Brookside Inn

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents, particularly in relation to transportation safety and fall prevention. One resident with vascular dementia, bilateral lower extremity impairments, and dependence on staff for transfers was transported to an outside appointment in a facility vehicle while seated in a wheelchair without foot pedals. During the trip, the resident began sliding forward in the wheelchair. The transportation driver reported he could not immediately pull over while exiting the highway, and by the time he stopped, the resident had slid further forward so that her knees and legs were resting on a step behind the driver’s seat. The resident subsequently exhibited multiple bruises, abrasions, swelling of both legs, and severe pain. Facility records and later hospital documentation identified bilateral tibial fractures associated with this transport incident. The report details that the wheelchair was secured with a four‑point tie‑down, but the resident’s body was not properly restrained. The driver later demonstrated that he had routed the shoulder portion of the seat belt around the back of the van seat instead of across the resident’s shoulders, and placed the lap portion across the resident’s chest instead of her lap. He acknowledged this was not the proper use of the seat belt and attributed his actions in part to concern about disturbing the resident’s ostomy bag. He also stated that the resident was sitting on a blanket and a Hoyer sling, which he believed contributed to sliding, and that the absence of foot pedals left nothing to stop the resident’s forward movement. The facility’s own transportation policy required that drivers and passengers wear seatbelts and shoulder harnesses any time the vehicle was in motion and that wheelchairs be made secure with straps, but there was no evidence that the seat belt system was applied as intended in this case. The report further identifies systemic issues in transportation training and oversight that contributed to the deficiency. The van driver had been in the role for a little over a month and was trained informally by the central supply coordinator, who herself had been trained years earlier by a prior driver without documented competencies, checklists, or reference to an operations manual. The central supply coordinator reported no additional training or competencies since that initial instruction and was unaware of any policy or procedure for driving emergencies or clear guidance on whom the driver should contact for clinical or mechanical emergencies during transport. The maintenance director, responsible for monthly checks of the van, used a generic medical transport checklist, had no van‑specific training or competencies, and was unsure whether an operations manual was available. The administrator acknowledged that she was not sure what competencies the trainer had when she trained the current driver, that the DON and ADON were not trained on transportation, and that no investigation was completed into the driver’s admitted misuse of the seat belt. Collectively, these actions and inactions led to the transportation‑related accident and constituted a failure to maintain an accident‑free environment and adequate supervision. In addition, the deficiency includes failures related to fall management for two other residents at high risk for falls. One resident with vascular dementia, muscle wasting, difficulty walking, and severe cognitive impairment experienced 16 falls over a defined period, including an unwitnessed fall that resulted in a facial laceration and a maxillary sinus fracture requiring emergency department evaluation. The facility had a fall management policy requiring IDT review of falls and individualized care plan interventions, and the resident’s care plan contained multiple fall interventions such as scheduled toileting, prompted voiding, use of a non‑recording video monitor, and assistance with transfers. However, the report notes that care‑planned fall interventions were not consistently implemented in a timely manner, and surveyor observations during the survey period showed that staff were not consistently following the resident’s fall interventions. The report also notes that the IDT did not consistently review falls in a timely manner or ensure that recommended interventions were implemented. For the high‑risk resident with multiple falls, IDT notes documented repeated unwitnessed and witnessed falls associated with poor safety awareness, failure to use the call light, weakness, and attempts to ambulate or transfer without assistance. New interventions such as occupational therapy evaluations, room relocation closer to staff, and pharmacy review were recommended, but one occupational therapy evaluation was recommended after a fall even though it had already been recommended after a prior fall, indicating delays or gaps in implementation. Another resident with multiple falls had no timely identification and documentation of fall interventions after several falls. These patterns demonstrate that the facility did not ensure timely IDT review of falls or consistent implementation of care‑planned fall interventions, contributing to repeated falls and at least one major injury. Overall, the cited deficiency encompasses the facility’s failure to safely transport a dependent, cognitively impaired resident in accordance with its own transportation safety policy, resulting in bilateral tibial fractures, and its failure to consistently implement and timely review fall prevention interventions for residents at high risk for falls, including residents who sustained multiple falls and a serious injury.

Removal Plan

• Temporarily suspend all facility resident transportation services and transfer transportation to an outside company pending completion of training and validation.
• Immediately remove all staff members assigned transportation responsibilities from transportation duties pending completion of retraining and competency validation.
• Transport residents requiring appointments using medical transportation services through external transportation companies.
• Implement a resident transportation risk assessment tool to identify residents who require special transportation precautions; assess all residents who utilize facility transportation using this tool.
• Implement a comprehensive transportation safety program including: updated Transportation Safety Policy; Transportation Driver Job Description with defined safety duties; Transportation Staff Competency Validation process; Pre-Transport Safety Checklist (reviewed by administrator or designee); Transportation Special Circumstances Protocol; Transportation Incident Investigation Template; Transportation Safety Training Program; and Transportation Safety QAPI Monitoring Process.
• Require wheelchairs to be secured using a four-point tie-down system.
• Require residents to be secured with lap and shoulder seatbelts.
• Verify wheelchair brakes and foot pedals prior to transport by the administrator or designee.
• Confirm resident stability before departure by the administrator or designee.
• Evaluate residents’ medical devices/special medical circumstances individually (e.g., ostomies, indwelling urinary catheters, suprapubic catheters, oxygen equipment, other devices) and implement appropriate precautions prior to transportation as necessary.
• Provide mandatory transportation safety training for all transportation staff (wheelchair securement, restraint placement, medical device accommodations, emergency response); document attendance and validate competency using a checklist, with validation by the maintenance director and clinical liaison/designee as approved by the administrator.
• Complete a Pre-Transport Safety Checklist prior to each transport verifying wheelchair brakes engaged, foot pedals attached, four-point tie-down secured, lap and shoulder restraints applied, medical devices protected, and resident stability confirmed (completed by Maintenance Director and Clinical Liaison/Designee).
• Use a transportation incident ad hoc QAPI tool to ensure structured review of any transportation-related incident (incident description, equipment review, root cause analysis, corrective action planning).

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to ensure food was prepared, distributed, and served under sanitary conditions in the main kitchen. During observation of lunch meal service, cook #1 prepared a peanut butter and jelly sandwich while wearing gloves, but after opening the walk-in refrigerator door to retrieve jelly, he continued handling bread and assembling the sandwich without changing gloves or performing hand hygiene. He also carried the finished sandwich into the dirty dish area to retrieve a clean plate before sending it to the servers for resident service. Additional observations showed multiple instances of the same food handling practice. Cook #1 used gloved hands while handling butter, brushing it onto dinner rolls, and then used the same gloves to handle the rolls for placement into a steam table bin. The regional dietary supervisor also handled ready-to-eat foods with gloved hands while preparing chef salads, including opening packaging, handling boiled eggs, and placing lettuce, eggs, and ham into salad bowls without changing gloves after touching packaging or moving between tasks. Further observations included cook #1 handling hamburger buns, patties, lettuce, and pickle slices with the same gloves after touching utensils and packaging. He also repeatedly handled buns and patties while assembling hamburgers without changing gloves between tasks. The regional dietary supervisor stated that ready-to-eat foods should be handled with single use/single task gloves and that kitchen staff should change gloves when going from task to task.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to conduct and document a facility-wide assessment that identified the resources necessary to care for residents competently during day-to-day operations and emergencies. The assessment, last reviewed by the NHA on 5/8/25 and provided during the survey, did not include staff competencies needed for the resident population, a staff training program for new and existing staff, all contracts and agreements for services or equipment, facility resources needed for resident support, or how policies and procedures were evaluated for current professional standards of practice. It also did not identify the areas of a facility-based and community-based risk assessment using an all-hazards approach. The assessment was also not facility specific. Staff interviews confirmed the secured unit housed 19 residents and was for female residents only, but the assessment did not include that detail. The DON stated the facility had contracts with an oxygen company, laboratory company, and X-ray company, but these were not identified in the assessment. The DON also stated the facility admitted non-English speaking residents and used a translation line, yet the assessment did not identify how a translator would be obtained for those residents. The NHA acknowledged the assessment did not include training, staffing plans, contracts, emergency hazards, or specific information about the all-female secured unit.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to ensure an effective QAPI program was implemented to identify and address compliance concerns related to quality of care, quality of life, and resident safety. The record showed repeated citations for F600 Abuse prevention during the recertification survey on 11/3/22, the recertification survey on 2/8/24, and the abbreviated survey on 3/6/25, with the most recent citation at the G level scope and severity for actual harm that was not immediate jeopardy. The report states the QAPI performance improvement committee failed to identify and address concerns related to quality of life and quality of care. The report also cross-referenced F689 and described a transportation incident involving Resident #106 on 1/30/26, when the facility failed to ensure the resident was secured properly in a facility transportation vehicle. As a result, the resident sustained multiple fractures to the lower extremities. The facility also failed to address concerns regarding transportation staff training and proper fastening of restraints for residents during transportation. The survey found this failure created an immediate jeopardy situation with actual serious harm.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to provide residents with a response, action, and rationale for grievances raised in resident/family group meetings. The grievance and concern policy stated residents have the right to receive a written decision on a grievance, and that within three days of receiving a grievance the grievance coordinator was to provide an explanation of the finding and proposed remedies to the complainant and aggrieved party. However, residents who regularly attended the resident council and food council meetings reported that concerns brought up in those meetings were not followed up on and continued to recur month after month. During interviews, residents said concerns about staff using ordering tablets incorrectly, lack of healthy snack choices, refusal of fresh fruit, and not receiving soup varieties or homemade soup were repeatedly raised without clear resolution. Record review showed food council minutes documenting concerns about staff communication, fresh fruit, homemade soups, cold room trays, inconsistent room tray delivery times, missing room tray meals, and low sodium soup options. The grievance materials provided by the facility referenced that some concerns had been addressed in meeting minutes, but the record did not show follow-up with the individual residents or the food council as a group regarding what had been done to resolve the concerns after the meetings. Staff interviews confirmed that concerns raised in the food council meetings were not consistently written up as formal grievances and that residents were not brought back a resolution.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles and stored properly in locked medication areas. During review of the medication storage room, surveyors found one vial of TB serum that had been opened but was not dated, along with multiple expired medications and supplies, including Flucelvax pre-filled syringes, hydrocortisone acetate suppositories, blood collection sets, Luer Lock caps, a Vacutainer needle, an enteral feeding tube clog remover, Vacutainer blood collection vials, and blue capped needles. Surveyors also reviewed medication carts on the secure unit, A-Hall, and B-Hall. On the secure unit cart, they found one opened bottle of Refresh Tears that was not dated, a bottle of Drug Buster stored in the same drawer as liquid medications, and one opened foil package of ipratropium bromide and albuterol sulfate ampules that was not dated. On A-Hall, they found one opened bottle of GenTeal tears that was not dated, two acetaminophen 650 mg suppositories lying loose in a small plastic container, one opened vial of lispro insulin that was not dated, and one naloxone nasal spray kit that had expired. On B-Hall, they found two acetaminophen 650 mg suppositories lying loose in a small plastic container, one opened foil package of lidocaine patches, one opened urinary drainage bag package in the bottom drawer, one opened foil package of ipratropium bromide/albuterol sulfate ampules that was not dated, and one tube of miconazole nitrate cream that had expired. The DON stated that night shift nurses were responsible for routinely reviewing the medication storage room and medication carts for expired medications and supplies, and that the pharmacist also completed routine medication cart reviews but did not check the medication storage room for expired items. An LPN stated that nurses were to check expiration dates during medication passes and that night shift nurses were to routinely review the medication room and carts and remove expired medications or supplies from use.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to ensure meals were served according to resident preferences on five of six units, with residents reporting that they were not consistently offered substantive menu alternatives and that requested food items were often unavailable. The Dining and Food Preferences policy stated that residents who refused food or beverage were to be offered an alternate selection of comparable nutritional value in a timely manner, but multiple residents and staff described a meal service process that no longer supported resident choice. Residents reported that the facility had eliminated an always-available menu, reduced menu options, and changed meal ordering so that nursing staff collected orders the day before meals were served, which often resulted in residents receiving preset tray items instead of what they had requested. Several residents described not receiving ordered items or being offered only limited substitutes. One resident said she repeatedly asked for fresh fruit and was told the facility no longer served it, while another resident said she was still hungry after breakfast and had not been offered a snack between meals. That same resident requested a peanut butter and jelly sandwich, but kitchen staff said they were out of sandwiches and she would have to wait until the scheduled snack time. Another resident reported ordering an omelet, sausage, toast, and oatmeal but receiving scrambled eggs, hashbrowns, and oatmeal instead, and said she could not eat hashbrowns. Residents in group interviews said they often did not receive what they ordered, that staff sometimes failed to take meal orders, and that if they did not like the meal served there was nothing else available. Food council and resident council records showed repeated requests for fresh fruit, vegetables, and soups, along with concerns that the alternate menu had been condensed. The minutes documented responses that fresh fruit and vegetables would be purchased when available and in season, and that soups were made fresh and shipped frozen, but one grievance form tied to the food council did not document further follow-up or investigation. Staff interviews confirmed that the kitchen no longer offered the same snacks or menu alternatives as before, that bistro items were only available during scheduled meal times, and that residents who wanted something outside those windows were offered snack items instead. The NHA stated the dietary manager position had been vacant for months and that she had been running the kitchen until an outside dietary company took over shortly before survey.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to maintain an infection control program during housekeeping room cleaning in two resident rooms. In one double-occupancy room, a housekeeper performed hand hygiene, put on gloves, and used Sani-Clean disinfectant on the television console, overbed table, and toilet seat, wiping each surface immediately after spraying instead of allowing the disinfectant to remain wet for the required 10-minute dwell time. The housekeeper also did not clean identified high-touch areas in the room, including the individual call lights, bathroom call lights, door knobs, sink, and grab bars. In a second double-occupancy room, another housekeeper performed hand hygiene, put on gloves, and used damp cloths with Sani-Clean to clean surfaces. She sprayed and wiped the toilet, then used the same gloves to clean the TV console, dresser, and overbed table after touching the toilet seat and the resident’s personal items. She did not change gloves or perform hand hygiene between tasks, and she also did not clean the high-touch areas identified in the room, including the call lights, door knobs, sink, and grab bars. The housekeeper wiped the toilet only four minutes after spraying it with disinfectant, rather than waiting the required 10 minutes. The facility also failed to follow infection control practices for residents on enhanced barrier precautions and during medication administration. A resident on EBP had an open sacral wound, an indwelling urinary catheter, and a PICC line. A restorative aide performed range-of-motion exercises in the resident’s room after only donning gloves, without a gown, and did not change gloves or perform hand hygiene after touching the resident’s personal items and bed frame before continuing care. During later incontinence care for the same resident, the restorative aide, a CNA, and an LPN initially entered without gowns, then donned gowns only after prompting. The CNA, restorative aide, and LPN each touched surfaces or moved the bed and then continued incontinence care without changing gloves and performing hand hygiene. Separately, an RN was observed dispensing oral medications from blister packs into her bare hand before placing them into a medication cup, and acknowledged she knew she was not supposed to do that because it would be an infection control issue.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to ensure that one resident was kept free from abuse when Resident #37 directed racial slurs at Resident #53. The deficiency was based on record review and interviews showing that Resident #37, who had vascular dementia with mood disturbance, depression, cognitive communication deficits, severe cognitive impairment, and a history of verbal and physical aggression, approached Resident #53 near his room and began making racial slur comments toward him. Resident #53 also had severe cognitive impairment, aphasia, hemiplegia and hemiparesis, vascular dementia, major depressive disorder, and cerebral infarction. Resident #37’s record showed a pattern of behavioral issues, including yelling, calling people names, racial comments toward residents of color, inappropriate sexual comments, and physical aggression toward staff. His behavior care plan identified that he could be verbally aggressive, easily irritated, and had made racial comments toward residents of color. The record also documented prior incidents of yelling obscenities at other residents and making inappropriate comments and touching toward staff. Despite these documented behaviors, the report states there was no further follow-up documentation related to the incident in which Resident #37 directed racial slurs at Resident #53. Resident #53’s record documented that after the incident he laughed, shook his head, gave a thumbs up, and later chuckled and waved his hands when asked if he was upset. Staff interviews indicated that when residents had verbal or physical behaviors, they would separate them, redirect them, and notify nursing staff. However, the facility determined the incident was not abuse because Resident #53 did not appear upset and there was no physical contact. Survey findings concluded that Resident #53 was subjected to verbal abuse when Resident #37 used racial slurs directed at him, and the facility failed to protect him from that abuse.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to ensure that two residents were free from involuntary seclusion by not accurately and timely re-evaluating whether their placement in the secure unit remained appropriate. The report states that the facility’s policy required secure unit placement only when specific criteria were met and that placement should end when the condition or behavior justifying it had diminished or the resident no longer met criteria. For both residents, the record lacked documentation from the primary care physician showing that the locked unit was the least restrictive reasonable setting to protect the resident and assure health and safety. Resident #85 had diagnoses including cerebrovascular disease, hypertensive heart disease with heart failure, hypertension, falls, and dementia. The 2/3/26 MDS showed severe cognitive impairment with a BIMS score of 3, total dependence for ADLs, and no physical behavioral symptoms directed toward others. During a continuous observation of the secure unit, the resident sat in the same Broda chair position at the dining table for nearly four hours, was fed by staff, received a magazine, had a hospice nurse visit, was given a doll and a sensory apron, and did not attempt to self-propel or wander. Staff interviews stated the resident was unable to walk or propel herself, never attempted to exit-seek, and could not communicate her needs. The wandering risk assessment documented no wandering in the prior three months and incorrectly stated she could move herself in her wheelchair. Resident #29 had diagnoses including non-Alzheimer’s dementia with behavioral, psychotic, mood, and anxiety disturbances, hypertension, and a history of fractures and TIA. The 1/6/26 MDS showed moderate cognitive impairment with a BIMS score of 9 and dependence on staff for ADLs. The resident told the surveyor she did not like living in the secure unit and did not know the door passcode or why she was there. Observations showed she attended activities outside the secure unit, was returned to the unit, spent time reading in the common area, and later received incontinence care in her room; during the observation she exhibited no wandering, exit-seeking, or aggressive behaviors. The wandering risk evaluation documented no wandering in the prior six months and only occasional following of instructions and redirection, while the nurse practitioner note described her as calm and cooperative. Staff stated she had not been trialed off the unit for three days to evaluate whether transition out of the secure unit was appropriate, and that she had not exhibited exit-seeking behavior.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to adequately monitor the use of a psychotropic medication for one resident, Resident #85, who had vascular dementia, restlessness, agitation, and severe cognitive impairment. The resident’s March 2026 physician orders included lorazepam 0.5 mg by mouth every four hours as needed for dementia with behaviors, restlessness, and agitation for 90 days, ordered on 2/2/26. The order was written for longer than the 14-day limit for PRN psychotropic medications and did not include a physician-documented rationale for continuing the medication beyond that limit. Resident #85’s psychotropic medication care plan identified the resident as receiving psychotropic medications for vascular dementia and behaviors, with interventions to administer medications as ordered and monitor for side effects. The resident received PRN lorazepam doses on 2/21/26 and 2/26/26, but the record contained no documentation that the physician reevaluated the PRN lorazepam after 14 days or documented a rationale to justify continued use beyond the 14-day limit. The DON acknowledged that PRN psychotropic medications should be prescribed for 14 days and then reevaluated unless a rationale for longer use is documented.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to report an alleged incident of verbal abuse to the State Survey and Certification Agency after one resident directed racial slurs toward another resident. The abuse reporting policy stated that if abuse was suspected, the administrator would initiate an investigation and, if abuse was confirmed, notify the State Agency within 24 hours. Surveyors found that the facility did not report the incident because staff and leadership determined it was not abuse after speaking with the residents involved. Resident #37 had vascular dementia with mood disturbance, depression, and cognitive communication deficits, and was assessed as severely cognitively impaired with a BIMS score of 5. His behavior care plan documented verbal aggression, racial comments toward residents of color, physical aggression toward staff, and threats toward staff. A progress note documented that he was found yelling racial slurs at Resident #53, who was redirected away from the area. No further follow-up documentation related to the incident was available, and the facility was unable to provide an investigation because it had determined the event did not constitute abuse. Resident #53 had aphasia, hemiplegia and hemiparesis, vascular dementia, major depressive disorder, and cerebral infarction, and was also assessed as severely cognitively impaired. Documentation showed he was near his room when Resident #37 approached him and began making racial slur comments. Staff later asked Resident #53 about the incident, and he laughed, shook his head, gave a thumbs up, and said he was okay. The social worker also documented that Resident #53 chuckled and waved his hands when asked if he was upset. During interviews, the director of operations, social services director, and nursing home administrator stated the facility did not report the incident because there was no physical contact and they believed Resident #53 was not harmed, despite the verbal slurs directed toward his race.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevent additional pressure injuries for two residents. One resident, who was dependent on staff for ADLs and assessed as high risk for skin breakdown, was observed sitting in the same Broda wheelchair position for long periods without staff attempting to reposition her or check her for incontinence. During one continuous observation, she remained at the dining room table from 11:40 a.m. until 3:37 p.m., and during another observation she remained in the same position from 8:45 a.m. until 1:28 p.m. before being taken for incontinence care. Her care plan identified her as high risk for skin breakdown and included monitoring for repositioning and following facility protocols for prevention and treatment of skin breakdown. Staff interviews confirmed that the resident was incontinent and needed assistance for incontinence care, but the CNA task list did not include repositioning. The RN stated the resident was at high risk for skin breakdown and that not providing incontinence care for four hours or more was a long time. The DON stated that residents at high risk for skin breakdown should receive interventions such as repositioning, hydration, and barrier cream, and acknowledged that sitting long hours in the same position could increase the risk for pressure injuries. The DON also stated she did not know why staff did not provide incontinence care and repositioning for long periods of time. A second resident had a stage 4 sacral pressure injury, osteomyelitis of the sacral and sacrococcygeal vertebrae, cerebral palsy, profound intellectual disabilities, contractures, and was dependent on staff for all ADLs. He used a wheelchair with a ROHO cushion and had an air mattress. During observation, he was seen sitting at an angle in his wheelchair in the common area and remained in the same position for over four hours without repositioning assistance. Staff later transferred him to bed, provided incontinence care, and repositioned him onto his right side. The wound care physician noted the resident had an unavoidable stage 4 sacral pressure injury and recommended pressure-relieving measures, offloading, and repositioning as tolerated, but the care plan did not document how often he should be repositioned or how the ROHO cushion should be monitored and maintained.

Penalty

Inspection fine: $25,65034 days payment denial

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

Summary

The facility failed to provide respiratory care consistent with physician orders and professional standards for two residents receiving oxygen therapy and, for one resident, CPAP care. Resident #42 had diagnoses including CHF, type 2 DM, OSA, depression, and dependence on supplemental oxygen. She was observed multiple times receiving oxygen via nasal cannula from a concentrator set at 4 LPM, while the physician order in the record was for 3 LPM. The record also showed staff documenting oxygen administration at 3 LPM on the MAR during the same period, and there was no documentation that the physician had been notified of the higher observed flow rate. Resident #42 also had a CPAP order requiring the humidifier chamber to be disconnected, emptied, wiped with a disinfectant wipe, dried, and stored out of direct sunlight each day shift. During repeated observations, the humidifier chamber remained connected to the CPAP machine, contained water, and had visible condensation on the chamber walls. The resident stated nursing staff were responsible for cleaning the CPAP machine, and a roommate was observed rinsing the humidifier chamber in the bedroom sink. Staff interviews confirmed the chamber should have been disconnected and cleaned, and the DON acknowledged the resident’s care plan did not reflect the CPAP use, cleaning, and maintenance needs. Resident #16 had chronic right heart failure, a history of pulmonary embolism, and dependence on supplemental oxygen, with severe cognitive impairment and total dependence for many ADLs. The physician order called for oxygen at 2 LPM via nasal cannula, but repeated observations showed the concentrator set between 3 and 3.5 LPM. The MAR documented oxygen at 2 LPM despite the higher observed setting. Staff interviews confirmed the oxygen flow rate was not consistent with the physician order, and the DON acknowledged the resident was not receiving oxygen as ordered.

Penalty

Inspection fine: $1,196

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 by staff members. Resident #2 was subjected to physical abuse by a CNA who roughly repositioned her, causing physical pain and mental anguish. Despite the family reporting the rough treatment to the facility, no investigation was initiated, and the incident was not reported to the state agency. The facility's policy required such allegations to be promptly investigated, but this was not adhered to, leading to a deficiency in protecting the resident from abuse. Resident #2, who had severe cognitive impairments and required assistance with daily activities, was admitted to the facility with a diagnosis of dementia with severe agitation. Her family installed a hidden camera in her room due to concerns about her treatment. The camera captured the CNA handling Resident #2 roughly, which was reported to the facility staff, including the DON. However, the staff did not take appropriate action to investigate or report the incident, violating the facility's abuse prevention policy. Additionally, Resident #1 was physically abused by an LPN who grabbed her arm, resulting in bruising. The incident was observed by a CNA, but the facility's investigation concluded that the abuse was unsubstantiated, despite evidence to the contrary. Resident #1, who also had severe cognitive impairments, was unable to recall the incident. The facility's failure to substantiate the abuse and take appropriate action further highlights the deficiency in protecting residents from abuse.

Penalty

Inspection fine: $1,196

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 physical restraints imposed for staff convenience and not required to treat medical symptoms. Specifically, the facility did not prevent the use of a recliner chair as a physical restraint for a resident with severe cognitive impairments and a history of attempting to get out of bed unassisted. The facility's policy mandates that restraints should only be used when necessary for medical treatment, and behavioral interventions should be exhausted prior to restraint application. The resident, who was over 65 years old and diagnosed with dementia with severe agitation, was found on multiple occasions with a recliner chair pushed up against her bed, preventing her from getting out of bed. The resident's family had installed a hidden camera in her room, which captured these instances. The family expressed concerns about the facility's treatment of the resident, noting that the staff often complained about the resident's attempts to get out of bed unassisted. The video evidence showed a CNA pushing the recliner chair against the bed and handling the resident roughly, which the family interpreted as a method to keep the resident in bed. Interviews with facility staff, including the NHA and DON, confirmed that the use of the recliner chair in this manner constituted a physical restraint. The staff acknowledged the resident's impulsivity and hallucinations, which led to her attempts to get out of bed. Despite these challenges, the facility's actions were not aligned with their policy of maintaining a restraint-free environment, as the recliner chair was used to restrict the resident's movement without exhausting other behavioral interventions.