Imboden Creek Senior Living

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 obtain physician orders for the use and cleaning of Continuous Positive Airway Pressure (C-PAP) and Bilevel Positive Airway Pressure (BI-PAP) machines for four residents. In each case, the residents were using their own C-PAP or BI-PAP machines, which were brought from home, but there were no corresponding physician orders documented in their medical records. Additionally, the facility did not document orders for the cleaning, monitoring, or settings of these machines, despite the residents' ongoing use and medical needs. The facility also failed to consistently monitor and document vital signs, including oxygen saturation and respirations, for three residents using C-PAP/BI-PAP machines. Medical records showed significant gaps in the documentation of these vital signs, and interviews with residents and family members confirmed that staff were not regularly obtaining or recording this information. Some residents and their families reported that staff did not assist with cleaning the machines or checking the settings, and in some cases, family members or the residents themselves were responsible for these tasks. Observations revealed that C-PAP and BI-PAP machines and their components, such as tubing and masks, were not stored in a sanitary manner, with equipment left uncovered and in direct contact with surfaces. Staff interviews confirmed a lack of oversight regarding the management of these devices, and the facility's own policy required physician orders, regular monitoring, and cleaning by licensed nurses, none of which were consistently followed. The absence of a respiratory therapist and lack of staff involvement in managing the machines further contributed to the deficiency.

Penalty

Inspection fine: $119,7003 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

Facility staff failed to provide timely emergency resuscitative efforts to a resident who was a Full Code, resulting in a ten-minute delay before CPR was initiated. The resident, who had multiple complex medical diagnoses including sepsis, COPD, heart failure, and diabetes, was found unresponsive in bed by CNAs during morning care. Initial assessment by staff revealed no pulse, no oxygen saturation, no blood sugar, and no measurable blood pressure. Despite the resident's documented Full Code status, no immediate CPR was started by the CNAs or the first LPNs who assessed the resident. Instead, staff left the room to seek verification of the code status and to find additional staff, further delaying the initiation of life-saving measures. Multiple staff members, including CNAs and LPNs, entered the resident's room, assessed the resident, and determined there were no signs of life, but none initiated CPR at that time. The DON was eventually called to the room, and only after confirming the code status as Full Code did the DON and other staff begin CPR, approximately ten minutes after the resident was first found unresponsive. During this period, 911 was not called immediately, and resuscitative efforts were not started as per facility policy, which states that CPR should be initiated immediately if code status is unclear and continued until EMS arrives or a physician provides further instruction. Interviews with staff revealed a lack of prompt assessment and action regarding the resident's change in condition, as well as uncertainty and delays in verifying code status. The night nurse did not report the resident's abnormal condition to management or the physician, and day shift staff did not check on the resident promptly despite being informed the resident was not feeling well. The facility's failure to initiate CPR immediately upon finding the resident unresponsive, and the delay in calling emergency services, directly contributed to the deficiency cited by surveyors.

Removal Plan

• The facility implemented a revised Cardiopulmonary Resuscitation (CPR) policy to instruct staff to call emergency services (911) earlier in the CPR process.
• All facility direct care personnel have been educated to ensure they are aware of the policy related to change of condition assessment, immediate initiation of CPR, and identification of the location where the resident's code status is documented.
• A new ‘acknowledgement' form was introduced for all new employees to sign, indicating they have been trained on the facility CPR policy and where to find a resident's code status.
• Training on location and identification of code status began and will continue with any new staff hired or staff categorized as ‘As needed.’
• Facility management staff received education on the updated CPR policy and procedures.
• Direct care floor staff were trained on the updated CPR policy and procedures.
• The facility updated their CPR policy to incorporate effective CPR procedures for residents who have chosen to be fully resuscitated.
• Every resident chart was reviewed and reconciled with the resident Physician Order Sheet (POS) and face sheet to ensure any resident who chooses to be a ‘Full Code’ has that information easily accessible to staff.
• A Quality Assurance Performance Improvement (QAPI) meeting was held to discuss change of condition assessment, initiation of CPR, and to review policies and procedures.
• Facility staff reviewed 100% of resident charts to ensure proper orders are in place and appropriate chart identification for advanced directives.
• The Interdisciplinary Team (IDT) will continue with reeducation of change of condition assessment, reporting, and initiation of CPR, with education offered for one year, annually, and upon hire.

Penalty

Inspection fine: $119,7003 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 employ a qualified Infection Preventionist who remains onsite, as required for the infection prevention and control program. Record review showed that while a member of the nursing directors' team was designated as the certified Infection Preventionist in the facility assessment, the facility was unable to provide an Infection Preventionist certificate for any employee working onsite. Observations conducted over several days confirmed that there was no Infection Preventionist present in the building. The Administrator confirmed that the facility does not have an Infection Preventionist onsite and that the corporate Infection Preventionist is never in the building. This deficiency has the potential to affect all 70 residents residing in the facility.

Penalty

Inspection fine: $119,7003 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 a safe environment and adequate supervision to prevent accidents for four residents, as evidenced by incomplete fall investigations, failure to perform post-fall neurological assessments, improper transfer techniques after a fall, and lack of implementation of fall prevention interventions. One resident with multiple medical diagnoses, including a history of falls and severe cognitive impairment, was found on the floor and was manually lifted back to bed by staff instead of using a mechanical lift as required by the resident's care plan and facility policy. Neurological assessments were not completed per policy after the unwitnessed fall, and the fall investigation did not include interviews with all involved staff or determination of a root cause. The resident subsequently developed swelling and pain in the right leg, which was later diagnosed as an acute, displaced femur fracture. Another resident, identified as a fall risk and cognitively intact, had a care plan intervention for a non-slip mat in the wheelchair, but repeated observations showed the mat was either missing or improperly placed. This resident had a history of multiple falls and was observed with visible bruising. The Director of Nursing confirmed the absence or improper placement of the non-slip mat during interviews and observations. Two additional residents, both at risk for falls and not cognitively intact, had care plans specifying interventions such as body pillows, bed alarms, overlay bolsters, fall mats, and accessible call lights. Observations revealed that these interventions were not in place as required: body pillows and bed alarms were missing, overlay bolsters were not present, and call lights were out of reach or on the floor. Staff interviews and direct observation confirmed these deficiencies, and the facility's own policies required individualized fall prevention interventions based on resident risk assessments.

Penalty

Inspection fine: $119,7003 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 accessible and complete medical records for five residents, as required by accepted professional standards. Staff, including CNAs and LPNs, were unable to verify which fall prevention interventions had been implemented or completed for several residents because the electronic medical record (EMR) system did not have a centralized or easily accessible location for this information. This lack of organization in the EMR compromised staff's ability to deliver consistent care and monitor resident safety effectively. Additionally, the facility's binder intended for emergency use, which should document advanced directives and code status, was not up to date and did not include this information for multiple residents. Staff reported difficulty locating residents' code status and advanced directives in both the EMR and the physical binder, with some staff unaware of the binder's existence or location. The administrator confirmed that while the POLST forms were present in the EMR, they were not easily accessible, and the binder was not current, which could delay emergency care. There was no specific policy ensuring that medical records, including advanced directives, were easily accessible to staff.

Penalty

Inspection fine: $119,7003 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 timely notify the physician and other responsible parties of a resident's fall. According to nurse progress notes, a resident was found on the floor early in the morning and assessed by staff, who found no injuries or pain at that time. The resident was assisted back to bed, and the night shift LPN was informed. However, the night shift LPN did not verbally report the fall to the incoming day shift LPN, instead leaving a written note, which was not received. As a result, the day shift LPN was unaware of the fall until a CNA reported swelling and pain in the resident's right leg later that morning. Upon assessment, the day shift LPN noted swelling, pain, and discoloration in the resident's right leg and administered pain relief and an ice pack before contacting the physician. Further review revealed that the night shift LPN did not report the unwitnessed fall to the next shift, nursing management, the physician, or the resident's power of attorney. The resident was later sent to the emergency room, where an X-ray confirmed an acute, displaced fracture of the distal femoral shaft. The Director of Nursing confirmed that the required notifications were not made following the fall, as was necessary.

Penalty

Inspection fine: $119,7003 days payment denial

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

Summary

The facility failed to maintain an undisturbed environment following the death of a resident prior to the arrival of the coroner. After the resident passed away, video footage showed that four CNAs entered the resident's room and provided post-mortem care, including transferring the resident's body from the floor back to the bed using a mechanical lift. The CNAs reported that they were not instructed not to touch the body or the environment, and stated that they acted at the request of the resident's family to clean up the resident. The LPN on duty contacted EMS and the coroner's office, but did not recall being instructed not to disturb the body or the environment. The LPN acknowledged that staff should not touch the body or environment until cleared by the coroner. When the coroner arrived, the resident's body had already been moved and the room had been cleaned, with no medical supplies present. The coroner stated that in such cases, the body and environment should be left untouched as it is considered a possible crime scene, and that the facility should not have tampered with the body after death. The facility administrator confirmed that there was no policy in place regarding post-mortem care for coroner cases, and that staff were expected to follow the standard of care.

Penalty

No penalty information released

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

Summary

The facility failed to assess wounds and complete wound treatments as required for two residents with pressure sores. For one resident, there was no admission skin or wound assessment performed by facility staff, nor were there any weekly skin or wound assessments documented after admission. The resident was admitted with only a surgical wound, but later developed a large, unstageable deep tissue injury on the posterior right upper buttock. The treatment administration record showed that wound care treatments were missed on multiple days, and the resident's family observed that dressings were often not changed as scheduled, with old dressings remaining in place. The Director of Nursing confirmed the lack of required assessments and missed treatments, acknowledging that treatments were not completed as ordered by the physician. Another resident, admitted with multiple diagnoses including Parkinson's disease, dementia, and a history of malignancy, also did not receive required weekly skin or wound assessments. The treatment administration record indicated that wound care for a sacral pressure ulcer was not completed as ordered on several occasions. The last documented skin or wound assessment for this resident was several weeks prior to the survey, despite ongoing physician orders for wound care. During wound care observations, the wound was found to have full-thickness tissue loss with muscle exposed, and the resident experienced pain during the procedure. Facility policy required comprehensive skin assessments upon admission, weekly risk assessments, and completion of wound care according to physician orders. Interviews with the Director of Nursing and review of records confirmed that these policies were not followed for the two residents. The failure to perform timely assessments and complete wound treatments as ordered led to the deficiencies cited 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 notify a family member of an accident involving a resident who had a history of falls, impaired cognitive function, and decreased mobility. The resident, who had diagnoses including a pelvic fracture, chronic pain, and unsteadiness, was found on the floor by an LPN after being heard yelling. The resident had visible bruising on the right temple, right arm, and left forearm. Despite the incident and the resident's condition, the family was not notified at the time of the accident. Staff interviews revealed that the LPN who assessed the resident after the fall did not document the assessment, vital signs, or any information about the fall, nor did she notify the family, the administrator, or the DON. The LPN stated she believed another nurse would handle the notifications, but that nurse did not go to the resident's room. The facility's policy requires documentation of the date and time a family member is notified of an accident, which was not followed in this case.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. According to the facility's initial report and staff interviews, two residents with cognitive and behavioral diagnoses were involved in an altercation at the nurse's station. One resident, who had a history of anxiety, agitation, poor impulse control, and documented behavioral problems, accused the other of stealing a fan and proceeded to strike the other resident on the shoulder with an open hand. Staff present at the time attempted to separate the residents, but the physical contact still occurred. The incident was witnessed by a CNA and corroborated by an LPN, who described the aggressor as having a tendency to become agitated and verbally aggressive. Both residents involved had documented cognitive impairments and behavioral health issues, including dementia, anxiety, and depression. The facility's abuse policy prohibits abuse of any kind and commits to protecting residents from abuse by anyone, including other residents. Despite these policies and the known behavioral risks, the facility did not prevent the physical altercation, resulting in a failure to uphold the resident's right to be free 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 timely review and revise comprehensive care plans for three residents, as required by their own policy and federal regulations. Specifically, the most current care plans for the affected residents were not updated in accordance with the required schedule, with documented dates showing significant lapses. During an interview, the Administrator confirmed that no one at the facility was responsible for care plans, as this task was handled at the corporate level. The facility's policy mandates that the interdisciplinary team must review and update care plans after significant changes, unmet outcomes, and at least quarterly with the Minimum Data Set (MDS) assessment, but this process was not followed for the residents reviewed.

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 the facility failed to implement a fall prevention intervention for a resident with a history of falls, impaired cognitive function, and decreased mobility. The resident's care plan required the use of a chair alarm due to impulsivity and a high risk for falls, as documented in both the care plan and fall risk evaluation. Despite these documented interventions, surveyors observed on multiple occasions that the resident did not have a chair alarm in place while seated in the wheelchair. The resident reported attempting to transfer independently and having experienced multiple recent falls, and was observed with faded bruising on both arms and the right temple. Staff interviews confirmed awareness of the care plan requirement for a chair alarm, but the intervention was not consistently implemented.

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 was identified when a resident with severe cognitive impairment, who is totally dependent on staff for all activities of daily living and is always incontinent of bowel and bladder, did not receive timely and appropriate incontinence care. The resident had a recent history of urinary tract infection (UTI) and was on antibiotic and probiotic therapy. On the morning of the survey, a CNA admitted to not having changed or repositioned the resident since the start of her shift, citing being busy with another resident and the fact that the resident was asleep. The CNAs did not receive a report from the night shift regarding the last time the resident was changed. Upon assessment, the resident was found in a heavily soiled incontinence brief with evidence of prolonged exposure to urine. During the provision of care, the CNAs failed to follow proper infection control practices. After removing the soiled brief, the CNAs continued to use the same contaminated gloves to perform multiple tasks, including cleaning the resident's eyes and mouth, handling supplies, and performing peri-care. One CNA also touched various surfaces in the room with the same contaminated gloves. Both CNAs only removed their gloves and performed hand hygiene after completing all care tasks. The improper technique and lack of hand hygiene during incontinence care were acknowledged by the facility's regional RN as a breach of expected standards.

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 nurse left a medication cup containing 17 medications at a resident's bedside without supervision, contrary to facility policy and without a physician's order permitting self-administration. The resident was found asleep and unresponsive to verbal prompts, with the medication cup still present. The nurse later acknowledged that medications should not be left at the bedside and that staff are required to observe residents taking their medications unless there is a specific order allowing self-administration. The facility's policy states that medications must be administered safely and in a timely manner, with staff required to observe administration unless the attending physician has determined the resident can self-administer. In this case, there was no such order for the resident, and the nurse confirmed that leaving medications at the bedside was not permitted. The resident also reported that this nurse had previously left medications at the bedside for unsupervised administration.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurate medical records for one resident reviewed for medical records. The resident's current diagnosis list did not include a diagnosis of psychosis, despite a historic psychiatric evaluation documenting psychosis and irritable/frequent anger, which was the basis for the original order of Risperdal, an antipsychotic medication. The current physician order for Risperdal inaccurately listed the indication as 'prophylaxis' and did not reflect the correct diagnosis. Additionally, the Minimum Data Set indicated the resident received antipsychotic medications on a routine basis. The Medication Administration Record (MAR) required nursing staff to monitor and document specific behaviors every shift, using 'Y' for no behaviors observed and 'N' for behaviors observed, with further documentation in the nurses' notes if needed. However, for an entire month, nurses failed to document either 'Y' or 'N' for each shift and did not record any behaviors in the corresponding nurses' notes, resulting in 93 incomplete documentation errors. The facility's policy requires documentation to be objective, complete, and accurate, which was not followed in this case.

Penalty

Inspection fine: $111,72517 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

A deficiency occurred when the facility failed to promptly notify a physician of a resident's significant change in condition and decline in mobility, resulting in prolonged discomfort and pain. The resident, who was cognitively impaired and had a history of falls, muscle weakness, and difficulty walking, began experiencing new onset pain in her left lower extremity during physical therapy. Over the course of several days, multiple physical therapy assistants observed and documented a marked decline in the resident's ability to bear weight and increased pain, with the resident herself expressing concern that her hip might be broken. Despite these observations, the nursing staff did not promptly notify the physician or obtain an order for an x-ray. A physical therapy assistant reported the change in condition and requested an x-ray to the assigned LPN, but the LPN did not follow through with physician notification or documentation of the change. The Director of Nursing was not made aware of the situation until the resident's daughter raised concerns at the nurses' station, at which point a STAT x-ray was ordered and a left intertrochanteric hip fracture was identified. The facility's policy required prompt notification of the physician and the resident's representative in the event of a significant change in condition. However, the lack of timely communication and documentation by the nursing staff led to a delay in diagnosis and treatment of the resident's hip fracture, as confirmed by interviews with therapy staff, the Director of Nursing, and the resident's daughter.

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 timely toileting assistance and implement effective fall interventions for three residents, leading to significant injuries. One resident, who was cognitively intact but had a history of falls and required assistance with toileting, attempted to use the restroom independently after waiting for help. This resulted in a fall that caused a hematoma and a femur fracture, necessitating surgery and hospitalization. The resident was found on the floor, incontinent and without proper footwear, indicating a lack of supervision and timely assistance. Another resident, also cognitively intact but with a history of repeated falls, experienced an unwitnessed fall in their room, resulting in a skin tear and bruising. The resident's care plan included the use of a body pillow, which was not present at the time of the fall, suggesting that fall prevention measures were not adequately implemented. The lack of documentation in the nurse's progress notes further highlights the facility's failure to thoroughly investigate and document the incident. A third resident, with moderate cognitive impairment and a history of falls, fell out of bed while attempting to retrieve an unknown item. The resident was not wearing the required slipper socks, and the overlay bolster on their bed was found to be ineffective. The facility's failure to maintain and replace necessary equipment contributed to the resident's fall. The Director of Nursing acknowledged that the fall investigations lacked sufficient detail and that the fall interventions were not in place at the time of the incidents.

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 the services of a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 69 residents residing in the facility. The deficiency was identified through observation, interview, and record review. The facility's Dietary Manager, identified as V15, was actively managing kitchen personnel and directing food sanitation and preparation activities without being a Certified Dietary Manager (CDM). V15 was hired on July 12, 2024, as the CDM, but at the time of the survey, V15 had not completed the necessary Dietary Manager course, although V15 was enrolled in it as of September 2024. Interviews with various staff members, including the Regional Dietary Manager and the facility's Administrator, confirmed that V15 was functioning as the Dietary Manager despite not having the required certification. The facility's documentation, including V15's employee file, indicated that V15 was expected to manage all aspects of the Dietary department, including regulatory oversight related to safe food handling. However, V15 admitted to not being a Certified Dietary Manager at the time of the survey, which constitutes a failure to meet the regulatory requirements for the position.

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 timely meals and evening snacks to its residents, which has the potential to affect all 69 residents. During a resident council meeting, several residents reported that breakfast was served closer to 9 AM, and evening snacks had not been offered for the past two to three months. The Dietary Manager confirmed that meal times were set at 8 AM, 12 PM, and 5 PM, and stated that snacks were available in the nutrition room for staff to distribute after the kitchen closed. However, a resident who eats in their room reported not receiving lunch by 12:15 PM and was unaware of the availability of evening snacks. The facility's policy requires that residents receive at least three meals daily, with no more than a 14-hour span between the evening meal and breakfast, and that nourishing snacks be routinely offered to all residents, especially if the time span between meals exceeds 14 hours.

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 report an allegation of resident-to-resident verbal abuse to the Abuse Coordinator for two residents who were both severely cognitively impaired. The incident occurred when one resident, while self-propelling out of the dining room, ran into another resident's wheelchair, leading to a verbal altercation. The staff intervened, and the resident who initiated the movement was taken to the lobby while crying. Despite the incident, the Licensed Practical Nurse (LPN) involved did not report it as an allegation of abuse, viewing it instead as a behavioral issue. The Director of Operations confirmed the incident and identified the residents involved. The Administrator stated that any allegation of abuse should be reported to the Abuse Coordinator to initiate an investigation. However, the LPN did not report the incident, and the Administrator was unaware of it until much later. The LPN acknowledged the oversight, recognizing that the incident could be considered an allegation of abuse that should have been reported. This failure to report prevented the necessary investigation and subsequent reporting to the State Agency.

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 weight management services for two residents experiencing unplanned weight loss. One resident experienced a weight loss of 10.1 pounds, equating to a 9.1% decrease in a month, without any documentation of physician notification. Another resident lost 13.5 pounds, an 8.6% decrease, and was subsequently hospitalized and returned with a PEG tube for continuous feeding. Upon readmission, the resident was not weighed, and there was no documentation of an admission weight. The facility's protocol requires nursing staff to notify the physician and dietician of significant weight changes, defined as a 5% or more loss, and to verify weight changes by obtaining a new weight. However, these procedures were not followed, as evidenced by the lack of documentation and notification in the cases of the two residents. The interdisciplinary team reviews weight changes monthly, but the immediate response to significant weight loss was inadequate, leading to a deficiency in weight management services.

Penalty

No penalty information released

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

Summary

The facility failed to implement non-pharmacological interventions before administering psychotropic medications to a resident. The facility's policy, revised in December 2016, requires that psychotropic medications be considered only if behavioral symptoms pose a danger and after behavioral interventions have been attempted and included in the care plan. However, for one resident, there was no evidence of behavior tracking or behavior notes, and the care plan did not include psychotropic medication interventions or non-pharmacological interventions for anxiety. The resident's Medication Administration Record for November 2024 showed an order for Quetiapine to be administered for anxiety, despite the resident's medical diagnosis report indicating unspecified dementia without behavioral disturbance, psychotic disorder, mood disorder, or anxiety. Interviews with the Director of Nursing and a Clinical Nurse revealed they could not find any documentation of behavior tracking for the resident. Additionally, the resident expressed uncertainty about the medications being administered, as staff did not communicate changes in medication to her.

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 properly label medications for three residents, leading to deficiencies in medication administration. For one resident, a Licensed Practical Nurse (LPN) administered an inhaler, eye drops, and a cream, none of which had labels indicating the resident's name or the date they were opened. The LPN confirmed that these medications were not labeled and lacked an open date, which is against the facility's policy and professional standards. Another resident received insulin from a pen that was not labeled with the resident's name, medication, or administration directions, and it also lacked an open date. The LPN administering the insulin confirmed the absence of these labels. Additionally, a third resident's medication cards had labels indicating administration at bedtime, conflicting with the Medication Administration Record (MAR) that specified administration at 4:00 PM. These discrepancies highlight a failure to adhere to labeling protocols, potentially impacting the safe administration of medications.

Penalty

No penalty information released

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

Summary

The facility failed to implement an effective antibiotic stewardship program by not assessing the criteria for determining an infection for a resident (R9) who was receiving hospice services. According to the facility's Antibiotic Stewardship policy, the purpose is to monitor antibiotic use among residents. However, R9's medical records did not include a completed McGeer Criteria for Infection Surveillance Checklist, nor was there documentation of any testing or cultures to confirm the infection. Despite this, an order was placed for the resident to receive Bactrim DS, an antibiotic, for a urinary tract infection (UTI) based on confusion observed by a hospice CNA. Interviews with the Director of Nursing and a Clinical Nurse revealed that there was no supporting documentation or lab results to justify the antibiotic use, indicating a lapse in the facility's infection surveillance and antibiotic stewardship 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 an accurate Advanced Directive for a resident, identified as R5, which led to a deficiency in honoring the resident's treatment preferences. Upon admission, the facility's policy requires that residents be provided with information about their rights to accept or refuse treatment and to formulate an advance directive. The policy also mandates that the Social Services Director or designee inquire about existing advance directives and ensure the plan of care aligns with the resident's documented preferences. However, when R5 was readmitted to the facility from the hospital on hospice care, the facility did not obtain a new Physician Orders for Life-Sustaining Treatment (POLST) form to reflect R5's updated wishes regarding cardiopulmonary resuscitation (CPR) and extraordinary measures. R5's existing POLST form indicated a preference for CPR and selective treatment, but upon readmission, R5 had chosen not to have CPR or extraordinary measures upon death. Despite this change, the facility did not update the POLST form or obtain a new order for a Do Not Resuscitate (DNR) status, as confirmed by the Director of Nursing (DON). Consequently, when R5 was confirmed expired, no attempt at CPR was made, which was inconsistent with the documented POLST form in R5's medical record. This oversight highlights a failure in the facility's process to ensure that the resident's treatment preferences were accurately documented and followed.

Penalty

No penalty information released

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

Summary

The facility failed to maintain resident dignity by not providing timely bowel and bladder incontinence care for a resident with moderate cognitive impairment and a history of congestive heart failure and aspiration pneumonia. The resident, who is totally dependent on staff for toilet use due to weakness and blindness, was left in a heavily soiled incontinence brief for an extended period. The resident's family member reported that the resident had a bowel movement during lunch and requested assistance, but was told by a CNA that they were too busy at the time. The resident was left waiting for care for over an hour after lunch, which was confirmed by the Director of Clinical Operations as too long. When the incontinence care was finally provided, the resident's brief was found to be heavily saturated with urine and feces, with dried feces present on the resident's skin. The CNAs involved in the care performed appropriate hygiene practices during the process. The delay in care was acknowledged by both the Director of Clinical Operations and the President of Clinical Operations as a dignity issue, with the latter noting that residents who are heavy wetters should receive more frequent incontinence care checks. The facility's policy on dignity emphasizes that residents should be treated with dignity and respect, and assisted in maintaining their self-esteem and self-worth.

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 measure and serve consistent food portions during meal service, affecting three residents and potentially impacting all 75 residents in the facility. Observations revealed that portion sizes varied significantly, with some residents receiving larger portions while others received much smaller ones. This inconsistency was unrelated to the residents' diet order slips, which did not specify any deviation in portion sizes. Staff involved in meal preparation and service did not identify or address these discrepancies. Interviews with staff and residents highlighted ongoing issues with portion sizes. A Licensed Practical Nurse and Certified Nursing Assistants reported that portion sizes depended on who was cooking, and residents often complained about the inconsistency. Some residents were unable to get seconds, and others were left unsatisfied with the portions they received. A cook confirmed that portion sizes varied based on their knowledge of residents' eating habits, despite using the correct scoop size according to the menu. Specific incidents included a resident who had to eat their family member's food due to insufficient portions and another resident who received a meal with very small portions, prompting their spouse to purchase additional food from a fast-food restaurant. The facility's policy requires staff to demonstrate the ability to read menus and select the correct serving utensils, but this was not adhered to, leading to the observed deficiencies.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate wound care and maintain a pressure sore plan of care for two residents. For one resident, identified as R2, the facility did not document a wound on the left buttock in the care plan, despite a physician's order for specific treatment. The wound doctor had ordered the application of Calcium Alginate covered with a hydrocolloid sheet three times per week, along with a protective barrier wipe to the peri wound. However, the treatment record did not include this order, and during an observation, the resident was found without a dressing on the buttock, and the wound was covered with slough. The Licensed Practical Nurse applied zinc oxide and border gauze instead of the prescribed treatment. For another resident, identified as R1, the facility failed to document the completion of dressing changes on the Treatment Administration Record for specific dates. The resident's care plan documented a wound on the left sacrum, and the treatment order required daily dressing changes with a silicone bordered foam dressing. However, the dressing changes were not signed out as completed on three occasions. The Regional Nurse confirmed the lack of documentation and could not verify if the treatments were completed as ordered.

Penalty

Inspection fine: $19,295

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 physician-ordered wound care for a resident's surgical incision, which led to a wound infection. The resident was admitted to the facility with medical diagnoses including surgical aftercare following a lumbar laminectomy and dislocation of an internal left hip prosthesis. The physician's orders required daily wound care and monitoring for signs of infection or dehiscence, with instructions to notify the medical doctor if complications arose. However, the facility's nursing staff did not perform the required wound care and monitoring on specific dates, leading to the resident developing an infection. The resident's treatment administration record indicated that the nursing staff failed to clean and dress the incision and monitor it on several occasions. As a result, the resident was sent to the hospital for a surgical debridement and received multiple intravenous antibiotics. The hospital records confirmed the presence of E. coli in the wound, attributed to fecal contamination, and noted additional issues such as rashes and bed sores that were not present at the time of discharge from the hospital to the facility. The resident's daughter reported that the facility's nurses did not perform the necessary wound care, and the dressings did not adhere properly. The resident was left on a bedpan for extended periods and was mostly lying on her back, contributing to the development of rashes and bed sores. The neurosurgeon confirmed the poor quality of care at the facility, which led to the infection and subsequent hospitalization.

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 the potential for foodborne illness by serving undercooked hamburgers. This deficiency affected one resident, who is cognitively intact, and reported receiving undercooked hamburgers several times. A cook confirmed that a former dietary employee had grilled hamburgers outside for a resident lunch meal, and many were undercooked when returned to the kitchen. The dietary staff believed they had caught all the undercooked hamburgers before serving them to residents. The Regional Dietary Manager acknowledged that serving hamburgers still pink in color would be considered a foodborne illness risk.