Handmaker Home For The Aging

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 resident remained free from self-harm by not immediately assessing, reporting, and investigating observed injuries. The resident had multiple medical conditions, including acute and chronic respiratory failure with hypoxia, heart failure, paroxysmal atrial fibrillation, muscle weakness, reduced mobility, gout, depression, hyperlipidemia, and hypertension, and was receiving hospice services. Care plans identified communication problems related to hearing deficit and impaired visual function related to blindness, with interventions to ensure a safe environment and monitor the resident’s ability to communicate and function. On one morning, an LPN observed marks with dried blood on both sides of the resident’s neck during rounds at approximately 6:45 AM. When questioned, the resident stated the injuries were scratch marks. After this initial observation, there was no documentation that the LPN reported the injuries to the provider, DON, or management, and no documentation of further assessment or protective interventions at that time. This inaction occurred despite facility expectations and policies requiring staff to assess injuries, determine cause, and immediately notify appropriate leadership of observed injuries or changes in condition. Later that same day, at approximately 12:20 PM, when the LPN returned to clean the area, the injuries appeared deeper than scratches, and the resident then disclosed having attempted suicide by trying to cut his carotid artery with a razor and expressed ongoing suicidal intent. Interviews with the LPN, a CNA, the ADON, and the Administrator confirmed that facility protocol and expectations required immediate reporting and investigation of any observed scratches, dried blood, or injuries, and that this did not occur when the injuries were first seen. The facility’s Abuse, Neglect, and Exploitation policy stated that the facility protects each resident to prevent abuse, neglect, exploitation, and misappropriation of resident property and analyzes occurrences to determine why neglect occurred and what changes are needed to prevent its occurrence.

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 conduct a thorough investigation into an incident involving a resident with multiple medical conditions, including acute and chronic respiratory failure with hypoxia, heart failure, paroxysmal atrial fibrillation, muscle weakness, reduced mobility, gout, depression, hyperlipidemia, and hypertension. The resident had a care plan addressing communication impairment related to hearing deficit and was documented as cognitively intact with a BIMS score of 15 on a Significant Change MDS. On the morning of the incident, staff observed marks with dried blood on both sides of the resident’s neck, which the resident initially described as scratch marks. When staff reassessed the resident later that day and attempted to clean the area, the injuries appeared deeper, and the resident disclosed that he had attempted to cut his carotid artery with a razor and expressed suicidal ideation, stating that life was not worth living and verbalizing continued intent for self-harm. Items including a razor, letter opener, and pocket knife were removed from the resident’s room. Review of the facility’s five-day investigation report for this event showed that the investigation was incomplete and lacked key elements required by the facility’s Abuse, Neglect, and Exploitation policy. Specifically, the report did not include a resident interview, staff interviews, skin assessment documentation, a detailed description of the events leading to the incident, or investigative conclusions. Interviews with the ADON and Administrator revealed that the five-day report is expected to include witness, resident, and employee statements, as well as information on what led up to the incident, what occurred that day, what the facility did, and what happened afterward. The Administrator acknowledged that, for this incident, the five-day report for the resident’s suicidal ideation should have contained these details and that the incomplete report did not meet his or the facility’s expectations. The facility’s written policy required immediate investigation of suspected abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons (alleged victim, alleged perpetrator, witnesses, and others with knowledge), determining whether abuse, neglect, exploitation, or mistreatment occurred, and providing complete, thorough documentation, which was not done 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 deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with dementia, major depressive disorder, and anxiety disorder had a documented history of behavioral problems, including sexually inappropriate comments to female staff, persistent yelling out, and verbal and physical aggression toward staff during care. His care plan, initiated in early October, identified these behaviors and included interventions such as administering medications as ordered, anticipating and meeting needs, intervening to protect the rights and safety of others, using calm approaches, diverting attention, and removing him from situations as needed. Behavior notes from late December documented that this resident was up and down all night, was restless, was looking for a family member, and expressed dislike and suspicion toward another male resident, stating he did not like the other resident looking at him and questioning why he was there. Staff attempted redirection several times, which was ineffective, and administered anti-anxiety medication for increased restlessness. The alleged victim was another resident on the same memory care unit, also with dementia and anxiety disorder, and with a BIMS score indicating severely impaired cognition. This resident did not exhibit behavioral symptoms or wandering. Both residents had been on the same unit since mid-December. On a day after lunch, the cognitively impaired victim was sitting at a dining room table, asleep and wearing a cowboy hat, with his back facing the other resident. The resident with behavioral issues was observed by staff coming out of his room looking very angry and moving quickly toward the sleeping resident. He then hit the back of the other resident’s head, knocking the cowboy hat off. Staff documented that the aggressive resident repeatedly stated that the other resident had just gotten out of prison and had denied him a job. A CNA witness described seeing the resident smack the back of the sleeping resident’s head, and considered this to be physical abuse. The facility’s own investigation and leadership interviews confirmed that the incident constituted abuse. The 5-day investigation report documented that the CNA saw the aggressive resident smack the cowboy hat off the other resident and that both residents were unable to recall the event. The DON stated that the aggressive resident went straight to the other resident and smacked his hat off, and that this action was not allowed and was considered physical abuse, even if the DON believed the hat rim was struck. The administrator also stated that the aggressive resident hit the back of the other resident’s head and considered it abuse. The facility’s abuse policy defined abuse broadly and required identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, and witnesses. Despite prior documentation of the aggressive resident’s behavioral issues and recent agitation directed toward another male resident, the incident occurred, demonstrating that the facility did not effectively protect the victim resident from physical abuse by another 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 deficiency involves the facility’s failure to provide adequate supervision and interventions to prevent a fall for one resident identified as being at risk for falls. The resident had multiple diagnoses, including type 2 diabetes mellitus, osteomyelitis of the right ankle and foot, cervical spinal stenosis, major depressive disorder, bipolar disorder, left below-knee amputation, and morbid obesity. The resident’s BIMS score was 15, indicating intact cognition, and the care plan identified the resident as high risk for falls due to deconditioning, with interventions such as prompt response to requests for assistance, ensuring the call light was within reach, following the facility fall protocol, and ensuring non-skid footwear when ambulating or mobilizing in a wheelchair. A Morse Fall Scale score of 40 indicated a moderate fall risk. On the date of the incident, documentation initially described the event as an unwitnessed fall in the shower room, with the resident reportedly stating she slipped off from her bed, and an x-ray was ordered for left hip pain. A subsequent nursing note documented that the x-ray showed an acute fracture of the left hip at the intertrochanteric region, and the resident was sent to the ED. A later incident note clarified that the resident had sustained a fall inside the shower room after being left alone by a CNA, despite report that the resident required a two-person assist for transfers and use of a Hoyer lift. The CNA left the resident alone twice to get assistance to stand the resident, and the resident was found on the floor complaining of left hip pain. Interviews with staff confirmed that residents should never be left unattended in the shower. The DON stated that residents should not be left alone in the shower and acknowledged that the resident was left alone, even if only for a brief period, and that the resident was typically able to ambulate with little assistance but was feeling weak that day. A CNA with over twenty years of experience stated that shower procedures include positioning the wheelchair and shower chair for stability and that, while ideally two staff assist, it can be done with one; she also stated it was never permissible to leave a resident unattended in the shower. An LPN reported assisting the CNA with pulling up the resident’s pants and brief and helping get the resident back on the shower chair; after being told by the CNA that she could leave, the LPN departed and later learned the resident had been left unattended. The facility’s shower policy required assisting residents with bathing, helping them into the shower, ensuring the shower chair is locked if the resident remains seated, and encouraging use of safety rails, but the resident was left alone in the shower room contrary to these expectations and the resident’s assessed need for assistance.

Penalty

No penalty information released

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

Summary

A deficiency occurred when staff members failed to protect a resident from abuse. The resident, who had a history of dementia, bipolar disorder, major depressive disorder, and anxiety disorder, was care planned for behavioral issues and a tendency to refuse assistance with transfers and showers. On the day of the incident, the resident refused multiple offers for a shower from a CNA, who then notified the assigned RN. The RN instructed the CNA not to ask for consent but to proceed with the shower regardless of the resident's wishes. Subsequently, the RN and another CNA physically removed the resident from bed and forced her into the shower, despite her vocal objections and resistance. The resident expressed distress during the incident, stating she was cold and did not want her hair wet, and was described as angry afterward. Interviews and documentation confirmed that the resident was pulled out of bed by her arms while she was yelling to stop. A bruise on the resident's arm was investigated but determined to have been present prior to the incident. Staff interviews revealed that it was not standard practice for nurses to perform showers and that refusals were typically respected, with documentation of the refusal if the resident continued to decline after being approached by both CNA and nurse. Personnel records for the involved staff showed prior disciplinary actions for discourtesy, insubordination, and failure to follow procedures. Both staff members involved in the incident had completed abuse prevention training earlier in the year. The facility's investigation substantiated the abuse allegation, confirming that the staff members forced the resident to shower against her will, in violation of facility policy and resident rights.

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 two residents from abuse, resulting in substantiated incidents involving both staff-to-resident and resident-to-resident abuse. One resident, who had multiple diagnoses including hypertensive heart and chronic kidney disease, morbid obesity, major depressive disorder, anxiety disorder, and unspecified dementia, was dependent on staff for activities of daily living and had moderate cognitive impairment. This resident reported that a CNA was angry, aggressive, and rough during care, and that the CNA threw a snack at her. Multiple residents confirmed that the CNA was physically aggressive and displayed an angry demeanor toward them. Documentation and interviews revealed that the resident did not feel safe when cared for by this staff member, and the CNA was described as verbally rude and rough with care by several residents and staff members. Another incident involved a resident with metabolic encephalopathy, anxiety disorder, and muscle weakness, who exhibited wandering behaviors and attempted to help other residents, making her difficult to redirect. This resident entered another resident's room, leading to a physical altercation where the second resident, who had severe cognitive impairment and a history of behavioral problems including aggression, grabbed the first resident's arm and would not let go, causing a scratch and bruise. Staff witnessed the incident and confirmed that the resident who initiated the physical contact had a history of aggression and was difficult to redirect. The care plan for the wandering resident did not address her wandering behavior, despite repeated documentation of her entering other residents' rooms and interacting with them in ways that led to conflict. Facility documentation, including care plans, nursing notes, and staff interviews, confirmed that both incidents were substantiated as abuse. The facility's policy defined abuse as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and included both staff-to-resident and resident-to-resident altercations. The failure to prevent these incidents demonstrated a lack of effective measures to protect residents from abuse by staff and other residents.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from repeated verbal and physical abuse by another resident, despite ongoing incidents and staff awareness. Documentation shows that the abusive behavior began as verbal aggression and threats, escalating over several months to physical abuse, including a witnessed incident where one resident slapped another. Multiple staff members, including CNAs and an LPN, observed and reported these behaviors to administration, but there was no evidence that effective interventions were implemented to prevent further abuse or to separate the residents consistently. The clinical records and staff interviews reveal a pattern of inaction by facility management. Staff reported that incidents were treated as behavioral issues rather than abuse, and management did not respond to staff concerns or implement protective measures. The care plans for the residents involved did not reflect the ongoing aggression, and there was a lack of documentation or follow-up on reported incidents. Additionally, the facility failed to document a physical altercation until several days after it occurred, despite staff and family being aware of the event. The affected resident, who had severe cognitive impairment and was dependent on staff for care, exhibited signs of psychosocial harm following the abuse, including increased agitation and fearfulness, particularly at night. The abusive resident had a documented history of paranoia and aggression toward the victim, but no effective interventions or increased supervision were put in place prior to the escalation to physical abuse. The facility's own policy defined such behaviors as abuse and required protective actions, but these were not followed, resulting in harm to the resident and a failure to uphold resident rights.

Removal Plan

• Resident #2 was assigned a 1:1 sitter and relocated to a different unit, with behavior monitoring
• Resident #1 was assessed for injuries, including possible psychosocial harm. Clinical documentation was reviewed, and behavior was tracked
• Individualized care plans were updated
• Ongoing staff training was implemented on how to identify abuse
• Ongoing staff training was provided on how to intervene and stop abuse
• Ongoing staff training was conducted on the proper protocol for reporting abuse
• All residents were interviewed to identify any potential abuse. For residents unable to be interviewed, the MDS nurse completed an assessment for signs or symptoms of abuse
• Quality Assurance and Performance Improvement (QAPI) meetings were scheduled to review any incidents or concerns related to 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 facility failed to implement its policies and procedures regarding resident protection, abuse reporting, and investigation following multiple incidents of verbal and physical abuse by one resident toward another. Despite repeated documentation of aggressive behaviors, including yelling, threats, and physical altercations, there was no evidence that these incidents were reported to the State Agency (SA) or Adult Protective Services (APS), nor that a thorough investigation was conducted. Staff and witness interviews confirmed that the abusive behaviors were ongoing and known to staff, yet no effective interventions or increased supervision were implemented to prevent further incidents. The residents involved had significant cognitive impairments, with one resident having a documented history of dementia, muscle weakness, and severe cognitive impairment, as indicated by a BIMS score of 00. The alleged perpetrator also had dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder, and exhibited paranoid and possessive behaviors toward another resident. Multiple behavior notes detailed a pattern of verbal aggression, threats, and physical altercations, including slapping and pushing, which were witnessed by staff and other residents. Despite these documented incidents, the facility did not take timely or adequate steps to separate the residents or provide increased monitoring to ensure safety. Interviews with staff revealed confusion and inconsistency regarding the reporting process for abuse, with some staff being instructed not to escalate or report incidents involving residents with cognitive impairment. The facility's own policy required immediate reporting and investigation of abuse allegations, regardless of the cognitive status of those involved, but this was not followed. Documentation showed delays in recording incidents and a lack of protective measures for the victim, resulting in continued exposure to abuse and psychological distress.

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 multiple incidents of verbal and physical abuse between residents were reported to the State Agency (SA) and Adult Protective Services (APS) as required by both regulation and facility policy. Documentation and interviews revealed that one resident with severe cognitive impairment was repeatedly subjected to verbal aggression, threats, and physical abuse by another resident with a history of behavioral disturbances, including paranoia and anger. Despite staff witnessing these incidents and documenting them in clinical records, there was no evidence that the required reports were made to the appropriate authorities. Staff interviews indicated that several team members, including CNAs and LPNs, observed or were informed of incidents where one resident yelled at, threatened, and physically assaulted another resident. In one instance, staff witnessed a resident being slapped, resulting in visible injury, and this was reported internally to facility management. However, management instructed staff not to escalate or report the incident externally, citing the cognitive status of the residents involved. The facility's Assistant Director of Nursing and other staff confirmed that they did not report the abuse to the SA or APS, believing it was the responsibility of the administrator, who in turn determined the incident was not reportable if the victim could not recall the event. The facility's own policy required immediate reporting of all alleged violations to the administrator, state agency, and APS, with specific timeframes for reporting based on the severity of the incident. Despite this, there was a consistent pattern of internal reporting without external notification, even in cases involving physical harm and repeated verbal abuse. Documentation also showed that family members were informed of some incidents, and staff were later provided with abuse education, but the required notifications to authorities were not made as stipulated by policy and regulation.

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 allegations of verbal and physical abuse of one resident by another were thoroughly investigated and that appropriate corrective actions were taken. Multiple documented incidents showed a pattern of verbal and physical aggression by one resident towards another, including yelling, threats, and physical altercations such as slapping and punching. Despite staff witnessing these events and documenting them in behavior notes, there was no evidence that the facility initiated or conducted a thorough investigation into these incidents. The clinical records and staff interviews revealed that the resident who was the victim had severe cognitive impairment, as indicated by a BIMS score of 00, and a history of dementia and muscle weakness. The alleged perpetrator also had dementia, along with major depressive disorder, anxiety disorder, and schizoaffective disorder, and exhibited repeated aggressive behaviors, particularly when the victim was near another resident. Staff documented multiple episodes where the aggressor yelled at, threatened, and physically confronted the victim, sometimes in the presence of other residents and staff. Family members of the victim also reported noticing physical signs of harm, such as a bruise on the victim's face, after being informed by staff of an altercation. Despite these repeated incidents and staff awareness, the facility did not document any initiation of an investigation or protective measures in response to the abuse allegations. Staff interviews indicated that management was informed of the incidents, but no substantial action was taken to address the behaviors or protect the victim. The facility's own policy defined such behaviors as abuse and required investigation and protection, but there was no evidence that these procedures were 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 ensure that the care plan for a resident with multiple psychiatric and neurological diagnoses, including unspecified dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder-bipolar type, was revised to address the resident's verbal and physical aggression towards others. The resident was admitted with severe cognitive impairment, as indicated by a BIMS score of 5, and exhibited verbal behavioral symptoms directed toward others 4 to 6 days a week, as documented in the quarterly MDS assessment. Despite this, the care plan dated October 17, 2024, did not include interventions for these behaviors, focusing instead on social and emotional needs. Clinical record review and staff interviews revealed that the resident had documented incidents of verbal aggression, including yelling at and threatening another resident. However, there was no evidence that the interdisciplinary team (IDT) had reviewed the quarterly MDS assessment for behaviors or updated the care plan accordingly at that time. The care plan was not revised to include behavioral interventions until September 11, 2025, despite ongoing documentation of aggressive behaviors in the clinical record. Interviews with nursing staff, the MDS nurse, the assistant director of nursing, and administrative staff confirmed that the behavioral symptoms were identified in the MDS and clinical records but were not transferred to the care plan in a timely manner. Staff acknowledged that the lack of behavioral interventions in the care plan could impede behavior identification, de-escalation, and communication among staff. Facility policy required the comprehensive care plan to be reviewed and revised by the IDT after each comprehensive and quarterly MDS assessment, which 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 ensure that the assistant administrator was duly appointed by the governing board, as required by regulation. Review of the assistant administrator's personnel file showed a job description signed by the individual but lacking CEO approval, and a handwritten HR approval signed by the same individual. The resume did not document any licenses or certifications, and the staff list, business card, and facility documentation all identified the individual as the assistant administrator. A letter designated the assistant administrator as the responsible party in the administrator's absence, but there was no evidence of a formal appointment by the governing board. The administrator confirmed there was no policy for assistant administrator appointment and was unaware of the requirement for board appointment. Interviews with staff revealed that incidents of abuse were reported to the assistant administrator, who, along with the ADON, instructed staff to let the incident go and not escalate it, particularly as it involved residents in the behavioral unit. Despite continued reports of verbal abuse and intimidation, there was no evidence of a thorough investigation or reporting to the state agency. Staff interviews confirmed the assistant administrator's role in handling such incidents, but the lack of proper appointment and oversight contributed to the deficient practice.

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 monitor and communicate abnormal respiratory rates for a resident with multiple complex medical conditions, including chronic obstructive pulmonary disease, heart failure, and morbid obesity. The resident was admitted following hospitalization for shortness of breath, sepsis, pneumonia, and heart failure. During the resident's stay, vital sign records showed two instances of elevated respiratory rates (28 breaths per minute), which triggered warnings in the electronic health record for exceeding the normal threshold. Despite these abnormal findings, there was no evidence that the physician was notified, as required by facility policy. Interviews with staff confirmed that respiratory rates outside the normal range should prompt re-checks and physician notification, and that such notifications should be documented in the electronic health record. The director of nursing and other staff acknowledged that the abnormal respiratory rates were not communicated to the physician and that this was not documented. Facility policy requires prompt notification of significant changes in a resident's condition, and the failure to notify the physician and monitor the abnormal vital signs constituted neglect as defined by the facility's own 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 provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene, for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including dementia, Bipolar disorder, and Major Depressive Disorder. The resident was documented as being dependent on staff for showering and bathing, as reflected in both the Minimum Data Set and the care plan, which specified that all ADLs should be met with staff assistance daily. However, facility records showed that the resident received or was offered a shower only six times in November and three times in December, which is less frequent than the facility's stated policy of showers twice a week. Staff interviews revealed that CNAs are assigned shower duties based on a schedule, but staffing shortages sometimes make it difficult to complete all showers as planned. When showers cannot be completed, CNAs are expected to notify the nurse and request that the evening shift provide the service. Both CNA and nursing staff confirmed that showers are scheduled twice a week, and there is a protocol for which rooms receive showers on which days. The facility's policy, updated in October 2024, requires that residents be assisted with bathing according to the facility schedule to maintain hygiene and prevent skin issues. Despite these protocols, the resident did not consistently receive the required assistance, resulting in a deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely reporting of an allegation of abuse involving a resident who was cognitively intact and admitted with multiple fractures. Documentation shows that a family member was aggressively attempting to obtain the resident's debit card, claiming it was to pay rent, and later took the resident's phone, debit card, and keys with the resident's permission. Staff noted concerns about the family member's behavior, including aggressive demands for money and a chemically odor, and conveyed these concerns to nursing staff. The social worker documented the events and indicated ongoing monitoring for potential abuse. Further incidents included the family member being aggressive with nursing staff, demanding pain medication for the resident, and being present during medication administration. Staff observed unusual behavior during medication administration, such as the resident holding a pill in her mouth and the family member making remarks about medication being crushed. These incidents were discussed among staff, and a safety plan was put in place, but there was no documentation that these events were reported to the Long Term Care Licensing authority as required by facility policy. Interviews with staff confirmed awareness of the family member's actions and the expectation to report abuse allegations immediately to management and appropriate authorities. However, the Assistant Administrator acknowledged that not every suspicion of abuse is reported and that, in this case, the social worker reported the financial concerns to Adult Protective Services (APS) but did not report the incidents to the state agency as required. The facility's policy mandates immediate reporting of all alleged violations to the Administrator, state agency, and other required agencies within two hours, but this was not followed in these instances.

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 conduct a thorough investigation into an allegation of financial misappropriation involving a resident with mild cognitive impairment and major depressive disorder. The resident required extensive assistance with daily activities and was reported to be cognitively intact at the time of the incident. A complaint was received by Long Term Care Licensing indicating that a family member was misappropriating the resident's finances and not paying for bills or equipment repairs. Despite this, the required five-day report documenting the investigation was not completed or submitted. During staff interviews, the Assistant Administrator confirmed that there was no five-day report for the incident and was unaware of the specific details of the complaint. The facility's policy on abuse, neglect, and exploitation requires that the Administrator follow up with government agencies and submit the results of the investigation within five working days of the incident. This policy was not followed in this case, resulting in a failure to appropriately respond to the alleged violation.

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 its abuse policies in two separate incidents of resident-to-resident abuse. In the first incident, Resident #222, who had intact cognitive function but exhibited behavioral symptoms, reported being hit multiple times in the stomach by Resident #169, who had severe cognitive impairment and a history of aggressive behavior. Despite the aggressive behavior exhibited by Resident #169, including threatening staff and other residents, the facility did not adequately intervene to prevent the altercation. The incident was reported to the state agency, but the facility's investigation revealed that staff were not fully aware of the abuse as it occurred. In the second incident, Resident #223, with intact cognition, was involved in an altercation with Resident #49, who also had no cognitive impairment. A CNA observed Resident #49 hitting Resident #223 after a verbal exchange about coughing at the dining table. Although the incident was reported to the state agency, the facility failed to provide a 5-day report or conduct a thorough internal investigation as required by their policies. The facility's policy on abuse, neglect, and exploitation mandates the prevention and reporting of abuse within two hours, as well as a follow-up investigation within five days. However, in both incidents, the facility did not adhere to these policies, failing to prevent the abuse and to conduct comprehensive investigations. This lack of adherence to established protocols could lead to further instances of resident-to-resident 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 facility failed to report an incident of abuse between two residents accurately and in a timely manner. Resident #222, who had intact cognitive impairment, reported being hit in the stomach by Resident #169, who had severe cognitive impairment and exhibited aggressive behavior. The incident was reported to a registered nurse, but discrepancies were found in the timeline of the incident's reporting to the state agency. The facility's documentation did not align with the state agency's incident reporting system, leading to a delay in the proper reporting of the event. Additionally, the facility did not conduct a thorough investigation of the incident involving Resident #222 and Resident #169. The facility's policy required that abuse be reported to the state agency within two hours, but the investigation revealed that the incident was not reported until several hours later. Interviews with staff members, including the Director of Nursing and the Administrator, indicated a lack of clarity regarding the timeframe for reporting such incidents, which contributed to the delay. In another incident, the facility failed to report and investigate an altercation between Resident #223 and Resident #49 within the required timeframe. A Certified Nursing Assistant observed Resident #49 hitting Resident #223, but the facility did not have a 5-day report or additional investigation notes for the incident. The facility's policy required a follow-up with government agencies within five working days to report the investigation of the incident, but this was not completed, indicating a failure to adhere to established procedures for handling abuse allegations.

Penalty

No penalty information released

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

Summary

The facility failed to properly manage and discard expired medications, which could lead to the administration of expired drugs to residents, contrary to professional standards. During a medication administration observation, a controlled substance, Lyrica, was found with an unsealed capsule taped behind the medication blister pack. The Registered Nurse (RN) involved acknowledged that this practice was not part of the facility's best practices and could potentially contaminate the medication. Additionally, in the Unit Rich medication room, four expired 0.9% Sodium Chloride Injection USP 100ml bags were observed, with one bag having a used-by date that had already passed. The RN confirmed that these medications should have been discarded. The Director of Nursing (DON) stated that the controlled substance should have been wasted and that it was against facility expectations to have medication taped to the back of blister packs. The DON also mentioned that expired medications should be removed from active stock and discarded according to facility policy. The facility's policy on the storage of medication requiring refrigeration emphasizes the importance of monitoring temperature daily and removing expired medications from active stock. However, the facility failed to adhere to these policies, resulting in the presence of expired medications in the medication room.

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 food was stored under sanitary conditions, which could potentially lead to foodborne illness. During an initial tour of the kitchen, surveyors observed several food items in the large walk-in refrigerator and secondary walk-in fridge that were beyond their use-by dates, including six Gold's Horseradish sauces and a block of Swiss cheese. Additionally, several opened food items, such as a salsa container, apple juice package, and sour cream container, were not dated or labeled according to when they were opened or expected to be discarded. Further observations in the nourishment refrigerators on the units revealed additional expired items, including sugar-free, fat-free ice cream and milk cartons, as well as opened items that were not labeled with dates, such as salsa, sour cream, various loaves of bread, oat milk, soy milk, butter, orange pineapple juice, and rainbow sherbet ice creams. The Food Services Director discarded all expired, unlabeled, and undated foods. Interviews with the Food Services Director and the Administrator revealed that the facility's process for food labeling and discarding expired foods was not consistently followed, posing a risk of residents consuming expired food.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from abuse by another resident, resulting in a deficiency. Resident #222, who had a history of behavior problems and was placed in a secured memory care unit, reported being hit several times in the stomach by Resident #169. Despite the altercation, there was no immediate evidence of injury, and the facility did not conduct a timely skin assessment following the incident. Resident #222's medical history included unspecified dementia, bipolar disorder, and major depressive disorder, among other conditions. Resident #169, who had severe cognitive impairment and exhibited frequent behavioral symptoms, was involved in multiple aggressive incidents leading up to the altercation. The resident's care plan included interventions for behavioral problems and wandering, but these measures were insufficient to prevent the incident. On the day of the altercation, Resident #169 displayed aggressive behavior, including threatening staff and other residents, and was eventually sent to the hospital for evaluation. The facility's policy on abuse, neglect, and exploitation required the prevention and reporting of abuse within two hours, but the incident was not reported until later. The facility's investigation revealed that staff were aware of Resident #169's aggressive behavior but failed to prevent the altercation. The RN on duty did not witness the physical abuse but was informed by Resident #222 afterward. The facility's failure to adequately monitor and intervene in Resident #169's behavior led to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to develop a comprehensive person-centered care plan for a resident who was readmitted with diagnoses including COPD, acute and chronic respiratory failure with hypoxia, and a history of falling. The resident had a BIMS score indicating intact cognition and was taking an anticoagulant medication. However, the care plan initiated did not include any focus or interventions regarding the use of anticoagulants, despite a physician's order for Lovenox for DVT prophylaxis. On a specific date, the resident began vomiting coffee-ground emesis, indicating a possible upper GI bleed. The physician ordered the anticoagulants to be held, but the Treatment Administration Record did not document any symptoms of bleeding. Interviews with staff revealed that the RN on duty alerted the doctor and administered Zofran, which was effective in preventing further vomiting. The Director of Nursing acknowledged that anticoagulants are high-risk medications and expected staff to monitor for bleeding symptoms, although it was unclear if the facility policy required these medications to be care-planned.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that two out of six sampled nursing staff members, a Registered Nurse and a Certified Nursing Assistant, possessed the necessary competencies and skills to care for residents' needs. The personnel records for these staff members, hired in June and July 2023 respectively, lacked evidence of training on freedom from abuse, neglect, and exploitation, as well as gift-giving policies. This deficiency was identified through a review of personnel records, facility assessments, and interviews with facility staff. Interviews with the Human Resource Coordinator and the interim Director of Nursing revealed that the facility's expectation is for all staff to complete required training annually. Staff who have not completed the training are to be removed from the schedule until they do so. The facility's policies on Continuing Education and Abuse, Neglect, and Exploitation emphasize the importance of timely completion of training, with disciplinary actions outlined for non-compliance. Despite these policies, the lack of documented training for the two staff members indicates a failure in the facility's implementation of its training 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 ensure that a resident received necessary behavioral health services despite the resident expressing multiple concerns and grievances. The resident, who was admitted with diagnoses including rheumatoid arthritis and muscle weakness, had a BIMS score indicating no cognitive impairment. Despite being described as pleasant and cooperative, the resident reported issues such as not receiving the correct medication, not having a shower since admission, and feeling frustrated and distrustful of the aides. These concerns were documented in various progress notes, yet there was no evidence of a referral for behavioral health or social services. The resident expressed a desire to return home, citing dissatisfaction with the care received, including issues with medication and therapy. The resident also reported feeling upset about the lack of attention from staff, such as an aide being on the phone during meal service. Additionally, the resident was worried about housing issues and the potential theft of a walker. Despite these documented grievances, the facility did not follow up with social services or behavioral health services to address the resident's concerns. Interviews with facility staff revealed a lack of action in response to the resident's grievances. Staff members described processes for reporting abuse and psychological impacts of isolation, but there was no indication that these processes were followed in this case. The facility's policies on abuse, neglect, and promoting resident dignity were not adhered to, as there was no documentation of interviews or care plan revisions. The medical director acknowledged the need for better documentation and follow-up on complaints, indicating a gap in the facility's response to the resident's 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 a resident was informed of the risks and benefits of, and had consented to, the usage of a psychotropic medication, specifically Sertraline. The resident, who was admitted with multiple psychiatric diagnoses including Schizoaffective Disorder and Bipolar Disorder, had a BIMS score indicating no cognitive impairment. Despite this, the clinical record lacked evidence that the resident was informed about the medication's risks and benefits. A consent form dated several months after the medication was prescribed was found, but it was incomplete as the boxes indicating consent were left unchecked. Interviews with the interim Director of Nursing revealed that medication consents should be signed upon admission and again if a new medication is added to the treatment regime. However, no signed consent for the use of psychotropic medications prior to the administration of Sertraline could be located for the resident. The facility's policy mandates that residents or their representatives be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments, which 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 that a resident with a diagnosis of serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. This deficiency was identified through clinical record review and staff interviews. The resident, who was admitted with multiple mental health diagnoses including Schizoaffective Disorder, Major Depressive Disorder, and Bipolar Disorder with Psychotic Features, did not have evidence of a completed Pre-Admission Screening and Resident Review (PASARR) Level 1 screening in their chart. The absence of this screening could result in the resident not receiving necessary specialized services in accordance with professional standards. During an interview, the interim Director of Nursing acknowledged that PASARR screenings should be completed at the time of admission and expressed that there was inconsistency in their completion. The facility's policy requires that any resident not previously screened should be evaluated within 40 days of admission. However, the PASARR screening for this resident was only signed on the day of the interview, indicating a delay in the process. The interim DON admitted that the screening could have been completed sooner, and the lack of timely screening posed potential risks for inappropriate monitoring of the resident's medication and behavior.

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 nutritional status of a resident was assessed and managed according to its policy. Resident #60, who was admitted with diagnoses including major depressive disorder, muscle weakness, and hypertension, was identified as malnourished with a mini nutritional assessment score of 7. Despite physician orders to weigh the resident weekly for four weeks and then monthly, the facility did not obtain any weight readings after July 7, 2024, when the resident weighed 145 pounds. This lack of follow-up on the resident's weight was confirmed during a multidisciplinary conference and through interviews with the resident and staff. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that weights are supposed to be recorded in the electronic health record by Certified Nursing Assistants. However, the facility's policy on weight monitoring, which requires weekly weights for newly admitted residents and those with weight loss, was not adhered to. The resident reported a belief of significant weight loss during their stay, but this was not documented due to the absence of regular weight monitoring, highlighting a deficiency in the facility's adherence to its own 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

The facility failed to provide dialysis care consistent with professional standards for a resident with stage 4 chronic kidney disease and dependence on renal dialysis. The resident's care plan indicated the need for dialysis and included interventions such as monitoring for signs of infection at the access site. However, there was no evidence of physician orders for dialysis care and treatment, including the name of the dialysis facility and the days for receiving dialysis. Additionally, the Minimum Data Set (MDS) assessment did not show evidence that the resident received hemodialysis upon admission or while at the facility. The facility also failed to follow post-dialysis care instructions. A post-dialysis form indicated that the dialysis access site should be observed every 30 minutes for 4 hours, and palpation for thrill and bruit should occur every 8 hours. However, the clinical records lacked evidence of these assessments. Interviews with the RN and DON confirmed the absence of physician orders for dialysis and documentation of access site assessments. The facility did not have a policy regarding dialysis care and treatment, which contributed to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that medication records were accurately maintained according to professional standards of care. During an observation, it was found that the Narcotic Count Sheet on a medication cart had missing signatures for both the Out-Going and In-Coming nurses on several occasions. Specifically, the records were not properly documented on multiple dates in September and October 2024. An interview with an LPN revealed that the expected procedure is for one nurse to sign as the Out-Going nurse and another as the In-Coming nurse, with both nurses counting the medication together. The LPN acknowledged that the medications were not recorded properly on the specified days, which did not meet the facility's expectations. The Director of Nursing (DON) confirmed that the lack of accurate recording poses a risk as there would be no proof that the medication was counted, aligning with the facility's policy that requires controlled substances to be signed in the narcotic book.

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 appropriately manage the anticoagulant therapy for a resident, leading to a deficiency in medication administration. The resident, who was admitted with atrial fibrillation and a history of gastrointestinal bleeding, reported dark stools, a potential sign of bleeding, on October 19, 2024. Despite this, the resident continued to receive doses of Apixaban, an anticoagulant, on October 20, 2024. It was not until October 21, 2024, that the provider ordered the medication to be held and a consultation with a gastroenterologist was requested. The resident had been experiencing dark stools for several days and expressed concern about a possible GI bleed, which was confirmed by a positive hemoccult test. Interviews with staff revealed a lack of timely communication and documentation regarding the resident's condition and the continuation of Apixaban. The Director of Nursing acknowledged the failure to follow protocol by not contacting the provider on October 19, 2024, when the dark stools were first noted. Additionally, there was no documentation to confirm that the provider was aware or approved the restart of Apixaban on October 23, 2024. The facility's policies on high-risk medications and notification of changes were not adhered to, contributing to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate below 5%, with an observed rate of 6.9%. One incident involved a resident with type 1 diabetes who was supposed to receive 8 units of insulin Lispro based on a sliding scale for a blood sugar level of 389. However, the RN administered only 3 units and did not notify the provider, contrary to the physician's orders. The RN acknowledged the error and the potential risk of increased blood sugar due to the incorrect dosage. Another incident involved a resident with a diagnosis of idiopathic gout, hypothyroidism, and major depressive disorder. The LPN administered a 12.5 mg dose of Carvedilol instead of the prescribed 6.25 mg. The LPN admitted to not checking the updated physician's order and acknowledged the risk of overdose. The facility's policy requires adherence to the right resident, dosage, drug, route, documentation, and time, which was not followed in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The resident, who was admitted with diagnoses including stage 4 chronic kidney disease, respiratory failure, and type 1 diabetes, had a physician's order for insulin Lispro to be administered according to a sliding scale. On a particular day, a registered nurse administered 3 units of insulin Lispro instead of the 8 units prescribed for the resident's blood sugar level of 398. The nurse documented inaccurately in the medication administration record, indicating that 8 units were given, and did not inform the physician of the deviation from the prescribed dosage. The nurse stated that the resident requested only 3 units, and she complied, believing it was the resident's decision. However, the physician clarified that while residents can refuse medication, they cannot decide the dosage. The facility's policy requires following physician orders as written and notifying the physician if a medication is administered outside of the order. The Director of Nursing confirmed that the facility's process was not followed, as the physician was not notified, and the incorrect dose was administered, which did not align with the facility's policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that glucometer controls were consistently completed, as revealed during an observation on October 23, 2024. The Quality Control Record sheet on Unit Rich with medication Cart 2 showed that glucometer controls were not consistently completed. Interviews with various staff members, including the Assistant Director of Nursing (ADON), a Registered Nurse (RN), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), confirmed that glucometer controls were not consistently completed on multiple days in August, September, and October 2024. The facility's manual for the glucometers indicated that there is a 24-hour quality control reminder feature, which was not adhered to, as evidenced by the flashing icon on the glucometers when quality control was not tested. The RN provided specific dates in August, September, and October 2024 when glucometer controls were not completed, highlighting a pattern of non-compliance with the facility's expectations. The LPN and DON both acknowledged the risk of not completing glucometer controls, which could lead to inaccurate readings. The DON stated that the night staff is responsible for checking glucometer controls, but the failure to do so was evident from the records and staff interviews. This deficiency in completing glucometer controls poses a risk of inaccurate glucose readings for residents, which could impact their care and treatment.

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 appropriately implement their Enhanced Barrier Precaution (EBP) program for two residents, leading to a deficiency in infection prevention and control. Resident #38, who was admitted with paroxysmal atrial fibrillation, Type 2 Diabetes, and an open wound infection of the right artificial knee, did not have EBP orders initiated upon admission despite having a PICC line and receiving wound care. Similarly, Resident #64, admitted with Type 2 Diabetes, ulcers, dementia, and an indwelling catheter, also did not have EBP orders initiated at admission. Observations revealed that there were no EBP signs or PPE carts near the residents' rooms until several days after admission. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that EBP orders should have been initiated at admission for both residents due to their medical conditions. The IP acknowledged that EBP orders can be overlooked during weekend admissions, as she does not work on weekends. The facility's policy on Transmission-Based Precautions requires signage and PPE to be readily available for residents known or suspected to be infected or colonized with certain infectious agents, which was not adhered to in these cases.

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 three residents were free from preventable falls, leading to increased risks for serious injury and harm. Resident #5, who was admitted with severe cognitive impairment and a history of falls, experienced multiple unwitnessed falls resulting in major injuries, including a concussion and fractures. Despite being identified as high risk for falls, the care plan interventions were not updated following these incidents, and no new measures were implemented to prevent further falls. The resident continued to exhibit restlessness and a lack of safety awareness, yet the recommended intervention of a private sitter was not documented as being implemented. Resident #40, with a history of dementia and falls, also experienced multiple unwitnessed falls, including one resulting in a major injury with a mid-shaft fracture to the right leg. Although the resident was assessed as high risk for falls, the care plan did not reflect the fall with major injury, and no new interventions were added to address the increased risk. The resident's absence from the facility during a shift was not documented, and upon return, the resident required substantial assistance for transfers, indicating a lack of adequate supervision and fall prevention measures. Resident #24, diagnosed with dementia and Parkinson's disease, was identified as high risk for falls but experienced an unwitnessed fall with minor injury. The care plan included monitoring for 72 hours but did not incorporate further interventions post-monitoring. Observations revealed the absence of a fall mat in the resident's room, contrary to the care plan. Interviews with staff indicated inconsistencies in identifying and communicating fall risks, with some residents lacking visible indicators such as signs or wristbands. The Director of Nursing acknowledged the lack of new interventions following repeated falls, highlighting a deficiency in the facility's fall prevention program.

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 allow a resident to return after hospitalization, which constitutes a deficiency in their care practices. The resident, who had significant cognitive impairment and multiple diagnoses including dementia and bipolar disorder, was sent to the hospital due to altered mental status and labored breathing. The hospital case manager confirmed that the resident was ready to return to the facility, with no change in the level of care required. However, the facility refused to readmit the resident, citing ongoing issues with the family as the reason. Interviews with facility staff revealed differing perspectives on the decision not to readmit the resident. The Director of Nursing expressed concerns about the safety of bringing the resident back, referencing the resident's distress and emergency hospitalization. Meanwhile, the facility administrator cited threatening behavior from the resident's family towards staff and the building as the reason for their decision. This refusal to readmit the resident after hospitalization, despite the hospital's assessment that the resident was ready to return, highlights a failure in the facility's discharge and readmission practices.