Savoy Care Center

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 failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.

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 resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident’s mattress was compatible with and properly fit the bedframe, as required by the expectation that all bed frames, mattresses, and bed rails be regularly inspected for safety and that mattresses attach safely to the bed frame. The affected resident had an admission date of 12/07/2023 and diagnoses including Myoneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease, with a Quarterly MDS BIMS score of 6 indicating severe cognitive impairment. On 03/23/2026 at 11:39 a.m., surveyors observed the resident lying in bed with his feet hanging off the mattress, which appeared too small for the bedframe. On 03/24/2026 at 10:12 a.m., further observation showed the resident lying on his back with his head elevated on an air mattress that did not fit the bedframe properly, leaving approximately a 1-foot gap between the top of the bedframe and the head of the mattress, with the resident’s head partially above the mattress. At 12:48 p.m., a CNA confirmed the mattress did not fit the bedframe and explained that pulling the resident and mattress up in the bed would create a gap at the footboard. At 1:00 p.m., the ADON confirmed the mattress was not accommodating to the resident’s height and should be. At 3:00 p.m., the DON observed that the air mattress was approximately 1 foot smaller than the bedframe and confirmed that the bed was not accommodating the resident and that the mattress did not fit the bedframe properly.

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 services in accordance with professional standards of practice for two residents. For one resident with severe cognitive impairment and total dependence on staff for self-care and transfers, a physician's order and care plan intervention required a fall mat to be in place at the bedside following a recent fall. However, during observation, the fall mat was not present, and facility staff confirmed it should have been in place as ordered. For another resident who was dependent on staff for all activities of daily living and received nutrition and hydration via PEG tube, the registered dietician recommended, and a physician's order was entered, to increase the water flush from 30ml/hr to 40ml/hr. Despite this, observations on multiple occasions showed the water flush remained set at 30ml/hr. Staff interviews confirmed the order had not been implemented as required, and nursing staff had not verified or adjusted the pump settings to ensure the resident received the prescribed water flush.

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 services were provided in accordance with professional standards of practice by not notifying a resident's Medical Director of the Registered Dietician's recommendations in a timely manner. According to the facility's policy, dietician notes and recommendations are to be given to the Director of Nursing (DON) for nursing staff to send to the physician for review and follow-up. In this case, a resident with multiple complex diagnoses, including supraventricular tachycardia, chronic kidney disease, chronic obstructive pulmonary disease, cardiac pacemaker, aphasia following cerebrovascular disease, and chronic atrial fibrillation, was admitted and had specific tube feeding orders in place. On 02/18/2025, the Registered Dietician made recommendations to change the resident's tube feeding formula and add liquid protein supplements. These recommendations were faxed to the Medical Director's office the same day. However, there was no follow-up via telephone after the facility did not receive a response from the Medical Director. The facility did not receive any correspondence regarding the recommendations until 03/05/2025, after the resident had already passed away in the hospital. Interviews confirmed that the process for follow-up was not completed as required by facility policy.

Penalty

Inspection fine: $347,3401 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 residents from various forms of abuse and neglect, resulting in an Immediate Jeopardy situation. A staff member, identified as a CNA, verbally abused a resident by yelling and using profanity, which caused emotional distress and fear. The resident, who was cognitively intact, reported the incident to the administrator, but the response was inadequate as the staff member was merely reassigned to a different hall without further investigation or action. Additionally, there were incidents of resident-to-resident physical abuse. One resident, who had a history of aggressive behavior, hit another resident in the face with a box of cookies and later pulled another resident's hair. These incidents were not properly addressed or reported as abuse by the facility's administration, indicating a lack of appropriate response to resident altercations and failure to ensure a safe environment for all residents. Furthermore, the facility neglected a resident by failing to adhere to the required two-person assist with a mechanical lift during transfers. A CNA transferred the resident alone, without the necessary equipment, despite the care plan clearly indicating the need for a two-person assist. This neglectful action was not isolated, as other staff members also admitted to transferring residents without assistance due to staffing issues, highlighting systemic neglect in adhering to care protocols.

Removal Plan

• S4 CNA was placed on administrative leave pending thorough investigation.
• All current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure.
• Monitoring tool initiated for S5 CNA Supervisor or designee to complete the lift protocol monitoring tool 4 times a week for 4 weeks, then twice per week for 2 weeks to ensure compliance with lift protocol and mechanical lifts for residents who require 2 person transfer.
• Monitoring tool initiated for every 15 minute and every 30 minute checks for Resident #6, Resident #15, Resident #25, and Resident #51, and shall be turned into S2 DON daily for review.
• S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
• Monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately.
• All on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure.
• There was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift.
• S6 CNA was in serviced on the policy and procedure for patients requiring mechanical lift.
• Return demonstration for S6 CNA was required. Visual return demonstration was observed by S2 DON.
• Resident #68 was discharged home.
• Interviews were conducted with Resident #15, Resident #6, Resident #25, and Resident #51 to ensure freedom of abuse/neglect. Resident #15 shall continue to be on every 30 minute checks indefinitely. Resident #6 was placed on every 30 minute checks indefinitely. Resident #25 had every 15 minutes checks for 24 hours, then every 30 minute checks indefinitely. Resident #51 was placed on every 30 minute checks for two weeks.
• Resident #25's psychiatrist was informed of resident's behaviors. No new orders were given.
• The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.

Penalty

Inspection fine: $347,3401 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 report several instances of abuse involving both staff-to-resident and resident-to-resident interactions. One incident involved a CNA who verbally abused a resident by yelling and using profanity, which was reported by the resident to the administrator. Despite the resident expressing fear and discomfort, the facility did not report this incident to the State Agency as required. Another incident involved a resident with severe cognitive impairment who physically assaulted two other residents on separate occasions. The first altercation involved the resident hitting another resident in the face with a box of cookies, and the second involved the resident pulling another resident's hair. These incidents were documented in the facility's progress notes, but the facility did not report them to the State Agency, as the Director of Nursing did not perceive them as abuse. The facility's failure to report these incidents in a timely manner, as mandated by state law, resulted in an Immediate Jeopardy situation. The lack of proper reporting and investigation of these abuse allegations has the potential to affect all residents within the facility.

Removal Plan

• All current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure.
• S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
• All on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure.
• There was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift.
• The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.

Penalty

Inspection fine: $347,3401 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 thoroughly investigate allegations of verbal, physical, and mental abuse involving three residents. Resident #15, who is cognitively intact, reported an incident where a CNA yelled at her using derogatory language, which caused her emotional distress and fear. Despite Resident #15 reporting the incident to the Administrator, the facility did not consider it an abuse allegation and failed to conduct an investigation or monitor the CNA's behavior. Resident #51 experienced a physical altercation when another resident, Resident #25, hit her in the face with a box of cookies. Although the incident was documented, the Director of Nursing (DON) did not investigate it further, as she was not informed of the physical aspect of the altercation. This lack of investigation left the incident unaddressed, despite the potential for harm. Resident #6, who has severe cognitive impairment, was involved in an incident where Resident #25 pulled her hair. The DON did not perceive this as abuse and did not investigate further, despite a witness reporting the altercation. The facility's failure to recognize and investigate these incidents as abuse resulted in an Immediate Jeopardy situation, as the safety and well-being of the residents were compromised.

Removal Plan

• All current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure.
• S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
• Monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately.
• There was a mandatory all staff meeting to discuss Abuse and Neglect Policy and Procedure, Lifting protocols, and the facility's Use of Mechanical Lift. In-service included monitoring for a reporting resident to resident abuse, staff to resident abuse, and neglect. In addition, reporting and investigation requirements of all alleged incidents of abuse and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse and neglect.
• The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.

Penalty

Inspection fine: $347,3401 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 provide drinks consistent with resident preferences and needs, specifically failing to offer water to 10 residents during lunchtime in Hall X dining room. Observations on two consecutive days revealed that staff served lunch trays with only juice and milk, without offering or providing water. Interviews with the S5 CNA Supervisor confirmed that the kitchen did not include water on the meal trays, and water was only provided if specifically requested by a resident.

Penalty

Inspection fine: $347,3401 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 administer its resources effectively and efficiently, resulting in multiple instances of abuse and neglect affecting five residents. One resident was subjected to verbal abuse by a CNA, who yelled derogatory remarks, causing emotional distress and fear. Another resident experienced physical abuse from a fellow resident, who hit them with a box of cookies, leading to anger and distress. Additionally, a resident was neglected when a CNA failed to follow the required two-person assist protocol during a transfer, risking physical harm. The facility did not have an effective system in place to ensure that all alleged violations involving abuse and neglect were reported immediately. This failure was evident in the lack of timely reporting of incidents involving verbal and physical abuse, as well as neglect. The facility's administration did not recognize certain incidents as abuse, leading to a lack of investigation and monitoring of the involved staff and residents. This oversight contributed to the continuation of abusive and neglectful situations within the facility. Interviews with the facility's administration revealed a lack of awareness and understanding of the incidents as abuse or neglect. The Director of Nursing and Administrator did not consider certain incidents as reportable, resulting in a failure to investigate and report them to the State Agency. This deficiency in recognizing and addressing abuse and neglect compromised the safety and well-being of the residents, highlighting significant gaps in the facility's policies and procedures for handling such incidents.

Removal Plan

• In-service was completed with all current staff on shift for abuse and neglect policy and procedure, lifting protocol, and what constitutes abuse and neglect.
• S4 CNA was placed on administrative leave pending thorough investigation.
• S6 CNA was in services on proper lifting techniques with proper return demonstration completed.
• S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
• Administrative oversight was provided to S1 Administrator and S2 DON by the regional administrator. The regional administrator shall thoroughly investigate all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Regional administrator will monitor S1 Administrator weekly by direct observation and onsite oversight weekly for 30 days.
• There was a mandatory all staff meeting to discuss Abuse and Neglect Policy and procedure, reportable incidents, lifting protocols, and use of lifters. In-service also included monitoring for and reporting resident to resident abuse, staff to resident abuse, and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Any staff member not in serviced will be in serviced prior to the beginning of their shift.
• A monitoring tool was initiated for nurse's notes to be reviewed daily for any alleged cases of abuse and neglect to be investigated as necessary. All alleged cases will be brought to S2 DON and S1 Administrator's attention and investigation and reporting are to be done immediately.
• The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.

Penalty

Inspection fine: $347,3401 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 resident's right to formulate an advance directive was properly documented in their medical record. Specifically, there was inconsistency in the documentation of the resident's code status. The resident, who had a history of cerebrovascular disease, dysphagia following cerebral infarction, generalized anxiety disorder, bipolar disorder, and chronic systolic heart failure, was listed as a Full Code in the electronic record dashboard/orders, while the physician's orders and care plan indicated a DNR (Do Not Resuscitate) status. Interviews with facility staff revealed that the staff relied on the electronic record dashboard/orders to determine a resident's advance directive during a code. The Director of Nursing confirmed the inconsistency in the resident's electronic record and care plan regarding the advance directive and acknowledged that the records should have been updated to reflect the correct DNR status, but they were not.

Penalty

Inspection fine: $347,3401 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 resident with a mental disorder had an accurately completed PASARR Level II screening. The deficiency was identified for a resident who was admitted with a Level I PASARR screening, which indicated no need for a Level II screening due to the absence of a mental illness diagnosis at the time of admission. However, after admission, the resident was diagnosed with Bipolar Disorder, which should have triggered a Level II screening according to the facility's PASARR policy. The deficiency was confirmed through a review of the resident's medical records and an interview with the Director of Nursing (DON). The records showed that the resident was diagnosed with Bipolar Disorder after admission, and a psychiatric evaluation indicated persistent symptoms of depression and delusions. Despite these developments, the required Level II screening was not completed, as confirmed by the DON during the interview.

Penalty

Inspection fine: $347,3401 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 a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #34, who has a history of falls and requires a fall mat as per physician's orders, was observed multiple times without the fall mat in place. Despite the care plan and physician's orders specifying the need for a fall mat, it was not present at the bedside, as confirmed by both the LPN and the DON. Resident #36, who also has a history of falls and requires a fall mat, was observed with the fall mat propped against the wall instead of being placed on the floor beside the bed. This improper placement of the fall mat was confirmed by the DON, who acknowledged that the mat should have been on the floor to prevent falls. Resident #37, who requires two-person assistance for bed mobility and toileting, experienced a fall when a CNA attempted to provide care alone. The care plan clearly indicated the need for two-person assistance, but this was not followed, resulting in the resident rolling out of bed during incontinent care. The DON confirmed that the CNA did not adhere to the care plan, leading to the incident.

Penalty

Inspection fine: $347,3401 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 provide appropriate pressure ulcer care for a resident with a Stage 3 pressure ulcer on the sacral region. The resident, who was admitted with multiple diagnoses including cerebrovascular disease, dysphagia, generalized anxiety disorder, bipolar disorder, and chronic systolic heart failure, had specific physician orders for wound care. These orders included cleaning the ulcer with a wound cleanser, applying Santyl, and using a collagen dressing covered with a silicone bordered foam dressing, to be changed daily or as needed. However, during an observation of wound care, the treatment nurse placed clean gloves on an unclean bedside table, which was on top of the resident's belongings, before using them for wound care. This action contaminated the gloves, which were then used to clean the wound. Additionally, the treatment nurse failed to follow proper infection control procedures by not removing soiled gloves and sanitizing hands before obtaining new supplies from the clean field and continuing with the wound care. This lapse in protocol was confirmed during an interview with the treatment nurse, who acknowledged the findings. The failure to adhere to professional standards of practice in wound care compromised the resident's treatment and potentially increased the risk of infection.

Penalty

Inspection fine: $347,3401 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 administer a resident's enteral flush according to the physician's orders. The resident, who was admitted with conditions including cerebrovascular disease, dysphagia following cerebral infarction, generalized anxiety disorder, bipolar disorder, and chronic systolic heart failure, had a physician's order for Glucerna 1.5 cal at 60cc/hour with 35cc/hour water flushes per pump. However, observations on two consecutive days revealed that the resident's water flush was set at 30cc/hour instead of the prescribed 35cc/hour. An interview with the Assistant Director of Nursing confirmed that the water flush was incorrectly set, deviating from the physician's orders.

Penalty

Inspection fine: $347,3401 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 provide necessary respiratory care for a resident by not administering oxygen as ordered by the physician. The resident, who was admitted with diagnoses including cerebrovascular disease, shortness of breath, and severe cognitive impairment, was dependent on staff for activities of daily living and required continuous oxygen therapy. The physician's order specified oxygen at 2 liters per minute via nasal cannula, but observations on two consecutive days revealed the oxygen was set at 3 liters per minute. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the oxygen settings were not in accordance with the physician's order. The LPN acknowledged that the oxygen concentrator was set incorrectly and should have been at 2 liters per minute. The Director of Nursing also confirmed that a physician's order is required to adjust oxygen settings, indicating a failure to adhere to the prescribed care plan for the resident.

Penalty

Inspection fine: $347,3401 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 provide pharmaceutical services that ensured the accurate administration of drugs to meet the needs of each resident. During an observation, it was noted that the narcotic log for a resident's Gabapentin 300mg capsules showed 18 capsules documented, but the blister pack contained only 17 capsules. Similarly, the narcotic log for the same resident's Morphine 30mg tablets showed 2 tablets documented, while the blister pack contained only 1 tablet. The LPN responsible for administering these medications admitted to not signing out the medications on the narcotic record log sheet after administration. Another resident's narcotic record log for Gabapentin 300mg capsules showed 44 capsules documented, but the blister pack contained 43 capsules. The LPN confirmed that she failed to update the narcotic record log sheet with the correct amount remaining in the medication packs after administering the medications. The Director of Nursing confirmed that all controlled medications should be signed off on the narcotic record log sheet immediately after administration by the nurse.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received services with reasonable accommodation of needs, specifically regarding the placement of a call bell. The deficiency was identified for a resident who had a history of cerebral infarction, CVA, seizure disorder, and hypertension, and was cognitively impaired with a BIMS score of 8. The resident was dependent on staff for activities of daily living, including oral hygiene, showering, bathing, and dressing. Despite the facility's policy requiring call bells to be within reach, observations on multiple occasions revealed the call bell was draped over a plug-in receptacle box on the wall behind the resident, making it inaccessible. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the resident was capable of using the call bell to request assistance. However, the call bell was repeatedly found out of reach during observations. The LPN confirmed the call bell's inaccessibility and subsequently placed it within reach, allowing the resident to activate it. The facility's failure to ensure the call bell was consistently within reach of the resident constituted a deficiency in accommodating the resident's needs.