Silver Stream Rehabilitation And Nursing 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 conduct a complete and thorough investigation of an allegation of resident-to-resident sexual abuse involving one resident (R1) out of three reviewed. Facility policy titled “Abuse Investigating and Reporting” (revised 2016) required the Administrator to assign investigations appropriately and ensure prevention of further potential abuse, neglect, exploitation, or mistreatment when an incident or suspected incident is reported. R1 had diagnoses including dysphagia, aphasia, dementia, and cerebral infarction, and was documented as cognitively impaired on the January 2, 2026 MDS. Another resident, R2, had multiple diagnoses including diabetes, seizures, chronic kidney disease, schizoaffective disorder, and frontotemporal neurocognitive disorder, and was documented as awake, alert, and oriented on the February 19, 2026 MDS. On the date of the incident, documentation submitted to the State Survey Agency indicated that a resident (R3) reported that R1 was inappropriately touched in the dining room by R2. An incident report completed by a nurse (E3) stated that an activity worker (E4) reported R2 inappropriately touching R1 in the first-floor dining room and that both residents were immediately separated, with R1 taken back to her second-floor bedroom. E3 was not present for the incident and completed an incident report based on what she was told when she started her shift. E3 performed a full body assessment on R1 and found no bruises or injuries. A statement by activity staff (E4) documented that he witnessed R2 caressing R1’s inner thigh before removing him from the dining room, and a second undated statement from E4 indicated that R3 told him he had witnessed R2 assaulting R1 and that R1 was being groped. In an interview, E4 reported that R1 and R2 were seated near the back wall of the first-floor dining room, with two activity workers present and about 50 residents in the room. E4 stated that R3 called him and told him to remove R2 because R3 saw R2 touching R1 inappropriately, including feeling R1’s thighs and breast and putting his hands in her pants. E4 reported taking R2 to the nursing station and informing a nurse whose name he could not recall, then later observing R2 back in the activity room near R1 with his hand on her inner thigh close to her vagina, after which he again took R2 to the nursing station. A separate incident report by another nurse (E5) documented that R2 had been observed by another resident earlier, was placed at the nursing station for supervision, and later was seen kissing the same female resident (R1) in the same dining room. E5 stated she was told by the activity aide that R2 was witnessed touching and kissing R1 and that R2 returned to the dining room and was again involved in an incident of kissing R1. A nursing note by the 3–11 p.m. nursing supervisor (E6) documented that she was notified by a male staff member that R2 was seen inappropriately touching R1 and that R2 was placed on 1:1 supervision, with the physician notified and an order obtained to send R2 to the emergency room for evaluation. In an interview, E6 reported she was completing an admission when notified that R2 was observed touching R1’s breast area and that, by the time she left her office, the residents had already been separated and R2 placed on 1:1 supervision. The facility’s investigation ultimately unsubstantiated the allegation of resident-to-resident abuse for inappropriate touching, noting that E4 reported seeing R2 caressing R1’s inner thigh while she was wearing blue pants and that he was touching the outside of the pants. Surveyor review of the investigation found that it lacked key elements required for a complete and thorough inquiry. The investigation did not include any statements from residents who were present in the dining room during the alleged incidents. There was no dated, signed interview statement from R3, who initially reported the inappropriate touching. The investigation also did not contain any statement from the second activity worker (E7) who was present in the dining room and giving out snacks at the time of the events, nor any witness statement from R2 regarding the various accounts of his behavior. During interviews with the DON, the Nursing Home Administrator, and the Regional NHA, it was acknowledged that there were no resident witness statements from those present in the dining room, no statement from R3, and no statement from E7 about what he may or may not have witnessed. This incomplete documentation and failure to obtain and include all relevant witness accounts formed the basis of the cited deficiency for failure to conduct a complete and thorough abuse investigation.

Plan Of Correction

Plan of Correction: The facility immediately assessed Resident R1 with no injuries noted. Resident R2 was immediately separated, placed on 1:1 supervision, sent to the hospital for evaluation, and remained on 1:1 supervision until cleared by psychiatry. The provider and responsible party were notified and the incident was reported to the Department of Health. The facility conducted an investigation and interviewed all available witnesses during the investigation. All residents have the potential to be affected by this deficient practice. An abuse and neglect checklist tool will be implemented to ensure all allegations are thoroughly investigated, including obtaining statements from all available witnesses. Education will be provided to staff on abuse/neglect reporting and investigation requirements, including immediate protection of residents and obtaining required witness statements. Administrator or designee will review all abuse investigations for completeness and required documentation. Audits will be conducted weekly x4 weeks, then monthly x3 months. Findings will be reported to the QAPI committee.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide adequate supervision to prevent resident-to-resident inappropriate touching involving a cognitively impaired resident. The facility’s abuse policy states that when an incident or suspected incident of abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation and ensure any further potential abuse, neglect, exploitation, or mistreatment is prevented. Resident R1 had diagnoses including dysphagia, aphasia, dementia, and cerebral infarction, and was documented as cognitively impaired on a recent MDS assessment. Resident R2 had multiple medical and psychiatric diagnoses, including diabetes, seizures, chronic kidney disease, schizoaffective disorder, and frontotemporal neurocognitive disorder, and was documented as awake, alert, and oriented on a recent MDS. On the date of the incident, documentation submitted to the State Survey Agency indicated that another resident (R3) reported that R1 was inappropriately touched in the dining room by R2. An activity staff member (Employee E4) stated that R3 told him he witnessed R2 touching R1 inappropriately and asked him to remove R2 from the dining room. The activity worker reported that there were two activity aides and approximately 50 residents in the first-floor dining room at the time. He stated that R2 was feeling R1’s thighs and breast and putting his hands in her pants, after which he took R2 to the nursing station and reported the situation to a nurse. The activity worker later observed that R2 had returned to the dining room and was again near R1, with his hand on her inner thigh close to her genital area, and he again removed R2 to the nursing station. A licensed nurse (Employee E5) documented that R2 had been observed by another resident earlier and was placed at the nursing station for supervision, but that R2 went back into the same dining room and was seen kissing the same female resident, R1. The nurse reported that she notified the Nursing Home Administrator and Unit Manager after the first incident and again after the second incident. A nursing supervisor (Employee E6) documented being notified that R2 was seen inappropriately touching R1’s breast area and that by the time she left her office, the residents had been separated. A body assessment of R1 found no bruises or injuries. The facility’s investigation ultimately unsubstantiated the allegation of resident-to-resident abuse, but the investigation file lacked dated, signed statements from residents present in the dining room, from R3 who initially reported the inappropriate touching, and from the second activity worker (Employee E7) who was present. During interviews with the DON, NHA, and Regional NHA, it was acknowledged that when the first allegation of inappropriate touching was reported by R3 and R2 was removed from the dining room, R2 was able to return and was again observed touching the cognitively impaired resident, which was attributed to inappropriate supervision by the facility.

Plan Of Correction

Plan of Correction:The facility reviewed the incident involving Resident R2 and Resident R1 related to supervision and inappropriate behavior. Resident R2 was immediately removed from the area. Following the incident, Resident R2 was placed on 1:1 supervision and sent to the hospital for evaluation and remained on 1:1 supervision post return from the hospital until cleared by psychiatry. Resident R1 was assessed with no adverse outcome noted. The provider was notified and the incident was reported to the Department of Health.All residents have the potential to be affected by this deficient practice.Education will be provided to staff on supervision requirements, including immediate intervention and ensuring residents who require supervision are appropriately monitored. The Administrator or designee will conduct weekly audits to ensure residents requiring supervision are appropriately monitored. Audits will be conducted weekly x4 weeks, then monthly x2 months. Findings will be presented to the QAPI committee.

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 according to physician orders and resident needs by not ensuring that a paraplegic resident requiring total care was turned and repositioned every two hours as ordered. The resident’s medical record showed a physician’s order dated January 6, 2026, directing staff to turn and reposition the resident every two hours on every shift. However, the Treatment Administration Record for March 2026 contained only one checkbox per eight-hour shift for turning and repositioning, rather than documentation for every two hours. The DON confirmed that the order had not been correctly entered into the software to allow for every-two-hour checks and that there was no place for nurse aides to document the two-hourly turning and repositioning, acknowledging that the existing documentation did not follow the physician’s orders. This deficiency involved one of ten residents reviewed (Resident R2), who had diagnoses including paraplegia and required total care, and was cited under 28 Pa. Code: 201.18(a)(b)(1)(3) Management and 28 Pa. Code: 211.12(d)(1)(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 ensure that a working call system was available and operable in a resident’s room bathroom/bathing area, resulting in a nonfunctioning call bell for one of nine residents interviewed. During an interview in room [ROOM NUMBER], Bed C, the resident reported that the call bell did not work; when the red button was pressed, neither the red light on the panel where the cord was plugged in nor the white light in the hallway above the door frame illuminated. A licensed nurse (Employee E6) confirmed that the call light was not working. The Assistant Maintenance Manager (Employee E4) stated that he had repaired the call bell, but when it was tested shortly thereafter, it still did not function. Employee E4 acknowledged ongoing issues with this particular call bell and indicated that the wall panel had required repeated replacement. The Administrator also confirmed that maintenance had ongoing problems with the call bell in room [ROOM NUMBER], Bed C, and believed that the bed was striking the wall panel and causing the malfunction. This deficiency was cited under 28 Pa. Code 205.67(k) Electric requirements for existing construction, 28 Pa. Code 201.18(b)(1) Management, and 28 Pa. Code 211.12(d)(1)(3)(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 deficiency involves failure to provide a safe, clean, comfortable, and homelike environment, including maintaining appropriate room temperatures and functional room features for multiple residents. On an initial tour, one resident was observed in bed near the door wearing a winter coat under blankets in a very cold, dark room; she stated she liked a cool room but that it was "way too cold." Light from outside was seen shining through a gap between the PTAC heating unit and the wall, and 20-degree outdoor wind was blowing through the crack into the room. A newly admitted resident in the same room, near the heating unit, was observed wearing only a t-shirt with a thin blanket pulled up around her neck and stated she was freezing. Infrared temperature readings taken in the room showed temperatures ranging from 49 to 60 degrees, below the facility’s acceptable range of 71–81 degrees. In the same room, the light above the bed near the door had a broken pull string that was only a few inches long and could not be reached by the resident, who reported it had been this way for a few days and that she was tired of waiting for staff to turn it on and off. Further observations revealed additional environmental deficiencies affecting the same and other residents. One resident reported that her ceiling was leaking and that the wall beside her bed near the hallway was wet; the wall was damp to the touch, and the ceiling tile above and a ceiling tile in the hallway were dark and wet. The resident also reported a leak in the first-floor dining room where residents wait to go out to smoke, and a dark, wet ceiling tile was observed in that dining room area. In another resident room shared by two residents, the curtains were stained with what appeared to be a liquid spill; both residents stated the curtain had been dirty for a long time and had not been cleaned or changed. A towel was observed placed on top of the air conditioning unit in that room, and the residents stated cold air was coming through the panel and that the unit was not sealed properly. In the same room, the bathroom door did not close properly. These conditions collectively demonstrate the facility’s failure to maintain resident rooms and common areas in a clean, well-maintained, and comfortable 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 deficiency involves the facility’s failure to conduct and document a complete and thorough investigation to rule out neglect after an allegation that a resident ingested a staff member’s medication. The facility’s Abuse, Neglect, and Exploitation Prevention Policy required immediate protective measures, factual documentation of incidents, leadership notification, initiation of an investigation by the administrator or designee, external reporting as needed, and updating care plans with interventions to prevent recurrence. Resident R8 had multiple diagnoses, including CHF, epilepsy, schizophrenia, intellectual disability, cognitive communication deficit, anxiety, and psychosis. A nursing note documented that at approximately 6:30 a.m., a nurse aide reported her pocketbook missing from the nursing station, and a licensed nurse later found the pocketbook and other personal belongings in the resident’s possession, with documentation that the resident had ingested Zofran 4 mg from the pocketbook. During interviews, the licensed nurse confirmed that the nurse aide stated she knew the resident had taken the pocketbook because the resident was “just taking things.” The nurse and aide located the resident in either the dining room or the resident’s bedroom, retrieved the pocketbook, and the aide reported that her keys, money, and Zofran were missing. The nurse reported that empty blister packs from the Zofran prescription were found in the resident’s room trash can, and that the resident denied taking the pocketbook, money, keys, and medication, although at one point the resident opened her mouth and said, “Mommy look,” with nothing visible in her mouth. The nurse contacted the police because the aide’s money and keys were not found. In an interview, the Nursing Home Administrator confirmed there was no documentation showing that an investigation was completed to rule out neglect related to the allegation that the resident ingested Zofran after the nurse aide left her pocketbook unattended at the nursing station.

Penalty

No penalty information released

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

Summary

The facility failed to develop a comprehensive, person-centered care plan to address a resident's visual impairment, as required by its own policy and regulatory standards. The facility's policy on comprehensive person-centered care plans, dated December 2016, states that an interdisciplinary team, in conjunction with the resident and/or representative, must develop and implement a comprehensive person-centered care plan with measurable goals and timetables to meet the resident's physical, psychological, and functional needs. The policy further requires that areas of concern identified during the resident assessment be evaluated before interventions are added to the care plan, that the comprehensive care plan be developed within seven days of completion of the comprehensive MDS assessment, and that the care plan be reviewed and updated at least quarterly with the required quarterly MDS. Review of the clinical record for Resident R77 showed admission with diagnoses including Type 2 diabetes mellitus and dry eye syndrome of bilateral lacrimal glands. The resident's MDS assessment documented that the resident was visually impaired in Section B1000 (Vision) and cognitively intact with a BIMS score of 15 in Section C0500. Despite this documented visual impairment, there was no care plan developed to address the resident's visual impairment in the clinical record. In an interview, the resident stated that he cannot see. This lack of a care plan for the identified visual impairment constituted noncompliance with the facility's care plan policy and 28 Pa. Code 211.11(a) regarding resident care plans.

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 personnel supervising residents during meals and providing emergency response were properly certified in CPR/BLS, as required by facility policy. Facility policies on Cardiopulmonary Resuscitation (CPR) and Meal Supervision required that key clinical staff directing resuscitative efforts maintain American Red Cross or American Heart Association BLS/CPR certification, and that nursing staff and designated personnel supervising meals monitor for signs of aspiration or choking and not leave high‑risk residents unsupervised. The Dining Room Supervision standard further required direct observation of high‑risk residents, continuous alertness, and immediate nursing notification if signs of distress were observed. Despite these policies, on the day of the incident only two nurse aides (Employees E12 and E13) were available at the nurse’s station and were the staff present in the dining room when a resident experienced choking. According to the facility’s investigation, Employee E12 provided a lunch tray to Resident R114 in the main dining room. Another nurse aide, Employee E13, observed the resident sitting upright with his tray when he began coughing and raised his hands to his chest. Employee E12 immediately administered back blows and initiated the Heimlich maneuver while calling for assistance, and two nurses then came over and administered CPR, which included the Heimlich maneuver. Review of personnel files showed that both Employee E12 and Employee E13 did not possess valid CPR certification at the time of the incident, and Employee E12 only completed an online CPR course (not from AHA or the American Red Cross) later that same day. Interviews with the DON, Unit Manager, and Administrator confirmed that the two aides assisting in the dining room did not have valid CPR certification at the time of the event and that there should have been at least a nurse in the dining room to supervise residents at risk for aspiration or on aspiration precautions.

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 administer medications in accordance with physician orders, facility policy, and required time frames for one cognitively intact resident. Facility policy on medication administration dated December 2012 requires that medications be administered safely, timely, and as prescribed, including within one hour of the scheduled time unless otherwise specified, and that nursing personnel administering medications verify the right resident, medication, dose, time, and method. Resident R53 was admitted with diagnoses including hypokalemia, hypertension, congestive heart failure, diabetes, deep vein thrombosis, atrial fibrillation, neuropathy, and gout, and had multiple scheduled medications ordered for morning administration with meals or at specific times. Review of Resident R53’s Medication Administration Audit Report showed that on a specific date, multiple medications ordered for 9:00 AM administration were not given until after 4:00 PM. These included potassium chloride ER 20 mEq (2 tablets BID), Toprol XL 50 mg daily with meals for HTN, metformin 500 mg in the morning with breakfast for diabetes, Lasix 40 mg on designated days for CHF, Eliquis 5 mg BID for DVT, diltiazem 30 mg daily for A-fib, gabapentin 100 mg BID for neuropathy, and allopurinol 100 mg daily for gout. The resident reported that nurses give his medications very late, and a licensed nurse confirmed that medications scheduled for 9:00 AM on that date were documented as administered after 4:00 PM, demonstrating noncompliance with the facility’s medication administration policy and physician orders.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to prevent an accident hazard when a resident with multiple cognitive and psychiatric diagnoses obtained and ingested a staff member’s prescription medication that had been stored at the nursing station. The resident had diagnoses including CHF, epilepsy, schizophrenia, intellectual disability, cognitive communication deficit, anxiety, and psychosis. A nursing note documented that early in the morning a nurse aide reported her pocketbook missing from the nursing station; the resident was later found in possession of the pocketbook and other personal belongings. It was discovered that the resident had ingested Zofran 4 mg tablets that were in the aide’s pocketbook, and empty blister packs from the Zofran prescription were found in the trash can in the resident’s room. During an interview, the licensed nurse confirmed that she had been in the medication room when the aide reported the missing pocketbook and that the aide stated she knew the resident had taken it because the resident was “just taking things.” The nurse and aide located the resident in either the dining room or the resident’s bedroom and retrieved the pocketbook, after which the aide reported that her keys, money, and Zofran were missing. The resident denied taking the pocketbook, money, keys, and medication, and at one point opened her mouth and said, “Mommy look,” but nothing was seen in her mouth. The Nursing Home Administrator confirmed that staff are expected to keep personal belongings in the employee break room in the basement and not at the nursing station, indicating that the aide’s storage of her pocketbook with prescription medication at the nursing station constituted a violation of facility expectations and contributed to the accident hazard.

Penalty

No penalty information released

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

Summary

The facility failed to address a resident’s significant weight loss in a timely manner, contrary to its policy on Weight Assessment and Intervention. The policy, revised in March 2022, required that any weight change of 5% or more since the last weight assessment be rechecked the next day for confirmation. The resident, who had diagnoses including hypertension, cerebral infarction (stroke), and chronic kidney disease, had a documented weight of 138 pounds on a monthly weight dated May 3, 2025. A subsequent monthly weight dated June 6, 2025 showed a weight of 129 pounds, reflecting a 9‑pound loss and a significant 6.5% decrease. The clinical record from May 2025 through June 2025 did not contain evidence that a re‑weight was obtained to verify this significant weight loss. A dietician note dated June 11, 2025 documented that weight loss was noted and that a re‑weight had been requested, and a subsequent dietician note dated June 25, 2025 indicated the dietician was still awaiting the re‑weight and recommended an increase in house shakes until an accurate weight was determined. Despite these documented requests, there was no documentation in the clinical record that a re‑weight was completed in a timely manner to verify the weight loss and to ensure that any needed services and interventions were implemented. During an interview on January 23, 2026, the dietician confirmed the resident’s 6.5% significant weight loss, acknowledged the prior notes requesting a re‑weight, and confirmed that the next recorded weight after the June 6, 2025 measurement did not occur until July 1, 2025, 25 days after the significant weight loss was first recorded. The dietician also reported that the facility did not have a standard time frame for obtaining re‑weights for residents with possible significant weight loss.

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 or arrange routine dental services for a long-term care resident, resulting in a deficiency related to dental services and nursing services. The resident, who was admitted in March 2025, was a Medicaid recipient and was documented as cognitively intact on an MDS assessment dated December 10, 2025. Pennsylvania Medical Assistance Dental Coverage for Adults allows exams, x-rays, and cleanings every six months, yet the resident reported during an interview in January 2026 that he had not seen a dentist since admission and was experiencing tooth pain requiring an extraction. Review of the clinical record showed no documentation that the resident had seen a dentist or had any dental appointments scheduled from admission through January 2026, and there was no evidence of any refusal of dental care by the resident. In an interview, the Unit Manager confirmed that the resident had not seen a dentist or had a dental consult since admission and that there was no documented refusal of dental services. The Unit Manager stated that an appointment was only scheduled after the resident reported tooth pain, and that no routine dental exams or visits had been arranged prior to the onset of pain. These findings demonstrate that the facility did not offer or obtain routine dental services for this resident as required under 28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services and 28 Pa. Code 211.15(a) Dental 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 ensure that garbage and refuse were disposed of properly in the Food Service Department receiving area. During an initial tour of the department, surveyors observed a green dumpster with various pieces of equipment improperly stored behind it, including a hospital-style bedframe lying on the ground partially covered in snow, a stainless-steel counter-height ice machine, and a wheelchair with six leg rests piled on top of its armrests. The Food Service Director confirmed that the ice machine was no longer working, and the Administrator confirmed that this equipment did not belong in the receiving area. These observations demonstrated that the facility did not maintain proper disposal or storage of refuse and non-functioning equipment in the designated area. No residents or their medical conditions were mentioned in relation to this deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident with multiple respiratory diagnoses, including chronic obstructive pulmonary disease, chronic hypoxia, emphysema, and obstructive sleep apnea, received appropriate treatment and care according to physician orders and facility policy upon admission. Specifically, there was no documentation that physician's orders for supplemental oxygen or breathing therapy, including the use of a BiPAP machine, were obtained at the time of admission. The admitting nurse did not reconcile or confirm these essential respiratory treatments, as required by facility policy, despite clear instructions in the hospital discharge summary. Additionally, the resident had physician orders for Bromide inhalation and Albuterol inhalation solution to be administered for shortness of breath, but there was no evidence in the Medication Administration Record that these medications were given as ordered. The DON confirmed that these medications were not administered. Subsequently, the resident was transferred to the hospital emergency room after experiencing shortness of breath and a change in mental status, with hospital records indicating an abnormally high respiratory rate and inadequate use of noninvasive ventilation therapy.

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 its emergency generator system, which is crucial for ensuring the safety and functionality of the facility during power outages. Document review revealed that several key maintenance tasks were not performed after July 18, 2024. These tasks included weekly visual inspections, weekly battery voltage inspections, monthly battery conductance testing, monthly generator exercises for 30 minutes, and monthly operation of transfer switches. Additionally, an annual fuel quality test was not conducted, and a generator inspection from March 21, 2024, indicated issues such as wet stacking and fuel injector warnings. During a follow-up visit on February 5, 2025, it was confirmed that the monthly operation of transfer switches and the annual fuel quality test had still not been completed. The generator continued to exhibit problems with wet stacking and fuel injector warnings. The facility acknowledged the lack of documentation and stated that they were awaiting the delivery of parts necessary to complete these tasks.

Plan Of Correction

The facility will comply with emergency generator weekly visual checks, weekly battery voltage checks, monthly battery conductance testing, 30-minute monthly exercise, monthly operation of transfer switch, and annual fuel tests. The facility completed a fuel analysis on 1/22/2025 and failed the analysis. The facility requested for fuel to be polished to successfully pass analysis, and this work was completed on 2/13/2025. A TLW was requested on 1/24/2025 to fix the injector warning to address the deficiency from the 3/21/2024 inspection. The facility ran a monthly exercise on 2/13/2025. The facility corrected the wet stacks on 5/13/2024. All residents and areas have the potential to be affected. The Maintenance Director will be educated on the importance of conducting weekly and monthly inspections and scheduling the yearly test. LNHA will monitor all weekly, monthly, and yearly tests. LNHA will monitor future generator inspection deficiencies for appropriate and timely corrections. LNHA / designee will audit weekly inspections, weekly x4 then bi-weekly x2 then monthly x2. LNHA / designee will audit monthly inspections x3. LNHA / designee will audit yearly tests, yearly. LNHA / designee will audit generator inspection deficiencies quarterly.

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 fire resistance rating for its building construction, which affected the entire component. During a document review on December 16, 2024, it was found that the Center Building is a two-story structure with a basement, classified as Type III (200), unprotected ordinary construction, and fully sprinklered. However, the story height exceeds the maximum allowance for this construction type by one story. This was confirmed during an exit interview with the Administrator and Maintenance Director. Similarly, the Villa Building component was found to be a two-story structure with a basement, classified as Type V (000), unprotected wood frame construction. This building also exceeded the maximum allowable story height by one story. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. The facility is working to obtain a Fire Safety Evaluation System (FSES) to address these issues.

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 fire resistance rating of stairway enclosures, affecting three of four levels within the building. During a document review and interview on December 16, 2024, it was found that the communicating stairway enclosure did not meet the required one-hour fire-rated construction. This deficiency was due to the presence of wired glass in wooden frames, as well as non-rated doors, frames, and hardware used within the stairway. The condition of the stairway was confirmed during an exit interview with the Administrator and Maintenance Director. A follow-up onsite revisit on February 5, 2025, revealed that the issue had not been resolved, as the stairway enclosure still lacked the necessary fire-rated construction.

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 be non-compliant with the NFPA 101 requirements for the number of exits per story and compartment. During a document review and interview on December 16, 2024, it was determined that the facility lacked two approved exits that are remote from each other for each floor or fire section of the building. The existing exit strategy relied on a communicating stairway located in the center of the building, which does not meet the requirement for distinct egress paths. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. A follow-up onsite revisit on February 5, 2025, confirmed that the issue had not been resolved, as the facility still lacked acceptable fire exits. The facility acknowledged the deficiency and indicated that they are working to obtain a Fire Safety Evaluation System (FSES) to address the issue.

Penalty

No penalty information released

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

Summary

Essential pieces of food service equipment used for the transportation, holding, and delivery of hot foods were not in use at the facility, leading to deficiencies in maintaining safe and satisfactory food temperatures for residents. Observations revealed that the facility was not utilizing a complete and standard thermal system to transport, hold, and deliver hot foods from the main kitchen to the nursing units, resident rooms, and dining areas. This lack of essential equipment resulted in hot foods being served at inadequate temperatures, affecting the palatability and satisfaction of the residents. Interviews with several residents indicated dissatisfaction with the temperature and taste of the foods served. Residents reported that the foods were often lukewarm, tasted undesirable, and hot beverages were not served hot enough to dissolve creamer. Specific complaints included grilled cheese sandwiches being served with hard, unmelted cheese and meals arriving cold when served in resident rooms. These issues were corroborated by interviews with the director of dietary services and the registered dietitian, who confirmed the absence of a complete system of standard dietary equipment for transporting hot foods. Clinical record reviews showed that the residents involved in the complaints were cognitively intact, indicating that their reports were reliable. The dietary staff confirmed that essential equipment, such as heated pellets and thermal pellet holders, were not in use. These items were designed to keep hot foods at the appropriate temperature for twenty minutes beyond the time they left the kitchen, but their absence contributed to the deficiency in food service quality.

Plan Of Correction

The facility will order and put into service heated pellet and thermal pellet holder. All residents receiving meals from the Food Services department have the potential to be affected. The facility will observe the use of the heated pellet and thermal pellet holder for its intended purpose of essential pieces of food service equipment used for the transportation, holding and delivery of hot foods to residents. Food Services Director / designee will conduct observations for the use of the heated pellet and thermal pellet holder 3 times a week x4 weeks, then monthly x2 months. Findings will be reported to the QAPI committee.

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 complete, separate, and accurate accounting of a resident's personal funds. This deficiency was identified during a review of financial and accounting documentation and interviews with administrative staff. The issue involved a resident who alleged inaccuracies in her quarterly financial statement, including unrecognized charges. The facility's policy requires a full and separate accounting of each resident's personal funds, with quarterly statements provided to residents or their representatives. However, the resident in question, who only withdrew a monthly allowance of $45, did not recognize additional withdrawals of $100, $200, and $300, which were allegedly made with her signature. Interviews with the business office manager revealed that the facility's protocol involves residents signing a receipt when withdrawing funds. However, the new business office manager, who recently assumed the position, was unable to locate any receipts for the questioned transactions. The nursing home administrator confirmed that there were two dates of concern regarding the withdrawals, and the facility could not find one of the receipts, leading to the reimbursement of $300 to the resident. This situation indicates a failure in the facility's financial management and record-keeping processes for resident funds.

Plan Of Correction

The facility provided resident R28 a reimbursement for the $300 charge that resident R28 stated was not paid out to her, and facility was unable to locate a withdrawal receipt for. A receipt was signed by resident R28 and a copy provided to her. LNHA has completed an audit of all residents who have a facility account established, reviewing statements and withdrawal receipts from January 2024 through November 2024 and will complete a December 2024 audit. The facility will monitor residents' money requests by having the Business Office Manager withdraw the requested money and provide a receipt to be signed by the resident, confirming the resident has received the money. LNHA will educate the Business Office Manager on the process for categorizing resident money withdrawals. The Business Office Manager will maintain organized records of all resident withdrawal receipts. LNHA / designee will audit resident funds withdrawal receipts monthly x3 months. LNHA / designee will audit resident statements quarterly x4 quarters. Findings will be reported to the QAPI meeting.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from verbal abuse, as observed by surveyors. The incident involved a Licensed Practical Nurse (LPN) who removed a spare oxygen cannula from a resident's room and subsequently engaged in a verbal altercation with the resident. The LPN yelled at the resident from the nurses' station, accusing the resident of being manipulative and dismissing the resident's expressed need for the spare tubing. The resident, who was diagnosed with acute and chronic respiratory failure, chronic obstructive pulmonary disease, and mental health illnesses including anxiety disorder and major depressive disorder, appeared upset and anxious during the interaction. The resident's care plan indicated that the resident required continuous oxygen therapy and had specific interventions to manage anxiety and compulsive behaviors. The care plan also noted the resident's need for a long oxygen tubing to walk in his room and hallway. Despite these documented needs, the LPN's actions and verbal communication did not align with the care plan's interventions, which included anticipating and meeting the resident's needs and providing opportunities for positive interactions. The psychological services notes highlighted the resident's ongoing struggles with anxiety and irritability, with recommendations to manage mental health symptoms more appropriately. The incident observed by surveyors demonstrated a failure to adhere to these recommendations, as the LPN's approach escalated the resident's anxiety rather than mitigating it. The facility's policy on abuse education defines verbal abuse as acts that cause humiliation, shame, or agitation, which were evident in the LPN's interaction with the resident.

Plan Of Correction

The facility immediately educated employee E18 on abuse and suspended E18 pending investigation. LNHA opened event report 1055382. The facility immediately began the investigation by obtaining statements from resident R28, E18 and witnesses. The facility provided Psych services to resident R28. The facility has conducted an abuse training in-service with all staff. The facility will review abuse reporting with residents at Resident Council. The facility will conduct a random sample of 5 residents checking for resident's safety and comfort with staff. The facility will monitor employee training on abuse prevention upon hire and at least yearly thereafter or as needed. The facility will verify that information on how to report abuse is located on resident/visitor areas. The facility will monitor that grievance forms are available on the units for residents to file complaints/make reports. The facility will review and remind residents of the types of abuse and how to report abuse at least every quarter at resident council meetings. Nurse Educator / designee will audit all current staff and new staff's education files for abuse prevention training upon hire and at least yearly, monthly x3 months. Director of Social Services / designee will surveil that advocacy posters and grievances are highly visible in resident/visitor areas weekly x4 weeks then monthly x3 months. Recreation Director / designee will monitor resident council meeting topics and audit resident council meeting minutes to include abuse prevention information to residents monthly x3 months. Findings will be reported to the QAPI committee.

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 and develop individualized discharge plans for three residents, R11, R34, and R46, upon admission and throughout their stay. Despite being cognitively intact and expressing their needs, these residents did not have documented discharge plans that aligned with their preferences. Resident R11 expressed a desire to transfer to another nursing home closer to his brother, but there was no documentation of assistance from the social worker after the initial request. Resident R34 wanted to return to the community closer to family, but no discharge care plan was established. Resident R46 desired to be discharged to the community with her cousin, but there was no follow-up documentation after an initial social service note. Additionally, Resident R46 was involved in a physical altercation with another resident, R81, which led to a consideration for transfer to a facility specializing in behavioral wellness. However, there was no documented update on this discharge plan. The lack of interdisciplinary care planning for discharge was confirmed by interviews with the director of nursing and social work staff. The facility's failure to adhere to its discharge policy and procedure resulted in unmet discharge planning needs for these residents.

Plan Of Correction

The facility has assessed and documented residents R11, R34, and R46 for placement and/or discharge goals. The facility will complete an audit of residents with a quarterly/annual review in the last 30 days to appropriately identify placement and/or discharge goals. The facility will monitor all residents' documentation and care plans identifying appropriate placement and/or discharge goals in the resident's health record and review at least quarterly at each care conference with the resident and/or resident representative. Social Worker / designee will complete a documentation and care plan audit for 8 residents, weekly x3 months. Findings will be reported to the QAPI committee.

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 safe and comfortable adaptive equipment to maintain a resident's ability to perform activities of daily living, specifically mobility. Resident R34, who is cognitively intact but dependent on staff for transfers, reported not receiving the necessary assistance for mobility needs. Observations revealed that the resident's manual wheelchair was not suitable for safe transfers, as it lacked an adjustable back, making it difficult for staff to position the resident properly and safely. Interviews with nursing staff confirmed the challenges they faced in transferring the resident due to the inadequate wheelchair, which posed safety concerns. The physical therapist acknowledged that a wheelchair with a reclining back was an option but was unaware of the issues faced by the nursing staff, as there had been no observations of transfer attempts since August 2024. The director of nursing confirmed the lack of appropriate adaptive equipment, which hindered the staff's ability to safely transfer the resident as per the care plan.

Plan Of Correction

The facility immediately made available to resident R34 a reclining manual wheelchair. The facility has re-educated nursing staff on safe mechanical lift and transfers. The facility will compile a list of residents that need assistance with mobility (transfer and ambulation) and complete an audit to identify that the respective residents have the appropriate, safe and comfortable adaptive equipment for mobility. The facility will monitor residents that need assistance with mobility (transfer and ambulation) to review that resident's adaptive mobility equipment remains appropriate at least quarterly at each care conference or as needed. The facility will monitor nursing staff training and competency on safe mechanical lift and transfers upon hire and at least yearly thereafter, or as needed. Director of Rehabilitative Therapy / designee will audit residents' adaptive mobility equipment for each scheduled resident's quarterly / annual review, semi-weekly x3 months. Nurse Educator / designee will audit all current nursing staff and new nursing staff's education files for safe mechanical lift and transfers training and competency, monthly x3 months. Findings will be reported to the QAPI committee.

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 treatment for opioid addiction for two residents, resulting in missed doses of Suboxone, a medication used to treat opioid dependence. Resident R56 experienced missed doses over the Thanksgiving period, leading to withdrawal symptoms such as stomach pains, aches, and sweating. The facility's documentation showed delays in obtaining a prescription refill from the physician, and there was no evidence of nursing staff checking on the resident's condition during this period. Similarly, Resident R61 also experienced missed doses due to delays in prescription refills, with no documented assessments or nursing notes during the time the medication was not administered. Additionally, the facility failed to follow a bowel care protocol for Resident R81, who had a history of constipation and was hospitalized for stomach distention. Despite physician orders for preventive measures, such as administering prune juice and milk of magnesia, the nursing staff did not follow these orders when the resident had no bowel movements for several days. This lack of adherence to the bowel protocol was confirmed by a registered nurse, and the resident was eventually sent to the hospital for further evaluation due to stomach ache and vomiting. The facility's Director of Nursing acknowledged the issues with medication administration, citing delays in receiving prescriptions from physicians and pharmacy deliveries as contributing factors. The report highlights deficiencies in medication management and adherence to care protocols, which resulted in residents experiencing discomfort and potential health risks.

Plan Of Correction

Resident R56 received their suboxone on 11/29/2024. Resident R61 received their suboxone on 5/28/2024. The facility completed a suboxone supply count immediately to verify appropriate supply before needing to request a refill. The facility has re-educated all licensed nurses on the facility's policy on Medication/Opioid Management and Reordering such as: when counting controlled drugs, the licensed nurses must be alert for medications needing refills or new script within 10 days of the last dose. The facility has re-educated all nursing staff on Bowel and Bladder policy and protocol including monitoring, assessing, documenting resident's bowel movements. The facility will complete a medication audit on all residents who are presently on suboxone to monitor consistency and appropriateness of pain management regimen and receiving their medication in a timely manner. The facility will complete a bowel and bladder audit on 10 residents to ensure a proper bowel and bladder protocol is in place. The facility will monitor and check for knowledge on licensed nurses' ability to verbalize understanding of facility's policy on Medication/Opioid Management and Reordering. The DNS will oversee and serve as the point of escalation in contacting the physician and/or pharmacy for refill and/or new script and specifically monitor Suboxone supply. The facility will monitor for effective bowel and bladder program and verify that nursing staff are appropriately documenting and following physician orders and recommendations. DNS / designee will audit 4 residents prescribed Opioids to monitor consistent, timely and appropriate medication administration and pain management regimen. Audits will be conducted daily x2 weeks, then weekly x4 weeks and then monthly x3 months. UM/ designee will audit 4 residents BM log to monitor for consistent and appropriate bowel hygiene and regimen. Audits will be completed weekly x4 weeks then monthly x2 months. Findings will be reported to the QAPI committee.

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 pharmaceutical services for two residents, R56 and R61, who were prescribed Suboxone for opioid dependence. The facility's policy for Medication Shortage/Unavailable Medication requires urgent action by the licensed nurse in cooperation with the attending physician and pharmacy provider when medications are not received. However, this protocol was not effectively followed, leading to missed doses for both residents. Resident R56 missed multiple doses of Suboxone on November 27, 28, and 29, 2024, due to delays in medication delivery. Similarly, Resident R61 did not receive their prescribed doses on May 27 and 28, 2024, because the prescription was not filled and delivered in a timely manner. Interviews with the residents confirmed that there were times when the facility failed to provide their medication. The Director of Nursing acknowledged that the delays were due to the physician not sending prescriptions to the pharmacy promptly or the pharmacy not delivering the medication on time. This deficiency in pharmaceutical services is a violation of the facility's responsibility to ensure that residents receive their prescribed medications as needed.

Plan Of Correction

Resident R56 received their suboxone on 11/29/2024. Resident R61 received their suboxone on 5/28/2024. The facility completed a suboxone supply count immediately to verify appropriate supply before needing to request a refill. The facility has re-educated all licensed nurses on the facility's policy on Medication/Opioid Management and Reordering such as: when counting controlled drugs, the licensed nurses must be alert for medications needing refills or new script within 10 days of the last dose. The facility has re-educated on assessing and documenting residents for withdrawal symptoms and reaching the medical provider for an alternative to manage withdrawal symptoms and/or pain. The facility has informed the pharmacy account manager of the importance in receiving ordered medications in a timely manner and agreed upon filling the Omnicell/Pixus as a backup system. The facility will complete a medication audit on all residents who are presently on suboxone to monitor consistency and appropriateness of pain management regimen and receiving their medication in a timely manner. The facility will monitor and check for knowledge on licensed nurses' ability to verbalize understanding of facility's policy on Medication/Opioid Management and Reordering. The facility will monitor and check for knowledge on licensed nurses' ability to verbalize understanding of signs and symptoms of opioid withdrawal and how to appropriately assess and communicate with the medical provider for recommendations. The DNS will oversee and serve as the point of escalation in contacting the physician and/or pharmacy for refill and/or new script and specifically monitor Suboxone supply. The facility will monitor for timely receipt of medications from the pharmacy and immediately inform the pharmacy account manager of any concerns, as needed. DNS / designee will audit 4 residents prescribed Opioids to monitor consistent, timely and appropriate medication administration and pain management regimen. Audits will be conducted daily x2 weeks, then weekly x2 weeks and then monthly x2 months. Findings will be reported to the QAPI committee.

Penalty

No penalty information released

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

Summary

The facility failed to properly manage and monitor the use of psychotropic medication for a resident, identified as R88, who was prescribed divalproex sodium (Depakote) for agitation. The clinical record review revealed that there was no documentation indicating that the nursing staff clarified the order with the physician to ensure adequate indications for its use. Additionally, the nurse did not verify the order to clarify the duration, dosage, and intended use of Depakote, nor did they confirm whether it was to be administered as needed or on a standard schedule. Furthermore, there was a lack of documentation for Valproic acid blood levels, which are necessary to monitor the continued use of the medication. The psychiatrist's assessment noted that the resident had dementia with behavioral disturbances and was exhibiting agitation with aggressive behaviors. Despite this, the nursing staff failed to obtain an order for adequate monitoring of the drug and did not ensure that the medication was not used for an excessive duration. An interview with the director of nursing confirmed these deficiencies, highlighting the facility's failure to adhere to its policy on psychotropic drug use, which requires monitoring for adverse side effects, appropriate drug selection, and dosage.

Plan Of Correction

The facility has assessed resident R88 for the use of Depakote. The nurse has clarified the other for the Depakote with the physician to provide adequate indications for its use for resident R88. The facility will complete an audit for all residents on Depakote to verify that documentation and order substantiates the appropriate use of Depakote. The facility conducted a review of the current Psychotropic Use policy and made no changes. The facility will monitor the appropriate use of Depakote and verify that orders and documentation validate the use of Depakote. The facility will monitor the effectiveness of the Depakote and side effects will be monitored and recorded. DNS / designee will audit 20% of all PRN psychotropic medication weekly x4 weeks, then monthly x2 months. Findings will be reported to the QAPI committee.

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 two residents were free from significant medication errors. Resident R69, who had a medical history including heart failure, atrial fibrillation, and hypertension, was prescribed Coumadin with two different dosages on separate orders. On November 6, 2024, a charge nurse administered both a 5mg and a 6mg tablet of Coumadin to the resident, totaling 11mg, due to confusion over the orders. This error occurred because the nurse noticed two different orders for Coumadin on the medication administration record (MAR) and administered both doses, despite the potential for major or fatal bleeding associated with Coumadin, as highlighted in the manufacturer's warning. Resident R64, diagnosed with type 2 diabetes, arthritis, and low back pain, experienced a medication error when the nurse administered Metformin instead of Gabapentin. On July 14, 2024, the resident was given the wrong medication but spit it out and refused to take it. Despite this, the resident was upset and requested a supervisor. On August 12, 2024, the resident again received Metformin instead of Gabapentin, but did not swallow the pill and spit it out. The resident was stable but required hospitalization following the incident.

Plan Of Correction

The facility immediately assessed resident R69 after administering the incorrect dosage of Coumadin. The facility immediately contacted the medical provider, and a PT/INR was ordered. The facility continued to monitor resident R69 for bleeding or bruising. The facility followed all subsequent MD orders. The facility immediately assessed resident R64 after administering the wrong medication on 7/14/2024. The medical provider was notified. Resident R64 did not require any further intervention, as per MD. The facility immediately interviewed LPN that administered incorrect medication and issued a written education to the LPN. The facility immediately assessed resident R64 after administering the Metformin medication 90 minutes prior to the scheduled time on 8/12/2024. The medical provider was notified. Resident R64 "spit out the medication and" did not require any further intervention as per MD. The facility immediately interviewed the LPN and took appropriate disciplinary action. The facility immediately initiated education to licensed nurses on medication administration and documentation in resident's electronic health record. All residents have the potential to be affected by the deficient practice. The facility will educate all licensed nurses on medication administration and documentation in resident's electronic medical record. The facility will utilize medication administration record documentation audit tool. Director of Nursing / designee will complete random audits of 5 resident MAR weekly x4 weeks, then monthly x2 months. Findings will be reported to the QAPI committee.

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 proper infection control practices related to wound care for a resident, identified as R47, who was reviewed for wound care. The facility's policy on wound care emphasizes cleanliness and the use of a clean environment for procedures. However, an incident was reported where wound care was attempted in the resident dining room, which is not a clean environment, with other residents present. This action was confirmed by the infection preventionist, who stated that the care was attempted due to the resident's behaviors and refusal of care, although the procedure was not completed due to the resident's undesirable behaviors. Resident R47 has a complex medical history, including chronic venous insufficiency, hypertension with ulcers on both lower extremities, local infections, cellulitis, intellectual disability, schizophrenia, and asymptomatic HIV infection. The resident's physician orders included the application of calcium alginate silver dressing and Santyl ointment to the lower extremities. The incident was brought to attention by another resident, R64, who provided video evidence of the wound care attempt in the dining room and expressed concerns about the unsanitary conditions and potential for infection.

Plan Of Correction

Employee E5 was reeducated on facility treatment policy to align with infection control practices. Residents in the 1st floor dining room were indirectly affected by the cited deficient practice. Residents were assessed by clinical team and do not have any ill effects related to the cited deficient practice. All residents have potential to be affected by deficient practice. The facility infection control risk assessment will be reviewed to monitor for accuracy and will be revised, as needed on or before January 3, 2025. The new IPN will educate all nursing staff on proper wound care treatment and following the facility's infection control policy. Infection Preventionist / designee will conduct visual rounds on both units to monitor that staff are practicing appropriate infection control practices during wound care. Audits will be done weekly x4 weeks then monthly x3 month. Findings will be reported to the QAPI committee.

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 effective antibiotic stewardship program, as evidenced by the lack of documented surveillance for antibiotic use over a four-month period. The review of facility documentation, policies, and CDC guidelines revealed that the facility did not utilize any surveillance tools for monitoring antibiotic use, which is a critical component of an antibiotic stewardship program. The facility's antibiotic tracking log from August to November 2024 showed no evidence of consultant pharmacist reports, laboratory reports, infection descriptions, or details on antibiotic dose and duration, which are necessary for effective monitoring and management of antibiotic use. An interview with the infection preventionist confirmed that the facility's antibiotic stewardship program did not include reports or data from the pharmacist or laboratory. This lack of integration and monitoring indicates a failure to adhere to CDC guidelines and facility policies, which require the inclusion of cultural reports, sensitivity data, and antibiotic usage reviews in surveillance activities. The absence of these critical components in the facility's antibiotic stewardship program led to the deficiency identified during the survey.

Plan Of Correction

The facility will complete an audit of antibiotics stewardship including all new and current antibiotic usage for the last 15 days to be completed by the Infection Preventionist. All residents on antibiotics have the potential to be affected. Residents receiving or that have received antibiotics in the last 15 days will be audited by the IPN for proper surveillance and tracking. Education provided to the infection preventionist on Antibiotic stewardship program to include tracker that consists of surveilling infection description, antibiotic dose and duration, and lab or pharmacy reports. The facility will utilize a tracker that consists of surveilling infection description, antibiotic dose and duration, and lab or pharmacy reports. Director of Nursing / designee will conduct audits of antibiotic stewardship surveillance program to monitor for proper tracking. Audits will be completed weekly x4 weeks then monthly x2 months. Findings will be reported to the QAPI committee.

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 effective pest control program, resulting in the presence of common household pests and rodents. Observations in the main kitchen of the Food and Nutrition Department revealed significant cleanliness issues, including a white/grayish film resembling hard water deposits on the industrial-sized dish machine and surrounding flooring. Additionally, there was a heavy accumulation of dirt and brown saturated slime under the dish machine and three-compartment sink. The grouting between ceramic tiles in the dish room and food preparation area was missing, leading to porous flooring that was not easily cleanable and allowed food debris and water to accumulate. The water-damaged flooring provided an environment conducive to pest infestation, as it allowed food debris, dirt, and moisture to settle. Many ceramic tiles were missing in the dish room area, and it was reported that new plumbing had been installed beneath the flooring three months prior. Despite regular visits from a pest control operator for treatment of roaches, fruit flies, drain flies, and mice, the facility's pest control measures were inadequate, as evidenced by the continued presence of these pests in the kitchen and dry food storage areas.

Plan Of Correction

The facility completed work on the kitchen floor in the identified areas on 12/31/2024 to allow for easy cleaning and avoid food debris and pooling of water to accumulate. All residents have potential to be affected by deficient practice. The facility identified the focus areas to be in the kitchen where the flooring had no ceramic tiles. The facility will educate dietary staff to maintain the kitchen flooring clean of food debris and pooling of water. The facility will educate all dietary staff to report to the Maintenance Director when there are deficiencies in the grout and or tiles in the kitchen. Pest control professionals will evaluate the identified areas to verify that they are up to par. Food Services Director / designee will monitor kitchen flooring at least 3x a week for 4 weeks, then 3 weekly x3 months. Findings will be reported to the QAPI committee.