Aviata At Santa Barbara

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 immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.

Plan Of Correction

This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.

Removal Plan

• Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
• Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
• Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
• Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
• Educated licensed nurses regarding change in condition.
• Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
• Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
• Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
• Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.

Plan Of Correction

This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.

Removal Plan

• Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
• Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
• Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
• Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
• Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
• Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved

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 allow a resident to return following a hospitalization and involuntary mental health evaluation, and failure to follow required transfer, discharge, and bed-hold procedures. The resident had been admitted with diagnoses including problems with social environment, mild cognitive impairment due to unknown origin, a condition with mixed features, and an adjustment disorder with mixed anxiety and depressed mood. A quarterly MDS showed intact cognition and no physical or verbal behavioral symptoms directed toward others at that time. The resident’s care plan documented that he wished to remain in LTC at the facility and identified goals related to managing verbally aggressive behaviors such as yelling at other residents. Progress notes show that on one day the provider documented that the resident had been increasingly agitated, responding to internal stimuli, refusing medications and care, and exhibiting aggressive and impulsive behavior that was considered dangerous to himself. The provider stated that the resident had failed all staff interventions to keep him safe and required a higher level of care, leading to an involuntary emergency mental health examination. The DON documented in a late entry that the resident had a burst of anger with uncontrolled behavior, including screaming, kicking the entrance door of his room and creating a hole in the wall, and kicking another wall near his TV, also creating a large hole. Law enforcement and EMS were notified, a Baker Act order was presented, and the resident was transported from the facility under this order. The DON noted that the behavior was frightening to staff and other alert residents and that the resident needed to be out of the facility for the safety of staff and residents. The clinical record did not contain documentation that a bed-hold policy was offered to the resident or his representative at the time of transfer. The hospital record shows that the resident was admitted under involuntary commitment for evaluation of mental health concerns following reported aggression at his memory care facility. On admission to the hospital, he was calm, cooperative, and oriented, with no acute distress, and denied suicidal or homicidal ideation. He was medically cleared in the ED, and a psychiatric evaluation, including telemedicine consultation, determined that he did not meet criteria for involuntary inpatient or outpatient psychiatric placement; the Baker Act and associated safety protocols were discontinued, and he was cleared for discharge from a psychiatric standpoint. Case management and social work became involved because the prior SNF refused to accept him back, and alternative placement options were explored. The DON confirmed there was no documentation that a bed hold was offered and stated that the resident’s emergency contact had declined the bed hold, and that when the resident was ready for discharge from the hospital, the facility refused to take him back because she believed he would be better off in a group home due to his age and volatile behavior. The emergency contact reported that, because the facility refused readmission, the resident was placed in another nursing home approximately 73 miles away, and she expressed a desire for him to return to the original facility. The Admissions Director stated that several days after the transfer, the hospital notified the facility that the resident was ready to return, but her regional leader instructed her not to accept the resident and not to admit him to any sister facilities. The Administrator acknowledged that a bed hold was not offered and that there was no documentation of the basis for the resident’s discharge, and stated that the regional team decided not to allow the resident to return based on information from facility staff.

Plan Of Correction

This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. The identified resident's #2 discharge documentation was reviewed. Resident no longer resides in facility. 2. A 100% audit of all transfers/discharge forms and bed hold within the past 30 days was conducted to verify compliance with F627 requirements. Any discrepancies identified were immediately corrected, including issuance of proper notices and documentation updates. Residents under consideration for transfer/discharge will be reviewed to ensure full compliance with regulatory requirements. 3. A discharge checklist was developed to ensure all required steps are completed prior to any transfer or discharges. Education completed with all licensed nurses on discharge checklist and transfer/discharge forms and bed hold education. All planned discharges will be reviewed by IDT prior to discharge to ensure compliance. 4. Social Services Director or designee will conduct 4x/week audits of all transfers/discharges for 4 weeks, then, 3x/week x 4 weeks; then, 2x/week x 4 weeks; then, weekly x 4 weeks to ensure regulatory compliance. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 or until committee determines substantial compliance has been met.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR and activation of EMS, to a resident with a documented full code status. The resident had diagnoses including peripheral vascular disease, COPD, vascular dementia, and Alzheimer’s disease, and had a physician’s order and care plan indicating full code status. In the early morning hours, a CNA found the resident unresponsive in bed and notified the RN on duty. Assessments documented by the RN indicated absence of pulse and respirations and nonreactive pupils. Despite this, EMS was not called at that time, and the RN later stated she believed the resident was on hospice and did not verify the code status as required by facility policy. According to witness statements, the RN initially instructed a CNA to clean and cover the resident, indicating she believed the resident had died. In a separate statement, the RN reported that she called a code blue, and she and an LPN brought the crash cart and performed CPR for approximately 20 minutes. The LPN corroborated that CPR was performed and that the RN stopped CPR after about 20 minutes, stating that the resident was gone or words to that effect. The RN acknowledged that she did not call 911 and discontinued CPR despite the resident’s full code status and the facility policy requiring immediate initiation of CPR and continuation until EMS arrival or resident response. The DON received a text message from the RN around 2:42 a.m. that the resident had expired, but EMS was not contacted until hours later. The RN reported that at approximately 5:50 a.m., the DON called the facility and asked if 911 had been called; only then did the RN contact EMS and reinitiate CPR roughly four hours after the resident was first found without pulse or respirations. EMS records show activation shortly after this call, arrival to find staff performing CPR, and documentation of rigor mortis, algor mortis, and lack of respirations and pulse, with resuscitation deemed futile. The facility’s investigation and the Medical Director’s interview confirmed that the resident was a full code and that staff did not follow the established policy to verify code status, immediately call 911, and continue CPR until EMS arrival, leading to the determination of Immediate Jeopardy. The facility’s policy titled “Florida Cardiopulmonary Resuscitation (CPR)” required that CPR be provided to all residents in cardiac arrest unless a fully executed Florida DNRO was present, and that in the event of cardiac arrest, staff must immediately call for assistance, overhead page a code blue, and begin CPR in the absence of a DNRO. The policy further required that CPR continue until EMTs assume responsibility or the resident responds. In this incident, the RN did not confirm the resident’s code status, did not immediately activate EMS, and discontinued CPR without appropriate authority, while the LPN followed the RN’s direction. The facility’s root cause analysis identified that the nurse believed the resident was hospice, did not check the code status, and did not follow policy regarding when CPR can be discontinued and when 911 must be called. Surveyors determined that this failure to immediately activate EMS and maintain CPR for a full code resident until EMS arrival constituted a failure to provide appropriate lifesaving interventions in the event of cardiac and/or respiratory arrest. This placed other residents with full code status at a likelihood of serious injury or death from not receiving appropriate basic life support. The deficiency was cited under F726 and initially determined to be Immediate Jeopardy before being reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that clinical staff had the competencies to respond appropriately to a cardiac and respiratory arrest for a resident with full code status. A resident designated as full code was found without a pulse or respirations at approximately 2:07 a.m. The RN on duty (RN Staff A) and an LPN (LPN Staff B) initiated CPR but did not activate EMS as required by facility policy, which states that CPR must be initiated immediately in the absence of a valid DNR and continued until Emergency Medical Technicians assume responsibility or the resident responds. After about 20 minutes of CPR, RN Staff A stopped resuscitation efforts, stated that the resident was dead based on lack of vitals and respirations, and effectively pronounced the resident’s death despite having no authority to do so and without contacting EMS. The report notes that RN Staff A believed the resident was on hospice and did not check the resident’s code status before deciding not to call 911. LPN Staff B reported that he assumed RN Staff A had called 911 and continued chest compressions for about 20 minutes until RN Staff A “called the code” and left, stating they were not going to bring the resident back. LPN Staff B acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours later, around 6:00 a.m., after the DON called the facility and instructed RN Staff A to contact EMS, CPR was restarted and EMS was activated. A CNA (CNA Staff D) was then instructed by RN Staff A to place a board under the resident and perform chest compressions; the CNA performed approximately 5–6 compressions until EMS arrived and directed her to stop. EMS subsequently pronounced the resident’s death. The investigation also identified multiple competency and credentialing issues related to emergency response and CPR. RN Staff A’s personnel file lacked documentation of any orientation or skills competency assessment despite her hire and later promotion to weekend supervisor. Her BLS/CPR certification was obtained through a fully online course without an instructor-led, hands-on component or live feedback, contrary to accepted national standards. LPN Staff B’s BLS/CPR certification was expired, and the CNA’s BLS/CPR certification was also expired, even though facility policy stated CNAs were not allowed to perform CPR, including chest compressions. The facility’s own documents indicated that skills competency assessments were required upon hire and annually, but no such assessment was found for RN Staff A. Leadership interviews confirmed that newly employed licensed nurses were expected to receive clinical orientation and complete skills competencies before working independently, and that RN Staff A had not completed these processes. These actions and omissions led to the determination that staff were not adequately trained or competent to respond to cardiac and respiratory arrests, resulting in Immediate Jeopardy.

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 comply with federal and state transfer and discharge requirements by not permitting a resident to return following an emergency hospital transfer and by not following its own policies and procedures. The facility’s written policy, “Transfer/Discharge Notification & Right to Appeal,” states that residents sent emergently to an acute care setting must be permitted to return to the center, and that if the center initiates a discharge while the resident is in the hospital, it must show evidence that the resident’s status at the time of return meets specific regulatory criteria. The policy also incorporates federal and Florida requirements that govern when a transfer or discharge may be initiated by the facility. The resident at issue had been admitted with multiple psychiatric and behavioral diagnoses, including a problem with social environment, history of [R], mild [R] of unknown origin, [R] due to known [R], condition with mixed features, [R], and adjustment with mixed [R] and depressed [R]. A quarterly MDS showed intact cognition with a BIMS score of 15 and no physical or verbal behavioral symptoms directed toward others, and the resident’s care plan documented a wish to remain in LTC at the facility. The care plan also identified behaviors of verbal aggression, including yelling at other residents and telling them to “Shut your [R].” Progress notes show that on [R], a [R] provider documented that the resident had been [R], responding to internal stimuli, presenting with bizarre and tangential behavior, refusing all medications and staff care, and being aggressive and impulsive to the point of being considered a danger to self. The provider stated that the resident had failed all staff interventions to keep him safe and required a higher level of care, and ordered an involuntary emergency examination ([R]). The DON later documented in a late entry that the resident had a burst of anger with uncontrolled behavior, including screaming, kicking the entrance door of his room, creating holes in the wall, and damaging the area near his TV. Following this episode, the resident was transferred emergently to the hospital. The DON verified that there was no documentation that a bed hold was offered to the resident at the time of transfer, although she stated that the resident’s emergency contact declined the bed hold. The DON also confirmed that when the hospital later notified the facility that the resident was ready for discharge, the facility refused to accept the resident back, and she stated she thought the resident would be better off in a group home due to his age and volatile behavior. The Admissions Director reported that 4–5 days after the transfer, the hospital notified the facility that the resident was ready to return, but her regional leader instructed her not to accept the resident and not to accept him at any sister facilities. The Administrator confirmed that a bed hold was not offered and that there was no documentation of the basis for discharge of the resident. Because the facility refused readmission, the resident’s emergency contact reported that the resident was placed in another nursing home approximately 73 miles away, and that he later called her in the middle of the night screaming for help, leading her to take him home. She reported that this caused her distress, missed work, and emotional problems because she did not know how to manage his care, and that the resident was not doing well at home. The surveyors concluded that the facility failed to allow the resident to return post-hospitalization and did not follow required transfer/discharge procedures and documentation requirements.

Plan Of Correction

This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. The identified resident's #2 discharge documentation was reviewed. Resident no longer resides in facility. 2. A 100% audit of all transfers/discharge forms and bed hold within the past 30 days was conducted to verify compliance with F627 requirements. Any discrepancies identified were immediately corrected, including issuance of proper notices and documentation updates. Residents under consideration for transfer/discharge will be reviewed to ensure full compliance with regulatory requirements. 3. A discharge checklist was developed to ensure all required steps are completed prior to any transfer or discharges. Education completed with all licensed nurses on discharge checklist and transfer/discharge forms and bed hold education. All planned discharges will be reviewed by IDT prior to discharge to ensure compliance. 4. Social Services Director or designee will conduct 4x/week audits of all transfers/discharges for 4 weeks, then 3x/week x 4 weeks; then, 2x/week x 4 weeks; then, weekly x 4 weeks to ensure regulatory compliance. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 or until committee determines substantial compliance has been met.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to allow a resident to return following a hospital transfer and to follow its own transfer/discharge and bed-hold policies. The facility’s policy stated that residents sent emergently to an acute care setting must be permitted to return, and that if the center initiates a discharge while the resident is in the hospital, it must show evidence that the resident’s status at the time of return meets specific regulatory criteria. The resident, admitted with diagnoses including chronic Hepatitis C, traumatic brain injury history, mild cognitive impairment, mood and anxiety disorders, and adjustment disorder, had a care plan goal to remain in LTC at the facility. Prior assessments, including a quarterly MDS, showed intact cognition and no documented physical or verbal behavioral symptoms directed toward others at that time. On the day of transfer, facility documentation described an acute behavioral episode in which the resident was reported as manic, psychotic, delusional, refusing medications and care, and considered a danger to self and others. The DON documented that the resident had a burst of anger, screamed, kicked the entrance door and walls creating holes, and disrupted his room for approximately 30 minutes, leading to notification of law enforcement and EMS and a Baker Act (involuntary emergency examination) order from the psychiatric provider. The DON noted that the behavior was frightening to staff and other alert residents and that the resident needed to be out of the facility for safety. The resident was transported to the hospital under this involuntary status. Hospital records showed that upon admission the resident was calm, cooperative, oriented, and without acute psychiatric distress, and that he did not meet criteria for involuntary inpatient or outpatient psychiatric placement. The Baker Act orders were discontinued, and he was cleared for discharge with outpatient recommendations. Case management and social work became involved because the prior facility refused to accept him back. The facility’s clinical record lacked documentation that a bed-hold policy was offered at the time of transfer, and the DON later acknowledged there was no documentation of a bed hold offer or of the basis for discharge, stating that the emergency contact declined the bed hold and that the regional team decided not to allow the resident to return or be admitted to sister facilities. As a result, the resident was discharged to another nursing home approximately 73 miles away from his family, and his emergency contact reported distress related to his placement and subsequent fall at the new facility.

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency related to the facility’s failure to provide and document incontinent care for a resident who was always incontinent of bowel and bladder. The resident, admitted with diagnoses including chronic obstructive pulmonary disease, traumatic brain injury, anxiety, and major depressive disorder, had an MDS dated 1/16/26 indicating intact cognitive skills for daily decision making and complete incontinence of bowel and bladder. The resident’s family representative reported arriving on 2/4/26 to find the resident in bed with bedding soaked with urine, no incontinent brief or pad in place, and a strong urine odor. This account suggested that necessary incontinence products were not in use at that time. Review of CNA documentation for January and February 2026 showed multiple shifts with no recorded incontinent care for this resident. In January, there was no documentation of incontinent care on multiple specified dates across day, evening, and night shifts, and some entries were marked “N/A.” In February, there was no documentation of incontinent care on several consecutive days on both day and evening shifts. A CNA stated that residents are toileted every two hours and when they request it, but the Director of Nursing and Regional Nurse Consultant confirmed the lack of documentation that this resident received necessary incontinence 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 protect residents from verbal and mental abuse by a CNA, resulting in substantiated abuse of two cognitively intact residents. One resident with Parkinson’s disease, which caused slow and deliberate movements, reported that around Christmas a CNA changed her brief after an incontinence episode while yelling at her, ignoring her request to slow down, and roughly turning her by grabbing the sheet and whipping her to the side, causing the resident to catch herself on the windowsill to avoid falling. The resident reported that the CNA called her “heavy,” stated “I don’t get paid enough to do this. My back hurts,” complained that the resident could not get into her wheelchair, and “bitched at me for not being able to get into my wheelchair.” The resident also reported that the CNA rolled her roughly onto her right side using the pad and that she overheard the CNA yelling to the night nurse about her. The resident later told a psychiatric provider she felt emotional discomfort following this interaction and that the CNA’s rough handling and failure to listen made her feel inconsequential. A roommate with intact cognition corroborated that the CNA was very loud and mean, yelled at the first resident during the brief change, and told her she could break her back changing her. This roommate stated she became nervous and scared, hid under her blanket, and did not speak up out of fear of what the CNA might do to her. An LPN reported that when the first resident activated her call light, the CNA, who “likes to talk loudly,” said out loud words to the effect of “what she wants now,” and vented loudly enough outside the closed door that the resident could hear, prompting the resident to call the nurses’ station and complain that if the CNA had time to talk, she had time to provide care. Another resident reported that the same CNA would enter his room in the middle of the night, slam on the lights without explanation, insist that care be done her way, yell at him and his cognitively impaired roommate, and talk down to them, leading to the CNA eventually being restricted from his room. The administrator later confirmed that, based on collected statements from the involved residents, the allegation of abuse was substantiated.

Penalty

Inspection fine: $135,640

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

Summary

Facility staff failed to ensure that laboratory tests were completed as ordered for three residents. For one resident, an APRN ordered a complete metabolic panel (CMP), complete blood count (CBC), and Pro-BNP to monitor persistent bilateral leg edema and shortness of breath. Although the Treatment Administration Record indicated that blood was drawn, there were no results in the clinical record, and the Director of Nursing (DON) and Regional Nurse confirmed the labs were never obtained. Another resident had a practitioner's order for blood work, including a Hemoglobin A1C, but only part of the blood work was collected, and the Hemoglobin A1C was missed. A third resident had a lab order that was not drawn as scheduled, requiring the labs to be reordered and rescheduled. The facility's process required practitioners and licensed nurses to print laboratory requisitions and place them in a binder for the laboratory technician, who would then collect specimens and document them in a laboratory log. The DON stated that Unit Managers were responsible for ensuring labs were completed and results reported to the physician, using daily reports and morning meetings to track orders. However, these processes were not followed, resulting in missed and untracked laboratory tests for the affected residents. An audit revealed additional residents with missing labs during the same period.

Penalty

Inspection fine: $26,685

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 appropriate interventions to prevent falls for two residents with a history of falls and major injuries. Resident #1, who was admitted with diagnoses including Metabolic Encephalopathy and Osteoarthritis, was identified as being at risk for recurrent falls due to various factors such as gait/balance problems and impaired cognition. Despite the care plan indicating the use of hipsters and Dysem to prevent falls, staff did not ensure these interventions were in place, leading to an unwitnessed fall and subsequent fracture requiring surgical repair. Resident #2, admitted with conditions such as Moderate Protein Malnutrition and Hemiplegia, was also at risk for falls. The care plan included the use of floor mats on both sides of the bed to prevent falls. However, observations revealed that these mats were not in place, and staff were unaware of the requirement, resulting in a fall that led to a fracture of the right femur. Interviews with staff and the Director of Nursing (DON) highlighted a lack of awareness and documentation regarding the fall prevention interventions outlined in the care plans. The DON confirmed that the interventions were listed on the care plans and CNA Kardex, but there was no documentation verifying their implementation, contributing to the deficiencies observed.

Plan Of Correction

F789: Free of Accident Hazards/Supervision/Devices (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1, Dycem was placed in resident wheelchair on Care plan and Kardex updated. Resident #1, Hipsters were put on resident, on Care plan and Kardex updated. Resident #2, floor mats were placed on each side of the bed. Educated CNAB on resident #1 on interventions. Educated CNAC on resident #2 on intervention. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A Quality review that contains look period of 60 days was completed to ensure residents with that the care plans, kardex and interventions are in place. Issues or concerns were addressed as they were identified. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Director of Clinical Services/Designee re-educated the licensed nurses and certified nursing assistants on the components of this regulation with an emphasis on: management policy and procedure, care plan and kardex to be updated with interventions, intervention to be in place. During clinical morning meeting, Director of Nursing/Designee will review resident to ensure care plan, kardex and intervention in place. Newly hired licensed nurses and certified nursing assistants will receive education in orientation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The facility Director of Clinical Services/designee will conduct a weekly audit of 5 residents to ensure interventions are care planned, kardex updated and intervention in place weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Divisional Director of Clinical Services when completing their systems review.

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 appropriate interventions for two residents with a history of major injuries. Resident #1, who had severe cognitive impairment and required assistance with transfers, was not wearing hipsters as per the care plan, which were intended to prevent injuries. The resident had a history of gait and balance problems, poor communication, and hearing issues. Despite these risks, staff did not ensure the resident was wearing the hipsters, and the resident sustained an unwitnessed fall resulting in a fracture that required surgical repair. Resident #2, also with severe cognitive impairment and decreased physical mobility, was at risk for falls and related injuries. The care plan required floor mats to be placed on both sides of the bed to prevent falls. However, during observations, no floor mats were found in the resident's room, and staff were unaware of the requirement. The resident had previously been found on the floor beside the bed, and later sustained a fracture requiring hospital treatment. The deficiencies were identified through observations, interviews, and record reviews, revealing that staff were not following the care plans for these residents. The Director of Nursing was unaware of the specific interventions required for these residents, and there was no documentation verifying that the interventions were being completed daily. This lack of adherence to care plans and communication among staff contributed to the residents' injuries.

Plan Of Correction

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1, Dycem was placed in resident wheelchair on Care plan and Kardex updated. Resident #1, Hipsters were put on resident, on Care plan and Kardex updated. Resident #2, floor mats were placed on each side of the bed on Educated CNAB on resident #1 on interventions. Educated CNAC on resident #2 on intervention. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A Quality review that contains look period of 60 days was completed on to ensure residents with that the care plans, kardex and interventions are in place. Issues or concerns were addressed as they were identified. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Director of Clinical Services/Designee re-educated the licensed nurses and certified nursing assistants on the components of this regulation with an emphasis on; management policy and procedure, Care plan and kardex to be updated with interventions, intervention to be in place. During clinical morning meeting Director of Nursing/Designee will review resident with to ensure care plan, kardex and intervention in place. Newly hired licensed nurses and certified nursing assistants will receive education in orientation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, l.e., what quality assurance program will be put in place; The facility Director of Clinical Services/designee will conduct a weekly audit of 5 residents to ensure interventions are care planned, kardex updated and intervention in place weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Divisional Director of Clinical Services when completing their systems review.

Penalty

Inspection fine: $9,280

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 injury of unknown source and serious bodily injury within the prescribed timeframe for a resident. The facility's policy requires that any employee or contracted service provider who witnesses or has knowledge of an act of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must report such information immediately, but no later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. In this case, the resident was found with bruising on the left hip, thigh, and groin area, and an acute left femoral fracture was diagnosed. The incident was identified on the evening of 5/28/24, but the preliminary report was not submitted to the State Survey Agency until 48 hours later, on 5/30/24. The resident involved had a history of senile degeneration and moderate dementia with behavioral disturbance, which may have contributed to the incident as it was speculated that the resident attempted to get out of bed unassisted. The LPN was notified of the bruising and took immediate steps to assess the resident, notify the Power of Attorney, MD, Hospice, and the Assistant Director of Nursing, and obtain witness statements. However, despite these actions, the report to the State Survey Agency was delayed, resulting in a deficiency finding. The Regional Nurse Consultant and the Assistant Director of Nursing confirmed the timeline of events and the delay in reporting the injury.