Largo Nursing And Rehabiliation 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 the facility’s failure to implement provider-recommended pressure ulcer prevention interventions and to complete and document weekly skin assessments for a resident identified as at risk for skin breakdown. A Skin and Wound Progress Note dated 01/22/2026 documented that the resident had no wounds but was at risk for skin breakdown, and the wound NP recommended preventative interventions, including floating the resident’s heels while in bed. This recommendation was not translated into physician orders, and the resident’s care plan, although identifying the resident as at risk for pressure ulcers, did not include an intervention to float heels while in bed. The DON and ADON later confirmed that the 01/22/2026 provider recommendation to float heels was not implemented through orders or the care plan. The clinical record further showed that by 02/20/2026 the resident had developed multiple wounds, including pressure injuries to the heels/feet and a Stage 2 pressure ulcer to the sacrum, as documented in a Skin and Wound Progress Note. The Treatment Administration Records indicated that weekly skin assessments were marked as completed on multiple dates in January and February 2026, but review of the skin observation tool documentation revealed no corresponding entries for those dates, with only one skin observation tool completed on 02/20/2026 since admission. The ADON stated that the wound care provider’s recommendations are communicated to the assigned nurse and unit manager, who are responsible for entering orders and updating the care plan, and that weekly skin assessments are to be documented using the skin observation tool. An LPN confirmed, upon review of the record with the surveyor, that no additional weekly skin assessments were documented aside from the 02/20/2026 entry and was unsure who was responsible for entering new orders based on the wound provider’s recommendations.

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 appropriate assistance with bed mobility and to implement care-planned fall interventions for residents at risk for falls. Resident #6, admitted with a history of cerebral infarction and resulting hemiplegia/hemiparesis, had a Minimum Data Set (MDS) showing severe cognitive impairment (BIMS score of 0) and dependence on staff for toileting hygiene and rolling in bed. The resident’s care plan, initiated shortly after admission, directed staff to provide two-person assistance with bed mobility and to keep the bed in the lowest position while the resident was in bed. Despite this, a progress note documented that the resident fell during activities of daily living care. An LPN reported that a GNA pulled the resident to turn them in bed and the resident rolled off the bed; the GNA stated she believed the resident was a one-person assist and described releasing contact with the resident to retrieve an incontinence brief, after which the resident began to roll and she eased the resident to the floor. The ADON, another LPN, the DON, and the Administrator all stated that Resident #6 required two-person assistance for bed mobility and that two staff should have been present during such care. The facility also failed to implement fall interventions that were included in Resident #6’s care plan. The care plan for Resident #6, updated after a recent hospitalization and fall risk identification, included interventions to place fall mats on both sides of the bed and to maintain the bed in the lowest position while the resident was in bed. Multiple observations of the resident’s room on different days showed that fall mats were not present on either side of the bed and that the bed was not in the lowest position, despite these interventions being listed on the care plan. During interviews conducted concurrently with these observations, a GNA and the ADON acknowledged that fall mats were not in place and that the bed was not in the lowest position, even though the care plan required these measures. Resident #4, admitted with hemiplegia, muscle weakness, cerebral infarction, and lack of coordination, was also care-planned as being at risk for falls related to weakness, hemiplegia, and a recent hospitalization. The resident’s care plan included an intervention to place fall mats at the sides of the bed. However, during observations on multiple occasions, Resident #4 was seen in bed without fall mats present. In concurrent interviews, a GNA and the ADON confirmed that fall mats should have been in place according to the care plan but were not. The DON and the Administrator both stated they expected fall interventions to be implemented, yet the observations showed that the planned fall-prevention measures for Resident #4 were not carried out.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to implement care-planned fall interventions for two residents identified as being at risk for falls. Facility policy required licensed nursing staff, with the interdisciplinary team, to develop and implement individualized care plans to provide necessary services for each resident’s highest practicable well-being. Resident #6, admitted with a history of cerebral infarction and resulting hemiplegia/hemiparesis, had a Minimum Data Set (MDS) showing a BIMS score of 0, indicating severe cognitive impairment. The resident’s care plan, initiated after a recent hospitalization and fall, included interventions to place fall mats on both sides of the bed and to keep the bed in the lowest position while the resident was in bed. On multiple observations in February, surveyors and staff noted that fall mats were not present and the bed was not in the lowest position, despite these interventions being listed on the care plan. Resident #4, admitted with hemiplegia and hemiparesis following cerebral infarction, muscle weakness, cerebral infarction, and lack of coordination, had an admission MDS with a BIMS score of 12, indicating moderate cognitive impairment. This resident’s care plan, also initiated after a recent hospitalization and fall, identified risk for falls related to weakness and hemiplegia and directed staff to place fall mats at the sides of the bed. On repeated observations, the resident was in bed without fall mats present. Staff, including a Geriatric Nursing Assistant and the Assistant Director of Nursing, acknowledged during interviews that fall mats should have been in place according to the care plan but were not. The Director of Nursing and the Administrator both stated they expected fall interventions to be implemented, confirming that the planned interventions were not carried out 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

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when staff administered Dilantin despite an active order to hold the medication. Facility policy required medications to be administered in accordance with written prescriber orders. The resident, admitted with a history of seizures and care planned as being at risk for complications related to seizures, had an active order for Dilantin 50 mg chewable tablets, three tablets by mouth twice daily. A quarterly MDS showed the resident had intact cognition and was receiving an anticonvulsant during the assessment period. On the day of the incident, a lab result showed the resident’s Dilantin level was greater than 40 mcg/mL. LPN #5 documented that the physician was notified and ordered the Dilantin to be held and the level repeated on a later date. Despite this order to hold the medication, the Medication Administration Audit Report showed that LPN #5 administered a dose of Dilantin to the resident later that same evening. The physician later stated concern that the resident received more Dilantin after he ordered it held, though he reported no lasting effect from the extra dose. The ADON, DON, and Administrator each confirmed through review of the electronic medical record that the nurse administered Dilantin after the order to hold the medication had been received, contrary to the physician’s order and facility policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure staff consistently used required personal protective equipment (PPE) for residents on contact precautions and enhanced barrier precautions (EBP). Resident #10, admitted with a history including a local skin and subcutaneous tissue infection and extended spectrum beta lactamase (ESBL) resistance, had active orders and a care plan for contact precautions related to an ESBL wound infection, directing staff to use appropriate PPE and maintain isolation precautions. A contact isolation sign was posted on the resident’s door. During observation, an LPN entered the resident’s room without a gown or gloves, stood next to the resident’s bed, and stated she believed PPE was only required if she was providing care. After reviewing the posted contact isolation information, the LPN acknowledged she should have donned a gown and gloves before entering. The ADON, DON, and Administrator each stated that staff were required to wear a gown and gloves whenever entering the room of a resident on contact isolation, even if only asking a question. The facility also did not ensure proper PPE use for Resident #12, who had an indwelling urinary catheter and a surgical wound, with active orders for EBP every shift and a care plan indicating the need for EBP. During observation, a GNA and an LPN transferred the resident from bed to wheelchair using a mechanical lift while wearing gloves but no gowns. The LPN later stated that EBP should be used, including PPE, when caring for residents with urinary catheters and acknowledged she should have stopped the transfer to put on a gown upon seeing the catheter. The GNA stated that residents with wounds, infections, feeding tubes, or catheters required EBP and that a gown and gloves were to be worn when providing care. The ADON, DON, and Administrator each confirmed that EBP, including both gown and gloves, was required when providing care, such as transfers, to residents with devices like indwelling urinary catheters or wounds, and that staff were expected to follow the PPE requirements listed on signage.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that allegations of abuse were immediately reported as required. A resident reported to a nurse that a Geriatric Nurse Assistant had touched them inappropriately during care. The resident stated that the night nurse was informed of the incident on the same day it occurred, but the nurse did not report the allegation to a supervisor in a timely manner. Further review showed that another LPN became aware of the allegation during a meeting with the resident and immediately notified the Social Worker, Administrator, and Director of Nursing. The administrative record and staff interviews confirmed that the initial staff members who received the resident's report did not follow the facility's expectation to report abuse allegations immediately to administration. The deficiency was identified during a complaint survey, and the facility's investigation found that the required immediate reporting protocol was not followed by the night shift nurse and the LPN who first received the allegation.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the proper process of discharge for a resident, as evidenced by a lack of required documentation and communication regarding the resident's needs, appeal rights, and bed-hold policies. The assigned Social Services Coordinator was repeatedly unresponsive to the family's attempts to communicate and did not follow through on discharge planning. During the Social Services Coordinator's leave of absence, the resident was unable to obtain a necessary RN assessment for home care setup. Upon the coordinator's return, the RN assessment was completed, but the family was then informed of difficulties obtaining insurance clearance for home care. There was no documentation provided regarding the expiration and renewal of the resident's Medicaid benefits, nor was there evidence of communication or transfer of responsibility to another social worker during the coordinator's absence. The resident, who had developed a wound during their stay, left the facility on an approved leave of absence with family and subsequently declined to return. The facility discharged the resident due to failure to return, but no home care was arranged, and the required discharge documentation was not provided. The wound worsened and became infected, resulting in the resident's hospital admission. Record reviews and interviews confirmed the absence of documentation related to discharge readiness, home care approval, and communication with the family, indicating a failure to follow the required discharge process.

Penalty

Fine: $72,51435 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 medications and hazardous items were safely and securely stored, which was evident in two of the three units observed. Surveyors found that the central supply room on the second floor and the first-floor medication room were both accessible without the use of a keypad, allowing unauthorized access to various medications and supplies. This included aspirin, acetaminophen, insulin, and other hazardous items. Additionally, the maintenance log revealed that the keypad to the second-floor central supply room had been reported as not working since June, but no action had been taken to repair it. Residents with cognitive impairments were observed near these unsecured areas, posing a significant risk to their safety. As a result, a state of immediate jeopardy was declared, and multiple plans to remove the immediacy were initially rejected before one was finally accepted by the state agency. The facility also failed to investigate the root cause of falls and initiate nursing interventions to prevent further incidents. For instance, Resident #38 experienced a fall from bed, resulting in swelling and an open area near the left upper cheek and knee. However, there was no documentation to indicate the cause of these injuries or any investigation into the fall. The Director of Nursing (DON) confirmed that the night shift nurse did not report the fall, and no fall assessment or documentation was completed to address the incident. Additionally, the facility did not regularly assess residents' fall risks before actual fall incidents. Resident #323 was found lying face down with injuries, but the most recent fall assessment prior to this incident was conducted more than three months earlier. The assessment form used did not indicate the level of fall risk or the resident's health condition, which could affect the fall risk. The DON acknowledged that the fall assessment form had changed, but no additional documentation was provided to support the assessment of Resident #323's fall risk.

Removal Plan

• A 100% audit of all medication rooms and supply rooms have been conducted by the Administrator, Maintenance Director and DON to ensure medications and hazardous items were safely and securely stored.
• The lock to the central supply room on the 2nd floor located on Independence unit has been replaced with a new code by maintenance staff and is currently secured. Only authorized staff will be allowed access to this room.
• The nurse managers immediately removed all the over-the-counter medications from the central supply room on Independence unit and secured them in the 2nd floor medication room nearest to the nurses' station.
• All insulin needles, hypodermic needles, tuberculin syringes, twin blade shaving razors, and bandage scissors are all currently safely secured in the 2nd floor central supply room on the Independence unit.
• The door to the 1st floor medication room has been repaired and is secured. Education with all licensed nurses has been initiated and will be completed. Training is being conducted by the Staff development nurse, ADON, and DON to ensure the refrigerator is kept locked when not in use.
• The door to the 1st floor supply room across from rehab gym is repaired, locked, and code changed. Education with all licensed nurses has been initiated and will be completed. Training is being conducted by the Staff development nurse, ADON, and DON to ensure the supply room is kept locked when not in use.
• A Staff member was immediately stationed outside each door that did not lock appropriately until the repairs were completed by maintenance.
• Training with licensed nurses, housekeeping staff, and Maintenance staff was initiated by the Staff Development nurse to make certain that the staff pulls the door shut when exiting to ensure all medications and hazardous items are kept safe and secure, and to notify the Administrator and Maintenance director immediately if any door is identified as in need of repair. This will be completed.
• The Administrator and Maintenance director will validate all supply rooms and medication room doors are repaired and secured.
• The Unit managers and nursing supervisors will inspect all supply rooms and medication rooms to ensure all medications and hazardous materials are properly secured and in compliance every shift, then daily.
• Results of the audits will be submitted to the QAPI committee for further review and recommendations as needed.

Penalty

Fine: $72,51435 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 staff failed to ensure all residents were free from abuse and mistreatment, resulting in actual harm to a resident. Resident #18 experienced a laceration requiring 6 sutures to the forehead after an altercation with a receptionist. The incident occurred when Resident #18 attempted to call 911 due to a delay in the scheduled smoke break. The receptionist, Staff #29, tried to stop the resident from making the call, leading to a physical confrontation where both parties struck each other. Witnesses and staff confirmed that the resident sustained the injury from being hit with the phone handset by Staff #29. The medical record indicated that the resident was found with a bloody face and was sent to the hospital for evaluation and care. The facility's investigation included statements from witnesses and staff, revealing that the receptionist attempted to unplug the phone, leading to the altercation. Staff #30, who witnessed the event, confirmed that the resident was injured as a result of being struck by the receptionist. The incident highlights a failure in the facility's duty to protect residents from abuse and mistreatment.

Penalty

Fine: $72,51435 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 grievances and concerns from the resident group were documented, reviewed, and responses provided to the group in writing. This was evident in the review of seven resident council meeting minutes, which showed minimal documentation and only one concern noted. The resident council president confirmed that the minutes did not reflect the concerns expressed by residents, such as short staffing on weekends, staff using phones while in residents' rooms, and issues with cold water. The water temperature in the resident council president's bathroom was checked and remained cold without heating up, corroborating one of the concerns raised by the residents. Interviews with the Director of Activities and the nursing home administrator revealed that there was a lack of proper documentation and follow-up on the residents' concerns. The administrator acknowledged hearing the complaints but did not ensure they were addressed in the meeting minutes or followed up in writing. Additionally, the facility failed to hold resident council meetings for December 2023 and January 2024, further neglecting the residents' right to organize and participate in resident/family groups effectively.

Penalty

Fine: $72,51435 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 full-time clinically qualified nutrition professional for the oversight of food preparation and daily kitchen operations. During an interview, the Food Service Manager revealed that she was not a certified dietary manager (CDM) despite being in the role since March 2021. Documentation provided confirmed that she had completed a Nutrition and Foodservice Professional Training Program but did not have the necessary dietary manager certification. Additionally, the Nursing Home Administrator confirmed that the registered dietician was not full-time at the facility. This deficiency affects all residents as it compromises the quality and oversight of food and nutrition services.

Penalty

Fine: $72,51435 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 assess a resident's needs and preferences and respond to a resident who expressed dissatisfaction with the food provided by the facility. Resident #109, who was at risk for weight loss due to chronic diagnoses, indicated that they did not eat the facility's food and relied on food brought by family members. The dietitian's initial nutrition assessment and subsequent notes did not document the resident's food preferences or dislikes, and there was no evidence that the resident had met with the dietitian to discuss these preferences. Despite the resident's dissatisfaction being documented by a psychogeriatric certified registered nurse practitioner, the facility did not make reasonable efforts to provide food that the resident would eat, as evidenced by the lack of documentation and follow-up in the resident's medical record. The dietitian's notes and interviews revealed that the facility's process for determining food preferences for newly admitted residents or any other resident was unclear and inconsistently documented. The dietitian admitted to not knowing whether the food service manager documented in resident medical records. The surveyor's review of the medical record and interviews with the dietitian highlighted the facility's failure to address the resident's expressed concerns about the food, leading to the resident's reliance on outside food sources. The resident was eventually transferred to the hospital, and the dietitian's late entry progress notes did not reflect timely or adequate efforts to address the resident's nutritional needs and preferences.

Penalty

Fine: $72,51435 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 administration failed to provide effective oversight to ensure that resident needs were met. This included insufficient nursing staff, as evidenced by multiple residents reporting delays in receiving care, such as bathing, changing, and medication administration. Staff interviews confirmed that the facility often operated with fewer GNAs than required, leading to burnout and inadequate resident care. The Regional Director of Operations indicated that staffing levels were determined by a combination of budget, census, and special needs, but the facility itself could not independently adjust staffing levels without corporate approval. The Administrator was unaware of the federal staffing posting regulation, further highlighting the lack of oversight in staffing management. The facility's physical environment was also found to be in disrepair, with multiple resident care areas needing attention. The Administrator acknowledged these issues but attributed them to the building's age. Additionally, unsecured storage room doors posed potential hazards, which the Administrator was unaware of until the survey team brought it to his attention. The facility also employed unqualified kitchen staff, with the Food Service Manager not being a Certified Dietary Manager, a fact unknown to the Administrator until the survey. Social services were inadequately managed, with the Regional Licensed Clinical Social Worker admitting to insufficient oversight and being unaware of multiple missed care plan meetings. The facility's QAPI program was ineffective, as the Administrator, who chaired the QAPI Committee, could not describe any formal QAPI process and admitted to recurring issues due to a lack of accountability. No QAPI projects had been undertaken to address the identified concerns in staffing, environment, kitchen/dietitian, or social services.

Penalty

Fine: $72,51435 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 have an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced during the QAPI facility task investigation conducted during the recertification survey. The Administrator, who was responsible for the QAPI program, provided a 3-ring binder containing QAPI information and sign-in sheets for the 2023 monthly QAPI meetings. However, the process described by the Administrator revealed that each department head was responsible for identifying and bringing issues to the monthly QAPI meetings, with informal tracking and no formal audits to ensure sustained changes over time. The Administrator mentioned a Performance Improvement Project (PIP) on baseline care plans conducted in May 2023, but there was no evidence of sustained improvement or formal audits to support this claim. During the interview, the Administrator was unaware of any missed or late baseline care plans, despite the survey team's findings indicating such deficiencies. The Administrator could not provide additional evidence of tracking or auditing for the QAPI program. This lack of formal tracking, auditing, and awareness of ongoing issues demonstrates the facility's failure to maintain an effective QAPI program, potentially affecting all residents, families, and visitors.

Penalty

Fine: $72,51435 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 essential equipment in safe operating condition, as evidenced by multiple observations and staff interviews. During an initial tour of the kitchen, the walk-in freezer was found to have poor visibility due to cloudiness, and subsequent visits revealed significant ice buildup on the ceiling, fan units, and food boxes. Despite the food service manager's acknowledgment and intention to call maintenance, the issue remained unresolved over multiple inspections, indicating a lack of timely corrective action. Additionally, the facility did not ensure the safety of assistive equipment in resident areas. A seated bath chair in the [NAME] Wing shower room was found with a detached and ripped back support, and another shower chair exhibited significant wear and fraying. Furthermore, a sitting chair in a resident's room had an exposed sharp metal piece and loose arms, posing a safety hazard. Staff confirmed the unsafe conditions of these items upon inspection but did not take immediate action to rectify the issues, leading to continued use of compromised equipment.

Penalty

Fine: $72,51435 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 staff failed to maintain a clean, neat, attractive, and well-repaired environment, as observed by surveyors across all three nursing units on both floors of the facility. The maintenance director, who had been in his position for three months, acknowledged the ongoing renovation project but admitted that several areas still required attention. During the tour, surveyors noted numerous issues, including discolored and marked shower room doors, a hanging electric box, scraped paint, holes in bumper moldings, and various other damages in multiple rooms and hallways. These observations were confirmed by the maintenance director, who indicated that contractors were handling more complex issues while his crew addressed other areas. Specific rooms exhibited significant deficiencies, such as warped window blinds, exposed wallboard, unpainted spackled areas, stained ceiling tiles, and damaged door frames. Additionally, there were issues with loose outlet plates, rust-colored stains, and chipped paint. The maintenance director acknowledged these problems and indicated that systemic issues, such as door frames and unpainted repairs, were prevalent throughout the building. He also mentioned that contractors were being brought in to address more complex issues, while his team worked on other areas. Further observations included dirty air vent grates, dark stains on floors below hand sanitizer units, and damaged ceiling tiles in the newly remodeled lounge area. The environmental services director admitted responsibility for the dirty vent grate and indicated plans to address it. The maintenance director also noted that some rooms on the first floor had not yet received renovations and exhibited similar systemic concerns. Despite the ongoing renovation project, the facility staff failed to maintain a safe, clean, and comfortable environment for the residents, as evidenced by the numerous deficiencies observed by the surveyors.

Penalty

Fine: $72,51435 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 an interdisciplinary team, including the resident and/or the resident's representatives, contributed to the resident's comprehensive care plan. This was evidenced by the failure to conduct care plan meetings for residents at quarterly intervals and the lack of documentation and evaluation of each care plan to ensure the interventions continued to be appropriate for the resident's condition. This deficiency was observed in five residents reviewed for care planning, including instances where care plan meetings had not been held for extended periods, and care plans were not updated to reflect current conditions or interventions accurately. Resident #5 reported not having a care plan meeting for over three months, and a medical record review confirmed that the last documented care plan meeting was held in May 2023. Similarly, Resident #75's care plan inaccurately indicated the presence of a midline venous access site, which the resident did not have, and the care plan was only updated after the surveyor's intervention. Resident #17's medical records showed no documentation of care plan meetings for several MDS ARD dates, and the social worker could not provide an explanation for the missed meetings. Resident #39 indicated that care plan meetings were infrequent and could not recall the last meeting. A review of the resident's electronic health record confirmed that the last documented care plan meeting was in November 2022. Resident #96's medical records revealed that care plan meetings were not held within the required seven-day window after MDS assessments, and there was a lack of documentation for care plan meetings between June 2023 and September 2023. The Director of Nursing acknowledged these deficiencies when reviewed by the surveyor.

Penalty

Fine: $72,51435 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 have sufficient nursing staff to meet the needs of the residents, as evidenced by multiple complaints and interviews with residents and staff. Three complaints submitted to the Office of Health Care Quality (OHCQ) highlighted issues such as residents being left wet with urine for over two hours, not receiving timely medication, and being found heavily soiled. Resident interviews further corroborated these issues, with several residents reporting long wait times for assistance, lack of bathing or changing, and insufficient staff presence during night and weekend shifts. For instance, one resident mentioned not seeing staff from 11 PM to 5:30 AM, while another reported a two-hour wait for a response to a call bell. Additionally, residents expressed concerns about short staffing on weekends, leading to some residents remaining in bed all weekend due to a lack of available staff to assist them out of bed. Staff interviews also confirmed the issue of insufficient staffing. An LPN reported having to extend their work hours to complete tasks, including medication administration, due to short staffing. GNAs described experiencing burnout and being assigned to more residents than they could adequately care for, which affected their ability to change, feed, and respond to call bells for residents. The Director of Nursing (DON) validated these concerns during an interview with the surveyor, acknowledging the issues related to insufficient staffing in the facility.

Penalty

Fine: $72,51435 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 act upon multiple pharmacy drug problems identified for a resident reviewed for unnecessary medications. The surveyor's review of the medical record revealed that pharmacy medication regimen reviews on two occasions noted irregularities and recommendations that were not acted upon. Despite requests for documentation, the surveyor was only provided with incomplete records, and it was found that recommendations regarding the administration of Fosamax were not followed. The medication administration record did not reflect the necessary instructions for Fosamax, such as not sucking, chewing, or crushing the medication, and ensuring it was taken with water in the morning before any other food or drink. Interviews with the DON and other staff revealed a flawed process for handling pharmacy recommendations, where the recommendations were placed in the physician's box but not consistently acted upon. The surveyor found that significant drug therapy problems identified in a May 2023 review were not addressed, and there was no documentation of responses to these recommendations. The DON acknowledged the concerns, and it was confirmed that no follow-up actions were taken to address the pharmacy recommendations as of the surveyor's exit from the facility.

Penalty

Fine: $72,51435 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 resident was free from unnecessary medications. Resident #1 had an active medical order for Levothyroxine Sodium tablet 112mcg, but the last lab result for monitoring the TSH level was almost a year old, indicating elevated levels. The Director of Nursing (DON) acknowledged the lapse in monitoring and ordered the lab test only after surveyor intervention, revealing a significant delay in addressing the resident's elevated TSH levels. The facility also failed to reconcile and transcribe medication orders accurately, leading to Resident #12 receiving a duplicate medication. The Medication Administration Record (MAR) showed two different orders for Dorzolamide HCL-Timolol Maleate Solution (Cosopt) eye drops, resulting in the resident receiving more medication than necessary. The Unit Manager (UM) confirmed the error and took steps to discontinue the duplicate order only after the surveyor's observation. Additionally, the facility did not ensure clear physician orders for pain medication for Resident #18, leading to the administration of as-needed pain medications without clear parameters. The MAR revealed that staff administered Oxycodone and Acetaminophen for varying pain levels, including instances where the resident reported no pain. The LPN involved could not provide a rationale for choosing one medication over the other, highlighting a lack of clear guidelines for pain management in the resident's care plan.

Penalty

Fine: $72,51435 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 effective infection control program in several key areas. Firstly, a resident who tested positive for Clostridium difficile colitis did not have an order for contact precautions, which is necessary to prevent the transmission of this infectious agent. The Infection Control Preventionist confirmed that an order should have been placed but was not. Additionally, during wound treatment observations, an LPN failed to perform proper hand hygiene before and after applying gloves, which is a critical step in preventing infection. The LPN incorrectly believed that hand hygiene was not required because gloves were used, contrary to the facility's policy that mandates handwashing after removing gloves or aprons. The facility also failed to keep linens from contamination. In the Arcadia unit, the bottom portion of the linen closet was stained and soiled with dust, and some linens and a fabric shopping bag were found on the floor. In the laundry room, soiled linen bags were observed untied in a linen bin, contrary to the procedure that requires them to be tied before being sent to the laundry chute. These issues were validated by staff during interviews. Furthermore, the facility's infection control policies and procedures were not reviewed annually, with some policies having effective dates as far back as 2020. Lastly, the facility did not ensure consistent infection prevention monitoring of waterborne infections. The water temperature monitoring logs were incomplete, with gaps in data and inconsistencies in documentation. The logs did not indicate who performed the checks or the specific locations, and some entries were made on days when the responsible maintenance tech was not working. These deficiencies were confirmed through interviews with the Maintenance Director and a review of the maintenance tech's timecards.

Penalty

Fine: $72,51435 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 monitor and track antibiotic usage and resistance data, as evidenced by the lack of documented indications for antibiotic use in residents' orders and the inadequacies in the facility's antibiotic stewardship program. Specifically, for two residents, the facility did not include the diagnoses in the antibiotic orders. One resident had an order for Clindamycin without a diagnosis listed, and another had an order for Ceftriaxone without specifying the type of infection being treated. These deficiencies were confirmed during interviews with the Infection Control Preventionist (ICP) and the Director of Nursing (DON), who acknowledged the absence of appropriate indications in the antibiotic orders during daily clinical meetings and upon review by the surveyor. Additionally, the facility's antibiotic stewardship program failed to document essential elements for antibiotic use, such as the duration of antibiotic use and resistance data. The ICP provided a generic Infection Surveillance Monthly Report that did not include a specific report for antibiotic surveillance. This deficiency was confirmed during interviews with the ICP and the DON, who validated the concerns about the inadequacies in the antibiotic surveillance program. The facility did not have a specific report to monitor and track residents' antibiotic use effectively.

Penalty

Fine: $72,51435 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 a comprehensive behavioral health training program for all staff, which included care for residents diagnosed with mental, psychosocial, or other behavioral health conditions and individualized non-pharmacological approaches to care. This deficiency was evident in the case of a resident who was allegedly struck by a staff member during a physical struggle. The staff member involved had only received minimal training on managing aggressive behaviors and no specific behavioral health training. The facility's staff development nurse was unable to describe any specialized training for staff related to caring for residents with psychiatric disorders. The facility's most recent assessment indicated a significant number of residents with behavioral health needs, including schizophrenia, depression, anxiety disorder, psychosis, and bipolar disorder. Despite this, there was no evidence that staff received adequate training on behavior management, including handling aggressive behavior, hallucinations, or delusions. The facility's records and training programs did not meet the required standards for providing care to residents with behavioral health conditions.

Penalty

Fine: $72,51435 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 treat residents with dignity and respect in several instances. Resident #72 reported not getting along with Staff #49, a Geriatric Nursing Assistant (GNA), and stated that Staff #49 was unhelpful and rude during activities of daily living (ADL). Despite the resident's request to the Director of Nursing (DON) to have Staff #49 removed from their care, the staff member continued to be assigned to the resident. The DON acknowledged the complaint but only provided verbal counseling to Staff #49 without removing her from the resident's assignment. Additionally, Resident #11 reported that staff were not timely in emptying their urinals, which was confirmed by surveyor observations of filled urinals in the resident's room on multiple occasions. The resident expressed distress over the situation, and a Licensed Practical Nurse (LPN) confirmed the surveyor's concerns. Another deficiency was observed when GNA #56 was seen pulling Resident #114's Geri chair backward while also pushing an IV/tube feeding pole. This improper transport method was noted by the Unit Manager, who then corrected the GNA by demonstrating the proper way to push the resident facing forward. These incidents highlight the facility's failure to ensure residents' dignity and proper care practices, as evidenced by the staff's actions and inactions in handling resident care and transport.

Penalty

Fine: $72,51435 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 multiple allegations of abuse, neglect, misappropriation of resident property, and injuries of unknown sources. For Resident #87, the investigation lacked a written statement from the resident, did not identify the alleged perpetrator, and failed to document specific dates or times of the incident. Additionally, the alleged perpetrator continued to work and was assigned to the resident during the investigation. The investigation also lacked proper documentation of interviews and notifications to relevant authorities, including the police department. Furthermore, one of the residents documented as having been interviewed had expired prior to the date of the interview, indicating a significant lapse in the investigation process. For Resident #319, the investigation into an allegation of physical abuse by a Nursing Assistant was incomplete. While statements were taken from the GNA and other staff, there was no evidence of interviews with other residents. The Director of Nursing and Social Worker were unable to provide the missing documentation, indicating a failure to maintain thorough records. Similarly, for Resident #369, the investigation into an injury of unknown origin was inadequate. Although staff interviews were conducted, there were no statements from other residents, and the facility failed to document the cognitive levels of other residents in the dementia unit. The facility also failed to maintain evidence of a thorough investigation into an allegation of inappropriate sexual behavior involving Resident #39. The investigation summary lacked actual statements or witness accounts. In another case, the facility did not investigate a physical assault witnessed by a staff member involving Resident #470 and Resident #18. The investigation focused solely on the sexual assault allegation and did not include statements from the alleged victim, perpetrator, or other residents. Additionally, the facility's investigation into a verbal abuse allegation involving Resident #418 was incomplete, lacking witness statements and documentation of staff training. Lastly, the investigation into an injury of unknown origin for Resident #419 was not thorough, with missing medical records and incomplete documentation of the incident and subsequent assessments.

Penalty

Fine: $72,51435 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 complete and accurate medical records in accordance with accepted professional standards. For Resident #18, there was no documentation related to the circumstances of a court order for emergency evaluation, including any changes in the resident's condition leading up to the transfer or the basis for the transfer. Additionally, there was no evidence that pertinent medical information was provided to the receiving hospital or a physician's order to send the resident to the hospital. The Director of Nursing confirmed the lack of documentation regarding the resident's behaviors and the rationale for the transfer. For Resident #30, the medical order for wound treatment did not include the location for the application of skin prep and foam dressing. This omission was confirmed by the wound nurse and later corrected after the surveyor's observation. For Resident #323, there was no documentation from the hospital visit in the resident's electronic medical records. The Director of Nursing confirmed that the facility expected to receive and scan hospital visit records into the residents' charts, but this was not done for Resident #323. Regarding Facility Reported Incident MD00145026, the facility was unable to provide complete medical records for Resident #419, who had discoloration to the left eye. The facility staff could not access the resident's records from the previous owner, and the provided login information did not yield any records. The Director of Nursing acknowledged the incomplete records and the facility's responsibility to maintain them. Despite efforts to retrieve the records, the surveyor was unable to find documentation of the resident's condition at the time of the incident.

Penalty

Fine: $72,51435 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 accurately code significant weight loss for a resident on the Minimum Data Set (MDS) assessment. The medical record review revealed that the resident experienced a weight loss from 191.6 lbs to 168.6 lbs in July 2023, which is greater than 10%. Despite this significant weight loss, the MDS assessment coded by the MDS coordinator did not reflect this change, marking the section for weight loss as no/unknown. The resident's medical record also indicated the use of an appetite-stimulating medication and a dietician's note confirming the significant weight loss. During an interview, the MDS coordinator was unable to explain why the significant weight loss was not captured in the MDS assessment. The coordinator mentioned that the resident was eating and had refused to be weighed, and they had struck out the weight entry, which they believed was permissible. However, there was no recollection of obtaining a re-weight. This discrepancy in documentation and coding led to the deficiency noted by the surveyor.

Penalty

Fine: $72,51435 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 residents and their representatives with a summary of the baseline care plan within 48 hours of admission. This deficiency was identified for three residents during the survey. Resident #173 was admitted in January 2024, and although a baseline care plan was developed on 1/6/24, there was no evidence that the resident or their representative received a summary of the plan within the required timeframe. The Unit Manager confirmed that the baseline care plan was missing from the resident's record. Similarly, Resident #96, admitted in November 2022, did not have any documentation of a baseline care plan in their medical records, and the Director of Nursing confirmed the absence of such documentation. Resident #50, admitted in December 2023, received a baseline care plan later than the required 48 hours, as evidenced by a form signed by the resident on 12/14/23. Interviews with staff, including the Unit Manager and the Director of Nursing, revealed that the facility's process for providing baseline care plans was not consistently followed. The Unit Manager acknowledged that the baseline care plan for Resident #173 was not uploaded into the electronic medical record system. The Director of Nursing confirmed the lack of documentation for Resident #96 and could not provide further information regarding the delay in providing the baseline care plan to Resident #50. These findings indicate a systemic issue in the facility's process for ensuring that residents and their representatives receive timely summaries of baseline care plans upon admission.

Penalty

Fine: $72,51435 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 staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for one resident with behavioral-emotional health needs and two residents reviewed for comprehensive care plans. For Resident #18, the care plan did not include measurable objectives or specific interventions for the resident's behaviors, depression, and antipsychotic use. Additionally, the care plan did not address the resident's diagnoses of Anxiety Disorder or Schizophrenia. The Regional Corporate Social Worker indicated that the MDS nurse and the Social Worker were responsible for overseeing the development of behavioral care plans, but the interdisciplinary team failed to incorporate psychogeriatric services progress notes into the plan of care. Resident #75 had a suprapubic catheter and was re-admitted to hospice care, but the care plan did not include measurable goals and nursing interventions for both the suprapubic catheter and hospice care. The Director of Nursing confirmed that the care plans were missing these elements due to a failure to carry forward all aspects of the care plan when the current care plan was created. The DON acknowledged that the staff failed to ensure that all aspects of the care plan were included after the resident's transfer to the hospital. Resident #23 had an order for antibiotics to treat C. diff, but the care plan did not include a comprehensive plan for C. diff. The Licensed Practical Nurse verified that the C. diff care plan should have been developed when the provider ordered a new medication or added a new diagnosis. The Infection Control Preventionist validated that no care plan had been developed for the C. diff infection and resulting antibiotic usage for Resident #23.

Penalty

Fine: $72,51435 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 meet professional standards of practice by not ensuring staff followed physician orders for medication administration and documentation. During a recertification survey, an LPN was observed administering Acetaminophen to a resident at 10:05 AM, despite the medication being scheduled for 6:00 AM, 12:00 noon, and 8:00 PM. The LPN signed off on the medication before giving it to the resident, contrary to the facility's policy, which requires medications to be administered within a 60-minute window of the scheduled time and documented immediately after administration. The LPN justified the early administration by stating that the resident preferred to take the medication early to avoid missing it during lunch in the dining room. The Unit Manager confirmed that nurses are expected to follow the five rights of medication administration and that any deviation from the scheduled time should be addressed by obtaining a PRN order. The Director of Nursing expressed a preference for minimal medication pass errors. A review of the facility's medication administration policy corroborated the requirement for timely administration and proper documentation. The surveyor shared these concerns with the facility's administration and corporate staff during the survey exit.

Penalty

Fine: $72,51435 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 adequate activity services to meet the needs of a resident, specifically Resident #39. The resident reported that there were not enough staff to transport him/her to and from activities. The last activity note in the resident's medical record was dated 11/2/2022, and it indicated that the resident preferred independent activities such as listening to music and audio books. However, the resident later indicated that he/she did not have a device to listen to books and that the staff did not read the daily activity flyer to him/her. The resident also mentioned that he/she had not been taken to the patio for four years and described an incident where he/she was left outside without a way to get back into the building. The resident expressed a need for adaptive equipment, such as a document reader, to participate in activities due to blindness. The care plan for the resident had not been updated to reflect these needs and preferences adequately. The Director of Activities was interviewed and revealed that she was unaware of the need to document all aspects of the resident's activity routine. She stated that the resident was very independent and would communicate his/her needs, but this was not reflected in the care plan. The director also mentioned that the resident had contacted the Lighthouse for the Blind for assistance, but there was no documentation to support this. Additionally, the director could not provide recent documentation of progress notes or evaluations related to the resident's activity program. This lack of documentation and failure to update the care plan contributed to the deficiency in meeting the resident's activity needs.

Penalty

Fine: $72,51435 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 treatment and services upon admission for the care of a resident with an indwelling catheter. Resident #169 was readmitted to the facility from an acute care facility with a Foley catheter. The resident's discharge summary from the hospital indicated that the urine culture grew Proteus Mirabilis, a common pathogen responsible for complicated urinary tract infections. Despite this, there was no documentation that the facility staff provided the necessary Foley catheter care for Resident #169 from the time of readmission on 1/05/24 until 1/08/24, when an order for Foley catheter care every shift was finally placed on 1/09/24. This gap in care was confirmed through medical record review and staff interviews, including an interview with an LPN who stated that orders were required for Foley catheter care and that nurses were responsible for the care, while nurse assistants emptied the bag. The Director of Nursing validated the concerns raised by the surveyor regarding the lack of Foley catheter care for Resident #169 during this period. The deficiency was identified through a combination of medical record review, staff interviews, and observations. The failure to provide timely and appropriate Foley catheter care upon the resident's readmission to the facility highlights a significant lapse in the facility's adherence to proper catheter care protocols. This lapse potentially exposed the resident to an increased risk of infection and other complications associated with improper catheter management. The deficiency was evident for one of the four residents reviewed for Foley catheter care during the survey.

Penalty

Fine: $72,51435 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 recognize, evaluate, and manage the pain of Resident #50, who was admitted in December 2023 with nearly constant severe pain. Observations on multiple occasions revealed the resident moaning and yelling out in pain, with staff nearby but not intervening. Despite the resident's evident distress, pain assessments were infrequent, with only two documented assessments on 12/11/23 and 1/10/24. The resident's Medication Administration Record (MAR) showed that pain medication was administered only once per day before dressing changes, and additional as-needed doses were rarely given, with only two instances recorded on 1/02/24 and 1/09/24. On 1/10/24, after the surveyor raised concerns about the resident's frequent moaning, the Director of Nursing (DON) contacted the resident's physician, who ordered a psychiatric consult, bloodwork, and behavior management medication. Later that day, the resident became less responsive, prompting a transfer to the hospital. The facility could not provide additional evidence of pain assessments for the resident, indicating a failure to adequately manage and document the resident's pain over the observed period.

Penalty

Fine: $72,51435 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 physician evaluation of a resident's current medication regimen. During the recertification survey, it was found that the physician's visit note for a resident with Diabetes Mellitus did not match the active medical orders for medications. The physician's note documented that the resident should continue with Lantus and Metformin, but the resident was no longer taking these medications. This discrepancy was confirmed by the physician during an interview with the surveyor.

Penalty

Fine: $72,51435 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 Licensed Practical Nurses (LPNs) and Geriatric Nursing Assistants (GNAs) were competent with their skill sets, as evidenced by a review of employee files and interviews. Specifically, the files for three out of five employees reviewed did not contain documentation to support that they had completed their competency skills and techniques to provide safe care to residents. GNA #42, hired in October 2021, and GNA #40, hired in July 2019, both lacked competency skills and techniques evaluations in their files. Additionally, LPN #41, hired in April 2020, had incomplete competency records, missing validation for medication administration, physician orders, and foley insertion skills. During interviews, Staff #23, the Educator, confirmed that competency evaluations should be done yearly but noted that there was no previous documentation when they started in May 2023. The Director of Nursing (DON) stated that prior to Staff #23's tenure, the DON provided education and Human Resources filed the records. However, the DON was unable to produce the missing competency records for LPN #41, validating the surveyor's concerns about the lack of documentation. This deficiency indicates a systemic issue in maintaining and documenting staff competencies, which is crucial for ensuring safe and effective resident care.

Penalty

Fine: $72,51435 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 conduct yearly performance reviews for its Geriatric Nursing Assistants (GNAs) at least every 12 months. This deficiency was identified during a review of employee records and staff interviews. Specifically, GNA #40, hired in July 2019, had only one performance evaluation in 2019 with no further evaluations documented. Similarly, GNA #42, hired in October 2021, had one performance evaluation in January 2024 with no additional evaluations since hire. The Director of Nursing (DON) and Human Resources confirmed the lack of annual performance reviews, and no additional records were provided to the surveyor team to rectify this issue. The DON validated these concerns during the survey process.

Penalty

Fine: $72,51435 days payment denial

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

Summary

The facility failed to ensure that its medication error rates were below 5 percent, as evidenced by an error rate of 6.67 percent during medication administration observations. Specifically, an LPN administered Acetaminophen to a resident at 10:05 AM, despite the medication being scheduled for 6:00 AM, 12:00 noon, and 8:00 PM. The LPN stated that the resident preferred to take the medication early to avoid missing it during lunch. This action was against the facility's policy, which requires medications to be administered within a one-hour window of the scheduled time unless a PRN order is obtained for early administration. The Unit Manager confirmed that nurses are expected to follow the five rights of medication administration and that medications should be signed after administration, not before. The Director of Nursing expressed disappointment in the medication error rate, hoping for little to no errors. A review of the facility's medication administration policy corroborated the requirement for strict adherence to the scheduled times and the five rights of medication administration. The total error rate observed was 6.67 percent, exceeding the acceptable threshold of 5 percent.

Penalty

Fine: $72,51435 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 properly store medications, allowing residents and unauthorized staff access to them. On two of the three nursing units, medications were stored in areas that were not secure. Specifically, on the 2nd floor, the Central Supply Room, which contained various medications, was accessible without using the keycode pad. Staff members were observed entering this room without using the keypad, and the room contained a wide range of medications and supplies. Additionally, the first-floor medication room was found to be locked but unlatched, allowing easy entry. Inside, the medication refrigerator was unlocked, containing various medications including insulins and vaccines. During an interview, the Director of Nursing (DON) acknowledged the issue and stated that the maintenance director was addressing the problem. The DON also mentioned that the Central Supply Room was used for the whole facility and that various staff, including Geriatric Nursing Assistants (GNAs) and ancillary staff, had access to it. The facility's medication storage policy was reviewed, which stated that only authorized personnel should have access to the medication room. The DON later decided to move the medications from the Central Supply Room to the medication room near the 2nd-floor nurses' station.

Penalty

Fine: $72,51435 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 have an effective process in place for accurately serving meals according to medical orders and documenting dietary changes. For Resident #87, the medical record showed a recommendation for a house supplement twice daily due to severe protein-calorie malnutrition. However, the supplement was decreased to once daily without documented rationale. The resident reported receiving supplements at different times than documented, and the Registered Dietician confirmed that the required documentation for the change was not made. Resident #11 reported receiving smaller food portions despite having an order for double portions. The resident's weight had significantly decreased, and the medical record indicated they were to receive a house supplement daily and snacks twice daily. However, the resident was receiving the supplement twice daily and no snacks. The Registered Dietician and Food Service Manager were aware of the issue but did not address it promptly, and the concern was not documented in the medical record. For Resident #30, the medical order required double protein portions, but the kitchen did not implement this change. The Food Service Manager was unaware of the double protein needs, and the Registered Dietician admitted that the communication might have been the issue. The resident's menu ticket did not reflect the double protein portions, and the Registered Dietician acknowledged that the problem could not have affected only one meal, indicating a broader issue with communication and documentation.

Penalty

Fine: $72,51435 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 have adequate and functional mechanically operated exhaust ventilation necessary to control moisture and odors, ensuring good air circulation to keep all parts of the facility odor-free. During the initial tour of the facility, surveyors noted a persistent ligneous malodorous smell throughout the second floor. This odor was consistently observed on multiple dates. A tour with the Maintenance Director revealed that all 10 intakes on the second-floor nursing unit were non-functional and vented to the outside using 2.5-inch PVC pipe without motors. The Maintenance Director confirmed the malodorous smell and suggested it might be coming from the carpet, although no carpet was observed in the secure unit on the second floor.

Penalty

Fine: $72,51435 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 nurse aides received the required training, including dementia care and abuse prevention, for no less than 12 hours per year. This deficiency was identified through a review of personnel files for three Geriatric Nursing Assistants (GNAs). GNA #29, hired in July 2019, had no records of required training upon hire and in the year 2021. GNA #40, also hired in July 2019, lacked records of abuse and dementia training upon hire in 2022. GNA #42, hired in October 2021, did not have documentation supporting the completion of abuse training upon hire and annual required training in 2022. During interviews, Staff #23, the educator, acknowledged that the facility used an online training program to assign and track employee training. However, Staff #23, who started in May 2023, admitted that training was not tracked before their tenure, leading to gaps in the training records. The Director of Nursing (DON) validated these concerns, confirming the deficiencies in the GNAs' training documentation.

Penalty

Fine: $72,51435 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 or their responsible party was offered the opportunity to develop an advance directive. This deficiency was identified during an annual survey for one of the sampled residents. The resident was admitted to the facility, and while a MOLST form was initiated, there was no documentation indicating that the resident or their representatives were recently offered the opportunity to formulate an advance directive. This was confirmed through a chart review and staff interviews, where it was revealed that the social worker did not document any discussion or offer regarding advance directives for the resident in question. During an interview, the social worker stated that they typically discuss advance directives with residents and document the discussion, including whether the resident accepts or declines the opportunity to formulate one. However, in this case, the social worker could not find any documentation that an advance directive was offered to the resident or their representatives. The Director of Nursing confirmed that the process involves the social worker discussing and documenting advance directives, but acknowledged that there was no documentation for this particular resident, highlighting a lapse in the facility's procedure.

Penalty

Fine: $72,51435 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 allegations of abuse and injuries of unknown origin were reported to the state agency within required timeframes. This was evident in three cases. In the first case, a resident reported being pushed by a head nurse, resulting in a fall and injury. The incident was reported to the facility's management but was not reported to the state agency. In the second case, a resident's swollen wrist, later confirmed to be fractured, was not reported to the state agency immediately upon discovery. The Director of Nursing acknowledged that the incident should have been reported within 24 hours but could not provide documentation to show it was reported on time. In the third case, a resident physically assaulted another resident, and although the facility reported an allegation of sexual assault, the physical assault was not reported within the required timeframe. The deficiencies highlight a pattern of delayed or incomplete reporting of serious incidents. The facility's staff, including the Unit Manager, Assistant Director of Nursing, and Regional Nurse, were aware of the incidents but failed to report them to the state agency as required. The Administrator and Director of Nursing were made aware of these findings, indicating a systemic issue in the facility's reporting procedures. The failure to report these incidents promptly and accurately compromises the safety and well-being of the residents involved.

Penalty

Fine: $72,51435 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 staff failed to permit each resident to remain in the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility. For Resident #18, the medical record did not reflect the circumstances of the court order or the basis for the transfer to the hospital. Despite the presence of the physician when the police arrived, there was no documentation of the resident's condition or rationale for the transfer. Additionally, pertinent medical information was not communicated to the receiving hospital, and there was no written physician's order for the transfer. The social worker confirmed that there was no documentation regarding the behaviors exhibited by Resident #18 on the day of the transfer, and the Director of Nursing confirmed the lack of documentation and communication with the hospital. For Resident #322, the facility failed to provide appropriate discharge paperwork upon discharge. The nurse's discharge progress note indicated that the resident was discharged in stable condition with all belongings and paperwork, but the facility could not produce copies of the discharge paperwork. The social worker provided a discharge instruction form that was not signed by the resident or the nurse, and the nurse confirmed that the discharge packet should include various documents, but these were not found in the resident's medical records. The Director of Nursing was made aware of these concerns. These deficiencies highlight the facility's failure to ensure proper documentation and communication during resident transfers and discharges, which is crucial for maintaining the continuity of care and ensuring the safety and well-being of the residents. The lack of documentation and communication in both cases indicates a significant lapse in the facility's procedures and protocols for handling resident transfers and discharges.

Penalty

Fine: $72,51435 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 the required notice of discharge/transfer when a resident was transferred to a hospital. This deficiency was evident for one resident who was found with swelling and limited mobility in his right arm, and an x-ray revealed a shoulder fracture. The resident was seen by the Nurse Practitioner who ordered a transfer to the hospital. A review of the medical record revealed no evidence that a transfer notice was provided to the resident or the resident's representative. Interviews with the Corporate Registered Nurses indicated that the notice of transfer/discharge was normally provided by the unit nurse or social services, and if not given at the time of transfer, it would be mailed by the medical records department. However, no such notice was found in the medical record for this resident.

Penalty

Fine: $72,51435 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 staff failed to sufficiently prepare and orient a resident for their transfer to the hospital. The medical record review revealed that the resident was discharged to the hospital with no documentation indicating that staff informed the resident about the transfer or took steps to minimize their anxiety. The incident involved a court-ordered transfer to the emergency room/psychiatric unit, facilitated by sheriffs and paramedics. The Director of Nursing confirmed the lack of documentation regarding the resident's emergency petition transfer.

Penalty

Fine: $72,51435 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 a bed-hold notice to residents or their representatives before transferring them to the hospital. This deficiency was identified for three residents. Resident #173 was transferred to the hospital on two occasions, but there was no evidence that a bed-hold policy was provided during the first transfer, and the policy provided during the second transfer was incomplete as it did not include the reserve bed payment policy. The Director of Nursing (DON) confirmed the absence of the required documentation and the incomplete policy during an interview with the surveyor. Resident #169 was transferred to an acute care facility twice, but there was no documentation of a bed-hold policy being provided during the first transfer. During the second transfer, the bed-hold policy provided did not include the daily payment amount. The DON acknowledged these deficiencies during an interview. Additionally, Resident #13 was transferred to the hospital due to a shoulder fracture, but there was no evidence that a bed-hold notice was provided to the resident or their representative. The Corporate Registered Nurse confirmed the absence of the required documentation during an interview with the surveyor.

Penalty

Fine: $72,51435 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 staff failed to accurately complete assessments and refer a resident for Preadmission Screening and Resident Review (PASRR) Level II determination. This deficiency was identified for one resident who was reviewed for behavioral-emotional issues. The resident was sent to the hospital on an emergency court order and was discharged back to the facility. Upon return, a PASRR Level I Screen was completed, indicating the resident had a Serious Mental Illness (SMI). However, the required Part D of the form was not completed, and the resident was not referred for a Level II evaluation as mandated by the PASRR process. Staff #2, a social worker, incorrectly indicated that the resident had been hospitalized for psychiatric issues in the past three years but failed to complete the necessary sections of the PASRR form. Despite the hospital discharge summary stating the resident was admitted for psychiatric reasons, Staff #2 did not refer the resident for a Level II evaluation. A corporate social worker consultant confirmed that Part D should have been completed and the resident should have been referred for further evaluation based on the screen.

Penalty

Fine: $72,51435 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 proper documentation and intervention for significant weight loss in Resident #324. Despite a weight loss of over 20 lbs from admission to discharge, the weight loss was not reported to the doctor or dietitian, nor was it addressed by the facility staff. The care plan did not include any mention of the weight loss, and interviews with staff revealed a lack of proper communication and follow-up regarding the resident's weight changes. The dietitian was not made aware of the significant weight loss, and no interventions were implemented to address the issue. Additionally, the facility failed to ensure accurate medication orders for Resident #55, who was admitted with multiple medical diagnoses including Alzheimer's disease and Schizophrenia. The psychogeriatric services notes recommended changes to the resident's Risperdal dosage, but the orders were not correctly transcribed, leading to the potential for double dosing on Sundays. The Medication Administration Record (MAR) did not specify the days of administration, creating a risk for medication errors. Interviews with the LPN and DON confirmed the discrepancies and the potential for duplicate medication administration.

Penalty

Fine: $72,51435 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 preventative measures to prevent the development of pressure ulcers for three residents. Resident #169 was observed with multiple pressure ulcers, including a stage 4 ulcer on the sacrum and deep tissue injuries on both heels. Despite documentation indicating the need for regular repositioning, the resident was repeatedly observed in the same position, and staff incorrectly claimed the resident could turn themselves, which was contradicted by the Director of Rehab and the Wound Nurse. This lack of proper repositioning likely contributed to the worsening of the resident's pressure ulcers. Resident #370 had an unstageable wound on the sacrum and deep tissue injuries on both heels upon admission. Although the wound consult team recommended pressure reduction and heel protection, there was no documentation to support that these interventions were applied. An LPN confirmed that deep tissue injuries could be preventable with proper heel protection and frequent repositioning, which was not adequately documented or implemented for this resident. Resident #30 had a history of a stage 3 pressure ulcer on the heel and was observed without the required specialty boot on one foot, despite medical orders for bilateral specialty boots and heel elevation. Additionally, Resident #31 was observed sitting directly on a Hoyer lift sling with hard plastic pieces, which could exacerbate existing skin issues. The staff acknowledged the difficulty in removing the sling but did not take appropriate measures to address the resident's discomfort and potential for further skin damage.