Lewis & Clark Gardens

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that the Director of Nursing (DON) functioned in the full-time DON role and did not routinely work as a charge nurse when the average daily census exceeded 60 residents. The facility’s DON job description, dated May 2006, specified that the primary purpose of the position was to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with applicable regulations and facility policies, and that the DON must be in the facility or engaged in work-related activities a minimum of eight hours per day, Monday through Friday. Review of the daily census recapitulation for March 2026 showed a census ranging from 83 to 91 residents, indicating an average daily occupancy well above 60 residents. Despite this census level, staffing sheets for March 2026 showed that the DON repeatedly worked the floor as the charge nurse on multiple evening, night, and day shifts throughout the month. During interview, the DON reported that since December 2025 she had been working evening and night shifts as a floor nurse due to shortages of licensed nursing staff and stated she was unaware that the DON could not routinely cover the floor with a census over 60 residents. She also stated it was difficult to work the floor and complete DON duties, and that she was unable to adequately review and audit charts, including falls and related interventions, and that on days she worked the floor she only managed a few hours of DON duties and found this exhausting. In a separate interview, the Administrator stated she was unaware that the DON could not routinely work the floor with a census over 60 and that she expected the facility to follow the regulatory requirement regarding the DON and floor coverage.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment free from persistent urine and fecal odors and with carpets in good repair. Surveyor observations over multiple days showed strong odors and visibly stained carpeting in multiple areas. On one day of observation, upon entry there was a very strong smell of air freshener throughout the lobby, with C hallway carpeted and showing several stained areas and a strong air freshener smell, two resident rooms with strong urine odors, and B hallway carpet with several stained areas and a faint urine smell masked by strong air freshener. On subsequent days, surveyors noted a strong urine odor throughout the lobby, a strong urine odor throughout the entire A hallway, and a strong urine and feces odor near the B hallway nurses’ station. One resident room had a strong urine and feces odor and several areas of stained carpet. On another day, surveyors again noted urine odors in the lobby and A hallway, and urine odors in B hallway masked by strong air freshener. During interview, the Housekeeping Supervisor reported there were two floor technicians who rotated cleaning carpets daily using a floor extractor and odor cleaning agent, and that carpets on each hall were cleaned every two to three days. The supervisor stated that odors in the facility were usually related to the floors, that one resident on A hall would not allow staff into the room and that room had very strong odors, and that certain residents frequently spilled urinals, making floor cleaning a constant battle. The supervisor also stated some aides routinely sprayed a “spring time” air freshener to help with odors. The Administrator stated there was no policy specific to odors, that she expected staff to find and eliminate the source of any odor, that carpets were cleaned daily on a rotating basis and as needed for spills, and that she expected the facility to be homelike, including being odor free. The facility’s housekeeping policy stated that no dust, no spots, no smudges, and no smells equaled clean, but persistent odors and stained carpets were still present throughout multiple areas of the building.

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 consistently investigate resident falls, determine root causes, and evaluate or revise fall-prevention interventions, as well as failure to follow its own event/accident policy requiring immediate nursing assessment before moving a resident after a fall. The facility’s Event Investigation policy required any staff member who discovered or witnessed an event to immediately report it to the nurse in charge, with the charge nurse responsible for completing a Report of Event form, documenting factual details, location, type of event, injuries, vital signs, neuro status, pain, first aid, and actions taken to prevent recurrence. The facility’s Fall Champion Program guidelines further required that every fall be reviewed in morning meetings, with IDT notes, updated fall risk assessments, and care plan revisions, and that after 72 hours the DON, ADON, and MDS Coordinator review the event and documentation. Post-fall guidelines required staff to stay close to the resident, provide emergency care, take vital signs, notify the physician, fall champion, administrator, and family, and for the charge nurse to initiate and document preventative fall interventions in the care plan. For one resident with repeated falls, dementia, stroke, difficulty walking, and muscle weakness, the facility documented multiple falls but did not consistently complete event reports, analyze contributing factors, or update the care plan after each fall. The resident’s care plan initially included a history of falls and interventions such as keeping the bed in the lowest position with brakes on, and after a fall on 2/23/26, fall mats and a bolster mattress were ordered and a directive to analyze falls for patterns and trends was added. However, after subsequent unwitnessed and witnessed falls on 03/06/26, 03/07/26, 03/11/26, 03/16/26, 03/18/26, 03/20/26, and 03/25/26, documentation repeatedly lacked completed event reports, contributing factor analysis, or evidence that the care plan was reviewed or revised. Some event reports listed no contributing factors or immediate measures, and several falls were only documented in progress notes without corresponding event reports or care plan updates, despite the resident experiencing pain, skin tears, and multiple unwitnessed falls. Interviews with nursing staff and the MDS Coordinator confirmed that the only consistent interventions were a fall mat, low bed, and bolsters, that the MDS Coordinator had been off work and was unaware of the multiple March falls, and that care plans with new fall interventions had not been reviewed or revised for some time. For another resident with moderate cognitive impairment, dependence in ADLs, Alzheimer’s disease, non-Alzheimer’s dementia, spinal stenosis, and identified as at risk for falls on the MDS, the facility failed to complete a fall risk assessment, event reports, or a fall-related care plan with interventions after two documented falls. A nurse’s note described an unwitnessed fall from bed at 5:30 A.M. with mild left shoulder pain and administration of pain medication, but there was no event report or documented fall-prevention interventions. The nurse later stated that upon returning from break, he was informed by staff that the resident had fallen and that CNAs had already put the resident back in bed. The CNA reported that, unable to find the RN and with the resident asking to get off the floor, he assessed the resident by moving arms and legs, noted no complaints of pain, and, together with another CNA, assisted the resident off the floor before a nurse assessment, contrary to facility policy. A second fall was documented in a nurse’s note as an unwitnessed fall near a window with no injury identified, but again there was no event report, no documented interventions to prevent further falls, and no fall care plan, even though the comprehensive MDS identified the resident as at risk for falls. Interviews with the Administrator, DON, and MDS Coordinator confirmed that CNAs should not get residents up before a nurse assessment, that any nurse could update care plans after falls, that staff were expected to follow the event/accident policy and update care plans with each fall, and that routine IDT meetings to review falls were not being conducted.

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 immediately report an allegation of physical abuse to the state survey agency within the required two-hour timeframe and to conduct an appropriate investigation. Facility policy stated that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately, and no later than two hours, when abuse or serious bodily injury is alleged. Despite this, the Administrator acknowledged that an allegation that a staff member squeezed a resident’s face and told the resident to shut up was not reported to the state agency, and no investigation was completed because the resident later denied the allegation when interviewed in the presence of the accused staff member. The resident involved had a quarterly MDS dated 1/6/26 showing that the resident was cognitively intact (BIMS score of 13), able to make self-understood and understand others, and dependent on staff for ADLs, with diagnoses including hemiparesis, respiratory failure, and traumatic spinal cord dysfunction. The resident’s care plans documented behavioral issues, including becoming easily angered, yelling at staff and family, and pushing against staff while demanding unsafe repositioning methods. Interventions included redirection, involvement of family, and reminders about safe repositioning techniques. These documented behaviors formed part of the context in which the alleged abuse occurred but did not negate the requirement to treat the report as an abuse allegation. Multiple staff interviews established that on or about Friday, January 9th, the resident told a CNA and the Activity Director that a staff member the resident called “Firehead” had squeezed the resident’s cheeks and told the resident to shut up while the resident was yelling and felt like falling out of bed. The CNA and Activity Director reported this as potential abuse to the DON and Administrator. The DON and ADON then interviewed the resident, who reported that a CNA had come into the room, told the resident to be quiet, and squeezed the resident’s cheeks, and the Administrator walked the suspected CNA past the resident’s door, where the resident identified the CNA as the person involved. The Administrator then brought the CNA into the room and questioned both together; at that time, the resident denied the allegation. The Administrator later confirmed that the allegation had been reported to her on January 9th, but she did not report it to the state agency or complete an investigation because the resident denied the allegation during that joint interview.

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 conduct a timely and thorough investigation of an allegation of verbal and physical abuse involving one resident. Facility policy required that all reports of abuse, including verbal and physical abuse, be promptly and thoroughly investigated, with the investigation begun immediately and including interviews with the involved resident, alleged perpetrator, other residents, and staff, as well as steps to protect residents. Resident #1, who was cognitively intact per a recent MDS with a BIMS score of 13 and dependent on staff for ADLs with diagnoses including hemiparesis, respiratory failure, and traumatic spinal cord dysfunction, reported that a CNA the resident referred to as “Firehead” had been rude. The Administrator stated that CNA B reported to the DON and ADON that Resident #1 said this staff member, later identified as CNA A, squeezed the resident’s face and told the resident to shut up. Resident #1 later described that the staff member entered the room, yelled at the resident to shut up, and squeezed the resident’s cheeks very hard, causing pain and fear. The Administrator initially considered the report could be abuse but interviewed the resident with CNA A present, and when the resident denied the allegation in that setting, the Administrator did not report the allegation to the state agency and did not initiate or complete an investigation. Review of facility documentation showed no interviews or statements from the alleged perpetrator, other staff, residents, or witnesses, and no evidence of a thorough investigation. The Administrator later clarified that the incident had been reported to her on January 9 but still had not been investigated at the time of the surveyor’s 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 provide residents with meals that were palatable, served at appetizing temperatures and textures, and that conserved nutritive value and flavor, as required by facility policy. Observations and interviews revealed that hot foods were often served below the required temperature, with a sample tray showing a hot dog at 118°F, below the minimum standard of 120°F, and salads and desserts served at improper temperatures. The dietary temperature logs were incomplete, with missing entries for vegetables and desserts, and staff admitted to not recording temperatures due to being busy. Additionally, the preparation of menu items did not always follow standardized recipes, such as the banana pudding being served without bananas or vanilla wafers due to lack of ingredients and no substitutions being made. Multiple residents reported dissatisfaction with the food, describing it as cold, undercooked, bland, and sometimes unidentifiable. Several residents stated that their meals were cold by the time they were delivered, and that food was often served without proper covering, resulting in dried-out meals. Observations confirmed that salads were limp and at room temperature, and desserts were not properly chilled. Residents also noted that condiments and margarine were not consistently provided with meals. Interviews with dietary staff and the Dietary Manager revealed inconsistencies in following recipes and food preparation procedures. The Dietary Manager acknowledged receiving complaints about cold food and described efforts to keep food hot, such as using plate warmers and domes, but was unable to explain delays in meal delivery. The staff also deviated from recipes, such as using more salad dressing than required, and failed to document food temperatures as expected. The Administrator stated that there were no instructions for the amount of salad dressing to use and was unaware of the extent of food temperature and palatability issues.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate bathing assistance to four residents who were dependent on staff for activities of daily living (ADLs) during their temporary relocation to the COVID isolation unit. These residents, some of whom were receiving hospice services and had varying levels of cognitive impairment and incontinence, did not receive scheduled showers or alternative bathing assistance for extended periods, ranging from six to thirteen days. Documentation such as shower sheets and care plans lacked specific instructions on bathing frequency, and there was no record of showers or bed baths being provided during the isolation period for these residents. Interviews with residents revealed that they were not offered showers or assistance with bathing while on the COVID isolation unit, despite requesting help from staff. Some residents reported feeling dirty, not having changed clothes, or not having brushed their teeth for several days. Observations confirmed physical signs of poor hygiene, such as greasy hair and unshaven facial hair. Staff interviews indicated confusion regarding responsibilities for providing showers, especially for residents on hospice, and inconsistent documentation of care provided. Facility leadership, including the DON, ADON, and Administrator, acknowledged that residents were supposed to receive showers at least twice a week, including those on the COVID isolation unit and those receiving hospice care. However, there was a lack of clear documentation and follow-through, particularly when the designated shower aide was absent or when the shower facility was temporarily out of service. Staff reported that bed baths were to be provided when the shower was unavailable, but these were not documented. The deficiency was identified through observation, interview, and record review, highlighting a failure to ensure basic hygiene care for dependent residents during a critical period.

Penalty

Fine: $97,580

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

Summary

A deficiency occurred when a certified nurse aide (CNA) failed to protect a resident with Huntington's disease from abuse and neglect. The resident, who had a history of falls, impaired mobility, and behavioral symptoms related to Huntington's disease, requested assistance to retrieve paper from the floor. The CNA, while sweeping the resident's room, refused to assist and instead grabbed the resident's left hand/arm, pushing the resident back, which caused the resident to fall onto the footboard of the bed and then slide off onto the floor. The CNA did not attempt to prevent the fall or assist the resident after the incident, nor did the CNA call for a nurse to assess the resident. The resident sustained a large bruise to the right buttock area and reported pain, but the facility did not assess the resident after the fall until ten days later, when the surveyor brought the resident's complaint of pain to the facility's attention. Video footage confirmed the CNA's actions and lack of intervention, and interviews with the resident and family corroborated the events. The resident expressed frustration with the CNA's behavior and stated that the CNA was not nice and did not want the CNA in the room again. Facility policies reviewed indicated a clear expectation that residents be free from abuse, neglect, and exploitation, and that staff are to provide necessary assistance and report any allegations or suspicions of abuse immediately. Despite these policies, the CNA's actions and the facility's failure to promptly assess the resident after the fall constituted neglect and a violation of the resident's right to be free from abuse and neglect.

Penalty

Fine: $97,580

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 services to maintain a clean, sanitary, and orderly environment for one resident diagnosed with Huntington's disease, who required assistance with activities of daily living and had a history of falls. Video footage and direct observation revealed the resident's room was cluttered with numerous disposable plates, cups, utensils, and food debris on the floor, a full trash can, and dark stains on the bed linens. The over-bed table was covered with dried food and spilled drinks, attracting gnats, and the bathroom was unsanitary with a dirty toilet, empty paper towel dispenser, and no trash can. Dirty and clean clothing were scattered on the floor, and the bed frame was broken. Interviews indicated that housekeeping staff had not entered the resident's room for over a week due to a prior incident involving aggression, as directed by a former administrator. The current administrator was unaware of this directive and the lack of cleaning, as well as a request for a larger trash can to accommodate the resident's needs. The resident's family member reported that the resident often refused cleaning due to staff not communicating or discarding items without asking, and that staff did not understand the resident's condition. The facility did not provide a policy for housekeeping services or maintaining a clean and comfortable environment.

Penalty

Fine: $97,580

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

Summary

The facility failed to report an allegation of abuse in a timely manner after a resident with Parkinson's disease reported that a staff member threatened to hit them with a closed fist following an incident where the resident, unable to use their hands due to their condition, threw a urinal at the aide who refused to assist. The resident expressed fear of retaliation. The facility's policy requires all staff to report any allegations of abuse, neglect, or mistreatment to the Administrator or designee, and mandates reporting to the State Survey agency within specified timeframes depending on the severity of the event. Multiple staff members, including a therapy aide and the Social Services Director (SSD), became aware of the incident through direct reports from the resident and discussions among staff. The SSD reported the incident to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), but the ADON did not relay the information to the Administrator until much later. The DON was not aware of the incident until interviewed by surveyors. The delay in reporting the allegation to the appropriate authorities constituted a failure to follow the facility's abuse reporting policy.

Penalty

Fine: $97,580

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 a comprehensive, person-centered care plan for a resident diagnosed with Huntington's disease, traumatic subdural hemorrhage, and anxiety. The care plans in place addressed some behavioral symptoms, activities of daily living (ADLs), and communication challenges, but none were specific to the unique symptoms and care needs associated with Huntington's disease. The care plans lacked detailed interventions to address the resident's neurodegenerative condition, including the progressive cognitive decline, mood disturbances, and involuntary movements characteristic of Huntington's disease. Observations, interviews, and record reviews revealed that staff were not adequately informed or trained about Huntington's disease and its impact on the resident. Multiple staff members, including a Certified Medication Technician and housekeeping staff, expressed fear of the resident and admitted to not knowing what Huntington's disease was or how to approach or communicate with the resident. The resident reported that staff did not listen or understand that certain behaviors, such as spilling things, were due to the disease and not intentional actions. Family members and staff interviews further indicated that the lack of disease-specific care planning led to misunderstandings and inadequate care. Family observed that staff did not communicate effectively with the resident, often entering the room without explanation or knocking, and misinterpreted the resident's behaviors as intentional aggression rather than symptoms of the disease. The Registered Nurse responsible for care planning acknowledged the absence of a care plan specific to Huntington's disease, and the Administrator confirmed the expectation that such plans should be in place to guide staff and ensure appropriate 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

A deficiency occurred when a certified medication technician (CMT) verbally abused a resident by yelling, cussing, and using vulgar language, including telling the resident to "shut the F up" and calling the resident derogatory names. The incident took place when the resident, who had a history of dementia with behavioral disturbances, generalized anxiety disorder, Alzheimer's disease, and cerebral infarction, refused care. The resident was described as having moderately impaired cognitive skills, frequent care refusals, and requiring significant assistance with activities of daily living. Multiple sources, including the resident, another resident, a visitor, and a licensed practical nurse (LPN), confirmed that the CMT yelled and used inappropriate language toward the resident. The resident reported feeling shocked and scared by the CMT's behavior. Witnesses described the CMT as becoming frustrated and using the F word while providing care, and a visitor observed the CMT screaming and cussing at the resident in the hallway. The CMT admitted during an interview to verbally abusing the resident after being yelled at and having care refused. The CMT acknowledged that this was the first time encountering such behavior from a resident and admitted to responding inappropriately. The facility's abuse policy explicitly prohibits any form of abuse, including verbal or mental, and requires that residents be protected from such treatment.

Penalty

Fine: $26,130

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

Summary

A resident with a history of schizophrenia, bipolar disorder, Alzheimer's disease, and vascular dementia, who was assessed as being at risk for wandering and elopement, exited the facility through an alarmed fire exit door without staff knowledge. The resident was ambulatory with a wheelchair, had a severely impaired cognition, and had recently exhibited aggressive behavior, resulting in an order for 15-minute checks. However, staff failed to complete and document the required 15-minute checks during the relevant time period. The door alarm intended to alert staff to unauthorized exits was not loud enough to be heard until staff were already partway down the hall, as confirmed by multiple staff and resident interviews. Neither the resident's roommate nor another resident on the same hall heard the alarm, and staff only became aware of the resident's absence when a call light was noticed and the resident was found missing from their room. The resident's wheelchair was found by the exit door, and the alarm was only heard after staff began searching for the resident. The resident was later found outside the facility by a local citizen, having sustained multiple serious injuries including facial fractures and a subdural hemorrhage. The timeline and interviews indicate that the lack of timely supervision, failure to perform required checks, and insufficient alarm volume contributed to the resident's unsupervised exit and subsequent injury.

Removal Plan

• Conduct an investigation and notify appropriate parties including the police.
• Provide in-service education for all facility staff including elopement policies, check policies and door monitoring policies.
• Complete elopement risk assessments for all residents.
• Update the elopement risk and code white procedure books with current risk assessments and code white procedures.
• Adjust alarmed, fire, exit door alarms to increase the volume of the alarm for staff to recognize the alarm promptly.
• Perform alarmed door audits and check audits and continue ongoing audits.

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 certified nurse aide (CNA) took a resident's government-issued debit card without the resident's knowledge or permission and used it to make unauthorized withdrawals and purchases. The resident, who was newly admitted, able to make themselves understood, had some difficulty making decisions, and was independent with activities of daily living, noticed discrepancies in their account balance. The resident reported the missing funds to the business office manager (BOM), who, with the resident's permission, set up an online account to review the transactions. The review revealed multiple unauthorized ATM withdrawals and payments for food delivery, utilities, and a cell phone provider, totaling $1,369.69 over several days. The resident denied giving anyone permission to use the debit card for these transactions, except for a previous instance where the CNA was allowed to purchase cigarettes and returned the card. Law enforcement was notified, and the resident identified the CNA as the individual using the card in ATM footage provided by the police. The CNA claimed to have received permission to use the card for some purchases, but the resident denied this. The incident was reported to the facility administrator, who confirmed the resident's ability to handle their own finances and that the resident had not authorized the transactions in question. The facility's policy required that residents be free from abuse, including misappropriation of property, and outlined procedures for investigating such incidents. The investigation included interviews with the resident, staff, and review of transaction records. The facility also confirmed that the CNA was suspended pending investigation, and the incident was reported to the appropriate authorities as required by policy.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean and sanitary kitchen environment, leading to multiple deficiencies in food storage, preparation, and service. Observations revealed that open food items were not properly sealed, labeled, or dated, and various kitchen surfaces, including the stove, microwave, and cooler/freezer, were not clean. The kitchen floor, walls, and equipment such as the plate warmer and steam table were heavily soiled with food debris and grease. Additionally, the facility did not ensure that the temperature in one freezer was maintained at 0 degrees Fahrenheit or below, with temperatures observed as high as 28 degrees Fahrenheit, causing ice to melt and pool inside the freezer. Staff failed to adhere to proper handwashing and glove use protocols during meal preparation and service. Dietary staff were observed handling food with gloved hands, then touching various surfaces and utensils without changing gloves or washing hands. This included handling ready-to-eat food, opening refrigerator doors, and touching meal cards and utensils, all while wearing the same pair of gloves. The facility's policies on handwashing and glove use were not followed, as staff did not wash hands between tasks or after disposing of trash and handling dirty dishes. The facility's three-compartment sink was not properly set up for dishwashing, as the sanitizer solution was unavailable, and the sink compartments did not hold water. Staff washed dishes in dirty water without rinsing or sanitizing them, and the floor drain overflowed with dirty water and food debris. The Dietary Manager was aware of these issues but had not effectively addressed them, and the Administrator was not informed about the sink drainage problem. The facility's failure to maintain a clean kitchen and adhere to food safety protocols resulted in significant deficiencies in food service operations.

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 hazardous materials were secured and inaccessible to residents, as observed during a life safety code tour. Several hazardous items were found in unlocked cabinets throughout the facility, including six containers of chafing fuel, a bottle of nail polish remover labeled as extremely flammable, a commercial surface disinfectant, and two unlabeled spray bottles containing cleaning products. These items were located in areas accessible to residents, such as dining rooms and sitting areas, posing potential safety risks. Interviews with facility staff revealed a lack of awareness and oversight regarding the secure storage of these hazardous materials. The Maintenance Supervisor was unaware of the unsecured items and expected them to be properly secured and labeled. The Activities Director, who had only recently started working at the facility, was also unaware of the need to secure these items from resident access. This lack of awareness and failure to secure hazardous materials contributed to the deficiency identified during the survey.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate respiratory care for several residents, as evidenced by multiple observations and interviews. Resident #135 did not receive oxygen therapy per physician's orders and lacked proper documentation for the use of a CPAP machine upon admission. The resident expressed frustration over the lack of assistance in setting up the CPAP machine, which was necessary for managing obstructive sleep apnea. Observations showed the resident using oxygen without a physician's order and the oxygen tubing was not labeled as required. Resident #136 also experienced inadequate respiratory care, as the BiPAP machine was not applied at night as ordered by the physician. The resident reported feeling more tired due to not using the BiPAP, which had been a part of their routine for years. Observations confirmed that the BiPAP machine was not in use, and interviews with staff revealed a lack of awareness and responsibility for ensuring the machine was applied correctly. Additionally, the facility failed to properly store and label respiratory equipment for other residents. Residents #3, #22, #43, and #42 had issues with unlabeled oxygen tubing and humidification bottles, as well as improperly stored nebulizer masks. Observations showed nebulizer equipment left uncovered and on the floor, contrary to the facility's policy. Interviews with the Director of Nursing and the Administrator highlighted expectations for staff to label and store equipment correctly, but these practices were not consistently followed.

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 food served to residents was palatable and at an appetizing temperature, as observed during a survey. The facility's policy required hot foods to be at least 120 degrees Fahrenheit when served, and cold items to be placed over an ice bath. However, multiple residents reported dissatisfaction with the food, describing it as bland and cold. Observations revealed that the pasta salad was not prepared according to the recipe, as it was served at 85 degrees Fahrenheit without being placed over an ice bath. Additionally, the barbeque pork was served at 100 degrees Fahrenheit, below the required temperature, due to the steam table heating unit being turned off. Further observations showed that potatoes were served instead of the planned cornbread stuffing, without any seasoning, resulting in a bland taste. The potatoes were served at 110 degrees Fahrenheit, below the required temperature. Interviews with residents confirmed the lack of flavor in the potatoes. The Dietary Manager admitted that staff only took food temperatures at the beginning of the meal service, indicating a lack of ongoing monitoring to ensure food was served at the correct temperature throughout the meal service.

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 staff offered nourishing evening snacks to residents who wished to have them, affecting nine residents out of a sample of 18, and potentially impacting the entire facility census of 82. The facility's policy required that bedtime snacks be offered to all residents, but interviews and record reviews revealed that this was not being consistently implemented. Several residents, including those with intact cognition and those with moderate cognitive impairment, expressed that they were not provided with bedtime snacks despite having physician orders for them. Some residents reported that snacks were only available at the nurse's station and were limited in quantity, leading to situations where not all residents could receive a snack. Interviews with staff, including a CNA, the Dietary Manager, the Director of Nursing, and the Administrator, highlighted a lack of awareness and communication regarding the policy to offer snacks to all residents. The CNA was unaware of the requirement to provide bedtime snacks, and the Dietary Manager described a process where snacks were prepared and taken to the nurse's station, but not directly offered to residents. The Director of Nursing and the Administrator both acknowledged that snacks should be offered to all residents, but were not aware that this was not happening. This deficiency indicates a breakdown in the implementation of the facility's policy on providing snacks, resulting in residents not receiving the nourishment they desired and were entitled to.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper hand hygiene and glove use among nursing staff during the provision of care for several residents. Observations revealed that staff members did not wash their hands or change gloves appropriately when moving from dirty to clean tasks. For instance, a CNA was observed providing incontinence care to a resident without washing hands or changing gloves before touching clean items and assisting the resident with a drink. Similar lapses were noted with other residents, where staff did not change gloves or wash hands between tasks, leading to potential cross-contamination. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. The resident's care plan did not identify the need for EBP, and staff were observed not wearing gowns when providing care, despite the presence of PPE on the resident's room door. Interviews with staff indicated a lack of awareness regarding the purpose of the PPE and the requirements for EBP, leading to non-compliance with infection control guidelines. The facility also failed to complete Tuberculin Skin Testing (TST) for three employees as part of their pre-employment procedures. Employee files showed missing documentation for the second-step TST, and in one case, no documentation of the first-step TST. The Director of Nursing acknowledged the oversight, attributing it to the departure of the Staffing Coordinator responsible for employee TB testing. This lapse in protocol could potentially compromise the health and safety of both staff and residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide pneumococcal vaccinations according to CDC guidelines for five residents out of a sample of 18. The facility's policy required physician consultation and orders for vaccinations, as well as informed consent from residents or their responsible parties. However, the facility did not document the administration of the PCV20 vaccine for several residents who had consented to receive it, nor did they document any clinical decision-making or refusal by the residents or their representatives. Resident #23 had received previous pneumococcal vaccinations but had not been administered the PCV20 vaccine despite consenting to it. The resident's POA confirmed that the updated pneumonia vaccine was not offered. Similarly, Resident #78 had received the PPSV23 vaccine but was not offered the PCV15 or PCV20 vaccine, and the resident's POA expressed a desire for the updated vaccine. Resident #3, who had intact cognition, believed their vaccines were up to date, but there was no evidence of receiving any pneumococcal vaccines after admission. Residents #19 and #45 had both consented to receive the pneumococcal vaccination, but their medical records showed no documentation of the vaccine being administered. Interviews with the DON and ADON revealed that the facility was aware of the issue and that the ADON was responsible for ensuring vaccinations were up to date. However, the necessary follow-up actions to administer the vaccines were not completed, leading to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to reasonably accommodate the needs of a resident, identified as Resident #135, who required portable oxygen and a wheelchair for mobility due to shortness of breath and a history of falls. Despite the resident's requests and medical conditions, staff did not provide the necessary equipment, leading to the resident feeling confined to their room. The resident attempted to walk to the dining room without assistance or oxygen, resulting in dizziness and shortness of breath. The resident's care plan and assessments did not adequately address their need for a wheelchair, portable oxygen, or the use of a cardiac monitor for their pacemaker. Staff, including a Certified Medication Technician, a Certified Nursing Assistant, and an agency Licensed Practical Nurse, were unaware of the resident's needs for these accommodations. The Director of Therapy Services was informed about the need for a wheelchair but did not evaluate the resident, and the Director of Nursing was unfamiliar with the resident's needs due to being off during the admission. Observations confirmed the absence of a portable oxygen tank and wheelchair in the resident's room, and the resident was seen without supplemental oxygen or mobility aids in the dining room. The facility lacked a policy for accommodating resident needs, contributing to the oversight in providing necessary equipment and support for Resident #135.

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 prepare pureed food items according to the required smooth consistency for a resident on a pureed diet. Observations revealed that the pureed chicken and carrots served to the resident contained visible chunks, indicating that the food was not processed to the appropriate consistency. Additionally, the pureed barbeque pork was stringy with visible pieces of pulled pork, and the pureed pasta salad and three-bean salad contained chunks of pasta and beans, respectively. These observations were inconsistent with the facility's policy and recipes, which specified that pureed foods should be processed until smooth. Interviews with the Dietary Manager and the Speech Therapist confirmed that pureed food should be the consistency of baby food or applesauce, without any chunks or the need for chewing. However, the pureed roast turkey served during a test tray observation was thick and required chewing, resembling ground turkey rather than a smooth puree. The facility's failure to adhere to the pureed food preparation guidelines resulted in the resident receiving meals that did not meet their dietary needs.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that staff provided necessary care and services to maintain good personal hygiene for two residents who were unable to complete their own activities of daily living (ADL). Specifically, staff did not assist with nail care and grooming, including shaving, for these residents. This deficiency was identified through observation, interview, and record review during the survey, which included a sample of nine residents out of a facility census of 82.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate care for a resident with hand contractures by not applying hand splints and palm protectors as directed by Occupational Therapy. This deficiency was identified through observation, interview, and record review. The resident, who was part of a sample of nine residents, required these devices to support and protect injured tissues and to prevent further deformity. The facility's census at the time was 82.

Penalty

Fine: $91,06033 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 sexual abuse between two residents whose capacity to consent to sexual activity had not been determined. Resident #1, who was severely cognitively impaired with diagnoses including Alzheimer's disease, dementia, herpes viral infection, and HIV, was found engaging in sexual intercourse with Resident #2, who had vascular dementia and depression. The incident occurred despite Resident #2 expressing fear and unwillingness to be around Resident #1 after the event. The facility's abuse prohibition protocol and policy on resident sexual expression were not effectively implemented, as there was no documentation of interventions regarding the residents' capacity to consent to a sexual relationship. Prior to the incident, staff observed interactions between the two residents, such as holding hands and being in each other's rooms, but these observations were not adequately reported or addressed. Certified Nurse Aide C and the Maintenance Director both witnessed the residents together in situations that should have prompted further investigation and intervention. However, these observations were not communicated to the Director of Nursing or the Administrator, and no measures were taken to assess the residents' capacity to consent or to prevent inappropriate contact. The facility's failure to monitor and report the interactions between the residents led to the incident of sexual abuse. The primary care physician confirmed that neither resident had the cognitive ability to consent to sexual activity, highlighting a significant oversight in the facility's responsibility to protect its residents. The lack of communication and appropriate action by the staff contributed to the deficiency, as the facility did not ensure a safe environment for the residents involved.

Penalty

Fine: $91,06033 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 adequate care and assistance with activities of daily living (ADLs) for two residents who were unable to complete these tasks independently. Resident #1, who was cognitively intact but dependent on staff for all ADLs due to quadriplegia and severely impaired vision, did not receive regular grooming and hygiene care. The resident's shower records indicated infrequent showers, with significant gaps between them, and observations showed long, dirty fingernails with debris, dry skin, and a foul odor. The resident expressed dissatisfaction with the lack of care, stating that the long nails caused pain and the lack of shaving led to discomfort. Resident #5, also cognitively intact and dependent on staff for personal hygiene, experienced similar neglect. The resident's care plan indicated a preference for weekly showers, but records showed only one shower in June 2024. Observations noted a strong body odor and flaky, dry skin. The resident reported going without a bath for up to two weeks and expressed a desire for more frequent bathing, stating that staff did not return to assist after initial refusals due to feeling unwell. Interviews with facility staff, including CNAs and the Director of Nursing, revealed systemic issues contributing to the deficiencies. Staff acknowledged difficulties in trimming nails and shaving due to time constraints and the absence of a full-time shower aide on the residents' hall. The Director of Nursing and the Administrator both stated expectations for regular showers and grooming, but acknowledged that staffing changes and inadequate follow-up on refusals may have led to missed care opportunities.

Penalty

Fine: $91,06033 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 appropriate care for a resident with hand contractures by not applying hand splints and palm protectors as directed by occupational therapy. The resident, who had diagnoses including quadriplegia and contractures of both hands, was dependent on staff for all activities of daily living. Despite therapy instructions and training provided to staff, there was no documentation in the medical record indicating that the splints were applied, nor was there any record of the resident refusing them. Observations over two days showed that the resident did not have palm protectors or splints in place, and their hands were in poor condition, with long, uneven fingernails and patches of dry skin. Interviews with the resident and their family member revealed that the resident experienced pain due to the lack of splints and palm protectors, and the family member confirmed that the resident never had these devices in place during visits. Staff interviews indicated a lack of clarity and consistency in applying the splints and palm protectors, with some staff unsure of the procedures or the location of the devices. The Rehab Director and Director of Nursing acknowledged the issue, noting that staff were not following through with the application of splints and palm protectors as instructed. The Rehab Director suggested that the CNAs were too rushed and did not take the time to properly stretch the resident's hands, leading to pain. The Director of Nursing admitted that new staff might not have been adequately educated on the use of special devices, resulting in the oversight. The Administrator expected that the restorative aide would ensure the application of these devices, but this was not happening consistently.