Hearthstone Nursing & Rehabilitation Center

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from misappropriation of money when a staff member used the resident’s bank card without authorization. The resident, admitted with anxiety and depression and documented as cognitively intact on the admission MDS, kept a bank card in a billfold in their room. A public complaint was made after the resident’s representative reviewed the resident’s bank statement and found multiple charges totaling approximately $1,696 over several weeks, despite the resident not having used the card. The resident reported not authorizing the purchases and stated that the police had seen pictures of the person who took the money. A subsequent investigation, including involvement of law enforcement, identified a CNA/receptionist as the individual who used the resident’s bank card. Police presented a photograph of this staff member to the facility and reported approximately $1,700 in charges for household goods and toys beginning in December. The staff member admitted to using the resident’s card, acknowledging at least $100 used for personal purposes and characterizing it as borrowing money from someone considered “like family.” Facility leadership stated they would expect staff not to use a resident’s bank card, confirming that the staff member’s actions constituted misappropriation of resident funds.

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 received required admission documents at or before admission, as required for resident rights and understanding of services. One resident admitted in October 2025 with diagnoses including diverticulosis and a cognitive communication deficit did not receive the admission packet at the time of admission. A certified mail receipt dated February 6, 2026, with a handwritten note showed that the admissions packet had originally been generated on October 30, 2025, but it was later discovered that it was not signed. The packet was subsequently sent to the resident by certified mail, and the resident’s family member confirmed that the admission documents were not received until after the resident had discharged from the facility. The Admissions Director stated he noticed that some residents had not received their admission documents upon admission and that he mailed the documents to those residents, also noting that many staff had been in the admissions position and some had been terminated or had quit. The DNS stated she expected staff to provide residents their admission documents in a timely manner.

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 required assistance with activities of daily living (ADLs), specifically bathing and toileting, to dependent residents. One resident admitted with muscle weakness and adult failure to thrive had an admission MDS indicating moderate cognitive impairment and dependence on staff for showers. CNA task documentation for a specified 10‑day period showed the resident did not receive any type of bathing, with entries marked as “NA” on two of those days. A CNA later stated she documented “NA” when she did not have time to provide a shower during that period, and another CNA stated that during that time showers were not always offered to residents. The DNS stated she would expect residents to receive their scheduled showers. Another resident, admitted with chronic kidney disease and UTI, was cognitively intact, dependent on staff for toileting transfer and hygiene, and occasionally incontinent of bladder. This resident reported having to wait up to an hour at times for staff assistance with toileting, particularly during the daytime, and described experiencing pain and an urgent need to urinate during these waits. A former CNA and another CNA both stated they had observed this resident have incontinent episodes after waiting too long for toileting assistance, and one CNA reported seeing the resident’s call light on and being told the resident was waiting to use the toilet, after which she would apologize when she could not meet care needs promptly. A third resident, admitted with muscle weakness and a need for assistance with personal care, had an MDS and care plan indicating a need for partial to maximal assistance with bathing and was scheduled for bathing twice weekly in the evening. Documentation showed this resident received bathing only four times in a given month and went a 10‑day span without any bathing. A complaint was later received by the State Survey agency alleging this resident was not receiving bathing, and an agency CNA stated she did not recall refusals of bathing and at times could not complete the resident’s bathing. The DNS stated she would expect residents to receive their scheduled showers.

Penalty

No penalty information released

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

Summary

Facility staff failed to follow physician orders for a resident’s medications, resulting in missed doses. The resident was admitted with diagnoses including chronic pain and sepsis, and the Medication Administration Record (MAR) for late December listed orders for Linezolid for sepsis, Oxcarbazepine for convulsions, and Gabapentin for pain, with directions to see Administration Notes. The Administration Notes for the same date documented that these medications were on order from the pharmacy. A complaint later alleged that the resident missed physician-ordered medications. During interview, a CMA reported that after the resident was sent to the hospital and then returned, someone had destroyed all of the resident’s medications, and the resident was not gone long, resulting in the resident not receiving the ordered medications. The DNS stated she would expect staff to communicate with the pharmacy and have no lapse in resident medication. These findings show that despite active physician orders and documentation that medications were on order from the pharmacy, the resident did not receive the prescribed Linezolid, Oxcarbazepine, and Gabapentin after a hospital transfer and return, due to the destruction of the medications and lack of continuity in medication administration.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurate medical records for multiple residents. For a resident with diabetes admitted in January 2025, the Diabetic Administration Record (DAR) for December 2025 directed staff to administer insulin before meals. However, at the 5:30 PM administration time there were 4 of 31 instances with no documentation indicating whether insulin was administered or refused, at the 5:00 PM administration time there were 4 of 31 instances with no documentation, and at the 8:00 PM administration time there was 1 of 31 instance with no documentation. An LPN reported that this resident would refuse insulin and ask for it later, then refuse again when it was offered, and acknowledged she forgot to document the refusals on the DAR. The DNS stated the expectation that staff document residents’ refusals on the DAR. For a resident with traumatic brain injury and dementia admitted in January 2025, a quarterly MDS in June 2025 indicated the resident was rarely understood and dependent on staff for eating, and a care plan revised in December 2024 documented total dependence on one staff for eating. Despite this, an August 2025 Documentation Survey Report showed that out of 124 opportunities, staff documented the resident as independent with eating on ten occasions and as requiring setup or clean-up assistance on four occasions. A CNA stated she should not have documented the resident as independent because the resident had always been dependent and required staff support with eating. For another resident admitted in October 2025 with muscle weakness, lack of coordination, and Alzheimer’s disease, an admission MDS indicated significant cognitive issues and a need for substantial to maximal assistance with dressing, and a care plan dated October 15, 2025 documented substantial to maximal assistance of one staff for lower-body dressing. However, a November 2025 Documentation Survey Report showed that out of 61 opportunities, staff documented this resident as independent with lower-body dressing on three occasions. A CNA stated the charting used to be unclear and that she probably missed documenting the resident’s lower-body dressing abilities. The DNS stated she expected accurate documentation of residents’ eating and dressing assistance needs.

Penalty

No penalty information released

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

Summary

The facility failed to revise care plan interventions and re-evaluate a resident's elopement risk, resulting in inadequate supervision and failure to prevent repeated elopements for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including psychosis, delusional disorder, schizophrenia, and suspected vascular dementia, was under guardianship and had documented impaired strength, balance, and endurance. Despite these factors, the care plan did not address the resident's elopement incidents, and no new interventions were developed after the resident left the facility on two occasions. Progress notes indicated the resident expressed a desire to leave, and staff allowed the resident to leave against medical advice (AMA), only leaving a voice message for the guardian rather than using the emergency contact as specified in the guardianship paperwork. Staff interviews revealed a lack of awareness regarding the resident's guardianship status and the appropriate procedures for contacting the guardian. Staff members believed the resident was alert and oriented and had the right to leave, despite documentation indicating the resident lacked decision-making capacity. The facility did not conduct investigations into either elopement incident, and staff failed to notify law enforcement or use the correct emergency contact methods. The guardian confirmed that she was not contacted appropriately and reiterated that the resident did not have the capacity to make decisions about leaving 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 develop a comprehensive assessment for a resident who was admitted with a feeding tube and multiple diagnoses, including acute kidney failure, UTI, diabetes, severe septic shock, high blood pressure, and enteral feeding. The Admission Nutritional Status CAA did not include essential information such as the resident's eating pattern, communication problems, input from the resident or family, or care plan considerations. Both the MDS Coordinator and the Director of Nursing Services acknowledged that the assessment was incomplete and not person-centered, lacking the necessary details to be considered comprehensive.

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 dialysis services for a resident with end stage renal disease were properly completed, including necessary monitoring and communication with the dialysis provider. The resident, who had moderate cognitive impairment and was at risk for fluid overload, was supposed to have pre- and post-dialysis assessment forms completed and returned to the facility after each dialysis session. However, on multiple occasions, these forms were either incomplete or contained inaccurate information, such as incorrect weights. Staff interviews revealed confusion and inconsistency regarding responsibility for obtaining and verifying dialysis information, with some staff stating it was difficult to get forms returned and others unclear about the process for follow-up with the dialysis provider. Additionally, the facility did not ensure that the resident's dietary needs, as communicated by the dialysis center, were met in a timely and accurate manner. The resident was prescribed a renal diet with specific protein recommendations due to elevated phosphorus levels, but meal tickets and staff interviews indicated that the resident often did not receive adequate protein options and was routinely given cottage cheese, a food high in sodium and phosphorus, despite recommendations to limit it. Dietary staff and CNAs were unaware of the need to limit certain foods and had limited knowledge of the resident's specific diet requirements. Communication between the facility's dietary, nursing, and dialysis staff was inconsistent and delayed, resulting in the resident's diet not being updated promptly to reflect current recommendations. Staff acknowledged confusion regarding diet orders and the need for improved training and information sharing related to renal diets. The lack of timely and accurate communication and documentation regarding both dialysis care and dietary management led to the deficiency identified in the report.

Penalty

No penalty information released

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

Summary

The facility failed to follow up on dental services for a resident who had requested assistance with dental appointments. The resident, admitted with diagnoses including bipolar disorder and chronic pain, was cognitively intact and had documented dental issues such as cavities or broken teeth. Despite repeated requests for dental work during care conferences and a care plan indicating the need for staff assistance with oral care, no dental appointments were scheduled or followed up on as required by facility policy. Staff interviews confirmed that the resident's requests for dental services were known, but the process for scheduling and following up on appointments was not completed. Documentation showed that the resident had a dental appointment, but staff did not obtain provider notes upon the resident's return, nor did they follow up with the dental provider. The Social Service Director acknowledged that updates regarding the resident's dental needs were not received as expected, and the staff responsible for scheduling appointments did not ensure proper follow-up. The DNS confirmed that staff were expected to follow up on all resident appointments, but this did not occur for the resident in question.

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 two residents from abuse, specifically sexual abuse, as evidenced by an incident in which one resident with dementia and agitation was witnessed touching the breast of another resident who was severely cognitively impaired. Multiple staff members observed the inappropriate contact in the dining room and reported that the resident who initiated the contact was verbally aggressive and resistant to redirection. Staff attempted to separate the residents and keep them apart, but the resident continued to attempt to approach the other and displayed ongoing aggressive behavior toward both staff and other residents. The residents involved had significant cognitive impairments, with one being severely impaired and the other diagnosed with dementia but assessed as cognitively intact at admission. Despite staff interventions to redirect and monitor the residents, the inappropriate contact occurred and was witnessed by several staff members. The facility's administrator acknowledged that neither resident had the mental capacity to consent to the contact and recognized the obligation to ensure residents are free from abuse. The events described indicate that the facility did not effectively prevent or protect residents from abuse as required by policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that alleged violations involving sexual abuse were reported immediately, but no later than two hours after the allegation was made, for two residents. One resident, who was severely cognitively impaired following a stroke, and another resident, who was cognitively intact with a history of dementia and agitation, were involved in an incident where staff witnessed one resident touch the other's breast in the dining area. Although the incident occurred at approximately 5:45 PM and was reported to a registered nurse at around 8:15 PM, the formal report to the State Agency was not submitted until 9:23 PM. The administrator acknowledged that the facility did not report the alleged sexual abuse in a timely manner as required.

Penalty

No penalty information released

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

Summary

The facility failed to properly dispose of expired medications in various storage areas, including the medical storage room, medication carts, and resident medication storage refrigerators. During an inspection, it was observed that several expired medications and supplements were present. In the medical storage room, expired items included bottles of alpha lipoic acid, naproxen, Prosource No Carb, Osmolyte 1.5, and Robitussin. Additionally, the 300-hall resident medication storage refrigerator contained bags of IV Vancomycin with a use-by date that had passed, and the 100-hall refrigerator had a carton of moderately thickened water that was also expired. Further inspection of the medication carts revealed more expired items. The 300-hall medication cart contained expired bottles of Robitussin, naproxen, Fem Flora Probiotic, Active Liquid Protein without an expiration date, and nitroglycerin that had expired in 2022. The 100-hall medication cart also had expired bottles of Vitamin D, naproxen, and Robitussin. Staff members verified the presence of these expired medications, and the Vice President of Clinical Services acknowledged that the expectation was for all expired medications to be removed from storage areas and carts.

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 update a resident's POLST (physician orders for life-sustaining treatment) for one of the four sampled residents reviewed for ADLs. The resident, who was admitted to the facility with a diagnosis of a brain injury, initially had a POLST indicating resuscitation if their heart and breathing stopped. Despite having moderate cognitive impairment, the resident was able to communicate their needs and expressed a desire to change their code status to DNR (do not resuscitate) during an interdisciplinary care conference. However, the resident's POLST was not updated to reflect this change, as acknowledged by the social services staff during the survey. This oversight placed the resident at risk of having their end-of-life choices not honored.

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 written transfer notices with appeal rights to residents and their representatives, and did not notify the Office of the State Long-Term Care Ombudsman of resident hospitalizations. This deficiency was identified for two residents. Resident 4, who was admitted to the facility in March 2021 with a diagnosis of epilepsy, was discharged to the hospital on October 30, 2024, due to a seizure. Upon review, there was no evidence in Resident 4's clinical record that a transfer notice with appeal rights was provided to the resident's representative or that the ombudsman was notified of the transfer. Similarly, Resident 36, admitted in February 2024 with a brain injury, was transferred to the hospital on August 21, 2024. The resident's record lacked documentation indicating that the ombudsman was notified of this transfer. Interviews with facility staff revealed a lack of awareness and a system to ensure proper notification procedures were followed. Staff 2 (DNS) acknowledged the absence of a system to notify representatives and the ombudsman, while Staff 37 (Social Services) was unaware of who was responsible for notifying the ombudsman.

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 information regarding its bed hold policy to two residents who were hospitalized, which is a requirement to ensure residents are aware of their right to return to the same bed within the facility. Resident 4, who was admitted in March 2021 with epilepsy, was discharged to the hospital due to a seizure on October 30, 2024, and later readmitted. However, there was no documentation in Resident 4's clinical record indicating that the facility's bed hold policy was reviewed with the resident or their representative upon discharge to the hospital. Staff 2, the Director of Nursing Services (DNS), acknowledged that the facility lacked a system to ensure residents and their representatives were notified of the bed hold policy when discharged. Similarly, Resident 36, admitted in February 2024 with a stroke diagnosis, was discharged to the hospital on August 21, 2024. The resident's record did not include documentation that the bed hold policy was provided to the resident or their representative. Staff 37 from Social Services mentioned that residents were given the bed hold policy upon admission but was unsure who provided it before hospitalization. Staff 34, an Agency RN, stated that the nurse on duty was responsible for providing the policy at the time of discharge, and if done, it should be documented in the progress notes. However, no documentation was found to confirm that Resident 36 or their representative received the policy on the specified date.

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 assist two residents with their personal hygiene needs, specifically in relation to shaving preferences. Resident 8, who was admitted with Parkinson's disease and required assistance with personal hygiene, was observed on multiple occasions to have a mustache and beard growing in, despite expressing a preference to be clean-shaven except for the mustache. The resident reported that staff typically assisted with shaving only about every two months, which was insufficient to meet their stated preference. Staff 33, a CNA, acknowledged that it appeared Resident 8 had not been shaved for some time. Similarly, Resident 36, who was admitted with a brain injury and had moderate cognitive impairment, was dependent on staff for ADL care, including personal hygiene. This resident expressed a preference for having a mustache but not a beard and required staff assistance for shaving. Despite receiving a bed bath, Resident 36 was not shaved, as confirmed by Staff 34, an Agency RN. Both residents' preferences for shaving were not adequately addressed, leading to a deficiency in providing necessary assistance with activities of daily living.

Penalty

No penalty information released

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

Summary

The facility failed to follow physician's orders and provide necessary care for a resident with a diagnosis of brain injury and liver disease. The resident was admitted in February 2024, and a physician's note from August 9, 2024, indicated a referral to a gastrointestinal (GI) specialist for liver disease. A subsequent note on August 16, 2024, reiterated the need for a GI follow-up. However, the resident's clinical record did not contain a GI consult report. Interviews with staff revealed that the process for making referrals involved notifying the reception staff, who would then arrange appointments and transportation. Despite this process, there was no confirmation that a GI appointment was made for the resident. The LPN Unit Manager stated that the resident's liver condition was treated by the physician and a GI consult was not needed, but no documentation was provided to support this claim.

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 accurate provision of prescribed medications for three residents, leading to a risk of not receiving medications as prescribed. Resident 2, admitted with heart failure, was given metoprolol succinate despite having a systolic blood pressure of 96, which was below the threshold of 100 as per the physician's order. This occurred on December 2, 2024, and was documented in the resident's health record. Additionally, Resident 13, who was also administered metoprolol succinate, had a blood pressure reading of 174/70, which was not in accordance with the physician's order to hold the medication if the systolic blood pressure was greater than 140. Resident 4, admitted with epilepsy, did not receive the prescribed lacosamide on October 26, 2024, due to a delay in receiving the medication from the pharmacy. The facility contacted the pharmacy and refaxed the order, but the medication was not administered as required. The provider was notified of the missed dose two days later. Interviews with facility staff revealed an expectation that physician orders should be followed and that orders should be faxed to the pharmacy on the day they are received.

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 pharmacy recommendations for a resident who was reviewed for medications, placing them at risk for adverse medication reactions. The resident, admitted in December 2021, had a diagnosis of orthostatic hypotension and was prescribed midodrine to manage low blood pressure. The pharmacy recommended adjusting the administration times of midodrine to 8:00 AM, 12:00 PM, and 4:00 PM to prevent supine hypertension and assist with hypotension symptoms during waking hours. However, the facility continued to administer the medication at 8:00 AM, 12:00 PM, and 8:00 PM through October and part of November 2024, failing to implement the recommended changes until mid-November. The deficiency was identified through interviews and record reviews, revealing that the facility did not always receive pharmacist reports, which contributed to the oversight. The resident continued to receive midodrine at the incorrect times for several weeks, despite the pharmacy's recommendations. This oversight was part of a broader issue where the facility did not ensure pharmacy recommendations were consistently addressed, as evidenced by the audit conducted in November 2024.

Removal Plan

• Completion of an audit to ensure provider followed up was completed and documented in the resident chart.
• Nurse Managers were educated by the President of Clinical regarding requirements related to pharmacy consultant recommendations.
• The DNS was educated on a pharmacy recommendations tracking system and would start the tracking system to ensure timely follow-up.
• Audits would be completed to ensure pharmacy recommendations were addressed and completed appropriately.
• Findings would be reviewed and reported to the QAPI Committee to ensure compliance was sustained.

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 timely evaluation of falls and update care plan interventions for two residents, leading to a risk of accidents. Resident 12, admitted with a history of stroke and low blood pressure, experienced multiple un-witnessed falls. Investigations into these falls were delayed, with notes completed weeks after the incidents. Despite interventions like the addition of Zoloft for impulsive behavior and the use of fall mats, the care plan was not updated promptly, and safety checks were not consistently maintained. Staff acknowledged the lack of thorough and timely investigations, which hindered the evaluation and implementation of effective fall prevention strategies. Resident 32, admitted with dementia and hip pain, also experienced multiple un-witnessed falls. The investigations into these incidents were similarly delayed, with completion occurring nearly a month after the falls. The care plan for Resident 32 included interventions that were not applicable due to the resident's cognitive impairment, such as the use of a push palm call light and toileting assistance. Staff noted that some interventions, like the use of fall mats, were not documented in the care plan, and there was a lack of assessment for the appropriateness of certain interventions. The facility's failure to conduct timely and thorough fall investigations resulted in inadequate and inappropriate care plan interventions for both residents. This oversight placed the residents at risk for further accidents, as the care plans did not accurately reflect their needs or the interventions being used. Staff acknowledged the deficiencies in the investigation process and the discrepancies in the care plans, which contributed to the ongoing risk of falls for the 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 conduct gradual dose reductions (GDR) for a resident's psychotropic medications, which placed the resident at risk of receiving unnecessary medications. The resident, admitted in 2019 with a post-operative knee infection, was assessed to have mild depression in February 2023. Despite a health questionnaire in August 2024 indicating no feelings of depression, the resident continued to receive daily doses of Sertraline and Duloxetine, with the last GDR attempt documented in June 2022. The facility's team had previously decided not to alter the medication regimen due to the resident's upcoming surgery, with a plan to review the medication in the next quarter. However, no documented rationale was provided for the lack of GDR since 2022. Interviews with facility staff, including an LPN Unit Manager, CNAs, and Social Services, revealed that the resident did not exhibit negative moods or behaviors, and any occasional grumpiness was easily resolved by addressing the underlying cause. Despite these observations, no additional information or rationale was provided by the Social Services staff for not attempting a GDR of the resident's psychotropic medications since 2022. This lack of action and documentation contributed to the deficiency identified by the surveyors.

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 misappropriated narcotic medication for a resident who was admitted with a diagnosis including arthritis of the joints. Upon review of narcotic receipts, it was found that the facility received 30 pills of morphine, of which 16 remained unadministered, and 30 pills of hydrocodone/acetaminophen, of which 28 remained unadministered. The discharge paperwork for the resident included prescriptions for these medications, but there was no documentation indicating that the resident received any medications upon discharge. An incident investigation revealed that the medications were missing, and the facility was unable to determine how they went missing. The Director of Nursing Services was notified of the missing hydrocodone/acetaminophen pills, and the evening staff identified the missing morphine pills. The investigation concluded that the resident was not given any medication upon discharge as per physician orders, and the facility acknowledged the misappropriation of the medications.

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 adequate sanitation in the kitchen, which placed residents at risk for food-borne illnesses. During an observation, a cook was seen filling a sink and a bucket with sanitizer solution for pot washing and cleaning kitchen surfaces. The cook used a test strip to check the sanitizer concentration, which showed a level of 150. The cook confirmed that the concentration was the same earlier in the day when pot washing was completed and did not indicate any issue with the concentration. However, the Dietary Manager later retested the sanitizer concentration and found it to be zero, confirming that a concentration of either zero or 150 was inadequate.

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 silverware for residents during dining, specifically affecting a resident who was cognitively intact and required set-up assistance with meals. The resident expressed feeling undignified eating with tablespoons instead of teaspoons, a request that had been ongoing and unaddressed. Observations confirmed that all place settings in the dining room were set with tablespoons, and staff acknowledged the resident's complaints about the lack of teaspoons. The Dietary Manager was unaware of the shortage of teaspoons, indicating a communication lapse within 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 maintain a quiet and comfortable environment for its residents, as evidenced by multiple observations and complaints regarding excessive noise levels. During Resident Council meetings on three separate occasions, residents expressed concerns about loud noise during all shifts, which was disruptive to their environment. The facility's initial response was to educate staff on noise levels, but this measure proved insufficient as the issue persisted. Observations made by surveyors on various dates confirmed the residents' complaints. Staff members were frequently observed speaking loudly and yelling across halls, particularly near the nurse's station. Residents and their family members reported that the noise was so disruptive that it interfered with conversations and required residents to keep their doors closed, yet the noise was still audible. Staff members, including CNAs and the Social Service Director, acknowledged the residents' complaints, and the facility's administration admitted that more could be done to address the noise issue.

Penalty

No penalty information released

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

Summary

The facility failed to conduct care conferences as required for several residents, leading to deficiencies in care planning and resident participation in care goals. Resident 1, who was admitted in 1998 with brain damage and paraplegia, was not assessed for the ability to use a call light, resulting in the call light being placed out of reach. Staff members confirmed that the call light was intentionally kept out of reach because the resident was not believed to know how to use it. This oversight in assessing the resident's needs and abilities led to a lack of appropriate care planning for Resident 1's mobility and safety needs. Additionally, the facility did not conduct quarterly care conferences for other residents, including Resident 20, who has PTSD and depression, and Resident 42, who has diabetes and depression. Both residents expressed a desire to discuss their care needs with staff, but no care conferences were held after their initial assessments. Resident 3, who suffered a stroke, and Resident 24, diagnosed with Parkinson's disease, also did not have care conferences following their most recent MDS assessments. Staff members acknowledged these omissions, indicating a systemic failure to adhere to care conference schedules and revise care plans as needed.

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 adhere to infection control standards in two separate instances, placing residents at risk for exposure to infectious diseases. In the first instance, a resident diagnosed with pneumonitis and under contact precautions was transferred from a wheelchair to a bed by two staff members, neither of whom wore the required gowns. Despite the presence of a contact precautions sign and a PPE bin, the staff did not follow the expected protocol for wearing appropriate PPE during the transfer. In the second instance, staff members assisting residents during lunch in the main dining room failed to perform hand hygiene between assisting different residents. Specifically, two CNAs were observed wiping the mouths of residents without using hand sanitizer afterward, contrary to the infection prevention expectations stated by the facility's Infection Preventionist.

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 timely disposal of narcotics for multiple residents, as observed in three of four medication carts. The deficiency was identified through observation, interviews, and record reviews. Specifically, the facility did not destroy controlled substances within the required timeframe of one to two days after a resident's discharge or discontinuation of medication. This issue was noted across several cases, including residents who were discharged or had their narcotic medications discontinued, yet their medications remained in the carts for extended periods before being destroyed. For instance, Resident 108 was discharged after back surgery, but 62 tablets of diazepam were not destroyed until over a month later. Similarly, Resident 4's Norco was discontinued, but 15 tablets were not destroyed until more than a month later. Other residents, such as Resident 109 and Resident 204, also had their narcotic medications, like Tramadol and Morphine, left in the medication carts for weeks before destruction. These delays in medication disposal were consistent across various residents and types of narcotic medications. Staff 2, the Director of Nursing Services (DNS), acknowledged the facility's policy that controlled substances should be removed and destroyed by two nurses or one nurse and one CMA within one or two days. However, Staff 2 was unaware that the medication carts contained controlled substances awaiting destruction. This lack of awareness and adherence to the facility's policy contributed to the deficiency in timely narcotic disposal, affecting multiple residents and medication carts.

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 or their responsible parties were involved in decisions related to their care, specifically concerning medications and restraints. Resident 21, who was admitted in 2021 with a diagnosis of diabetes and was cognitively impaired as of a significant change MDS in April 2024, was using a scoop mattress for safety. However, the facility did not review the risks and benefits of this restraint with the resident or their responsible party. Staff acknowledged this oversight during an interview. Similarly, Resident 31, admitted in 2022 with a diagnosis of depression, was prescribed Zoloft starting in January 2024. The clinical record for this resident lacked informed consent for the use of the antidepressant. Staff confirmed the absence of consent during an interview. These deficiencies placed residents at risk for lack of healthcare choices.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident was assessed for the ability to self-administer medications, specifically antacids, which led to a deficiency. Resident 6, who was admitted to the facility in 2019 with a diagnosis of heart failure, was found to be cognitively impaired according to a quarterly MDS assessment conducted on April 12, 2024. On June 24, 2024, a bottle of antacid was observed on Resident 6's bedside table. Upon review of Resident 6's clinical record, it was revealed that there was no assessment conducted to determine if the resident was capable of safely self-administering medications. Staff 18, an LPN, confirmed that Resident 6 had medications at the bedside and acknowledged that the resident was confused and should not have medications at the bedside without an assessment confirming it was safe for self-administration.

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' advance directives were included in their clinical records and that residents were provided with advance directive information. This deficiency was identified for two residents. The first resident, admitted in 2018 with a diagnosis of a stroke, had a care plan initiated in 2022 indicating that the resident declined advance directive information and that staff would review the resident's end-of-life choices quarterly. However, the resident's clinical record did not contain an advance directive, and staff acknowledged that the resident was not offered advance directive information after 2022. The second resident, readmitted in 2024 with a diagnosis of Parkinson's disease, had a care plan indicating that the resident's desires and wishes would be followed according to a signed directive. However, the care plan was revised to indicate that the resident declined advance directive information. Despite being cognitively intact, the resident's clinical record did not include an advance directive or documentation that advance directive information was provided. The resident stated that a family member had a copy of the advance directive, but staff confirmed that it was not in the clinical 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 facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident within the required timeframe, resulting in a deficiency. The resident, who was admitted with a leg fracture, was informed that their covered services would end on June 13, 2024. However, the resident received the notification on June 12, 2024, which was less than the mandated 72 hours prior to the termination of services. During an interview, Staff 10 from Social Services acknowledged the oversight and confirmed that the NOMNC should have been provided 72 hours in advance to allow the resident time to appeal the decision. Despite stating that documentation would be provided to explain the delay, no additional information was submitted.

Penalty

No penalty information released

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

Summary

The facility failed to conduct thorough investigations for falls involving a resident who was at risk due to multiple factors, including impaired mobility, cognition, and medication use. The resident, admitted in 2022 with PTSD, depression, and anxiety, was receiving psychotropic medication, which increased the risk of falls and impaired balance. The care plan required partial to moderate assistance for transfers and included interventions to prevent falls, such as keeping the bed in a low position and locking wheelchair brakes. However, the fall investigations on 6/14/24 and 6/16/24 were incomplete, lacking details on care provided before the falls, such as staff observations, toileting assistance, or medication administration. The reports for the falls did not include interviews with staff or documentation of care provided prior to the incidents. On 6/27/24, the Regional Director of Clinical acknowledged the absence of staff interviews and incomplete information regarding care before the falls. This lack of thorough investigation placed residents at risk for accidents, as the facility did not adequately determine the causes of the falls or implement necessary preventive measures.

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 received continuous oxygen as ordered, which was necessary for their respiratory care. The resident, who was admitted in October 2022, had a diagnosis of chronic obstructive pulmonary disease, a condition that requires careful management of airflow and breathing. A physician's order dated June 4, 2024, specified the need for continuous oxygen. However, observations on June 24, 2024, at 12:31 PM and 5:18 PM revealed that the resident was not using oxygen. A Certified Nursing Assistant (CNA) confirmed the absence of oxygen and noted that the resident usually used it. On June 27, 2024, a Licensed Practical Nurse (LPN) Unit Manager verified the continuous oxygen order and expressed an expectation that staff should ensure compliance with the 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 that annual performance reviews were completed for three out of five sampled Certified Nursing Assistants (CNAs), specifically staff members hired on 4/9/07, 8/28/15, and 1/15/18. This deficiency was identified through interviews and record reviews conducted on 6/27/24. The absence of these performance evaluations placed residents at risk due to the potential lack of competent staff. During the investigation, the facility's administrator confirmed the inability to locate the performance reviews for the mentioned staff members.

Penalty

No penalty information released

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

Summary

The facility failed to adequately monitor and manage medications for two residents, leading to potential health risks. Resident 20, who was admitted in 2023 with PTSD and a pulmonary embolism, was prescribed Apixiban, an anticoagulant. However, from early June 2024, the monitoring for adverse reactions such as bleeding, bruising, and shortness of breath was improperly documented using checkmarks instead of specific numeric codes. Additionally, the nursing staff did not inform the RNCM that the monitoring had been discontinued, resulting in a lack of thorough assessment and accurate monitoring. Resident 31, admitted in 2022 with diabetes, had a physician's order to withhold insulin if their CBG was below 100. Despite this, insulin was not withheld on three occasions in June 2024 when the CBG was below the threshold. The RNCM acknowledged that the insulin was not held as ordered, indicating a failure to follow the prescribed medication regimen.

Penalty

No penalty information released

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

Summary

The facility failed to consistently monitor residents on psychotropic medications, which placed them at risk for receiving unnecessary medications. For Resident 20, who was admitted with PTSD and depression, the monitoring of adverse reactions and behaviors related to the use of Citalopram was inadequately documented. Instead of using specific numeric codes to record behaviors, adverse side effects, and interventions, checkmarks were used, leading to insufficient assessment and monitoring. Staff 16, an RNCM, was not informed that the monitoring had been discontinued, resulting in a lack of thorough evaluation of Resident 20's outcomes. Similarly, Resident 27, with diagnoses of PTSD, depression, and anxiety, was prescribed Diazepam, Zoloft, and Bupropion. The monitoring for adverse reactions and behaviors was also inadequately documented using checkmarks instead of specific codes. Staff 26, an LPN-Unit Manager, was unaware of the discontinuation of monitoring, leading to inaccurate tracking of the resident's medication effects. Resident 38, admitted with depression and anxiety, was prescribed Trazadone, Buspar, and Aripiprazole. The monitoring for adverse reactions, behaviors, and sleep was similarly documented with checkmarks, and Staff 16 was not notified of the system changes, resulting in insufficient assessment of the resident's medication impact.

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 understood an arbitration agreement, which was a deficiency identified during a survey. Resident 38, who was admitted to the facility with a diagnosis of heart disease, was found to be cognitively intact according to an admission MDS. However, the resident reported being in a coma upon arrival and did not recall signing the arbitration agreement. The resident mentioned that the facility made it seem urgent to sign a large number of papers. Staff 59, responsible for admissions, stated that residents signed approximately 13 forms upon admission and were informed that agreeing to the arbitration agreement meant giving up their right to trial. Staff 59 also mentioned that residents could rescind the agreement within 30 days and provided her business card for questions but did not follow up to ensure residents understood what they signed.

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 Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by a review of training records. Specifically, three out of five randomly selected staff members did not meet this requirement. Staff 4 completed only eight hours, while Staff 6 and Staff 8 each completed ten hours of in-service training. This deficiency was identified during a review conducted on June 27, 2024. The facility's administrator and the Regional Director of Clinical were informed that the additional documentation provided did not fulfill the annual training requirement for these staff members.

Penalty

Fine: $88,28248 days payment denial

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

Summary

The facility failed to ensure residents were free from sexual abuse, specifically for two residents with severe cognitive impairments. Staff witnessed repeated intimate nonconsensual sexual activity between the two residents without completing assessments to determine their ability to consent and without implementing appropriate interventions. The facility's policy on freedom from abuse, neglect, and exploitation was not followed, as the incidents were not properly investigated, and the residents' cognitive abilities to consent were not adequately assessed. Resident 15, admitted in 2019, had diagnoses including cognitive communication deficit, vascular dementia, and a stroke, with a recent assessment indicating severe cognitive impairment. Resident 16, admitted in 2022, also had severe cognitive impairment due to a stroke. Multiple incidents of inappropriate touching between the two residents were observed by staff on different occasions. Despite these observations, the facility failed to conduct thorough investigations, update care plans appropriately, or notify the residents' families in a timely manner. Interviews with staff revealed that there was confusion and a lack of clear direction regarding the handling of the incidents. Some staff believed the residents were not cognitively able to consent, while others were unsure due to language barriers. The facility administrator initially ruled out abuse and did not report the incidents to the State until much later. The facility's failure to implement policies and procedures to prevent sexual abuse resulted in repeated non-consensual sexual activity without appropriate assessments and interventions in place.

Removal Plan

• An investigation for the interaction between Resident 15 and Resident 16 was to be completed.
• Staff 1 was provided education regarding abuse and reporting of abuse. Staff 1 was removed as the abuse coordinator pending completion of the investigation.
• Care Plans for Resident 15 and Resident 16 were updated to identify sexual behaviors and interventions to prevent ongoing sexual interactions. Interventions included monitoring of residents to ensure they do not engage in sexual behaviors including kissing and fondling, and redirection away if attempts at sexual behaviors are observed. Additional intervention included immediate notification of charge nurse. Who would notify the DON and administrator.
• DON was to complete baseline interview audit of all cognitively intact residents to ensure there are no additional residents who have experienced non-consensual sexual contact.
• DON would complete an interview audit of 15 staff members from various shifts and departments to ensure there has been no observed abuse with cognitively intact and cognitively impaired residents.
• DON was to provide education on active staff regarding abuse and reporting abuse.
• Facility staff would be provided with information regarding who to contact if there was a lack of perceived response to reports of abuse from management at the facility level.
• Audits would be conducted by DNS or designee weekly until substantial compliance was reached, then monthly with verification of sustained compliance.
• Audit trends would be reported to the facility QAPI for review and further recommendations.

Penalty

Fine: $88,28248 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 administration failed to implement their abuse policy procedures in the areas of identification, investigation, protection, and reporting, which resulted in repeated incidents of sexual abuse for two residents. Resident 15, who was admitted in 2019 with a diagnosis of dementia and severe cognitive impairment, and Resident 16, who was admitted in 2022 with a diagnosis of stroke and severe cognitive impairment, were involved in multiple nonconsensual sexual activities. Despite staff witnessing these incidents, the facility administration did not take appropriate actions to protect the residents or report the incidents in a timely manner. On multiple occasions, staff observed Resident 15 and Resident 16 engaging in inappropriate sexual behavior in public areas of the facility. These incidents were reported to the unit manager and the administrator, but no thorough investigation was conducted, and no interventions were put in place to prevent further incidents. The facility's administrator ruled out abuse without conducting a proper investigation and instructed staff not to report the incidents to the state. Additionally, the facility failed to update the cognitive evaluations and care plans for the residents involved. Interviews with facility staff revealed that they were aware of the incidents but were instructed by the administrator to minimize the documentation and not report the incidents to the state. The facility's social services and nursing staff were not properly notified or involved in addressing the incidents. The facility's failure to follow their abuse policy and procedures resulted in repeated incidents of sexual abuse between Resident 15 and Resident 16, and the state survey agency was not contacted until several days after the initial incident.

Removal Plan

• Investigation for interaction between Resident 15 and Resident 16 was to be completed.
• The contact between Resident 15 and Resident 16 was reported to DHS.
• The Facility administrator was provided education regarding abuse and reporting of abuse and has been removed as the abuse coordinator pending completion of the investigation.
• The Care Plans for Resident 15 and Resident 16 would be updated to identify sexual behaviors and interventions to prevent ongoing sexual interactions. Initial interventions were to include monitoring of resident(s) to ensure that they did not engage in sexual behaviors including kissing and fondling, and re-direction away if attempts at sexual behaviors such as touching or fondling were observed. Additional intervention included immediate notification of charge nurse, who would subsequently notify the DON and administrator.
• The DON/Designee would complete a baseline interview audit of all cognitively intact residents to ensure there were no additional residents who had experienced non-consensual sexual contact.
• The DON/Designee would complete an interview audit of 15 staff members from various shifts and departments to ensure that there were no observations of abuse in the past with cognitively intact or cognitively impaired residents.
• The DON/Designee would provide education to all scheduled and PRN staff not currently on a leave of absence on abuse and guidelines for reporting abuse.
• Facility staff would be provided with information regarding who to reach out to at a higher management level if there is a perceived lack of response to reports of abuse from management at the facility level.
• Audits would be conducted by DON or designee weekly until substantial compliance is reached, then monthly with verification of sustained compliance.
• Audit trends would be reported to facility QAPI for review and further recommendations.
• The Plan of Correction would be completed.

Penalty

Fine: $88,28248 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 treatment orders, administer timely treatment, and provide correct treatment for a surgical wound for a resident who was admitted with a right below the knee amputation and stroke. Upon admission, there were no wound care orders for the surgical site, and it took seven days for the facility to obtain the necessary orders. During this period, the resident's wound care was neglected, leading to infection and dehiscence, ultimately resulting in the resident being re-hospitalized and requiring an above the knee amputation. Additionally, the facility failed to follow physician orders related to fluid restriction for a resident with heart failure. The resident exceeded the fluid restriction 21 out of 30 days, and staff did not consistently remind the resident or report the non-compliance to the physician. This placed the resident at risk for fluid overload. The facility also failed to follow wound care orders for two other residents. One resident did not receive the prescribed wound care treatment on the scheduled day, and the nurse falsely documented that the treatment was completed. Another resident did not receive daily wound treatments as ordered, and the nurse also falsely documented the completion of the treatment. These failures in wound care management and documentation further highlight the deficiencies in the facility's care practices.

Removal Plan

• Facility would verify wound treatments were in place for Resident 6.
• A baseline audit of all residents to ensure there were no unidentified wound areas.
• A baseline audit of residents with current wounds would be completed to ensure treatment orders were in place.
• All licensed nurse staff would receive education regarding initiation of treatment orders for new admits with identified skin impairments and facility acquired skin impairments.
• Weekly audits would be conducted.
• Audit trends would be reported to the facility QAPI for review and further recommendations.

Penalty

Fine: $88,28248 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 comprehensively assess, monitor, treat, and follow physician orders for pressure ulcer treatment for a resident, resulting in the worsening of a Stage 2 pressure ulcer to an infected, unstageable pressure ulcer. Upon admission, the resident had multiple skin concerns, including a pressure wound on the sacrum, but the initial pressure ulcer assessment did not include measurements, staging, or characteristics of the wound. Despite having physician orders for wound care, no treatments were completed for the sacrum wound from the date of admission until new orders were initiated several days later. The wound was not properly monitored or assessed until nearly a month after admission, by which time it had deteriorated significantly and showed signs of infection and necrosis. The facility also incorrectly documented the pressure ulcer as a different type of ulcer, further delaying appropriate care. The resident's condition continued to decline, with the sacrum wound showing increased measurements, infection, and severe deterioration over time. The wound was eventually assessed to be an unstageable ulcer due to the presence of slough and eschar. Despite the worsening condition, the facility failed to provide consistent wound treatments, and the resident was eventually transferred to the hospital with a diagnosis of an infected sacral pressure ulcer with osteomyelitis, requiring surgical debridement. The hospital records confirmed the ulcer had progressed to a Stage IV pressure ulcer. Interviews with facility staff confirmed the failure to follow physician orders, monitor, and treat the resident's wound appropriately. The facility's lack of timely and accurate wound assessments, incorrect documentation, and failure to provide necessary treatments contributed to the significant deterioration of the resident's pressure ulcer. The immediate jeopardy situation was identified, and the facility was notified of the deficiency.

Removal Plan

• A baseline audit of all residents would be completed to ensure there were no unidentified wounds.
• A baseline audit of residents verified to have current wounds will be completed to ensure treatment orders are in place.
• A baseline audit will be completed of residents with current wounds to ensure there is a wound evaluation in place.
• A baseline audit will be completed to verify residents with current wounds have care plan for skin impairment risk in place and identify interventions to promote skin integrity and wound healing.
• Licensed nurse staff will be provided education regarding completing thorough evaluation on admission to identify areas of skin impairment. Education would identify the need to initiate treatment orders for new admissions with identified skin impairments as well as any newly identified facility acquired skin impairments.
• Unit managers will be educated regarding the admit review process to include review for identified areas of impaired skin integrity and to verify treatment orders were initiated, and care plans were initiated based on skin risk factors.
• Unit Managers will be educated regarding the completion of weekly wound evaluations. The DON/Designee will ensure the wound evaluations are completed weekly for residents who are identified as having wounds.
• Audits will be conducted by DON or designee.
• Audit trends will be reported to facility QAPI for review and further recommendations.

Penalty

Fine: $88,28248 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 there was sufficient nursing staff available to meet the needs of residents, as evidenced by multiple complaints and observations. Public complaints received by the State Survey Agency indicated that residents experienced falls, attempted elopements, and were left in urine-soaked bed sheets at night. Resident Council Notes from April 2024 revealed slow call light response times and care staff not returning when residents requested items. The facility's Direct Care Staff Daily Report for April and May 2024 showed that the facility was understaffed for CNAs for 7 out of 20 days reviewed, failing to meet the State minimum staffing requirement. Interviews with residents confirmed long wait times for call lights, particularly during evening and night shifts and towards the end of the week. Residents reported waiting over an hour for assistance, which was corroborated by staff interviews and observations of staff struggling to manage their workload due to insufficient staffing levels. Staff members, including LPNs and RNs, expressed frustration and concern over their inability to provide adequate care, administer medications on time, and manage their assigned wings effectively. The Regional Director of Clinical acknowledged the low staffing levels, further confirming the deficiency.

Penalty

Fine: $88,28248 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 had the appropriate wound care competencies and skills, affecting 12 of 12 licensed nurse staff reviewed. This deficiency placed residents at risk for unmet wound care needs. A review of the facility's employee list revealed that 12 LPNs and RNs worked at the facility. On two separate dates, a request was made to review documentation to ensure that the facility and contract agency licensed nurse staff had the required wound care skills and competencies, but no documented proof was provided. Staff interviews revealed that the facility did not complete skills competencies to ensure new staff knew what they were doing before providing wound and nursing care to residents. Several staff members admitted that most nurses were not comfortable providing wound care and had received no wound care training from the facility, leading them to do the best they could without proper guidance. Specific incidents highlighted the deficiency, such as Staff 19 finding an unauthorized calcium alginate dressing on Resident 6's surgical wound and another nurse regularly ignoring physician wound care orders in favor of using xeroform on all residents. Staff 19 also discovered an unauthorized calcium alginate dressing on Resident 7's surgical site and reported the treatment error to the unit manager. Staff 20 confirmed that staff did not receive any wound care training and competencies were not checked by the facility prior to caring for residents. The Regional Director of Clinical acknowledged the lack of documentation showing staff competencies were checked, further confirming the deficiency.

Penalty

Fine: $88,28248 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 effective systems were in place to identify problems, and take action to improve and monitor its performance. The undated 2024 Quality Assurance and Performance Improvement (QAPI) Plan for Hearthstone Nursing and Rehabilitation Center included oversight of various services and processes. However, a review of the facility's Quality Assessment and Assurance (QAA) records from October 2023 through May 28, 2024, revealed no evidence that the facility enacted procedures related to problem identification, analysis, performance improvement, and monitoring. This deficiency was acknowledged by the Vice President of Operations on May 28, 2024.

Penalty

Fine: $88,28248 days payment denial

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

Summary

The facility failed to ensure residents were treated with respect and dignity, as evidenced by the interaction between Resident 22 and Staff 29, a Certified Occupational Therapy Assistant. Resident 22, who was admitted with diagnoses including hemiplegia and adult failure to thrive, expressed that her/his arm hurt and refused to continue with the arm exercise. Despite the resident's refusal, Staff 29 persisted, leading to a confrontation observed by a nurse who intervened and instructed Staff 29 to stop the treatment. Additionally, Resident 22 filed a grievance stating that Staff 29 was rough and hurt her/him multiple times during the therapy session, and when the resident threatened to hit Staff 29, the staff member responded inappropriately by threatening to press charges for assault. This behavior was deemed unprofessional and disrespectful by the resident and was acknowledged by the Regional Director of Clinical, who confirmed that Staff 29 did not treat the resident with dignity and respect. The incident led to Staff 29 being suspended pending an investigation, after which she resigned. The report highlights that the facility did not uphold the resident's right to a dignified existence and self-determination, as Staff 29's actions and responses were inappropriate and disrespectful. The resident's grievance and subsequent statements indicate a clear failure in maintaining the standards of respect and dignity required in the care provided to residents.