Lane House, The

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 monitor, assess, and treat a cognitively intact resident with new onset altered mental status and gastrointestinal symptoms in a timely and thorough manner, in accordance with physician orders, care paths, and facility policies. The resident had significant medical diagnoses including prostate cancer, lung cancer, insulin‑dependent diabetes, GERD, and COPD, and a care plan identifying risk for rehospitalization with interventions such as completing labs as ordered and timely communication with the physician regarding changes in condition. Despite this, when the resident developed new symptoms of coughing, coffee‑ground emesis, feeling "drunk," and staggering while ambulating, nursing staff documented the initial episode and a physician order for a CBC and medication changes, but the CBC was never obtained and there was no further documentation of the resident’s condition that day. On subsequent days, the resident continued to experience nausea, vomiting, confusion, dizziness, and abdominal pain, with a documented pulse of 128. The physician ordered STAT chest and abdominal x‑rays and a STAT CBC for cough, nausea, vomiting, abdominal pain, altered mental status, weakness, and dizziness. The x‑rays later showed a mild to moderate colonic stool burden contributing to a colonic ileus and a small right pleural effusion, and the physician ordered stool softeners, MiraLAX, and doxycycline. However, the STAT CBC was again not obtained prior to the resident’s death, and the laboratory request log showed the CBC was entered without being marked as STAT. The clinical record lacked documentation that the laboratory was called when the STAT lab was not completed, and there was no evidence that the facility followed its GI Symptoms and Acute Mental Status Change care paths, which called for vital signs and assessments every 4–8 hours, abdominal exams, neuro checks, and monitoring of intake/output. Throughout this period, the record lacked documentation of ongoing assessments, follow‑up vital signs, neurological checks, abdominal assessments, or nursing interventions on multiple days when the resident was symptomatic. Although there were active PRN orders for Zofran 8 mg and Meclizine 12.5 mg for nausea, vomiting, and dizziness, there was no documentation that these were administered on the days in question; only a later order for Zofran 4 mg was documented as given once in the evening, with no subsequent nursing assessment recorded after that administration. The resident’s emergency contact was not notified by nursing staff of the change in condition, and there was no documentation that the resident or his representative was consulted regarding transfer to the hospital, despite the POST form allowing hospital transfer for stabilization and comfort. Confidential interviews indicated staff believed upper management could block hospital transfers and that the DON was aware of the resident’s deteriorating symptoms but instructed staff to wait for physician orders before sending him out. The physician reported he was not informed that vomiting and symptoms persisted for multiple days and had not ordered a hospital transfer based on the limited information provided. The resident was later found with bile‑like emesis, became unresponsive, and died in the facility, with no nursing documentation between the last evening medication administration and the time of the code. Additional record review and interviews confirmed that there were no faxed or scanned urgent communications to the physician beyond what was already in the electronic record, and the physician’s office had no additional documentation from the facility for the days surrounding the change in condition. The facility’s own policies on nursing documentation and changes in resident condition required documentation of condition changes, vital signs, system reviews, and timely notification of the physician and resident representative when there was a significant change in physical or mental status, as well as use of INTERACT tools such as Stop and Watch and SBAR. The resident’s record lacked evidence that these tools were used or that the required notifications and assessments were consistently performed. Surveyors also noted that the facility’s laboratory services policy did not define expectations for STAT lab timelines, and the DON later acknowledged that audits had identified other missed changes in condition in additional residents during the same period.

Removal Plan

• Implemented a systemic plan that included assessments, audits, and updated care plans.
• In-serviced staff on resident assessment, change in condition, physician and resident representative notification, and laboratory policy and procedures.

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 immediately notify a cognitively intact resident’s emergency contact and/or resident representative of significant changes in his condition, and failure to document any consultation with the resident or representative regarding transfer to the hospital. Resident B had diagnoses including prostate cancer, lung cancer, insulin-dependent diabetes mellitus, and GERD, but was assessed on a recent quarterly MDS as cognitively intact and independent with eating, mobility, and ambulation, with good oral intake and recent weight gain. On one day, nursing documentation showed he developed new symptoms of coughing, coffee-ground emesis, and a sensation of feeling drunk and staggering when ambulating. The physician was contacted and ordered a CBC and medication changes, including discontinuing diclofenac and starting protonix for GI upset, but the nursing notes from that day did not document any notification of the resident’s family or emergency contact. On the following day, nursing notes documented that Resident B continued to have nausea and vomiting, confusion, dizziness, abdominal pain, and a pulse of 128. The physician ordered STAT chest and abdominal x‑rays and a STAT CBC, which was never obtained before the resident’s death. Later that same day, documentation showed the resident continued to have yellow liquid emesis, ongoing confusion, and a temperature of 99.1°F, and the physician ordered additional medications including sennosides-docusate, Miralax, and doxycycline for pleural effusion. None of these notes contained documentation that the family or emergency contact was notified of the resident’s ongoing and worsening condition or of the new treatment orders. The clinical record also lacked documentation that the resident or his representative was consulted about his preference for transfer to the ER for evaluation and treatment during this period of decline. On the morning of his death, the DON’s progress note documented that CNAs and an LPN found Resident B with bile-like emesis in a trash can and on the bed, and that he became unresponsive with no pulse or respirations while the nurse was in the room. CPR was initiated at 4:50 a.m., EMS arrived shortly thereafter, and resuscitation efforts were stopped at 5:20 a.m., after which the resident was pronounced deceased. The daughter, ED, DON, and Regional Director of Clinical Services were notified after his death, and the coroner later took possession of the body. Confidential staff interviews indicated staff were aware the resident had been ill with vomiting, including coffee-ground emesis and altered mental status, and one staff member reported being told that upper management would not allow the resident to go to the hospital. Another staff member stated that the DON had been kept apprised of the resident’s deteriorating symptoms and had instructed staff to wait for physician orders before sending him to the hospital. The daughter reported she was the emergency contact, had frequent contact with the resident, and learned from him that he was vomiting black material, could not walk, and was confused, but she was not notified by staff of his change in condition and instead only received a call after his death. Review of the clinical record with the ED and DON confirmed there was no documentation that the emergency contact had been notified of the resident’s change in condition or that the resident’s wishes regarding ER transfer had been obtained, despite a facility policy requiring immediate notification of the resident, physician, and resident representative for significant changes in condition.

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 STAT laboratory services were properly ordered, obtained, and tracked for a resident with significant medical conditions, including prostate cancer, lung cancer, insulin-dependent DM, and GERD. Nursing documentation showed that the resident developed coughing, a small amount of coffee-ground emesis, complaints of feeling drunk, and staggering with ambulation. A CBC was ordered for gastrointestinal upset and vertigo but was not obtained. The following day, the resident continued to experience nausea, vomiting, confusion, dizziness, abdominal pain, and had a pulse of 128 beats per minute. In response, the physician ordered a STAT chest x-ray, STAT abdominal x-ray, and a STAT CBC. The STAT CBC was not completed prior to the resident’s death. The contracted laboratory request daily log showed an electronic order for a CBC, but the DON stated the order did not specify that it was STAT. Confidential interviews indicated staff were aware the resident was ill, with one employee describing vomiting of thick, stringy, coffee-ground-like black material that later became bile, and that STAT labs ordered were supposed to be completed within 8 hours, but the lab technician did not arrive until after the resident had died. Another employee stated that STAT labs meant urgent and should be completed as soon as possible. The DON confirmed that a STAT CBC with differential ordered in the morning was not completed before the resident’s death and was unsure why the labs had not been done. The clinical record lacked documentation that nursing staff called the laboratory when the STAT lab was not performed, and review of the record with the ED and DON confirmed there was no documentation that the STAT CBC was completed. The facility’s Laboratory Services policy stated the facility was responsible for the quality and timeliness of laboratory services but did not define STAT or specify expected timelines for blood draws.

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 complete an elopement risk assessment for a resident with severe cognitive impairment, alcohol-induced amnestic disorder, metabolic encephalopathy, and major depressive disorder. The resident, who was able to self-propel in a wheelchair and required assistance for daily activities, was found outside the facility after falling from his wheelchair, without staff knowledge. The resident had previously demonstrated behaviors indicating a desire to leave, such as pulling the facility fire alarm to go home, but the elopement risk evaluation did not reflect his cognitive deficits, history of substance abuse, or independent mobility. The resident's clinical record also lacked a care plan addressing elopement risk. On the day of the incident, the resident was last seen by staff around the nurses' station and was later found outside by emergency medical services after a bystander reported seeing him in the grass next to his wheelchair. The resident stated he had been let out by an unknown person and was attempting to go home. Staff interviews confirmed that the elopement risk assessment was not accurate, as it failed to account for the resident's cognitive and behavioral history, and the facility's policy required interdisciplinary review and care plan updates for elopement risk, which were not completed.

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 food safety and sanitation practices in several key areas. During a kitchen tour, the low temperature dish machine was found to be operating below the required wash and rinse temperatures, with recorded temperatures of 115°F and 118°F, respectively, which did not meet the facility's policy of 120°F to 140°F. Additionally, the dish machine temperature logs for March 2025 were incomplete after March 17, 2025. The Dietary Manager attributed these lapses to new dietary staff who were still undergoing training. Further deficiencies were observed in the lack of documentation for sanitizer solution bucket measurements, refrigerator and freezer temperature logs, and food temperature logs for dinner, breakfast, and lunch meals on multiple dates in March 2025. During a dining observation, a registered nurse was seen placing an ice scoop directly onto the ice inside the cooler after use, contrary to facility policy, which requires the scoop to be stored outside the ice chest. The Dietary Manager confirmed that these practices did not align with established procedures for maintaining food safety and sanitation.

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

During meal service on the [NAME] Hall, employees were observed cleaning rooms, mopping floors, and cleaning handrails while residents were eating and food trays were being distributed. Specifically, two employees were seen performing cleaning tasks in resident areas during the noon meal, and one employee was observed cleaning handrails outside resident rooms as residents ate. The Housekeeping Supervisor confirmed that staff had been instructed not to clean resident rooms or hallways during meal service and that cleaning carts should be removed from resident halls while meals are being served. Facility policy also states that resident rooms should not be cleaned during meal services and that cleaning carts should be removed during tray pass. These actions were not followed, resulting in a failure to maintain a sanitary environment during meal service for residents.

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 ensure that falls were properly documented, appropriate interventions were implemented, and a call light was kept within reach for a resident with a history of falls. During observation, the resident was found in a recliner without the call light accessible, and the resident confirmed he could not use it when needed. The resident had a history of multiple falls, both witnessed and unwitnessed, some resulting in injuries such as skin tears and a possible wrist fracture. Despite these incidents, documentation in the Progress Notes was incomplete or missing for several falls, and immediate post-fall assessments or new interventions were not consistently recorded. The resident's medical history included generalized muscle weakness, a history of falling, and a previous wrist fracture. The care plan indicated the resident was at risk for falls and listed interventions such as keeping the bed in the lowest position, using a floor mat, providing two staff for assistance with activities of daily living, and ensuring the call light was within reach. However, these interventions were not always implemented or communicated effectively to staff. For example, the call light was not within reach during observation, and a CNA was unaware of specific interventions related to the resident's recliner or recent falls. Interviews with the DON and staff revealed that falls were supposed to be documented in both Progress Notes and internal Risk Management documents, and that interventions should be initiated at the time of each fall. However, the record review showed gaps in documentation and a lack of timely intervention implementation. The facility's policy required assessment and individualized interventions after each fall, but this was not consistently followed, leading to the deficiency.

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 address significant weight discrepancies and to obtain required daily weights for multiple residents, as evidenced by record review and staff interviews. For one resident with chronic heart failure and severe cognitive impairment, there were notable fluctuations in recorded weights, with no documentation that these discrepancies were addressed or that weights were consistently obtained before breakfast as ordered by the physician. The care plan required daily weights and prompt reporting of significant changes, but the records did not show compliance with these interventions. Staff interviews revealed concerns about the accuracy of the scale and a lack of timely recalibration, despite awareness of the issue. Another resident with a history of protein calorie malnutrition, dysphagia, and a gastrostomy tube experienced a documented significant weight loss over several months. The registered dietitian questioned the accuracy of the weights and recommended a re-weigh, but there was no evidence that this was promptly carried out. The resident's care plan included weekly weights, but inconsistencies in the scale and lack of timely follow-up on questionable weights were noted. The DON acknowledged the expectation that re-weights should be done promptly when significant discrepancies are identified, but this was not documented in the records. A third resident with chronic systolic congestive heart failure had a physician's order for daily weights before breakfast, with instructions to report significant weight gains. However, documentation was missing for several days, and there was no record of refusals or reasons for not obtaining the weights. The DON confirmed that daily weights were required due to the resident's diagnosis but could not find evidence that the weights were consistently obtained or that omissions were explained. Facility policy required prompt notification and re-weighing for significant discrepancies, but this was not consistently 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 ensure proper storage of respiratory equipment for a resident with chronic obstructive pulmonary disease (COPD) and asthma. Multiple observations over several days showed that the resident's nebulizer mouthpiece and tubing were repeatedly left unbagged on top of the nebulizer machine or placed in an unlabeled plastic trash bag. The equipment was not stored in accordance with facility policy, which requires respiratory supplies to be bagged, labeled with the resident's name, and dated when not in use. The resident was observed in her room, either in her wheelchair or resting in bed, with the equipment improperly stored each time. Interviews with staff, including an LPN and the DON, confirmed that the expected practice was to rinse, dry, and store the nebulizer mouthpiece and tubing in a labeled bag. The resident herself acknowledged awareness of the need to bag the equipment but cited difficulty due to poor finger dexterity. Record review indicated the resident was cognitively intact and had orders for regular nebulizer treatments. Despite these requirements and staff knowledge of proper procedures, the equipment was not consistently stored as required.

Penalty

No penalty information released

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

Summary

Surveyors observed that the facility failed to maintain proper security and storage of medications and biologicals. The Director of Nursing (DON) was seen retrieving medication room keys from an unsecured drawer at the nurse's station, which was accessible to both staff and visitors. These keys provided access to the medication room, including narcotic and emergency drug kits. Additionally, food items, specifically a container of peanut butter bars, were found stored on the counter in the medication room, contrary to facility policy. An opened vial of Aplisol (tuberculosis testing solution) was found in the medication room refrigerator without an opened date, and the DON acknowledged that food should not be stored in the medication room. Further observations revealed that a Registered Nurse (RN) opened a medication cart containing a Humalog insulin pen for a resident with type 2 diabetes that had been opened beyond the recommended 28-day period, as well as undated multi-use containers of Prosource Plus Liquid Protein and Milk of Magnesia (MOM) for two residents. The Assistant Director of Nursing (ADON) confirmed that insulin should be discarded 28 days after opening and that all multi-use medications should be dated when opened. Facility policies provided by the DON supported these requirements, indicating that only authorized staff should have access to medication storage areas, food should not be stored with medications, and opened medications should be dated and discarded per manufacturer guidelines.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that daily nurse staffing sheets were accurately posted for three out of five days during the recertification survey. Observations revealed that the posted staffing sheets were missing required information, including the total number of residents in the facility (census) and the facility name. On one occasion, the staffing sheet displayed inconsistent dates on different parts of the form. During an interview, the DON stated she was unaware that the staffing sheets were incomplete and explained that the scheduler was responsible for posting them, but she would do so herself if the scheduler was unavailable. The facility's policy requires that the daily posting include the facility name, current date, and resident census, but these elements were not consistently documented.

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 adequate supervision and a safe environment for a dependent resident, identified as Resident B, who was found with injuries of unknown origin. On the morning of July 6th, Resident B was discovered with bruising on both sides of her face, swelling of the nose, and a skin tear on her left forearm. Despite a thorough investigation, the facility was unable to determine the cause of these injuries. The resident, who was severely cognitively impaired and required assistance for mobility and transfers, was sent to the emergency room for evaluation, where no fractures or abnormal lab values were found. Resident B's medical history included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The care plan, updated after the incident, noted the potential for skin tears and facial bruising due to unknown injury, with interventions to prevent further skin damage. Observations of the resident's room revealed potential hazards, such as an end table close to the bed, but no side rails were present. Staff interviews and signed statements indicated that the resident was not combative and had no known behaviors that could have led to self-inflicted injuries. The facility conducted interviews with staff and residents, but no evidence of abuse or rough handling was found. The Director of Nursing and other staff members expressed theories about the cause of the injuries, such as the possibility of the resident's head getting caught between the mattress and bedside table, but these could not be substantiated. The facility's policy on incident management emphasized providing an environment free from accident hazards, yet the investigation yielded no conclusive findings regarding the incident.

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 a resident's gastrostomy tube (g-tube) in a clean and sanitary condition, leading to a serious deficiency. Resident C, who had a history of malignant neoplasm and g-tube placement, was found to have live maggots around his g-tube site during a visit to the emergency room. The resident's care plan indicated non-compliance with care related to refusal of additional g-tube feedings, but lacked documentation of assessments to any dressings applied to the g-tube site. A nurse's progress note, documented as a late entry, claimed the g-tube site was assessed with no parasites noted, but there was no documentation to support this assessment. On the same day, another nurse's progress note indicated that maggots were found around the g-tube site while cleaning, prompting the resident's transfer to the ER for evaluation. The ER report confirmed the presence of maggots and noted mild inflammation around the site, suggesting substandard care at the nursing home. Further review of the resident's records showed a lack of physician orders to assess the g-tube site dressing prior to the incident, and the Treatment Administration Record and Medication Administration Record also lacked such documentation. Interviews with the resident and staff revealed that the resident had seen flies in his room on multiple occasions, and a CNA confirmed the presence of a dressing on the g-tube. The facility's policy on Enteral Access Device (EAD) Site Care and Management emphasized the need for careful skin care to prevent infection, but this was not adhered to in Resident C's case. The deficiency was identified as past noncompliance, as corrective actions had been implemented by the time of the survey.