Mesa Hills Post Acute

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 protect a resident from physical abuse by another resident. Resident #1, a male with a history of other mental and behavioral disorders and a BIMS score of 12 indicating moderate cognitive impairment, had documented care plan focuses for physical aggression related to anger and poor impulse control, as well as behavior problems including verbal outbursts toward staff and other residents. Interventions in his care plan included intervening before agitation escalated, guiding him away from sources of distress, engaging calmly in conversation, walking away and re-approaching later if he became aggressive, and intervening as necessary to protect the rights and safety of others by diverting attention and removing him from situations as needed. Despite these identified behaviors and planned interventions, Resident #1 remained in situations where he could and did become physically aggressive toward another resident. Resident #2, a male with bipolar disorder and a BIMS score of 15 indicating intact cognition, had a care plan focus for verbal aggression related to ineffective coping skills, poor impulse control, anxiety, and bipolar disorder. His care plan included similar interventions to those of Resident #1, such as intervening before agitation escalated, guiding him away from distress, engaging calmly in conversation, and walking away and re-approaching later if he became aggressive. Prior to the incident, records indicated that neither resident had displayed documented physical or verbal behaviors toward others on their MDS assessments, although multiple staff interviews described Resident #1 as having a short fuse, being verbally aggressive, making racist comments, and having been physically aggressive with another resident by shaking that resident’s wheelchair. On the night of the incident, nursing notes documented that Resident #1 and Resident #2 were initially talking in a normal tone in the hallway before going into Resident #1’s room. Resident #2 then exited the room, and loud voices were heard from both residents in the hallway. Resident #2 went to the patio, and staff noted he was very upset. Resident #1 obtained a long grabber/reaching aid and wheeled himself to a hallway area while being loud and angry toward Resident #2. When Resident #2 heard him and came into the hallway, both residents yelled profanities at each other. According to LVN B, Resident #1 claimed Resident #2 had shaken his chair, then Resident #1 grabbed the reaching aid from the back of his wheelchair and swung it at Resident #2, who blocked the blow with his left forearm. A subsequent skin assessment revealed a minor bruise less than an inch in diameter on the posterior left forearm of Resident #2. Resident #2 reported that Resident #1 had previously threatened to hit him with the reaching aid and that this was the first time he followed through. Multiple staff, including the DON, ADON, LVN B, and the Administrator, characterized the event as physical abuse and acknowledged that every resident has the right to be free from abuse, including abuse by other residents. Staff interviews further established that Resident #1’s aggressive and verbally abusive behaviors were known prior to this incident. The ADON stated Resident #1 had a short fuse, made racist comments to staff, and had been physically aggressive with another resident by shaking that resident’s wheelchair. The DON similarly reported witnessing Resident #1 grab and shake another resident’s wheelchair and described him as having a short fuse, though improved compared to when he first arrived. LVN A described Resident #1 as edgy, impatient, verbally aggressive toward staff and residents, and having threatened to get her fired, and stated it did not surprise her when she learned he had hit another resident. Despite these known behaviors and the facility’s written policy stating that residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property, including abuse by other residents, Resident #1 was able to use his reaching aid to strike Resident #2, resulting in a bruise and constituting physical abuse.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to implement its written abuse policy by not reporting and not thoroughly investigating two separate abuse-related incidents involving two residents on 04/03/26. Resident #1, a male with multiple diagnoses including type 2 diabetes, osteoporosis, hepatic encephalopathy, alcoholic cirrhosis, major depressive disorder, adult failure to thrive, and a history of mental and behavioral disorders, had a BIMS score of 12 indicating moderate cognitive impairment. His care plan, revised shortly before the incident, identified him as physically aggressive related to anger and poor impulse control, with interventions such as early redirection, calm engagement, and staff walking away and re-approaching later. Resident #2, a male with type 2 diabetes, major depressive disorder, and unspecified dementia, had a BIMS score of 8, also indicating moderate cognitive impairment, and was care planned for impaired cognitive function/dementia. On the morning of 04/03/26, staff documented and later described an altercation between Resident #1 and Resident #2 at a portable coffee stand. A progress note by LVN A at 8:38 AM recorded that Resident #1 began verbally and physically getting aggressive when Resident #2 asked for coffee, yelling derogatory words and then getting up and swatting at Resident #2. LVN A and other staff attempted to redirect Resident #1, but he refused and continued yelling. In interviews, CNA B and MA D stated they saw Resident #1 become aggressive, with CNA B reporting that Resident #1 was able to “sort of push” Resident #2 in the chest and LVN A stating that Resident #1 was able to hit Resident #2 on the arm despite her standing between them. Staff reported that the administrator (ADM) was notified and spoke with the residents. However, the DON and ADM later stated they believed there had been no physical contact between the residents, and the ADM acknowledged that, although he said he interviewed staff, he had no documentation of those interviews or any other records to show a thorough investigation beyond the nursing progress note. Later that same day around lunchtime, a second incident occurred involving Resident #1 and the DON. A progress note at 12:15 PM documented that the DON redirected Resident #1 to his room, during which Resident #1 was still yelling, and that once inside the room Resident #1 started throwing kicks and hit the bed frame with his left shin, resulting in a 1 cm skin tear. In interviews, CNA B and MA D stated that Resident #1 later alleged that a “doctor” had rolled him in a chair and banged his leg on the bed, and both indicated that LVN A and the ADM were aware of this allegation. LVN A confirmed that Resident #1 said a doctor had pushed him into the bed and hurt his leg, and that she did not know if he meant the DON, while the DON stated that he only wheeled Resident #1 into the room, that Resident #1 turned his wheelchair on his own, kicked his leg, and then blamed the DON. The ADON stated Resident #1 said the DON had taken him to his room and that he hit his leg, which she interpreted as Resident #1 hitting his leg himself. The ADM stated that Resident #1 gave conflicting accounts, at one point saying the DON rammed him into the bed frame and at another saying he might have kicked the bed himself, and that Resident #1 later called the police and told them somebody had pushed him into the bed frame. The ADM acknowledged that he did not further investigate beyond speaking with Resident #1 and the DON, did not obtain or retain staff statements, and did not report either the resident-to-resident physical contact or the allegation that the DON caused the skin tear to the State Survey Agency, despite the facility’s abuse policy requiring allegations of abuse to be reported and investigated within required timeframes. Resident #2 later told surveyors he was doing well, had no problems, and did not recall the incident or know who Resident #1 was, and he was observed without distress or injury. Resident #1, when interviewed by surveyors, stated that a doctor had brought him to his room and banged his leg into the metal bed frame, causing a bleeding cut that nurses treated, and that he had called the police because he wanted that doctor arrested. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy stated that residents have the right to be free from abuse and that the facility must protect residents from abuse by anyone, develop and implement policies to prevent and identify abuse, and investigate and report any allegations within required federal timeframes. Despite this policy, the DON confirmed that neither the incident between Resident #1 and Resident #2 nor the allegation that the DON caused Resident #1’s leg injury were reported to the State Survey Agency, and the ADM conceded that he had no documentation to demonstrate a thorough investigation of these allegations.

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 immediately report alleged abuse and resident‑to‑resident aggression to the State Survey Agency within the required two‑hour timeframe. One male resident with multiple diagnoses including type 2 diabetes, osteoporosis, hepatic encephalopathy, alcoholic cirrhosis, major depressive disorder, adult failure to thrive, and a history of mental and behavioral disorders had a BIMS score indicating moderate cognitive impairment. His care plan identified physical aggression related to anger and poor impulse control, and a behavior problem related to major depressive disorder with verbal outbursts toward staff and other residents. Despite these identified behaviors and interventions, an incident occurred in which this resident became verbally and physically aggressive toward another male resident with dementia and moderate cognitive impairment while both were at a portable coffee stand. Progress notes and staff interviews reflected that the aggressive resident began yelling derogatory words at the other resident when he asked for coffee, and then began swatting at him. Staff, including an LVN, a CNA, and a medication aide, intervened and attempted to redirect and separate the residents. The LVN reported that the aggressive resident was able to hit the other resident on the arm even though she positioned herself between them, and staff then moved the residents away from each other. The second resident was documented as having no acute distress or abnormalities after the incident and did not recall the event during a later interview. The DON and Administrator were notified of the altercation, but the DON stated he believed there had been no physical contact, and the Administrator stated staff did not tell him that any physical contact had occurred. The incident, which involved an allegation and observation of resident‑to‑resident physical aggression, was not reported to the State Survey Agency. A second unreported allegation involved the same aggressive resident and the DON later that day. According to progress notes and interviews, the DON wheeled the resident to his room around lunchtime. Once in the room, the resident turned his wheelchair, yelled about his leg, and was found to have a 1 cm skin tear on his left shin with minimal bleeding and well‑approximated edges. The resident alleged that a “doctor” had pushed or rammed him into the bed frame, and multiple staff, including a CNA and a medication aide, understood that he was referring to the DON when he said “doctor.” The DON, ADON, LVN, and Administrator were all aware that the resident was alleging that the DON had caused the injury, although the DON and ADON believed the resident had kicked the bed frame himself and noted that the resident’s statements changed back and forth. The Administrator acknowledged that the resident again alleged that somebody had hurt him when speaking with police later that day and stated that, under the facility’s policy requiring allegations of abuse to be reported within two hours, he should have reported the allegation to the State Survey Agency. Despite this, neither the resident‑to‑resident physical aggression nor the allegation that the DON caused the resident’s leg injury was reported to the State Survey Agency as required by the facility’s abuse, neglect, exploitation, and misappropriation prevention policy and federal reporting timeframes. The facility’s written policy stated that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that the facility would protect residents from abuse or mistreatment by anyone, including other residents and staff. The policy further required the facility to investigate and report any allegations within timeframes required by federal requirements. In these two incidents, staff and leadership were aware of an observed physical altercation between residents and an allegation by a resident that a staff member (identified by the resident as a doctor and understood by staff to be the DON) caused a skin tear to his leg. Nonetheless, the Administrator, acting as abuse coordinator, decided not to report either allegation to the State Survey Agency within the mandated two‑hour window, resulting in the cited deficiency for failure to ensure all alleged violations involving abuse, neglect, or mistreatment were reported immediately 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 deficiency involves the facility’s failure to have evidence that all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for two residents. One incident occurred when a resident with moderate cognitive impairment and a history of physical aggression and behavioral problems became verbally and physically aggressive toward another cognitively impaired resident while both were at a portable coffee stand. According to a progress note by an LVN, the aggressive resident began yelling derogatory words, the other resident defended himself, and the aggressive resident got up and started swatting at him. Staff attempted to redirect the aggressive resident, but he refused and continued yelling. Interviews with CNA and medication aide staff indicated that the aggressive resident was able to push the other resident in the chest and hit his arm before staff separated them and moved them away from each other. The DON and ADM were notified, but the DON later stated he believed there had been no physical contact, and the ADM stated staff had not told him that any contact occurred. The second incident involved an allegation that the DON (whom the resident referred to as a doctor) caused a 1 cm skin tear on the aggressive resident’s left shin while taking him to his room later that same day. A progress note documented that the resident, while being redirected to his room by the DON, began throwing kicks and hit the bed frame with his left shin, resulting in a small, well-approximated skin tear. However, multiple staff interviews revealed that the resident repeatedly alleged that a doctor had rolled him in a chair and banged his leg on the bed, and that he wanted that doctor arrested for abuse. The medication aide and LVN both reported that the resident was telling staff that a doctor had hurt his leg, and the ADON recalled the resident saying the DON had taken him to his room and that he hit his leg, though she interpreted this as the resident having hit his leg himself. The DON stated he only wheeled the resident into the room and that the resident turned his own wheelchair, kicked his leg, and then complained of pain, while blaming the DON for pushing him into the bed. The ADM, identified as the abuse coordinator, stated he investigated both incidents but could not produce documentation of a thorough investigation beyond the nursing progress notes. For the resident‑to‑resident altercation, he said he interviewed staff and concluded there was no physical contact, despite staff interviews to surveyors describing pushing and hitting. He acknowledged that the progress notes did not show his investigation process and that he had no records of staff statements. For the allegation that the DON caused the skin tear, the ADM stated he spoke with the resident, who alternated between saying the DON rammed him into the bed and saying he might have kicked the bed frame himself. The ADM also spoke with police after the resident called them, but he did not further investigate by interviewing other staff who were nearby and did not report the allegation to the State Survey Agency. The facility’s abuse policy required investigation and reporting of any allegations of abuse within required timeframes, but the ADM admitted he could have done a better job investigating and had nothing else to show a thorough investigation of these abuse allegations.

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 a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple documented diagnoses and ADL needs. Record review showed that the resident, an older male admitted with type 2 diabetes, major depressive disorder, and unspecified dementia, had an MDS indicating moderate cognitive impairment (BIMS score of 8) and documented needs for supervision or touching assistance with several ADLs, including toileting hygiene, bathing, lower body dressing, footwear, transfers, and ambulation over various distances. Despite these identified conditions and functional limitations, the resident’s care plan, initiated earlier in the admission, only addressed impaired cognitive function/dementia and did not include the diagnoses of diabetes or major depressive disorder, nor did it reflect the resident’s ADL assistance needs. During interviews, the MDS nurse confirmed that the resident’s diabetes, major depressive disorder, and ADL dependence should have been included in the care plan and acknowledged that these elements were missing because she was backed up with care plans and trying to catch up. The DON also confirmed that the resident’s diagnoses and ADLs should have been care planned, even though the resident was more independent, and stated that care plans were developed and updated by the MDS nurse. Observation and interview with the resident showed he was doing well at the time, able to ambulate and communicate needs without distress, and reported that staff treated him respectfully and provided what he needed. The facility’s own policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs, but this was not followed for this 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 maintain an infection prevention and control program when a CNA did not perform hand hygiene while feeding two residents during the same meal service. During a lunch observation on 3/10/2026, CNA A sat between Resident #1 and Resident #2 and used the same right hand to alternately feed both residents without performing hand hygiene between residents. CNA A later acknowledged that residents should be assisted one at a time and that feeding two residents simultaneously without hand hygiene created a possibility of cross contamination. The facility’s own staff education practices included monthly in-services on infection control and weekly reminders on hand hygiene. Resident #1 was an older male with Alzheimer’s disease, dysphagia, and lack of coordination, admitted on 8/06/2025. His MDS assessment showed he required substantial/maximal assistance with eating, and his care plan indicated an ADL self-care performance deficit related to dementia and impaired balance, with an intervention stating he required setup to eat. Resident #2, admitted on 12/10/2024, had diagnoses including cerebral ischemia, muscle weakness, and lack of coordination, and also required substantial/maximal assistance with eating per his MDS, with a care plan noting an ADL self-care performance deficit related to confusion and dementia and an intervention that he required setup to eat. During the meal, LVN B was assigned to oversee lunch, ensure correct diets, and monitor resident safety, but did not notice the CNA’s feeding practice because she was de-escalating another resident situation. The DON stated that CNAs were expected to feed one resident at a time and perform hand hygiene between residents, and that a nurse was assigned to the dining room to monitor infection control practices, but these expectations were not followed during the observed 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 coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for two residents who were identified as PASRR positive. Specifically, the facility did not incorporate the recommendations from the PASRR Level II determination and evaluation report into the residents' care planning. The service request forms were not sent to the state PASRR unit within 30 days of the Interdisciplinary Team (IDT) meeting, which was necessary for the residents to receive the specialized services identified during the meeting. Both residents required total care and assistance with all activities of daily living (ADLs) and had diagnoses including bipolar disorder, anxiety disorder, and severe intellectual disabilities. Interviews with facility staff revealed a lack of understanding and familiarity with PASRR requirements and processes. The MDS nurse, who was responsible for submitting PASRR specialized services, was not employed at the time of the residents' admissions and confirmed that the required submissions had not been made. The ADON and DON both acknowledged limited knowledge of PASRR procedures and the importance of timely reporting. As a result, the residents were not receiving the specialized services recommended by the PASRR process, and the facility's own policy regarding PASRR was not followed.

Penalty

No penalty information released

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

Summary

The facility failed to develop and update comprehensive, person-centered care plans with measurable objectives and timeframes for three residents, as required by policy and regulation. For one resident with end stage renal disease and metabolic encephalopathy, the care plan was not revised after a hospitalization for pneumonia, despite a significant change in condition and new interventions such as nebulizer treatments and oxygen therapy. Documentation showed that the care plan's target dates and interventions were not updated to reflect the resident's most recent hospitalization and treatment needs. Another resident with chronic obstructive pulmonary disease and a tracheostomy received intravenous antibiotics for a positive sputum culture, but the care plan did not identify or address this new treatment. Interviews with staff confirmed that the care plan should have been updated when the antibiotic order was received, and that failure to do so could affect the ability of nurses to provide appropriate care. A third resident with diabetes, hypertension, and moderate cognitive impairment was found to possess cigarettes in his room, but his care plan did not address tobacco use. Staff interviews revealed that although the resident was not identified as a smoker on admission, he did smoke while at the facility, and this should have been included in his care plan. The facility's policy required care plans to be updated upon significant changes in condition, new treatments, or upon readmission from the hospital, but these requirements were not met for the residents involved.

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

Surveyors observed multiple failures in food storage, preparation, and sanitation within the facility's kitchen. Raw chicken was found thawing in a two-compartment sink labeled for vegetables only, without running water, and raw ground beef was placed on the counter next to this sink. Additionally, three clear bags containing meat in the walk-in freezer were not labeled or dated. Inside the reach-in refrigerator, a small box labeled as an employee's medication and a large soft drink cup were found stored alongside food items. These practices were not in accordance with professional standards and the facility's own policies, which require all foods to be covered, labeled, and dated, and prohibit the storage of personal items and medications in food storage areas. Interviews with staff and administration confirmed that the observed practices were not compliant with facility policies or food safety standards. The Dietary Director acknowledged that the meat should have been labeled and dated, and that the medication and soft drink cup should not have been stored in the refrigerator. The staff member whose medication was found in the refrigerator admitted to storing it there without informing management, despite knowing it was not allowed. The administrator confirmed that staff had been in-serviced on these policies and that alternative storage options for personal items and medications were available, such as employee lockers and a lounge refrigerator.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's assessment accurately reflected their status, specifically regarding falls. Record review showed that the resident, who had Alzheimer's disease, muscle weakness, lack of coordination, and hemiplegia/hemiparesis, experienced multiple falls as documented in the care plan and incident log. Despite these documented falls, the resident's most recent quarterly MDS assessment did not indicate any falls since admission or the prior assessment. Interviews with facility staff, including the ADON, DON, and MDS coordinator, confirmed that the MDS assessment was inaccurately coded and did not capture the resident's falls. The staff acknowledged that the MDS should have been updated to reflect the falls, and that the failure to do so could result in the MDS not triggering appropriate interventions for fall risk. The MDS nurse responsible for the inaccurate assessment was no longer employed at the facility. Facility policy and CMS RAI Manual guidelines require that MDS assessments consistently reflect information from progress notes, care plans, and resident observations. In this case, the MDS assessment did not align with the documented incidents and care plan interventions, resulting in an inaccurate representation of the resident's fall history.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate foot care for a resident with multiple medical conditions, including dementia, diabetes mellitus, muscle weakness, and difficulty walking. The resident's toenails were observed to be long, thick, discolored, and curving toward another toe, with staff and podiatrist documentation confirming the inability to trim the nails due to the resident's combative and resistive behaviors. Despite care plan interventions to refer to a podiatrist and monitor foot care needs, there were no documented further attempts to address the toenail issue after an initial refusal, and the resident's condition persisted over several months. Staff interviews revealed that the resident was known to be combative and would not allow staff to provide personal care, including nail trimming, often requiring multiple staff members for basic hygiene tasks. The CNA and LVN both acknowledged the resident's refusal and the risk posed by the untrimmed nails, but also indicated that alternative approaches or interventions, such as medication to facilitate care, had not been attempted. The podiatrist confirmed multiple unsuccessful attempts to provide care, and the responsible family member was aware of the ongoing issue and the need for podiatric intervention. Facility leadership, including the DON and Administrator, were aware of the resident's right to refuse care but had not implemented additional strategies to address the ongoing refusal or to mitigate the risk associated with the resident's foot condition. The facility's policy required staff to attempt to identify underlying causes of care refusal and to try different approaches, but there was no evidence that such measures were consistently or effectively implemented in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident received adequate supervision to prevent accidents and did not maintain an environment free from accident hazards. A male resident with moderate cognitive impairment, as indicated by a BIMS score of 11, and diagnoses including Type 2 Diabetes Mellitus, hypertension, alcohol abuse, and gait abnormalities, was found with a box of cigarettes at his bedside. Facility policy prohibits residents without independent smoking privileges from keeping smoking items in their rooms, requiring such items to be stored securely by staff. Despite this, the resident was able to obtain and keep cigarettes in his room without staff knowledge. Multiple staff interviews confirmed that cigarettes are supposed to be kept locked at the nurses' station or in medication carts, and that residents are not allowed to have them in their rooms. The resident admitted to bringing the cigarettes in his jacket and not informing staff. Staff members, including a CNA and an LVN, reported not seeing the cigarettes during their rounds earlier that day. The DON and Administrator both acknowledged the policy and were unsure how the resident was able to keep cigarettes in his room, noting that the resident may have brought them in after being out on pass.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a licensed vocational nurse (LVN) failed to follow Enhanced Barrier Precautions (EBP) during the administration of medication via a gastrostomy tube for a resident with hemiplegia and gastrostomy status. The resident was severely cognitively impaired, totally dependent on staff for nutrition, and required EBP during high-contact care activities due to the presence of an indwelling medical device. The resident's care plan specified the need for EBP, including the use of gowns and gloves during high-contact activities such as device care. During an observed medication administration, the LVN performed hand hygiene and donned gloves but did not wear a gown as required by the resident's care plan and facility policy. Interviews with the LVN, other nursing staff, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed that staff were aware of the EBP requirements for residents with indwelling devices, and that personal protective equipment (PPE) was available on the linen carts. The LVN acknowledged the oversight and the importance of following EBP to prevent the spread of infection. Facility policy required the use of gowns and gloves for residents with devices such as feeding tubes, but this protocol was not followed during the observed event.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form was properly completed, specifically lacking the required physician's signature. The resident in question had a documented history of metabolic encephalopathy, unspecified dementia, muscle weakness, and bipolar disorder, and was admitted with a code status of DNR. The resident's care plan and physician orders reflected a DNR status, and the OOH-DNR form was signed by the resident's spouse but not by the attending physician, as required by both facility policy and state law. Interviews with facility staff revealed a breakdown in the process for obtaining and verifying the necessary physician signature on the DNR form. The social services staff provided the form to the resident or family and obtained their signatures, then forwarded the form to medical records for physician signature. However, the form was uploaded into the electronic medical record system without the physician's signature, and staff did not recall why this incomplete form was uploaded. The medical records staff confirmed that the physician's signature was only obtained after the surveyor's inquiry, despite the form being received the previous year. Further interviews with nursing and administrative staff indicated confusion and inconsistency regarding when a resident's DNR status should be updated in the electronic record system. Some staff believed that a DNR status in the system indicated a completed and valid DNR, while others acknowledged that without the physician's signature, the DNR was not legally valid. The facility's policy and state requirements both specify that the physician's signature is necessary for the DNR to be honored, but this step was not completed in a timely manner for the resident in question.

Penalty

Fine: $8,821

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 the facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment and multiple diagnoses, including dementia, schizophrenia, Alzheimer's disease, psychosis, muscle weakness, malnutrition, and lack of coordination. The resident, who was independently ambulatory and admitted to a secured unit due to a history of wandering and elopement attempts, was able to leave the facility undetected. On the day of the incident, the resident approached a CNA, who was subsequently distracted by other duties. An alarm sounded from the back door, which the CNA turned off without verifying the cause or notifying a nurse, as required by facility protocol. The resident's absence was not discovered until after a shift change, at which point staff initiated a search and notified the appropriate personnel. The resident was later found by police several miles away from the facility and returned safely. Interviews and record reviews confirmed that the CNA did not follow the elopement protocol, specifically by disabling the alarm and failing to alert nursing staff. The facility's elopement policy required monitoring of residents at risk for elopement and immediate action if an alarm was triggered, but these procedures were not followed, resulting in the resident's unsupervised exit from the secured unit.

Removal Plan

• Resident was placed on 15-minute visual checks by nurse
• Wander guard
• Code changed to the Secure Unit Doors
• Added a camera with motion detection on the back door
• Added a fence to the back of the facility for an extra layer of security
• Staff were trained in elopement/supervision procedures
• The care plan was updated to include a wander guard and medications were reviewed

Penalty

Fine: $8,821

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

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for four residents in the memory unit, as evidenced by multiple observations and interviews. Resident rooms were found to be inadequately cleaned and maintained, with specific issues such as missing or broken fixtures, unpainted and damaged walls, holes in doors, and the presence of food particles and soiled items on the floor. For example, one resident's room had a cracked sink, missing hot water knob, unpainted areas with holes, and brown sticky substances on the floor. Another resident's room contained broken ceiling tiles, soiled toilet paper on the floor, broken blinds, and food debris on various surfaces. Staff interviews revealed that the residents in question had significant cognitive impairments, including dementia, encephalopathy, and schizoaffective disorders, and some exhibited behaviors such as destroying furniture and throwing items on the floor. Despite these known behaviors, staff and housekeeping did not consistently ensure that rooms were cleaned as needed. Housekeeping staff reported only cleaning the memory unit once per day, typically at the end of their shift, and stated that the workload was too great for one person. Staff also indicated that they had notified supervisors about the need for repairs and cleaning, but maintenance and housekeeping supervisors claimed they were unaware of the specific issues. Facility records showed no work orders for repairs or replacement of blinds, fixtures, or wall repairs in the memory unit during the relevant period. The facility's own policy required that rooms be maintained in a safe, functional, and comfortable condition, with all staff responsible for reporting and addressing maintenance and cleanliness issues. However, these policies were not followed, resulting in residents living in rooms that were not thoroughly cleaned or properly maintained.

Penalty

Fine: $8,821

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

Summary

The facility failed to ensure that residents receiving enteral nutrition via feeding tubes were provided with appropriate care and that only trained and authorized staff handled feeding pumps. In one instance, a certified nurse aide (CNA) who was not properly trained and not permitted by facility policy adjusted a resident's feeding pump while providing incontinent care. The resident in question was a female with severe cognitive impairment, total dependence for toileting and personal hygiene, and a history of dysphagia requiring tube feeding. During care, the resident's head was lowered and the feeding machine was placed on hold, after which the CNA restarted the feeding pump without a nurse present. Interviews with CNAs and nursing staff revealed that CNAs were not supposed to pause, stop, or restart feeding pumps, as this was outside their scope of practice and not included in their job description. Both CNAs involved admitted to not being properly trained on feeding pumps, and the Director of Nursing confirmed that only licensed nurses were authorized to handle feeding machines. The facility's policy and job descriptions did not support CNAs performing these tasks, and there was no documentation of training for CNAs on feeding pump operation.

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 all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, were reported to the State Survey Agency within the required time frames. Specifically, staff detected a strong smoke odor from a resident's room and, upon searching, found drug paraphernalia. The LVN who discovered the paraphernalia reported the incident to the ADON, who then notified the Administrator and the police. However, the incident was not reported to the State Survey Agency as required by federal regulations. Interviews with the DON and Administrator revealed that they did not consider the incident reportable because there was no negative outcome and it was not viewed as related to abuse or neglect. The facility's policy requires investigation and reporting of any allegations within federally required time frames, but this was not followed in this case. The resident involved had moderate cognitive impairment and multiple medical conditions, including cerebral infarction and chronic obstructive pulmonary disease.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and that smoking supplies were properly stored, as required by the resident's care plan and facility policy. The resident, an adult male with diagnoses including type 2 diabetes, anxiety disorder, and nicotine dependence, was care planned to have his smoking supplies stored at the nurses' station. Despite this, the resident was observed outside in the parking lot smoking with a box of cigarettes and a lighter in his possession. The resident stated he forgot to return the cigarettes to the CNA the previous night and kept them with him. Interviews with staff revealed that the CNA was responsible for retrieving and returning smoking supplies to the nurses' station during supervised smoking times, and that residents were not supposed to keep smoking items due to fire risk. The DON and Administrator both confirmed that the resident was expected to return smoking supplies after use, and that failure to do so could result in a fire hazard. Facility policy specified that residents without independent smoking privileges may not keep smoking items except under direct supervision.

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 parameters of nutritional status for a resident, resulting in significant weight loss over a three-month period. The resident, a male with a history of bipolar disorder, stroke with dysphagia, diabetes, and malnutrition, was identified as being at risk for nutritional deficit. Despite care plan interventions such as double portions, supplements, and monitoring for signs of malnutrition, the resident experienced an 8.4% weight loss, dropping from 119 pounds to 109 pounds. The facility's computerized records showed no other weights documented during this period, and the resident's nutritional intake was consistently recorded as 76%-100% for all meals reviewed. The dietitian recommended additional interventions, including a multivitamin with minerals and fortified cereal, after noting the significant weight loss. The physician agreed with these recommendations. However, the LVN responsible for implementing the new orders failed to enter them into the electronic medication record system, resulting in the resident not receiving the recommended nutritional support. The LVN acknowledged forgetting to input the orders and was unaware of how the omission occurred. Interviews with facility staff, including the dietitian, LVN, FNP, and DON, confirmed that the resident continued to lose weight despite being on supplements and that the recommended interventions were not carried out due to the missed order entry. The DON stated that weights should be monitored weekly and interventions implemented when weights decline, but this process was not effectively followed for this resident.