Auburn 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 identify, report, investigate, log, and respond appropriately to multiple resident-to-resident altercations, including alleged sexual, physical, and verbal abuse. Facility policy required immediate investigation of any suspicion or report of abuse, thorough documentation, and reporting to the state survey agency, with an Abuse Prevention Coordinator designated to oversee these processes. Despite this, the facility did not treat several documented incidents as reportable allegations of abuse and did not initiate investigations or protective measures as required. For one resident with dementia, confusion, wandering, and intrusive behaviors, progress notes documented that this resident was grabbing and touching various staff and residents, hitting staff and residents, touching another resident’s buttocks, and grabbing another resident’s coat as they walked by. These notes did not indicate what was done to protect other residents, whether staff identified who the affected residents were, whether notifications were made, or whether the incidents were reported or investigated. The facility’s abuse log for the relevant month contained no entries for these events. Another cognitively intact resident reported that this same resident spanked their buttocks while they were bending over to get condiments from a coffee cart; the nurse’s note documented the report and that it was relayed to the DON, but again did not show any protective actions, notifications, reporting, or investigation. A later incident involved another cognitively intact resident who reported that the same behaviorally impaired resident grabbed their breasts near an elevator. An investigation was completed for this single event, including interviews, and concluded that the behavior was related to dementia and was considered behavioral rather than intentional abuse, with abuse ruled out. However, this investigation did not identify or incorporate the prior documented inappropriate touching incidents, and those earlier events were not logged, reported, or investigated as abuse allegations. The deficiency also includes unaddressed physical abuse between roommates. One cognitively intact resident reported to an LPN that they had a physical altercation with their roommate, resulting in scratches on their left arm. The nurse documented the report, the presence of scratches, the offer of a room move, and provider notification, but there was no documentation of actions taken to protect either resident, prevent further abuse, or any indication that the incident was reported, logged, or investigated. Progress notes for the roommate over the same period contained no documentation of the altercation or staff response, and the facility’s abuse log for that month had no entries related to this physical altercation. Additionally, the facility failed to address resident-to-resident verbal abuse as an allegation of abuse. One cognitively intact resident was documented as being verbally aggressive and demeaning toward their roommate, calling them derogatory names, stating the roommate smelled, and expressing disgust that the roommate needed to be changed in bed. The nurse documented that the verbally aggressive resident was offered and accepted a room change and had no further concerns, but the note did not indicate who was notified, nor whether the verbal abuse was reported, logged, or investigated as required by facility policy. Across these events, the facility did not follow its abuse, neglect, and exploitation policy to treat these incidents as allegations of abuse requiring reporting, investigation, and preventive measures.

Removal Plan

• Conducted resident and staff interviews
• Ensured residents with sexual behaviors were placed on one-on-one supervision
• Re-educated all staff regarding abuse policies/procedures
• Ensured an effective system was in place to safeguard, protect and prevent residents at risk for abuse

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure a safe environment free from accident hazards related to smoking and elopement, and to provide adequate supervision to prevent accidents. Surveyors found that the facility did not timely or accurately assess multiple residents’ ability to smoke safely, did not develop or implement resident-specific smoking care plans, did not secure smoking supplies, and did not maintain a safe designated smoking area. The facility’s own smoking policy prohibited smoking on the premises and required new admissions to smoke off premises under direct supervision by a non-staff responsible party, with smoking supplies stored off premises. Despite this, the designated smoking area in the parking garage was littered with hundreds of cigarette butts, had a fire extinguisher lying on the ground, and another extinguisher and a smoking blanket blocked by trash cans, a chair, and a bed frame, making safety equipment inaccessible. One resident admitted for skilled services with impaired mobility and dependence on staff for care signed the non-smoking agreement but was later documented smoking or vaping in their room and in an indoor atrium. A smoking assessment identified this resident as wishing to smoke, having impaired short-term memory, and being unsafe to smoke independently, yet this was the only evaluation in the record. Their comprehensive care plan contained no information about smoking preferences, the failed smoking assessment, prior indoor smoking events, or interventions for smoking safety or nicotine dependence. Progress notes documented repeated indoor smoking, refusal to surrender a lighter, and use of a cigar in the room, but there was no evidence of incident logging or investigation. Observations showed this resident independently in the road outside, picking up cigarette butts, lighting them in their lap while wearing thin pants and a disposable brief, and obtaining lit cigarettes from other residents in the driveway of the parking garage. The receptionist stated the resident frequently went out to smoke, should sign out but did not, and staff were not informed that the resident was unsafe to go out or smoke independently. Another resident with moderate cognitive impairment, dementia, traumatic brain injury, severe mental illness, and dependence on a wheelchair had no documentation of being informed of the non-smoking policy and no smoking safety assessment, despite multiple documented incidents of smoking inside the facility. Progress notes showed this resident smoked in their restroom, in a shared bathroom where smoke filled the room and disturbed a roommate, and in the atrium, and was reported by other residents to have smoked marijuana with others in the atrium. These events were not entered on the incident log, and there was no documented investigation or new interventions. A cognitively intact resident observed on camera smoking an unknown substance in the garage with another resident also had no smoking assessment or care plan, and the incident was not logged or investigated beyond a note that it would be discussed at a staff meeting. Another resident with mild cognitive impairment and a roommate on oxygen was associated with a strong smell of smoke and ash on the floor in their room, but there was no documentation of locating or removing smoking materials, implementing protective interventions, or logging and investigating the incident. Additional residents who smoked were not properly assessed or care planned. One cognitively intact resident with wandering behaviors had an outdated and incomplete smoking assessment indicating they were not a smoker, with no subsequent assessments despite later documentation of the resident smoking outside and refusing nicotine cessation. This resident was later observed off facility property in a power wheelchair, with coats, bags, and a blanket on the chair, smoking a cigarette. Two other residents observed smoking in the driveway of the parking garage had no smoking safety assessments or care plans. Staff interviews confirmed that 17 residents were known smokers, that three were grandfathered under a prior policy allowing smoking in a designated area, and that active smokers were supposed to be assessed and have smoking-focused care plans, but the DON acknowledged that the reviewed residents lacked such assessments and that there was a breakdown in the system for managing resident smoking. The facility also failed to reassess a resident’s ability to smoke independently after a cigarette burn and did not report or investigate the injury. A progress note documented that this resident told a shower aide they had accidentally burned their leg with a cigarette while smoking outside, but the note did not describe how the burn occurred or any new interventions to prevent future burns. The state tracking and reporting system showed the burn injury was not reported. In interviews, leadership stated that a resident burn was expected to be reported, logged, investigated, and followed by nursing assessment, provider notification, treatment orders, reassessment of independent smoking ability, and consideration of protective equipment and cessation support, none of which were documented for this resident. The deficiency further includes failures related to elopement prevention and supervision for the cognitively impaired resident with dementia, traumatic brain injury, and severe mental illness who used a wheelchair and a Wander Guard device. This resident had an elopement care plan identifying them as a wanderer at risk for elopement, with interventions including frequent monitoring, safety interventions, and use of a Wander Guard. Progress notes documented exit-seeking behavior, agitation, and multiple episodes where the resident left the facility unassisted and went to nearby stores or was found several blocks away. Some events involved staff following and returning the resident, and one involved police notification and initiation of 1:1 supervision, but several elopements were not entered on the incident log or investigated, and there was no documentation of why the Wander Guard system did not alarm during at least one elopement. Later observation showed the resident near an elevator with a Wander Guard device on the wheelchair; the system did not alarm until the elevator button was pushed, and the resident expressed intent to go to the store, while no 1:1 staff were present despite a written 1:1 supervision guideline and staff sign-in logs indicating such supervision should have been in place. Throughout these events, the facility did not consistently follow its own policies for smoking, incident reporting, and elopement. Smoking incidents inside the building, in resident rooms, shared bathrooms, the atrium, and the garage were not reliably reported to administration, entered on the incident log, or investigated. Elopement events for the high-risk resident were similarly omitted from the incident log and not investigated as required. Leadership interviews confirmed expectations that such incidents be reported, logged, and investigated, and acknowledged that the smoking policy was unclear and not followed by residents or staff, and that the elopement policy was not followed for the resident who repeatedly eloped.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide necessary pressure ulcer (PU) prevention and treatment services consistent with its own policy and professional standards, affecting three residents reviewed for pressure ulcers. The facility’s Pressure Injury Prevention and Management policy required Braden Scale risk assessments on admission, weekly for four weeks, quarterly, and as needed, weekly licensed nurse skin inspections, prompt reporting of open areas or dressing issues by CNAs, development of care plans with measurable goals and interventions, and provider notification of new or worsening PUs. Surveyors found that these processes were not followed: Braden assessments were not completed as required, skin and wound assessments were incomplete or missing, care plans lacked appropriate skin and wound interventions, and there was a failure to notify the provider and dietician of new wounds. For one resident with bilateral humerus fractures, moderate cognitive impairment, and total dependence on staff for all ADLs, the admission MDS and admission collection tool documented no PUs on entry, only surgical wounds and bruising. A Braden assessment shortly after admission identified this resident as at moderate risk for PUs, but no further Braden assessments were documented and no skin or wound care plan or preventive interventions were added to the comprehensive care plan. Later, skin and wound evaluations documented new open lesions on both elbows as facility-acquired, but key fields such as the exact date of onset, wound stage, who staged the wounds, and whether the dietician was notified were left blank. Progress notes over the period when these wounds appeared contained no documentation of the new PUs, no description of staff response, and no evidence that the DON or dietician were notified. Dressing changes for the elbow wounds were not initiated and documented until several days after the wounds were first recorded, and subsequent wound evaluations were incomplete and contained wound measurements that did not match the wound provider’s assessment. The resident later reported elbow pain and stated that elbow protectors were provided only after a delay. For a second resident who was cognitively intact, dependent on staff for several ADLs, and assessed as high risk for PUs with constant moisture, bedfast status, complete immobility, and friction/shear problems, the care plan identified a right gluteal fold shearing wound and directed staff to avoid friction and shearing, assist with repositioning, and monitor and document skin injuries. A nurse documented skin breakdown to the posterior thoracic fold and repeatedly charted on this back wound over several months, describing it at one point as open and fleshy, but the notes did not indicate that the provider was informed, what type of wound it was, or any wound measurements. No skin/wound evaluations were completed for this back wound. Later, hospital transfer orders listed four wounds present on admission, including a right gluteal fold PU and additional full and partial thickness wounds, but on readmission the RN left the skin integrity section of the assessment blank, and physician orders reflected treatment for only one of the four wounds. During observations, the resident reported pain from a right buttock wound, stated they had to ask staff for dressing changes and help with turning, and was found with no dressing over the open right gluteal fold area and wearing a brief that was too small and sitting in the wound area. A dressing on the resident’s back was dated nearly a month earlier, was soiled, emitted a strong odor when removed, and no open area was found underneath, indicating the dressing had not been changed or the area reassessed during routine care. The DON later acknowledged that the first resident was at risk for PUs due to bilateral arm fractures, limited mobility, and potential nutritional problems, and confirmed that only one Braden assessment had been completed despite policy expectations for weekly assessments after admission and additional assessments with new skin issues. The DON also acknowledged that there was no skin/wound care plan with prevention and treatment interventions for this resident, that staff did not document progress notes or initiate an investigation or notifications when new facility-acquired PUs developed, and that skin/wound evaluations were not thoroughly completed or consistent with the wound provider’s assessments. For the second resident, the DON stated that the resident was followed by an outside wound provider and was on an air mattress with ointment and staff assistance for bed mobility, but also stated they were unsure how staff missed the long-standing dressing on the resident’s back if showers, skin checks, and care were being completed. The DON described expectations that staff notify providers of new wounds, obtain and implement treatment orders, document thorough wound assessments including measurements and pain, change dressings as ordered, and thoroughly assess skin during care, but survey findings showed these expectations were not met for the residents reviewed.

Penalty

No penalty information released

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

Summary

Facility administration failed to manage the facility in compliance with state and federal requirements by not ensuring effective oversight, monitoring, investigation, reporting, and prevention related to abuse, smoking, elopement, and staff training. The administrator’s job description, signed in October 2025, assigned responsibility for daily operations, effective use of resources, ensuring residents are free from abuse, ensuring adequate and competent staffing, and monitoring outcomes of all facility programs, policies, and procedures. The administrator also served as the abuse coordinator and stated that staff were educated on abuse policies upon hire, annually, and as needed. However, a regional market leader reported that management did not consistently review resident progress notes every 24–72 hours as expected to identify care concerns and incidents, and that not all incidents of abuse, smoking, or elopement were identified or reported to management, resulting in missed investigations and missed opportunities for prevention. Surveyors identified repeat issues related to accident hazards and supervision, particularly around resident smoking. A prior complaint survey in May 2024 had already cited the facility at F689 for failing to timely and accurately assess a resident’s ability to smoke safely, secure smoking supplies, and enforce the smoking policy when a resident repeatedly smoked inside the facility, which had risen to Immediate Jeopardy at that time. During the current survey, the administrator provided a list of 17 known resident smokers and stated that residents who smoke were identified on admission, signed a non‑smoking policy, and were required to go off property to smoke. The DON stated that smokers should be assessed, have a smoking‑focused care plan, and have smoking supplies checked in and out from the med cart. Despite this, the administrator acknowledged knowing that two residents had recently smoked multiple times inside the facility, including one resident who smoked indoors three days before the interview, and the DON confirmed that seven identified smokers had no smoking assessments in their medical records. The survey determined an Immediate Jeopardy at F689 beginning in late December 2025 due to repeated indoor smoking by two residents who were assessed as not safe to smoke independently. One resident was identified smoking inside the facility on multiple dates in December 2025 and January 2026, and another resident smoked inside on several dates in December 2025 and again in February 2026. Additionally, the interim administrator later stated that the administrator is responsible for resident safety and that staff are required to report incidents so interventions can occur, but acknowledged that the facility did not implement a smoking policy that supported resident rights and safety and that the elopement policy was not followed for one of the residents. Separately, the staff development coordinator reported that there was no system in place to schedule, document, track, or monitor required staff training and competency, and could not provide documentation of orientation, mandatory training, annual evaluations, or training described in the facility assessment. The interim administrator confirmed that the facility lacked and did not implement a policy for training, documentation, or tracking of required training and competency, contributing to deficiencies cited under F600, F610, F689, and F947.

Penalty

No penalty information released

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

Summary

The facility failed to implement and effectively maintain a smoking policy in accordance with Federal, State, and local laws and regulations, resulting in unsafe smoking practices for resident smokers, non-smokers, and staff. The written smoking policy prohibited residents from smoking cigarettes, marijuana, tobacco products, e-cigarettes, and vaping devices anywhere on the premises and required residents admitted after 04/18/2024 to smoke off premises under direct supervision of a non-staff responsible party, with all smoking supplies stored off premises. The policy stated that staff would assess smokers for smoking safety, handling of smoking materials, and use of mobility devices outside, and that residents would sign out to smoke and sign back in upon return, with a section for residents to acknowledge and comply with the policy. However, the policy did not define where the premises ended, did not identify a designated smoking area, did not define smoking safety, and did not address rules for residents admitted prior to 04/18/2024. Surveyor observation showed that the designated smoking area used by residents was in the back of the parking garage, where the ground was littered with hundreds of cigarette butts. A fire extinguisher was found lying on the ground in the gravel, and a fire blanket and a second fire extinguisher were mounted on the wall but blocked by two large trash cans, a chair, and a bed frame, making them inaccessible. A maintenance assistant confirmed that certain residents were allowed to smoke in this area, acknowledged the large number of cigarette butts, and identified the fire extinguisher on the ground as unsafe. The administrator and DON reported that 17 residents were known smokers, that residents signed a non-smoking policy on admission, and that three residents were grandfathered under a prior policy allowing them to smoke in the parking garage while other residents were required to go off property to smoke. The DON stated that active smokers were assessed as independent, with assessments and smoking-focused care plans in their records, and that smoking supplies were kept on the med cart and checked out by residents who then signed out to smoke. When asked if the policy was being followed, the administrator stated the policy was unclear and not followed by residents or staff, and the DON stated there was a breakdown in the system of residents smoking. An interim administrator later stated that the facility did not implement or maintain a smoking policy that supported resident rights and safety.

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 develop, implement, and permanently maintain an in‑service training program for nurse aides that was appropriate and effective based on nurse aide performance reviews and the facility assessment. The facility assessment identified that residents had psychiatric, mood, and substance use disorders, cognitive impairment, memory deficits, dementia, traumatic brain injury, and behavior issues, and that they required assistance with skin and wound care and activities of daily living such as bathing, dressing, oral care, eating, transfers, and ambulation. The assessment also specified that staff required training in multiple areas, including communication, resident rights, abuse/neglect identification, reporting and prevention, infection control, resident‑centered care, cultural competency, ADLs, disaster planning, vital signs, care for residents with cognitive and mental/psychosocial disorders, non‑pharmacological behavior management, trauma‑informed care, and care for residents with substance use disorders. Despite this, the facility did not have systems in place to ensure nurse aides received the minimum 12 hours of annual in‑service training, nor did it conduct or use performance reviews to identify and address training needs. Interviews and record review showed that nurse aides were actively providing resident care, but there was no documentation of required training or competency evaluation. Staff X, Y, and Z, all CNAs hired between October 2024 and January 2026, were assigned to resident care on the day and evening shifts, yet the facility could not provide documentation of their annual mandatory training, performance evaluations, skills assessments for competency, or completion of the required 12 hours of in‑service education. The Staff Development Coordinator reported that staff received video training on a corporate portal before orientation on topics such as abuse/neglect, resident rights, infection control, and dementia, and that these topics were discussed at staff meetings; however, there was no tracking system to ensure participation in annual required training, no system to track the 12‑hour nurse aide in‑service requirement, and no process to assess competency through skills evaluation. The Staff Development Coordinator also stated there was no support from the Administrator to implement tracking or competency systems and no involvement in nurse aide performance reviews. The Interim Administrator confirmed that there were no systems or documents in place to meet the training and competency requirements identified in the facility assessment.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident’s right to be free from abuse when a cognitively intact resident experienced unwanted and unconsented touching of their breasts by another resident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required the establishment of a safe environment to prevent sexual abuse and protect all residents from abuse. Despite this policy, the resident reported that while passing a snack closet near the nurse’s station on the way to their room, another resident positioned in the hallway made unwanted physical contact with their chest area, and the resident had to tell the other resident to stop and then sought staff assistance. The resident who experienced the touching had an admission MDS indicating they were cognitively intact, able to make their own decisions, and required moderate assistance with transfers, dressing, toileting, and personal hygiene. Their emotional/trauma care plan documented a history of sexual assault, physical assault with a weapon, and an unexpected sudden death of someone close, and identified them as at risk for decreased psychosocial well-being and emotional distress. The care plan directed staff to help identify triggers and attempt approaches to reduce anxiety and fear so the resident would feel safe and secure in the environment. Following the incident, the resident reported to social services that they felt safe in the facility provided the other resident was kept away from them. The resident who engaged in the inappropriate touching had an MDS showing confusion, memory loss, limited ability to understand or be understood, a non-English preferred language requiring an interpreter, and diagnoses including heart failure, Alzheimer’s disease, anxiety, and depression. This resident had documented physical, verbal, and wandering behaviors, as well as a care plan for sexually inappropriate behavior that included grabbing private areas and hitting buttocks, and another care plan for intrusive behaviors and wandering into other residents’ spaces. Progress notes documented three prior incidents of this resident sexually and inappropriately slapping and grabbing other residents, but the notes did not indicate what staff did in response or what actions were taken to protect other residents. On the day of the incident, observations showed this resident in their room without one-on-one supervision for extended periods, and the facility’s investigation concluded that abuse and neglect were ruled out, determining the incident to be behavioral rather than intentional, despite the history of similar behaviors and the facility’s abuse policy requirements.

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 submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system for Quarter 2 of 2025. Review of the June 2022 CMS Long-Term Care Facility PBJ Policy Manual showed facilities are required to electronically submit complete and accurate direct care staffing information, including direct care staff, category of work, resident census data, and direct care staff turnover and tenure, by the required deadlines. For Q2 (April through June 2025), the PBJ data submitted by the facility showed a reported census total of 6988. However, review of the facility’s own monthly census records showed 2266 for April, 2242 for May, and 2238 for June, for a total of 6746, revealing a discrepancy of 242 census days. During an interview, the Administrator stated that PBJ submission and census reporting were completed at the corporate level and acknowledged that issues had been identified with prior MDS submissions being timely and accurate. In an email communication, corporate staff later stated that, after reviewing all PBJ submission documents, the accurate census for Q2 was 6789, which still differed from the originally reported PBJ census total. The Administrator stated they would expect complete and accurate PBJ information to be submitted as required. This failure affected the accuracy of nursing home staffing level data collected by CMS and had the potential to impact provisions of resident care and services.

Penalty

No penalty information released

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

Summary

A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency were not detailed in the report, nor were any particular residents or staff members mentioned.

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 safe, clean, and homelike environment for residents across three units: Long Term 1, Short Term 1, and Short Term 2. Observations revealed multiple environmental deficiencies, including scuff marks, chipped and peeling paint, and exposed sharp edges on doorways. Hallways were cluttered with motorized scooters, wheelchairs, and other equipment, obstructing passage and creating potential hazards. Resident rooms lacked personalization, contributing to a less-than-homelike atmosphere. Specific incidents included a resident expressing a desire for a more personalized room and a nursing assistant tripping over detached floor trim. Additional issues were noted in the Short Term 1 and Short Term 2 units, where door frames were worn and chipped, and floor thresholds were separated, posing tripping hazards. Ceiling tiles were stained, and rust-colored drip marks were observed under shared sinks. The facility's administrator acknowledged the importance of maintaining a safe and comfortable environment and recognized the need for timely maintenance to address these deficiencies.

Penalty

No penalty information released

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

Summary

The facility failed to implement a system to ensure residents received required written notices at the time of transfer or discharge, or as soon as practicable. This deficiency was identified for five residents who were reviewed for hospitalizations. The facility did not provide written notifications to residents and/or their representatives in a language and manner they understood, which is necessary for making informed decisions about transfers or discharges. Additionally, the facility did not notify the Office of the State Long-Term Care Ombudsman (LTCO) about these transfers, preventing the LTCO from educating and advocating for residents regarding the discharge process. Specific instances included Resident 36, who was discharged to an acute care hospital on multiple occasions without receiving the required notifications. Resident 120, with moderate memory impairment and complex medical diagnoses, was transferred to the hospital without receiving a transfer notice. Resident 25, who had no memory impairment, was hospitalized several times without documentation of written transfer notifications. Resident 19 and Resident 52 also did not receive written notices of transfer with their rights. Interviews with staff revealed a lack of familiarity with the regulations regarding notifying the LTCO and providing residents with written notices, and the facility's current practice did not include sending written notices when residents were transferred to the hospital.

Penalty

No penalty information released

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

Summary

The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required by their policy. This deficiency was identified for three current residents and one closed record. Resident 36 was transferred to an acute care hospital on two occasions, with no documentation of a bed-hold notice provided for the first transfer and incomplete documentation for the second. Resident 120, who had moderate memory impairment and complex medical diagnoses, was transferred to the hospital without being offered a bed hold. Similarly, Resident 19 was transferred to a hospital with no documentation of a bed-hold offer. Resident 25, who had no memory impairment and diagnoses including stroke and heart failure, was hospitalized twice without documentation of a bed-hold offer. In interviews, Resident 25 confirmed that the facility staff did not discuss bed-hold options with them. Staff F, a Resident Care Manager, acknowledged the importance of offering a bed hold with each hospitalization, while Staff O, the Business Office Manager, stated that staff should document the offer in nursing progress notes and complete an e-interact form. The failure to provide this information placed residents and their representatives at risk of not being informed of their rights and the cost associated with holding a bed during hospitalization.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents received and participated in care conferences, as well as failed to update and revise care plans to reflect person-centered care. Specifically, six residents did not have timely care conferences, which are essential for discussing care needs and making necessary adjustments to care plans. For instance, Resident 50 expressed frustration over not having a care conference for eight months, while Resident 57 had not had a care conference for over ten months, despite having significant health issues such as memory loss and chronic pain. Additionally, the facility did not maintain proper documentation of care conferences, as evidenced by Resident 38's case, where staff claimed a care conference was held but lacked documentation to support this. The absence of documentation and failure to conduct regular care conferences as per facility policy left residents without the opportunity to participate in their care planning, potentially leading to unmet care needs and inappropriate care. Furthermore, the facility failed to update care plans to reflect current resident conditions. For example, Resident 36's care plan indicated participation in a walking program, but observations and staff interviews revealed that the resident was not engaged in such a program due to leg pain. This discrepancy between the care plan and the resident's actual condition highlights the facility's failure to revise care plans as needed, which is crucial for providing appropriate and effective 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 ensure that resident meals were prepared according to the dietician-approved menu, which placed residents at risk of unmet nutritional needs. During the lunch service on January 30, 2025, the menu indicated that residents on a regular diet should receive a regular preparation of mandarin chicken, while those on controlled carbohydrate and renal diets should receive a diet preparation. However, Staff Y, the kitchen cook, served all residents from the same pan of orange chicken, without providing a separate diet-specific main course. Staff X, the Dietary Supervisor, confirmed that only the diet version of the mandarin chicken was prepared and was unsure of the nutritional differences between the two preparations. Staff Z, the Registered Dietician, later stated that it was important to follow the menu due to the nutritional differences, which included 15 fewer kilocalories, 26 fewer grams of carbohydrates, and 33 fewer grams of sugar in the diet preparation. This oversight in meal preparation was observed and documented, highlighting a failure to adhere to the prescribed dietary requirements.

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 comprehensive and readily accessible medical records for several residents, leading to incomplete documentation and potential delays in treatment. For Resident 1, who was dependent on dialysis due to end-stage renal disease, the facility did not scan dialysis notes and lab results into the medical record. This included missing documentation of a significant drop in blood pressure and related inquiries from the dialysis center. Staff interviews confirmed that these records should have been promptly entered into the electronic medical record but were not, creating a risk of incomplete information for care providers. Resident 4, who was receiving hospice services due to a prognosis of less than six months, had only four hospice documents scanned into their record, despite regular visits from the hospice provider. Staff acknowledged a backlog in the medical records department, which delayed the scanning of important hospice documentation. Similarly, Resident 120's record lacked documentation of a prostate condition that justified the use of a urinary catheter, as noted in hospital discharge papers. Additionally, pharmacy recommendations for several residents, including Residents 44, 33, 25, and 49, were not scanned into their medical records. This included recommendations to adjust medications, which were addressed by staff but not documented in the residents' records. Furthermore, an LPN left a computer screen open to a resident's medication administration records, failing to secure resident privacy. Staff interviews confirmed that these lapses in documentation and privacy were not in line with facility expectations.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper hand hygiene and personal protective equipment (PPE) protocols were followed, as observed with Resident 269. Staff I, a Certified Nursing Assistant, did not remove gloves or perform hand hygiene before touching the resident's blankets and closet handle, and removed their gown improperly. This was confirmed by Staff J, the Infection Preventionist, who stated that staff should perform hand hygiene and change gloves when transitioning from dirty to clean tasks, and remove PPE in the correct order. In the dining room, Staff AA, an Activity Aide, did not perform hand hygiene between assisting different residents and handling clean and dirty dishes. Staff AA placed dirty trays on the same cart as clean trays, which was against the facility's infection control expectations. Staff J confirmed that staff should perform hand hygiene between handling clean and dirty items and not mix clean and dirty trays. The facility also failed to maintain clean and cleanable surfaces and equipment. Observations showed torn material on chairs and wheelchairs, which Staff J confirmed were uncleanable and increased infection risk. Additionally, a mechanical lift used for resident transfers had dried, brown splatter and was not sanitized after use, as observed with Staff V. Staff J and Staff H confirmed that assistive equipment should be sanitized after each use to prevent cross-contamination.

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 uphold resident dignity for several residents by not providing privacy bags for catheter bags, not ensuring residents were fully covered during transport to the shower room, and not knocking before entering a resident's room. Specifically, Resident 52's catheter bag was repeatedly observed without a privacy cover, visible from the hallway, and similar issues were noted for Resident 12. Staff confirmed that catheter bags should have privacy covers to maintain dignity. Additionally, residents were not adequately covered during transport to the shower room, exposing them to other residents and family members. Resident 12 was observed with exposed body parts while being transported, and similar observations were made for Residents 17 and 29. Staff acknowledged that residents should be fully covered during such transports to prevent embarrassment and maintain dignity. Furthermore, staff entered Resident 1's room without knocking, and items were removed from the rooms of Residents 1, 26, 15, and 29 without permission. Resident 1 reported that staff took specially ordered incontinence bed pads from their closet without consent, and similar complaints were made by other residents. Staff confirmed that items should not be taken from residents' rooms without permission, as it is their home and belongings.

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 informed consent was obtained for the use of a tilt-in-space wheelchair for Resident 48. The resident, who had a history of stroke, dementia, and muscle wasting, was observed using the wheelchair, which could potentially restrict their ability to walk independently. The consent form completed for the wheelchair did not identify any potential risks, such as the risk of restraint, and inaccurately stated that the wheelchair assisted with walking. Staff B, the Director of Nursing, acknowledged the inaccuracies and stated that the form should reflect the resident's inability to walk independently regardless of wheelchair positioning. Additionally, the facility did not provide informed consent for the use of high-risk medications for several residents. Resident 64, who had progressive neurological conditions and was on psychotropic medications, had no documentation of consent for these medications. Staff F, the Resident Care Manager, confirmed the absence of consent documentation, acknowledging the risk of loss of the resident's right to be informed and to refuse medication. Similarly, Resident 419, who had neurological conditions and was on psychotropic medications, also lacked documentation of informed consent, which Staff F confirmed. Resident 44, with complex medical diagnoses including anxiety, depression, and schizophrenia, was receiving multiple psychotropic medications without completed consent forms. The forms lacked signatures from the resident or their representative, indicating they were not informed of the risks and benefits. Staff F emphasized the importance of these consents for communication and acknowledgment of medication use. Resident 33, with severe cognitive impairment, was also receiving an antidepressant without a completed consent form, as confirmed by Staff B. The form did not indicate whether the resident or their responsible party was informed or consented to the medication.

Penalty

No penalty information released

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

Summary

The facility failed to implement an effective program to ensure that residents' Advance Directives (ADs) were included in their records and that residents without ADs were offered assistance to formulate one. This deficiency was identified for two residents, Resident 120 and Resident 49, out of six residents reviewed for ADs. Resident 120, who had a moderate memory impairment and medically complex diagnoses, did not have an AD in their record, and there was no documentation indicating that assistance to formulate an AD was offered. Additionally, there was no care plan addressing Resident 120's AD status. Staff interviews confirmed that the care conference documentation for Resident 120 did not address their AD status. For Resident 49, who had no memory impairment, the facility records showed an AD acknowledgment dated from their admission, but no further documentation of AD discussions or offers of assistance since then. Staff interviews revealed that Resident 49 was only offered assistance to formulate an AD once upon admission, contrary to the facility's policy of reviewing ADs quarterly at care conferences. This lack of adherence to the facility's policy placed residents at risk of not having their treatment goals met.

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 thoroughly investigate an injury accident involving Resident 6, who used a power wheelchair and had a history of stroke and one-sided paralysis. Despite multiple nursing progress notes indicating bruising and pain in Resident 6's right ankle, the incident was not logged in the facility's September 2024 Incident Log. An observation later showed Resident 6 in pain after another accident with their wheelchair, leading to a hospital assessment revealing a right femur fracture. The Director of Nursing was unaware of the initial accident, indicating a lack of communication and investigation. Resident 38, who had some memory deficits and complex medical diagnoses, reported feeling threatened by a nurse. Despite describing the nurse and expressing fear, no follow-up was conducted to assess Resident 38 for psychosocial harm, and no interventions were put in place to ensure their safety. The facility's incident report indicated that alert charting should have been implemented, but only one progress note was found, showing a lack of documentation and follow-up. Resident 419 experienced a fall resulting in swelling and bruising, but the incident was not logged in the facility's incident log. A previous non-injury fall was recorded, but the injury fall was not, indicating a failure to investigate and ensure the resident's safety. Staff acknowledged the lack of an incident report and the importance of investigating such events to maintain resident safety.

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 Minimum Data Set (MDS) accurately reflected the status of five residents, leading to potential risks for unmet care needs and diminished quality of life. For Resident 44, the MDS did not indicate the use of antianxiety medication, despite records showing administration three times daily. Additionally, the MDS failed to mark indications for high-risk drug class medications and inaccurately documented the resident's influenza vaccination status. Staff P acknowledged these inaccuracies during an interview. Resident 36's MDS incorrectly recorded the date of the influenza vaccine, listing it as the previous year instead of the current season, which was confirmed by a review of immunization records. Resident 4's MDS lacked a complete cognitive assessment, which was noted as the responsibility of the Social Services department. Similarly, Resident 6's MDS did not include a cognitive assessment, leaving their cognitive status undetermined. For Resident 25, the MDS inaccurately stated the resident had natural teeth, while records showed the resident had an upper denture and no natural teeth. Staff P confirmed these discrepancies, emphasizing the importance of accurate MDS documentation for appropriate care planning.

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 Pre-Admission Screening and Resident Review (PASRR) assessments were completed for five out of seven residents reviewed for PASRR screening. This deficiency was identified through interviews and record reviews, revealing that the necessary PASRR Level I and Level II evaluations were either missing or inaccurately completed. For instance, Resident 33, who had diagnoses of anxiety, depression, and a mood disorder, did not have a PASRR included in their record. Similarly, Resident 25, with multiple serious mental disorders, did not have a PASRR I completed prior to admission, and a Level II evaluation was not conducted as required. Additionally, the report highlights inaccuracies in the PASRR Level I assessments for Residents 44 and 64, where serious mental illness indicators were not identified, leading to a lack of necessary Level II evaluations. Staff interviews confirmed these oversights, with admissions processes failing to identify and correct errors in PASRR documentation. The absence of accurate and complete PASRR assessments left residents at risk of inappropriate placement and not receiving timely and necessary mental health services.

Penalty

No penalty information released

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

Summary

The facility failed to ensure physician orders were clarified and followed for several residents, leading to potential risks for ineffective treatments and medication errors. For Resident 38, the IV antibiotic order lacked a specified flow rate, and the IV tubing was not labeled with the date and time of change, which was against the facility's policy. Staff failed to clarify the order, and the tubing was not labeled, as confirmed by interviews with staff members. Resident 64's care plan indicated a need for bowel management due to constipation, but the MAR lacked a physician order for a suppository, which was part of the bowel protocol. Additionally, a powdered laxative was administered twice daily due to a duplicated order, leading to loose stools and diarrhea, increasing the risk of dehydration and skin breakdown. Staff interviews confirmed the lack of order clarification and the error in administration. Residents 44 and 50 were administered medications outside of the prescribed parameters for blood pressure management, with several instances of medication being given when the systolic blood pressure was below the specified threshold. Resident 44 also had pain medication orders that required clarification, as the parameters for administration were not followed. Resident 49's bowel management protocol was not initiated despite the absence of bowel movements, which could lead to severe complications. Staff interviews confirmed these deficiencies in following physician orders and 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 adequate nail care and assistance with shaving for residents who were dependent on staff for activities of daily living (ADLs). Resident 120, who had moderate memory impairment and complex medical diagnoses, required substantial assistance with personal hygiene. However, from January 9, 2025, to January 31, 2025, there was no documentation of nail care being provided, and observations showed the resident's fingernails were long, sharp, and dirty. Similarly, Resident 21, with severe cognitive impairment and chronic health issues, required substantial assistance with personal hygiene. Despite a care plan directive for weekly nail care, observations revealed long nails with debris, and staff admitted to forgetting to offer nail care. Residents 36 and 169, both requiring extensive assistance for personal hygiene, were observed with long chin hairs despite expressing a preference for shaving. Resident 36, who had no memory impairment, was observed with long chin hairs even after receiving a shower, which was when shaving was typically performed. Resident 169, admitted on January 23, 2025, had no documented bathing until January 30, 2025, and was also observed with long chin hairs. Staff interviews confirmed that shaving should be part of daily care, especially during showers, but this was not consistently done. The facility's failure to adhere to its ADL policy placed residents at risk for poor hygiene and diminished self-worth.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper assessment, monitoring, and treatment of residents' skin conditions, as evidenced by the cases of two residents. One resident, who was cognitively intact, reported having a sore on their abdomen, which was observed to have a dressing with drainage. Despite this, there were no physician orders for treating the wound, and a weekly skin evaluation failed to identify any skin impairments. Staff interviews confirmed the absence of treatment orders and highlighted a lack of communication and documentation regarding the resident's wound care needs. Another resident reported a rash on their abdomen and thighs following a vaccination, which was not documented in the skin assessments. Although a provider's note indicated a plan to add medication and conduct daily skin checks, the facility records showed no daily monitoring of the resident's skin condition. Observations later confirmed the presence of a rash and scratch marks, indicating a failure to accurately document and monitor the resident's skin condition as expected by facility policy. Additionally, the facility did not implement nonpharmacological pain interventions for a resident with frequent pain due to a left leg amputation, relying solely on opioid medication. Furthermore, after a fall, another resident with neurological conditions and a risk for falls was not monitored for latent injuries as directed by the provider. The resident's health records lacked progress notes or skin assessments related to the injuries, demonstrating a failure to follow up on the resident's condition post-fall, as required by the facility's policies.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper assessment and reassessment of residents using power wheelchairs, leading to accidents and injuries. Resident 6, who had a history of stroke and one-sided paralysis, used a power wheelchair independently. Despite a policy requiring reassessment after hospitalizations or cognitive changes, Resident 6 was not reassessed after two hospitalizations, a change in cognition from intact to moderately impaired, or after an incident where they injured their ankle by running into a wall with their wheelchair. This lack of reassessment resulted in Resident 6 sustaining a fracture requiring surgery after another accident involving their power wheelchair. Additionally, the facility did not conduct safety assessments for the placement of beds against the wall for Residents 25 and 49. Resident 25, who had diagnoses including stroke and morbid obesity, had their bed placed against the wall without a safety assessment, as ordered by a physician. Similarly, Resident 49, who had a left leg amputation and other mobility issues, also had their bed placed against the wall without a safety assessment. Staff interviews confirmed that safety assessments should have been completed to prevent entrapment and ensure resident safety. The facility's failure to adhere to its own policies regarding the assessment and reassessment of residents using power wheelchairs and the lack of safety assessments for bed placements against the wall resulted in significant safety hazards. These oversights placed residents at risk of injury and demonstrated a lack of adequate supervision and hazard prevention in the facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure adequate weight monitoring for two residents, leading to a deficiency in nutritional care. Resident 120 experienced a significant weight loss of 10.24% over 29 days, with a further 5.4% loss in just 8 days after returning from the hospital. Despite these changes, there was no documented reweigh or refusal to be reweighed, as confirmed by the registered dietician. This lack of follow-up placed Resident 120 at risk for further weight changes and an inaccurate assessment of their nutritional status. Resident 38, who had complex medical conditions including heart failure and depression, also experienced inadequate weight monitoring. The resident refused weekly weights and meals multiple times over two months, with the last recorded weight taken over two months prior. Despite being on an antidepressant to stimulate appetite, the resident's refusal to take the medication and meals was not effectively addressed. Staff interviews revealed a lack of alternative interventions to monitor the resident's weight and nutritional intake, highlighting a deficiency in the facility's approach to managing the resident's nutritional 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 administer enteral nutrition to a resident in accordance with physician orders and professional standards of practice. Resident 23, who had multiple medical conditions including Multiple Sclerosis, Quadriplegia, and Dysphagia, was receiving enteral nutrition through a feeding tube. The physician's orders specified that the resident should receive 1620 ml of formula and 1170 ml of water daily. However, the Medication Administration Records (MAR) for November 2024, December 2024, and January 2025 showed that the resident only received 1080 ml of formula and 585 ml of water daily, which was significantly less than the prescribed amounts. During an observation, a Licensed Practical Nurse (LPN) was seen setting the tube feeding pump incorrectly and admitted to not reviewing or resetting the pump to document the previous day's intake. The LPN acknowledged the importance of accurate documentation and administration of enteral nutrition to ensure adequate nutrition and hydration for the resident. The Director of Nursing also stated that staff were expected to follow physician orders for enteral nutrition and hydration. This failure to adhere to physician orders placed the resident at risk for inadequate nutrition and hydration.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during a medication pass observation. This deficiency involved two residents. For one resident, a Licensed Practical Nurse (LPN) administered dry eye relief drops instead of the prescribed eye lubricant plus drops. The LPN failed to identify the discrepancy between the medication ordered and the medication available, which contained different ingredients and therapeutic effects. The Director of Nursing confirmed the error, noting that the wrong eye drops were stocked in the medication supply room, and the expectation was for medications to match the provider's order. For another resident, a Registered Nurse (RN) administered a multivitamin with minerals instead of the standard multivitamin as ordered. The RN verified the error after reviewing the medication administration record and acknowledged that the resident did not receive the correct medication dose. The Director of Nursing reiterated the expectation that staff should administer medications as ordered. These errors highlight the facility's failure to ensure accurate medication administration, as required by their policies.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's right to be free from abuse, specifically sexual abuse, as evidenced by an incident involving two residents. Resident 1, who had severely impaired cognition and was unable to make decisions or communicate effectively, was inappropriately touched on the breast by Resident 2. This incident was observed by a staff member who intervened by separating the residents. Resident 1's medical history included conditions such as Alzheimer's disease, aphasia, and schizophrenia, which contributed to their inability to recall or communicate about the incident. Resident 2, who also had cognitive impairments and a history of sexually inappropriate behaviors, was identified as the perpetrator. Their medical records indicated a pattern of behaviors that included touching female residents and other inappropriate actions. Despite these documented behaviors, Resident 2 was able to ambulate independently and required staff assistance for personal hygiene. The incident with Resident 1 was not the first occurrence, as previous records showed similar behavior directed at other female residents. The facility's policy on abuse, neglect, and exploitation was not effectively implemented to prevent this incident. Although the policy outlined measures to protect residents from abuse, the failure to adequately supervise Resident 2 and prevent them from interacting inappropriately with Resident 1 led to the deficiency. The incident highlighted a lapse in ensuring a safe environment for all residents, particularly those with cognitive impairments who are unable to advocate for themselves.

Removal Plan

• Having only male caregivers work with Resident 2 to decrease and remove the triggers or stimulation from females.

Penalty

Fine: $22,315

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

Summary

The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident who required support with teeth brushing, transfers out of bed, and eating. The resident, who had a history of a brain bleed resulting in left-sided weakness, heart failure, high blood pressure, diabetes, and other conditions, was assessed to need moderate assistance with eating and oral hygiene, and was dependent on staff for bed to chair transfers. Despite these needs, documentation showed that the resident was often recorded as independent or requiring only setup assistance, which was inconsistent with their care plan and physician's orders. The resident's care plan and physician's orders specified that they should be out of bed for all meals and assisted with feeding to prevent aspiration. However, the ADL documentation frequently indicated that transfers did not occur or were left blank, and the resident was noted as independent with eating on multiple occasions. Additionally, the care plan did not clearly identify the level of assistance required for oral hygiene, leading to inconsistencies in the care provided. Interviews with staff revealed that there was a lack of adherence to the care plan and physician's orders. Staff acknowledged the resident's difficulties with swallowing and the risk of aspiration, yet the documentation did not reflect the necessary assistance being provided. The Director of Nursing and Administrator confirmed that the care plan should guide the level of assistance required and expected staff to follow it, highlighting a disconnect between the care plan directives and the actual care provided.

Penalty

Fine: $22,315

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

Summary

The facility failed to provide necessary care and services to a resident, leading to skin breakdown and placing all residents at risk for similar issues. Upon admission, the resident's physician orders were not reviewed, clarified, or implemented, resulting in a lack of appropriate nutritional support and protective measures. Specifically, orders for a high protein diabetic snack, liquid nutritional supplements, and heel protectors were not followed, leading to a delay in implementing these essential care components. Additionally, the facility did not conduct baseline thyroid lab testing as ordered by the physician. The resident was admitted with no skin injuries but was later identified with a new stage two pressure ulcer on the buttocks, acquired three weeks after admission. The facility's documentation was inadequate, as there were no nursing progress notes regarding the new pressure ulcer, and wound care orders were delayed. The Director of Nursing Services acknowledged the failure to implement physician orders and the lack of documentation, which contributed to the resident's skin breakdown and compromised care.

Penalty

Fine: $93,616

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 consistent supervision and ensure a safe environment free from dangerous accident hazards for six residents reviewed for smoking. The facility did not timely and accurately assess residents' ability to safely smoke, secure smoking paraphernalia, or implement and enforce the facility smoking policy. This led to multiple incidents where residents were found smoking in prohibited areas, including near a resident who required and was wearing oxygen, posing significant risks of fire and explosion, and serious bodily injury. The facility's failure to address these issues constituted an Immediate Jeopardy (IJ) situation. Resident 1, who had a history of smoking and was assessed as not able to make their own decisions, was repeatedly found smoking in their room and common areas, including near a resident using oxygen. Despite multiple incidents and staff interventions, Resident 1 continued to smoke indoors, and the facility did not effectively secure smoking supplies or update the resident's care plan to reflect the smoking behavior. Other residents, such as Resident 4, Resident 8, and Resident 5, were also found with smoking supplies in their rooms or smoking in prohibited areas, indicating a lack of consistent enforcement of the smoking policy. The facility's smoking assessments and care plans were not consistently updated or followed, leading to residents smoking unsupervised and in unsafe conditions. Staff interviews revealed confusion and lack of clear direction on managing non-compliant smoking behaviors. The facility's policies on smoking and accident prevention were not effectively communicated or enforced, resulting in repeated violations and placing all residents at risk for serious adverse outcomes.

Removal Plan

• Ensured all residents were accurately assessed to smoke
• Educated all residents who smoked on the facility smoking policy
• Informed residents of the consequences for not abiding by the policy
• Secured all smoking paraphernalia

Penalty

Fine: $93,616

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 direct care staff were provided the mandatory effective communication training. This deficiency was identified through interviews and record reviews. The facility's policy on training requirements indicated that an effective training program, including communication training for all direct care staff, would be developed, implemented, and maintained. However, the 2024 training/inservice proposals for Licensed Nurses (LNs) and Nursing Assistant Certified (NACs) showed no documentation of the required communication training. Additionally, an email communication from Staff A claimed that communication training was part of the Relias training, but a review of the education documents revealed no evidence of effective communication training provided to direct care staff.

Penalty

Fine: $93,616

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 comfortable homelike environment for residents due to a malfunctioning boiler that was not repaired in a timely manner. The boiler issue resulted in inadequate hot water supply to one side of the upper level of the facility, affecting the ability of residents to wash hands, faces, and receive showers or baths. Staff interviews confirmed that the boiler had been leaking and that the facility was waiting for an electrician to provide a quote for the necessary repairs. This situation persisted for 24 days, during which residents had to use lukewarm water for their hygiene needs. Resident 1 reported that the water in their room was not getting hot, with temperature readings showing 73.7 degrees Fahrenheit, significantly below the required range. Resident 12 also experienced cold water in their room, preventing them from washing their face and hands, and they had not received a shower in over two weeks. Although Resident 12 was offered a room move, they declined, and there was no follow-up from the staff to address their situation. Resident 6 was unable to participate in physical therapy due to water leaking outside their room, creating a slippery and unsafe environment. Staff interviews revealed that the facility was aware of the boiler issue and had contacted multiple vendors for assessments and quotes. Despite this, the repairs were delayed, and the boiler was only replaced after 24 days. During this period, the affected residents did not have access to hot water, compromising their cleanliness, quality of life, and dignity. The facility's failure to maintain water temperatures within the required range and to promptly address the boiler issue resulted in a deficiency in providing a safe and homelike environment for the residents.

Penalty

Fine: $93,616

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 who were dependent on staff for assistance with Activities of Daily Living (ADLs) received the necessary help with bathing and showers. This deficiency was observed in six residents who did not receive showers according to their preferences or needs. For instance, Resident 12, who required maximum assistance and preferred showers twice weekly, reported not receiving a shower in over two weeks. Documentation showed that Resident 12 was not offered or provided a shower six out of nine opportunities in April 2024. Similarly, Resident 14, who also required maximum assistance, reported only receiving one shower in a month, despite preferring showers twice weekly. The documentation confirmed that Resident 14 was not offered or provided a shower four out of six opportunities in April 2024. Resident 9, who required moderate assistance, reported not receiving showers twice weekly as preferred, and the documentation showed that the resident was not offered or provided a shower four out of four opportunities in April 2024. Resident 1, who required maximum assistance, reported preferring daily showers but only received two showers in a 30-day period. The documentation indicated that Resident 1 was not offered or provided a shower six out of six opportunities. Resident 3, who required one-person assistance, preferred showers twice weekly but only received five showers in thirty days, with documentation showing that the resident was not offered or provided a shower three out of three opportunities. Resident 10, who required extensive assistance, preferred showers twice weekly but only received four showers in 30 days. The documentation showed that Resident 10 was not offered or provided a shower four out of four opportunities. Interviews with staff, including the Staff Scheduler and the Director of Nursing, confirmed that the facility did not meet the residents' preferences for showers and that refusals were not consistently documented or communicated to nursing leadership. The facility's failure to provide adequate bathing assistance placed residents at risk for poor hygiene and diminished quality of life.

Penalty

Fine: $93,616

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 establish and maintain an effective infection prevention and control program, leading to a gastrointestinal (GI) outbreak affecting 33 residents and 5 staff members. The facility did not have an effective system of surveillance to identify possible contagious infections, prevent the spread of infection, report a suspected outbreak, and control the spread of the GI infection. Specifically, the facility did not ensure staff used appropriate Personal Protective Equipment (PPE) and performed proper hand hygiene, and lacked an effective Water Management Policy (WMP). This placed all residents at risk for facility-acquired or healthcare-associated infections and related complications. Resident 15, who had a history of brain bleed, heart failure, diabetes, and a urinary tract infection with sepsis, was the first resident identified with GI symptoms. Despite presenting with loose stools, cramps, and vomiting, there was no comprehensive care plan developed for Resident 15's infection or antibiotic use. The resident's lab results indicated abnormal values for liver and kidney function and elevated white blood cells, suggesting a possible infection. Resident 15 was placed on contact precautions nine days after the onset of symptoms and was eventually sent to the emergency room, where they passed away due to a GI bleed and pneumonia with sepsis. Residents 18 and 19 also experienced GI symptoms but did not have comprehensive care plans developed for their suspected infections or isolation precautions. There was no documentation of when these residents experienced symptoms, when they were isolated, who was notified, or daily monitoring of their symptoms. Additionally, the facility's water management program was found to be inadequate, with no specific information for the facility and a lack of documentation and validation of the program. The facility also failed to maintain proper water temperatures and did not notify residents or their representatives of issues with hot water availability.