has dementia and bipolar disorder, was also observed without water pitchers or glasses of fluids in their room. The care plan for this resident also highlighted the importance of encouraging fluids to prevent urinary tract infections and skin breakdown due to incontinence. Resident #110, diagnosed with dementia, anxiety, and depression, was observed with dry lips and no water pitcher or glass of fluids in their room. Staff interviews revealed that fluids were not consistently offered, and water pitchers were not available for many residents. The Director of Nursing and the Administrator both confirmed that fresh water should be passed every two hours and that fluids should be offered with meals, but this was not being done consistently.

Penalty

Fine: $44,50012 days payment denial

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

Summary

The facility failed to ensure that two nurse aides, NA BB and NA U, completed a certified nurse aide (CNA) training program within four months of their employment. NA BB was hired on 02/09/23, and NA U was hired on 06/02/23. Review of their employee files showed no documentation of completion of the CNA training program within the required timeframe. During an interview, the Administrator acknowledged responsibility for enrolling NAs in the training program and admitted awareness of the four-month completion timeline. However, the Administrator stated that the NAs had not yet tested and had 'slipped through the cracks.' The facility census was 116, and the Director of Nursing confirmed that the facility did not have a specific policy on Nursing Assistant and Certified Nursing Assistant training programs.

Penalty

Fine: $44,50012 days payment denial

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 four residents who were prescribed psychotropic medications received a gradual dose reduction (GDR), unless clinically contraindicated. The facility's Medication Administration and Monitoring Policy mandates that psychotropic medication reductions be reviewed by the pharmacy consultant and the prescribing physician. However, for Resident #48, there was no recommendation for a GDR for olanzapine from the pharmacy review notes, and the psychiatric physician's notes showed no documentation of any attempts at a GDR for the olanzapine. Similarly, Resident #96's pharmacy review notes recommended a GDR for aripiprazole, Trazadone, and Zoloft, but there was no documentation found by the physician to address these recommendations, and no GDR was attempted for these medications in the resident's medical record for March 2024. Resident #28's care plan indicated the use of multiple psychotropic medications, but there was no evidence of a GDR attempt or clinical rationale from the physician to show a GDR was contraindicated. The psychiatric physician notes for Resident #28 also lacked documentation of any attempts or contraindications for a GDR. Similarly, Resident #95's care plan and psychiatric visit notes showed the use of paliperidone and mirtazapine, but there was no documentation of a GDR attempt or clinical rationale for contraindication. Observations of Resident #95 showed a slight mouth tremor, which the resident reported as bothersome, yet no GDR was attempted for the medications. Interviews with the Director of Nursing and the residents' physician revealed that the facility protocol for GDRs was not followed. The Director of Nursing could not find any recommendations for a GDR for the residents, and the physician expected staff to consult with psychiatry if a resident experienced extrapyramidal symptoms when taking an antipsychotic medication. The physician also stated that a GDR should be done with consideration of the resident's clinical condition, aiming to use the lowest dose necessary to keep the resident stable and symptoms manageable.

Penalty

Fine: $44,50012 days payment denial

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 discard an opened insulin pen after 28 days of use for one resident with diabetes. The resident's Lantus insulin pen, which was opened on 2/6/24, was still in use on 3/6/24, exceeding the manufacturer's recommended usage period of 28 days. This oversight was observed during a medication cart inspection, revealing that the pen should have been discarded on 3/5/24. Additionally, the facility's policy mandates monthly inspections of medication carts and rooms, but this protocol was not effectively followed in this instance. Furthermore, the facility did not dispose of expired house stock influenza vaccines. During an inspection of the medication room refrigerator, 20 vials of influenza vaccine with an expiration date of 6/2023 were found. Despite the facility's policy requiring weekly destruction of expired medications by the DON and monthly checks by the pharmacy, these expired vaccines were still present. Interviews with the LPN and DON revealed a lack of awareness and adherence to the established protocols for managing expired medications.

Penalty

Fine: $44,50012 days payment denial

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 meet the nutritional needs of the residents and ensure staff served the correct portion sizes during meals. The dietary staff did not follow the standardized recipes and portion sizes as outlined in the facility's policies. For instance, during a lunch meal, residents were served one slice of turkey instead of the required three ounces, and a 3-ounce scoop was used for tomatoes instead of the required 4-ounce scoop. The dietary manager confirmed that the portion sizes were incorrect and that staff should use the diet spreadsheet menu to determine appropriate portion sizes. Several residents reported that the portion sizes were too small, and they often felt hungry after meals. One resident, who had been losing weight, was served a meal that did not include all the items listed on the diet spreadsheet, such as bacon for breakfast. Another resident mentioned that they had to take food from an uneaten tray because they were still hungry after their meal. Multiple residents expressed dissatisfaction with the portion sizes and the lack of availability of seconds or substitutes. The registered dietitian and the dietary manager acknowledged that staff should follow the diet menu spreadsheet, recipes, and physician orders when serving food items to residents. They also noted that substitutions should be recorded and monitored to ensure they are of equal nutritional value. The administrator expected the menu to be followed and the required portions to be served. However, the observations and interviews indicated that these expectations were not consistently met, leading to residents not receiving adequate nutrition.

Penalty

Fine: $44,50012 days payment denial

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 residents with palatable meals served at appetizing temperatures and a variety of snacks. Multiple residents reported that the food was often bland, lacked seasoning, and was not served at the appropriate temperature. For instance, Resident #67 mentioned that the food was bad, not always seasoned, and that they did not always receive their preferred oatmeal for breakfast. Resident #91 also complained about the food being terrible, lacking flavor, and receiving overcooked and hard noodles. Additionally, the residents frequently received the same types of snacks, such as honey buns and oatmeal cream pies, which many found unsatisfactory and not filling. Observations confirmed these complaints. For example, Resident #91's meal tray included burnt and hard bow tie pasta, and Resident #57's lunch included a burrito and salad, which the resident refused to eat due to its poor quality. The facility's dietary policies were not consistently followed, as evidenced by the frozen health shakes served to residents like Resident #97 and Resident #4, which they could not consume. The dietary manager admitted that the health shakes were served frozen because they had just arrived and were not thawed in time. The facility's staff also failed to honor residents' meal preferences and dietary needs. Resident #100 reported that their breakfast was cold and tasted awful, and they were unable to get sandwiches because they were reserved for diabetics. Resident #116's meal of tomato soup and grilled cheese was described as tasting like watered-down ketchup, and the grilled cheese was cold and lacked cheese. The dietary manager acknowledged that meal preferences should be honored and that the facility should provide fresh fruits and vegetables, but these were often not available or served. The registered dietitian emphasized that food should be served at the correct temperature and that residents' requests for fresh fruits and substantial bedtime snacks should be honored.

Penalty

Fine: $44,50012 days payment denial

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 policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The maintenance director admitted to not checking the cold-water temperatures throughout the facility, and the Director of Nursing (DON) confirmed that it was the maintenance supervisor's responsibility to ensure quarterly water testing was completed. The Administrator was unaware that cold water temperatures needed to be tested for the water management program. Additionally, the facility did not perform detection and surveillance of possible cases of LD among the residents, as evidenced by the lack of documentation and monitoring of water temperatures from December 2023 through February 2024. The facility also failed to ensure proper infection control measures for COVID-19. There was no signage on the entrance of the building notifying visitors of a COVID outbreak, and no transmission-based precaution signage outside of the rooms of COVID-positive residents. Two COVID-positive residents shared a bathroom with non-COVID residents, and one COVID-positive resident was taken out of their room without proper personal protective equipment (PPE). Staff did not consistently follow hand hygiene protocols, and there was a lack of hand sanitizer and proper PPE outside of isolation rooms. The facility's infection control procedures were not adequately followed, as evidenced by staff not wearing appropriate PPE and not performing hand hygiene after removing gloves. Additionally, the facility failed to ensure that Tuberculin Skin Tests (TST) were completed in accordance with the requirements for TB testing for long-term care employees. Three staff members hired since the previous survey did not have their TSTs administered and read prior to or on their first paid day. The facility also failed to use appropriate infection control procedures for hand hygiene and changing gloves during accu check procedures and insulin administration for three residents. Furthermore, the facility did not store a resident's respiratory equipment in a way that it remained free of contaminants, as the nebulizer machine and tubing were found on the floor and not properly covered.

Penalty

Fine: $44,50012 days payment denial

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 the physician and/or responsible parties when three residents experienced a change in condition. Resident #19 had a tooth extraction and was prescribed antibiotics, but the legal guardian was not informed about the procedure or the new medication orders. The guardian expressed disappointment upon discovering the changes belatedly. Resident #55, who had a guardian and severely impaired cognition, developed pneumonia and was prescribed multiple medications, but there was no documentation that the guardian was notified about the infection or the treatment plan. The guardian later found out about the new antibiotic charge while reviewing bills and expressed a desire to be informed about all changes in the resident's condition. Resident #106, who had hypertension, experienced a significant drop in blood pressure and was sent to the emergency room for evaluation. Despite the resident's condition worsening throughout the day, there was no notification to the resident's physician about the change in condition. The resident's physician later stated that he expected to be informed about such significant changes. Interviews with staff, including the Director of Nursing and the Administrator, revealed that they expected nursing staff to notify guardians and physicians about condition changes and new medication orders, but this protocol was not followed in these cases. The facility's policies on notifying clinicians and significant changes were not adhered to, leading to a lack of communication with responsible parties and physicians regarding the residents' health conditions. This failure to notify relevant parties about significant changes in residents' conditions and new medication orders constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.

Penalty

Fine: $44,50012 days payment denial

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 staff failed to ensure that a resident remained free from misappropriation of property when a Certified Nurse Aide (CNA) took $450.00 from the resident. The resident, who was alert, oriented, and able to make decisions, had diagnoses of quadriplegia, heart disease, anxiety, and pain. The incident began when the CNA discussed personal financial problems within earshot of the resident, who then offered to assist the CNA with unpaid bills. The CNA initially refused but eventually accepted the money, promising to repay it in installments. However, the CNA only made one repayment and failed to return the remaining amount, prompting the resident to inform a family member, who then reported the incident to the facility administrator. The Assistant Director of Nursing (ADON) initiated an investigation upon learning of the incident from the administrator. The ADON interviewed both the resident and the CNA, who admitted to taking the money. The CNA was suspended pending the investigation and subsequently terminated from employment. The Human Resource Director confirmed the CNA's admission and termination. The administrator and primary physician both stated that they would expect staff to decline any offers of money from residents and to avoid discussing personal problems with them.

Penalty

Fine: $44,50012 days payment denial

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

Summary

The facility failed to prevent a decline in the range of motion and the development of contractures for a resident with a history of left hand contracture, hemiplegia, hemiparesis, and chronic pain. Despite the resident's condition, the facility did not provide the necessary restorative therapy or regular care to manage the contracture. The resident's care plan included measures such as checking nail length, cleaning the palm, and referring to therapy as needed, but these were not consistently followed. Observations showed that the resident's left hand was severely contracted, with fingers bent and nails untrimmed, causing discomfort and pain. Interviews with staff revealed a lack of awareness and implementation of a restorative care program. Nurse aides and certified nurse aides were unaware of any restorative services being provided to the resident. The physical therapist confirmed that therapy orders were pending insurance approval, and the therapy director noted that the resident had refused initial screenings and had no therapy orders since admission. The director of nursing acknowledged the absence of a restorative care program and the inability to keep a restorative aide employed. The resident's guardian and primary physician expressed concerns about the lack of therapy and contracture management. The guardian was unsure if the resident had received any therapy services since admission and desired such services if beneficial. The primary physician expected the facility to identify and address contractures upon admission. The facility's failure to provide appropriate care and therapy services led to the worsening of the resident's contracture and associated pain, highlighting significant deficiencies in the facility's restorative care practices.

Penalty

Fine: $44,50012 days payment denial

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 assess residents for the risk of entrapment, document attempted alternatives prior to installing a bed rail, and obtain informed consent with risks prior to installing and using a bed rail for two residents. Resident #32, who had multiple diagnoses including Type 2 diabetes mellitus, morbid obesity, rheumatoid arthritis, and impaired visual function, was observed with a bed rail in the raised position on multiple occasions. There was no documentation in the resident's care plan addressing the use of the bed rail, nor was there any record of a bed rail assessment or obtained consent for its use. Resident #35, who had a history of fractured femurs and cerebral palsy, was also observed with assist rails on each side of the bed. The resident was able to grab the assist rail and assist with rolling over in bed with staff assistance. However, similar to Resident #32, there was no documentation of a bed rail assessment or obtained consent for the use of the bed rail in the resident's medical record. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that no assessments or consents were completed for the assist rails. The ADON admitted that she did not complete an assessment for the residents, and the maintenance staff had not performed the entrapment assessment. The DON confirmed that consents and assessments should be done quarterly, but this was not adhered to in these cases. The Administrator also acknowledged that an assessment should be completed before the use of bed rails.

Penalty

Fine: $44,50012 days payment denial

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 appropriately administer insulin to two residents, leading to significant medication errors. Specifically, an LPN did not prime the insulin pens before administration and did not hold the needle in the skin for the required six seconds after administration, as directed by the manufacturer. This was observed during the administration of Novolog insulin to two residents, one receiving 5 units and the other receiving a combination of 8 units scheduled and 4 units sliding scale insulin. The LPN removed the needle immediately after the button stopped, contrary to the manufacturer's instructions. The facility's Blood Glucose Monitoring and Insulin Administration Policy did not address the specific procedure for administering insulin via an insulin pen, only covering administration via vial and syringe. During interviews, the LPN acknowledged awareness of the need to prime the pen but mistakenly believed that holding the pen for three seconds was sufficient. The Director of Nursing confirmed the expectation for staff to prime the insulin pen with two units and hold for six seconds after administration.

Penalty

Fine: $44,50012 days payment denial

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 received necessary dental services and follow-up care. The resident, who had a history of anxiety and schizophrenia, was dependent on staff for activities of daily living, including brushing teeth. The resident was seen by a local dental clinic, which recommended the extraction of all remaining teeth due to multiple areas of decay and non-restorable teeth. However, the facility did not follow up on these recommendations, and the resident continued to experience dental pain and decay, as observed during a later inspection. Interviews with staff revealed that the recommendations for further dental intervention were mistakenly filed away and not acted upon. The Director of Nursing and the facility Receptionist both acknowledged that the resident's dental needs were not addressed in a timely manner. The primary physician also expressed that staff should have made arrangements for the resident to see a dentist and followed the recommendations promptly. The facility did not provide a policy for dental services, and the resident's care plan did not address dental care or issues.

Penalty

Fine: $44,50012 days payment denial

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 the pneumococcal vaccine to a resident who had given consent upon admission. The resident, who was cognitively intact and had a history of diabetes mellitus, seizures, multiple sclerosis, and chronic obstructive pulmonary disease, had not received the vaccine since their admission. Despite the resident's consent and the facility's policy to offer the vaccine upon admission, the vaccine was not administered, and the resident expressed a desire to receive it during an interview. The Director of Nursing confirmed that the resident had not been offered the pneumococcal vaccine and was unsure why this had not occurred. The process typically involves ordering the vaccine if a pharmacy immunization clinic is not scheduled soon. The Director of Nursing is responsible for ensuring the vaccine is administered once consent is obtained. The Administrator and the primary care physician both expected that all residents, especially new admissions, would be offered the pneumococcal vaccine without delay. The facility's policy and CDC guidelines indicate that the pneumococcal vaccine should be offered to residents upon admission unless medically contraindicated or previously received. However, the facility did not follow through with this policy for the resident in question, leading to a deficiency in providing the necessary immunization.

Penalty

Fine: $44,50012 days payment denial

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 complete entrapment assessments for two residents who had side rails attached to their beds. Resident #32 had a 1/8 bed rail on the left-hand side of the bed in the raised position, but there was no documentation in the care plan addressing the use of the bed rail, nor was there a bed rail assessment or consent for its use. The resident's medical history included conditions such as Type 2 diabetes mellitus, morbid obesity, rheumatoid arthritis, and impaired visual function, among others. Despite these conditions, the necessary safety assessments and consents were not completed. Resident #35 had candy cane rails on each side of the bed at the head of the bed, which the resident used to assist with rolling over in bed with staff assistance. However, there was no physician order for the use of side rails, no consent for their use, and no entrapment assessment documented. The resident's medical history included cerebral palsy, diabetes, anxiety, schizoaffective disorder, depression, and bipolar disorder. The resident was dependent on staff for all bedside care and mobility, yet the required safety measures were not in place. Interviews with the Assistant Director of Nursing, Maintenance Director, Director of Nursing, and the Administrator revealed that assessments, consents, and physician orders for the use of bed rails were not completed as required. The Maintenance Director admitted to not measuring mattresses for entrapment risks, and the Director of Nursing confirmed that consents and assessments should be done quarterly but were not. The Administrator also acknowledged that assessments should be done before the use of side rails and that the maintenance department should measure the beds for entrapment risks.

Penalty

Fine: $44,50012 days payment denial

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 post the results of the most recent survey and complaint investigations in a place readily accessible to all residents, family members, and legal representatives. During a resident council meeting, residents expressed that they were unaware of their right to view the survey results and did not know where the results were kept. Observations over several days confirmed that the survey results were not posted in the front foyer/common area or in Station 2, a secured unit. Interviews with residents and staff revealed that the survey results were not accessible without asking staff, and there was a lack of awareness among staff about the requirement for survey results to be readily accessible to residents. The Business Office Manager (BOM) and the Director of Nursing (DON) both indicated that the survey results should be available but were not aware of the specific requirements for accessibility. The BOM mentioned that the survey results binder was supposed to be on a cabinet at the front door and that a sign inside the nurses' station on Station 2, which informed residents they could ask to see the survey results, had fallen down. The Administrator acknowledged responsibility for ensuring the survey results were posted and accessible but was unaware that the results were not posted on Station 2. The survey results binder had been moved during furniture rearrangement and was not returned to its proper place.