Riverstreet Manor

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 dietary department, including the main kitchen and the Station 2 pantry, was observed to be maintained in unsanitary conditions during a tour with the facility's Certified Dietary Manager. The bottom shelves of multiple metal food preparation tables had liquid stains and food debris, and several silver banquet trays stored on those shelves had dried food residue and standing water. Multiple coffee cups identified as clean had a white film and brown staining, and multiple cereal bowls contained dried food debris. The kitchen floor perimeter had a sticky black substance with food, paper, and plastic debris, and there was a large accumulation of sticky black and brown substance behind the steamer unit and in the floor drain beneath it. The floor beneath the kitchen ice machine also had food debris, paper and plastic waste, and a sticky black and brown substance around the drain. The ice machine drainpipe discharged directly into the floor drain without an air gap, and the drainpipe had a thick accumulation of dark residue extending from the pipe to the machine. The Station 2 pantry was also observed to have unsanitary conditions, including an ice machine drainpipe that discharged directly into the floor drain with no visible air gap. During tray line observation, a cook served portion-controlled lunch items using gloved hands instead of portion-controlled utensils, handling chicken tenders and tater tots directly with gloved hands. The same employee then turned away from the serving line, handled a plate from a cart, placed it onto a meal tray, and resumed serving food with the same gloves without performing hand hygiene or changing gloves, and this was observed for multiple residents. The Certified Dietary Manager stated that dietary staff are expected to use appropriate serving utensils to portion and serve food items from the tray line, and the Nursing Home Administrator acknowledged that the dietary department is required to be maintained in a clean and sanitary condition.

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 residents were consistently offered a nutritious evening snack when more than 14 hours elapsed between the substantial evening meal and breakfast the following day, affecting 5 of 5 residents reviewed who expressed a desire for a bedtime snack (Residents 10, 53, 9, 65, and 105). Scheduled mealtimes showed dinner was served between 4:40 PM and 5:15 PM and breakfast between 7:35 AM and 8:15 AM, creating overnight intervals of 14 hours 55 minutes to 15 hours across Pine, Oak, Willow, and Spruce Halls. Food Committee meeting minutes documented ongoing resident concerns that snacks were not always being passed, then still were not consistently passed, and later that snacks were being delivered to the units and placed in the pantry but were not being offered to residents. During a resident council meeting, all 5 residents interviewed reported they were not offered a snack in the evening and did not receive a snack before bedtime. The Nursing Home Administrator was unable to provide documentation showing that evening snacks were consistently offered to 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 required quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings were conducted and failed to ensure the Medical Director or a physician designated by the Medical Director attended the required quarterly QAPI meetings for two of four quarters reviewed, specifically Quarters 3 and 4 of 2025. Facility documentation showed the QAPI policy, last reviewed May 1, 2025, described a comprehensive, ongoing program to review data and care practices, but it did not specify required participation by the Medical Director or a designated physician and did not outline expectations for attendance or accountability at quarterly QAPI meetings. A review of available QAPI committee meeting sign-in sheets and supporting documentation showed the facility could not provide evidence that required quarterly QAPI committee meetings were held during August 2025 through December 2025. The facility also could not provide documentation that the Medical Director or a designated physician representative attended QAPI meetings during July 2025 through December 2025. During an interview on April 17, 2026, the DON and NHA acknowledged the facility was unable to provide documentation supporting the required quarterly meetings and acknowledged that the Medical Director or designated physician representative had not attended the identified QAPI meetings.

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 duration and clinical rationale for a PRN psychotropic medication order and failed to document non-pharmacological interventions before administration for one resident. The resident was admitted with metabolic encephalopathy and had an admission MDS showing severe cognitive impairment with a BIMS score of 6. The clinical record showed a physician order for lorazepam 0.5 mL orally every 6 hours as needed for terminal agitation, but the record did not indicate that the resident was receiving hospice services. The eMAR showed lorazepam was administered on three occasions, including after the 14-day limit for PRN psychotropic medication orders. The February 13, 2026 order did not include documentation of a clinical rationale or a specified duration to support continued PRN use beyond 14 days, and the medication remained active and was administered beyond that limit without the required prescriber documentation. The eMAR and supporting documentation also did not show that non-pharmacological interventions were attempted before administration on the documented dates, and documentation from February 13, 2026 did not indicate the presence of agitation at the time the medication was given. The DON confirmed the record did not contain documentation specifying the duration or clinical rationale for continuation beyond 14 days.

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 an individualized baseline care plan that addressed a resident’s immediate needs and documented treatment preferences within 48 hours of admission. Resident 56 was admitted with metabolic encephalopathy and had severe cognitive impairment, with a BIMS score of 6 on the admission MDS. The resident also had a POLST signed on February 11, 2026, indicating Do Not Attempt Resuscitation and Comfort Measures Only, with instructions to remain in the facility and not be transferred to the hospital unless comfort needs could not be met. The baseline care plan initiated on February 11, 2026, stated that the resident’s advance directives would be followed and that the resident wished to allow a natural death and did not want resuscitation, but it did not include specific, person-centered details about remaining in the facility, avoiding hospital transfer when possible, or interventions to provide comfort such as symptom management or relief of pain and suffering. The clinical record later documented a change in condition with altered responsiveness, inability to follow commands, and facial drooping, and the physician assistant and family were present when the decision was made to continue comfort-focused care in the facility. During interview, the DON confirmed the baseline care plan did not include individualized interventions addressing the resident’s treatment preferences and immediate comfort care needs, and also confirmed the facility did not have a policy addressing comfort 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 provide adequate supervision to prevent Resident 28 from exiting the building without authorization. Resident 28 was admitted with diagnoses including localization-related symptomatic epilepsy and essential thrombocythemia, and a quarterly MDS dated March 6, 2026, showed a BIMS score of 13, indicating intact cognition. The elopement risk assessment did not identify the resident as being at risk for elopement, and the care plan did not address elopement risk or include interventions related to supervision for leaving the facility. Nursing documentation indicated the resident was independently mobile with the use of a rollator walker. On April 14, 2026, at about 7:00 PM, the resident approached the front desk and asked to leave the facility. The receptionist asked whether he was a resident, and he said he was not, so she allowed him to exit. The resident later stated he intentionally gave incorrect information so he could go outside and reported walking toward the corner of the property before a nurse found him and returned him to the building. The receptionist later observed him stumbling and notified the nursing supervisor, who initiated a Code Green at 7:05 PM. An LPN responded, found the resident walking on the sidewalk near the side of the facility closest to the cemetery, and escorted him back inside at about 7:10 PM. The clinical record contained no documentation of the exit event and no evidence that the physician or responsible party was notified.

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

Failure to provide enough food and fluids to maintain a resident's health occurred when the facility did not monitor and manage hydration status for a resident with a physician-ordered 1500 mL daily fluid restriction. Resident 39 was admitted with Parkinsonism and hypertensive heart and chronic kidney disease with heart failure, and the quarterly MDS showed a BIMS score of 9, indicating moderate cognitive impairment. The resident had a care plan identifying fluid restriction related to fluid overload, along with a history of noncompliance and weight loss and gain. The facility policy required clinical nutrition staff to coordinate with nursing for a 24-hour distribution of the daily fluid allowance, review fluid preferences with the resident, and monitor adherence to the restriction. The clinical record showed a physician order for 1500 mL of fluids per day, including 900 mL with meals and 600 mL during nursing care and medication administration. A nutrition evaluation documented the fluid restriction, but the record did not include evidence of resident education, review of fluid preferences, or monitoring of adherence as required by policy. Documentation of intake showed the resident exceeded the ordered limit on multiple occasions, including 1560 mL, 1920 mL, 1680 mL, and 1660 mL on separate days. During interview, the resident stated being unaware of the fluid restriction and not recalling involvement in care planning, and the DON and NHA confirmed the facility failed to monitor adherence and failed to involve the resident in the plan 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 follow its medication labeling and storage policy for multi-dose injectable medications in two medication rooms. The facility policy, last reviewed on May 1, 2025, required that once a multi-dose vial is opened or accessed, it be dated and discarded within 28 days unless the manufacturer specifies a different timeframe. During observation of the Station 2 Medication Room on April 15, 2026, at 8:53 AM, a multi-dose vial of Tuberculin Purified Protein Derivative, Diluted Aplisol, was found in the medication refrigerator opened and available for use, but not dated when initially opened. An LPN confirmed at 8:54 AM that the vial had been opened and was not dated when opened. During observation of the Station 1 Medication Room on April 15, 2026, at 9:02 AM, two multi-dose vials of Tuberculin Purified Protein Derivative, Diluted Aplisol were found in the medication refrigerator opened and available for use, but not dated when initially opened. The ADON confirmed at 9:04 AM that both vials were open and not dated when opened. Manufacturer safety information reviewed by surveyors stated that the multi-dose vials of Tuberculin Purified Protein Derivative, Diluted Aplisol should be discarded within 30 days of opening. The DON was interviewed later that day regarding the facility’s failure to adhere to acceptable storage and use-by dates for multi-dose 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 make prompt and adequate efforts to resolve a resident grievance in accordance with its own grievance policy. The policy required that grievances be resolved within five working days and that routine follow-up on outstanding concerns be completed through daily meetings. A resident, admitted with diagnoses including frequent falls and chronic pain syndrome, filed a grievance stating that prescribed oxycodone was not administered upon admission. The grievance was assigned to the DON and Unit Manager for follow-up, but documentation showed that the medication was not given until the following day, and the resident did not receive timely evaluation or resolution of the grievance. Further review revealed that social services met with the resident three days after the grievance was filed, but the grievance was closed with the notation that the resident was discharged prior to resolution. The resident remained in the facility for eight days after filing the grievance, exceeding the policy's five-day resolution timeframe. There was no documented evidence of attempts to resolve the grievance within the required timeframe, nor was there documentation of corrective action, findings, or communication of a resolution to the resident prior to discharge. Interviews with the NHA confirmed that no further action was taken to resolve the grievance.

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 by not completing an accurate medication reconciliation upon admission. Despite having an updated medication list from the referring facility dated November 3, 2025, staff used an outdated list from May 22, 2024, during the reconciliation process. This resulted in the resident being prescribed and administered multiple medications that had previously been discontinued, including methimazole, simvastatin, and lisinopril. The resident had a medical history that included hypertension, hypothyroidism, and other chronic conditions. Upon admission, the resident was placed on methimazole for hyperthyroidism and lisinopril for hypertension, despite the current medication list indicating treatment with levothyroxine for hypothyroidism and losartan for blood pressure control. The referring facility's documentation confirmed that methimazole, simvastatin, and lisinopril had been discontinued due to an episode of hyperkalemia. Following the administration of these discontinued medications, the resident experienced another episode of hyperkalemia, as evidenced by elevated potassium levels in laboratory results. The facility's failure to follow its own medication reconciliation policy, which required resolving discrepancies and using the most current medication information, directly led to the resident receiving inappropriate medications and experiencing a significant medication error.

Penalty

Fine: $12,735

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, who was severely cognitively impaired and dependent on staff for bed mobility, was not provided care according to their established plan. The resident's care plan and facility policy required two staff members to assist with bed mobility due to the resident's physical limitations, including hemiplegia and a history of falls. Despite this, a nurse aide provided incontinence care alone, rolling the resident onto their side without assistance. During the care episode, the nurse aide turned away to retrieve a clean brief while maintaining only one hand on the resident. The resident continued to roll toward the edge of the bed, and the aide was unable to prevent the resident from falling. The resident fell from the bed, striking their head on an oxygen concentrator and sustaining a laceration, multiple subdural hematomas, and a closed nasal fracture. The incident was witnessed by another staff member who responded to the aide's call for help and found the resident on the floor with facial bleeding. Facility documentation and staff interviews confirmed that the nurse aide was aware of the requirement for two-person assistance but failed to follow the resident's care plan. The facility's internal investigation substantiated neglect due to the failure to provide care as planned, resulting in actual physical harm to the resident. The resident required hospital evaluation and treatment for the injuries sustained during the incident.

Penalty

Fine: $12,735

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

Surveyors observed that the facility failed to maintain a clean and sanitary environment in both resident shower areas and the outdoor smoking area. In the Area 145 shower/bathroom, multiple items were inappropriately stored within resident bathing areas, including shower chair buckets, a mechanical lift sling, sneakers, and an open plastic bag of briefs inside the bathtub. The bathtub's waterspout had a thick layer of dried white residue, and the first shower stall's floor perimeter was coated with a black, sticky substance and visible soil. The stainless-steel soap dispenser was streaked and discolored, and the ceiling vent and air conditioning/heating unit were layered with lint and dust. The second shower stall's shower bed had a white powdery film and dried residue. In Area 158, similar black, sticky buildup was found on the floor perimeter, a large rust stain was visible beneath the handrails, and the ceiling vent had significant lint accumulation. The shower chair was stained, the wheelchair scale had visible buildup and liquid residue, and the mechanical lift showed dried deposits and staining. The bathtub contained wheelchair leg rests, and the floors had visible debris and adhesive-like residue. The outdoor smoking area near the laundry entrance was also found to be unclean, with extensive cigarette litter, ashes, and cigarette butts scattered across the concrete. The patio furniture, including three white plastic chairs and a table, was coated with black residue and cigarette debris. Four fabric chairs were worn, soiled, and had several burn holes. During an interview, the Nursing Home Administrator acknowledged that all facility areas are expected to be maintained in a clean and sanitary condition at all times.

Penalty

Fine: $12,735

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

Summary

The facility failed to implement its established smoking policy to ensure resident safety. Surveyors observed that the smoking policy was not posted in a conspicuous and legible manner in any resident area or common space, contrary to facility requirements. Additionally, the designated smoking area lacked required safety equipment, and residents were found to possess and use smoking materials independently, without staff supervision, and without adherence to the policy's storage and supervision requirements. Multiple residents, all identified as independent smokers with diagnoses such as COPD, emphysema, hypertension, and chronic respiratory failure, were observed smoking in the designated area without staff present. These residents had access to their own cigarettes and lighters, which they kept in their rooms or on their person, despite care plans and facility policy requiring these materials to be secured at the reception desk. Some residents also knew the door code to the smoking area and accessed it independently, further bypassing the intended supervision and control measures. Interviews with the DON and NHA confirmed that the facility's actual practices did not align with the written smoking policy. Smoking materials were not consistently secured by staff, and the smoking policy was only posted outside the smoking-area exit door, not in other required locations. The facility's failure to follow its own policy was evident in both staff and resident interviews, as well as direct observations by surveyors.

Penalty

Fine: $12,735

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 food delivery equipment in a clean and sanitary condition, as observed during meal service on four separate hallways (Pine, Oak, Willow, and Spruce). Surveyors found that the stainless-steel food delivery carts in each hallway had significant accumulations of dried food, liquid residue, paper debris, and visible dirt on both exterior and interior surfaces. In one instance, a metal shelving unit inside a cart was broken, with detached metal brackets resting inside the cart. These conditions were directly observed by surveyors at various times during meal service. According to established standards by the USDA and FDA, all equipment and utensils used in food storage, preparation, and delivery must be kept clean and in good repair, requiring a two-step process of cleaning and sanitizing. The observations made indicate that these procedures were not followed, resulting in unsanitary conditions of the food delivery carts. The findings were reviewed with the Nursing Home Administrator during an interview on the same day.

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 and implement individualized pain management programs consistent with professional standards of practice for two residents. Clinical record reviews showed that both residents, who had diagnoses including Parkinson's Disease, chronic pain, and osteoarthritis, had physician orders for as-needed narcotic pain medications that required non-pharmacological interventions to be attempted prior to administration. However, medication administration records revealed that staff administered these pain medications multiple times without first attempting or documenting any non-pharmacological interventions, as required by the physician orders and facility policy. Additionally, there was an instance where pain medication was administered to a resident despite a pain score of zero, which was outside the parameters of the physician's order. Interviews with the Director of Nursing confirmed that the facility could not provide documentation supporting the use of non-pharmacological interventions prior to medication administration for the residents in question. These findings indicate a failure to follow both facility policy and physician orders regarding pain management.

Penalty

No penalty information released

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

Summary

The facility failed to consistently provide snacks to residents in accordance with their needs, preferences, and requests, as required by facility policy. A review of the facility's snack policy indicated that snacks and beverages should be provided as identified in residents' care plans, with bedtime snacks available for all residents and additional snacks upon request. However, during a group interview, all seven residents present reported that snacks were not routinely offered in the evenings, and they expressed a desire to receive evening or bedtime snacks. Some residents noted that, previously, kitchen staff would offer snacks in the evening, but currently, the snack cart is delivered to the nurses' station, and nursing aides are responsible for distribution. Residents reported that aides often do not have time to deliver snacks, requiring residents to go to the nurses' station if they want a snack. Additionally, one resident expressed dissatisfaction with the limited quantity of snacks provided, stating that only one small snack was allowed, which was sometimes insufficient. The Nursing Home Administrator was interviewed and could not explain why residents were not consistently offered snacks as desired, though acknowledged awareness of the issue and affirmed that residents should be provided a snack at bedtime. These findings were reviewed with the Nursing Home Administrator, confirming that the facility was not adhering to its own policy regarding the provision of snacks and beverages to 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 implement enhanced barrier infection control procedures and ensure the proper use of personal protective equipment (PPE) for one resident with chronic kidney disease and peripheral vascular disease, who had a sacral wound requiring enhanced barrier precautions. Despite a physician's order for these precautions, staff were observed using hospital gowns instead of the designated reusable gowns intended for this purpose. The facility policy required the use of specific gowns and gloves during high-contact care activities, but this was not followed during care provided after the resident experienced a fall. Further investigation revealed that staff had not received adequate education regarding the correct selection and use of PPE, specifically the designated color of gowns for enhanced barrier precautions. The Director of Nursing confirmed that reusable gowns were to be used, and that the use of hospital gowns was not appropriate. Additionally, the facility lacked a system for laundering, maintaining, and storing the reusable gowns as required by CDC recommendations. These failures resulted in the ineffective implementation of enhanced barrier precautions 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 consistently provide necessary care and services to residents dependent on staff for activities of daily living (ADLs), specifically in the areas of personal hygiene and incontinence care. One resident with Parkinson's Disease and muscle weakness, who was cognitively intact and required substantial assistance for bathing, reported that scheduled showers were frequently missed, sometimes for up to three weeks. Documentation confirmed multiple instances where showers were not provided or not documented as completed, with no supporting evidence of a medical reason for omission. The facility's records and staff interviews corroborated these inconsistencies, and the Nursing Home Administrator was unable to explain the lapses in care or documentation. Another resident with paralytic syndrome, hydrocephalus, and muscle weakness, who was always incontinent of urine and bowel, was care planned to receive regular toileting assistance and incontinence checks. However, the resident reported extended periods in soiled briefs, including an incident where requests for a change after dinner were not addressed until the following morning. Review of electronic care records showed gaps and inconsistencies in documentation of incontinence care, with missing entries and lack of evidence that the resident's individualized needs were met as outlined in the care plan. The Director of Nursing confirmed that the resident should have been on a two-hour check and change program, but the facility could not provide documentation to support that this was consistently implemented. These findings were based on clinical record reviews, resident and staff interviews, and facility documentation, demonstrating that the facility did not ensure residents dependent on staff for ADLs consistently received the necessary care and services to maintain personal hygiene and dignity.

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

Licensed nursing staff failed to adhere to professional standards and facility policy during medication administration for four residents. Observations revealed that the nurse did not perform hand hygiene between residents, wore elongated acrylic nails, and did not use gloves while preparing medications. The nurse used bare hands and nails during medication preparation, dropped pills onto the medication cart and then placed them into a medication cup without proper sanitation, and prepared medications for two residents in the same room simultaneously, labeling the cups only with bed numbers. This led to a situation where the wrong medication cup was handed to a resident, who questioned the contents, prompting the nurse to exchange the cups without verifying the resident's identity or medication details. Additionally, the nurse left a cup containing a narcotic medication unattended on top of the medication cart and left the cart unlocked while leaving the area on two occasions, contrary to facility policy. These actions were confirmed by the Director of Nursing as not meeting the facility's expectations for medication administration and infection control, as outlined in both state regulations and facility 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

Facility staff failed to follow physician orders for a prescribed bowel protocol for a resident with a history of congestive heart failure, chronic obstructive pulmonary disease, and Type 2 diabetes. The physician's orders specified a stepwise bowel regimen involving Milk of Magnesia, Dulcolax suppository, and Fleet Enema, to be administered if the resident did not have a bowel movement within specified timeframes, with documentation of effectiveness and notification of the physician if the protocol was ineffective. Despite these orders, the resident went four consecutive days without a bowel movement, and there was no documented evidence that the prescribed bowel protocol was administered during this period. The resident reported frequent constipation and described a recent episode of significant straining that resulted in hemorrhoids and rectal bleeding. Review of the Medication Administration Record confirmed that nursing staff did not implement the bowel protocol as ordered. The Director of Nursing acknowledged that staff failed to carry out the physician's orders. Additionally, the facility was unable to provide a written policy regarding bowel elimination management.

Penalty

No penalty information released

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

Summary

The facility failed to provide colostomy care and services consistent with professional standards of practice for one resident. The facility's policy required that residents needing colostomy services receive care that prevents skin exposure to fecal matter. The resident in question had a history of peritoneal abscess, end-stage renal failure, dependence on dialysis, and a colostomy. A physician's order was in place for the colostomy appliance to be changed every three days and as needed. However, the resident's care plan did not address the specific needs related to the colostomy, such as the type and size of the appliance or collection bag required for maintenance. The resident reported not having a colostomy appliance or bag in place for weeks and stated that requests for an appliance before dialysis were not fulfilled. Instead, the resident was sent to dialysis wearing only an adult brief, allowing the colostomy to drain directly into it. Interviews with facility staff indicated that the resident frequently refused colostomy care, but there was no documentation in the clinical record to support this claim. The deficiency was identified through a review of clinical records, facility policy, and interviews with the resident and staff.

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 and implement an individualized, person-centered care plan to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted with diagnoses including major depressive disorder, anxiety, malignant neoplasm of the lung, and PTSD, did not have their PTSD triggers or specific interventions identified in their current care plan as of the review date. This omission meant that the resident's needs for minimizing triggers and preventing re-traumatization were not addressed according to professional standards of practice. An interview with the Nursing Home Administrator confirmed that the facility could not demonstrate the provision of culturally competent, trauma-informed care that accounted for the resident's experiences and preferences.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a physician signed medication orders in a timely manner, resulting in missed doses of a prescribed medication for one resident. The resident, who was admitted with diagnoses including polyneuropathy and congestive heart failure, was prescribed Pregabalin to manage neuropathic pain. The original prescription included 45 capsules with no authorized refills. When the medication supply ran out, staff contacted the physician's office multiple times to obtain a new signed order, as required for continued therapy. Despite assurances, the physician did not come to the facility to sign the order as expected. As a result of the delay in obtaining the physician's signature, the resident missed eight scheduled doses of Pregabalin over a three-day period. The delay persisted until a unit manager personally delivered the unsigned prescription to the physician's office and obtained the necessary signature. The facility's failure to secure timely physician authorization directly led to interruptions in the resident's 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

A resident with a history of congestive heart failure, chronic obstructive pulmonary disease, and Type 2 diabetes reported ongoing constipation and developed hemorrhoids with rectal bleeding. The resident stated that staff repeatedly indicated they would provide treatment, such as suppositories or cream, but no intervention was provided, resulting in continued discomfort and burning. Nursing documentation confirmed the presence of hemorrhoids and rectal bleeding. A physician ordered topical hydrocortisone cream (Preparation H) to be applied twice daily for the resident's hemorrhoids. However, the medication was not administered as prescribed on multiple occasions due to a delay in pharmacy delivery, as the cream was not a stock item at the facility. The DON confirmed the medication was unavailable during this period, resulting in the resident not receiving timely pharmaceutical services 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

Nursing staff failed to properly label and store multi-dose insulin pens in accordance with professional standards and manufacturer instructions. During an observation of a medication cart on the Pine Hall unit, one multi-dose insulin pen of Insulin Lispro and three multi-dose insulin pens of Insulin Glargine were found to be opened and in use without being labeled with the date they were initially opened. Additionally, one Insulin Glargine pen was labeled with an opening date of April 16, 2025, but was still available for use beyond the manufacturer-recommended discard date of 28 days after opening. Interviews with a registered nurse and the Nursing Home Administrator confirmed that the insulin pens were being used without proper labeling and that one pen was used past its recommended discard date. Facility policy requires multi-use medication vials and bottles to be labeled accordingly and for nursing staff to maintain proper medication storage, including labeling. These findings were in violation of both facility policy and state regulations regarding pharmacy and 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 maintain the electrical system properly in one location, specifically affecting the first floor. During an observation on January 30, 2025, at 9:45 a.m., it was noted that in Station 1, Resident Room 19, an outlet receptacle was not secured into the wall. This created a gap that exposed the wiring inside the room, near bed 19W. This deficiency was confirmed during an exit interview with the Facility Administrator and Facility Representative #1 at 10:00 a.m. on the same day.

Plan Of Correction

- The outlet receptacle in Room 19 was secured into the wall. - Outlet receptacles in the facility are being checked to ensure they are secured into the wall. - NHA/Designee will re-inservice Maintenance Staff on ensuring outlet receptacles are secured to the wall, and current staff will also be in-serviced to ensure they are reporting any issues with same immediately. - Maintenance Director/Designee will complete an audit on random outlet receptacles weekly for 4 weeks and then monthly to ensure they are secured into the wall. - Results of the audits will be discussed at the monthly Quality Assurance Performance Improvement Meeting for review and/or recommendations.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely responses to residents' requests for assistance, negatively impacting their quality of life. Resident 97, who has moderate cognitive impairment, reported waiting 20 minutes for ice water during breakfast. Similarly, Resident 159, who is cognitively intact, experienced a 20-minute wait for assistance, with staff attributing the delay to being busy. Concerns about staffing and call bell response times were consistently raised in Resident Council meetings from June to August 2024. Residents expressed dissatisfaction with the time it took for staff to respond to their needs, particularly during the evening and night shifts. During a group interview, several residents reported waiting times ranging from 30 minutes to several hours, with some residents feeling neglected and frustrated due to the lack of timely care. The Nursing Home Administrator and Director of Nursing acknowledged that all residents should be treated with dignity and respect but could not explain the delays in staff responses. The ongoing staffing issues and long wait times for care were highlighted as significant problems affecting the residents' quality of life, as documented in the clinical records and resident interviews.

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 comprehensive care plans were developed and revised with the participation of residents and their representatives. This deficiency was identified for two residents out of 27 sampled and five out of seven residents during a resident council interview. The facility's policy requires that residents be informed of their right to participate in care planning and be provided advance notice of care planning conferences. However, the facility did not adhere to this policy, as evidenced by the lack of documentation showing resident participation or invitations to participate in care planning. Resident 62, who is cognitively intact with a BIMS score of 15, reported not participating in any care plan meetings and could not recall being invited to such meetings. Similarly, clinical record reviews for Residents 38, 49, 53, 79, 91, and 94 revealed no evidence of their participation or invitation to participate in the development of their person-centered care plans. During interviews, these residents confirmed they had not been invited to participate in care conference meetings. Interviews with facility staff, including the Social Services Director, Nursing Home Administrator (NHA), and Director of Nursing (DON), confirmed that care planning conferences were not occurring quarterly for each resident. The NHA and DON acknowledged the facility's responsibility to ensure resident participation in care planning but were unable to provide documented evidence of such participation for the affected residents. This lack of adherence to policy and failure to involve residents in their care planning process constitutes a deficiency in resident rights as per 28 Pa. Code 201.29(a).

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 acceptable practices for the storage and service of food, which increased the risk of food-borne illness in two resident pantries. Observations in Station 1 revealed that the interior of the microwave was soiled with dried-on food splatters, and the back interior was pitted and rust-colored. Additionally, a dustpan stored next to the counter was heavily soiled with dirt and debris. The ice machine's condensation hose was covered with a thick layer of a black mold-like substance, and it lacked an air gap, posing a risk of contamination. In Station 2, the freezer had food substance stains and debris scattered across the base, and a cabinet containing resident snacks had food debris on the shelving. The microwave was stained and discolored both inside and out. The ice machine's condensation hose was similarly covered with a black mold-like substance. These observations were confirmed by the nursing home administrator, who acknowledged that sanitary practices for food and ice storage should be maintained in the resident pantries.

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 notice to a resident and their representative before a room change, as required by federal regulatory guidelines. The guidelines emphasize the importance of considering a resident's preferences and providing a written explanation for room changes initiated by facility staff. In this case, Resident 62, who was cognitively intact and had a medical history of cerebral infarction with right side hemiparesis, was moved from one room to another on August 28, 2024. Although the resident verbally agreed to the move, there was no documented evidence that a written notice, including the reason for the room change, was provided to the resident or their representative. Interviews conducted with Resident 62 and the social services director confirmed the lack of written notice. The resident reported being informed of the room change only a few hours before it occurred and did not receive any written explanation. The social services director acknowledged the absence of documentation regarding the provision of written notice to the resident and their responsible party. This oversight constitutes a violation of the resident's rights as outlined in the federal regulatory guidelines and state code.

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 identify and document a resident's wishes regarding future health care and advance directives. The clinical record review, resident interview, and staff interview revealed that the facility did not have documented evidence of the resident's advance directive, despite the resident being cognitively intact and having expressed her wishes. The resident, who was admitted with a diagnosis of cerebral infarction and right side hemiparesis, had a POLST form indicating a desire for CPR, but it was not signed by the resident or a surrogate as required. During an interview, the resident stated she did not want CPR and denied having a Living Will, contradicting the POLST form. The facility also failed to provide evidence of periodic review of the resident's advance directive to ensure her wishes were honored. The director of nursing confirmed that the POLST form was not signed by the resident and did not accurately reflect her wishes, indicating a failure to uphold the resident's rights as per the relevant Pennsylvania codes.

Penalty

No penalty information released

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

Summary

The facility failed to timely and thoroughly investigate an incident involving a resident who sustained a fall with a minor injury. The resident, who was cognitively intact and required the assistance of two staff for bed mobility and transfers, was found on the floor with a small skin tear on her forehead. The incident occurred while a nurse aide was assisting the resident with a sit-to-stand lift, and only one staff member was present, contrary to the care plan that required two staff members for such transfers. The facility's investigation into the incident was inadequate. There was no documentation indicating that the facility determined whether the required two staff members were present during the transfer. Additionally, the facility did not obtain all necessary witness statements at the time of the incident, and the investigation did not thoroughly explore potential neglect or mistreatment as a cause of the fall. The facility's incident report and subsequent documentation failed to address these critical aspects, and the investigation was not conducted in a timely manner. The director of nursing later confirmed that the facility could not provide documented evidence of a full investigation to rule out potential neglect. The facility did not identify that planned interventions were not in place to ensure the resident's safety and prevent the fall. This lack of thorough investigation and failure to implement care-planned interventions 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 failed to provide nursing services consistent with professional standards of practice by not following physician orders for the consistent application of a prescribed neck positioning pillow for a resident. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage, lack of coordination, and muscle disorder, was observed multiple times without the neck positioning pillow while lying in bed. This was contrary to the physician's orders, which specified the use of the pillow to maintain the neck in a neutral position. Observations on two consecutive days revealed that the resident's neck was laterally flexed towards the left shoulder without the prescribed pillow. Interviews with staff, including an LPN and the DON, confirmed the absence of the neck pillow as ordered. The facility was unable to provide documentation to show compliance with the physician's orders, indicating a failure to ensure the resident's therapeutic device was in place 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 provide person-centered care and follow physician orders for the management of a midline catheter for a resident diagnosed with a urinary tract infection and Extended Spectrum Beta Lactamase Resistance. The resident had a midline catheter inserted in the left arm, with an initial external catheter length of 0 cm. However, subsequent measurements showed a significant change to 10 cm, but there was no documented evidence that the physician was notified of this change. Additionally, after the completion of the ordered antibiotic, the midline catheter was removed intact, but the resident was later readmitted and required a new midline catheter due to being a hard stick and pulling out IVs. The facility also failed to ensure the availability of prescribed emergency supplies for the resident's midline catheter. Despite a physician's order to maintain an emergency kit at the bedside, an observation revealed that no such kit was available in the resident's room. Interviews with nursing staff confirmed the absence of the emergency kit and the inaccuracy in the documentation of the external catheter length in the Medication Administration Record. These deficiencies highlight a lack of adherence to physician orders and inadequate preparation for emergency situations.

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 implement appropriate pain management interventions for a resident, identified as Resident 92, who experienced pain without relief. Resident 92 was admitted with diagnoses including dementia and aftercare following a fractured femur. The facility's policy on pain management required the identification of individuals at risk for pain and the establishment of goals for pain treatment. Despite this, there was no documented evidence that the facility provided pharmacological or non-pharmacological interventions for Resident 92's pain, even though she experienced mild pain on multiple occasions. Resident 92 was readmitted to the facility after undergoing surgical repair for a fractured femur, with instructions to manage pain using Acetaminophen. Observations and interviews revealed that Resident 92 experienced pain during physical and occupational therapy sessions, yet there was no documentation of pain management interventions being offered or administered. The resident was unable to articulate what interventions alleviated her pain, and staff failed to document any efforts to manage her pain effectively. The Director of Nursing confirmed the facility's responsibility to provide pain management but was unable to provide evidence that interventions were offered to Resident 92 from her readmission through the observed period. The lack of documented pain management interventions, despite the resident's reported pain, indicates a deficiency in the facility's adherence to its pain management 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 provide therapeutic social services to promote the mental and psychosocial well-being of a resident diagnosed with major depressive disorder and intermittent explosive disorder. The resident, admitted with a care plan indicating a risk for distressed mood symptoms related to anxiety, expressed a desire to die during a nursing interaction on April 9, 2024. Despite the nurse providing emotional support and notifying the physician, the resident's care plan was not updated to include interventions addressing this expression of suicidal ideation. Furthermore, there was no documentation in the resident's clinical record indicating that therapeutic social services were provided following the resident's statement. An interview with the Social Service Director revealed that there was no follow-up or conversation with the resident regarding his expressed desire to die. The Nursing Home Administrator confirmed the absence of documented evidence of therapeutic social services being provided to the resident after the incident.

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 implement procedures to ensure accurate accounting and administration of controlled medications for a resident. A review of the clinical record showed that the resident had a physician order for Oxycodone HCl 5 mg to be administered every 6 hours as needed for pain. However, the Controlled Drug Administration Record indicated that doses were signed out by nursing staff on several occasions, but the administration of the medication was not recorded on the resident's Medication Administration Record (MAR). This discrepancy was confirmed by the Director of Nursing during an interview. Additionally, the facility did not adhere to the physician's updated order for Oxycodone HCl 10 mg, as the resident continued to receive the 5 mg dose. The Nursing Home Administrator confirmed that the nursing staff failed to follow the facility's policy by not verifying the correct medication dosage and did not comply with the physician's orders for pain management. The facility's policy required medications to be administered according to prescriber orders, with checks to ensure the right resident, medication, dosage, time, and method of 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 the presence of documented clinical necessity for the use of an antipsychotic medication for a resident diagnosed with dementia. The resident, who was moderately cognitively impaired, was prescribed Seroquel, an antipsychotic medication, for agitation without corresponding physician documentation indicating the clinical need for its initiation. The medication was prescribed after discontinuing Buspar, an anti-anxiety medication, and the resident's medication administration record showed no signs of anxiety, insomnia, or socially inappropriate behaviors from June through early September. During an interview, the Director of Nursing confirmed the absence of documented evidence supporting the clinical rationale for the antipsychotic medication. The facility is responsible for ensuring that antipsychotic drugs are not administered to residents without a documented diagnosed condition. The deficiency was identified through clinical record review and staff interviews, highlighting the facility's failure to comply with regulations regarding unnecessary 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 provide emergency care consistent with a resident's advance directives, specifically failing to administer CPR to a resident who was designated as full code status. The resident, who had multiple diagnoses including cancer, diabetes, and heart disease, had a physician order indicating CPR should be performed in the event of cardiac or pulmonary arrest. However, when the resident was found unresponsive with no pulse or respirations, the facility staff did not initiate CPR as required by the physician's order and the resident's advance directive. The incident was confirmed through a review of clinical records, facility policy, and staff interviews. The resident was observed declining in a wheelchair and was transferred to bed, where he was pronounced dead by a Physician Assistant. Despite the clear directive to perform CPR, the nursing staff did not act according to the resident's wishes and the physician's order. This deficiency was acknowledged by the Director of Nursing and the Nursing Home Administrator during an interview.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an environment free of potential accident hazards and obstacles for safe mobility on one of its resident units, specifically Station 2. During an observation, it was noted that the hallway leading to the therapy department from the main entrance had four large reclining/wheelchairs lined up against the right-hand side of the wall. Additionally, the hallway in the resident care area had multiple high back chairs placed outside of resident rooms, causing congestion. These items obstructed access to the handrails, which are intended for resident ambulation or mobility assistance, and did not create a homelike environment. The Nursing Home Administrator acknowledged that resident care areas should be maintained in a clean and orderly 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 facility failed to ensure proper storage and labeling of medications on one of its nursing units, specifically Station 1. During an observation, it was found that a mauve wash basin labeled 'Return to Rx' contained 16 medication cards that needed to be returned to the pharmacy. These medications were not properly inventoried or documented for disposition, as required by the facility's policy. Additionally, medications prescribed for a resident who had been discharged remained in the medication room without a completed medication disposition form. Further observations revealed an unlocked drawer at the nurse's station containing a blue zipper pouch filled with various single-use vials of medications, none of which were labeled for any current resident. The drawer also contained medications prescribed for specific residents, but they were not stored properly. Employee 2, an LPN, confirmed the improper storage and stated that the registered nurse unit manager kept these medications on hand due to potential delivery delays and theft concerns. The Nursing Home Administrator and Director of Nursing confirmed that the medications were not stored or labeled according to policy.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate and complete clinical records for three residents, as identified during a review of clinical records, observations, and staff interviews. Specifically, the issue involved an LPN, who was also functioning as a unit secretary, documenting the completion of treatments for residents before the scheduled shift time and without being scheduled to work as an LPN on that day. For Resident 7, treatments such as checking the placement and function of safety alarms and dressings were signed out as completed before the shift began. Similarly, for Resident 11, treatments including the application of zinc oxide and checking dressings were documented as completed prematurely. Resident 14's records also showed treatments signed out before the shift, including skin prep applications and checking alarm placements. The nurse staffing schedule for the day in question did not show that the LPN was scheduled to work as an assigned nurse, raising concerns about the accuracy of the documentation. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the LPN was not scheduled to perform nursing duties on that date, and the treatments were signed out before the start of the shift. This discrepancy indicates a failure to adhere to professional standards for maintaining accurate and complete medical records, as required by the Pennsylvania Code and the American Nurses Association's principles for nursing documentation.

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 comply with the requirement to post daily nurse staffing information. During an observation on August 11, 2024, at approximately 8:15 AM, it was noted that the facility's current posted nursing hours were not visible. An interview with a registered nurse supervisor revealed that she was unaware of what posted nursing time was. Further confirmation from the facility's Assistant Director of Nursing indicated that the facility did not post the daily nurse staffing data as mandated by 28 Pa. Code 211.12 (d)(1)(3)(5) and 28 Pa. Code 201.18 (b)(1)(3).

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 care in a manner and environment that promotes each resident's quality of life by not responding timely to residents' requests for assistance. This was evidenced by complaints from six out of 15 interviewed residents who reported extended wait times for staff assistance, including untimely responses to the nurse call bell system. The residents expressed that these delays occurred daily and across all shifts, leading to situations where residents soiled themselves while waiting for assistance. Specific instances included residents waiting up to an hour for help, with some experiencing these delays multiple times a week or month, particularly during the evening and night shifts. Interviews with the residents revealed consistent concerns about the facility's staffing levels and the impact on their quality of life. The Nursing Home Administrator confirmed the expectation that all residents be treated with dignity and respect but was unable to explain the reported delays in staff response times. The deficiency was noted under the regulations 28 Pa. Code 201.18 (e)(1) Management, 28 Pa. Code 201.29 (a) Resident rights, and 28 Pa Code 211.12 (c)(d)(5) 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 consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for two residents. Resident 59, who was admitted with chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen, was observed multiple times with his oxygen tubing and nasal cannula lying on the floor. Despite being aware of the situation, an LPN picked up the tubing from the floor and placed it on the resident's lap without cleaning or replacing it, leading to the resident using unsanitary equipment. The resident's care plan indicated he was noncompliant with treatment, but the facility did not ensure proper oxygen administration or infection control procedures were followed. Additionally, the facility obtained a physician order for hourly monitoring of the resident's oxygen and wound vac compliance only after the surveyor's observations and interviews with staff. The facility also failed to monitor Resident 72's compliance with oxygen use and oxygen saturation levels. Resident 72, who had multiple diagnoses including COPD and congestive heart failure, was observed without her nasal cannula on multiple occasions, despite having a physician order for continuous oxygen. The resident stated that she removed her oxygen daily and that staff were aware, but the facility did not consistently monitor her oxygen use or saturation levels. An LPN confirmed that the resident's nasal cannula was not in use and that her oxygen saturation was low when measured. The facility did not ensure that the physician's order for supplemental oxygen was consistently followed for both residents, and the oxygen equipment was not maintained in a sanitary 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 facility failed to provide food that accommodates resident preferences, as observed in 26 resident meal trays and reported by nine residents out of 15 interviewed. The deficiency was identified through a review of Resident Council meeting minutes, facility grievances, and resident interviews. Specific complaints included a lack of variety in meals, hard rice, tough meat, burnt scrambled eggs, and missing condiments like butter. Residents also reported that their documented food preferences were not being honored, leading to dissatisfaction with the meals provided. During interviews, several residents expressed their dissatisfaction with the food quality, stating that it was often overcooked, bland, or salty. Some residents mentioned that additional items like butter and condiments were frequently missing from their meal trays. Observations during lunch confirmed that butter was missing from all observed meal trays, despite the facility having a sufficient supply in the kitchen. The Dietary Manager acknowledged that butter packets were only provided with certain food items and that residents would need to request them specifically. The Nursing Home Administrator confirmed that the facility failed to consider individual food preferences to increase resident satisfaction with meals. The deficiency was further supported by the facility's own documentation and resident feedback, indicating a systemic issue in accommodating resident dietary preferences and ensuring the quality of food served. The facility's failure to address these concerns led to widespread dissatisfaction among residents regarding their meals.