The Oaks At Radford Hills Healthcare Center

Penalty

No penalty information released

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

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an observation of the kitchen freezer and refrigerator, surveyors found a large unsealed bag of frozen chicken that was not labeled or dated, a large bag of thawing chicken that was undated and unlabeled, and two bags of chili thawing that were also unlabeled and undated. In the refrigerator, mustard was observed with an opened date of 3/30 and a received date of 2/19. During interviews, the DM stated that all food, even when removed from the original box, should be labeled with the product name and dated when opened, and that failure to do so could cause residents to become sick if the food were contaminated. The ADMN stated staff should have followed the policy on dating and labeling food and that this should be done when delivery was made, even when products were taken out of the original box. The facility policy required refrigerated foods to be dated, labeled, and tightly sealed, and the cited Food Code required food packaged in a food establishment to be labeled with the common name or an adequately descriptive identity statement.

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

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure medications were accurately acquired, received, dispensed, and administered on Hall C and in the medication room. During an observation, the medication cart for Hall C contained a bottle of Nitroglycerin for Resident #19 with an expiration date of 02/13/2026. During the same observation, the medication cart for C Hall contained medication cups with pills that were not labeled, including one cup with a purple pill and a blue pill and another cup with 1 green pill, 1 yellow pill, and 3 white pills. LVN-A stated she did not know who the pills were for or what medication they were, said they must have been left from the night shift, and stated she had not checked the cart before accepting it. She also stated she was the only person with access to the medication cart and that medication should not be placed into a cup until it was about to be given. During a later observation, the refrigerator in the medication room contained 3 vials of Hepatitis B vaccine that expired on 09/03/2025. The DON stated it was her responsibility to perform routine checks of the medication carts for expired medications and to ensure all medications were labeled and dated properly, but she had not had time to complete the audits since becoming DON in December. She stated all expired medication should have been removed from the medication carts and the medication room immediately. She also stated the Hepatitis vaccines were for staff only and that no residents had received the expired vaccines. The facility policy titled Medication Access and Storage stated outdated, contaminated, or deteriorated medications are to be immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy.

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 medications on the medication cart for Hall C were labeled and stored properly when the cart was left unattended. During an observation on 03/18/2026 at 10:47 AM, the medication cart for C Hall was found unlocked with a medication cup containing six pills sitting on top of the cart and the cup was not labeled. LVN-A was in a resident's room while the cart was unlocked and out of sight. During an interview at 10:53 AM, LVN-A stated the cart was hers and that she was responsible for it, and she acknowledged she was supposed to lock the cart when it was not in use or out of sight. LVN-A initially stated the pre-popped pills belonged to the resident in the room she had come out of, then later stated the medication belonged to a different resident. She stated she knew there was a possibility of residents, staff, or visitors taking medications, but said she was in a hurry because a resident had a bowel movement. During an interview on 03/19/2026 at 11:22 AM, the DON stated medications should never be placed into a medication cup and left on the cart, and that medications are to be pulled and placed in cups only at the time of administration and never be pre-set-up. The facility policy stated medications and biologicals are to be stored safely and securely, and medication rooms, carts, and supplies are to be locked or attended by authorized persons.

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, implement, and maintain an effective training program for new and existing staff members. Record review showed that RN-A, CNA-D, CNA-E, and CNA-F had no evidence of required dementia management, HIV, restraint reduction, or fall prevention training upon hire. The same review showed that HK-G and the DOR had no evidence of annual dementia management, HIV, restraint reduction, or fall prevention training, and that AD and Maint had no evidence of annual fall prevention training. Personnel records reflected hire dates for RN-A in 12/2022, CNA-D in 04/2024, CNA-E in 03/2025, CNA-F in 09/2024, HK-G in 06/2001, AD in 11/2004, Maint in 09/2022, and the DOR in 09/2022. The Admn stated the Human Resources Director was responsible for monitoring training compliance and sending notifications when training was due. She also stated there had been three Human Resources Directors hired since June 2025 and that the current Human Resources Director had started two days before the interview. During interviews, the DON stated she did not have access to monitor staff training in the system and expected staff to complete all required training on time. The Admn stated she expected staff to have appropriate training during orientation and annually per regulation, and said the failure was related to a disconnect in onboarding new employees and maintaining training records for existing employees due to turnover in the Human Resources Director position. Facility staff also stated HR sent email reminders when training was due, and the facility policy stated orientation programs and in-service training classes are conducted to assist employees in understanding personnel policies and procedures.

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

Mandatory training on the facility’s QAPI program was not included for all new and existing staff, as required, for 4 of 13 staff reviewed. Personnel records for RN-A, CNA-D, CNA-F, and the AD showed no evidence that they had completed QAPI training upon hire or while working at the facility. RN-A was hired in 12/2022, CNA-D in 04/2024, CNA-F in 09/2024, and the AD in 11/2004, and none of their files contained documentation of QAPI education. During interviews, the DON stated the HR director was responsible for tracking training compliance and that she did not have access to monitor staff training in the system. The DON said her expectation was that staff complete all required training on time and explained that keeping staff current on rules, regulations, and best practices was beneficial so residents received the best care possible. The Admn stated staff should receive appropriate training during orientation and annually per regulation, and that HR was responsible for monitoring compliance and sending notifications when training was due. Staff interviews reflected that HR sent email reminders for training, but LVN-B and CMA-G stated they were not aware that QAPI training was a requirement.

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 drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys for medication carts. During observations, three out of four medication carts were found unlocked and unattended, with residents and staff in close proximity. Specifically, medication carts #1 and #2 were observed unlocked in the early morning with medication drawers facing outward, containing various prescription and over-the-counter medications. The responsible RN admitted to intentionally leaving the carts unlocked in anticipation of the day shift. Later, medication cart #3 was also found unlocked and unattended, with the responsible RN stating she believed she had visual contact with the cart, but her back was turned at the time of observation. She was unaware of the specific medications or the residents for whom they were intended. Interviews with facility leadership, including the administrator and assistant director of nursing, confirmed that all medication carts should have been locked when not in use and that only authorized personnel should have access. Both leaders acknowledged that the failure was due to staff being too busy or inattentive to proper medication storage protocols. Facility policy reviewed indicated that medications must be stored securely and only accessible to licensed or authorized personnel, with medication carts locked when not attended.

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 treat three residents with dignity and respect by not providing timely assistance with hygiene needs, including brief changes and scheduled showers. One resident, who had severe cognitive impairment and was frequently incontinent, was not assisted with a brief change after directly requesting help from nursing staff at the nurses' station. The resident's family member arrived at the facility to find the call light still on and the resident still soiled, with nurses present at the station but not responding. Documentation showed that this resident did not receive showers on any of his preferred days throughout the month, and the care plan specifically required keeping the resident clean and dry to minimize skin exposure to moisture. Two additional residents, both with moderate cognitive impairment and requiring assistance with hygiene, also did not receive showers on their preferred days for the entire month. Both reported only receiving showers infrequently, with staff citing short staffing as the reason. Observations confirmed foul odors coming from these residents and their rooms, and both residents expressed embarrassment and frustration over their hygiene and the lack of response to their needs. Both had reported their concerns to management, but no changes were made. Interviews with staff confirmed ongoing issues with short staffing, lack of nurse participation in direct care, and failure to answer call lights in a timely manner. The ADON acknowledged that there was no effective system for tracking or documenting showers, and that nurses were not thorough in documenting refusals. Resident council meeting minutes further corroborated these issues, with multiple residents voicing concerns about not receiving showers and call lights not being answered. Observations during the survey also noted multiple call lights ringing with nurses present at the station but not responding.

Penalty

No penalty information released

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

Summary

The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by direct care staff hours falling below the required levels on multiple days. On specific dates, the number of direct care staff hours worked was significantly less than what was needed based on the facility's PPD budget and resident census. This shortfall resulted in inadequate care for residents, particularly in areas such as hygiene and timely response to call lights. Multiple residents with significant care needs, including severe cognitive impairment, incontinence, and mobility limitations, did not receive scheduled showers or timely assistance with hygiene. Documentation showed that several residents missed their preferred shower days repeatedly throughout the month, and interviews with residents and their families confirmed that showers were often skipped due to short staffing. Residents reported having to wait extended periods for assistance with soiled briefs, and some were observed to be in dirty briefs or in rooms with foul odors. Family members and residents consistently stated that staff cited short staffing as the reason for missed care. Staff interviews corroborated these findings, with CNAs reporting that it was nearly impossible to complete all required tasks, including showers and answering call lights, due to insufficient staffing levels. The ADON acknowledged that three CNAs were not enough to meet resident needs, especially during mealtimes. Resident Council meeting minutes further documented ongoing concerns about inadequate staffing, missed showers, and delayed call light responses. The facility's own assessment tool indicated that staffing assignments were based on acuity and needs, but actual staffing did not meet these requirements on the reviewed days.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately or within the required timeframe to the administrator and appropriate authorities. Specifically, two residents were found in possession of illegal drugs (methamphetamine) and were attempting to smoke them inside the facility. The incident was not reported to the state agency as required by both state policy and the facility's own procedures. One resident, with a history of bipolar disorder, stimulant use, and nicotine dependency, was admitted to the facility and had previously asked other residents if they had connections to obtain methamphetamine. This behavior was reported internally to the DON, ADON, and Administrator. On the day of the incident, the resident left the facility, returned, and was found with another resident in a room with smoke and drug paraphernalia. The DON and Administrator confiscated the drugs and notified the police, but no report was made to the state agency. The second resident, with a history of liver cancer and bipolar disorder, was also involved in the incident and admitted to being offered methamphetamine by the first resident. Interviews with facility staff, including the Administrator and DON, revealed that they did not consider the incident reportable because they believed the drugs were not ingested and no harm occurred. There was no investigation conducted beyond confiscating the drugs and notifying the police. The facility's policy and state guidelines require reporting of such incidents, especially those that pose a threat to resident health and safety, but this was not followed 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 develop and implement comprehensive, person-centered care plans for two residents following incidents involving illegal drug use. Both residents had documented histories of behavioral health issues, including bipolar disorder and stimulant use, and were found in possession of and attempting to smoke methamphetamine within the facility. Despite these incidents, their care plans were not updated to reflect substance abuse or drug-seeking behaviors, nor were new interventions or measurable objectives added to address these new risks. For the first resident, records showed that after admission, the baseline care plan only addressed general behavioral needs and adjustment to the facility, with no mention of substance abuse. Progress notes documented that the resident sought methamphetamine from others and was later found with a suspicious substance and paraphernalia in another resident's room. The incident was reported to facility leadership and law enforcement, but the comprehensive care plan remained incomplete and did not address the substance abuse incident. The second resident, who also had a history of behavioral symptoms and nicotine dependency, was found in a similar situation with the first resident, attempting to smoke methamphetamine. The care plan for this resident focused on previous behavioral issues such as leaving the facility without signing out and not following the smoking policy, but did not include any interventions or objectives related to substance abuse following the incident. Facility policy required care plans to be updated with measurable objectives and timeframes after such events, but this was not done for either 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 ensure that all drugs and biologicals were stored securely in permanently affixed compartments, as observed during a medication storage inspection. Specifically, medication cart #2 was found unlocked and unattended, with residents and visitors in close proximity. During an interview, the ADMN acknowledged the cart should have been locked at all times when not in use. LVN A, who was responsible for the cart, admitted to leaving it unlocked while assisting a CNA with resident care, forgetting to secure it. This oversight could have allowed unauthorized access to medications. The DON and ADON both emphasized the importance of keeping medication carts locked to prevent unauthorized access, which could lead to medication errors or drug diversion. The facility's policy on the security of medication carts mandates that they be locked during medication passes and when not in use. The policy also specifies that carts should be parked in a way that minimizes unauthorized access. Despite these protocols, the failure to lock the cart was attributed to a lapse in adherence to the policy, possibly due to hurriedness or lack of attention to detail.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that a resident, identified as Resident #54, was free from neglect, as evidenced by an incident where the resident left the building unnoticed by staff. Despite the wander guard alarm sounding at the exit door, staff did not take immediate action to prevent the resident's elopement. The resident, who had severe cognitive impairment and required supervision, exited the facility and was later found wandering outside by members of the public. The incident occurred when the resident pushed on the emergency exit door, triggering the alarm. However, staff, including CNA A, did not perform a head count or adequately respond to the alarm. CNA A assumed another resident had set off the alarm and did not verify the whereabouts of all residents. Additionally, two nurses at the nursing station did not respond to the alarm due to a lack of knowledge of the door codes. Interviews revealed that the facility's staff were desensitized to the alarm due to frequent false alarms caused by another resident. The facility's policies and procedures for handling such situations were not effectively communicated to agency staff, and there was a lack of training on door codes and elopement procedures. This oversight led to a delay in realizing the resident was missing, and the resident was exposed to potential harm while outside the facility.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to implement its written policies and procedures to prevent neglect, resulting in a resident with severe cognitive impairment leaving the building unnoticed. The resident, who was wearing a wander guard, exited through a 15-second emergency exit door, triggering an alarm that went unaddressed by staff for several minutes. Despite the alarm sounding, staff did not perform a head count or follow the emergency procedure for a missing resident, allowing the resident to remain outside the facility for over two hours. The resident was eventually found by members of the public, who noticed her wandering in a nearby apartment complex. The resident was cold, shivering, and appeared confused. The public identified the resident's wander guard and contacted the facility, prompting the Assistant Director of Nursing (ADON) to retrieve the resident. Upon return, the resident was assessed and found to have no injuries, but the facility's failure to monitor and supervise residents with known elopement risks was evident. Interviews with staff revealed a lack of knowledge and training regarding door codes and procedures for responding to door alarms. Agency nurses and other staff members were unaware of the necessary actions to take when an alarm sounded, leading to a delay in response and failure to ensure resident safety. The facility's neglect in addressing the alarm and conducting a timely head count contributed to the resident's unsupervised absence and potential risk of harm.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to provide adequate supervision and assistive devices to prevent accidents for two residents. One resident, who had a history of exit-seeking behaviors and severe cognitive impairment, managed to elope from the facility. The resident exited through a 15-second emergency exit door, which sounded an alarm. However, the alarm was not promptly addressed by the staff, leading to the resident being found wandering outside in the rain and cold by a member of the public. The resident was eventually returned to the facility without injuries but was exposed to potential harm due to the lack of immediate response from the staff. The staff's inaction was evident as the alarm was ignored for an extended period, and a headcount was not conducted immediately after the alarm was deactivated. The CNA who responded to the alarm did not perform a headcount, assuming another resident had set off the alarm. Additionally, two nurses at the nurse's station did not respond to the alarm because they were unaware of the door codes. This lack of knowledge and response contributed to the resident's prolonged absence from the facility. Another deficiency was noted regarding the improper storage of smoking materials for a resident listed as a smoker. The resident was observed with a lighter and cigarette in his possession, which was not provided by the supervising staff. This oversight posed a risk of accidents related to smoking materials, highlighting the facility's failure to ensure the safe storage and supervision of such items.

Removal Plan

• Resident #54 returned to the nursing home. Resident was assessed with no injuries. Resident behaving per norm. Increased supervision implemented with Resident #54 which included resident in line of sight of an employee at all times until discharge. Elopement assessment updated. RP & MD informed.
• Resident head count performed no additional findings.
• All residents received an elopement assessment. Residents' current elopement assessment will reflect on their face sheet and care plan.
• Elopement binder reviewed to ensure it matches the current residents who were deemed as elopement risks per their elopement assessments.
• Sign on door verified for placement notifying visitors to, Please do not allow residents to follow you out.
• Sign posted by keypads stating: When alarms were sounding, and the door was disengaged perform a resident head count.
• All doors checked for functionality. No concerns noted.
• Check for all residents with roam alerts for functionality. No concerns noted.
• Elopement drill performed each shift.
• Education provided to direct care staff, to include agency staff, regarding missing resident/elopement & over the facility's abuse & neglect policy. Direct care staff will be educated on the elopement binder, its location, and its contents (shows which residents were elopement risks/wander guard residents). Direct care staff, including agency staff, will know when the door was alarming, to respond to the alarming door immediately. If the door was disengaged (open) and alarming the direct care staff will ensure all residents were in house by performing a head count (signs placed for reminders for staff to ensure all residents were in house when alarms were sounding, and the door was disengaged by keypads). Direct care staff, including agency staff, will know the door codes/door code location through this education. Direct care employees will be educated prior to working their next shift. All new and temporary direct care staff will be educated prior to working.
• Residents deemed an elopement risk, that require a roam alert/wander guard will be rounded on every 2 hours to ensure facility was aware of residents' whereabouts.
• All residents with exit seeking behaviors will be reviewed during clinical meeting to ensure safety. Appropriate supervision will occur until residents with exit seeking behaviors, that have a greater need than the roam alert system, were appropriately placed. No concerns noted.
• Elopement drill performed weekly to ensure staff's retention of education to prevent recurrence.
• Ad hoc QAPI performed with medical director to inform them of the incident and the facility's plan to remove the immediacy. No further direction required.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on specific dates. This failure was identified during an interview with the DON, who admitted to working the floor on six occasions due to staffing shortages. The DON stated that she was unaware of the regulation prohibiting her from working as a charge nurse and mentioned that corporate had instructed her to ensure floor coverage, even if it required her to work the floor. The DON also noted that working the floor prevented her from performing her administrative duties effectively. The Administrator (ADMN) confirmed that the DON frequently worked as a charge nurse due to staffing shortages and was also unaware of the regulation. The facility's policy for RN/DON coverage was requested but not provided. This lack of administrative oversight left residents without the necessary nursing administrative oversight that only the DON could provide, as the DON was occupied with charge nurse duties.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to promptly resolve grievances for 12 of 12 confidential residents reviewed for grievances. The residents reported that they were aware of how to file a grievance, but the concerns voiced during Resident Council meetings were not addressed, and resolutions were not communicated back to them. This lack of communication led to feelings of frustration among the residents, with one resident expressing that they no longer attended meetings because they felt it was ineffective. Record reviews of Resident Council meeting minutes from August to November 2024 revealed multiple unresolved issues, including delayed response to call lights, insufficient staff at night, and dietary discrepancies. Despite these concerns being documented, there was no evidence in the grievance logs that these issues were formally addressed or resolved. Interviews with staff, including the Social Worker (SW), Director of Nursing (DON), and Activities Director (AD), revealed a lack of clarity and communication in the grievance process, contributing to the unresolved grievances. The facility's grievance policy required grievances to be recorded and resolved within three working days, with findings communicated to the resident or their representative. However, the SW and DON admitted to lapses in following up with residents and completing the grievance process. The Administrator (ADMN) acknowledged the need for a more effective grievance handling process and recognized that unresolved grievances could lead to resident frustration.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans for four residents, which resulted in deficiencies in addressing their specific medical needs. Resident #6, a female with severe cognitive impairment, had a care plan that included continuous oxygen use but lacked any mention of nebulized breathing treatments, despite having a physician's order for such treatments. Observations revealed that her nebulizer was not stored properly, indicating a lack of adherence to care protocols. Resident #30, a male with moderate cognitive impairment, had a care plan that did not include oxygen therapy, even though there was a physician's order for continuous oxygen via nasal cannula. Observations showed that his oxygen equipment was not properly maintained, as the nasal cannula was found on the floor, and the nebulizer was not stored in a bag. This oversight in care planning and equipment management could lead to inadequate respiratory care. Resident #68, a female with a tracheostomy, did not have a comprehensive care plan addressing her trach maintenance and care needs until after the surveyors' entrance. Additionally, Resident #43, a female with no cognitive impairment, had a care plan that failed to document her preference to sleep in a recliner, which was a significant aspect of her care needs. Interviews with staff revealed a lack of communication and understanding of care plans, with some staff unaware of where to find them, leading to confusion about the care required for residents.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and residents' choices, as evidenced by the lack of availability of resident wipes. Observations revealed that cases of resident wipes were stored in the Director of Nursing's (DON) office, with supply closets on multiple halls lacking wipes. Interviews with staff, including CNAs and LVNs, confirmed that wipes were kept in the DON's office, and staff had to request them, often facing shortages during shifts. This practice led to the use of paper towels and toilet paper for resident care, which was not in line with the facility's policy for perineal care. Residents expressed dissatisfaction during a confidential meeting, with all 12 residents reviewed for quality of care reporting issues with the availability of wipes and briefs. Some residents had to personally request wipes from the DON or Assistant Director of Nursing (ADON). The DON acknowledged a shortage of wipes and admitted to not ordering them in time, resulting in insufficient supplies. The ADON noted that the lack of wipes could lead to skin breakdown and infection, emphasizing the importance of using wipes for resident care. The facility's admission agreement and perineal care policy highlighted the necessity of providing adequate supplies for resident care, which was not met in this instance.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of inadequate care and unmet resident preferences. Resident #30, a female with severe cognitive impairment and mobility issues, did not receive her preferred bathing schedule on several occasions, with no documentation of refusals. Similarly, Resident #37, who requires extensive assistance, also missed her preferred bathing days, indicating a lack of adequate staffing to meet these basic care needs. The facility's staffing records revealed consistent shortfalls in direct care staff hours compared to the required hours based on the facility's assessment and census. This staffing inadequacy was corroborated by resident council meeting minutes, which documented numerous complaints about delayed call light responses, insufficient aides, and unmet care needs. Additionally, a confidential group meeting with residents highlighted prolonged wait times for call light responses, leading to incidents of incontinence and potential health issues like urinary tract infections. Further compounding the issue, Resident #54, who has severe cognitive impairment, was able to exit the facility unsupervised, resulting in a police intervention to return her. Interviews with staff and management revealed systemic issues in staffing management, with the Director of Nursing and Administrator acknowledging the challenges in maintaining adequate staffing levels. The facility's reliance on agency staff and the lack of a robust system to address staffing concerns contributed to the ongoing deficiencies in resident care.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for each resident, specifically for one resident who was on anti-psychotic medication. The deficiency was identified during a review of records and interviews, which revealed that there was no documentation of a medication regimen review for the resident's anti-psychotic medication since the last survey. This oversight could potentially place the resident at risk of not having their medications reviewed for appropriate dosing or pharmacy recommendations implemented. The resident in question was a female with a history of schizoaffective disorder, bipolar type, and dementia, who was prescribed Abilify (aripiprazole) 10mg to be taken at bedtime. Despite a request for a gradual dose reduction in March 2024, there was no evidence of pharmacy recommendations or physician review of these recommendations. Interviews with facility staff, including the ADON and DON, revealed that documentation prior to July 2024 was missing, and there was no proof that the medical director had been notified of the GDR recommendation. The facility's policy required the attending physician and psychiatric provider to lead medication management, including evaluating residents for gradual dose reductions unless clinically contraindicated.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to adhere to the posted menus for two consecutive meals, which were observed on 11/18/24 and 11/19/24. On 11/18/24, the lunch menu intended for Monday was not served; instead, the menu planned for Tuesday was provided without informing the residents. Similarly, on 11/19/24, the supper menu was not followed, and residents were not notified of the substitution. These deviations from the planned menu were not communicated to the residents, which could potentially affect their nutritional intake. Interviews revealed that the Dietary Manager (DM) decided to switch the menu due to a few residents' requests to avoid pork, but this change was not communicated to all residents. A group of 12 residents expressed dissatisfaction with the inconsistency of the menu, stating that they often relied on the posted menu to make meal decisions. The Administrator (ADMN) was unaware of these changes and acknowledged that such deviations could disrupt meal planning and food ordering processes. The facility's policy emphasizes the importance of following a standardized menu to ensure nutritional adequacy, which was not adhered to in these instances.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to adhere to professional standards for food storage and preparation, as observed during a survey. In the kitchen's freezer, several food items, including pork loins, bread, turkey pot roast, and tater tots, were found without labels or open dates, which is against the facility's policy. The Dietary Manager (DM) acknowledged that all food should be labeled with expiration and receipt dates to prevent serving expired food, which could lead to illness. Additionally, the facility did not ensure proper hand hygiene among dietary staff during meal preparation. An employee was observed exiting and re-entering the kitchen without washing her hands, handling trash, and preparing food without proper handwashing or changing gloves between tasks. The DM confirmed that the staff was expected to wash hands frequently and change gloves between tasks to prevent cross-contamination and infection spread. Despite recent in-service training on hand hygiene, these practices were not followed, posing a risk of foodborne illness to residents.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by improper peri-care and hand hygiene practices observed among three CNAs during care for two residents. CNA-B and CNA-C were observed performing peri-care on a male resident with severe cognitive impairment and a chronic ulcer, using improper techniques such as wiping from back to front and reusing wipes. Additionally, they did not perform hand hygiene between glove changes, increasing the risk of infection. In another instance, CNA-B and CNA-D provided peri-care for a female resident with moderate cognitive impairment and irritant contact dermatitis. They failed to wash their hands or use hand sanitizer throughout the procedure. CNA-D was also observed folding wipes multiple times and using them repeatedly before discarding, and she did not change her gloves before touching the resident's call light and bed control, further compromising infection control. Interviews with the CNAs revealed awareness of the correct procedures, but they cited reasons such as nervousness and insufficient glove supply for their lapses. The Director of Nursing acknowledged the deficiencies, attributing them to a lack of standard training procedures and monitoring, which could lead to cross-contamination and serious health risks for residents.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that four out of sixteen employees received the required effective communication training. Specifically, the Director of Nursing (DON) and Certified Nursing Assistant (CNA B) did not complete this training during their orientation, while Registered Nurse (RN I) and Licensed Vocational Nurse (LVN F) did not complete it annually. This lack of training was identified through interviews and record reviews, which revealed no evidence of completed training in the employee files. CNA B confirmed during an interview that she had not undergone orientation or completed a checkoff list before starting work on the floor, as the DON allowed her to begin working immediately due to her prior experience as a CNA. Interviews with the facility's Compliance and Human Resources Leader (CHRL) and Administrator (ADMN) highlighted systemic issues in ensuring staff training. The CHRL acknowledged that the DON and CNA B had only recently completed their communication training, while RN I and LVN F had not completed their annual training. The CHRL attributed these failures to recent changes in the leadership team, which disrupted the routine monitoring of training. The ADMN expressed an expectation for staff to receive required training but noted that the responsibility for ensuring training completion lay with HR and corporate HR. The ADMN also mentioned that the impact of incomplete training on residents depended on the employees' prior experience, and he had not observed significant negative effects from the training lapses.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that two employees, RN I and LVN F, received the required annual training on resident rights. Record reviews of the employees' files showed no evidence that these staff members had completed the necessary training. RN I was hired on 9/27/2022, and LVN F was hired on 2/22/2023, yet neither had completed the mandatory training by the time of the survey. This oversight could potentially place residents at risk of receiving care from staff who are not adequately trained in resident rights. Interviews with facility staff revealed a lack of clarity and accountability regarding the responsibility for ensuring training compliance. The CHRL acknowledged that RN I and LVN F did not complete the training and mentioned that department heads are responsible for their staff's training, with the ADMN ultimately holding supervisors accountable. The ADMN expressed an expectation for staff to receive required training but noted that HR and corporate HR were responsible for monitoring training completion. Changes in the leadership team were cited as a factor contributing to the failure in training compliance.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that two employees, RN I and LVN F, received the required annual training on abuse, neglect, exploitation, and misappropriation of resident property, as well as dementia management. This deficiency was identified through interviews and record reviews, which revealed that there was no evidence of these employees completing the necessary training. The CHRL acknowledged that the training was not completed and attributed the oversight to recent changes in the leadership team, which disrupted the routine monitoring of staff training. The responsibility for ensuring that staff received the required training was shared among department heads, HR, and ultimately the ADMN, who should hold supervisors accountable. During interviews, the ADMN expressed that the expectation was for all staff to receive the required annual and orientation training. However, he was unaware of why the training was not completed prior to his tenure at the facility. The ADMN indicated that HR was responsible for ensuring training completion, with corporate HR monitoring the process. Despite the lack of training, the ADMN had not observed significant negative effects on residents, suggesting that the impact might vary depending on the employees' prior experience. The facility's assessment tool and policy documents highlighted the importance of staff training and competencies, yet the failure to adhere to these requirements placed residents at risk.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that four out of sixteen employees received the required infection prevention and control program training. Specifically, the Director of Nursing (DON) and a Certified Nursing Assistant (CNA B) did not complete the training during their orientation, while a Registered Nurse (RN I) and a Licensed Vocational Nurse (LVN F) did not complete the training annually as required. This lack of training was identified through interviews and record reviews, which revealed no evidence of completed training in the employee files. Interviews with staff highlighted systemic issues in the training process. CNA B reported that she was placed on the floor without completing orientation or a checkoff list, as the DON allowed her to work immediately due to her prior experience as a CNA. The Corporate Human Resources Leader (CHRL) acknowledged that the DON and CNA B eventually received training, but there was no documentation of when it occurred. The CHRL also noted that RN I and LVN F did not complete their annual training. The Administrator (ADMN) expressed that training completion was expected but was not aware of why it was not done before his tenure. The ADMN indicated that HR was responsible for ensuring training completion, with corporate HR monitoring the process. The facility's assessment tool outlined the necessity of staff training and competencies, but recent leadership changes were cited as a factor contributing to the oversight in training compliance.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that four out of sixteen employees received the required compliance and ethics training. Specifically, the Director of Nursing (DON) and a Certified Nursing Assistant (CNA B) did not complete this training during their orientation, while a Registered Nurse (RN I) and a Licensed Vocational Nurse (LVN F) did not complete their annual training. This lack of training was identified through interviews and record reviews, which revealed no evidence of completed training in the employee files. Interviews with staff highlighted systemic issues in the training process. CNA B reported that she was placed on the floor without completing orientation or a checkoff list, as the DON allowed her to start working immediately due to her prior experience as a CNA. The facility's Compliance and Human Resources Lead (CHRL) confirmed that the DON and CNA B eventually received training, but RN I and LVN F did not complete their annual training. The CHRL noted that department heads are responsible for ensuring their staff receive necessary training, and recent leadership changes may have contributed to the oversight. The Administrator (ADMN) acknowledged the expectation for staff to complete required training but attributed the oversight to HR and corporate HR's monitoring responsibilities.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to notify a resident's guardian in writing before transferring the resident to another facility. The resident, a female with severe cognitive impairment and multiple diagnoses including hypertensive heart disease and schizoaffective disorder, was transferred to a facility with a locked unit due to being an elopement risk. The transfer occurred without prior written notice to the resident's guardian or the State Long-Term Care Ombudsman, as required by regulations. The guardian was not informed of the transfer until several days later, which could have caused emotional distress to the resident due to the lack of visitors. Interviews with facility staff revealed a breakdown in communication and responsibility. The social worker acknowledged failing to notify the guardian and admitted to dropping the ball on this responsibility. The Assistant Director of Nursing (ADON) completed the discharge summary and prepared the resident for transfer but did not contact the guardian, believing it was the social worker's responsibility. The facility's policy requires documentation of discussions with the resident or their representative, which was not adhered to in this case.

Penalty

Fine: $23,2301 days payment denial

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

Summary

The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) discharge assessment was electronically transmitted to the Centers for Medicare & Medicaid Services (CMS) System for a resident whose records were reviewed for closed records. Specifically, the discharge MDS assessment for a resident was not transmitted to CMS within the required 14 days of completion. This oversight could potentially place residents at risk by not providing complete and specific information necessary for payment and quality measure purposes. The resident in question was a male with a history of chronic obstructive pulmonary disease, hypokalemia, malignant neoplasm of the colon, and pain, who was discharged to another facility. The MDS Coordinator and the Regional MDS Coordinator both acknowledged the failure to transmit the discharge MDS within the proper timeframe but did not know the cause of the failure. The Director of Nursing (DON) was also unaware of any discharge MDS not being transmitted in a timely manner. The facility's policy requires all MDS assessments to be completed and transmitted in accordance with current OBRA regulations, and staff responsible for MDS completion are trained accordingly.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the medical record was complete and accurately documented for a resident reviewed for resident records. Specifically, the facility did not ensure that a Certified Nursing Assistant (CNA) accurately documented the dinner meal intake for the resident. This discrepancy was identified during an observation where the Assistant Director of Nursing (ADON) fed the resident, who only consumed 1-2 bites of her meal, yet the meal intake log inaccurately indicated that the resident ate 75-100 percent of her dinner. The resident in question was a female with severe cognitive impairment, requiring extensive assistance for daily activities, and was on hospice care with a Do Not Resuscitate (DNR) order. Her diet was specified as regular fortified food with puree texture and thin fluid consistency. During an observation, it was noted that the resident was unable to swallow her food and required assistance to take drops of water, indicating a significant decline in her ability to eat independently. Interviews with the ADON, Director of Nursing (DON), and the Administrator revealed that the expectation was for accurate and timely documentation of diets by the person providing care. The CNA responsible for the inaccurate documentation admitted to making a mistake due to being in a hurry and acknowledged the importance of accurate documentation, especially for residents with specific dietary needs. The facility's policy on charting and documentation emphasized the need for complete and accurate records to facilitate communication among the interdisciplinary team regarding the resident's condition and response to care.

Penalty

No penalty information released

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

Summary

The facility failed to inform the representative of a resident about a significant change in the resident's physical status and the need to alter the resident's treatment. Specifically, the facility did not notify the resident's legal guardian of a hospital transfer, which occurred due to the resident's altered mental status. The resident, a female with a history of diabetes, amputation of the left leg, and altered status, was admitted to the hospital for a UTI and metabolic encephalopathy. The resident's electronic progress notes did not show any evidence of notification to the resident's representative about the hospital transfer. Interviews conducted during the investigation revealed that the facility's staff, including the Director of Nursing (DON) and the Administrator, acknowledged the failure to notify the resident's representative. The DON attributed the failure to a lack of communication between nursing staff, exacerbated by the use of agency staff, which led to gaps in communication. The facility's policy required prompt notification of changes in a resident's condition to the resident, their physician, and their representative, but this was not adhered to 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 safe, clean, comfortable, and homelike environment for two residents, leading to unsanitary and potentially harmful living conditions. Resident #2's room and bathroom were observed to be in poor condition, with discolored and stained tiles, a wet and stained floor, and a dirty oxygen machine. The resident, who is legally blind and has moderate cognitive impairment, struggled with mobility and incontinence, contributing to the uncleanliness of his environment. Interviews with staff revealed that while housekeeping was performed daily, the resident's blindness and frequent spills were not adequately accommodated, resulting in persistent unsanitary conditions. Resident #6's room and bathroom were also found to be in disrepair, with broken and cracked tiles around the toilet, a loose toilet base, and exposed drywall. The resident, who has severe cognitive impairment, was observed in a room with a pulled-back cover base and a sticky pink liquid stain on the wall. The maintenance supervisor acknowledged the unacceptable state of the bathroom and identified a breakdown in communication regarding work orders, exacerbated by the use of untrained agency staff. Interviews with facility staff, including the administrator and director of nursing, confirmed the unacceptable conditions in both residents' rooms and bathrooms. The maintenance policies and procedures were not effectively implemented, as evidenced by the lack of timely repairs and cleaning. The facility's failure to maintain a dignified and sanitary environment for its residents was acknowledged by multiple staff members, highlighting a need for improved communication and adherence to maintenance protocols.

Penalty

No penalty information released

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

Summary

The facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for a resident who was discharged home. This oversight was identified during a review of the resident's records and interviews with facility staff. The resident, a male with a history of osteomyelitis, shortness of breath, type 2 diabetes mellitus, and hypertension, was discharged against medical advice with his prescriptions and personal items. A family member assisted with the discharge, and the resident was in stable condition at the time of discharge. The facility's policy requires that a copy of the transfer or discharge notice be sent to the Ombudsman at the same time it is provided to the resident and their representative. However, the facility had not sent any 30-day discharge notices or transfer/discharge reports to the Ombudsman since March. Interviews revealed that the social worker, who was new to the role, was unaware of her responsibility to send these notices. The facility's failure to send the required notice could affect residents by limiting their access to advocacy services and appeal processes.

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 care plan for a resident who frequently went out on pass for personal needs. The resident, a male with a diagnosis including respiratory failure, unsteadiness on feet, and lack of coordination, had a BIMS score indicating moderate cognitive impairment. Despite leaving the facility 17 times between specific dates, there was no care plan in place to address his outings. The administrator and DON both acknowledged the oversight, with the administrator assuming the care plan was in place and the DON admitting that the resident was missed during recent audits for care plan updates. The MDS coordinator also believed the resident was going out with a friend, not on his own, and confirmed that such outings should be included in the care plan. The facility's policy requires a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident. This failure could place residents at risk of not receiving the care required to meet their individualized needs.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that orders were provided for the immediate care and needs of a resident. Specifically, the facility did not obtain a physician's order to allow a resident to go out on pass daily. The resident, a male with a diagnosis including respiratory failure, unsteadiness on feet, and lack of coordination, had a moderate cognitive impairment as indicated by a BIMS score of 8. Despite leaving the facility 17 times between specific dates, there was no physician order in place for these passes. The physician overseeing the resident stated he had not received any request regarding the resident going out on pass and would have concerns due to the resident's cognitive behavior and steadiness on his feet. The Director of Nursing (DON) acknowledged that the facility had been conducting audits on all residents for updates and changes but admitted that this resident was missed. The DON explained that the normal process involves a request by family or the resident, an assessment, and then sending it to the physician for an order, which did not occur in this case. The facility's policy requires verifying or obtaining a physician's order for a resident to leave the facility, which was not followed, potentially putting the resident at risk of missing medications or getting hurt while not under the facility's supervision.

Penalty

Fine: $148,55119 days payment denial

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

Summary

The report highlights a significant deficiency in a nursing home facility related to inadequate supervision and assistance to prevent accidents, specifically falls. The facility failed to ensure that three residents, identified as Resident #1, Resident #2, and Resident #3, received appropriate supervision and interventions to prevent falls. Resident #1, a male with multiple comorbidities including heart disease and COPD, experienced five falls within a 19-hour period, leading to hospitalization and subsequent death due to a subarachnoid hemorrhage and lumbar spine fracture. Despite being identified as a high fall risk, Resident #1 did not have appropriate interventions in place, such as 1:1 supervision, leading to multiple falls and serious injuries. Similarly, Resident #2, a female with a history of repeated falls and muscle weakness, had a documented high fall risk but did not have appropriate interventions in her care plan to prevent falls. Resident #3, another female resident with hemiplegia and muscle weakness, also experienced a fall due to inadequate supervision. The facility's failure to update care plans with fall risk assessments and implement resident-centered interventions for these high-risk residents contributed to the deficiency in preventing accidents and ensuring adequate supervision.

Penalty

Fine: $148,55119 days payment denial

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

Summary

The facility failed to develop a baseline care plan within 48 hours of admission for two residents, placing them at risk of not having continuity of care. Resident #2, a [AGE] year-old female with diagnoses including repeated falls, muscle weakness, anxiety, and depression, was admitted on 03/05/2024. Her clinical record revealed no evidence of a baseline care plan. Similarly, Resident #4, a [AGE] year-old male with diagnoses including kidney disease, heart disease, and amputation, was admitted on 03/22/2024, and his clinical record also lacked a baseline care plan. Both residents' MDS assessments indicated varying levels of cognitive impairment, with Resident #2 showing moderate cognitive impairment and Resident #4 showing no cognitive impairment. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed confusion and miscommunication regarding the responsibility for initiating baseline care plans. The DON believed that floor nurses were responsible for starting these plans, while the MDS Coordinator stated that the DON and Assistant Director of Nursing (ADON) were responsible. The DON admitted to starting Resident #2's baseline care plan but was unaware that it had not been submitted. The facility's policy, revised in December 2016, mandates that a baseline care plan be developed within 48 hours of admission to meet the resident's immediate needs, but this was not adhered to in these cases.

Penalty

Fine: $148,55119 days payment denial

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their fall risks. Resident #2, a [AGE] year-old female with diagnoses including repeated falls, muscle weakness, anxiety, and depression, was admitted on 03/05/2024. Despite a high fall risk score of 55% on the Morse Fall Scale and two documented falls, her care plan did not reflect any fall risk or interventions. Similarly, Resident #3, a [AGE] year-old female with hemiplegia, muscle weakness, anxiety, and lack of coordination, had a high fall risk score of 70% and experienced a fall, yet her care plan also lacked any mention of fall risk or interventions. Interviews with facility staff revealed significant miscommunication and confusion regarding responsibilities for updating care plans. The DON believed that floor nurses were responsible for initiating and updating care plans with acute and new issues, while the MDS Coordinator only added care areas triggered by the MDS completion. This miscommunication resulted in the failure to include fall risks and appropriate interventions in the care plans for both residents. The facility's policy on comprehensive person-centered care plans requires measurable objectives, timeframes, and a thorough overview of the resident's care and needs. However, the care plans for Resident #2 and Resident #3 did not meet these requirements, as they failed to address the residents' high fall risks and lacked appropriate interventions. The DON acknowledged the oversight and the need for staff education to ensure accurate and complete care plans in the future.