Royale Gardens Health & 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 deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall risk interventions for a resident with known cognitive impairment, behavioral issues, and a history of falls. The resident was admitted with dementia, anxiety, and a recent fractured thigh bone, and assessments documented that the resident was at risk for wandering, had multiple prior falls, poor safety awareness, dizziness, communication problems, incontinence, and behaviors such as frustration, aggression, and ambulating without assistance into others’ rooms. The care plan identified the resident as at risk for falls due to a recent fracture and balance problems, and specified the need for one staff to assist with transfers and non‑pharmaceutical interventions such as not forcing or rushing care and providing one‑on‑one and decreased overstimulation as needed. Behavior documentation in early January showed episodes of agitation, threats toward others, pacing without staff assistance, and unsuccessful interventions to address these behaviors. On the day of the incident, the resident experienced two falls. In the first, the resident was last seen in bed, then stood up and held the windowsill without assistance before falling onto a floor mat and hitting an elbow; staff reported that during that shift the resident required a second staff member for transfer safety due to increased behaviors and lack of balance, but only one staff member was available, and there were no available staff to provide one‑on‑one supervision despite the resident’s continued attempts to self‑transfer. Later that day, the resident was found sitting on the floor near the bed after an unwitnessed fall and stated having hit the head; no injuries were initially noted, but the resident was sent to the hospital for evaluation. Hospital records documented admission following a fall with head trauma and critical subdural hematomas, after which the resident remained unresponsive and was transitioned to palliative care. Facility staff, including the unit manager and DNS, acknowledged that one‑on‑one supervision was needed for this resident after the first fall and that the scheduling coordinator was unavailable to find staff to provide it.

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 prescribed antibiotics for one resident who returned from the hospital with an order for Ceftin twice daily for two weeks after evaluation for blood in the urine. The resident had been admitted to the facility with a diagnosis of cancer and had a Foley catheter with episodes of yellow/pink-tinged urine, dark red urine, and bloody urine. After the emergency department visit, the urine sample was described as cloudy with blood, white blood cells, and many bacteria, with the results noted as compelling evidence of infection. The resident’s clinical record and MAR showed the antibiotic was not administered from the time of the hospital discharge order through several days afterward. Facility staff stated the order was faxed to the pharmacy but was not transcribed into the clinical record, and the oncoming nurse did not verify that all orders were entered. The resident later developed low blood pressure, increased heart rate, and difficulty breathing and was transported back to the hospital, where the discharge summary documented admission for evaluation and management of complicated UTI.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that resident call lights functioned properly and independently in resident rooms and bathrooms. For one resident admitted in January 2021 with pain, a CNA tested the call light and found that when this resident’s call light was turned off, the roommate’s call light also turned off. Similar testing was done for two other residents, one admitted in January 2024 with stroke and diabetes and another admitted in January 2023 with heart disease, and in both cases, when each resident’s call light was turned off, the roommate’s call light also turned off. The facility administrator confirmed that the call lights should operate independently. Another resident, admitted in June 2024 with pain and repeated falls and documented as cognitively intact on a quarterly MDS, reported that it took staff about 20 minutes to answer call lights and believed the call light was malfunctioning because it would shut off by itself. This resident stated that these concerns had been reported to staff without follow-up. A CNA acknowledged that the resident had reported multiple times that the call light was not working but initially believed the resident was mistaken. Upon testing, the CNA confirmed the call light was not functioning properly and that turning off this resident’s call light also turned off the roommate’s call light.

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 kitchen was kept in a sanitary manner in 1 of 1 kitchen reviewed for food service. During an observation of the kitchen, a swamp cooler located above the stove and food preparation area had a visible buildup of dust, and a black pipe extending from the ceiling near the swamp cooler appeared greasy with dust accumulation. Staff 29, the District Manager, and Staff 30, the Dietary Manager, confirmed the swamp cooler should have been clean.

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 resident and the resident representative were included in the care planning process for Resident 5, who was admitted with diagnoses including brain damage and heart failure. A legal petition identified Witness 2, a family member, as Resident 5's guardian, and a 2/17/25 IDT Care Plan Conference/Welcome Meeting Form showed Resident 5 and Witness 2 attended that meeting and were involved in care plan development. However, the 11/17/25 Annual MDS indicated Resident 5 was unable to participate in the BIMS assessment, and on 3/9/26 Witness 2 stated he had not been included in any recent care planning process and had questions about Resident 5's therapy and nutrition. Staff 8 confirmed on 3/10/26 that Resident 5's last care conference was on 2/17/25, and Staff 5 stated on 3/12/26 that she was recently hired and was working to address the lack of timely care conferences, acknowledging that the last care conference was a long time ago.

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 to self-administer medications for 1 of 4 sampled residents reviewed for accidents. Resident 10 was admitted with a diagnosis of heart disease. An 8/11/23 Self-Administration of Medication form showed the resident wanted to self-administer medications, had no visual impairment, was alert and oriented, and was assessed as safe to self-administer medications, but the form did not identify which medications the resident was safe to administer. A 2/28/26 Quarterly MDS showed the resident was cognitively intact, and the 3/2026 MAR showed the resident was able to self-administer artificial tears BID and did so. On 3/9/26, observation found fluconazole nasal spray, an over-the-counter hair growth supplement, an over-the-counter weight loss medication, and a non-medicated eye drop on the resident’s bedside table. Staff 12 stated that if a resident had medications at the bedside, staff were to first assess the resident to ensure they were capable of medication self-administration, and that medications were to be stored safely such as in a lock box. Staff 12 also stated the resident had orders for self-administration of eye drops, but did not have orders for the fluconazole, weight loss medication, or hair growth supplement. Staff 2 stated no residents were currently identified to be able to self-administer medications and staff should have identified the medications at the bedside and assessed the resident. The resident stated the medications had been at the bedside forever.

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 Resident 36 received showers as frequently as preferred and as scheduled. Resident 36 was admitted with diagnoses including a below-knee amputation of the right leg and a diabetic ulcer of the left foot, and the 12/31/25 MDS indicated the resident was cognitively intact with a BIMS score of 14. The 1/5/26 care plan lacked information regarding bathing or showering, and the Kardex as of 3/10/26 did not include the level of assistance required for bathing. The resident stated on 3/9/26 and 3/11/26 that showers were not provided as often as desired and reported being told by CNAs that this was due to lack of staff. Documentation showed the resident received three of eight showers during 2/2026. Staff interviews confirmed showers were often not completed when CNAs were short-handed, evening shift staff often ran out of time to provide showers, and the DNS stated the facility had a shower schedule of two showers per week per resident unless otherwise preferred and acknowledged the resident did not receive the number of showers expected.

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 meaningful activities for a dependent resident who was admitted with diagnoses including brain damage and heart failure. The annual MDS indicated the resident was unable to participate in the BIMS assessment and that activity preferences were completed by staff. The Activities CAA stated appropriate activities were needed to help protect the resident from social isolation and loneliness. A revised care plan noted the resident required assistance with activity functions, preferred to socialize with staff members, and was able to sit in a chair to watch movies; it also listed watching comedy in the resident’s chair as a preferred activity, but did not include music as a preference. The CNA Task Activity Involvement report showed the resident received only one one-to-one conversation during the prior 30 days and no other activities were documented. During observations, the resident was seen in bed with the television on and no engagement with staff, and later was observed awake in bed looking at the wall. Staff stated the resident’s family visited infrequently, that the resident was rarely in a chair, and that only one CNA was successful in helping the resident avoid agitation when assisted into the chair. An Activities Assistant stated he was instructed to engage cognitively impaired residents once each month, believed the requirement was met, was not aware of the infrequent family visits, and said he lacked training to address the needs of cognitively impaired residents. Another staff member stated music was played on personal equipment because music was not set up in the resident’s room, and the Unit Manager stated staff required additional training and that the care plan needed updated information to include the resident’s music preference.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate ROM services for two residents who had documented mobility and contracture-related needs. One resident, admitted with diagnoses including brain damage and heart failure, had a restorative nursing plan calling for bilateral upper and lower extremity exercises one to three times each week, and later a revised care plan identified the resident as non-verbal with impaired mobility and bilateral upper extremity ROM impairment. However, the restorative logs showed multiple periods when ROM services were marked as not available, and the quarterly MDS showed the resident received ROM services only one day out of seven during the review period. Staff interviews confirmed that ROM services had declined over the prior months, CNAs were no longer providing ROM, and the Director of Therapy and DNS acknowledged that restorative aide hours had been reduced and that consistent ROM services were still expected. A second resident, admitted with diagnoses including pain and contractures of both hands, had a care plan directing staff to provide restorative therapy with active ROM exercises to both upper and lower extremities. The quarterly MDS showed the resident had impairment in all four extremities and received ROM services three days out of seven during the review period, but the clinical record contained no documented evidence that a restorative program was being provided. The resident stated restorative therapy had helped strengthen the arms, shoulders, and hands and that after it stopped the resident experienced increased tightness in the arms. Multiple CNAs and therapy staff stated the facility had not had a restorative program for months because staff were pulled from the floor, and the Administrator acknowledged the facility did not have a restorative program even though restorative services were expected.

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 x-rays were obtained timely for one resident who was reviewed for accidents. The resident was admitted with a diagnosis of heart disease and, after staff responded to a call for help, was found on the floor reporting bilateral feet pain, knee pain, and hip pain. X-rays were ordered for the left ankle, right ankle, left toes, right toes, left knee, right knee, hips, and pelvis, but the resident’s clinical record did not contain results for the 11/4/25 right foot/ankle x-rays. The resident later had bruising and swelling to the right foot, was offered transport to the hospital but declined, and continued to have unrelieved pain with physician notification. On 11/28/25, the resident developed a discolored, swollen area to the right lower shin, foot, and inner ankle, and right ankle x-rays were ordered. The 11/28/25 x-ray report showed the right ankle was fractured. Staff stated the x-ray technician did not ask for assistance with positioning and did not report that the ordered right ankle x-rays were not obtained, and the physician review of the x-rays did not note that the right foot x-rays were not completed.

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 one resident’s clinical record accurately reflected the resident’s resuscitation wishes. Resident 44 was admitted with chronic heart failure, and the clinical record contained a POLST dated [DATE] showing the resident elected Do Not Attempt Resuscitation (DNR). The resident’s IDT Care Plan Conference also documented that the resident elected DNR. However, the Clinical Resident Profile stated the resident was to receive CPR. Staff 11, an LPN, stated nurses are responsible for entering CPR/DNR status into the clinical record and confirmed the discrepancy between the Clinical Resident Profile and the POLST. Staff 11 also stated that if a resident were found unresponsive, staff would look at the Clinical Profile to determine whether to attempt CPR. Staff 2, the DNS, stated the expectation was that the clinical record would reflect the resident’s elected resuscitation status.

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 hallway water dispenser was maintained and sanitized in accordance with professional standards. A public complaint was received alleging that filtered water stations had pink slime and were not replaced or cleaned. During observation, the water dispenser across from the main nurses' station was found with an orangish buildup on the cold-water outlet and a gray to black buildup on the hot-water outlet. An LPN confirmed the buildup on both outlets. The housekeeping manager stated that housekeeping was responsible only for cleaning and sanitizing the outside of the dispenser, not the outlets or the inside. The maintenance director reported there was no cleaning schedule or documentation showing that the water dispenser outlets were regularly cleaned. The administrator stated he expected staff to complete the necessary activities for their job as required. The facility also failed to ensure that drinks stored in a resident snack refrigerator were labeled in accordance with professional standards. During observation, three clear pitchers containing red and yellow liquids were found in the resident snack refrigerator without any labels indicating when they were placed there or when they should be removed. The LPN confirmed the pitchers were not labeled. The dietary manager confirmed that the pitchers of juice in the resident snack refrigerator should have date labels. The administrator again stated he expected staff to complete the necessary activities for their job 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 inform a resident about the side effects of psychotropic medications prior to administration. The resident, who was admitted with a diagnosis of seizures, was prescribed and administered several psychotropic medications, including asenapine, buspirone, lamotrigine, and aripiprazole (Abilify), between February and June 2025. Record review and staff interviews confirmed there was no documented evidence that the resident was informed about the side effects of these medications before they were given. Facility staff, including the Social Services Director, Administrator, Director of Nursing Services, and Regional Nurse, acknowledged that the resident had not been informed, and no additional information was provided to demonstrate compliance.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident was not protected from sexual abuse by another resident. The incident involved two cognitively intact residents, one with diabetes and a below-the-knee amputation, and the other with a cognitive communication deficit. During a group activity, one resident made a joke about touching all the doughnuts, after which the other resident took a doughnut, wiped it in their crotch area, ate it, and made a comment implying they had now touched all the doughnuts. Multiple staff and witnesses confirmed the incident, with one staff member observing the affected resident become visibly upset and quiet immediately afterward. Following the incident, the affected resident reported feeling triggered by the presence of the other resident for at least a week and actively avoided them. Staff interviews indicated that the resident was angry and not acting like themselves for about a week after the event. The incident was corroborated by several staff members, including the activities director and CNAs, who noted the resident's emotional distress and confirmed that an unwanted sexual incident had occurred.

Penalty

No penalty information released

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

Summary

The facility failed to provide sufficient nursing staff to meet the care needs of all residents, resulting in missed and delayed incontinent care and resident showers for six sampled residents. Resident Council notes from January and March 2025 documented ongoing concerns about short staffing and unmet care needs, including missed scheduled showers. Review of shower records and staff documentation showed that multiple residents did not receive their scheduled showers, with reasons cited such as environmental limitations, refusals, or marked as not applicable. One resident's records indicated missed showers on two separate occasions. Interviews with residents and staff confirmed that staffing shortages were persistent, leading to untimely responses to call lights, missed showers, and delayed incontinent care. Several CNAs and licensed nurses reported being unable to meet care plan needs, with some residents found soaked in urine and not assisted out of bed. Staff consistently described the staffing situation as inadequate and chaotic, and facility leadership acknowledged the shortfall in CNA staffing and the resulting missed care for the identified 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 adequate wound care for three residents, leading to potential risks of worsening wounds and infections. Resident 101, admitted with second-degree burns on both feet, did not receive timely wound care as per hospital discharge orders. The facility did not initiate the prescribed wound care until two days after admission, and there was no documentation of wound care for several days. This resulted in the resident developing an infection, requiring hospital readmission and debridement. Resident 102, admitted with a fractured right femur, did not have their surgical site monitored for signs of infection until 23 days after admission. The care plan was not updated to include necessary monitoring until much later, and weekly skin evaluations were not completed. This lack of timely monitoring and care could have led to complications in the resident's recovery process. Resident 103, with a surgical site on the hip, also experienced delayed monitoring for signs of infection. The order to monitor the surgical site was not implemented until nine days after admission. The facility staff acknowledged the delay in monitoring and attributed it to issues with receiving wound care instructions from hospitals, which contributed to the deficiency in care provided to these 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 adequately assess and implement effective interventions to prevent falls for a resident with severe cognitive impairment and a history of repeated falls. The resident, who had a BIMS score of 5 indicating severe cognitive impairment, experienced 27 falls over a two-month period. The care plan for the resident included interventions such as frequent rounding, keeping the call light within reach, and staff-provided care. However, there was no documented evidence that the facility conducted an analysis of the falls to evaluate the effectiveness of these interventions. Additionally, some interventions listed in the incident reports were not part of the resident's care plan, indicating a lack of consistency and thoroughness in the implementation of fall prevention strategies. Interviews with staff and family members revealed concerns about inadequate staffing levels and the effectiveness of the fall interventions in place. Staff members reported that the resident required one-to-one care due to frequent falls and sundowning behaviors, but the facility did not have sufficient staff to provide this level of care. The facility administrator acknowledged that the care plan was followed for some falls but could not explain why the resident experienced so many falls or why there was no assessment of the interventions' effectiveness. The lack of adequate supervision and failure to reassess and adjust the care plan placed the resident at risk for recurring falls and subsequent injuries.

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 appropriate antibiotic administration for three residents, leading to significant health concerns. Resident 242, who had a history of dementia, was not given the correct antibiotic therapy for multiple UTIs, resulting in hospitalization. Despite a urinalysis indicating an infection and a culture showing resistance to the prescribed antibiotic, Cipro, the resident continued to receive ineffective treatment. This oversight contributed to the resident's decline, leading to hospice care and eventual death. Resident 29, admitted with a history of stroke and UTI, was found on the floor and transported to the ER, where a urine culture was initiated but not completed. Despite the absence of culture results, the resident was prescribed Keflex, which was later deemed ineffective. The provider did not respond to the antibiotic time-out assessment, and the resident completed the antibiotic course without appropriate documentation or adjustment based on culture results. Resident 30, with a history of stroke and chronic kidney disease, was prescribed amoxicillin-Pot clavulanate for a UTI caused by MDR Klebsiella pneumoniae, despite the organism's resistance to amoxicillin. The prescription was not aligned with the culture results, indicating a lack of appropriate antibiotic selection. These deficiencies highlight the facility's failure to ensure residents received effective antibiotic treatments based on culture and sensitivity reports.

Removal Plan

• Residents in the facility would be assessed for UTI symptoms and those assessed to have UTI symptoms would be placed on alert charting and the provider notified for recommendations.
• Review of residents who were treated for a UTI to ensure the residents' UTIs were treated with an appropriate antibiotic based on the Culture and Sensitivity Reports. The provider would be contacted regarding any changes in antibiotic therapy as indicated.
• Residents in the facility on hospice services or on comfort measures would have Physician Orders for Life Sustaining Treatment (POLST) forms reviewed regarding their wishes for treatment, including antibiotics, to ensure the information on the POLST form remained accurate to the residents' current wishes.
• Licensed Nurses would be educated on follow-up required for residents who complain of symptoms consistent with a UTI including provider notification. Daily morning clinical review process would be updated to include a review of any urinalysis tests completed to be followed up daily until the Culture and Sensitivity report was available to ensure antibiotics ordered were appropriate. Providers would be notified of the Culture and Sensitivity results as well as what antibiotics residents were currently administered if applicable.
• Staff education would be completed on reporting resident complaints or potential changes in condition to the charge nurse for follow up.
• Nurse managers would be educated on the need to review a resident's POLST wishes related to antibiotic treatment as indicated for residents on hospice or comfort services if an infection developed.
• The DNS or designee would audit residents treated for UTIs to ensure the Culture and Sensitivity reports were reviewed and followed up on as they became available, and the appropriate follow-up was done if the ordered antibiotic was not effective.
• The consultant pharmacist would review antibiotic use for UTIs and the accompanying Culture and Sensitivity results to ensure appropriate antibiotics were prescribed. Findings would be reported to the QAPI Committee and Medical Director. Reviews would continue ongoing if indicated.

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 was free from significant medication errors, specifically regarding the administration of antiseizure medication. The resident, who was admitted with a history of seizures, did not receive their prescribed lacosamide medication from the time of admission. The medication was supposed to be administered twice daily starting from the admission date, but it was consistently unavailable in the facility's automated electronic medication dispensing unit. Throughout the period from admission to the date of the survey, the medication was repeatedly noted as unavailable, and there was no documentation indicating that the facility contacted the pharmacy to follow up on the medication's delivery. The resident reported feeling shaky and experiencing symptoms consistent with seizure activity, such as an electrical current sensation and daily headaches, due to the lack of medication. The facility's staff, including the Director of Nursing Services, was unaware of the issues with the resident's admission medications. The process required the admission nurse to notify the pharmacy if a medication was not delivered, with follow-up expected on every shift until the medication arrived. However, this process was not followed, leading to the resident being at risk for increased seizure activity due to the lack of timely pharmaceutical services.

Removal Plan

• Resident 198's provider was notified of the medication error of missed lacosamide doses, and symptoms resident reported.
• Lacosamide was initiated.
• A medication error incident rate report was completed and an investigation initiated.
• Resident 198 was placed on alert charting to monitor for effectiveness of lacosamide and resolution or symptoms reported by the resident.
• Other residents in the facility with orders for antiseizure medications were to be reviewed to validate their medication was available in the facility and being administered as ordered.
• Resident admitted to the facility were to be reviewed to validate that medications ordered were available in the facility and being administered as ordered.
• Findings of the above audits will be reviewed with the medical director and the facility consultant pharmacist to review for recommendations.
• Licensed nurses and CMAs were to be educated on requirements related to ensuring medications for new admissions were delivered and available for administration, and the steps to take were when a medication was not delivered or available, including steps related to medications that required a prescription for pharmacy dispensation.
• The facility admission process was updated to include a review of medications ordered by the hospital to identify any medications that required a prescription to be filled by the pharmacy. Admissions staff would communicate with the hospital to ensure that prescriptions were sent with the resident and/or sent directly to the pharmacy.
• Morning clinical review processes were updated to include a review of admissions from the prior day to ensure medications were available in the facility. Prescriptions noted as not yet on-hand would receive follow-up by nursing to include calling the pharmacy to inquire about the status of the medication, notification of the status to be communicated to the provider, appropriate documentation as evidence of the follow-up actions. Additionally a review of a report of medications not administered would occur to identify any medications not administered due to availability issues.
• Audits would be done to ensure prescription medications were available in the facility and administered as ordered. Audits results would be reported to QAPI Committee and ongoing as indicated.

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 sanitary kitchen environment, which placed residents at risk for food-borne illness. During an observation, a dietary aide was seen using a rag from a sanitizing solution bucket to clean a soiled dish cart. The solution was found to be ineffective, with a concentration of only 100 PPM, below the required range of 150-400 PPM. The aide admitted that the sanitizer was changed every four hours, but the presence of black flecks in the solution indicated it was not clean or effective. The operational manager acknowledged the inadequacy of the system in place to ensure the sanitizer's effectiveness. Additionally, the facility's kitchen and snack area refrigerators were not properly cleaned. Black specks were observed on the gaskets of the walk-in refrigerator doors, and the cleaning list did not include tasks for refrigerator maintenance. The resident snack refrigerator had a torn gasket with dried brown particles in its creases and on the top shelf. The operational manager confirmed that the refrigerators were not cleaned and recognized the need to add this task to the cleaning list to ensure compliance.

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 meaningful activity programs for four residents, leading to a deficiency in meeting their needs for engagement and social interaction. Resident 14, who was admitted with depression and dementia, had a care plan indicating a desire for one-on-one activities, but there was no documentation of her preferred activities or reasons for lack of involvement. Observations showed that Resident 14 was not engaged in activities, and the Activities Director admitted to missing documentation in the care plan. Resident 48, admitted with rib fractures and respiratory failure, was not observed participating in activities during multiple observations. Despite expressing a preference for group activities and going outside, Resident 48 reported that staff did not facilitate her participation, especially on weekends. The Activities Director acknowledged not having spoken to Resident 48 about her activity preferences since her admission. Resident 52, who is blind and at risk for social isolation, was not assessed for activity preferences upon admission. Although she expressed interest in audio books and music, these were not provided. Observations showed limited participation in activities, and the Activities staff admitted to lacking experience with visually impaired residents. Similarly, Resident 68, with anoxic brain damage, was not offered activities despite a care plan indicating a need for cognitive stimulation. The Activities Director confirmed the lack of engagement for Resident 68.

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 physician orders were reviewed and signed by a physician for four sampled residents, which placed them at risk for unassessed medical needs and adverse side effects of medication. Resident 2, admitted in September 2021 with arthritis and heart disease, had no signed physician orders for several months spanning from January 2023 to June 2024. Staff acknowledged the absence of signed orders during a review of the resident's clinical record. Similarly, Resident 29, admitted in January 2024 with breast cancer and diabetes, had no signed physician orders after April 2023. Resident 31, admitted in August 2018 with left-sided paralysis and COPD, lacked signed physician orders for multiple months between August 2023 and October 2024. Resident 35, admitted in November 2023 with diabetes and heart disease, also had no signed physician orders after June 2023. The facility's administrator and regional director of clinical services confirmed the absence of signed orders for these 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 ensure that residents were seen by a physician every 60 days, as required, for four sampled residents. Resident 2, admitted in September 2021 with arthritis and heart disease, had no physician visit notes for several months in 2024, including January through March, May, June, and August. Resident 29, admitted in January 2024 with breast cancer and diabetes, had no physician visit notes after April 2023. Resident 31, admitted in August 2018 with left-sided paralysis and COPD, lacked physician visit notes for June, July, and September 2024. Resident 35, admitted in November 2023 with diabetes and heart disease, had no physician visit notes from May 2023 through July 2024, as well as September and October 2024. During an interview on October 28, 2024, at 4:00 PM, the facility's Administrator and the Regional Director of Clinical Services confirmed that no further physician visit notes were available for these residents. They acknowledged the absence of evidence indicating that the residents had been seen by a physician every 60 days, as required. This deficiency placed the residents at risk for unmet medical 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 maintain a medication error rate of less than 5 percent, resulting in an 11.36 percent error rate. This was identified through five errors out of 44 medication administration opportunities. One incident involved a resident admitted with respiratory failure who was prescribed Advair powder inhaler. The resident inhaled the medication twice without rinsing their mouth afterward, contrary to the physician's order. Staff acknowledged the error, noting that the resident should have rinsed their mouth to prevent mouth infections. Another incident involved a resident with heart failure, lung disease, and anorexia. The resident was prescribed Combivent and Incruse Ellipta inhalers, along with iron oral solution and metoprolol. The resident did not rinse their mouth after using the inhalers, and there was a failure to administer the iron oral solution and metoprolol due to unavailability. Staff admitted to not following the proper procedure for mouth rinsing and acknowledged the medication unavailability, which was not communicated to the Director of Nursing Services.

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 during an outbreak of illness in March 2024, which was characterized by residents experiencing vomiting and diarrhea across all halls. Despite the widespread nature of the outbreak, staff did not confirm whether the illness was Norovirus, and there was a lack of follow-up testing due to the wrong specimen containers being sent. Staff members, including a Registered Nurse and the Director of Nursing Services, acknowledged the outbreak but did not report it, and there was no verification of the illness being Norovirus. Additionally, the facility did not maintain proper infection control practices for a resident with an indwelling catheter. The care plan for the resident, who was admitted with acute kidney failure, required that the catheter collection bag be kept off the floor. However, an observation on October 22, 2024, revealed that the catheter tubing was on the ground, which was acknowledged by the Wound Nurse as not meeting the expected standard of care.

Penalty

No penalty information released

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

Summary

The facility failed to administer bowel care and follow therapy recommendations for several residents, leading to unmet care needs. Resident 8, admitted with diagnoses including stroke and heart disease, required extensive assistance for eating and was to be seated upright in a wheelchair during meals. However, observations revealed that Resident 8 was left in bed in a slouched position with meals unattended, contrary to therapy recommendations and care plan interventions. Staff interviews confirmed the lack of communication and adherence to the care plan, resulting in Resident 8 not receiving the necessary assistance and positioning during meals. Additionally, the facility did not provide timely bowel care for Residents 30 and 70, who experienced extended periods without bowel movements. Despite the care plan requiring bowel care every 24 hours and physician notification after four days without a bowel movement, Resident 30 did not receive care until the fifth day, and Resident 70's PRN bowel care was ineffective without further assessment or physician notification. Furthermore, Resident 191, admitted with a pressure ulcer and genital wounds, had inadequate documentation and assessment of the wounds, with no physician notification of new open wounds. These deficiencies highlight a failure in following care plans and ensuring proper documentation and communication regarding resident care needs.

Penalty

No penalty information released

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

Summary

The facility failed to ensure adequate supervision and environmental safety for several residents, leading to multiple deficiencies. Resident 14, diagnosed with dysphagia, was observed eating unsupervised despite care plan requirements for supervision during meals due to swallowing difficulties. Staff inconsistencies in understanding and implementing the care plan were evident, as some staff believed supervision meant frequent checks rather than continuous presence during meals. Resident 52, who is blind and at risk for falls, experienced an unwitnessed fall due to unlocked wheelchair brakes. Despite a care plan indicating the need for a safe environment and proper use of mobility aids, there was no documentation ensuring wheelchair brakes were locked. Staff failed to update the care plan to address this specific risk, and the resident's fall was not thoroughly investigated or documented. Resident 70, at risk for falls due to confusion and balance issues, experienced two unwitnessed falls without appropriate neurological assessments or care plan updates. Similarly, Resident 85, with dementia and orthostatic hypotension, had a care plan lacking specific interventions for her condition, such as routine checks. Resident 292, with a history of falls and severe cognitive impairment, had multiple unwitnessed falls without effective interventions or care plan updates. The facility did not conduct necessary skin assessments or alternative pain assessments, leading to unaddressed injuries.

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 staffing to meet the needs of residents on three of four halls, specifically the A, B, and G wings. This deficiency was highlighted by a public complaint received in April 2024, which reported that call light wait times frequently exceeded 30 minutes. Interviews conducted on October 21, 2024, with several residents revealed that they experienced long wait times for assistance, with some residents waiting up to an hour or more. Residents expressed frustration over the delays, which affected their ability to perform daily activities and receive timely care. One resident mentioned that the frequent change in staff led to a lack of familiarity with residents' needs, contributing to the delays. Staff interviews further corroborated the issue of insufficient staffing. A CNA reported being assigned 10 to 14 residents per shift, which hindered her ability to respond to call lights and complete necessary tasks such as resident showers and meal assistance. Another CNA noted that she often had more residents than state staffing requirements allowed, forcing her to start tasks early and stay late. A staff witness confirmed that the facility lacked an effective system to cover for absent staff, leading to situations where only one nurse was available for the entire facility during the day shift. The facility's administrator and DNS acknowledged the reliance on agency staff, who sometimes failed to show up, exacerbating the staffing shortages.

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 staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for 6 out of 55 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Reports covering specific periods in April, September, and October 2024. The absence of RN coverage for the required duration placed residents at risk for unmet assessment needs. During an interview on October 29, 2024, the Administrator and the Director of Nursing Services (DNS) acknowledged that RN call-offs occurred, and finding replacements was challenging.

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 was found to have multiple deficiencies that resulted in immediate jeopardy and substandard quality of care. These included failures in implementing and maintaining pressure ulcer treatments for a resident, leading to a worsening condition. Additionally, the facility did not adequately assess residents after falls or maintain an environment free from accident hazards for several residents. There was also a failure to provide sufficient RN and CNA staffing to meet resident needs, and residents were not consistently seen by physicians, nor were physician orders reviewed and signed as required. Further deficiencies were noted in the provision of timely pharmaceutical services, which constituted an immediate jeopardy situation for some residents. Significant medication errors were identified, also leading to immediate jeopardy and substandard care. Infection control standards were not followed for a resident and across four halls. Lastly, the facility failed to ensure appropriate antibiotics were administered for UTIs in several residents, which was another immediate jeopardy situation.

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 grievances related to personal property for two residents. Resident 52, who was admitted with a diagnosis of diabetes and was cognitively intact, reported a missing heavy jacket on a grievance report dated July 3, 2024. Despite staff efforts to locate the jacket in the laundry, it was not found, and there was no resolution to the grievance. Interviews with Resident 52 and staff confirmed the lack of follow-up and resolution for the missing jacket, which held sentimental value for the resident. Resident 70, admitted with a diagnosis of pneumonia, reported a missing gold wedding ring, as noted in a progress note dated October 4, 2024. The resident's inventory list included the gold ring, but staff did not locate it, and no grievance was filed. The Director of Nursing Services acknowledged the missing ring and the absence of a grievance, indicating a failure to address the resident's concern. This lack of action placed both residents at risk for unresolved grievances regarding their personal property.

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 assess the use of a physical restraint for a resident reviewed for physical restraints, placing residents at risk for potential abuse or neglect. The facility's policy indicated that a concave mattress could be considered a physical restraint if it prevents a resident from independently getting out of bed. A resident admitted in March 2024 with diagnoses including anxiety and catatonic schizophrenia was observed on a scoop mattress, which was not documented in the care plan as a restraint. Despite the resident's fall risk, there was no documentation in the clinical record assessing the mattress as a restraint. Staff initially stated the resident could not get out of bed independently, but later confirmed with therapy that the resident could indeed get out of bed on their own.

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 report a case of misappropriation to the State Survey Agency involving a resident who was cognitively intact and admitted with a diagnosis of diabetes. The resident reported a missing wallet and money from their bank account, which was documented in a grievance report. Although a police report was filed by social services on behalf of the resident, the facility did not submit a Facility Reported Incident (FRI) as required. This oversight placed residents at risk for abuse.

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 referred to the state agency authority for a Level II PASARR evaluation, which is necessary for individuals with serious mental illness. This deficiency was identified for a resident who was admitted to the facility with a mental illness diagnosis. Despite the resident's refusal of medications, care, and blood pressure monitoring, and exhibiting behaviors such as agitation and distrust towards staff, no PASARR Level II assessment was requested. The resident's medical records did not indicate any such referral, even though the resident's condition and behaviors warranted it. The resident, who was admitted in September 2023, showed signs of social isolation and depression, and a plan was made to refer them to behavioral health services. However, over the following months, the resident increasingly refused medications and care, exhibited high blood pressure, and expressed distrust towards staff, believing they were administering unnecessary medications. Despite these ongoing issues, the facility did not initiate a PASARR Level II evaluation, as confirmed by the Social Service Director, who stated that such a request was not made for the resident.

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 involve residents and/or their representatives in the care planning process, specifically for one resident who was admitted with a diagnosis of stroke and was moderately cognitively impaired. The resident, identified as Resident 8, was admitted in September 2024 and had a history of refusing or not receiving bathing on multiple occasions. Despite being present at a care plan conference, the resident's family member, who was also the Power of Attorney (POA) for care, was not involved in the care planning process. The family member expressed a desire to be involved due to the resident's memory issues and was unaware of whom to contact regarding concerns. Staff acknowledged the importance of involving the POA but failed to do so, leading to a deficiency in the care planning process.

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 evaluate a resident for an augmentative and alternative communication device (AAC) despite the resident's severe communication impairment due to aphasia. The resident, who was admitted with a diagnosis of aphasia, was observed to be nonverbal and relied on pointing and gestures for communication. During an interview, a CNA reported that the resident often confused 'no' for 'yes,' complicating the staff's ability to meet the resident's communication and care needs. It was confirmed by the speech therapist and clinical supervisor that three speech therapy evaluations were conducted, which identified the resident's primary mode of communication as nonverbal and recommended a non-speech generating device. However, the resident was not evaluated for an AAC device as recommended, nor was one provided in 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 adequate respiratory care and services for two residents who required the use of CPAP machines. Resident 21, admitted with a diagnosis of respiratory failure, had a physician's order for CPAP use at bedtime and specific instructions for cleaning the CPAP mask and maintaining the humidifier. However, observations over several days revealed that the CPAP mask was improperly stored in an unsanitary manner, and there was no documentation in the resident's medical record regarding the cleaning or maintenance of the CPAP equipment. Staff confirmed the lack of a system for the care of the resident's respiratory equipment. Similarly, Resident 48, also admitted with respiratory failure, had a physician's order for CPAP use and maintenance. Observations showed that the CPAP mask was not stored properly, and the resident reported that staff did not clean the mask or store it in a manner to keep it clean. Staff confirmed the unsanitary storage of the CPAP mask. These deficiencies indicate a failure to meet the respiratory needs of the residents, as there was no system in place to ensure the proper care and maintenance of the CPAP equipment.

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 trauma-informed care to a resident with a history of mental health illness and trauma related to the death of a child. The resident, who was cognitively intact, had previously reported nightmares about the incident. During a shower, a CNA offered to shave the resident's beard and trim their hair, to which the resident agreed. However, the CNA began shaving the resident's mustache, and despite the resident's request to stop, the mustache was shaved. This action upset the resident, as the mustache held sentimental value, reminding them of their deceased child who used to play with it. The facility's social service director acknowledged that the former social services staff did not complete an assessment to identify the resident's trauma triggers or determine how staff should monitor the resident for negative outcomes. The director was unsure why the staff did not recognize the resident's trauma related to the child's death, despite the resident reporting nightmares. This oversight placed the resident at risk for re-traumatization, as their specific emotional needs were not adequately addressed by 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 pharmaceutical services for three residents, leading to significant medication administration issues. Resident 198, who was admitted with a history of seizures, did not receive their prescribed antiseizure medication, lacosamide, from 10/11/24 to 10/21/24. The medication was consistently unavailable, and there was no documentation of follow-up with the pharmacy or physician to resolve the issue. This lack of medication placed Resident 198 at risk for seizures, as they reported feeling shaky and experiencing symptoms indicative of seizure activity. Resident 21, admitted with high blood pressure and lung disease, missed doses of Atorvastatin from 10/1/24 to 10/3/24 due to the medication being unavailable. There was no documentation indicating that the physician or pharmacy was notified about the missed doses. Similarly, Resident 78, who had respiratory failure, missed doses of dexamethasone and Advair inhaler due to unavailability, with no follow-up or notification to the physician or pharmacy documented. Additionally, the facility failed to ensure proper narcotic medication management. During a review of narcotic reconciliation records, it was found that many signature areas were left blank, indicating that staff did not consistently sign the narcotic reconciliation book at every shift change as required. This lack of adherence to protocol further highlights the facility's deficiencies in medication management and documentation.

Removal Plan

• Resident 198's provider was notified of the medication error of missed lacosamide dose, and symptoms the resident reported.
• Lacosaminde was initiated.
• A medication error incident rate report was completed and an investigation initiated.
• Resident 198 was placed on alert charting to monitor for effectiveness of lacosamide and resolution or symptoms reported by the resident.
• Other residents in the facility with orders for antiseizure medications were to be reviewed to validate their medication was available in the facility and being administered as ordered.
• Resident admitted to the facility were to be reviewed to validate that medications ordered were available in the facility and being administered as ordered.
• Findings of the above audits will be reviewed with the medical director and the facility consultant pharmacist to review for recommendations.
• Licensed nurses and CMAs were to be educated on requirements related to ensuring medications for new admissions were delivered and available for administration, and the steps to take were when a medication was not delivered or available, including steps related to medications that required a prescription for pharmacy dispensation.
• The facility admission process was updated to include a review of medications ordered by the hospital to identify any medications that required a prescription to be filled by the pharmacy. Admissions staff would communicate with the hospital to ensure that prescriptions were sent with the resident and/or sent directly to the pharmacy.
• Morning clinical review processes were updated to include a review of admissions from the prior day to ensure medications were available in the facility. Prescriptions noted as not yet on-hand would receive follow-up by nursing to include calling the pharmacy to inquire about the status of the medication, notification of the status to be communicated to the provider, appropriate documentation as evidence of the follow-up actions. Additionally a review of a report of medications not administered would occur to identify any medications not administered due to availability issues.
• Audits would be done to ensure prescription medications were available in the facility and administered as ordered. Audits results would be reported to QAPI Committee and ongoing as indicated.

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 monitor a resident on a psychotropic medication, specifically trazodone, which was prescribed for insomnia. Resident 85, who was admitted with diagnoses of dementia and depression, was noted to be severely cognitively impaired and had a history of multiple falls. Despite a physician's order to administer trazodone at bedtime, there was no documented indication for its use, nor was there any monitoring of the resident's sleep patterns. Staff interviews revealed that the resident was difficult to arouse in the morning, and it was acknowledged that there should have been a monitoring system in place, especially given the resident's fall history and the use of trazodone for sleep.

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 necessary dental services for a resident, identified as Resident 30, who was admitted with a diagnosis of diabetes and was cognitively intact. During an observation, it was noted that Resident 30 had a missing left upper tooth, and the resident reported that a family member, Witness 6, had noticed the broken tooth about a month prior. Witness 6 informed a CNA about the issue and later received a call from a dental office to set up an appointment for the resident. However, Witness 6 instructed the dental office to coordinate with the facility for the appointment and transportation, but did not receive any further communication from the facility regarding the dental appointment. Staff interviews revealed a lack of awareness and communication regarding the resident's dental needs. Staff 10, an LPN Unit Manager, stated he was not informed about the broken tooth, while Staff 50, an Agency CNA, mentioned that she did not pay much attention to missing teeth among residents. Additionally, Staff 27, the Social Service Director, who generally scheduled dental appointments, was unaware of the resident's need for a dental appointment. This lack of coordination and communication resulted in the resident not receiving timely dental care, placing them at risk for dental pain.

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 modified textured diets as ordered for a resident, placing them at risk for medical complications and aspiration. Resident 8, who was admitted with diagnoses including stroke and intestinal obstruction, required an Easy to Chew diet texture. However, during a lunch observation, the resident received one-inch cubed pieces of cooked pork without gravy, contrary to the prescribed minced pork with brown gravy. The Dietary Manager and Dietary District Manager confirmed that minced pork was not available for service. Additionally, a Speech-Language Pathologist observed multiple residents not receiving the correct modified textured diets, including a dessert that posed a choking hazard due to its size. This indicates a lack of understanding among dietary staff regarding modified texture diets.

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 assistive devices for a resident with a nutritional problem who required assistance with food and fluids. The resident, admitted with diagnoses including anxiety and catatonic schizophrenia, was care planned to receive a non-weighted built-up spoon with each meal. However, observations revealed that the resident was eating with their hands during breakfast and was provided with a regular spoon instead of the specialized one during another meal. A CNA confirmed that they did not have access to the resident's specialized equipment, and the kitchen did not provide the required non-weighted built-up spoon. The Regional Director of Therapy Operations confirmed that the staff should have provided the specialized spoon as per the care plan.

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 accommodate the needs of a resident, identified as Resident 242, who was admitted with diagnoses including anxiety and dementia. The resident's care plan, revised in February 2024, indicated a self-care performance deficit and required occasional assistance with toileting. However, a complaint received in April 2024 revealed that the resident's bedside commode was not being emptied or cleaned, leading the resident to attempt the task independently. This issue was confirmed by a witness and further supported by staff interviews. Staff members, including a CNA and housekeeping staff, acknowledged that there was a recurring problem with CNAs not cleaning bedside commodes and toilet risers in a timely manner. The housekeeping staff reported instances where meal trays were delivered to residents while their bedside commodes remained uncleaned, resulting in unpleasant odors. The facility administrator stated that the expectation was for staff to clean the bedside commode during rounds or immediately after assisting a resident, but this was not consistently followed.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's right to be free from mental and physical abuse, as evidenced by an incident involving two residents. Resident 291, who was admitted with PTSD and respiratory failure, was involved in an altercation with Resident 53. Resident 53, who had a history of stroke and muscle weakness, approached Resident 291 outside and complained about cigarette smoke affecting their time in the activity room. Security footage showed Resident 53 placing a hand on Resident 291's shoulder and pushing them, although Resident 291 sustained no physical injuries. The incident was reported to the State Survey Agency, and the investigation concluded that abuse could not be ruled out. Resident 291 expressed feeling drastically upset and fearful of Resident 53 following the incident. Staff interviews revealed that Resident 291 was often outside due to being triggered by closed spaces and continued their normal activities post-incident, albeit with concerns about causing problems in the facility. The facility's failure to prevent this altercation placed residents at risk for abuse.

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 baseline care plans were developed for two residents, leading to a risk of unmet needs. Resident 24 was readmitted with a diagnosis of type 1 diabetes and a history of diabetic ketoacidosis, yet the baseline care plan did not include information on diabetes management, insulin orders, or symptoms to monitor for high and low blood sugar levels. Staff acknowledged the absence of a baseline care plan addressing these critical aspects of Resident 24's care. Resident 243 was admitted with altered mental status and a lower back fracture, with a history of recurrent falls. However, the baseline care plan did not address the resident's fall risk or include fall interventions. Staff confirmed that fall interventions were expected to be part of the baseline care plan but were not included.

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 necessary assistance with activities of daily living (ADLs) for two residents, leading to unmet needs. Resident 31, who was admitted with diagnoses including stroke and dementia, required substantial to maximal assistance with toileting due to severe cognitive impairment and frequent incontinence. Despite a care plan that included frequent checks and assistance with toileting, documentation revealed multiple instances where Resident 31 was left incontinent, and a public complaint confirmed that staff ignored the resident's request for assistance, resulting in an incontinence episode. Staff interviews corroborated that Resident 31 was sometimes left unattended due to other tasks. Resident 240, admitted with diagnoses including stroke and anxiety, required extensive assistance with self-care and was scheduled for bathing twice a week. However, documentation showed significant gaps in bathing care, with multiple instances of missed or refused showers without proper follow-up or documentation. A public complaint alleged that staff denied Resident 240 showers, and staff interviews confirmed that some CNAs did not assist residents they disliked. The DNS stated that refusals should be documented after multiple attempts and nurse verification, but no additional information was found in Resident 240's records.

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 accurately assess, care plan, implement, follow, and maintain pressure ulcer treatments and care plans for a resident who was admitted with a Stage 2 pressure ulcer on the coccyx. The resident, who had diagnoses including kidney failure and was at risk for pressure ulcers due to incontinence and decreased mobility, was admitted with a Stage 2 pressure ulcer. However, the facility did not document the location of the wound in the initial Skin and Wound Evaluation, and the wound was later found to have slough, indicating it had become an unstageable pressure ulcer. The facility also failed to document new wounds and worsening conditions. A new open area on the resident's right buttocks was noted, but no Skin and Wound Evaluation or incident report was documented. The resident's condition worsened, with the wound becoming open, dark red, moist, and surrounded by purple bruising, yet there was no documentation or notification to the physician. Staff acknowledged that the treatments were ineffective, documentation was lacking, and the physician was not informed of the worsening condition, which contributed to the development of an avoidable unstageable pressure ulcer.

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 complete annual performance reviews for a Certified Nursing Assistant (CNA), identified as Staff 35, who was hired on May 22, 2022. This deficiency was identified during a review of the most recent performance reviews for CNA staff, where no documentation was provided for Staff 35. On October 29, 2024, the Administrator, identified as Staff 1, confirmed the absence of a performance review for Staff 35.

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 post accurate and complete staffing information, as required, which placed residents at risk for incomplete and inaccurate staffing information. Observations of the Direct Care Staff Daily Reports (DCSDR) from October 21, 2024, through October 25, 2024, revealed several deficiencies. On October 21, 2024, at 11:52 AM, no census was documented for the day shift. On October 22, 2024, at 6:51 AM, the DCSDR for that day was not posted, and similarly, on October 23, 2024, at 8:09 AM, the DCSDR was not posted. On October 25, 2024, at 10:31 AM, no census was documented for the day shift. Additionally, a review of the DCSDR from October 1, 2024, through October 20, 2024, showed no census was documented on the evening and night shifts.