Axiom Gardens Of Nashville

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure a safe environment and protection from physical abuse for a resident who was punched in the face by another resident. One resident (R1) had multiple neurocognitive and psychiatric diagnoses, including psychosis, dementia, altered mental status, and poor impulse control, and was care planned as having the potential to be physically aggressive, including punching and hitting. R1’s MDS documented severe cognitive impairment (BIMS score of 03) and behavioral symptoms such as physical and verbal behaviors directed toward others, as well as other disruptive behaviors that significantly interfered with her own participation in activities and significantly intruded on and disrupted the care and living environment of others. Prior to the incident with R2, R1 had a documented pattern of aggressive and disruptive behaviors toward staff and other residents. On multiple dates, R1 was involved in altercations, including punching another resident in the shoulder, rummaging through a staff purse and hitting staff with her fist, grabbing residents, hitting another resident, and throwing orange juice on another resident and hitting staff. The care plan interventions initiated in response to these behaviors included medication review for physical behaviors, securing staff personal belongings, redirecting R1 away from other residents during grabbing or hitting behaviors, redirecting her away from confrontations, and supervising her with visual checks every 30 minutes. R2, who was later punched by R1, had diagnoses including vascular dementia, delirium due to a known physiological condition, major depressive disorder, panic disorder, and anxiety disorder, and also had a BIMS score of 03, indicating severe cognitive impairment. R2’s care plan did not include a focus area for being at risk for abuse. During the incident in question, a CNA witnessed R2 grabbing R1 in the doorway of the TV room and calling R1 a derogatory name, after which R1 swung and hit R2 in the face, knocking R2’s glasses to the floor and causing slight redness to R2’s forehead. Staff and family interviews confirmed that R1 punched R2 in the face and that R1 had a history of frequent behavioral issues, while R2 was unable to recall the incident due to cognitive impairment. The facility’s abuse prevention policy affirmed residents’ rights to be free from abuse and mistreatment, but the events described show that R2 was not protected from physical abuse by another resident.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain a safe environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents, particularly related to falls, transfers, smoking safety, and exit door alarms. One resident with severe dementia, osteoarthritis, and high assistance needs for ADLs was admitted without a documented admission fall risk assessment, despite transfer paperwork indicating she was high risk for falls and required 1:1 observation. Her care plan later identified her as at risk for falls and wandering, but the fall risk evaluation and precautions were not initiated on admission. She experienced an unwitnessed fall in her room while attempting to toilet herself after removing her non-skid socks, complained of right hip pain, and was subsequently found to have a right hip fracture requiring hospital transfer and surgical repair. Later observation showed her call light attached to the bed sheet and out of her reach. Another resident with vascular dementia, a history of falls, fractures, restlessness, and incontinence was care planned for multiple fall interventions, including bed pad and chair alarms, placement near the nurse’s station, and keeping her within staff’s visual field when up in a wheelchair. She had an unwitnessed fall from her wheelchair in a common bathroom, sustaining a laceration above her right eye that required repair in the ER. She later had another unwitnessed fall from her wheelchair in a dining area, with reported loss of consciousness and multiple forehead lacerations requiring ER treatment. Despite these events and her care-planned interventions, surveyors repeatedly observed her in her wheelchair without the chair alarm connected, with the alarm monitor left on the bed and the pull cord on the back of the wheelchair, and at times placed in her room out of staff view. Staff interviews confirmed that the alarm was not consistently used when family was present. The facility also failed to provide safe mechanical lift transfers for multiple residents. One cognitively intact resident with a history of falls, fractures, weakness, and high fall risk was care planned to require two staff and a full-body mechanical lift for transfers, with a fall mat and other fall-prevention measures. During observation, CNAs transferred her from wheelchair to bed using a full-body lift while the wheelchair was left unlocked, and no fall mat was present or placed afterward. Another resident with severe cognitive impairment, dementia, and high fall risk was similarly transferred from a geriatric chair to bed with a full-body lift while the wheelchair remained unlocked. Smoking safety practices and exit door alarm management were also deficient. A cognitively intact bilateral above-knee amputee with a documented history of smoking and burn concerns was care planned as a smoker, but her smoking safety risk assessments twice documented that she did not currently smoke, and one assessment concluded she was safe to smoke unsupervised. Observations showed CNAs assisting her into a wheelchair, providing her with a burn-marked smoking gown, handing her cigarettes and a lighter from her bedside, and the resident reporting that she could smoke whenever she wanted, usually without staff outside. At the same time, the facility’s smoking policy required a smoking safety assessment to determine supervision needs and noted that burning clothing or being generally careless while smoking jeopardizes independent privileges. In addition, exit door alarms were not consistently activated or effectively audible. A surveyor opened the 200 hall exit door and found that the alarm did not sound until a CNA used a key to activate it; the CNA stated the alarm was often left off so residents could go out for fresh air and that keeping it on was considered a restraint. On another unit, an exit alarm sounded continuously for over ten minutes, and the administrator was unsure which door was alarming and acknowledged existing issues with door alarms, including a memory care unit exit alarm not functioning properly. The facility’s elopement device policy required regular inspection and documentation of exit door security systems and staff placement at malfunctioning doors, but survey findings showed alarms not being kept on and alarms that were difficult for staff in other areas to hear.

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 complete incontinence and catheter-related care, including appropriate perineal cleansing and hand hygiene, for multiple residents with bowel and bladder incontinence and/or indwelling catheters. One resident with a history of UTIs, an indwelling Foley catheter placed for pressure ulcers, cognitive impairment, and total dependence for toileting was observed after a bowel incontinence episode. Two CNAs assisted the resident to her side and used wet washcloths to wipe only the anal area, then repositioned and covered her without cleansing the entire buttocks or performing full incontinent care as outlined in her care plan and facility policy. Another resident, cognitively intact but frequently incontinent of urine and always incontinent of bowel, and dependent on staff for toileting, was assisted from a wheelchair to a bedside commode. Staff exposed a heavily urine-soaked brief, seated the resident on the commode, and later applied a clean brief. During cleansing, a CNA used a wet washcloth to clean only the buttocks before the brief and pants were pulled up. The staff did not cleanse the entire buttocks, perineal area, groin, inner thighs, or labia, despite the resident’s care plan directing assistance with toileting every two hours and as needed. A third resident with multiple chronic conditions, moderate cognitive impairment, frequent bowel and bladder incontinence, and dependence for ADLs was provided incontinent care while in a wheelchair using a sit-to-stand device. CNAs donned gloves without performing hand hygiene, removed a wet brief, and one CNA changed gloves without hand hygiene, then used only wet washcloths from the sink without soap or peri-cleaner to briefly wipe the front genital area and buttocks; the anal area was not cleaned. The same soiled gloves were then used to handle the resident’s clothing, equipment, and positioning. A fourth resident with severe cognitive impairment, total dependence for ADLs, and constant bowel and bladder incontinence was observed with a saturated, strong-smelling urine brief. A CNA, wearing the same soiled gloves used to remove the saturated brief, used wet cloths from a basin to wipe the vagina, buttocks, and anal area, then a dry cloth, and subsequently touched the resident’s pillows, sheets, and blanket without any glove change or hand hygiene. These practices were inconsistent with the facility’s written policies for incontinence care, glove use, and hand hygiene, which require thorough perineal cleansing, use of soap or peri-cleaner, changing gloves between contaminated and clean tasks, and performing hand hygiene after glove removal.

Penalty

No penalty information released

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

Summary

The facility failed to protect a severely cognitively impaired resident from sexual abuse by an employee. The resident, who had vascular dementia with behavioral disturbance and multiple other medical conditions, required substantial to maximal assistance with transfers. According to the facility’s abuse investigation reports, an activity director reported to the administrator that a unit aide kissed this resident on the mouth/lips in her room. The aide admitted in his statement that he kissed the resident once on the lips. The facility’s investigation, including interviews with staff and residents, concluded that the incident did occur and substantiated that the resident was subjected to sexual abuse. The facility also failed to prevent physical abuse between residents when one resident threw a cup of coffee on another resident. One resident, who was cognitively intact, independent with ADLs, and had diagnoses including end stage renal disease, COPD, major depressive disorder, diabetes, and anxiety disorder, reported that another resident had previously harassed him. On the day of the incident, the aggressor resident went outside, yelled at the cognitively intact resident, then returned to his room. When the cognitively intact resident came back inside and passed the aggressor’s room, the aggressor opened his door and threw coffee on him, after which the cognitively intact resident pushed the aggressor in the chest with open hands. The incident was witnessed, residents were separated and assessed, and no injuries were noted. These events occurred despite the facility’s written policy affirming residents’ rights to be free from abuse and describing measures intended to prevent abuse and mistreatment.

Penalty

Inspection fine: $261,500

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 follow and implement wound care orders from the Wound Nurse Practitioner (NP) in a timely manner for a resident with multiple complex wounds, including stage 3 pressure ulcers and chronic skin conditions. Orders for wound dressings, specialty equipment such as a low air loss mattress, and heel float boots were not promptly initiated or maintained as directed. Documentation shows that wound care treatments were delayed, incorrect treatments were applied, and there were multiple instances where dressing changes and skin assessments were either not performed or not documented as completed according to the NP's orders. The resident's low air loss mattress, which was ordered to provide pressure relief and prevent further skin breakdown, was not maintained in proper working order. Staff, family members, and the resident reported that the mattress frequently lost air, leaving the resident lying on a hard surface, which caused significant pain and discomfort. The mattress was described as being held together with duct tape, with hoses repeatedly disconnecting and the air pump malfunctioning. Despite repeated notifications to facility leadership and maintenance, the issues with the mattress persisted for an extended period before a replacement was provided. As a result of these failures, the resident experienced worsening of wounds, which became infected with multiple organisms including MRSA, Pseudomonas, Enterococcus faecalis, and ESBL E. coli. The infections led to several hospitalizations, surgical debridement, and the need for intravenous antibiotics. The facility's lack of timely and appropriate wound care, failure to maintain essential equipment, and inadequate documentation directly contributed to the deterioration of the resident's condition and the escalation of her wounds.

Removal Plan

• Facility wound care policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
• Director of Nursing or designee initiated in-servicing for all nursing staff on the wound care policy and procedures.
• Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on wound care policy and procedures.
• Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all wound orders are carried out and all interventions are in place.
• Director of Nursing or designee will conduct audits of all wound care orders and interventions weekly.
• The Director of Nursing or designee will interview 3 staff members, 3 times weekly to ensure that staff understand wound care policies and procedures.
• Maintenance Director checked all Low Air Loss (LAL) mattresses to ensure proper functioning.
• Maintenance will perform checks of LAL mattresses weekly to ensure proper functioning.
• IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents with wounds to ensure all orders have been processed and treatments are being done correctly.
• R2's mattress was replaced with a new mattress.

Penalty

Inspection fine: $261,500

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

Summary

The facility failed to implement and document new care plan interventions to prevent new or worsening pressure ulcers for a resident with multiple risk factors, including diabetes, peripheral vascular disease, and immobility. The staff did not consistently complete skin assessments, ensure the availability of wound care supplies, or perform wound treatments as ordered. As a result, the resident developed a stage II pressure ulcer on the right buttock, a stage III pressure ulcer on the left buttock, and experienced worsening of an existing right heel wound, which required antibiotic treatment. These wounds were discovered by a nurse practitioner during rounds, not by facility staff, indicating a lack of timely identification and intervention. Observations and record reviews revealed that the resident was left in a wheelchair for extended periods without adequate repositioning, and incontinent care was delayed, as evidenced by a full brief with bowel movement upon being returned to bed. Documentation showed repeated lapses in wound care, with multiple entries indicating that treatments were not completed due to unavailable supplies or lack of documentation. There were also missed or delayed skin assessments, including after hospital readmission, and no evidence that new wounds were promptly identified or addressed by staff. Behavioral tracking did not indicate that the resident refused care or treatments during the relevant period. Interviews with facility leadership and clinical staff confirmed expectations that nurses should follow up on treatment changes, document assessments, and notify supervisors if supplies are lacking. However, the nurse practitioner and administrator acknowledged that these processes were not followed, and new wounds were only discovered during external wound care rounds. The facility's own policy required regular skin inspections, timely repositioning, and the use of appropriate pressure-relieving equipment, but these measures were not consistently implemented for the resident in question.

Removal Plan

• Facility pressure ulcer prevention policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
• R1 was seen by Wound Care Provider and received new treatment orders, LAL (low air loss) mattress ordered, and wheelchair cushion replaced.
• Director of Nursing or designee initiated in-servicing for all facility and Agency nursing staff to include RNs, LPNs and CNA's, on the pressure ulcer prevention policy and procedures.
• In-servicing will be completed by the start of each staff member's next shift.
• Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on pressure ulcer prevention.
• Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all newly acquired pressure wounds are identified timely and addressed immediately by reviewing shower sheets daily and ensuring all skin assessments are completed timely and thoroughly.
• Director of Nursing or designee will in-service all facility and Agency nursing staff to include RNs, LPNs and CNA's on identifying all newly acquired pressure areas timely by completing assessments timely and accurately.
• All nursing staff will be educated by the beginning of their next shift.
• Director of Nursing or designee will conduct audits of skin assessments weekly to ensure all new skin conditions are identified timely and addressed accurately as part of the QA process.
• The Director of Nursing or designee will interview 3 staff members weekly x4 weeks to ensure that staff are completing assessments and addressing any new pressure areas.
• Director of Nursing and or designees will conduct skin assessments on all to ensure that any pressure areas are being identified and addressed.
• The staff members responsible for not completing assessments or wound treatments as ordered have been disciplined.
• The DON or designee will review all new admissions to ensure that all assessments are completed.
• The DON or designee educated all facility and agency nurses of how and when to complete skin assessments.
• All facility and agency nurses will be educated by the beginning of their next shift.
• R1 has had a full skin assessment performed by the ADON to ensure all areas of concern have been identified and addressed appropriately.
• All facility and Agency nursing staff to include RNs, LPNs and CNA's, educated by DON or designee that all residents need to be turned and repositioned at least every two hours and as needed.
• All in-servicing will be completed by the beginning of the staff member's next scheduled shift.
• IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents to determine if they are at risk for potential for impaired skin integrity.
• IDT team ensured all skin assessments have been done timely, all new skin areas have been identified and addressed accordingly including care plan review.

Penalty

Inspection fine: $261,500

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 environment was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to elopement risks. Multiple observations revealed that door alarms were either not functioning, turned off, or not responded to in a timely manner. On several occasions, doors leading to the outside were found cracked open or could be opened without triggering an alarm, and staff were observed not checking on residents who were at risk of elopement. These lapses allowed a severely cognitively impaired resident, who was identified as an elopement risk, to repeatedly leave the facility unsupervised, including incidents where the resident was found outside in unsafe conditions such as in the middle of the road or inside a visitor's van. The resident in question had a history of alcohol-induced dementia, Wernicke's encephalopathy, and chronic kidney disease, and was documented as being ambulatory and prone to wandering. Despite being placed on frequent checks and having a wander guard, the resident was able to exit the facility multiple times. Staff interviews confirmed that the resident was able to find ways to leave the building, sometimes with the assistance of visitors or by exploiting malfunctioning or inaudible alarms. Documentation also indicated that staff were aware of the resident's repeated elopements, but there was a lack of consistent monitoring and timely response to alarms, and the resident's legal guardian was not notified of these incidents. Another resident, also identified as an elopement risk with cognitive impairment and mobility limitations, was able to exit the facility on multiple occasions. This resident was found outside in inclement weather, inadequately dressed, and required staff intervention to be brought back inside. Staff interviews and progress notes indicated that alarms did not always sound when doors were opened, and there was uncertainty about how long the resident had been outside. The facility's own logs did not consistently document these incidents, and staff acknowledged that some doors were routinely left unalarmed for convenience, further contributing to the risk.

Removal Plan

• Facility Elopement Policy was reviewed by Regional Director of Operations and was found to be in compliance with state and federal regulations.
• Facility Administrator or designee initiated in-servicing for all staff on the elopement policy and procedures. In-servicing will be completed by the start of each staff members next shift.
• Facility Administrator or designee initiated in-servicing for all staff on ensuring all staff are monitoring door alarms and responding immediately. In-servicing will be completed by the start of each staff members next shift.
• Maintenance Director or designee will conduct an audit of all facility door alarms and to be completed weekly to ensure they are adequately functioning and audible to staff areas.
• Administrator or designee to conduct Elopement Drill weekly x4 weeks to ensure monitoring and compliance.
• The Administrator or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand elopement policies and procedures.
• IDT team (Admin, DON, SSD, MDS, DM) has assessed R4 and care plan updated to reflect new interventions for R4 being placed on the locked unit.
• IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents for the potential to elope and care plans updated to reflect interventions to protect residents from elopement.
• R4 was placed on the locked unit.
• All facility exit door keys were removed and placed in secured location.
• Facility Administrator or designee initiated in-servicing for all staff to not turn off door alarms. In-servicing will be completed by the start of each staff members next shift.
• Maintenance Director replaced the door lock to 300 Hall door to courtyard and is functioning properly.

Penalty

Inspection fine: $261,500

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 low air loss mattress was maintained in proper working order for a resident with multiple pressure ulcers and complex medical conditions. The resident, who was cognitively intact and required substantial assistance for mobility, had a care plan that included the use of a low air loss bariatric mattress for pressure reduction due to her high risk for skin breakdown and existing stage 3 pressure ulcers. Despite this, the mattress provided to her was not functioning correctly, as the hose that kept the mattress inflated repeatedly disconnected, causing the mattress to deflate and leaving the resident lying on a hard metal bed frame. Multiple staff members, including a CNA and an LPN, confirmed that the mattress was not staying inflated and that the hose would frequently come off, sometimes requiring makeshift repairs such as duct tape to keep it in place. Family members also reported the issue to facility leadership, providing photographic evidence and written communication about the malfunctioning equipment. The resident herself described experiencing extreme pain, rating it as a 10 out of 10, particularly when the mattress lost air and she was left without adequate pressure relief for her wounds. Interviews with the wound care nurse practitioner and review of the resident's care plan confirmed that the use of a properly functioning low air loss mattress was a necessary intervention for her condition. The facility's own preventive maintenance policy required systematic inspection and timely repair or replacement of essential equipment, but the failure to maintain the mattress in working order resulted in the resident enduring significant pain and inadequate pressure relief for an extended period.

Penalty

Inspection fine: $261,500

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 its facility-wide assessment was updated to include all necessary components as required by current standards of practice. The assessment provided did not identify the current Administrator or Director of Nursing (DON), nor did it specify resources required to provide necessary care and services to residents during both routine operations and emergencies, including nights and weekends. Additionally, the assessment lacked an evaluation of the overall number of staff needed to ensure sufficient qualified personnel are available to meet each resident's needs as identified through assessments and care plans. The assessment also omitted pertinent information about the resident population, such as race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, health literacy, or other factors affecting access to care and health outcomes related to health equity. Further deficiencies included the absence of information regarding the physical environment, assistive technology, individual communication devices, or other material resources needed to provide required care and services. The facility assessment did not evaluate the training program to ensure training needs are met for all staff, including managers, nursing and direct care staff, contracted service providers, and volunteers. There was also no evaluation of applicable policies and procedures, nor a facility-based and community-based risk assessment using an all-hazards approach to maintain continuity of operations and secure required supplies and resources during emergencies or natural disasters. When asked, the Administrator confirmed that the provided assessment was all the information available and stated there was no policy for the facility assessment. At the time of the survey, there were 60 residents residing in the facility.

Penalty

Inspection fine: $261,500

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 Certified Nurse Assistants (CNAs) completed the required 12 hours of annual education, including mandatory training in dementia care and abuse prevention. Record review showed that six CNAs had received between 0 and 2.5 hours of education in the past year, far below the required amount. The Administrator confirmed that the in-service records provided were limited to short sessions, with most lasting only 30 minutes and only one session lasting an hour. Additionally, there was no documentation of dementia training for the year, and the Administrator admitted that dementia training within 60 days of hire, as required by facility policy, was not being conducted. The facility's Employee Education policy mandates a coordinated staff education plan, including both pre-service and annual requirements in key areas such as infection control, abuse prevention, and dementia care. Despite this, both the Administrator and the Director of Nursing acknowledged that the required education hours had not been met for the CNAs reviewed. The deficiency has the potential to affect all 60 residents currently residing in the facility, as documented in the daily census report.

Penalty

Inspection fine: $261,500

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

Summary

The facility failed to notify a resident's representative after the resident, who was severely cognitively impaired and diagnosed with alcohol dependence with alcohol-induced persisting dementia, Wernicke's encephalopathy, and chronic kidney disease, was found outside of the facility on multiple occasions. Documentation showed that the resident was found by staff outside by the dumpster, sitting in a visitor van, and exiting through a back door with a broken lock. In each instance, staff responded by returning the resident to the facility and documenting the events in the progress notes, but there was no documentation that the resident's representative was notified of these incidents. Interview with the resident's family member, who is also the legal guardian, confirmed that she was not informed by the facility about the resident leaving the premises. The family member stated she only learned of one incident through her sister, not directly from the facility. Facility policy requires that the responsible party be notified in the event of a resident attempting to leave or leaving the premises, but this was not followed in the case of this resident. The administrator confirmed that staff are expected to notify the representative immediately and document the notification, which did not occur.

Penalty

Inspection fine: $261,500

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 adhere to infection prevention and control standards for hand hygiene, wound dressing disposal, and contaminated linen disposal for one resident who was under enhanced barrier precautions due to a coccyx wound and diagnoses of asymptomatic HIV and chronic Hepatitis B. The resident was observed in a single occupancy room with clear signage indicating the need for enhanced barrier precautions, including hand hygiene before entering and upon leaving the room, and the use of gloves and gowns for high-contact care activities such as wound care. During an observation, an LPN donned appropriate personal protective equipment (PPE) before entering the resident's room. While assisting the resident, who had a bowel movement, the LPN used a disposable brief to clean the resident and disposed of it in a trash bag placed on the floor by the room door. Without changing gloves or performing hand hygiene, the LPN touched the trash bag, room door, door handle, door frame, and requested clean bedding from a CNA. The LPN continued to touch various surfaces, including the bathroom door and sink faucet, while still wearing the same soiled gloves. The LPN then removed the resident's soiled wound dressing, cleaned the wound area, and allowed the wound to come into contact with the bed linens. The soiled dressing and PPE were disposed of in the same trash bag, and the LPN exited the room, again without performing hand hygiene, and touched additional surfaces including the medication cart before eventually using hand sanitizer in the hallway. Interviews with facility staff, including the LPN, ADON/Infection Control Nurse, and DON, confirmed that the resident was on enhanced barrier precautions and that facility policy required proper disposal of items contaminated with blood or body fluids in red biohazard bags in the dirty utility room. The facility's policy and referenced infection control guidelines emphasized the importance of hand hygiene, appropriate glove use, and proper disposal of contaminated materials to prevent the transmission of infectious agents. However, these protocols were not followed during the observed care of the resident.

Penalty

17 days payment denial

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

Summary

The facility failed to obtain timely treatment orders and complete physician-ordered treatments for a resident with pressure ulcers. The resident, who had diagnoses including congestive heart failure, pneumonia, urinary tract infection, and type 2 diabetes, was identified as high risk for pressure ulcer development and had a care plan in place for skin breakdown prevention. Despite documentation of abnormal findings on the left heel on multiple shower sheets, there were no corresponding progress notes, treatments, or orders on those dates. The weekly wound evaluation did not document the left heel until it was identified as a stage 3 ulcer, and the treatment order for the left heel was not obtained until several days after abnormalities were first noted. Additionally, the treatment administration records showed that the ordered treatments for the left heel were not completed on the first two days after the order was written. Interviews with facility staff confirmed that documentation and treatment for the left heel were lacking, and that the wound was not addressed in a timely manner. The wound nurse stated that the left heel was not open prior to the treatment order, but there was no documentation of assessment or intervention when the area was first identified as abnormal. The facility's policy requires assessment and documentation of risk factors and skin breakdown, but this was not followed for the resident's left heel, resulting in a delay in treatment and incomplete documentation.

Penalty

No penalty information released

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

Summary

The facility failed to prevent verbal and mental abuse for four out of six residents, resulting in psychosocial harm. Resident 3, who was cognitively intact, required assistance with activities of daily living due to conditions such as atherosclerosis, unsteadiness, and a fractured humerus. On one occasion, a Certified Nursing Assistant (CNA), identified as V3, refused to help Resident 3 get dressed in her room, insisting she dress in the bathroom despite her objections. V3 was forceful and rushed, leaving Resident 3 feeling exposed and cold without a button-up shirt. Resident 4, also cognitively intact, required assistance with transfers due to conditions like heart failure and hemiplegia. V3 displayed a dismissive attitude towards Resident 4, refusing to help her out of bed and making her feel terrible. Resident 4 reported V3's behavior to the facility administrator, who acknowledged the inappropriate actions. Additionally, Resident 5 witnessed V3 yelling at Residents 6 and 7, who had Alzheimer's disease and required assistance with dressing and toileting. V3's behavior included yelling at Resident 6 for not dressing in the clothes laid out and at Resident 7 for having an accident. The facility's investigation confirmed that V3 engaged in behaviors constituting abuse or neglect. The facility's abuse policy emphasizes providing an environment free from abuse, neglect, and exploitation, defining abuse as actions causing physical harm, pain, or mental anguish. Despite the policy, V3's actions led to residents experiencing feelings of shame, embarrassment, and humiliation, highlighting a significant deficiency in the facility's ability to protect residents from abuse.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper infection prevention and control measures were in place for residents who tested positive for COVID-19. Specifically, staff did not have ready access to or use appropriate personal protective equipment (PPE) such as N95 masks and eye protection when entering the rooms of COVID-positive residents. Isolation signage was also missing from the doors of these residents, which is crucial for indicating the type of isolation required. For instance, one resident was found in bed with the door open and no isolation signage, and the isolation cart outside the room lacked necessary PPE. Another resident was assisted by a CNA who wore inadequate PPE, and the CNA acknowledged the absence of N95 masks and face shields. The facility's medical records and supplies staff confirmed the availability of PPE, but it was stored in locked areas, making it inaccessible to staff when needed. Additionally, the facility did not document COVID testing for a resident who was exposed to a COVID-positive roommate. The facility's policy requires that only residents with the same respiratory pathogens be housed together, yet this was not adhered to. The Director of Nursing and other staff members were unaware of the reasons for the lack of isolation signage and the rooming arrangements. The facility's policy mandates that healthcare providers entering the room of a COVID-positive patient should wear a respirator with an N95 filter, gown, gloves, and eye protection, but this was not consistently followed, leading to a deficiency in infection control practices.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the presence of a qualified Infection Control Preventionist (ICP) working full-time, which has the potential to affect all 59 residents. On the specified date, the Administrator acknowledged the absence of an ICP and mentioned efforts to hire one. During the same period, residents who tested positive for COVID-19 were residing in the facility. The Director of Nursing, who was off due to a COVID infection, expressed uncertainty about the current situation, indicating a lack of oversight and management in infection control practices.

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 a safe and hazard-free environment for three residents on the dementia unit, all of whom were severely cognitively impaired. Resident 4, who can walk independently, was observed sitting in the dining room, and it was noted that the window in the area was broken and the door was not locked. The activities staff member was unaware of the broken window and unlocked door. Resident 5, also able to walk independently, was seen walking up and down the hall, passing the room with broken glass. Resident 6, who requires supervision or assistance for walking, was observed returning from therapy and became confused and agitated near the Alzheimer's unit door. She was later seen at the nurses' station, unable to make sentences or answer questions. The room with the broken window was supposed to be locked, as confirmed by the maintenance staff, who stated they were not asked to repair it. The administrator was under the impression that the room was locked. The facility's policy on safety and supervision emphasizes maintaining an environment free from accident hazards, but this was not adhered to in this instance.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to implement progressive fall interventions for two residents, resulting in injuries. One resident, admitted with conditions such as weakness, polyneuropathy, and cognitive decline, experienced multiple falls. On one occasion, the resident was found on the floor with lacerations requiring emergency room transfer and sutures. Despite being at high risk for falls, the resident's care plan and progress notes did not document any new interventions following these incidents. Interviews with staff confirmed the absence of documented progressive interventions for the falls. Another resident, diagnosed with vascular dementia and other conditions, sustained a bruise on the forehead after being bumped by a mechanical lift bar. The incident report noted the injury, but the social worker and registered nurse were unaware of the incident or the staff involved. The facility's policies on safe lifting and fall prevention were not effectively implemented, as evidenced by the lack of appropriate interventions and staff awareness.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to implement nutritional interventions to prevent significant weight loss in a resident diagnosed with Alzheimer's disease, anemia, and other conditions. The resident was admitted with a nutritional deficit, and interventions were documented to provide supplements as ordered. However, the resident experienced a severe weight loss of 15.7% over six months, indicating a failure to maintain adequate nutrition. The Registered Dietitian (RD) was responsible for recommending dietary changes, but there was a lack of documentation and communication regarding these recommendations. The RD did not document recommendations in the resident's progress notes for September and November, and the facility's Nutritional Care Form did not reflect the necessary dietary changes. The RD admitted to not seeing the resident in person and was unaware of the continued weight loss and refusal of supplements. The facility's documentation of meal and supplement intake was minimal, and the Director of Nursing acknowledged poor communication with the RD. Observations revealed that the resident appeared very thin with muscle and orbital wasting, and there was no meal tray or nutritional supplement provided at times. The Dietary Aid confirmed that the resident often refused supplements, and the Dietary Manager acknowledged the resident's poor intake of supplements. The facility's policy required monitoring and documentation of weight and dietary intake, but this was not effectively implemented, leading to the resident's significant weight loss.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through a review of staffing schedules and interviews with facility staff. The staffing schedules for the past 14 days revealed that there were no RNs working on nine specific days, including 12/1/2024, 12/2/2024, 12/3/2024, 12/5/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/10/2024, and 12/15/2024. The facility's administrator acknowledged the shortage of RN coverage, and the Director of Nursing confirmed that the facility currently employed only two RNs, including herself, and efforts were being made to hire more RNs. The deficiency potentially affects all 56 residents living in the facility. The facility's PBJ Report for the 4th quarter indicated a one-star staffing rating, and the Facility Assessment dated 7/1/2023 outlined a staffing plan based on the current census, which was not met. The facility's staffing policy, revised in 2017, stated that sufficient numbers of staff with the necessary skills and competency should be available to provide care and services for all residents. However, the lack of RN coverage on the specified days indicates a failure to adhere to this policy, potentially impacting the quality of care provided to the residents.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to post nurse staffing information in a clear and readable format in a prominent place, which is required to be readily accessible to residents and visitors. During a tour of the facility, it was observed that no nursing information, including the facility name, current date, total number of actual hours worked by RNs, LPNs, CNAs, and resident census, was posted or available for review. The facility's PBJ report for the 4th quarter documented insufficient RN coverage for 8 consecutive hours per day, resulting in a 1-star staffing rating. Interviews with the Director of Nursing and the Business Office Manager revealed a lack of awareness regarding the requirement to post staffing information, with the Business Office Manager noting that staffing was previously posted by the door but was unsure if it had been posted under new management. The facility's assessment and staffing policy indicated the need for adequate staffing to meet resident care needs, but no updated assessment was provided.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to ensure that food was stored and prepared in a manner that prevents potential contamination, affecting all 56 residents. During an inspection, surveyors observed several deficiencies in the kitchen and storage areas. The fryer station next to the oven was found with a basket covered in old grease and crisp pieces floating in it, indicating a need for cleaning. In the walk-in refrigerator, there was a large container of unidentified meat with noodles in red sauce, and a tray with eight bowls of unidentified food, both without labels or dates. Additionally, there was an 18-quart container of white liquid and another of red liquid, both lacking labels and dates. The freezer also presented issues, with large chunks of ice on the floor and ice crystals dripping from the ceiling onto various food items, including ice cream cups, waffles, chocolate pies, meat, and bread. A large block of ice was covering a box of hamburger. The Dietary Manager acknowledged the requirement for all items to be dated and labeled, and the Maintenance Man, who was new to the facility, was aware of the ice buildup issue but had not yet resolved it. The facility's Food Receiving and Storage Policy, revised in July 2014, mandates that food be stored in compliance with safe handling practices, including proper labeling and dating, which was not adhered to in this instance.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to ensure that its Facility Assessment was current and reviewed annually, which has the potential to affect all 56 residents living in the facility. On December 17, 2024, the Facility Assessment was requested and later provided by the Administrator, V1, with a revision date of July 1, 2023. When asked if this was the most up-to-date version, V1 confirmed it was. No other Facility Assessment was provided by the facility by December 18, 2024. Additionally, the Director of Nursing, V2, stated there was no policy on Facility Assessment. The facility's daily census sheets documented a total of 56 residents living in the facility.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to maintain a comprehensive infection surveillance program, as evidenced by the incomplete documentation in the Monthly Infection Control Log for November. Several residents were diagnosed with urinary tract infections (UTIs) and prescribed antibiotics, but the logs did not document the organisms causing these infections. Specifically, residents were prescribed Cipro and Cephalexin for their UTIs, yet the causative organisms were not recorded, indicating a lapse in the facility's infection control documentation practices. Additionally, there was an observed breach in infection control practices by a Licensed Practical Nurse (LPN) during a dressing change for a resident with pressure ulcers. The LPN did not wash or sanitize hands after leaving and returning to the resident's room, nor did they sanitize hands between glove changes. This failure to adhere to proper hand hygiene protocols further highlights deficiencies in the facility's infection prevention and control measures.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to ensure they had a qualified Infection Control Preventionist (ICP) working full-time, which has the potential to affect all 56 residents. The Administrator identified the Director of Nursing (DON) as the current ICP. However, the DON admitted to not having completed the required training for the role and stated there was no oversight in place. The facility's Antibiotic Stewardship Policy outlines responsibilities for the ICP, including monitoring antibiotic use and resistance, collaborating with the pharmacist, and providing education to nursing staff. Despite these outlined duties, the lack of a qualified ICP suggests these responsibilities may not be adequately fulfilled.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to maintain a dignified existence for a resident, identified as R11, who was cognitively intact and dependent on a wheelchair with an indwelling urinary catheter due to neurogenic bladder. The resident's catheter bag was observed uncovered on multiple occasions, which was a source of embarrassment for the resident. R11 expressed frustration about the lack of a cover for the catheter bag, stating it was embarrassing when people walked by the room. Certified Nursing Assistants (CNAs) acknowledged the need for a dignity bag to cover the catheter bag, especially when the resident was moving around the unit. The facility's Administrator and Director of Nursing also stated that they expected catheter bags to be covered. The facility's Resident Rights Policy emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance, as the resident's dignity was compromised by the visible catheter bag.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to notify the physician and obtain an order for treating a non-pressure sore on a resident's lower left leg. The resident, who is cognitively intact and has a medical history including an acquired absence of the right leg above the knee and peripheral vascular disease, reported a sore on her leg that was leaking. Despite this, there was no documented order in the Electronic Health Record for the dressing applied to the sore. The nurse's note from the previous day indicated that the sore was dressed and covered with triple antibiotic ointment and a bandage, with no signs of warmth or redness, and the plan was to continue monitoring. The Director of Nursing confirmed the absence of a treatment order, and a Licensed Practical Nurse (LPN) noted the sore was scabbed over but had an open tip. The LPN cleansed the area, applied ointment and a bandage, and noted a new area on the leg that was not measured. The LPN stated she would call the doctor, and the physician confirmed being contacted but had not yet seen the resident. The facility's policy requires the charge nurse or supervisor to contact the attending physician for immediate discussion and management if a clinical situation necessitates it, which was not adhered to in this case.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to protect a resident from abuse, as evidenced by an incident involving a cognitively severely impaired resident with Alzheimer's Dementia and other medical conditions. The incident occurred when the resident fell out of their wheelchair, and a CNA reported the fall to an LPN. The LPN became visibly angry, yelled at the resident, and was reported to have physically handled the resident inappropriately. Multiple staff members witnessed the LPN mistreating the resident, including aggressive talking and forcibly moving the resident's wheelchair. The facility's investigation substantiated the allegations of abuse, leading to the termination of the LPN's employment. The facility's policy on Abuse Prevention, revised in 2017, states that residents should be provided with an environment free from abuse, neglect, or misappropriation of property. Despite attempts to contact the involved staff for interviews, they were unavailable, and their written statements were included in the investigation.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to adequately monitor a resident, identified as R34, who required dialysis and paracentesis. R34's electronic health record documented diagnoses of end-stage renal disease, alcoholic cirrhosis of the liver with ascites, and dependence on dialysis. Despite these conditions, the facility did not document post-dialysis and post-paracentesis monitoring in the resident's records. The care plan for R34 indicated a risk for complications related to end-stage renal disease and dialysis, but there were no documented orders or evidence of monitoring for signs and symptoms of fluid overload in the electronic health record. Additionally, the facility did not document the post-paracentesis instructions provided by the local hospital, which included specific care instructions such as removing the bandage in 3 to 5 days and monitoring for redness or drainage. The Medication Administration Record and Treatment Administration Record lacked documentation of these instructions. Licensed Practical Nurses (LPNs) at the facility acknowledged checking the dialysis access site for thrill and bruit but did not document these checks unless issues were noted. Furthermore, there was no dialysis and paracentesis policy provided upon request, indicating a lack of formalized procedures for these critical care activities.

Penalty

Inspection fine: $265,965113 days payment denial

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

Summary

The facility failed to ensure that residents who required assistance with feeding were attended to by properly trained staff under the supervision of a registered nurse (RN) or licensed practical nurse (LPN). This deficiency was identified during an observation where a unit aid, who had not completed a state-approved training class for assisting residents with feeding, was feeding a resident diagnosed with dysphagia and other digestive issues. The resident was on a pureed diet, and the feeding occurred without the presence of a nurse in the dining room. The unit aid's job description did not include feeding residents, and the Director of Nursing (DON) confirmed that unit aids were not supposed to feed residents, especially those at high risk for choking. The facility did not have any paid feeding assistants, nor did it have a policy on feeding assistance or residents needing assistance with feeding. The facility's existing policy required that paid feeding assistants complete a state-approved training course and be supervised by a registered dietitian and an RN, but this was not adhered to in practice.

Penalty

Inspection fine: $13,580

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 monitoring to prevent the elopement of a resident identified as R2, who was at risk due to her cognitive impairments. R2, who had been admitted to the facility with a diagnosis of Alzheimer's disease and dementia, was known to be confused, agitated, and frequently expressed a desire to leave the facility. Despite these known risks, R2 was able to elope from the facility undetected on the afternoon of 10/15/2024. On the day of the incident, R2 was last seen by staff at approximately 3:00 PM. She was later found by a passerby at around 4:30 PM, walking in a field near the local hospital. The facility's investigation revealed that a window in an unoccupied room on the memory care unit was found ajar, suggesting that R2 may have exited through it. Alternatively, it was suspected that she might have followed a visitor out of the secured door. The facility's staffing on the memory care unit was insufficient, with only one CNA present when the LPN was administering medications on other halls, leaving the residents unsupervised. R2's care plan and elopement risk assessments were not adequately updated or implemented. Although R2 was identified as an elopement risk upon admission, she was not equipped with an electronic monitoring bracelet, which could have alerted staff to her exit. The facility's failure to ensure that R2 was continuously monitored and that preventive measures were in place directly contributed to her elopement.

Removal Plan

• The issue has the potential to affect all memory care residents and any other residents within the facility that have been identified as an elopement risk.
• R2 was evaluated at local hospital following the elopement and again upon returning to the facility. No injuries were observed. R2's responsible party, attending physician, and State Survey Agency were all notified.
• All residents on the memory care unit were placed on 15-minute checks for a period. At the expiration of the period, residents were placed on a 2-hour check, with the exception of R2 who remained on 15-minute checks, and QA team will review to see if any changes need to be made.
• R2 care plan was reviewed and updated to assess exit seeking triggers and none were identified. The care plan was updated to include the use of an electronic monitoring device.
• The electronic monitoring device, which is present on all exterior doors of the facility, was tested and determined to be in working order. The electronic monitoring alert system was tested and determined to be functioning properly and the electronic monitoring bracelet was placed on the resident.
• The facility has conducted updated risk assessments on all current residents. This risk assessments included identifying exit seeking triggers, if any. No new elopement risks were identified.
• The facility's administrative and clinical teams, led by the administrator, met to review all elopement policies and procedures. Current policies and procedures were determined to be satisfactory, and no changes were proposed.

Penalty

Inspection fine: $13,580

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 adequate staffing for the memory care locked unit, affecting all 11 residents residing on the unit. These residents, who have dementia and Alzheimer's disease, require assistance with activities of daily living (ADLs) and are at risk of wandering and setting off door alarms. The staffing issue was observed during various shifts, where only one CNA was left to supervise the unit while the assigned nurse attended to residents on other halls. This left the CNA alone to manage high-acuity residents, which was deemed unsafe by multiple staff members. Interviews with staff, including LPNs, RNs, and CNAs, revealed that the current staffing pattern left the memory care unit inadequately supervised. Staff members reported that they were often required to leave the unit to care for residents on other halls, leaving only one CNA to manage the 11 residents. This situation was described as unsafe, particularly when the CNA had to provide 1:1 care, such as toileting, which left other residents unsupervised for extended periods. The Director of Nursing (DON) and the facility administrator acknowledged the staffing issues but did not have a clear understanding of the acuity of the memory care unit or the specific staffing assignments. The facility's staffing policy requires a minimum of 3.8 hours of nursing and personal care each day for residents needing skilled care, but the current staffing did not meet these requirements, leading to the deficiency noted in the report.

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 secure and control the disposition of administered medications for several residents, leading to deficiencies in medication management. Resident 1, who was cognitively intact but required assistance with activities of daily living, was found with hydrocortisone cream in her wheelchair and diclofenac gel at her bedside without a documented order for medications at bedside. The registered nurse and licensed practical nurse were unaware of any assessments for residents to have medications at bedside, and the care plan nurse admitted there was no comprehensive assessment policy in place. Resident 7, who was severely cognitively impaired, had medications left unattended on a dining table for over half an hour. The licensed practical nurse left the medication cup on the table without continuous nursing observation. The care plan nurse acknowledged the lack of a comprehensive self-administration assessment for Resident 7, despite the expectation of nursing supervision and oversight of medications left for residents to administer. Resident 8, who was cognitively intact, also had medications left unattended on a dining table for nearly an hour. The licensed practical nurse left the medication cup on the table without continuous nursing observation. Additionally, Resident 2 had seven pills left out of reach on a bedside table, and Resident 3, who was confused, had diclofenac gel on her bedside table without a self-administration assessment. The facility's policy on self-administration of medications was not followed, as there was no documentation of comprehensive assessments or secure storage of medications.