Perimeter Rehabilitation Suites By Harborview

Penalty

No penalty information released

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

Summary

The facility failed to develop comprehensive care plans for activities needs for four residents and failed to care plan a PTSD diagnosis for one resident. The report states that the facility’s policy required the care planning process to include resident strengths and needs, culturally competent and trauma-informed care as indicated, all triggered CAAs, and any specialized services identified through PASARR recommendations. The MDS/RAI guidance cited in the report states that triggered care areas are to be assessed further and used as the foundation for the care plan. For R13, the admission record showed diagnoses including encephalopathy, respiratory failure, dementia, malnutrition, and dysphagia. The admission MDS showed a BIMS score of 10 out of 15, moderate mood symptoms of depression, and that it was very important for him to participate in religious and group activities. The CAA indicated additional activities assessment was needed because of little interest or pleasure in doing things and directed staff to proceed to care planning for activities needs and interventions, but the EMR contained no care plan addressing activity needs, goals, or interventions. For R29, the admission record listed stroke, epilepsy, hemiplegia and hemiparesis, muscle weakness, respiratory failure with tracheostomy, and gastrostomy tube. The admission MDS showed severe cognitive impairment, inability to complete the BIMS, and activities interests that could not be assessed. The CAA indicated additional activities assessment was needed because staff assessment did not indicate the resident preferred participating in favorite activities and directed staff to proceed to care planning, but no activity care plan was present. For R114, the admission MDS showed moderate cognitive impairment, activities were somewhat important, moderate depression, and the CAA triggered for activities and directed staff to develop a care plan, but the care plan did not contain an activities plan. For R242, the admission record listed type 2 diabetes, multiple sclerosis, dementia, PTSD, and major depressive disorder; the MDS CAA summary showed activities triggered with a yes for care plan decision, but no activities care plan was found. The facility also failed to care plan PTSD for R117, whose admission record listed PTSD and whose quarterly MDS showed a BIMS score of 15 out of 15 and a diagnosis of PTSD. The care plan did not contain evidence that PTSD was addressed. During interviews, MDS staff, the Activities Assistant, the SSD, the DON, and other leadership staff confirmed that the residents did not have the required care plans and discussed which departments were responsible for developing them.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that five of six residents reviewed for bed rails were assessed for safety and need before bed rails were used. The report states that the facility’s Bed Rail Safety policy required assessment of the resident’s needs and risks, including risk of entrapment between the mattress and bed rail or in the bed rail itself, before determining whether bed rails met the resident’s needs. For R11, the admission record showed diagnoses including COPD, SOB, and pneumonia, and the MDS showed severely impaired cognition with substantial/maximal assistance needed for bed mobility and sitting up and dependence for transfers. Admission assessments documented that R11 did not desire bed rails, was not using them, and that bed rails would not assist with turning or transfers; the entrapment review was not completed and bed rails were documented as not indicated. Despite this, R11 was observed in bed with bilateral bed rails up, and the UM confirmed the rails were present on the hospice bed but was unsure whether an assessment was needed when the hospice bed with rails was implemented. For R13, the admission record showed diagnoses including encephalopathy, respiratory failure, dementia, malnutrition, and dysphagia, and the MDS showed moderately impaired cognition with substantial/maximal assistance needed for bed mobility and dependence for transfers. Admission assessments documented that R13 did not desire bed rails, was not using them, and that bed rails would not assist with turning or transfers; the entrapment review was not completed and bed rails were documented as not indicated. R13 was later observed with bilateral bed rails up, and the UM confirmed the rails were present on the hospice bed and stated there was no assessment of appropriateness or need when the hospice bed rails were implemented. For R29, the admission record showed diagnoses including stroke, hemiplegia and hemiparesis, epilepsy, muscle weakness, and respiratory failure, and the MDS showed severely impaired cognition with dependence for all mobility and ADLs. Admission nursing evaluations documented that R29 did not desire bed rails, was not using them, and that bed rails would not assist with turning or transfers; the entrapment review was not completed and bed rails were documented as not indicated. R29 was observed with bed rails up, and the UM stated she did not know he had them on the bed and that they may have been left from the last resident who used the bed. The DON and NDRM stated the assessment should have been completed when the bed with rails was received. For R190, the record showed diagnoses including multiple sclerosis, coordination problems, seizures, generalized muscle weakness, cognitive communication deficit, and major depressive disorder. The quarterly MDS showed a BIMS score of 15 and need for moderate help with rolling and sitting to standing. The quarterly nursing evaluation with side rail evaluation documented that R190 was not using side rails for positioning, support, or bed mobility, did not express a desire to use them, and that side rails were not indicated; however, the evaluation did not assess use of side rails or entrapment risk. R190 was observed with loose right-hand mid-bed side rails, and the ADON reviewed the evaluation and stated he should have had an assessment completed. For R204, the record showed paraplegia, and the quarterly MDS showed a BIMS score of 15, no upper or lower extremity impairments, and minimal help needed with rolling and lying to sitting. The quarterly nursing evaluation with side rail evaluation documented that R204 was not using side rails for positioning, support, or bed mobility, did not express a desire to use them, and that side rails were not indicated; however, the evaluation did not assess use of side rails or entrapment risk. R204 was observed with side rails in use on the bed, and the UM stated the procedure included completing an assessment, assessing restraint, signing consent, and assessing for entrapment. The ADON later reviewed the evaluation and stated the resident did not need side rails, while also acknowledging that the bars were physically the same as side rails and that there could still be a risk of entrapment.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect residents from abuse, including sexual and verbal abuse, and to correctly identify and treat certain resident-to-resident contact as sexual abuse. One cognitively intact resident with dementia and occasional confusion was found in bed with another resident who had moderate cognitive impairment and impaired decision-making. A CNA witnessed the cognitively impaired resident in the other resident’s bed kissing her on the lips and reported the incident to nursing staff. The roommate of the kissed resident reported hearing smacking noises, hearing the cognitively impaired resident ask if the other resident wanted more, and hearing laughter. The facility’s investigation documented that attempts to interview both residents and law enforcement interviews were unsuccessful due to confusion, and the facility concluded that the interaction was not sexual abuse because the residents did not appear distressed and seemed to enjoy themselves. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, but the Administrator and ADON stated they did not believe abuse occurred in this incident. The Administrator described sexual abuse as involving a resident who was upset, crying, and not wanting to be touched, and stated that both residents were capable of making their own decisions and that consent was determined by whether residents could make their needs known. The ADON acknowledged that one resident had fluctuating coherence and that the other resident had moderate cognitive impairment, yet still did not consider the incident to be abuse. The legal guardian for the cognitively impaired resident stated that this resident was not able to consent, was not capable of signing paperwork, and was not capable of making decisions, but this was not reflected in the facility’s determination that the event was not sexual abuse. The deficiency also includes an incident of staff-to-resident verbal abuse. A cognitively intact resident with multiple complex medical conditions, including end stage renal disease, Parkinsonism, liver cirrhosis, chronic pain, anxiety, seizures, and bilateral leg amputation, reported that during a smoke break he asked a Resident Care Assistant to roll his wheelchair back toward the door. The RCA refused, telling the resident that since he rolled himself out, he should roll himself back in, and called him an expletive. The resident and other residents reported that the RCA refused to assist and engaged in a verbal altercation, and the resident stated that the RCA threatened to pull him out of his wheelchair, stomp on him, and cussed at him. The RCA’s written statement confirmed that he refused to assist and used profanity toward the resident, and the facility substantiated the allegation of verbal abuse based on the resident’s account, witness statements, and the RCA’s admission.

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 implement its abuse, neglect, and exploitation policies related to capacity to consent to sexual activity and immediate protection measures following a resident-to-resident sexual interaction. The facility’s written policy required establishing a safe environment that supports consensual sexual relationships by identifying when, how, and by whom determinations of capacity to consent to sexual contact would be made, and where this documentation would be recorded. The policy also required written procedures to assist staff in identifying different types of abuse, including sexual abuse, and mandated immediate protective actions such as responding immediately to protect the alleged victim, examining the alleged victim for injury or psychosocial harm, increasing supervision, making room or staffing changes if necessary, and providing emotional support. Despite these requirements, there was no evidence in the records that capacity assessments were completed or that consent was evaluated by a qualified professional for the residents involved. The incident involved two residents out of a sample of 51. One resident was admitted with dementia without behavioral disturbances and had a quarterly MDS BIMS score of 15/15, indicating cognitively intact status. The other resident was admitted with delirium with a known psychological disorder and had a quarterly MDS BIMS score of 10/15, indicating moderate cognitive impairment. An incident report documented that one resident was found in the other resident’s bed and was observed kissing the other resident on the lips. The facility did not immediately separate the residents at the time of the incident, did not implement 30‑minute checks as required, and did not notify police until two days after the event. During a subsequent interview, the Administrator stated that both residents were capable of making their own decisions, believed that sexual abuse had not occurred, and stated that both residents had consented to the interaction. The report notes that the facility’s misunderstanding of the definition of resident‑to‑resident sexual abuse resulted in a failure to initiate capacity assessments and protective interventions as required by policy.

Penalty

No penalty information released

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

Summary

The facility failed to timely report an allegation of sexual abuse involving two residents to the Administrator and the State Survey Agency (SSA), as required by its abuse, neglect, and exploitation policy dated 07/15/2025. The policy required all alleged violations, regardless of residents' cognitive status, to be reported to the Administrator, the state agency, and all other required agencies within specified timeframes, specifically immediately but not later than two hours after the allegation is made if the events involve abuse. Resident 35 was admitted on 09/05/2024 and Resident 236 was admitted on 10/26/2023. On 01/11/2026, according to a facility incident report dated 01/13/2026, Resident 236 was found in Resident 35's bed and was observed kissing Resident 35 on the lips. A document titled Abuse-Resident to Resident, dated 01/20/2026, indicated that CNA 9 wrote a statement on 01/11/2026 stating she witnessed Resident 236 in Resident 35's bed and kissing Resident 35 when she directed Resident 236 to get out of the bed, and that she reported the incident to a nurse, later identified by the facility as LPN 1, although no nurse's name was documented in the investigation. The Administrator stated in an interview on 03/17/2026 that he was notified of the sexual incident on 01/13/2026 by the Assistant Director of Nursing (ADON 1), and that he reported the resident-to-resident incident to the SSA at that time. He also stated that CNA 9 reported the sexual encounter to LPN 1 and that the incident between the two residents was not considered sexual abuse, and that he reported it to the SSA out of an abundance of caution. In a separate interview on 03/18/2026, ADON 1 confirmed he learned about the sexual encounter two days after it occurred and that the staff involved were CNA 9 and LPN 1; he also confirmed he notified the Administrator two days after the incident and was unable to identify how he initially obtained the information. In another interview on 03/18/2026, LPN 1 stated she was not the nurse to whom CNA 9 reported the resident-to-resident incident. The record review and interviews showed a delay between the date of the incident and the date the Administrator and SSA were notified, and a lack of clear documentation and identification of the nurse who received the initial report, resulting in noncompliance with the facility’s abuse reporting policy and required reporting timeframes.

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 that the facility failed to provide required written notices of transfer, bed-hold practices, and appeal rights to residents’ responsible parties for two residents who were transferred to the hospital. Facility policy on Transfer and Discharge required that, once admitted, residents and their representatives receive a written transfer/discharge notice in a language and manner they can understand, including the specific reason for transfer, effective date, transfer location, explanation of the right to appeal, and the name, address, and telephone number of the State entity that receives appeal requests, as well as information on how to obtain an appeal form. The facility’s Bed Hold Notice policy required that, at the time of transfer to the hospital, written information be provided to the resident and/or representative specifying the reserve bed payment policy and facility bed-hold policies, and that a signed and dated copy of this notice be kept in the resident’s record. Record review showed that one resident with severe cognitive impairment, dependent for all tasks and diagnosed with non-traumatic intracerebral hemorrhage, cerebral edema, pneumonia, osteoarthritis, right-sided hemiplegia/hemiparesis, aphasia, and seizures was transferred to the hospital after the daughter requested transfer due to worsening condition and breathing concerns; the progress note documented that the responsible party was notified, but there was no written transfer or bed-hold notice in the EMR. Another resident, also severely cognitively impaired and dependent for all tasks, with diagnoses including non-traumatic subacute subdural hemorrhage, seizures, cerebral infarction, atrial fibrillation, unspecified dementia, malnutrition, and type II diabetes, was transferred to the hospital after family reported cyanosis of the fingernail beds and the physician ordered oxygen and transfer for further diagnosis and treatment; again, the record only reflected that the responsible party was notified, with no written transfer or bed-hold documentation retained. In interviews, the National Director of Risk Management stated that staff always called the responsible party when a resident was discharged but did not send written notification, and that while a bed-hold notification form was sent with the resident to the hospital, a copy was not kept in the EMR. The Administrator reported he was not aware that the responsible party needed to receive written notice of transfer and bed-hold information upon any hospital transfer.

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 follow its own infection prevention and control policies, including hand hygiene, glove use, and enhanced barrier precautions (EBP), during incontinence care for two residents. Facility policies required perineal care to promote cleanliness, comfort, and infection prevention, and specified that hand hygiene must be performed before moving from a contaminated to a clean body site and after contact with bodily fluids. The EBP policy required gown and glove use for high-contact care activities such as changing linens, changing briefs, providing hygiene, and wound care, and the hand hygiene policy stated that glove use does not replace hand hygiene and that hand hygiene must be performed before donning and immediately after removing gloves. One resident, admitted with hemiplegia and hemiparesis following cerebral infarction and needing assistance with personal care, had a BIMS score indicating moderate cognitive impairment and was on EBP for potential infection related to wounds. An EBP sign on the resident’s door directed staff to wear gloves and a gown for high-contact care activities. During observed incontinence care, a CNA performed hand hygiene and donned gloves but did not initially wear a gown, only putting one on after being instructed by the Regional Risk Consultant. The CNA did not perform hand hygiene during glove changes and exited the room while still wearing the gown to obtain a clean sheet from a linen cart in the hallway, then disposed of soiled linens and a brief in hallway receptacles without bagging them. In interviews, the CNA acknowledged not sanitizing hands between glove changes and not wearing a gown at the beginning of care, while the ADON and DON stated that staff are expected to wear gowns and gloves for EBP residents, perform hand hygiene with each glove change, have supplies in the room, and not go in and out of rooms while gowned or handle hallway linen carts while wearing gowns. For another resident with diagnoses including cerebrovascular insufficiency, hemiplegia, vascular dementia, and major depressive disorder, and who was always incontinent of bowel and bladder per the MDS, a separate incontinence care observation showed additional failures in infection control. A CNA donned gloves before entering the room and then provided the entire episode of incontinence care using the same pair of gloves. The CNA wrapped a urine-soiled brief, applied barrier cream to the perineal area, and placed a new brief on the resident without changing the contaminated gloves or performing hand hygiene between tasks. In a subsequent interview, the CNA confirmed that gloves were not changed during the care episode and that handwashing and glove application occurred only before entering the room.

Penalty

No penalty information released

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

Summary

The facility failed to ensure an adequate and ongoing program of activities for one resident who was dependent on staff for all stimulation and engagement. The resident was admitted with diagnoses including stroke, epilepsy, hemiplegia and hemiparesis, muscle weakness, respiratory failure with tracheostomy, and gastrostomy tube. The MDS showed the resident was unable to complete the BIMS, had short- and long-term memory problems, severely impaired cognition, no speech, could not make himself understood or understand others, and was totally dependent on staff for mobility and activities of daily living. His activity interests could not be assessed, and the CAA indicated additional activities assessment was needed and that staff should proceed to care planning for activities needs and interventions. The activities assessment documented that the resident could not participate in group activities physically or cognitively, was unable to respond, had no one to speak for him, and had no identified activity interests. The form stated the resident required one-to-one activities, including reading and music. However, the EMR contained no care plan addressing his activity needs, goals, or interventions. The individual activity participation records also contained inaccurate entries, including documentation of one-to-one visits on dates when the resident was not in the facility because he was at the hospital, and the Activities Assistant later stated she had transcribed information from other attendance sheets and incorrectly transposed another resident's information. Observations in the resident's room on multiple occasions showed him lying in bed without music or television on and without items in his hands or nearby for sensory stimulation or to keep his hands busy. During one observation, he had pulled out his tracheostomy tubing, and the Respiratory Therapist stated the resident would get restless at times and would use his hands to pull on the tubing. The Activities Assistant stated the resident received one-to-one visits by staff, that these visits should occur two to three times per week, and that he would benefit from additional in-room stimulation such as TV when staff were not visiting. The Administrator stated he expected activities staff to keep accurate records of participation, and the National Director of Risk Management stated the facility could be offering TV shows, music, or additional activities/objects for sensory stimulation and engagement and that staff could be doing more for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the activities program was directed by a qualified professional. Review of the Activities Director job description showed that the activities program must be directed by a qualified professional, including a qualified therapeutic recreation specialist, an activities professional who is licensed or registered if applicable, an individual eligible for certification as a therapeutic recreation specialist or activities professional by a recognized accrediting body, a person with 2 years of experience in a social or recreational program within the last 5 years with one year full-time in a therapeutic activities program, a qualified occupational therapist or occupational therapy assistant, or someone who has completed a State-approved training course. During interview, the Activity Assistant stated she had been serving as the AD since the previous director left and had not yet completed a training course. She stated she did not have corporate assistance with developing an activities program, had not received training in care planning, had not been involved in developing or revising activity care plans, and did not attend QAPI meetings or participate in quality improvement projects. The Administrator stated the former AD’s last day was 08/07/25 and that the AA was not the AD, adding that the AA was signed up for classes in April to obtain AD credentials.

Penalty

No penalty information released

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

Summary

The facility failed to ensure emergency tracheostomy care supplies were kept within close proximity for a resident with a tracheostomy. The resident was admitted with chronic respiratory failure, tracheostomy, quadriplegia, and encephalopathy. Her care plan directed staff to keep trach ties secured at all times and suction as necessary, and physician orders included daily and as-needed trach care, changing trach ties every night shift and as needed, changing respiratory supplies and setup weekly and as needed, and suctioning via trach every day and night shift for patency. During observation, no suction machine or tracheostomy supplies were present in the resident’s room, and the resident had a capped tracheostomy in place. The respiratory therapist confirmed that no tracheostomy care supplies, including a suction machine, spare tracheostomy, inner cannula, trach ties, and mask, were in the room and then brought the equipment from a supply cart kept in a closet across from the nurses’ station. Staff interviews indicated the resident had been moved from a shared room to a private room and the supplies were not moved with her, and the DON stated staff were expected to keep tracheostomy care supplies in the resident’s room for access during an emergency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that one resident, R43, received routine dental services. The resident was admitted on 12/26/24, and the quarterly MDS dated 01/21/26 showed a BIMS score of 6 out of 15, indicating severe cognitive impairment. The MDS also indicated no broken or missing teeth. Review of the clinical record did not show evidence that R43 received routine dental services during the 14 months of the resident’s stay. During an observation on 03/16/26, R43 opened her mouth and had a heavy white substance buildup around all upper teeth, with a reddish color on the two front top teeth. On 03/17/26, the SSD and RVPO confirmed that R43 had not had prior appointments with a dentist for routine dental care during the stay, and they verified the condition of the resident’s teeth. The SSD stated the resident’s teeth were in this condition upon admission, and the facility did not provide additional information regarding dental care or the status of the resident’s teeth. On 03/18/26, the family member stated he was looking for a community dentist to evaluate and treat the resident’s teeth and was not aware that a dentist contracted with the facility could provide routine dental care. On 03/19/26, the CSO stated R43 should be seen annually by a dentist.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that one resident with dysphagia received liquids in the form ordered by the physician. The resident was admitted with diagnoses including malnutrition and dysphagia, had a BIMS score of 10 out of 15 indicating moderately impaired cognition, and required a mechanically altered diet. The physician’s order specified thickened liquids at nectar consistency, and the care plan directed that the diet be provided as ordered. During a breakfast observation, the resident had regular thin juice, thin milk, and thin water at the bedside table, and had already consumed about half of the liquids. The resident stated the liquids were not thickened but that he was drinking them without trouble. The breakfast tray card indicated nectar-thick liquids, including milk and a beverage of choice. An LPN confirmed the resident had thin juice, thin milk, and thin water with the meal and stated she did not know why he was not given nectar-thickened liquids. Later, the LPN stated the thin liquids had been removed and replaced with nectar-thickened liquids, and that the juice and milk were provided by the kitchen. The DON stated the thin liquids were served from the kitchen, and the Administrator stated kitchen staff should check orders during the tray line and nursing staff serving meals should double-check that the appropriate thickened liquids were served.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the clinical record was complete for one resident reviewed out of a sample of 34. Review of the facility’s Medication Administration policy indicated that medications are to be signed on the MAR after administration, and the Documentation in Medical Record policy stated that each resident’s medical record must contain an accurate representation of the resident’s actual experience with complete, accurate, and timely documentation. Resident 79 was admitted with diagnoses including appendicitis, hemiplegia and hemiparesis, type 2 diabetes, major depressive disorder, and dementia. Review of Resident 79’s MAR showed no administration documentation for the 9:00 PM dose of Eliquis 5 mg on 03/12/26, as well as no documentation for Atorvastatin calcium 80 mg and Ezetimibe 10 mg at bedtime on 03/12/26. During interview, the LPN who worked the night shift on 03/12/26 stated the medications were given but she forgot to click them off in the computer system and said documentation should have been completed before the end of the shift. The DON stated that if it is not documented, it is not done, and that timely documentation is emphasized repeatedly.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a siderail was securely attached to the bed for one resident. The facility policy titled, Side Rail Safety, required regular inspection of the mattress and bed rails for entrapment areas and for bedrails to remain correctly installed without shifting or loosening over time. The resident involved was admitted with multiple sclerosis, other lack of coordination, seizures, generalized muscle weakness, cognitive communication deficit, and major depressive disorder. The care plan documented limited physical mobility related to repeated falls, multiple sclerosis exacerbation, history of seizures, weakness, and rib fractures, with staff to provide supportive care and assistance with mobility as needed. The resident's quarterly MDS showed multiple sclerosis, depression, seizures, upper and lower extremity impairments on one side, and a need for moderate assistance with rolling and sitting to standing, while also indicating a BIMS score of 15 out of 15. During observation, the resident's right-hand mid-bed metal rail was loose and unable to remain in the proper location; the resident lifted the rail and let it fall to the floor, stating he used it to hold on to while turning in bed. A CMT confirmed the rail was loose and posed a risk for injury. The Maintenance Director later inspected the rail and found it attached with one bolt near the head of the bed, and when lifted, it dropped to the floor. The facility was unable to provide documentation of weekly bed inspections completed by maintenance.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision and maintain a safe environment for a resident identified as being at high risk for elopement. The resident had a history of severe cognitive impairment, vascular dementia, and other medical conditions, and was assessed as a high elopement risk with a care plan that included the use of a wander guard device and regular checks. Despite these interventions, the resident was able to exit the secured unit through a second-floor door, as the alarms and delayed egress mechanisms on the exit doors were not functioning properly. The wander guard alarm did sound, but the search for the resident was initially focused inside the building, delaying the discovery that the resident had left the premises. Observations and interviews revealed that the exit discharge door's alarm had not been working for an extended period, and this malfunction was not reported or addressed through the facility's maintenance system. Staff interviews indicated that the door alarm was frequently triggered by the resident, and staff would reset the alarm without ensuring the underlying issue was resolved. Additionally, a contractor had previously unlocked the exit discharge door and failed to relock it, further compromising the security of the unit. The lack of proper signage indicating the delay time on the doors and the absence of a functioning alarm on the exit discharge door contributed to the resident's ability to elope undetected. Documentation showed that the resident was found outside the facility in a parking garage after an internal search and a delayed external search. The facility's policy required immediate action and notification of authorities in the event of a missing resident, but the initial response focused on searching inside the building. The failure to maintain functioning safety devices and to promptly identify and address the malfunctioning alarm system directly led to the resident's elopement.

Removal Plan

• Management-level staff oversight of the facility.
• Monitoring the physical building for functioning egress doors.
• Assessing and monitoring residents with elopement risk.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was informed of her rights regarding treatment, financial liability, and resident rights upon admission. Record review showed that the resident, who was cognitively intact but had unclear speech and some communication difficulties, was admitted with diagnoses including amyotrophic lateral sclerosis, hemiplegia, dysphagia, and slurred speech. The facility's policy required that residents be informed of their rights both orally and in writing, in a language they understand, prior to or upon admission. However, the resident's admission agreement, which included consent to treat, was signed electronically by a representative whose information was incorrect, and the resident herself did not sign any documents. The Resident Rights form was not signed, and the financial expectations and insurance forms were either incomplete or blank. Interviews with the resident's family member revealed that the admission paperwork was received electronically but could not be signed due to incorrect information, and the resident never signed any forms herself. The Director of Hospitality/Interim Admissions Staff could not confirm when the paperwork was sent, and the Administrator stated that the consent to treat should have been signed upon admission but was not present in the physical chart. The Vice President of Operations confirmed that the admission packet was not signed at admission and that there was no documentation showing the resident or representative was informed of rights, benefits, or costs. The admissions staff responsible had resigned at the time of admission, contributing to the lack of proper documentation.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a staff member, identified as a floor technician, exploited a resident by requesting money from her. The resident, who had diagnoses including Parkinson's disease, bipolar disorder, anxiety, depression, and a history of physical and sexual abuse, reported the incident to facility staff and provided screenshots of text messages as evidence. The resident was cognitively intact at the time, as indicated by a BIMS score of 13 out of 15, and had a care plan that included approaches to support her emotional well-being and involvement in her care. The facility's policy prohibits exploitation, defined as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. The facility's investigation confirmed that the staff member had requested money from the resident, substantiating the allegation of exploitation. It was also found that the staff member's personnel file lacked evidence of a criminal background check or reference checks prior to employment. The incident was reported to the state agency, and the staff member was suspended pending investigation. No additional residents were found to be affected by this staff member.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a floor technician (FT1) completed and documented a criminal background history, including checks for abuse, neglect, or exploitation, prior to employment. According to the facility's Abuse, Neglect and Exploitation policy, all potential employees are required to undergo background, reference, and credentials checks, with documentation maintained as proof. However, a review of FT1's personnel file revealed no evidence of a completed criminal background check or reference checks before employment. The file only indicated that two reference checks were attempted but not completed. This deficiency was identified following an investigation into a substantiated allegation of exploitation involving a resident (R6), who reported that FT1 sent text messages requesting money. The investigation included screenshots confirming the requests, and FT1 was subsequently terminated. During an interview, the Administrator, who also served as the Abuse Prevention Coordinator, confirmed the absence of a background check and incomplete reference checks for FT1.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that allegations of misappropriation of resident property and incidents resulting in injury were thoroughly investigated, as required by their own policies. In the case of one resident with intact cognition, the resident reported $173 missing from her lockbox, with the key found out of place after she returned from a shower. Although the incident was reported to the administrator and the police were notified, the facility's investigation was incomplete. Only one staff statement was documented, and there was no evidence of interviews with the resident's roommate or other potentially knowledgeable staff. The administrator admitted that not all interviews were documented and confirmed that the roommate was not interviewed, contrary to policy requirements for a thorough investigation. In another case, a resident with severe cognitive impairment experienced an unwitnessed fall in the dining room, resulting in a laceration to the back of the head and subsequent diagnosis of a cervical fracture after hospital transfer. Staff interviews revealed that the event was unwitnessed, and the resident was found on the floor with signs of seizure activity. However, the facility's incident report to the state agency inaccurately documented the event as a witnessed fall on a different date. The administrator acknowledged the discrepancy between the resident's record and the report submitted to the state agency and stated that a more thorough investigation would have been conducted if the event had been recognized as unwitnessed. In both cases, the facility did not follow its written procedures for investigations, which require identifying and interviewing all involved persons, focusing the investigation on determining the extent and cause of the incident, and providing complete documentation. The lack of thorough investigation and documentation had the potential to contribute to further misappropriation of property and inadequate response to incidents resulting in injury.

Penalty

No penalty information released

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

Summary

The facility failed to accurately code a urinary tract infection (UTI) on the quarterly Minimum Data Set (MDS) assessment for one resident. The resident was admitted to the facility with a diagnosis of cerebral infarction and was later transferred to the hospital due to unresponsiveness. Hospital records indicated that the resident was diagnosed with a multidrug-resistant E. coli UTI and treated with antibiotics. Upon return to the facility, the quarterly MDS assessment did not reflect the UTI diagnosis, as the infection item was not marked. Interviews with facility staff revealed that the MDS Coordinator did not code the UTI, believing it should only be coded if the infection occurred while the resident was in the facility. The Resident Assessment Director and the Vice President of Clinical Reimbursement both confirmed that the UTI should have been coded according to the RAI Manual, as the diagnosis and treatment occurred within the required 30-day look-back period. The MDS Director acknowledged that there was no audit process in place to ensure the accuracy of MDS assessments, and regional audits had not yet focused on UTI coding errors.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely notification and intervention for a resident who experienced a significant change in condition. The resident, who had a history of left hip arthroplasty, septic arthritis, and femur necrosis, was observed by therapy staff to have increased pain, an apparent shortening of the left leg, and inability to participate in therapy. An X-ray was ordered and performed, revealing a dislocated left hip arthroplasty. The facility's policy required that diagnostic test results, especially those requiring immediate attention, be communicated to the physician upon receipt and documented in the clinical record. Despite the X-ray result indicating a dislocation being faxed to the facility in the evening, there was no evidence that the result was reported to the physician or addressed by nursing staff until the following afternoon. Interviews with staff revealed that the night shift nurse did not retrieve or act on the faxed results, and the Assistant Director of Nursing only notified the physician the next day. The Director of Nursing confirmed the delay in physician notification and subsequent transfer of the resident to the hospital, and there was no documentation of an incident report or investigation into the delay.

Penalty

Fine: $309,850

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

Summary

A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific actions or omissions by staff that led to this deficiency are not detailed in the report, nor are there observations about the resident's medical history or condition at the time of the incident.

Penalty

Fine: $309,850

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

Summary

A deficiency was identified when a resident was admitted without obtaining a doctor's order for admission and without ensuring the resident was under a physician's care. The facility failed to secure the necessary medical authorization and oversight from a physician at the time of admission, as required by regulations. This lapse was observed and documented by surveyors during their review of the admission process.

Penalty

Fine: $309,850

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

Summary

The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.

Penalty

Fine: $309,850

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

Summary

A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and multiple complex medical diagnoses, including traumatic brain injury, Parkinson's disease, and a history of falls. The resident was involved in a witnessed fall from her wheelchair to her knees during a smoke break, after which multiple progress notes documented no visible injuries or skin issues for several days. However, the resident was later found with significant swelling and ecchymosis around the right periorbital area, and increased confusion, which led to her being sent to the emergency room. Hospital records confirmed the presence of a black eye and intracranial hemorrhage, with the injury's origin remaining unknown. Staff interviews revealed that the cause of the resident's injury could not be determined, and there was inconsistency between the observed fall and the resulting injury, as the fall was not witnessed to involve the resident's head. The police investigation and staff statements further indicated uncertainty about how the injury occurred, with no staff able to provide an explanation. The lack of adequate supervision and monitoring, especially given the resident's history of wandering, agitation, and severe cognitive impairment, contributed to the failure to prevent or promptly identify the cause of the injury.

Penalty

Fine: $309,850

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 honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or implement a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints in a timely and non-retaliatory manner.

Penalty

Fine: $309,850

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 enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and the lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.

Penalty

Fine: $309,850

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

Summary

The facility failed to provide a registered nurse (RN) on duty for at least eight hours a day during weekends, as required. Staffing record reviews for March, April, and May 2025 revealed that on the majority of days, there was no RN coverage for the required hours, with 27 out of 31 days in March, 25 out of 30 days in April, and 23 out of 29 days in May lacking the necessary RN presence. Interviews with staff, including the Scheduler Coordinator and Interim Director of Nurses (DON), confirmed ongoing nurse staffing shortages and reliance on assistant directors of nursing (ADONs), only one of whom is an RN, to attempt to fill coverage gaps. The facility's MDS staff, who are RNs, do not provide direct care and are not consistently included in the staffing numbers reported. Resident council minutes and interviews indicated that residents experienced significant delays in call light response, sometimes waiting up to three hours, and reported that care assistants would turn off call lights without resolving issues. Additionally, there were observations of nurses leaving medications on tray tables without ensuring residents took them. These findings were corroborated by both staff and resident council feedback, highlighting the direct impact of insufficient RN coverage on resident care and medication administration.

Penalty

Fine: $309,850

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 post nurse staffing data daily at the beginning of each shift in a prominent and accessible location, as required. Observations revealed that on multiple occasions, the posted staffing data was outdated, with one instance showing data from two days prior still displayed by the front door. Interviews with the Interim Director of Nursing (IDON) confirmed that the correct staffing sheet was not posted daily, and the process for ensuring daily updates was not consistently followed. The absence of current staffing information was attributed to a receptionist leaving early due to an emergency, resulting in no updated sheets being left for the weekend staff to post. Further observations and interviews indicated that nurse staffing data was not posted in various areas throughout the facility, including the front desk, hallways, elevators, and multiple floors. The Resident Council President and other staff members confirmed the lack of posted staffing information in these locations. When staffing data was posted, it was sometimes placed above wheelchair height and not easily visible to residents. The Administrator acknowledged that the only posting was at the front door, at a height that may not be accessible to all residents.

Penalty

Fine: $309,850

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 complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record reviews revealed that the facility assessment, dated 10/25/2024 and reviewed by the QAA Committee, contained incomplete sentences and blanks, particularly in sections addressing staffing patterns and goals. The assessment did not fully articulate how staffing levels and assignments were determined or maintained, and some statements were left unfinished, such as the goal for actual PPD (per patient day) staffing. The documentation also lacked specific details on how specialized rehabilitation and behavioral health services staffing were evaluated and ensured to be adequate. During a staff interview, the Administrator acknowledged that the facility assessment was considered complete despite the presence of incomplete information and missing data. This deficient practice was identified as having the potential to affect all 214 residents in the facility, as the assessment is a critical tool for ensuring that staffing and resources are sufficient to meet residents' needs at all times, including nights, weekends, and emergencies.

Penalty

Fine: $309,850

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

Summary

The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by incomplete infection surveillance documentation and unsanitary conditions in the laundry areas. Review of the Monthly Infection Control Logs for April 2025 showed that critical information such as cultures, dates obtained, organism types, and antibiotic resistance status was missing for 35 of 37 infections. The Infection Control Preventionist acknowledged that the log was not fully completed and confirmed that all sections should have been accurately filled out. Observations of the Clean and Dirty Laundry Rooms revealed multiple sanitation and maintenance issues. Clean linens were improperly stored on top of a linen cart instead of inside it, and wet towels used to clean up a leaking washer were placed on a clean storage rack. The clean storage shelf was soiled and dusty, with employee gowns placed on top of clean towels. The floor was dirty, sticky, and littered with tissues and paper towels. The washer was leaking a white fluid and had visible rust and buildup, while the wall base was cracked and missing sections. In the Dirty Laundry Room, the sink was soiled with residue, a pipe above the sink was leaking water down the wall, and the wall had holes and broken sections. Staff interviews confirmed awareness of these issues and that they had been reported to supervisors, but the problems persisted.

Penalty

Fine: $309,850

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

Handrails on the second, third, and fourth floors were found to be loose and crooked throughout the facility, as observed during multiple walkthroughs. Specific locations included areas across from the nurse station and various resident rooms, where handrails were not firmly secured or properly affixed to the corridor walls. Staff interviews confirmed that the handrails were loose on all floors, and the Maintenance Director acknowledged the issue. The facility's policy, as outlined in the Director of Maintenance job description, required ongoing inspections to identify and address needed repairs, but the loose handrails persisted across multiple days of observation. Staff were expected to report such issues through the TELS maintenance tracking system, with maintenance responsible for repairs.

Penalty

Fine: $309,850

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 immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the failure to provide prompt notification to all required parties when significant events impacting the resident occurred, as required by regulation.

Penalty

Fine: $309,850

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

Summary

The facility failed to maintain a safe, clean, and comfortable environment in two of its three shower rooms, as evidenced by multiple observations of unsanitary and unsafe conditions. On several occasions, surveyors found shower room doors propped open with no staff or residents present. The rooms contained soiled linens, wet washcloths and towels, used and unmarked bars of soap, gloves, masks, and other debris scattered on the floors. Toilets were found unflushed with visible feces and urine, and there were strong odors of feces. Unsecured cabinets contained unmarked toiletry items and a medicine cup with an unidentified green fluid. Equipment such as shower chairs had visible brown substances, and personal protective equipment was improperly discarded throughout the rooms. Interviews with staff, including LPNs, a CNA, and the Regional Nurse Consultant, confirmed that the shower room doors should not be left open and that the rooms should be cleaned and secured between uses. Staff acknowledged the poor condition of the shower rooms and indicated that cleaning should occur after each resident's shower. The Interim Director of Nursing also confirmed that shower rooms should always be closed and locked, and that CNAs are responsible for cleaning between residents. These observations and staff interviews demonstrate a failure to provide a safe, clean, and homelike environment for residents receiving showers.

Penalty

Fine: $309,850

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

Multiple instances were observed where medication carts were left unlocked and unattended by nursing staff, contrary to the facility's policy requiring all drugs and biologicals to be stored in locked compartments and only accessible to authorized personnel. During medication administration, an LPN left the cart unlocked while entering a resident's room, admitting to forgetting to secure it. On another occasion, a medication cart was found unlocked and unattended on the third floor, with gastrostomy supplements left exposed on top of the cart. Staff interviews revealed a lack of awareness regarding the ownership of the cart and failure to follow proper storage procedures. Additional observations on the fourth floor and near the nurse station documented medication carts left unlocked and unattended for several minutes, with no nurses present and residents in proximity to the unsecured carts. Further interviews with staff indicated that some nurses left medication carts unlocked due to distractions or leaving the facility in a hurry, with one LPN admitting to forgetting to lock the cart multiple times. The Interim Director of Nursing confirmed that the facility's policy mandates medication carts be locked when unattended and that only authorized personnel should have access. The repeated failure to secure medication carts as required by policy was confirmed through direct observation and staff interviews, demonstrating noncompliance with established medication storage protocols.

Penalty

Fine: $309,850

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

Summary

The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the meals did not consistently meet standards for taste, appearance, or temperature at the time of service.

Penalty

Fine: $309,850

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

Summary

The facility failed to ensure that a resident's responsible party (RP) had immediate access to the resident's funds, as required by facility policy. According to the Resident Funds Management Policy and Procedure, if a resident requests a check from their account, the facility is to process the request within 24 hours. However, record review showed that the resident's Social Security Administration (SSA) direct deposits were made monthly, but the corresponding cash advances to the RP were often delayed by one to two months. The RP confirmed receiving the funds late, with the May funds only received in June, despite checks being scheduled for mailing on the 10th of each month. Interviews with the Business Office Manager (BOM) revealed that the process required resident confirmation before releasing funds to the RP, and delays were attributed to staff being busy. The BOM acknowledged that the resident had no cognitive issues preventing her from authorizing the release of funds and that this resident was the only one with a consistent arrangement for monthly cash advances to her RP. The resident confirmed that her RP had access to her funds, but the facility did not consistently provide timely access as outlined in their policy.

Penalty

Fine: $309,850

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 that the facility failed to maintain the confidentiality of residents' personal and medical records as required by its policy. On two separate occasions, medication carts with computers displaying residents' sensitive medical information were left unattended in hallways. In the first instance, a medication cart on the fourth floor was observed unattended with the computer screen open, displaying a resident's name, date of birth, allergies, advance directives, and current physician orders. The responsible LPN stated they had stepped away after hearing someone coughing and did not lock the computer screen. In a second incident, another medication cart was found unattended beside the nurse station on the third floor, with the computer screen open and visible, displaying another resident's current physician orders. The LPN involved acknowledged forgetting to lock the computer screen before leaving the cart. The Interim Director of Nursing confirmed that all medication cart computer screens are expected to be locked when not in use by nursing staff.

Penalty

Fine: $309,850

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 allegation of abuse involving one resident, as required by its policy on Abuse, Neglect, and Exploitation. The policy mandates reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes. In this case, a resident with diagnoses including type 2 diabetes mellitus, muscle weakness, difficulty walking, and depression, who was care planned for behaviors such as false accusations, reported to staff that another resident had hit him on the head. The incident was documented by an LPN, who noted that the resident was loud and verbally abusive, demanding that police be called, but no staff witnessed the alleged altercation and the accused resident denied the incident. Despite the resident's report and the facility's policy, staff did not inform the Administrator of the incident, and there is no evidence that the required authorities were notified. The resident later stated that he had to call the police himself because staff did not address the incident. The current Administrator confirmed that staff failed to inform the previous Administrator about the allegation, resulting in a lack of timely reporting and investigation as required by facility policy.

Penalty

Fine: $309,850

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

Summary

A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which could impact the care planning process and the delivery of appropriate services to residents. Specific details about the residents involved or the nature of the inaccuracies in the assessments are not provided in the report.

Penalty

Fine: $309,850

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

Summary

The facility failed to develop a comprehensive care plan that addressed all of a resident's needs, specifically omitting care plans for activities of daily living (ADL) and legal blindness. The resident in question was admitted with multiple diagnoses, including acute respiratory failure with hypoxia, second-degree burns, legal blindness, and a history of homelessness. Despite being assessed as alert and oriented with a BIMS score of 15 out of 15, the resident's care plan only included interventions for skin issues, discharge planning, and fall risk, with no mention of ADL support or accommodations for legal blindness. Review of the facility's policy indicated that care plans should describe services to help residents attain or maintain their highest practicable well-being. However, documentation in the electronic medical record and interviews with the MDS Coordinator confirmed that the required care plans for ADL and legal blindness were not developed or entered. The MDS Coordinator acknowledged the omission and stated that staff were responsible for completing care plans, but could not explain why the comprehensive care plan was incomplete.

Penalty

Fine: $309,850

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 care plans were updated and revised in accordance with their own policies for three residents. For one resident with multiple diagnoses including rhabdomyolysis, orthostatic hypotension, and muscle weakness, the care plan was not updated after the resident experienced an unwitnessed fall that resulted in a head injury and required evaluation at the emergency department. The care plan, dated prior to the fall, did not reflect the incident or any new fall prevention interventions, and the electronic medical record did not document any updates related to fall prevention. Another resident with diagnoses such as congestive heart failure, COPD, hypertension, and diabetes was not care planned for new oxygen use or for weight loss interventions after a supplement was ordered. Additionally, a third resident with a history of traumatic brain injury, Parkinson's disease, and other complex conditions experienced a fall resulting in a black eye, but the incident was not included in the care plan. Staff interviews confirmed that care plan updates were the responsibility of clinical managers, nursing staff, DON, and MDS staff, but these updates were not consistently made following significant changes in condition or incidents.

Penalty

Fine: $309,850

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

Summary

A deficiency occurred when a resident, who was cognitively intact but dependent on staff for activities of daily living (ADLs) such as toilet transfers and bed mobility, did not receive timely assistance with personal hygiene. The resident, admitted with multiple injuries and significant mobility impairments, reported that her briefs had not been changed since the previous night and requested assistance by activating her call light. An LPN responded to the call light, turned it off, and left the room without providing care, stating later that she notified a CNA to assist the resident. However, subsequent interviews revealed that the CNA was not informed of the resident's need, and the call light was not left on to indicate ongoing need for assistance. Further investigation showed that neither of the CNAs on duty were aware of the resident's request for help, resulting in the resident remaining in soiled briefs for an extended period. The resident later confirmed that she had a bowel movement and expressed distress about being left in that condition. The facility's policy required staff to provide necessary ADL care based on the resident's needs and assessments, but this was not followed, leading to a failure to maintain the resident's hygiene and comfort.

Penalty

Fine: $309,850

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

Summary

A deficiency was identified when a resident with multiple complex medical diagnoses, including severe cognitive impairment, was not provided with timely podiatry services. The resident's electronic medical record indicated that they were not seen by the podiatrist due to the presence of COVID-19 positive residents on their floor, and a note was made to reschedule the appointment. However, there was a significant delay, as the resident was not seen by the podiatrist for eight to nine months. Interviews with facility staff revealed that the expectation was for nursing to notify social services to ensure residents were placed on the podiatry list, and that the in-house podiatrist returned every 62 days to follow up with missed residents. Despite these procedures, the system failed, resulting in the resident missing necessary podiatry care for an extended period. The facility did not provide a policy for podiatry care when requested.

Penalty

Fine: $309,850

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 each Certified Nursing Assistant (CNA) received the required minimum of twelve hours of annual in-service training, as specified in the facility's Nurse Aide Training Program policy. Record review showed that one CNA had only completed 10.7 hours of training between April 2024 and April 2025, falling short of the mandated requirement. This deficiency was confirmed during an interview with the Interim Director of Nursing, who acknowledged that the CNA did not meet the annual training hours.