Country Club Retirement Ctr Iv

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 adequate end-of-life care, pain management, and monitoring for a hospice resident admitted for comfort-focused services. The resident had advanced pancreatic cancer with liver metastases, severe pain, depression, insomnia, and total dependence for care. Prior to transfer, the inpatient hospice facility documented severe pain (7/10), facial grimacing, restlessness, agitation, and multiple non-verbal pain indicators, and had the resident on an active regimen of Roxanol, Morphine, MS Contin, Ativan, and other medications for pain and anxiety. Hospice records show that on the morning of transfer, the resident received multiple doses of Roxanol, Morphine, and Ativan for pain, restlessness, and facial grimacing, and that hospice staff faxed all paperwork, including signed scripts for Roxanol and an e-scribed Ativan order, to the receiving facility and verbally informed an LPN that the Roxanol script was signed and should be available from the facility’s pharmacy. Upon admission to the facility, critical admission processes and assessments were not completed. The nursing admission checklist had blank sections for code status, consents, physician-verified orders, diet, and nursing assessments, and it was not signed by the nurse. Multiple required assessments, including admission, bowel and bladder, Braden, fall, oral, TB, vitals and pain evaluation, AIMS, and elopement, were left blank; only a functional assessment and a pressure ulcer assessment (completed the day after admission) were documented. There was no evidence that an acute plan of care was initiated. Admission orders showed no medication orders, no diet orders, and no urinary catheter orders, despite hospice transfer information listing multiple active pain and anxiety medications and catheter care instructions. A drafted progress note by an LPN stated that consents were signed, history obtained, and medications reviewed with the physician, but also stated “No medications were ordered at this time” while simultaneously referencing “Morphine and Ativan for comfort,” and there was no evidence that an Ativan order was actually entered. The only documented facility order for symptom control was Morphine 20 mg three times daily, and this order was not implemented in a timely or consistent manner. Pharmacy records show the Morphine order was sent to the pharmacy late in the morning, pulled from the emergency box in the afternoon, but the first documented administration did not occur until 7:30 p.m., several hours after admission and after the resident’s wife reported ringing the call light for pain medication without response. The MAR shows only two doses of Morphine 20 mg given (bedtime on the day of admission and the morning of the next day), both signed by a medication technician who documented a pain score of zero, with no evidence of a comprehensive pain assessment before administration. The Morphine control sheet, however, reflects three doses signed out, including a 1:50 p.m. dose on the second day that was not documented on the MAR. There was no documentation that Ativan was ordered or administered, despite hospice and pharmacy confirmation that Ativan orders were submitted, and despite an LPN telling the hospice nurse that an as-needed Ativan dose had been given. On the second day, a visiting hospice RN documented that the resident’s wife wanted him returned to inpatient hospice for pain control and that the resident’s pain level was 9/10. The hospice RN recorded that an LPN stated the resident “was fine until his wife got here” and described the wife as unrealistic about his decline. The LPN reported having given Ativan at 10:00 a.m. and that Morphine was due at 2:00 p.m., but there was no corresponding Ativan order, control sheet, or MAR entry. The resident’s wife reported that staff attempted to force feed the resident despite his having had no intake for two days, that call lights for pain medication were unanswered, and that when she requested liquid Morphine and Ativan for his obvious pain and restlessness, staff refused or stated it was not time for his medication and gave multiple excuses for the lack of Ativan. Photos provided by the wife and reviewed by facility leadership showed the resident at the edge of the bed, restless and trying to get up, with facial grimacing consistent with pain. After transfer back to the inpatient hospice facility later that day, hospice records show frequent administration of Morphine, Roxanol, Ativan, and Haldol for pain, anxiety, and restlessness until the resident’s death the following day. Corporate and hospice representatives confirmed that, while multiple pain and anxiety medications were ordered at the time of transfer, the facility only had a Morphine order in place, did not complete admission assessments or pain evaluations, and did not implement or document the full ordered pain and anxiety regimen during the resident’s stay. This deficiency represents non-compliance investigated under Master Complaint Number 2789590 and Complaint Number 2785293.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to implement a comprehensive, individualized, and effective pain management program for a resident with a known history of severe, intractable migraines. The resident was admitted with diagnoses including migraine without aura, intractable, with status migrainosus, anxiety, depression, cerebrovascular disease, fibromyalgia, and hypertension. Admission orders included Aspirin, Gabapentin, Losartan, Metoprolol, and PRN Acetaminophen for pain. Early documentation showed incomplete vital signs and pain assessments on 11/26, and on 11/27 the resident reported posterior neck pain rated 4/10, occurring daily, with an assessment indicating she was alert and oriented. The care plan for potential alteration in comfort related to fibromyalgia directed staff to administer medications as ordered and per resident preference/request, encourage early reporting of pain, and observe for signs and symptoms of pain. Over the next two days, the resident experienced escalating pain and migraine symptoms. On 11/27, an LPN documented administering Acetaminophen 325 mg (two tablets) for a headache unrelieved by environmental measures, with the medication noted as effective. On 11/28 at 3:16 A.M., another LPN documented the resident was vomiting and complaining of headaches causing her to vomit; Tylenol 325 mg (two tablets) was given and documented as effective. Later on 11/28, after discussion among the nurse, the resident, and the resident’s daughter with a nurse practitioner, new orders were obtained for Topamax for migraines, Imitrex PRN for acute migraines, Magnesium, and Perphenazine, along with a psychiatry consult. However, review of the MAR/TAR for November showed no evidence that Topamax or Imitrex were administered after these orders were written, and pain levels on 11/28 and 11/29 were marked as not applicable despite prior documentation of pain scores of 8 and 10 and the MDS indicating frequent severe pain affecting sleep and daily activities. On 11/29, the resident’s daughter contacted the facility reporting that her mother had not received her medications. The assigned LPN later stated she was responsible for both Assisted Living and the skilled unit that day, and that when the daughter called, she told her she was preparing to pull the resident’s medications. The LPN acknowledged she did not administer Topamax because she believed it was scheduled for the afternoon and was unaware of the new Imitrex PRN order from the previous day. She confirmed that neither Topamax nor Imitrex had been administered and that she did not give PRN Tylenol for the resident’s headache, only the scheduled Gabapentin. The daughter subsequently arrived at the facility, found the resident covered in vomit with vomit on the floor, and requested transfer to the emergency room. The LPN obtained an order to send the resident to the hospital but did not complete a transfer form. Hospital records documented admission for intractable headaches with vomiting and hypertensive emergency, with an emergency room blood pressure of 200/100 mm/Hg and severe headache rated 9/10. The resident, her daughter, and the DON later confirmed that ordered migraine medications were not administered and that blood pressure monitoring was not performed as required, in contrast to the facility’s pain management policy, which required daily pain monitoring and assessment before and after PRN pain medication administration. The resident and her daughter reported that the resident did not receive her migraine medications as ordered and that her blood pressure was not adequately monitored, leading to rehospitalization three days after admission. The daughter stated she frequently could not reach staff by phone and often could not find staff when visiting, and that her calls to the DON were not returned. The resident reported that she believed she was supposed to receive Hydralazine for migraines, as she had prior to admission and in the hospital, but did not think she was receiving all of her medications correctly at the facility. The DON confirmed that the resident did not receive her ordered medications and that staff failed to monitor her blood pressure, and the facility’s pain management policy specified recognition, evaluation, and management of pain consistent with assessment and care plan, including daily monitoring of pain levels and assessment of PRN pain medication effectiveness. These documented failures culminated in the resident’s transfer and hospitalization for intractable migraines with vomiting and hypertension.

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 comprehensive infection prevention and control program that included effective tracking and monitoring for infection trends, potentially affecting all 37 residents. Review of the infection control trending tools from 10/2025 to 03/2026 showed that the facility used a map with a color-coded key for different infection types (respiratory, gastrointestinal, UTI, wounds, and others), but there was no documentation of specific infection types or other details needed to identify patterns. This meant there was no evidence that infections were being trended in a way that would reveal patterns by type or location. Further review of the infection log from 12/2025 to 03/2026 showed that, after implementation of a new log, multiple UTIs and other infections were recorded without documentation of the causative organism or, in some cases, the site of infection. Specifically, in December there were four UTIs without organisms listed; in January, three UTIs without organisms; in February, seven UTIs without organisms and two infections without site or organism; and in March, one UTI without an organism. During an interview, the IP/LPN confirmed that infections were not being monitored for trends by type and that most UTIs did not have culture results to identify organisms, and reported having previously voiced concerns to the former DON but was told not to contact providers and to administer antibiotics as ordered. The facility’s infection control policy required investigation, monitoring, identification, control, and surveillance of infections, including completion of infection reports, obtaining antibiotic orders upon proper microorganism identification if necessary, updating the surveillance map with type and location of infections, and discussing patterns in weekly QA meetings, which was not reflected in the documented practice.

Penalty

No penalty information released

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

Summary

The facility failed to have a qualified, designated Infection Preventionist (IP) who effectively monitored and implemented the Antibiotic Stewardship Program for all 39 residents. Upon survey entrance, the facility identified an LPN as the IP, but review of the March 2026 infection control log showed the facility did not meet antibiotic stewardship requirements. Documentation revealed a lack of understanding of the need for hospital documentation to support antibiotic use when residents returned from the hospital, and problems with the timing and accuracy of completing McGeer’s evaluations, which led to errors in determining whether residents met criteria for antibiotic use. During interviews, the identified LPN stated she had not performed the IP role since 2019 and was hired in October 2025 as the MDS nurse, later taking over infection control in December 2025 at the request of the former DON. She reported completing an IP course in February 2021 but was unable to provide a certificate, and her former employer could not immediately supply documentation of her training or continuing education. She confirmed she had not renewed her IP training every two years and had only taken standard infection control bloodborne pathogen education through Relias with her former employer. During the survey, the facility did not provide an IP certificate for this LPN, although it did provide an IP Certificate of Training for another LPN who was not yet serving as IP. Review of the facility’s IP policy showed it did not require a certificate of completion of an IP program or ongoing professional education to maintain competency, and it did not specifically address antibiotic stewardship in the nursing home setting.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure a functioning call light system that remained active until staff responded, affecting resident bathrooms and bathing areas and potentially all 37 residents. A resident’s daughter reported via email that her mother’s visitor had to ask someone in the hallway to check on the resident after waiting a long time for a response to the call light; the person who checked stated the resident was dry, but the visitor could smell urine and knew this was not accurate. The resident was later taken to the bathroom by others, including a physical therapist, who stated that because the resident was not bearing weight on her legs, they would not be able to continue taking her to the bathroom. The daughter expressed concern that her mother would be incontinent of urine and stool and remain so for hours before being changed, and that even when calling out for help, it took an extended time for assistance to arrive, if at all. She also stated that CNAs were supposed to check residents every two hours but did not, and that she had observed this pattern on each of her visits. During the survey, a state surveyor activated a resident’s call light and observed that it remained active for 16 minutes and 15 seconds before resetting, requiring re-activation by the resident. The surveyor activated the call light at 2:22 P.M., again at 2:33 P.M. while it was still red, and again at 2:38 P.M. after the red light disappeared, with staff not answering until 2:40 P.M. The CNA who responded confirmed she was alerted via walkie talkie but could not state when the call light was first activated. The maintenance director and assistant verified through the call system computer that the call light had been on for 16 minutes and 15 seconds before resetting and then was activated again, confirming the system automatically resets after that time. An anonymous staff member also confirmed that call lights were not answered timely and that residents had voiced concerns. The facility’s call light policy stated that call lights would be silent only after residents’ needs were met, which was not followed in these instances.

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 timely and appropriate pressure ulcer prevention and treatment for a resident at risk for skin breakdown. The resident was re-admitted after a left hip fracture with open reduction and internal fixation and had known risk factors including peripheral vascular disease, incontinence, impaired cognition, dependence on staff for mobility and transfers, frequent urinary incontinence, and bowel incontinence. A Braden assessment completed after readmission identified the resident as at moderate risk for pressure ulcers, but there was no evidence that new preventive interventions were implemented at that time. The resident’s care plan called for weekly skin assessments and a pressure redistribution mattress, but after readmission there was no documented skin assessment until the resident’s daughter identified a coccyx skin alteration, and the resident did not have pressure-reducing devices for bed or chair, was not on a turning/repositioning program, and had no documented nutritional or hydration interventions for skin management. The resident’s daughter submitted a concern form reporting that after the resident’s return from the hospital, the RN did not properly check the resident back into the facility and that staff were unaware of a coccyx pressure ulcer the daughter observed, which she described as several inches in size and facility-acquired. A protective dressing was first applied only after the daughter brought the ulcer to staff attention. Subsequent assessment by a consulting wound nurse practitioner documented a new in-house acquired wound on the sacrococcygeal area initially staged as a Stage II pressure ulcer with moderate serosanguineous drainage, and later facility wound documentation described the same area as an unstageable pressure ulcer with extensive eschar. The wound later cultured positive for proteus and pseudomonas, and the resident was treated with antibiotics. The wound practitioner also documented new suspected deep tissue injuries on both heels, with measurements recorded for the left heel on the day of identification and delayed documentation of right heel measurements several days later. Treatment orders were initiated for cleansing and dressing the coccyx/sacral and buttock areas with mesalt and dry dressings daily, use of an air mattress, heel boots as tolerated, offloading, and barrier cream. However, the treatment administration record showed missed wound treatments on specific days for the coccyx/sacral area and missed heel treatments on at least one day, with no documentation that the resident refused care. Observation showed that heel boots ordered for prevention were not in place while the resident was in bed, despite no recorded refusals and staff confirmation that the boots were tolerated. The DON confirmed that staff did not administer certain ordered treatments, that the coccyx pressure ulcer was first identified by the family rather than staff, that no new interventions were implemented when the resident’s Braden score increased from low to moderate risk, and that the care plan for the pressure ulcers contained only the intervention to provide treatments as ordered, contrary to the facility’s wound and skin care policy requiring timely risk assessment, repeat skin assessment within 24–72 hours of admission, and implementation of resident-specific preventive interventions.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to implement fall-prevention interventions as outlined in a resident’s care plan. The resident was admitted and later re-admitted with diagnoses including a displaced intertrochanteric fracture of the left femur, hypotension, urinary incontinence, dizziness, difficulty walking, and muscle weakness. The resident’s fall risk care plan, addressing dizziness, impaired gait, muscle weakness, and psychoactive medication use, was initiated on 03/02/18 and revised on 10/21/25 to include specific interventions: bright colored paper as a visual aid to prompt the resident to ask for help and use the call light system, bright colored tape on wheelchair brake handles as visual reminders, and dycem on the wheelchair seat. On observation, surveyors and RN #204 noted that these care-planned interventions were not in place. There was no bright colored paper in the resident’s environment to cue use of the call light, no bright colored tape on the wheelchair brake handles, and no dycem on the wheelchair seat, despite these being listed in the fall care plan. RN #204 reported that the resident had experienced a fall with fracture the previous month and had received a new wheelchair, but staff had not applied the bright colored tape or dycem to the new wheelchair, and the signs in the room were not bright colored as specified in the plan of care. The resident’s daughter stated she believed the facility failed to implement preventive measures to prevent her mother’s fall that resulted in a fracture and reported that, despite her request, she had not yet received information about the fall and the care plan. Review of the facility’s Fall Policy and Procedures confirmed that the interdisciplinary team is required to develop and implement fall interventions based on assessed risk factors and to update the fall care plan in the electronic record.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide ordered fluids to maintain a resident’s hydration status. The resident had diagnoses including recurrent urinary tract infections, hypotension, gastric reflux, protein-calorie malnutrition, and dysphagia, and had a dietary recommendation for 1950 ml fluid intake daily. After a hip fracture and readmission, the dietitian documented a recommendation and an order was obtained for an extra 240 ml of fluids with lunch and dinner, and this was also reflected on a diet order and communication form. Fluid intake records from 02/11/26 to 03/12/26 showed the resident’s intake per meal ranged from 60–240 ml, with an average daily intake of 760 ml, and there were days with missing meal intakes and several recorded refusals. There was no evidence in the records or care plans that the ordered extra 240 ml of fluids at lunch and dinner was being consistently provided or documented. Surveyor review of a supper meal ticket showed no indication of the extra 240 ml fluid order, and observation of the resident at supper revealed only one 240 ml cup of beverage and a 120 ml cup of UTI supplement, not the ordered additional fluids. The Dietary Manager stated she was unaware of the extra fluid order and confirmed that special dietary instructions should appear on the meal ticket and a reminder sheet in the kitchenette; the extra fluid order was not listed on that sheet. An LPN reviewed the orders with the surveyor and confirmed the resident was supposed to receive extra fluids with lunch and dinner, but this had not been communicated to dietary. The resident’s daughter reported concerns about inadequate hydration, including decreased urination, dark urine, and recurrent urinary tract infections, and stated she did not feel her concerns about her mother’s hydration needs had been addressed.

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 accurate and complete medical records for multiple residents. For one newly admitted resident, the medical record contained no listed medical diagnoses under the diagnoses category, with the medication orders, or in the care plan at the time of review. The DON confirmed that the resident’s diagnoses were not entered at admission and were only added six days later. For another resident with a history of a fall and left femur fracture, physician orders included nonskid strips on the bathroom floor in front of the commode every shift and visual reminders in the bathroom to use the call light for assistance with transfers twice a day. March and April 2026 treatment sheets showed staff signing off twice daily that these interventions were in place. However, the DON verified that this resident did not have fall strips in front of the toilet or a sign as a reminder to call for assistance, and that the facility had removed these interventions from the plan of care after the resident returned from the hospital and was no longer using the bathroom. The DON acknowledged that the corresponding physician orders were not discontinued and that nursing staff continued to document completion of treatments that were not actually in place. For another resident admitted with multiple diagnoses including cerebral infarction, protein calorie malnutrition, adjustment disorder with anxiety, anorexia, GERD, constipation, glaucoma, vascular disease, history of falling, muscle weakness, and difficulty walking, the record showed an in-house Stage II pressure ulcer to the left outer ankle. Active physician orders included one to pad and protect a healed left lateral ankle pressure ulcer twice weekly and as needed, and another to cleanse the left outer ankle and apply duoderm on specified days. The DON confirmed there were two contradicting active orders and that the pad and protect order was present in the physician orders but did not appear on the treatment sheet for staff to sign off.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to implement an effective antibiotic stewardship program that ensured appropriate antibiotic use and timely application of McGeer criteria. Surveyors found that the Infection Preventionist (an LPN) was off work over a weekend, and during that time multiple residents were started on antibiotics without any determination of whether they met McGeer criteria. The Director of Nursing and the Infection Preventionist acknowledged that when the Infection Preventionist is off, no one performs her infection control duties, including reviewing new antibiotic orders against McGeer criteria. As a result, residents were receiving antibiotics before any assessment of criteria, and the facility was administering antibiotics prior to notifying the physician if criteria were not met or obtaining a rationale for antibiotic use without meeting criteria. One resident had a history of multiple chronic conditions including acute respiratory failure with hypoxia, chronic pain syndrome, hypertension, hyperlipidemia, morbid obesity, syncope, chronic congestive heart failure, depression, GERD, insomnia, osteoarthritis, and weakness. This resident developed a full-thickness wound on the left third toe with serosanguinous drainage, erythema, exposed bone, tenderness, warmth, and slight edema. A wound nurse practitioner ordered clindamycin and transfer to the emergency room for suspected bone involvement and infection; the resident returned on doxycycline for wound infection. The resident was entered on the infection log as meeting McGeer criteria for cellulitis/soft tissue/wound infection, but the McGeer Infection Report Form showed only redness and swelling were documented. The Infection Preventionist incorrectly marked that the infection met McGeer criteria despite only two signs and symptoms being present, instead of the required four, and stated she had been told only one sign or symptom was needed and that she had not done infection control since 2019. Another resident, admitted with diagnoses including above-knee amputation, anxiety disorder, diabetes, hypertension, hyperlipidemia, major depressive disorder, and muscle weakness, was started on Bactrim DS and topical mupirocin for a large, purple/red, hard abscess under the right breast that was warm to touch and afebrile at the time. This resident was not initially entered on the infection log, and no McGeer Infection Report Form was completed when the antibiotic was ordered because the Infection Preventionist was off duty. Several days later, nursing documentation described drainage, yellow slough, surrounding redness, warmth, and a temperature of 99.2°F, and a McGeer Infection Report Form was then completed. The form indicated heat, redness, serous drainage, and fever, but the Infection Preventionist did not indicate on the form whether criteria were met, and the infection log was later revised to show the resident did not meet criteria. The DON later verified that only one temperature above 99°F had been documented, which would not meet the constitutional fever criterion, making the fever marking an error. A third resident was receiving Levaquin for a “culture infection” on an every-48-hour schedule. This resident was not initially listed on the infection log, and there was no completed McGeer Infection Report Form at the time of surveyor review. The Infection Preventionist stated she had started but not completed the form and believed the resident would not meet criteria because of an upper respiratory infection. A subsequent infection report form documented pneumonia, with all three required criteria checked: chest radiograph interpreted as pneumonia or new infiltrate, new or changed lung exam abnormalities, and leukocytosis. A revised infection log then listed this resident as meeting criteria for antibiotic use, with pneumonia, hypoxia, shortness of breath, and gram-negative rods noted. The Infection Preventionist confirmed that the McGeer Infection Report Form was not completed in a timely manner to determine antibiotic stewardship for this resident and that it was not timely identified whether the physician needed to be called if criteria were not met. Review of the facility’s Antibiotic Stewardship Program policy, revised in 2017, showed that all residents with newly diagnosed infections using antibiotics were to be reviewed for appropriate utilization, including review of infection symptoms prior to initiation, consideration of an antibiotic holiday when there was no proof of review, obtaining and reviewing culture and sensitivity results, and discussing results and treatment recommendations with the primary care physician to ensure responsible antibiotic use. The policy also required prescribers to document dose, duration, and indication for all antibiotic use. Despite this policy, the survey findings demonstrated that residents were started on antibiotics without timely or accurate application of McGeer criteria, infection logs were incomplete or delayed, and the Infection Preventionist lacked current knowledge of the criteria and did not consistently communicate with physicians regarding antibiotic appropriateness when criteria were not met.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain exit doors and related elopement alarm systems in good repair to prevent elopement of a resident identified as an elopement risk. The resident had multiple diagnoses including dementia, psychotic and mood disturbances, unsteady gait, history of falls, and a documented history and pattern of goal-directed wandering and elopement or attempted elopement. Progress notes documented that on two consecutive days the resident had previously gone out or attempted to go out the dining room doors and had to be redirected back into the facility. The resident wore elopement alert bracelets intended to lock and alarm exit doors when in proximity. On the night of the elopement, staff last observed the resident sitting in front of the nurse station shortly before he was discovered outside. An anonymous neighbor alerted the facility that the resident had walked out of the building, and he was subsequently found at the end of the driveway near the entrance sign with his walker, fully dressed in outdoor clothing. Staff reported that no door alarms sounded to alert them when the resident exited. There was no documentation that staff checked the resident’s alert bracelets or the functioning of the exit doors and alarm systems at the time of the elopement. Subsequent review and interviews revealed that the facility’s exit door alarm systems, including the Wander-guard and other door alarms, were functioning inconsistently. Maintenance staff acknowledged that weekly alarm checks showed doors sometimes required multiple attempts to function properly and that some issues could not be fixed. Observations by surveyors showed that when elopement bracelets were brought near the front door, the door did not consistently lock or alarm, and staff could exit while holding the bracelets without activation. The front door was sometimes left ajar and therefore did not lock or alarm, and the dining room door’s different alarm system would sometimes alarm without locking and at other times neither lock nor alarm. Staff interviews confirmed that doors were fairly easy to open, did not always close fully, and that no alarms sounded on the night the resident left 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 facility failed to safely administer and accurately document controlled substances for residents identified as receiving these medications. During a medication pass, it was observed that narcotic sheets on a medication cart were not accurately completed, and discrepancies in the shift-to-shift narcotic count records were noted. Documentation errors included incorrect counts, overwriting of numbers, missing signatures from incoming nurses, and incorrect dates on narcotic count forms. Interviews with LPNs confirmed that not all nurses were following the same procedures for counting and documenting controlled substances, making the records difficult to follow and leading to inconsistencies. Further review by the Director of Nursing revealed blank spots on narcotic sheets and missing signatures for the administration of controlled substances such as Tramadol and Ativan for a resident. The physical count of medications did not match the documentation, indicating further errors. The facility's policy required a physical inventory of all controlled substances by two licensed nurses each shift, with immediate reporting of discrepancies, but these procedures were not consistently followed, resulting in inaccurate recordkeeping and potential mismanagement of controlled substances for multiple 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 timely staff assistance with activities of daily living (ADLs) for five dependent residents, as evidenced by record reviews, call light audit reports, and resident and staff interviews. Several residents with significant medical conditions, including acute kidney failure, Parkinson's disease, multiple sclerosis, and mobility impairments, required substantial or maximal assistance with toileting, bathing, and other ADLs. Documentation showed that call lights for assistance remained unanswered for extended periods, with one resident's call light active for over 52 minutes and another for over 36 minutes before staff responded. Residents reported having to wait for long periods, sometimes resulting in incontinence episodes and missed showers or baths, which caused them distress and humiliation. On the date in question, only one CNA was available to provide care for all residents during a specific time frame, despite several residents requiring two-person assistance. The CNA confirmed being unable to answer most call lights in a timely manner and was unable to provide scheduled showers or baths. The Director of Nursing acknowledged that the lack of adequate CNA staffing led to delays in providing necessary ADL assistance to multiple residents. Residents also reported a decline in the timeliness of staff response and the frequency of receiving scheduled showers compared to previous months. Care plans and medical records for the affected residents indicated a need for regular assistance with toileting, bathing, and skin assessments due to their medical conditions and risk factors such as incontinence and decreased mobility. However, documentation and resident interviews confirmed that these interventions were not consistently provided as scheduled, particularly on the day when staffing was insufficient. The deficiency was substantiated by both resident accounts and facility records, demonstrating a failure to meet the residents' needs for timely ADL support.

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 sufficient direct care staff to meet the needs of all residents, as evidenced by a period on a specific day when only one Certified Nursing Assistant (CNA) was available to care for 46 residents. The facility's own assessment indicated that an average of five CNAs were required to meet resident needs, and staffing was to be adjusted daily based on census and acuity. However, documentation and interviews confirmed that between 12:19 P.M. and 2:11 P.M. on the day in question, only one CNA was present, resulting in significant delays in responding to call lights and providing assistance with activities of daily living (ADLs), including toileting and bathing. The CNA on duty reported being unable to answer most call lights in a timely manner, with some residents waiting up to an hour for assistance, and was unable to provide scheduled showers or baths. Multiple residents with complex medical conditions, such as multiple sclerosis, chronic kidney disease, Parkinson's disease, and mobility impairments, were directly affected by the staffing shortage. Residents reported waiting extended periods for assistance with toileting, leading to episodes of incontinence and feelings of humiliation. For example, one resident's call light remained unanswered for over 36 minutes, and another resident waited over 52 minutes for help, ultimately resulting in a bowel movement before staff arrived. Residents also reported missing scheduled showers and being unable to participate in facility activities due to lack of timely assistance. Documentation, such as call light audit reports and shower logs, corroborated these accounts. Interviews with staff, including the DON and Administrator, confirmed the staffing shortfall and acknowledged that several residents required two-person assistance for ADLs, which could not be provided with only one CNA on duty. The DON stated that another CNA had been scheduled but was running late, and acknowledged that nurses should have assisted with resident care during the shortage. Residents and staff expressed frustration with the lack of timely response to call lights and unmet care needs, and facility records showed that concerns about staffing and call light response times had been raised by residents but were not adequately addressed.

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 medical records were accurate and complete regarding the administration of controlled substances for multiple residents. Surveyors identified discrepancies between the Controlled Drug Record and the Medication Administration Record (MAR) for five residents who were prescribed and administered various controlled medications, including Hydrocodone-Acetaminophen, Tramadol HCL, Ativan, and Oxycodone-Acetaminophen. In each case, the Controlled Drug Record indicated that the medication had been administered at specific times, but the corresponding MAR entries were either missing or incomplete for those administrations. For example, one resident with diagnoses including hemiplegia, dementia, and heart failure had orders for Hydrocodone-Acetaminophen, which was documented as administered in the Controlled Drug Record but not reflected in the MAR for two doses. Another resident with multiple sclerosis, hypertension, and chronic kidney disease received Tramadol HCL and Ativan according to the Controlled Drug Record, but the MAR lacked documentation for these administrations on several dates. Additional residents with complex medical histories, such as chronic obstructive pulmonary disease, diabetes, and chronic pain, also had similar discrepancies between the Controlled Drug Record and the MAR for their prescribed controlled substances. During an interview, the Director of Nursing confirmed the discrepancies and acknowledged that all administered medications should be documented in the medical records at the time of administration, as required by the facility's medication administration policy. The facility's policy specifically states that after administration, documentation must occur in both the MAR and the controlled substance sign-out record. The failure to maintain accurate and complete records for controlled substance administration was observed for multiple residents 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 timely report a suspicion of misappropriation of narcotics involving a resident with multiple chronic conditions, including multiple sclerosis, hypertension, major depressive disorder, diabetes mellitus, conversion disorder with seizures, and chronic kidney disease. The resident was cognitively intact at the time of the incident. The Director of Nursing (DON) discovered several blank entries with the same handwriting in the narcotic book, indicating a registered nurse's signature, and found discrepancies between the Controlled Drug Records and the Medication Administration Records (MAR) for both Tramadol and Ativan. The resident reported not knowing about or requesting pain medication. Despite these findings, the DON concluded there was not enough evidence to confirm misappropriation but noted a concerning pattern of documentation errors. The DON immediately reported the suspicion to the Administrator, who, along with the President of Operations, advised the suspension of the nurse involved. However, the Administrator did not timely file a Self-Reported Incident (SRI) with the Ohio Department of Health as required by facility policy, which mandates notification of all alleged violations involving misappropriation within 24 hours. The investigation did not yield sufficient evidence to prove misappropriation, but the failure to report the suspicion in a timely manner constituted the deficiency.

Penalty

No penalty information released

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

Summary

A Certified Nurse Aide (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident who required assistance with activities of daily living due to decreased mobility and multiple medical conditions, including heart disease, hypertension, cerebrovascular disease, and a femur fracture. During the observed care, after cleansing the resident's perineal area following a bowel movement, the CNA did not wash her hands or change gloves before applying barrier cream and a new incontinence brief. Additionally, the CNA placed soiled linens on the floor of the resident's room instead of placing them in a bag or soiled linen container as required. The CNA confirmed during the observation that she did not perform hand hygiene, change gloves, or use a linen bag for soiled linens during the care process. The Director of Nursing also confirmed that proper procedures were not followed, stating that hands should be washed between perineal care and donning new gloves, and soiled linens should be immediately placed in a bag or linen barrel. The facility's perineal care policy required gloves to be worn and soiled items to be placed on an impermeable barrier, with gloves to be removed and hands washed following care, but did not provide specific guidance on hand hygiene or glove changes when applying barrier cream or a new brief.

Penalty

No penalty information released

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

Summary

The facility failed to comprehensively assess and manage urinary incontinence for two residents, leading to deficiencies in their care. Resident #45, who was admitted with multiple diagnoses including diabetes and heart disease, was noted to be occasionally incontinent of urine. Despite being aware of the need to toilet, the resident was not placed on a toileting program. The bladder assessments for this resident were incomplete, with sections on the type of incontinence and a three-day tracker left blank. The Director of Nursing (DON) confirmed that the resident experienced a decline in urinary function and would have benefited from a toileting program, but the facility lacked a procedure to determine eligibility for such a program. Resident #57, who had severe cognitive impairment and was frequently incontinent of urine, also did not receive a toileting program. The resident's bladder assessments were inaccurate, with a three-day bladder tracker indicating no urination for three days. The assessments failed to identify the type of incontinence or develop a treatment plan to prevent decline or improve bladder function. The DON acknowledged these inaccuracies and the absence of a policy to determine program eligibility, relying instead on the judgment of the nurse completing the assessments. The facility's policies on bowel and bladder assessment and incontinence, as well as the incontinence policy, were not effectively implemented. These policies were intended to ensure residents received appropriate treatment to restore bladder function and prevent infections. However, the facility did not perform adequate incontinence assessments or provide appropriate treatment and services, as evidenced by the incomplete assessments and lack of toileting programs for the affected residents.

Plan Of Correction

The facility failed to ensure to comprehensively assess residents' urinary incontinence to determine the type of bladder incontinence and to develop and implement an appropriate treatment plan to maintain and/or restore the resident's bladder function. This affected Resident #45 and #57. Resident #57 no longer resides in the building. Resident #45's bowel and bladder were evaluated, and a program was started on 3/12/2025 by the Assistant Director of Nursing and Director of Nursing. To identify other potentially affected residents, an audit of residents' bowel and bladder patterns was conducted for all residents, completed on 3/20/2025 by the Assistant Director of Nursing. To prevent reoccurrence, education was conducted for all licensed nursing staff regarding bowel and bladder policy and monitoring, completed on 3/20/2025 by the Director of Nursing. To evaluate the preventative actions taken, audits of bowel and bladder assessments for three residents will be conducted three times a week for four weeks by the Director of Nursing or designee. Audit findings will be reviewed with the QAPI committee weekly for recommendations.

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 address a resident's oxygen concentrator alarm in a timely manner, affecting a resident with multiple health conditions including dependence on supplemental oxygen, pneumonia, chronic respiratory failure with hypoxia, hypertension, heart disease, COPD, hyperlipidemia, and tobacco use. The resident's care plan required continuous oxygen at three liters via nasal cannula and regular oxygen saturation checks. During an observation, the resident's oxygen concentrator was alarming due to a low flow rate set at zero, but staff passing by did not respond to the alarm. The surveyor activated the call light, but it went unanswered for several minutes, during which the resident expressed difficulty breathing and opened a window for relief. Eventually, a CNA and an RN were alerted to the situation. The RN assessed the concentrator and determined a new one was needed. However, the new concentrator also failed to work properly due to the oxygen tubing being kinked around the resident's neck. After the tubing was straightened, the resident's oxygen saturation was initially low at 81 percent but improved to 90 percent with deep breathing instructions. The deficiency was confirmed by the RNs present during the observation.

Plan Of Correction

The facility failed to ensure a resident's oxygen concentrator alarm was addressed timely for resident #45. Resident #45 was evaluated immediately, and the issue was addressed with the concentrator by switching the concentrator and fixing kinked tubing, by the Assistant Director of Nursing on 3/10/2024. To identify other potentially affected residents, an audit of all residents was conducted by the ADON with oxygen on 3/10/2025 by the Director of Nursing/designee for kinked tubing or malfunctioning concentrators. To prevent reoccurrence, education was conducted for all licensed nursing staff regarding oxygen monitoring and observation of equipment and tubing on 3/20/2025 by the Director of Nursing/designee. To evaluate preventative actions taken, audits of call for 3 residents 3 times a week for 4 weeks will be conducted by the Director of Nursing/designee. Audit findings will be reviewed with the QAPI committee weekly for recommendations.

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 physician's order was in place prior to the use of a reclining safety and enabling chair for a resident. This deficiency was identified during an annual survey, where a resident was observed using a reclining geri chair without a corresponding physician's order. The resident had a history of chronic obstructive pulmonary disorder, white matter disease, and diabetes mellitus, and was noted to have significantly impaired cognition. Despite an assessment completed earlier indicating the chair was used for comfort and safety, there was no evidence of a physician's order in the resident's medical record. Interviews with a registered nurse and the Director of Nursing confirmed the absence of a physician's order and a facility policy regarding the use of such chairs.

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 Pre-Admission Screening and Resident Review (PASRR) documents accurately reflected new diagnoses and medications for two residents. Resident #38 was admitted with multiple diagnoses, including dementia, but the PASRR document incorrectly indicated there was no diagnosis of dementia. This discrepancy was confirmed by a Corporate Registered Nurse during an interview. The PASRR document did not reflect the resident's accurate medical condition, which was diagnosed months prior to the assessment. Resident #16 was admitted with schizophrenia and Parkinson's disease, and later received new diagnoses of adjustment disorder with depression and anxiety, which required medication changes. However, the PASRR completed prior to admission did not include these new diagnoses or the associated medications. The facility did not complete a new PASRR to reflect these changes, nor was the cumulative diagnoses list updated to include the resident's past history of anxiety or the new diagnoses. This oversight was confirmed by a Corporate Registered Nurse during an 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 ensure accurate completion of Pre-Admission Screening and Resident Review (PASRR) assessments for two residents upon their admission. Resident #20 was admitted with diagnoses including bipolar disorder and was prescribed Lamictal for mood stabilization. However, the PASRR completed did not reflect the current use of this medication, as confirmed by the Social Services Designee. This oversight indicates a discrepancy between the resident's medical records and the PASRR documentation. Similarly, Resident #16 was admitted with a history of schizophrenia and anxiety, and was prescribed Valium for anxiety and Seroquel for schizophrenia. The PASRR completed by the hospital staff only noted schizophrenia and the prescription of Seroquel, omitting the diagnosis of anxiety and the prescription of Valium. The Corporate Registered Nurse confirmed the inaccuracies in the PASRR, which did not align with the resident's medical history and current medication 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 provide timely treatment as ordered by the physician for a resident with multiple health conditions, including cardiomyopathy, hypertension, dementia, diabetes mellitus, and a history of COVID-19. The resident was admitted to the facility and had a severely impaired cognition as indicated by a BIMS score of 05. On a specific date, the physician ordered Furosemide 40 mg to be injected intramuscularly once a day for three days to address the resident's swelling. However, the resident did not receive the scheduled dose on the day the order was made. The nursing progress notes indicated that the resident had continued swelling of the legs and labored breathing, and the family was informed of the new medication order. Despite the availability of the medication in the facility's emergency supply, the resident did not receive the Furosemide injection until the following morning. The Director of Nursing confirmed the delay in administering the medication as per the physician's order.

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 to maintain and improve the range of motion and mobility for a dependent resident. Resident #9, who was admitted with multiple diagnoses including dementia, osteoporosis, and difficulty walking, was observed on multiple occasions sitting in a wheelchair with her lower legs dangling and unsupported on the footrests. This observation was confirmed by the Assistant Director of Nursing, who then repositioned the resident's legs onto the footrests. The resident's medical record indicated severe cognitive impairment and total dependence on staff for certain activities, including transfers and lower body dressing. The care plan noted the potential for discomfort due to osteoporosis, with interventions to assist with repositioning as needed. However, the facility's policy on patient positioning, which aims to ensure comfort and maximize therapy benefits, was not adhered to, as evidenced by the resident's unsupported leg positioning.

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 a physician order for oxygen therapy for a resident, which constituted a deficiency in providing safe and appropriate respiratory care. The resident, who was admitted with diagnoses including cardiomyopathy, hypertension, dementia, diabetes mellitus, and a history of COVID-19, had a severely impaired cognition as indicated by a BIMS score of 05. On a specific date, the resident experienced shortness of breath with an oxygen saturation of 86% on room air and a respiratory rate of 24 breaths per minute, accompanied by audible wheezing. Oxygen was administered at 2 liters per minute via nasal cannula without a physician's order. The Director of Nursing confirmed the absence of a physician order for the oxygen therapy and acknowledged that the nurse should have notified the physician to obtain the necessary order.

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 laboratory monitoring and documentation for two residents receiving medication for hypothyroidism and hyperlipidemia. Resident #28 was admitted with hyperlipidemia and hypothyroidism, yet there was no documented evidence of a hypothyroidism diagnosis in the resident's records. The resident was prescribed pravastatin for hyperlipidemia and Synthroid for hypothyroidism, but there was no evidence of a lipid panel being conducted to monitor the pravastatin, and the last thyroid test was conducted in June 2023, which showed high levels. Despite this, there was no follow-up or adjustment to the Synthroid dosage until much later, and the pharmacy did not recommend any laboratory monitoring for these conditions. Resident #47, diagnosed with hypothyroidism, depression, and anxiety, was receiving Synthroid. The resident's TSH levels were found to be low, indicating a need for medication adjustment, but the previous nurse practitioner did not address this issue. The resident exhibited increased agitation and confusion, prompting a review of laboratory results, which confirmed low TSH levels. However, no immediate action was taken to adjust the medication until the facility reached out to a new nurse practitioner, who then ordered a recheck of the TSH levels.

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 medication regimen was free from unnecessary drugs, affecting one resident out of five reviewed for medications. The resident, who was admitted with diagnoses including schizophrenia, anxiety, dementia, and diabetes mellitus, was prescribed Depakote, a medication for seizure and mood stabilization, without an appropriate indication for use. There was no evidence in the medical record or hospital records of a seizure disorder diagnosis or any evaluation by a physician or certified nurse practitioner justifying the initiation of Depakote. The Medication Administration Record indicated that Depakote was initially used for a seizure disorder and later for hallucinations, despite the resident having an independent and intact cognition level with no seizure disorder diagnosis. Interviews with the Director of Nursing and the resident confirmed the absence of any seizure diagnosis or activity, highlighting the inappropriate use of the medication.

Penalty

No penalty information released

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

Summary

The facility failed to administer psychotropic medications as ordered, affecting one resident out of five reviewed for medications. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, mood disorder, depression, and anxiety, was evaluated by a psychiatric certified nurse practitioner (CNP) who increased the dosage of Depakote to two 250 mg tablets in the morning and 250 mg at night. However, the new order was transcribed incorrectly into the medical record and Medication Administration Record (MAR), resulting in the resident receiving an additional 500 mg of Depakote every day, which was not ordered by the CNP. The error was identified during a review of the resident's medical record and confirmed through staff interviews. The psychiatric CNP confirmed that no order for an additional 500 mg of Depakote was made, and the registered nurse verified the transcription error. This error led to the resident receiving two doses of extra medication in error on two consecutive days, highlighting a failure in the medication administration process 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 provide timely dental care for a resident with ill-fitting dentures and ensure the dentures were accessible. The resident, who had a history of dysphagia and other medical conditions, was admitted with upper and lower dentures and had sores from the dentures and tongue pain. Despite these issues, the resident's Minimum Data Set (MDS) assessment inaccurately indicated no dental problems. The resident's bottom dentures were missing after a hospital stay, and staff were unaware of this until it was discovered during a surveyor's visit. The resident had been using Lidocaine for throat pain, but the order should have been for mouth sores. Interviews with facility staff revealed a lack of awareness regarding the resident's missing dentures and the ill-fitting nature of the upper dentures. The Corporate Registered Nurse confirmed that the resident had refused the facility's dental services upon admission, but there was no documentation of any follow-up to see if the resident wanted to consult a dentist of his choice. The facility's failure to address the resident's dental issues promptly and accurately document the resident's condition contributed to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents had an appropriate indication for the use of antibiotics, affecting three residents out of eight reviewed for antibiotic use. The infection control log for July, August, and September 2024 revealed 28 resident infections that did not meet McGeer's criteria for antibiotic use. Specifically, Resident #3 was prescribed Macrobid for a urinary tract infection (UTI) on 07/17/24, despite not meeting the criteria for antibiotic use. The physician was notified but chose to continue the antibiotic treatment. Similarly, Resident #16 was prescribed Macrobid for a UTI on 08/22/24, and Resident #44 was prescribed Macrobid and later Augmentin for UTIs on 09/04/24 and 09/10/24, respectively, even though neither met the criteria for antibiotic use. In each case, the physician was informed of the lack of criteria but decided to continue the antibiotics. The facility's policy on antibiotic stewardship, revised on 11/01/19, requires that antibiotics be used in accordance with McGeer's criteria and that a clinical rationale be documented if antibiotics are continued without meeting these criteria. The Director of Nursing confirmed the deficiency during an 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 notify the resident's representative and physician of a change in health status for Resident #35. The resident, who was admitted with diagnoses including cardiomyopathy, hypertension, dementia, diabetes mellitus, and a history of COVID-19, exhibited a significant change in condition. On a specific date, the resident experienced shortness of breath while sitting on the side of her bed, with an oxygen saturation level of 86% on room air and a respiratory rate of 24 breaths per minute, accompanied by audible wheezing. Oxygen was administered at 2 liters per minute via nasal cannula. Despite these changes, the facility did not inform the resident's family representative or physician as required by their policy. The Director of Nursing confirmed that the notification should have been made according to the facility's policy on resident condition changes, which mandates immediate contact with the resident's physician and responsible party in the event of a perceived change in condition. This oversight was identified during a complaint investigation, affecting one of the three residents reviewed for notification of change.