Courtyard Care Center

Penalty

No penalty information released

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

Summary

The facility failed to ensure that two dependent residents received and had documented assistance with meals three times a day as ordered. Resident 2 was admitted with conditions including a left tibia medial malleolus fracture, GERD, dementia, and muscle weakness, and had an MDS showing moderately impaired cognition and dependence on staff for all ADLs. Orders in effect included a fortified mechanical soft diet with thin liquids and a Restorative Nursing Assistant feeding program. Review of Resident 2’s Documentation Survey Reports for February and March 2026 showed missing documentation that the resident was assisted with meals three times daily on multiple specified dates, despite the resident’s dependence on staff and specialized diet and feeding program orders. Resident 8 was admitted with COPD, kidney transplant status, dementia, anemia, and morbid obesity, with an MDS indicating severely impaired cognition and dependence on staff for all ADLs. Active orders included a fortified pureed diet with mildly thick consistency. Review of Resident 8’s Documentation Survey Reports for February and March 2026 similarly showed no documented evidence that the resident was assisted with meals three times a day on multiple specified dates. During interviews and concurrent record reviews, the RN Supervisor confirmed the lack of documentation for both residents on the identified dates and acknowledged the need to ensure meals were recorded and that residents eat at least three times a day. The facility’s Food and Nutrition Services policy stated that each resident is to be provided with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary 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 deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, including failure to ensure documented feeding assistance for a dependent resident and timely response to call lights. One resident was admitted with multiple diagnoses including a left tibia medial malleolus fracture, GERD, dementia, and muscle weakness, and had an MDS showing moderately impaired cognition and dependence on staff for all ADLs. This resident had orders for a fortified mechanical soft diet with thin liquids and participation in a restorative nursing assistant feeding program. However, review of the resident’s February documentation showed no documented evidence that the resident was assisted with meals three times a day on a specific date, including breakfast and lunch, despite the resident’s dependence on staff for feeding. Additional evidence of insufficient staffing came from resident council meeting minutes on two dates, which documented concerns that call lights were not being answered in a timely manner. A family member reported during a phone interview that there were not enough nurses to help residents, particularly on weekends, which delayed care and services. During interviews and record reviews, the RN supervisor confirmed the lack of documented meal assistance for the dependent resident on the identified date, and the DON confirmed that Certified Nurse Assistant DHPPD on several dates, including the date of missing meal assistance documentation, were below the required 2.4 hours per patient day. The DON stated that short staffing affected resident care. The facility’s own staffing policy indicated it would provide enough nursing staff to deliver nursing and related care services for all residents, which was not met on the identified dates.

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 medications were administered as ordered for two residents, as evidenced by missing administrations and documentation on their Medication Administration Records (MARs). One resident with severe cognitive impairment and multiple diagnoses including COPD, GERD, bilateral hip osteoarthritis, and a bone density disorder had active orders for Alendronate Sodium 70 mg once weekly on Sundays, Omeprazole 20 mg daily, and Synthroid 75 mcg every morning. Review of this resident’s March MAR showed no documented evidence that Alendronate Sodium and Omeprazole were administered at 6 a.m. on 3/1, no documented evidence that Synthroid was administered at 6:30 a.m. on 3/1 and 3/3, and no documented evidence that Omeprazole was administered at 6 a.m. on 3/3. During interview and concurrent record review, the RN Supervisor confirmed these medications were not administered as ordered, and the DON stated that if the MAR was not signed, it meant the medication was not administered. A second resident, admitted with a left tibia medial malleolus fracture, dementia with moderately impaired cognition, and muscle weakness, was dependent on staff for all ADLs and had an active order for Visine Dry Eye Relief Ophthalmic Solution 1%, one drop in both eyes three times daily. Review of this resident’s March MAR showed no documented evidence that Visine was administered at 6 a.m. on 3/3. The RN Supervisor confirmed that this medication was not administered as ordered. The facility’s 2024 “Administering Medications” policy stated that medications are to be administered as prescribed and that the individual administering the medication must document the date, time, dosage, route, and their signature and title on the MAR, which did not occur 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 deficiency involves the facility’s failure to promptly implement its infection prevention and control policies for residents who developed respiratory symptoms. One resident with chronic obstructive pulmonary disease and pulmonary fibrosis, and with moderately impaired cognition and dependence on staff for several ADLs, developed shortness of breath, coughing, and congestion as documented on an SBAR form on 2/14/2026 at 9:30 p.m. Despite these symptoms, the resident was not placed on transmission-based precautions until 2/18/2026 at 8:33 p.m., and testing for a respiratory pathogen panel was not performed until 2/19/2026 at 5 a.m. The Infection Prevention Nurse (IPN) confirmed during interview and record review that this resident should have been tested for a respiratory pathogen panel or at least influenza and Covid-19 immediately when symptoms appeared and should have been placed on transmission-based precautions right away. Another resident, admitted with acute pulmonary edema and anemia, also had moderately impaired cognition and required set-up assistance with eating and oral hygiene and was dependent on staff for showering and toileting hygiene. This resident developed a productive cough documented on an SBAR form on 2/21/2026 at 8:29 p.m., but testing for a respiratory pathogen panel was not completed until 2/23/2026 at 3:30 a.m. The IPN confirmed that this resident likewise should have been tested for a respiratory pathogen panel or at least influenza and Covid-19 immediately when respiratory symptoms manifested. The facility’s own infection prevention and control policy stated it would maintain a safe environment to prevent and manage the spread of infections and follow current best practices, and the LA Department of Public Health toolkit specified that residents with signs or symptoms of respiratory illness should be immediately tested for Covid-19 and influenza and placed on empiric transmission-based precautions while awaiting results. The surveyors determined that these delays constituted a failure to implement infection control policies and public health guidance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident’s adaptive call light was accessible and within reach, resulting in a delay in care and services. The resident had been admitted with a fracture of the medial malleolus of the left tibia, dementia, and muscle weakness. According to the MDS dated 1/14/2026, the resident’s cognition was moderately impaired and she was dependent on staff for all activities of daily living. During an observation and interview in the resident’s room, the resident’s switch adaptive call light was found on the floor away from her, and CNA 1 confirmed that the call light was out of the resident’s reach. During the same observation, the resident stated she needed the call light positioned under her forearm so she could press it when she needed assistance from staff. In a separate interview, the DON stated that all residents must have an accessible call light within reach to ensure they can call for help. Review of the facility’s 2024 policy and procedure titled “Answering the Call Light” indicated that call lights need to be within residents’ reach. These observations, interviews, and record reviews showed that the resident’s call light was not positioned as required by facility policy or as needed by the resident, leading to the identified 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 neurological checks were completed as indicated in their policy for two residents following unwitnessed falls. For one resident with diagnoses including acute respiratory failure, congestive heart failure, and dementia, the care plan required neuro checks after an unwitnessed fall. However, the neurological assessments were not performed at the required intervals, as the checks were completed every 30 minutes twice, every hour twice, and then every three hours three times, instead of following the specified protocol. Similarly, another resident with diagnoses of pneumonia, meningitis, and mobility abnormalities also experienced an unwitnessed fall. The neurological assessments for this resident were completed at incorrect intervals, deviating from the facility's protocol. The DON confirmed during interview and record review that the neuro checks for both residents were not completed at the correct frequencies as required by the facility's policy and procedure, which mandates specific intervals for neurological assessments following unwitnessed falls.

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 nursing progress notes for one resident were accurate and properly documented. Specifically, a review of the resident's admission record showed the individual was admitted with diagnoses including acute respiratory failure, congestive heart failure, and dementia with severely impaired cognition. The resident was later sent to a general acute care hospital and subsequently expired. Upon review of the resident's daily nurse notes, it was found that entries made on a certain date were actually late entries for a previous date, but the nurse did not indicate that they were late entries or specify the actual date and time the events occurred. During interviews, the registered nurse acknowledged forgetting to document the entries as late and to include the correct timing. The Director of Nursing confirmed that documentation is required to be complete and accurate. The facility's policy also states that all services and changes in a resident's condition must be documented objectively, completely, and accurately. The failure to properly document late entries resulted in an inaccurate depiction of the care and services provided to the resident.

Penalty

No penalty information released

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

Summary

The facility failed to notify the primary care doctors of two residents when they refused to wear their BiPAP masks as ordered. Resident 1, who was admitted with obstructive sleep apnea and had intact cognition, refused to wear the BiPAP mask on multiple occasions in January 2025. Despite these refusals being documented in the Medication Administration Record, there was no evidence that the physician was notified of these refusals. Licensed Vocational Nurse 1 confirmed that the physician should have been notified and that the lack of documentation meant there was no evidence of such notification. Resident 2, who had moderately impaired cognition and required substantial assistance with activities of daily living, also refused to wear the BiPAP mask since admission. The resident expressed discomfort with the fit of the mask, stating it was not like the one used at home. Although the refusal was documented, there was no indication that the physician was notified. Licensed Vocational Nurse 2 acknowledged the importance of notifying the physician due to potential respiratory issues or sleep disturbances. The Director of Nursing confirmed that refusals should be documented and the physician notified, as per 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 provide adequate care for a resident who was unable to perform activities of daily living, specifically in maintaining personal hygiene. The resident, who had moderate cognitive impairment and was diagnosed with bipolar disorder, COPD, and bilateral hip osteoarthritis, was left in a wet diaper for over five hours. This situation arose when the resident initially refused a diaper change at 9:30 am, requesting the CNA to return later. The CNA, after attending to other residents and taking a lunch break, did not return to check on the resident until after lunch, at which point the resident's call light was on. Upon returning, the CNA found the resident's diaper to be extremely wet, acknowledging that this could lead to skin breakdown and discomfort. The CNA admitted that she should have informed the charge nurse of the resident's refusal and arranged for another staff member to assist before going to lunch. The Director of Nursing confirmed that CNAs are expected to notify the charge nurse in such situations to prevent prolonged exposure to wet conditions, which can cause skin issues and discomfort. The facility's policy emphasizes treating residents with respect, kindness, and dignity, ensuring equal access to quality 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 timely refilling of Norco, a controlled medication for severe pain, for a resident. The resident, who was admitted with diagnoses including bipolar disorder, COPD, and bilateral hip osteoarthritis, had an active order for Norco 7.5-325 mg to be taken every six hours as needed. However, there was a gap in availability from November 24, 2025, to December 3, 2025, during which the resident did not receive the medication. Instead, the resident was given tramadol and repositioned for comfort while waiting for authorization from the physician. The Licensed Vocational Nurse (LVN) acknowledged the importance of documenting the process in the resident's health records to ensure follow-up and continuity of care, which was not done in this case. Additionally, the facility failed to remove a discontinued medication from the medication cart. A discontinued Hydrocodone-Acetaminophen tablet for another resident was found in the cart, despite the order to discontinue it on January 27, 2025. The LVN responsible stated that discontinued medications should be removed immediately to prevent medication errors. The facility's policy requires that discontinued medications be destroyed or returned to the pharmacy, but this was not adhered to, as evidenced by the presence of the medication in the cart.

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 proper infection control practices when a Certified Nursing Assistant (CNA) did not perform hand hygiene between caring for different residents. Specifically, the CNA was observed adjusting a splint for one resident and then immediately touching another resident's call light and blanket without sanitizing her hands. The CNA admitted to not using the alcohol-based hand sanitizer and instead used alcohol pads, which is not in accordance with the facility's infection control policy. Resident 1, who was involved in this incident, had been admitted to the facility with diagnoses including bipolar disorder, chronic obstructive pulmonary disease (COPD), and bilateral hip osteoarthritis. The resident also had moderate cognitive impairment as indicated by the Minimum Data Set (MDS). The facility's policy requires staff to perform hand hygiene before and after direct contact with residents to prevent the spread of infection. Interviews with the Infection Preventionist nurse and the Director of Staff Developer confirmed that all staff were educated on the importance of hand hygiene, emphasizing the 'gel in and gel out' practice.

Penalty

Inspection fine: $20,965

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

Summary

The facility failed to ensure a safe discharge plan for a resident with cognitive impairment and the inability to make medical decisions. The resident was taken from the facility against medical advice by a significant other, who was not authorized to make medical decisions on behalf of the resident. The facility was aware of the significant other's intention to remove the resident five days prior but did not develop a discharge plan or notify the resident's physician of the situation. As a result, the resident's whereabouts were unknown for two days, and he was later found in a homeless encampment under unsafe and unsanitary conditions. The resident, who was non-ambulatory, incontinent, and required medication for multiple medical conditions, was found without necessary care or provisions. The facility did not assess the resident's medical condition upon locating him, nor did they call emergency medical services to evaluate his need for hospitalization. Instead, the facility allowed the resident and the significant other to sign an AMA form without ensuring the resident's safety or ability to care for himself outside the facility. Interviews with facility staff revealed that they were aware of the significant other's intentions but failed to take appropriate actions to prevent the unauthorized removal. The facility's policies and procedures for discharge and AMA situations were not followed, leading to the resident being placed in a potentially life-threatening situation without proper care or support.

Removal Plan

• Facility staff went to a homeless encampment at a park, located two miles from the facility. The DON drove by the local area park again where Resident 1 and his Responsible Party were found. The DON confirmed that this was Resident 1. Resident 1 was not in any distress and had no signs of diminished cognitive response. Resident 1 was sitting in a wheelchair, his breathing was even and unlabored, he was asked his full name and date of birth, and he was able to respond appropriately. The DON called 911 and the paramedics arrived while the DON remained at the park. The paramedics asked Resident 1 if they could assess him, and he refused. The paramedics offered to take the Resident 1 to the hospital, he and the significant other refused. The paramedics informed the ADM and the DON that they could not force Resident 1 to go to the hospital against and they had a right to refuse. Resident 1 refused transport with the paramedics and refused an offer to return to the facility. The facility offered Resident 1 and the significant other supplies, but Resident 1 and the significant other told facility representatives to stop bothering them. The DON attempted to notify the Resident 1's Physician. The Physician was notified that Resident 1 refused to come back to the facility or go to the hospital to be evaluated.
• The facility reviewed Resident 1's medical records, which were available during Resident 1's admission and confirmed the significant other was listed as his Responsible Party in his previous hospital records and his facility history and physical. The facility also confirmed that Resident 1 and the significant other once resided at the same address. The significant other refused to provide any identifying information to the paramedics or facility representatives because the significant other said that information was personal. The significant other introduced herself to the paramedics as Resident 1's wife and caretaker.
• The facility Social Services Director, DON and Minimum Data Set nurse reviewed documents for all residents discharged in the past months. No deficient practices were identified. No other residents left the facility AMA in the past 3 months.
• The Continuous Quality Improvement Nurse Consultant in-serviced all licensed nurses who were present and the Interdisciplinary Team on the facility's policy and procedure pertaining to the discharge process, discharge planning, AMA, and care for residents with cognitive impairment and physical limitations. In-services were done with licensed nurses who were present on all shifts. Staff who were not present for the in-services will be in-serviced via phone and will be asked to sign the in-service form upon return to the facility. If unable to in-service via phone, staff will be in-serviced upon returning to work. Staff will not be returned to the floor until in-serviced.
• The DON and CQI Nurse Consultant reviewed all current residents' records for presence of information about the responsible party, including contact information and followed up to request information for any residents missing this information. No discrepancies were found.
• The facility will initiate discharge planning with the resident or resident's representative if the resident has no capacity to make decisions during initial social service assessment and discuss the discharge process and plan during the initial IDT care conference within one week of admission if the resident or representative agree and are available.
• When a resident or resident's representative expresses the desire to leave the facility, the social service will call for a discharge plan meeting to discuss the resident's post discharge needs unless the plan is already in place. If a resident or representative expresses the desire or intention to leave facility AMA and the physician determines the resident is not ready for discharge and will not issue a discharge order, the facility will present the resident or the representative with information regarding the risks and the consequences of leaving and request that they sign an AMA form. The Physician will be notified regarding the AMA.
• In the event that a resident leaves the facility without notice, the facility staff will assess the resident for any signs of injury or change of condition once located. The facility may transfer the resident to the emergency department for further evaluation if needed and the resident will be returned to the facility if the resident or the representative agrees. The facility will involve emergency services personnel as necessary.

Penalty

Inspection fine: $20,965

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 safety and supervision of a resident with severe cognitive impairment and multiple medical conditions, resulting in the resident being taken out of the facility by an unauthorized person. The resident, who was non-ambulatory and dependent on staff for activities of daily living, was removed by a significant other who had no documented contact information and had previously refused to sign admission documents or provide contact details. The facility was unaware of the resident's whereabouts for two days until he was found in a homeless encampment, exposed to poor weather and unsanitary conditions without necessary medications or care. The resident's medical history included metabolic encephalopathy, post-stroke hemiplegia, functional quadriplegia, hypertension, dysarthria, benign prostatic hypertrophy, urinary tract infection, hypothyroidism, generalized weakness, and a history of repeated falls. Despite these conditions, the facility did not have a responsible person listed for the resident, only a contact person with no contact information. The resident's care plan indicated a need for retraining in skills for community return, but there was no effective communication or intervention to prevent the unauthorized removal. Interviews with facility staff revealed a lack of communication and monitoring regarding the significant other's intentions to take the resident out of the facility against medical advice (AMA). The facility's weekend receptionist, who remotely opened the front door for the resident and the significant other, was not informed of the situation. The Director of Nursing acknowledged awareness of the significant other's intentions but failed to notify the resident's physician or implement a care plan to address the risk. The facility's policy on safety and supervision was not effectively followed, leading to the resident's unsafe removal and subsequent exposure to hazardous conditions.

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 sanitary conditions in the kitchen, leading to potential food contamination risks. During an observation, it was noted that several opened food items, including Simply thick easy mix, horseradish sauce, bread, and hamburger buns, were not labeled with the date they were opened. This oversight was acknowledged by a staff member, who confirmed that these items should have been dated. Additionally, the dry storage area was found to be unclean, with a banana peel observed on top of kitchen supplies, which a dietary aide agreed to remove. Further deficiencies were identified in the storage temperatures of the residents' refrigerator and freezer. The refrigerator was found to be operating at 42 degrees Fahrenheit, and the freezer at 8 degrees Fahrenheit, both above the recommended temperatures for safe food storage. The Activities Director acknowledged these issues and indicated that maintenance would be notified to address the temperature discrepancies. The facility's policies and procedures, as well as federal guidelines, emphasize the importance of maintaining proper food storage temperatures to prevent foodborne illnesses.

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 assessed for the use of physical restraints, received informed consent, and had a physician order for their beds being placed against the wall. This practice was observed for three residents, all of whom had severely impaired cognition and were dependent on staff for various activities of daily living. The placement of beds against the wall was considered a form of restraint as it restricted the residents' freedom of movement, and there was no documentation of informed consent or physician orders for this arrangement. During observations, the beds of the three residents were noted to be against the wall, and interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that this setup could be considered a restraint. The facility's policy on the use of restraints requires informed consent, a restraint assessment, and a physician order, none of which were present in the cases of these residents. The policy also emphasizes the need for a pre-restraining assessment to explore less restrictive interventions, which was not conducted for these 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 accurately assess and code the Minimum Data Set (MDS) for two residents, leading to potential deficiencies in care planning and service provision. For Resident 1, the facility did not correctly code Section GG 0115 of the MDS to reflect the resident's functional limitations in the range of motion (ROM) of both arms. Despite the Occupational Therapy Joint Mobility Assessment indicating moderate to severe ROM loss in both arms, the MDS was incorrectly coded to show no ROM limitations. This discrepancy was confirmed by the MDS Nurse, who acknowledged that the incorrect coding could lead to inaccurate care planning. Resident 1 was admitted with diagnoses including cataracts, rheumatoid arthritis, and contracture of the upper arm. Observations and interviews revealed that Resident 1 had significant difficulty moving both arms, particularly the right arm, which was consistent with the findings of the Joint Mobility Assessment. The resident expressed reliance on staff for all daily care, highlighting the importance of accurate MDS coding to ensure appropriate care and services. For Resident 25, the facility failed to document the diagnosis of anxiety disorder in the MDS, despite the resident being prescribed and taking antianxiety medication. The resident's medical records, including the Order Summary Report and psychiatric visit progress reports, indicated a diagnosis of generalized anxiety disorder and the use of buspirone for treatment. Interviews with facility staff confirmed the resident's diagnoses, including anxiety, yet the MDS did not reflect this, potentially impacting the monitoring and care provided to the resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the availability of essential medications for three residents, leading to deficiencies in medication administration. Resident 5 was supposed to receive magnesium oxide as per the physician's order, but the medication was not in stock, and the LVN was confused about the strength on the bottle. This oversight could potentially affect the resident's magnesium levels, leading to muscle cramps and weakness. The Director of Nursing acknowledged that missing doses could result in abnormal magnesium levels, affecting the heart and causing muscle weakness. Resident 28 did not receive lactulose solution for bowel management due to the facility running out of the medication. The LVN noted that the absence of this medication increased the risk of bowel impaction, potentially leading to emergency situations or hospitalization. Additionally, Resident 28 was administered aspirin in a manner inconsistent with the physician's order, as the chewable tablet was swallowed instead of chewed, which could delay its effectiveness in preventing heart complications. Resident 202 was not administered gabapentin for neuropathic pain because the medication was not delivered by the pharmacy. The LVN reported that the resident experienced significant pain, rated at 9 out of 10, and refused an alternative pain medication. The delay in medication delivery was attributed to an error in entering the medication as house stock. The DON confirmed that untreated pain could lead to discomfort and affect the resident's ability to perform daily activities.

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 management of psychotropic medications for two residents, leading to deficiencies in medication administration and informed consent. For one resident, the facility did not specify a duration for the PRN Lorazepam order, failed to implement non-pharmacological interventions before administering the medication, and did not conduct behavior monitoring or obtain informed consent. This resident had a history of major depressive disorder, chronic pain syndrome, and cancer, and required significant assistance with daily activities. Another resident was administered Mirtazapine for major depressive disorder without updated informed consent reflecting the increased dosage and changed behavior monitoring. This resident, diagnosed with dementia, major depressive disorder, and anxiety, was unable to make medical decisions independently. The facility's failure to obtain new informed consent and monitor the resident's behavior for medication effectiveness was confirmed by a registered nurse supervisor. The facility's policies required monitoring for effectiveness and adverse reactions of psychotropic medications, attempting alternative behavior management before medication use, and obtaining informed consent for specific dosages. However, these policies were not followed, as evidenced by the lack of specified duration for PRN medications, absence of non-pharmacological interventions, and outdated informed consent documentation.

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% during medication administration, resulting in a 13.33% error rate. This deficiency was observed in the cases of three residents. For one resident, the facility did not have magnesium oxide in stock, which was prescribed to treat low magnesium levels. The Licensed Vocational Nurse (LVN) was confused about the strength of the available magnesium oxide and did not administer it, potentially affecting the resident's magnesium levels and causing muscle cramps and weakness. Another resident did not receive their prescribed lactulose solution due to it being out of stock, which was necessary for bowel management. Additionally, the resident was given aspirin in a form that was not chewed as required, which could delay its effectiveness. The LVN acknowledged the error and the potential risk of heart complications due to the improper administration of aspirin. A third resident did not receive gabapentin for neuropathic pain because the medication was not available. The resident reported significant pain, and the LVN noted that the medication request was delayed due to an administrative error. This oversight left the resident in pain, which could lead to increased blood pressure and affect their mood.

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 implementation of Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube, as there were no physician orders or documentation for EBP. A Certified Nurse Assistant (CNA) was observed providing care to the resident without wearing an isolation gown, despite a sign indicating the need for gown and gloves for high-contact care. The CNA admitted to forgetting to use the gown, and the Registered Nurse Supervisor confirmed the absence of physician orders for EBP, emphasizing the need for such orders to ensure proper care under physician supervision. Additionally, the facility did not maintain a clean and sanitary environment for medication storage. A red incinerator bin with an open lid containing liquid was found in a medication cart, posing a risk of contamination to nearby medications. The Licensed Vocational Nurse (LVN) responsible for the cart was unaware of when the bin was placed there and acknowledged the risk of contamination and infection control issues. The Director of Nursing (DON) also recognized the potential for spillage and contamination due to the open bin. The facility's policies and procedures for infection prevention, physician services, and medication storage were reviewed, indicating the need for a safe and sanitary environment and proper documentation and implementation of care practices. However, these policies were not followed, leading to the deficiencies observed during the survey.

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 feeding assistance at the same time as another resident, resulting in an undignified dining experience. Resident 23, who was admitted with diagnoses including age-related cataract, vision loss, hearing loss, and unspecified osteoarthritis, was dependent on staff for eating due to severely impaired cognition. The resident was on a regular diet with mechanical soft texture. During an observation, it was noted that Resident 23 was waiting for feeding assistance while Resident 17, who also had severely impaired cognition and was dependent on staff for eating, was being assisted by a Certified Nurse Assistant (CNA). Resident 17 was on a regular diet with pureed texture. The CNA stated that there was insufficient staff to assist both residents simultaneously, leading to one resident having to wait while the other was being fed. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the staff needed to be sensitive to residents requiring feeding assistance and that it was a dignity issue if residents did not eat at the same time. The facility's policy on Resident Rights emphasized treating all residents with kindness, respect, and dignity, which was not upheld in this instance.

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 call light device was within reach for a resident, which had the potential to prevent the resident from receiving necessary care and services. The resident, who was admitted with diagnoses including cataracts, rheumatoid arthritis, and contracture of the upper arm, had severely impaired vision, difficulty hearing, and severely impaired cognition. The resident required assistance with various daily activities and was assessed as having a high fall risk. During an observation, the resident's call light was found on the floor, out of reach, and the resident was unable to locate it due to her impaired vision. Licensed Vocational Nurse 1 confirmed that the call light was out of reach and stated that it should always be in the resident's hands to ensure accessibility. The Director of Nursing also stated that call lights should always be accessible and within reach to allow residents to call for assistance. The facility's policy indicated that call lights should be within easy reach of residents to ensure their needs and requests are met. This deficiency was identified through observation, interview, and record review, highlighting a failure to accommodate the resident's needs and preferences effectively.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a mental disorder, which is a federal requirement to ensure appropriate placement and services. The resident, identified as Resident 19, was admitted with diagnoses of major depressive disorder and post-traumatic stress disorder (PTSD). Despite these diagnoses, the PASARR Level I screening inaccurately indicated that the resident did not have a mental disorder, which should have triggered a Level II PASARR for a comprehensive evaluation. During interviews and record reviews, it was confirmed by the MDS nurse that the resident's PASARR Level I screening was incorrect and should have indicated the presence of a mental disorder, the prescription of psychotropic medications, and the experience of symptoms. The Director of Nursing also acknowledged that Level II PASARR is necessary for residents with mental disorders to ensure they receive the appropriate assistance. The facility's policy on PASARR, revised in May 2023, outlines the federal requirement to evaluate all applicants for serious mental disorders and ensure they receive the necessary services in the most appropriate setting.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to potential delays in care and services. Resident 25, who was admitted with major depressive disorder, generalized muscle weakness, and a gastrotomy tube, was found to have severely impaired cognition and was dependent on staff for all activities of daily living. However, during a review of Resident 25's care plans, it was discovered that there was no care plan addressing the resident's activities, as confirmed by the registered Nurse Supervisor. Resident 1, admitted with cataracts, rheumatoid arthritis, and contracture of the upper arm, was identified as having severely impaired vision, difficulty hearing, and severely impaired cognition. Despite these conditions, Resident 1's care plan did not address the severe visual impairments. Observations revealed that Resident 1 was unable to see the television positioned close to her face and could not locate or reach the call light due to her visual impairment. The Minimum Data Set Nurse confirmed that a care plan with specific goals and interventions should have been developed for Resident 1's visual deficits, but none was in place. The Director of Nursing acknowledged the importance of developing and implementing care plans to guide resident care and treatment, emphasizing that the absence of such plans could impede continuity of care. The facility's policy and procedure on care plans, revised in March 2022, mandates the development and implementation of comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the facility failed to adhere to this policy for Residents 1 and 25, resulting in deficiencies related to their 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 revise a person-centered care plan for Resident 149, who was receiving artificial nutrition through a gastrostomy tube. The care plan, created on January 5, 2024, indicated that Resident 149 was to receive Diabeticsource 1.2 at 75 ml per hour for 10 hours daily, which was discontinued on June 27, 2024. However, a new physician's order was placed on June 27, 2024, for Glucerna 1.2 at 60 ml per hour for 20 hours daily. Despite this change, the care plan was not updated to reflect the new order, leading to a discrepancy between the care plan and the current physician's orders. Resident 149, who has diagnoses of dysphagia, cerebral palsy, and unspecified abnormal physiological development, was observed on October 15, 2024, receiving Glucerna 1.2 at 60 ml per hour. The MDS nurse confirmed that the care plan was not updated with the current feeding order, and the director of nursing emphasized the importance of accurate care plans for ensuring continuity of care. The facility's policy requires care plans to be revised as residents' conditions change, but this was not adhered to in Resident 149's 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 provide necessary treatment and services to prevent a decline in range of motion (ROM) for a resident identified as having ROM limitations in both legs and a decline in ROM of both hips. The resident, who was admitted with diagnoses including rheumatoid arthritis and contracture of the upper arm, had been discharged from physical therapy services after reaching her highest practical level of function. However, the recommended Restorative Nursing Aide Program to apply splints was not fully implemented, as there were no orders for ROM exercises for the legs. Observations and interviews revealed that the resident was not receiving assistance with leg exercises, and staff assumed that ROM exercises were being provided by others. The Restorative Nursing Aide and Certified Nursing Assistant both confirmed that they did not perform ROM exercises, and the Director of Rehabilitation acknowledged that a therapy evaluation should have been ordered when a decline in ROM was noted. The resident's Joint Mobility Assessments indicated a worsening of ROM in both hips, knees, and ankles over time, yet no additional therapy services were initiated. The facility's policies and procedures required that any changes in ROM be addressed through evaluations and communication with the interdisciplinary team. Despite these guidelines, the resident did not receive the necessary ROM services to prevent further decline, leading to a significant reduction in mobility and potential risk for contracture development.

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 proper removal and storage of medications, leading to several deficiencies. In the medication room, an expired bottle of Folic Acid and discontinued Inbrija capsules for a resident were found. The Director of Nursing (DON) acknowledged that the expired Folic Acid should have been removed to prevent it from being administered, and the discontinued Inbrija should have been discarded immediately after the order was placed for discontinuation. The improper storage of these medications increased the risk of medication errors and misuse. Additionally, the facility did not store Brimonidine tartrate ophthalmic solution according to manufacturer requirements. The medication was found in the refrigerator alongside another resident's Latanoprost, which requires refrigeration. However, Brimonidine should be stored at room temperature. The DON confirmed that the Brimonidine was improperly stored, which could have rendered it ineffective and unsafe for treating the resident's glaucoma. Furthermore, an insulin Glargine prefilled pen for another resident was labeled with two different opened dates, contrary to the manufacturer's requirements. This discrepancy posed a risk of administering expired insulin, potentially compromising the resident's treatment for high blood sugar levels. The DON stated that the facility staff is required to label medication containers with an opened date and follow the standard for insulin expiration, which was not adhered to in this case.