Ormsby Post Acute Rehabilitation

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.

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 documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.

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 obtain and document cooking and holding temperatures for chicken before serving it to residents during lunch service. On the specified date, dietary staff removed three large trays of chicken breasts from the oven and transferred them to a holding tray on the steam table. The chicken was then plated and prepared for delivery to residents without the necessary temperature checks. The Dietary Manager confirmed that temperatures were neither taken nor documented before serving, although they claimed temperatures were checked during cooking. However, no documentation or observation of these checks was available. The Registered Dietician acknowledged that the facility did not record cooking temperatures and was following the facility's policy, which could potentially lead to foodborne illness if the chicken was undercooked. The Executive Director admitted that the facility lacked a policy related to foodborne illness. The facility's existing policies required a minimum cooking temperature of 165 degrees Fahrenheit for chicken and a holding temperature of at least 140 degrees Fahrenheit, with food temperatures to be documented daily before meal service. However, a cooking temperature log could not be located, indicating a lapse in adherence to these policies.

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 coordination of hospice care between the facility and hospice agencies for three residents receiving hospice services. This deficiency was identified through clinical record reviews, document reviews, and interviews. The lack of coordination resulted in missing documentation of hospice visits and care provided, which was not available in the residents' clinical records or hospice binders. This failure to document and coordinate care had the potential to compromise the quality of hospice care provided to the residents. Resident #230 was admitted to hospice care with a care plan that included skilled nursing, CNA visits, social worker, and chaplain services. However, the facility's records lacked documentation of these visits, and the hospice binder did not have a sign-in sheet for hospice staff. The DON confirmed that hospice visit notes were not documented in the resident's chart prior to a specific date, and the facility did not have evidence of the required CNA visits being completed as per the hospice care plan. Similarly, Resident #50 and Resident #4 also experienced deficiencies in the documentation and coordination of hospice care. Resident #50's records lacked hospice visit notes, and the sign-in sheets were incomplete. For Resident #4, the hospice communication binder and EMR lacked visit notes, and the facility did not have a current hospice care plan or documentation of completed visits. The DON confirmed that the facility did not have documented evidence of completed hospice visits for these residents and that the hospice agency did not consistently use a sign-in log to track hospice staff visits.

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 the proper Notice of Medicare Non-Coverage (NOMNC) to two residents, resulting in non-compliance with Medicare requirements. For the first resident, who was admitted with conditions including primary generalized osteoarthritis and chronic respiratory failure, there was no documented evidence that the NOMNC was provided before their discharge home. The Business Office Manager (BOM) confirmed the absence of the NOMNC in the resident's clinical record, despite the facility's policy to follow CMS instructions for the NOMNC. Similarly, the second resident, admitted with diagnoses such as type 2 diabetes mellitus and chronic kidney disease, did not receive the NOMNC for an extended admission period. Although the resident's discharge was initially planned for an earlier date, it was extended due to a medical condition. The BOM confirmed the lack of documentation for the NOMNC related to this extension. The facility's Executive Director acknowledged the expectation to provide the NOMNC two days before the end of benefits, as per CMS guidelines, but this was not adhered to in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were transmitted to the State within the required 7-day timeframe for 4 out of 10 months, starting in June 2024. This deficiency was identified through interviews and document reviews, revealing that a significant percentage of admission assessments were completed late during these months. Specifically, in June 2024, 10.3% of admission assessments were late, followed by 12.5%, 14.5%, 13.5%, and 11.9% in subsequent months. The Executive Director confirmed that the MDS Coordinator was responsible for submitting these assessments and acknowledged that the late filings were due to a change in MDS Coordinators at the facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, which could potentially deprive them of necessary care and services. Resident #4, who was admitted with diagnoses including spondylopathies and unspecified dementia, was receiving hospice services as documented in a Hospice Plan of Care. However, the quarterly MDS assessment did not indicate that Resident #4 was receiving hospice care, as required by the Resident Assessment Instrument (RAI) manual. This oversight was confirmed by the MDS Consultant upon review of the clinical record. Similarly, Resident #79, admitted with a diagnosis of a femur fracture, was documented in a Nursing Progress Note as being discharged home. However, the discharge MDS assessment inaccurately recorded the resident as being discharged to a short-term general hospital. The MDS Consultant confirmed this discrepancy upon reviewing the clinical record. The Director of Nursing acknowledged that the facility did not have a specific policy for completing MDS assessments and relied on the RAI manual for guidance.

Penalty

No penalty information released

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

Summary

The facility failed to develop a person-centered Comprehensive Care Plan for a resident with type 2 diabetes mellitus, specifically regarding the use of insulin. The resident was admitted with a diagnosis of type 2 diabetes mellitus and had physician's orders for HumaLOG and Insulin Glargine to be administered subcutaneously. Despite these orders being documented in the Medication Administration Record, the resident's Care Plan lacked documented evidence of the use of insulin. The Director of Nursing confirmed the absence of insulin-specific documentation in the Care Plan and expressed an expectation that the care plan would not be insulin-specific. According to the Resident Assessment Instrument (RAI) 3.0 manual, the care plan should be used to provide services to maintain the resident's highest practicable wellbeing and should be revised based on changing needs and interventions. The failure to include insulin use in the care plan had the potential to result in residents not receiving necessary care and services related to insulin management.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that behaviors monitored were associated with the specific condition indicated by the physician for the use of psychotropic medications for one resident. This deficiency was identified during an interview, clinical record review, and document review. The resident in question was admitted with diagnoses including major depressive disorder and generalized anxiety disorder. The resident's psychotropic medication orders included Buspirone, Clonazepam, Duloxetine, Trazodone, and Wellbutrin, prescribed for anxiety and depression. However, the behavior monitoring instructions in the electronic medical record were not specific to the behaviors that needed to be monitored for this resident. The Director of Nursing explained that CNAs documented behavior monitoring during each shift, inputting progress notes for new and escalating behaviors. However, the behavior monitoring was not tailored to the resident's specific behaviors. The facility's policy on psychotropic drugs required that residents with such medication orders be evaluated and appropriate interventions implemented, with the interdisciplinary team ensuring appropriate diagnoses of behavioral symptoms. Despite this policy, the lack of resident-specific behavior monitoring led to the potential for the resident to use unnecessary medication with possible adverse effects.

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 storage and monitoring of medications and biologicals, as evidenced by several deficiencies. One of the medication storage refrigerators, located in the Staff Development Coordinator (SDC) office, contained food items such as mozzarella cheese sticks, soda cans, yogurt, queso cheese, sour cream, and jalapeno stuffed olives, stored alongside vaccines and a vial of Tubersol Solution. The refrigerator lacked a temperature log, and the SDC confirmed that the refrigerator was left unsecured and that food should not have been stored with vaccines or biologicals. Additionally, a multi-dose vial of Tubersol Solution was found to be expired, having been open for 49 days, exceeding the facility's policy of discarding such vials 28 days after opening. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed the expiration policy, and the DON acknowledged the vial should have been discarded as its efficacy would have been reduced. The facility's policy mandates that outdated or expired medications be immediately removed from stock and disposed of. Furthermore, a medication cart in the 200 hallway was left unattended with the top drawer unlocked, allowing access to resident medications. The facility's policy requires medication carts to be kept closed and locked when out of sight of the medication nurse. These deficiencies indicate lapses in the facility's adherence to its medication storage and administration policies, potentially compromising medication integrity and safety.

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 safeguard resident-identifiable information and maintain complete medical records, as observed during a survey. A computer screen on a medication cart was left unattended and displayed resident medication information in a public area, which was confirmed by a Registered Nurse (RN) upon returning to the cart. This practice was against the facility's policy that required resident health information to remain private and not visible when not in direct use. Additionally, the facility did not maintain complete clinical records for a resident who had been admitted with conditions including orthopedic aftercare following surgical amputation and basal cell carcinoma. The Treatment Administration Record (TAR) for this resident had multiple blank spaces for scheduled administrations of wound care and medication, indicating missing documentation. The Director of Nursing (DON) confirmed these omissions, which were contrary to the facility's policies requiring documentation of care and medication administration in accordance with prescriber's orders.

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 document and ensure completion of required orientation, training, and competency validation for a newly assigned agency Registered Nurse (RN) prior to the RN providing direct resident care. The RN began working an overnight shift without having completed the facility's orientation packet, which included training competencies, as required by facility policy. The Staff Development Coordinator (SDC) and Executive Director (ED) confirmed that the RN did not arrive at the scheduled time to complete orientation and started the shift without documented orientation, skills check, or training. The RN also refused to review or fill out the orientation packet when prompted by an LPN assigned to train them. During the shift, several residents reported that the RN did not administer as-needed medications, prompting the LPN to notify management and administer the medications themselves. The Director of Nursing (DON) confirmed that the RN had not completed any documented orientation or training before providing care. The facility's contract with the staffing agency and internal policies required that all agency staff receive appropriate orientation and competency validation, including medication administration and infection control, prior to independent assignment. These requirements were not met in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to protect residents from various forms of abuse and neglect, as evidenced by several incidents involving different residents. One resident was neglected when a CNA refused to assist them out of bed and closed the door to prevent them from calling for help, despite the resident's increased anxiety at night and dependence on staff for mobility. This incident was verified by the facility, and the CNA admitted to the actions. Additionally, the same resident experienced neglect when their brief was not changed for eight hours, resulting in them sitting in soiled conditions, which was also confirmed by the facility's investigation. Another resident was verbally abused by an LPN who yelled at them during care, causing the resident to feel unsafe and cry the following day. Witnesses corroborated the resident's account, noting the LPN's inappropriate behavior and use of a cell phone during the incident. The facility verified the verbal abuse allegation and took action against the LPN involved. A separate incident involved a physician who continued a breast examination on a resident despite the resident's repeated requests to stop, making the resident uncomfortable. Witnesses confirmed the resident's account, and the facility acknowledged the situation as a potential concern of abuse. Additionally, a resident-to-resident sexual abuse incident occurred when one resident kissed another on the lips without consent, despite the latter's cognitive impairments and inability to consent. The facility was aware of the offending resident's history of inappropriate behavior, yet the incident still occurred.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's medication from being wrongfully used by a staff member. A Licensed Practical Nurse (LPN) was witnessed by another nurse self-administering insulin that was prescribed to a resident diagnosed with type I diabetes mellitus. The incident was documented in a Facility Reported Incident (FRI) on 08/05/2024, and the nurse involved admitted to the act in a signed statement dated 08/09/2024. The Director of Nursing (DON) expressed that the nurse should have sought management support or emergency medical care instead of using the resident's medication. The resident involved, who is blind, was unaware of the incident until informed by another resident and staff. The resident expressed feeling upset as the nurse did not seek permission to use the insulin. The facility's PRIDE Education Module, updated in 10/2022, defines misappropriation of resident property as the deliberate use of a resident's belongings without consent, and diversion of medication for staff use is cited as an example of such misappropriation.

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 professional standards for prescribing medications were followed, resulting in a resident receiving incorrect medications. A nurse mistakenly input medication orders for a resident from another resident's hospital discharge summary. This error went unnoticed for three days, during which the resident received medications for conditions they did not have, such as hypertension and Parkinson's disease. The error was discovered and reported after the resident exhibited symptoms of hypotension and was unable to stay awake or alert. The resident, who had been admitted with diagnoses including metabolic encephalopathy and protein-calorie malnutrition, was readmitted to the facility from the hospital. The incorrect medications were administered multiple times over the course of three days, leading to the resident being sent to the Emergency Department and subsequently hospitalized for four days. The medications included acetaminophen, asenapine, benztropine, and others, which were not appropriate for the resident's actual medical conditions. The physician involved admitted to having skimmed through the orders and signing them without thorough review, relying on the nurse to contact them with any questions. The Director of Nursing expressed an expectation that the provider should have questioned the orders for medications treating diagnoses the resident did not have. The facility's Medical Director Independent Contractor Agreement outlined the provider's responsibility for coordinating medical care and ensuring the facility provided the required care, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, resulting in a significant medication error. A resident was readmitted to the facility with specific diagnoses, including metabolic encephalopathy and sequelae of protein-calorie malnutrition. However, upon readmission, the admitting nurse mistakenly input medication orders from another resident's hospital discharge summary. This error led to the resident receiving incorrect medications for three days before the mistake was discovered. The medications administered included treatments for conditions such as hypertension, Parkinson's disease, and hyperlipidemia, which the resident did not have. The error was identified when the resident exhibited symptoms such as hypotension and an inability to stay awake or alert, prompting a transfer to the Emergency Department for further evaluation. The facility's policy on medication administration required that medications be administered according to the prescriber's written orders and that any discrepancies be clarified with the provider pharmacy or prescriber before administration. Despite this policy, the resident received medications unrelated to their diagnoses, leading to hospitalization to monitor for adverse side effects.

Penalty

Fine: $60,4636 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 investigate a potential incident of misappropriation of a resident's prescribed narcotic pain medication. This involved Resident #44, whose Morphine Sulfate solution appeared tampered with, as noted by a hospice RN. The medication was discolored, and a paper-like substance was visible in the bottle. Despite these observations, the facility did not initiate an investigation into the potential misappropriation of property until prompted by the surveyors. Additionally, the facility did not thoroughly investigate an allegation of abuse involving Resident #19. The resident alleged inappropriate touching by a male staff member during care. Despite the serious nature of the allegation, the facility allowed the alleged perpetrator to continue working in the facility, thereby failing to protect Resident #19 and other residents from potential further abuse. The DNS did not review the clinical records to verify the involvement of the staff member, which was a critical oversight in the investigation process. The facility's policies on abuse prevention and investigation were not adequately followed, as evidenced by the lack of immediate suspension of the alleged perpetrator and the failure to conduct a thorough investigation. The DNS admitted to not reviewing the clinical records as part of the investigation, which could have confirmed the staff member's involvement in providing care to Resident #19. This oversight allowed the alleged perpetrator to continue working, posing a risk to the safety and well-being of all residents.

Removal Plan

• The alleged perpetrator was suspended to ensure completion of the investigation regarding care provided to the resident of concern.
• All residents were interviewed related to sexual abuse, and non-interviewable residents were assessed for sexual trauma.
• All facility staff would be educated on Abuse Prevention and Investigation.

Penalty

Fine: $60,4636 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 the Infection Preventionist (IP) possessed the necessary skills to review lab results for determining the appropriateness of implementing transmission-based precautions (TBP). The IP incorrectly believed that a resident had to be symptomatic with visible signs of infection to be placed in TBP and did not consider lab results as a basis for isolation. Additionally, the IP did not review wound cultures obtained by a hospital prior to a resident's admission, despite the facility's policy allowing such reviews. This lack of competency in infection prevention could lead to residents not being placed on necessary precautions, potentially exposing others to communicable diseases. The facility also failed to ensure that a nurse administering medications had completed a competency for medication administration. A Registered Nurse (RN) incorrectly stated that medicated powders could be left in a resident's room and applied by Certified Nursing Assistants (CNAs). The Director of Nursing Services (DNS) admitted that the facility did not complete a competency checklist with nurses but relied on a pharmacy audit tool, which was not provided upon request. This deficiency could result in residents not receiving medications as prescribed, increasing the potential for adverse medication reactions. Furthermore, the IP lacked the knowledge necessary for the appropriate selection and administration of pneumococcal vaccines. The IP incorrectly believed that pneumococcal vaccines expired after five years and needed to be repeated, and the facility did not offer certain vaccines recommended by the CDC. The IP also failed to use CDC guidance, including decision flow sheets, to determine vaccine needs. Additionally, the IP did not correctly complete the Antibiotic Stewardship Program (ASP) tools and documentation, including antibiotic time outs, which could lead to residents being treated with ineffective antibiotics, resulting in prolonged infections or the development of multi-drug resistant organisms (MDRO).

Penalty

Fine: $60,4636 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 maintain proper food safety and hygiene standards in its dietary services. Personal items, including a beverage from a fast-food restaurant and a personal bag, were found on a food preparation counter, which was confirmed by the Nutritional Services Supervisor to be inappropriate. Additionally, charging cords were present on another food prep counter where sandwiches were being prepared, which the supervisor also acknowledged should not have been there. The facility lacked a policy regarding personal items in the kitchen, as confirmed by the Nutritional Services Supervisor. The facility also failed to ensure proper hand hygiene practices during meal service. A CNA did not perform hand hygiene after handling a soiled tray before delivering a new meal tray to another resident. Similarly, a Nursing Aid in Training and another CNA did not perform hand hygiene before delivering meal trays to residents. Both staff members acknowledged the requirement for hand hygiene but denied failing to perform it. The Nutritional Services Supervisor was unaware of these lapses in hand hygiene, which contradicted the facility's hand hygiene policy that mandates the use of alcohol-based hand rub or soap and water before and after handling food or assisting residents with meals.

Penalty

Fine: $60,4636 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 conduct a thorough investigation into an allegation of sexual abuse involving a resident. The Director of Nursing Services (DNS) was aware of the allegation but did not review the resident's clinical record to verify if the alleged perpetrators, a Certified Nursing Assistant (CNA) and a Nurse-Aid in Training (NAT), had provided care to the resident. Despite the ongoing investigation, the NAT continued to work unsupervised, as the DNS was unable to contact the NAT to inform them of the suspension. This oversight potentially exposed residents to further abuse. The Infection Preventionist (IP) at the facility lacked the necessary skills and knowledge to effectively monitor and track infections and antibiotic use. The IP failed to consistently document critical information such as the type of infection, the prescribed antibiotic, and lab results on the Line Listing Report. This omission hindered the facility's ability to track infections and antibiotic use accurately, increasing the risk of residents developing infections with Multi Drug Resistant Organisms (MDROs). Additionally, the IP demonstrated a lack of understanding regarding the administration of pneumococcal vaccines. The IP did not utilize CDC guidance or provide floor nurses with tools to determine which vaccines residents were eligible for. This resulted in the facility's failure to identify residents in need of additional pneumococcal vaccines, potentially compromising their health.

Penalty

Fine: $60,4636 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's Quality Assurance and Performance Improvement (QAPI) committee failed to identify several critical issues, leading to deficiencies in care and management. The committee did not recognize concerns related to Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP), which could have been identified through audits and led to necessary staff education. Additionally, the committee overlooked an Advanced Practice Registered Nurse (APRN) signing documentation with the credentials of a Medical Doctor, a discrepancy that could have been caught by Medical Records during daily audits. Furthermore, there was a lack of thorough investigation into resident abuse allegations, which could have been addressed by verifying employee contact information upon hire. The QAPI committee also failed to identify issues with tracking and reconciling narcotic medications, including those for hospice care, and the absence of a designated Hospice Coordinator, which affected communication regarding medications. Moreover, the committee did not address concerns related to the screening and offering of pneumococcal vaccines to residents, which could have been identified through immunization audits. These oversights indicate a failure in the facility's QAPI processes to effectively identify and address quality deficiencies and opportunities for improvement.

Penalty

Fine: $60,4636 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 the Infection Preventionist (IP) accurately documented and tracked infections and antibiotic use among residents. The Line Listing for Infections by Resident form, used by the IP, lacked necessary elements such as the prescribed antibiotic, start and stop dates, ordered lab work, and lab results. This omission affected the documentation for 10 out of 31 residents who were prescribed antibiotics for infections between January and May 2024. The IP confirmed that the form did not include a space to document the type of infection, and the column for Transmission Based Precautions was pre-populated with 'none', requiring manual changes. The IP's process for tracking infections involved daily reviews of the Orders Listing Report, which included physician orders for antibiotics. However, discrepancies were found between the Orders Listing Report and the Line Listing for Infections by Resident form. Several residents with physician orders for antibiotics were not included in the Line Listing Report for various months, indicating incomplete or outdated documentation. The IP acknowledged these discrepancies and confirmed that the documentation was not current. Additionally, the facility failed to provide education related to antibiotic use and the Antibiotic Stewardship Program (ASP) to both staff and residents. The Director of Nursing (DON) confirmed the lack of educational provision. The facility's policy on the ASP, dated September 2017, required education for nursing staff, providers, and residents, but there was no documented evidence of such education being provided. This lack of education and incomplete documentation could potentially affect the entire resident census of 89.

Penalty

Fine: $60,4636 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 timely completion of compliance and ethics training for 15 out of 20 sampled employees. The deficiency was identified through interviews and document reviews, revealing that several employees did not complete the required training upon hire or annually as stipulated by the facility's policy. Employees, including the Administrator, Director of Nursing, Activities Director, Dietary Manager, and others, either completed the training late or lacked documented evidence of having completed it for the year 2023. The Human Resources staff admitted to being unsure about the timing and frequency of the required compliance and ethics training. This uncertainty contributed to the failure in ensuring that employees received the necessary training to prevent and detect violations and promote quality care. The facility's policy, published in November 2019, clearly stated the requirement for all staff to complete this training upon hire and annually thereafter, but this was not adhered to, leading to the identified deficiency.

Penalty

Fine: $60,4636 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 medications were not left unsecured at a resident's bedside, as observed with two residents. For one resident, medications including Nystop powder, Phytoplex antifungal powder, and Fluticasone Propionate nasal spray were found unsecured in the resident's room. The CNA responsible for the resident's care admitted to applying the powders, which was outside their scope of practice, as they were not trained to administer medications. The RN confirmed the nasal spray should have been secured in the medication cart, and the Director of Nursing Services stated that CNAs should not apply medicated powders and that medications should not be left at the bedside. Another resident had multiple inhalers, including Albuterol, Spiriva, and Symbicort, left unsecured in their room. These inhalers were brought in by the resident's family due to the facility's initial lack of availability. A CNA found the Albuterol inhaler on the resident's lunch tray and returned it to the resident, intending to inform the nurse, which did not happen. The LPN was unaware the inhalers remained in the room and later removed them, placing them in the medication cart. The facility's policy prohibits medications from being left in resident rooms unsupervised due to safety concerns. Additionally, a medication cart was left unattended with over-the-counter medications on top while a CNA watched it as the nurse used the restroom. The CNA acknowledged that watching medications was not within their scope of practice. The facility's policy states that medications should only be accessible to licensed nursing personnel or authorized staff. The Nevada Nurse Practice Act supports this by prohibiting the delegation of tasks to unqualified personnel.

Penalty

Fine: $60,4636 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 security and proper storage of medications, as observed during a survey. A medication cart was left unattended with over 20 over-the-counter plastic bottles containing pills on top, while a CNA was asked to watch the cart as the nurse used the restroom. The CNA confirmed that watching medications was not within their scope of practice. The RN acknowledged that vitamins are considered medications and should not have been left unsecured. Facility policy states that medication supplies should only be accessible to licensed nursing personnel or those authorized to administer medications. Additionally, the facility did not store medications according to manufacturer guidelines and failed to remove discontinued medications from the medication cart. A bottle of Lactulose solution belonging to a deceased resident was found in the cart, despite the medication being discontinued. Furthermore, a bottle of Lorazepam was improperly stored in the medication cart instead of being refrigerated as required by the manufacturer. The LPN confirmed the improper storage and the need for refrigeration. The ADON and DNS acknowledged the expectation for medications to be stored according to guidelines and removed when discontinued. The facility also failed to ensure proper labeling of medications. An unopened bottle of Morphine Sulfate oral solution and a bottle of Lorazepam were found without proper labels, making them unusable. The RN2 and RCM confirmed the lack of labeling and explained that medications without complete labels should not be used. The facility's policy and the Pharmacy Services Agreement require medications to be labeled according to professional standards, but this was not adhered to in these instances.

Penalty

Fine: $60,4636 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 properly screened for eligibility to receive influenza and pneumococcal vaccines, and that education regarding these vaccines was provided to the residents or their representatives. Specifically, two residents were not screened for influenza vaccination eligibility, and seven residents were not screened for pneumococcal vaccination eligibility. The clinical records of these residents lacked documented evidence of screening, education, and whether the vaccines were offered, administered, or declined. For influenza vaccines, Resident #62 was not offered a vaccine due to being admitted after the end of the flu season, despite their original admission date being earlier. The Infection Preventionist (IP) acknowledged the oversight and noted that the admitting nurse failed to document immunization information, which could have been caught during weekly audits that were not conducted that week. Similarly, Resident #9's record lacked documentation of influenza vaccine screening and education, with the IP suggesting confusion due to the resident's hospice status, although hospice residents should still receive care, including immunizations. Regarding pneumococcal vaccines, several residents, including Resident #9, #80, #77, #85, #23, and #242, were not properly screened or educated about the CDC's recommended vaccines. The IP confirmed that these residents' records lacked documentation of eligibility screening and education, and the Director of Nursing Services (DNS) admitted that the facility had not been using CDC guidance or decision flow sheets to determine vaccine recommendations. The facility's policy stated that they followed CDC recommendations, but the lack of documentation and adherence to guidelines led to the deficiency.

Penalty

Fine: $60,4636 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 resident rights training was completed in a timely manner for 9 out of 20 sampled employees. These employees included the Administrator, Food and Nutrition Services Manager, Certified Nursing Assistants (CNAs), a Certified Occupational Therapist, a Licensed Practical Nurse (LPN), a Hospitality Aide, and a Housekeeper. The personnel records showed that some employees received their training significantly after their hire date, while others lacked documented evidence of having completed the training in the previous year or at all. Specifically, the Administrator and Housekeeper completed their training 48 and 46 days after hire, respectively, while the Hospitality Aide completed it 24 days after hire. Additionally, the Certified Occupational Therapist and one CNA had no documented evidence of having completed the training. The Human Resources staff expressed uncertainty regarding the timing and frequency of the required resident rights training. The facility's policy, last updated in July 2015, mandates that all staff complete resident rights training upon hire and annually thereafter. However, the facility did not adhere to this policy, as evidenced by the lack of timely training for the sampled employees. This deficiency was confirmed through personnel record reviews, interviews, and document reviews, highlighting a systemic issue in the facility's training processes.

Penalty

Fine: $60,4636 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 Quality Assurance Performance Improvement (QAPI) training was completed for 15 out of 20 sampled employees. The deficiency was identified through interviews and document reviews, revealing that several employees either did not receive QAPI training upon hire or lacked documentation of annual training as required by the facility's policy. Employees in various roles, including the Administrator, Director of Nursing Services, Dietary Manager, and Certified Nursing Assistants, were among those who did not receive timely QAPI training. The facility's policy mandates that all staff complete QAPI training upon hire and annually thereafter, but this requirement was not met for the majority of the sampled employees. The Human Resources staff confirmed the lack of timely QAPI training for the identified employees and expressed uncertainty about the frequency and timing of the required training. The facility's QAPI Plan, last updated in October 2018, emphasizes the importance of staff input in maintaining high-quality care for residents. However, the failure to provide timely and documented QAPI training suggests a gap in the facility's adherence to its own policies, potentially impacting the quality of care and services provided to residents.

Penalty

Fine: $60,4636 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 timely infection control training to a significant portion of its staff, as evidenced by the personnel records of seven employees. These employees, including an Administrator, Certified Nursing Assistants (CNAs), a Certified Occupational Therapist, a Licensed Practical Nurse (LPN), a cook, and a Hospitality Aide, did not receive infection control training in accordance with the facility's policy. The policy, published in November 2016, mandates that all staff complete infection control training upon hire and at least annually thereafter. However, the records showed delays in training completion ranging from 28 to 48 days after hire for some employees, while others lacked documentation of training for the previous year. During an interview, the Human Resources staff expressed uncertainty about the timing and frequency of the required infection control training. This lack of clarity contributed to the failure to ensure that all staff received the necessary training in a timely manner. The absence of documented evidence of infection control training for several employees highlights a systemic issue in the facility's adherence to its own infection prevention and control program standards.

Penalty

Fine: $60,4636 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 timely completion of behavioral health training for 10 out of 20 sampled employees. Employees #1, #4, #5, #9, #10, #11, #14, #16, #19, and #20 did not receive behavioral health training within the required timeframe. Employee #1, hired as the Administrator, completed the training 55 days after hire. Employee #4, the Dietary Manager, and Employee #6, the Food and Nutrition Services Manager, had no documented evidence of training for 2023. Employee #5, the Social Services Director, completed the training 26 days after hire. Employees #9, #10, #11, #14, #16, and #20 lacked documented evidence of behavioral health training altogether. The Human Resources staff expressed uncertainty about the timing and frequency of the required behavioral health training. The facility's policy, published in November 2016, mandates that behavioral health training be completed by employees upon hire and annually thereafter. The lack of timely training was confirmed by the Human Resources staff, indicating a systemic issue in adhering to the facility's training policy.

Penalty

Fine: $60,4636 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 obtain informed consent for psychoactive medications prior to their administration for three residents. Resident #23 was administered Duloxetine, Hydroxyzine, Melatonin, and Alprazolam without prior informed consent. The consent forms for Duloxetine and Xanax were signed after the medications had already been administered, and the consent for Hydroxyzine was signed even later. The Director of Nursing Services (DNS) and the Divisional Director of Clinical Operations (DDCO) confirmed that informed consent was required before administering these medications. Resident #28 was given Clonazepam and Vraylar without documented evidence of informed consent. The DNS confirmed that no informed consent had been obtained prior to the administration of these medications, which are classified as antianxiety and antipsychotic drugs. The facility's policy requires informed consent for such medications, but this was not adhered to in the case of Resident #28. Resident #66 received Hydroxyzine for anxiety on multiple occasions in March and April before a consent form was signed in late April. The DNS acknowledged that the medication was administered without the necessary informed consent. The facility's policies clearly state that informed consent must be obtained before administering psychotropic drugs, but this protocol was not followed for the residents involved.

Penalty

Fine: $60,4636 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 the current menu was posted, which would allow residents to review and request an alternative if preferred. On May 19, 2024, observations revealed that the menus for breakfast, lunch, and dinner posted in various units, including the Brookside Unit, Classics Unit, and Advantage Unit, were dated for May 17, 2024, rather than the current date. This discrepancy was confirmed by the Nutritional Services Supervisor on May 20, 2024, who acknowledged that the current day's menu should have been posted before breakfast was served. The supervisor admitted to providing verbal instructions for the menu change, which were not followed, and also noted the absence of a formal policy on menu postings.

Penalty

Fine: $60,4636 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 report a potential incident of misappropriation of a resident's prescribed narcotic pain medication. Resident #44, who has diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, and aphasia, was involved in this incident. On May 21, 2024, a hospice RN discovered that a bottle of liquid Morphine for the resident appeared tampered with, as it was discolored and contained a paper-like substance. The hospice RN and the facility RN discarded the bottle due to these concerns. However, the Resident Care Manager and the Director of Nursing Services were not informed of the issue, and no investigation was initiated at that time. The facility's policy requires immediate reporting of suspected misappropriation of resident property, but this was not followed. The Director of Nursing Services confirmed that the incident had not been reported or investigated as potential misappropriation. The failure to report and investigate the tampered medication could lead to undetected narcotic diversion, potentially causing increased pain and diminished quality of life for the resident. The facility only began investigating the concern after it was brought to their attention by the surveyors.

Penalty

Fine: $60,4636 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 a person-centered Comprehensive Care Plan for two residents, leading to deficiencies in their care. Resident #50, who was admitted with a diagnosis of type I diabetes mellitus, had a physician's order for NovoLOG insulin administration. However, the resident's Care Plan lacked documentation of both the insulin use and the diabetes diagnosis. This omission was confirmed by the Director of Nursing Services, who acknowledged that the correct diagnosis and insulin use should have been documented to ensure appropriate treatment. Resident #77, admitted with multiple diagnoses including a history of MRSA infection, also lacked a Comprehensive Care Plan addressing infection control measures. Despite having a PEG tube and a tracheal stoma, there was no documented evidence of a care plan related to infection control, including Enhanced Barrier Precautions (EBP) for these indwelling devices. The Assistant Director of Nursing confirmed the absence of a Comprehensive Care Plan policy and reliance on the Resident Assessment Instrument to guide care plan development. The Director of Nursing Services confirmed the expectation for care plans to include all types of transmission-based precautions, which was not met for Resident #77.

Penalty

Fine: $60,4636 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 update the care plan for a resident with a history of falls following an unwitnessed fall. Resident #5, who was admitted with diagnoses including repeated falls and difficulty in walking, experienced an unwitnessed fall while attempting to transfer themselves to a wheelchair. The fall occurred on 05/18/2024, and the resident was found on the floor by their roommate, who then notified the staff. Despite the incident, the resident's fall risk care plan, which was last updated on 02/18/2024, was not revised to include new interventions to prevent further falls. The Registered Nurse confirmed the unwitnessed fall, and the Director of Nursing Services acknowledged that the care plan should have been updated after such an event. The facility's policy, titled Fall Evaluation (Morse Scale) and Management, requires a licensed nurse to review and update the care plan with newly identified interventions after a resident falls. However, this policy was not followed, resulting in a deficiency in the care provided to Resident #5.

Penalty

Fine: $60,4636 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 scheduled showers to a dependent resident, identified as Resident #3, who required assistance and the use of a Hoyer lift for bathing. Despite being scheduled for showers twice a week on Wednesdays and Saturdays, the resident reported not receiving these showers over several months. The care plan documented the need for a two-person assist for bathing, yet the POC Response History lacked documentation of showers or bed baths being offered or refused on the scheduled dates. Specific instances were noted where there were gaps of five to six days between offered showers or bed baths. Interviews with facility staff, including a CNA and the DNS, confirmed the lack of adherence to the resident's bathing schedule. The CNA acknowledged that the resident typically received bed baths and noted the need for hair washing, while the DNS was unaware of the missed showers. The DNS emphasized the importance of regular showers for hygiene and infection prevention but admitted there was no facility policy or standard practice documented for showering and bathing. The ADON also confirmed the resident should have been offered showers or bed baths on the specified dates.

Penalty

Fine: $60,4636 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 nursing staff were trained and certified to perform Cardio-Pulmonary Resuscitation (CPR) in the event of a resident cardiac arrest. This deficiency was identified for one of the five sampled licensed nurses, specifically the Director of Nursing (DNS), referred to as Employee #2. Employee #2's personnel record indicated that their CPR training and certification had expired. During an interview, Human Resources staff confirmed that CPR certification was required for all licensed nurses and acknowledged that Employee #2 did not have a current CPR certification. The facility's policy on Cardiopulmonary Resuscitation, updated recently, also documented the requirement for licensed nurses to maintain current CPR certification.

Penalty

Fine: $60,4636 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 proper wound care and coordination with a contracted hospice provider for a resident with a serious infection and cellulitis. The resident was observed with a partially covered wound that appeared wet and infected, and there was a lack of coordination between the facility and hospice regarding wound care orders. Discrepancies were found between the hospice's plan of care and the facility's orders, including differences in medication dosages and administration schedules. The facility did not have a designated hospice coordinator, leading to inconsistencies in care. Another resident experienced a fall, and the facility failed to conduct a proper post-fall assessment as per their policy. The resident reported increased difficulty walking and had an unwitnessed fall, but there was no documented assessment by a registered nurse, nor were orthostatic vital signs or blood sugar levels checked. The facility's policy required these assessments to rule out injuries and manage the resident's condition effectively. Additionally, the facility administered medication without a current order and failed to notify the physician when a resident's blood sugar exceeded a critical level. A resident requested pain relief, and a nurse applied a topical gel without verifying an active order. Another resident's prescribed medication was unavailable, and the facility did not notify the pharmacy or physician promptly. These deficiencies highlight significant lapses in medication management and communication within the facility.

Penalty

Fine: $60,4636 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 the development of a new pressure ulcer and did not report it in a timely manner for appropriate treatment. Resident #62, who was at risk for pressure injuries, developed a new wound on the coccyx that was not reported to the wound care team or the Director of Nursing Services (DNS) until several days after it was first observed. The wound was initially noted on 05/11/2024, but the DNS was not informed until 05/20/2024, leading to a delay in obtaining physician orders for treatment. The resident's condition included unspecified dementia with psychotic disturbance, cognitive communication deficit, muscle weakness, age-related physical debility, and chronic heart failure. Despite being at risk for pressure injuries, the resident's Minimum Data Set (MDS) assessments did not document any unhealed pressure injuries prior to the incident. The resident experienced pain and discomfort, which was noted in various progress notes, but the wound care team was not notified as per the facility's policy. The facility's policy required that new skin impairments be documented and reported to the physician, DNS, and the Registered Dietician (RD) for nutritional evaluation. However, this process was not followed, resulting in the wound progressing to a stage II pressure injury. The lack of timely notification and treatment orders contributed to the deficiency, as the wound care team was not informed until nine days after the initial observation.

Penalty

Fine: $60,4636 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 proper care for a resident's urostomy drainage bag, which was observed on the floor while the resident was laying in bed. This incident involved a resident who was admitted with diagnoses including rheumatoid arthritis, other specified functional intestinal disorders, and chronic kidney disease, stage 3. A physician's order and care plan both documented the need for urostomy care every shift, starting from a specified date. However, during an observation, the resident's urostomy drainage bag was found on the floor, contrary to the care plan. Interviews with facility staff, including a Registered Nurse (RN) and a Certified Nursing Assistant (CNA), confirmed that the drainage bag should not be on the floor due to the risk of infection. The RN noted that the bag was placed on the floor to prevent kinks when hung on the side of the bed, while the CNA acknowledged the risk of infection from the bag being on the floor. The Director of Nursing Services also confirmed the increased infection risk and admitted that there was no facility policy or documented standard of practice for catheter or urostomy care, contributing to the deficiency.

Penalty

Fine: $60,4636 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 administer oxygen as ordered for a resident diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. The resident was admitted with a physician's order for oxygen at three liters per minute (LPM) via nasal cannula, with humidification. However, during an observation, it was noted that the resident's oxygen was being administered without the required humidification, leading to complaints of dryness in the nose and mouth. The Licensed Practical Nurse (LPN) confirmed the physician's order included humidification, but the oxygen was still being administered without it. The Director of Nursing Services (DNS) acknowledged that the facility's policy required oxygen to be administered per physician order, and the failure to include humidification was not in compliance with the order. The facility's policy also emphasized the importance of following the five rights of medication administration, which includes ensuring the right medication is administered as ordered.

Penalty

Fine: $60,4636 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 Dialysis Transfer forms were completed and maintained for two residents, Resident #80 and Resident #57, who required dialysis services. Resident #80, diagnosed with type II diabetes mellitus with kidney complications and end-stage renal disease (ESRD), was admitted to the facility with a physician's order for dialysis on specific days. On a particular day, it was observed that Resident #80's dialysis binder, which should have contained documentation related to dialysis and pre and post-dialysis assessments, only had blank copies of the Dialysis Transfer forms. The Registered Nurse (RN) confirmed that the binder was sent with the resident to the dialysis center but was not returned with the necessary documentation. The Director of Nursing Services (DNS) confirmed that the clinical record for Resident #80 did not include the scanned copies of the Dialysis Transfer form, indicating a lapse in maintaining accurate records. Similarly, Resident #57, also diagnosed with ESRD and dependent on renal dialysis, had a physician's order for dialysis treatment on specific days. However, the clinical record for Resident #57 lacked documented evidence of completed dialysis communication transfer forms for multiple dates. The DNS confirmed the absence of these forms in the clinical record and acknowledged that the nursing staff should have ensured the forms were completed and checked upon the resident's return from dialysis. The facility's policy required the dialysis center to provide specific information upon the resident's return, and if not provided, the facility was to notify the DNS. This policy was not adhered to, leading to the deficiency in maintaining proper documentation for dialysis care.

Penalty

Fine: $60,4636 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 timely physician visits for one of the sampled residents, identified as Resident #9. Resident #9 was admitted with diagnoses including a local infection of the skin and subcutaneous tissue, methicillin-resistant staphylococcus aureus infection, and cellulitis of the right lower limb. The clinical record indicated that the last physician visit for Resident #9 occurred on 04/07/2024. On 05/28/2024, the Director of Nursing Services confirmed that the resident had not been seen by a physician or nurse practitioner since the last documented visit, despite the facility's policy requiring residents to be seen by a physician at least once every 30 days for the first 90 days after admission.

Penalty

Fine: $60,4636 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 adequate staffing of licensed nurses during the weekend shifts in December 2023, as required by their Facility Assessment Tool. The Payroll-Based Journal (PBJ) Staffing Data Report indicated excessively low staffing levels on weekends. The Facility Assessment Tool projected the need for three to four licensed nurses per shift based on an average daily census of 72 residents. However, on December 17, 2023, the second shift was staffed with only two licensed nurses, despite the facility census being 89, which was 17 residents over the average daily census. The Director of Nursing Services confirmed that the staffing did not meet the facility's expectations, resulting in a shortage of nurses for that weekend shift.

Penalty

Fine: $60,4636 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 ordered medications were available and administered to residents, resulting in deficiencies in pharmaceutical services. Resident #88, who was admitted with diagnoses including aftercare following joint replacement surgery and essential hypertension, did not receive the prescribed Amlodipine-Olmesartan 10-20 mg for three consecutive days. The medication was marked as 'On Order from Pharmacy' in the Medication Administration Record (MAR), indicating it was not available at the facility. Despite daily pharmacy deliveries, the medication was not administered, and the nursing staff did not follow up adequately to ensure its availability. Similarly, Resident #5, with a diagnosis of postlaminectomy syndrome, did not receive the prescribed Cholecalciferol 1000 units as it was not available in the medication cart. The medication was also marked as 'On Order from Pharmacy' in the MAR. Additionally, Resident #23, who had multiple diagnoses including chronic obstructive pulmonary disease and type two diabetes mellitus, did not receive the prescribed Ammonium Lactate solution for several days. The facility's policy required staff to document non-administration reasons and notify the physician, but these steps were not effectively followed, leading to the deficiencies observed.

Penalty

Fine: $60,4636 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 maintain a medication error rate below 5%, resulting in an error rate of 8.51% based on 47 medication administration opportunities and four errors. The errors involved three residents, each with specific medication administration issues. Resident #88, who was admitted with diagnoses including aftercare following joint replacement surgery and hypertension, did not receive the prescribed Amlodipine-Olmesartan for three consecutive days due to the medication being unavailable in the facility. The LPN responsible for administering the medication acknowledged the absence of the medication and the potential concern due to the resident's elevated blood pressure. Resident #55, admitted with diagnoses including cerebral infarction and thrombosis, was administered the incorrect form of Aspirin. The RN gave the resident a chewable Aspirin 81 mg instead of the prescribed enteric-coated Aspirin 81 mg. The RN confirmed the error after administering the medication, acknowledging that the medication did not match the physician's order. Resident #5, with a diagnosis of postlaminectomy syndrome, did not receive the prescribed Cholecalciferol 1000 units due to its unavailability. Additionally, the RN applied Diclofenac Sodium 1% gel to the resident's knee without a current physician's order, as the order for this medication had been completed and was no longer active. The RN admitted to not contacting the physician before administering the gel, which was against the facility's medication administration policy. The Director of Nursing Services confirmed that all medications require an active physician's order and that the facility's policy mandates adherence to the five rights of medication administration.

Penalty

Fine: $60,4636 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 Medication Administration Records (MAR) for the administration of an anti-coagulant for one resident, identified as Resident #66. This resident was admitted with a diagnosis of pulmonary embolism and had a physician's order for Apixaban, an anti-coagulant, to be administered twice daily. However, the MAR for specific dates lacked documented evidence that the medication was administered or refused by the resident. The Director of Nursing Services (DNS) confirmed the absence of documentation and acknowledged that the nurse should have recorded the administration or refusal of the medication. Additionally, the facility did not ensure that the documentation in resident records accurately represented the licensure of a healthcare provider. The provider was documented as a Doctor of Medicine (MD) in the records of numerous residents, despite being licensed as an Advanced Practice Registered Nurse (APRN). This discrepancy was confirmed by the provider, the DNS, and the Medical Director, who were unaware of the incorrect documentation. The Medical Director was responsible for reviewing the provider's documentation but had not identified the error. The facility also failed to maintain complete clinical records for two residents. For Resident #80, the Treatment Administration Record (TAR) lacked evidence of required assessments of the resident's dialysis access site and blood sugar monitoring. The DNS confirmed that the facility's policy required blood sugar checks for diabetic residents receiving dialysis, but these were not documented. Similarly, Resident #68's care plan inaccurately documented the resident's behavior, stating that the resident touched private parts of other residents, which was not the case according to staff interviews.

Penalty

Fine: $60,4636 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 accurately report weekend staffing coverage in their Payroll-Based Journal (PBJ) submissions to the Centers for Medicare and Medicaid Services (CMS). The PBJ Staffing Data Report for the period from October 1, 2023, to December 31, 2023, indicated excessively low weekend staffing. However, facility nursing schedules and timesheets showed that there was sufficient staffing coverage for weekends during this period, except for the weekend of December 17, 2024. The Director of Nursing Services confirmed that the PBJ reports submitted to CMS were inaccurate, despite the facility having adequate staffing coverage for the weekends in question, excluding the specified weekend.

Penalty

Fine: $60,4636 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 implement appropriate infection prevention and control measures for a resident with a multi-drug resistant organism (MDRO) infection. Resident #9, who was admitted with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) and cellulitis, did not have the necessary transmission-based precautions (TBP) in place. On observation, there was no signage indicating enhanced barrier precautions (EBP) or TBP on the resident's door, nor was there a personal protective equipment (PPE) cart outside the room. The Licensed Practical Nurse (LPN) confirmed the absence of these precautions, despite the resident having a wound that required dressing changes and was colonized with MRSA. The Infection Preventionist (IP) and Director of Nursing Services (DNS) acknowledged the oversight in not placing a dedicated bin for PPE disposal inside the room of Resident #9, who was under contact precautions. The IP was found holding contaminated dressings, waiting for a proper disposal bag, indicating a lapse in the facility's protocol for waste management in TBP rooms. The facility's policy did not include specific instructions for PPE disposal, which contributed to the deficiency. Additionally, the facility did not maintain proper care for a resident with a urostomy. Resident #3's urostomy drainage bag was observed on the floor, which was confirmed by both a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) as inappropriate due to the increased risk of infection. The DNS confirmed the lack of a facility policy regarding catheter or urostomy care, which led to the improper handling of the urostomy drainage bag, further highlighting the facility's failure to adhere to infection control standards.

Penalty

Fine: $60,4636 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 Registered Nurse (RN), hired on July 10, 2023, was screened for eligibility to receive a COVID-19 booster vaccine, provided with education regarding the vaccine, and offered the vaccine, which was either administered or declined. The RN's COVID-19 Vaccination Record Card showed vaccinations on February 1, 2021, and February 22, 2021, with an additional dose recorded on September 17, 2021. However, there was no documented evidence in the RN's Human Resources (HR) file indicating that the RN was screened for a booster, educated about it, or that the booster was offered and either administered or declined. The Infection Preventionist (IP) confirmed that the facility held COVID vaccination clinics twice a year, with a third party administering the vaccines. The IP stated that when an employee received a booster, a copy of the immunization record was kept in the HR file, but no signed declination was collected if the vaccine was declined. The facility's policy, revised on April 18, 2022, required maintaining documentation of COVID vaccinations and boosters, including a declination form for those who declined. The CDC guidelines, updated on May 14, 2024, recommended updated COVID-19 vaccines for everyone five years and older, but the facility did not have the necessary documentation for the RN in question.