Rossville Rehabilitation And Healthcare Center

Penalty

Inspection fine: $157,2509 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 nursing staff had the appropriate competencies and skills to access a permacath for the IV administration of antibiotics. This deficiency was evident in the case of a resident who was admitted to the facility for hemodialysis and had a permacath placed prior to discharge from the hospital. Despite the resident's initial refusal to use the permacath for antibiotic administration, the resident later agreed, and the nursing staff proceeded without proper training or competency verification. The resident's medical history included chronic kidney disease, heart disease, high blood pressure, blindness, and diabetes, and the resident was cognitively intact with a BIMS score of 15/15. The nursing staff, including LPNs, administered the antibiotic Zosyn through the permacath without adequate training. One LPN reported that they had administered the antibiotic through the dialysis site based on instructions from another LPN, who had received minimal guidance from a dialysis nurse. The NP confirmed that only one nurse had received training from the dialysis staff, which included basic instructions on clamping and sterile technique. However, the trained nurse did not administer the antibiotic doses, and the untrained nurse who did administer the doses was not comfortable with the procedure. On the day of the incident, an LPN attempted to administer the antibiotic but encountered issues with the infusion machine. The LPN left the resident briefly, and upon returning, found the resident unresponsive with blood present. Despite efforts to stop the bleeding, the resident was pronounced dead by paramedics. The facility's investigation revealed that the LPN had forgotten to clamp the permacath site, leading to the resident's death. The facility lacked documentation of basic IV skills assessment for the involved LPN prior to the incident, highlighting a significant gap in staff competency and training.

Removal Plan

• Management of Central Venous device complications
• Change in Condition
• Licensed Nurses Skills and Techniques Evaluation - Phlebotomy/infusion therapy
• Do not access the dialysis site: permacath or fistula
• Providers were educated not to write orders for floor nurses to access dialysis catheters
• All like residents in the facility with IV access or dialysis access devices were evaluated
• A quality assurance (QA) plan was put in place for ongoing monitoring of the planned interventions
• LPN, Staff #34 was put on the do not return list and a report was submitted to the state board of nursing

Penalty

Inspection fine: $157,2509 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 wishes regarding cardiopulmonary resuscitation (CPR) were clearly and accurately communicated to staff. This deficiency was evident for three residents reviewed for advance directives or death. Specifically, Resident #184 had conflicting documentation regarding their code status, with an electronic health record indicating Full Code and a paper chart MOLST indicating No CPR. The unit nurse manager struck out the Full Code order without proper verification, leading to a failure to perform CPR when the resident's breathing ceased, resulting in Immediate Jeopardy for Resident #184. Resident #53 also experienced a similar issue where the electronic health record indicated Full Code, but the paper chart MOLST indicated No CPR. The assigned nurse initially believed the resident was Full Code based on the electronic record but later confirmed the MOLST indicated No CPR. This discrepancy highlighted the facility's failure to ensure consistent and accurate documentation of code status across different records. Resident #91's case revealed the existence of two active MOLSTs with conflicting orders for No CPR. One MOLST was found in the paper chart, and another in the dialysis communication book, each with different No CPR options. This inconsistency further demonstrated the facility's inadequate system for managing and communicating residents' code status, putting residents at risk of not receiving appropriate life-sustaining treatment as per their wishes.

Removal Plan

• 100% of current alert and oriented residents re-interviewed by Social Worker to confirm their code status.
• Residents with Advance Directives will have them honored.
• Residents with responsible parties will be contacted by Social Services to confirm resident code status.
• If any changes are requested the medical providers will be contacted to make the change.
• System Change: Current scanned-in copies of the MOLST will be moved to the Do Not Use Section.
• System Change: Current MOLST previously removed will be returned to the residents' charts by the medical records designee.
• System Change: Current MOLST will be placed in the resident's chart located at each nurse's station by the charge nurse with each new admission, re-admission and change of status.
• The medical director will educate the physicians when there is a revised MOLST to flag the chart, notify nursing leadership of changes to the MOLST and void the old MOLST.
• Nursing leadership will review the MOLST to ensure the old one is voided and the revised one is in the resident chart. Nursing leadership will ensure old MOLST is voided. Changes in code status will be documented on the twenty-four-hour report.
• Physician orders reflecting the resident code status in the EHR will say: See MOLST.
• 100% audit was completed to validate current code status say: See MOLST by the DON.
• Nurses will be educated on the process by the DON or designee.
• The medical director will educate the medical providers on ensuring they confirm and document the residents' wishes on the MOLST.
• The medical director will educate the medical providers that the NPs are responsible for notifying the attending physicians of MOLST changes.
• The NHA or designee will re-educate the medical providers on the importance of notifying the Unit Manager, Supervisor, ADON, or DON regarding changes in the MOLST.
• The DON or designee educated current nurses on the facility's policy for initiating CPR and location of code status for each resident, which is in the resident's chart on each unit.
• Agency nursing staff will be educated prior to start of their shift by DON, nursing supervisor or designee.
• Social Service will audit new admissions, re-admissions to compare the resident's MOLST to the physician orders for accuracy to assure it reflects See MOLST. This is ongoing.

Penalty

Inspection fine: $157,2509 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 an environment free from abuse, resulting in physical and psychosocial harm to Resident #505. The resident, who had moderate cognitive impairment, reported that a night shift GNA (GNA #9) was rough during care, yanking covers off, grabbing the resident's arms, and pushing them to roll over. This rough handling led to bruising on the resident's arms, which was later confirmed by another GNA (GNA #10) who noticed the bruises during a shower and reported the incident. Multiple residents corroborated the rough and uncommunicative behavior of GNA #9 during care, further substantiating the abuse allegations. The facility's investigation revealed that the bruises on Resident #505 were new and had not been present the day before the alleged abuse. Despite this, the facility failed to document the resident's change in condition and the injuries in the medical record. Additionally, the facility did not ensure that a nurse practitioner or physician examined the resident following the abuse allegation and injuries. The psychiatric provider who saw the resident after the incident was not aware of the recent abuse allegations and injuries, as this information was not documented in the medical record. Interviews with other residents indicated that GNA #9 had a pattern of neglectful and rough behavior. Residents reported that GNA #9 would turn off call lights without providing care, complain about residents' needs, and handle residents roughly. Despite these reports, the facility did not thoroughly investigate all the allegations or obtain statements from all relevant staff members. The facility's failure to document the abuse allegations and injuries in the medical record and to conduct a comprehensive investigation contributed to the deficiency.

Penalty

Inspection fine: $157,2509 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 complete Quarterly Minimum Data Set (MDS) assessments for residents within the regulatory time frames, which is required to facilitate appropriate care planning and maintain current assessment records. This deficiency was identified for 11 out of 67 residents reviewed during the survey. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs, which drives resident care planning decisions. The completion date of the Quarterly assessment must be within 92 days of the MDS Completion Date of the last OBRA assessment and no later than 14 days after the ARD. However, the facility did not meet these requirements for the specified residents, with delays ranging from 16 to 35 days past the ARD. During interviews, the Nursing Home Administrator acknowledged the challenges with staffing and mentioned that the corporate person in charge of MDS was aware of the situation and was trying to get help to catch up with the assessments. An MDS Coordinator also confirmed awareness of the late MDSs. Specific examples include Resident #85's Quarterly MDS assessment being completed 21 days after the ARD, Resident #28's assessment being 24 days late, and Resident #65's assessment being 33 days late, among others. These delays indicate a systemic issue in meeting the regulatory time frames for MDS assessments, impacting the facility's ability to maintain current and accurate resident assessment records.

Penalty

Inspection fine: $157,2509 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 system in place to ensure that maintenance concerns are reported and addressed. During an initial tour, surveyors observed multiple maintenance issues across three out of four units, including damaged walls, cracked floor tiles, broken corner guards, and non-functional clocks. These issues were visible in several rooms and were not reported or addressed by the facility staff. For instance, in one room, the lower part of the wall under the window was damaged, and in another, several floor tiles were cracked. Additionally, a resident complained about a non-functional clock, which was confirmed by the surveyor. Upon further inspection, additional maintenance issues were noted, such as separated grout and exposed drywall metal corner beads. The Maintenance Director confirmed these observations and indicated that the damage was primarily caused by residents hitting the walls with their wheelchairs. Despite having a system called TELS for reporting and managing maintenance concerns, the Maintenance Director reported having zero orders or concerns at the time of the survey. The Director of Nursing was informed that these environmental issues had not been identified or reported by any staff to maintenance in the last three weeks.

Penalty

Inspection fine: $157,2509 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 complete comprehensive Minimum Data Set (MDS) assessments within the regulatory time frames, which are essential for appropriate care planning and maintaining current and accurate assessment records. This deficiency was evident for eight residents, where the Admission MDS assessments were completed late, ranging from 1 to 9 days past the required 14-day period. For instance, Resident #98's Admission MDS assessment was completed 7 days late, and Resident #281's was 9 days late. The Director of Nursing and the Nursing Home Administrator acknowledged the delays, attributing them to staffing challenges within the MDS department. Additionally, the facility staff failed to assess residents' cognition and mood on comprehensive and quarterly MDS assessments. This was observed in three residents, where sections C (Cognitive Patterns) and D (Mood) were not assessed within the required time frames. For example, Resident #235's cognitive and mood assessments were completed after the MDS ARD date, and Resident #241's assessments were also not completed within the look-back period. The Social Service Director confirmed these lapses, noting that the assessments were conducted outside the required observation periods. Interviews with the MDS Coordinator and the Social Service Director revealed that the responsibility for completing these assessments was not adequately managed, leading to incomplete MDS records. The MDS Coordinator admitted to needing better time management, while the Social Service Director acknowledged the failure to complete assessments within the designated periods. These deficiencies highlight significant lapses in the facility's assessment processes, impacting the accuracy and timeliness of resident care planning.

Penalty

Inspection fine: $157,2509 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 Minimum Data Set (MDS) assessments were accurately coded for several residents. For Resident #65, the MDS assessment inaccurately documented an active diagnosis of deep vein thrombosis (DVT) and recorded incorrect antibiotic and oxygen use. The MDS Coordinator confirmed these errors during an interview and acknowledged the need for modifications. Similarly, Resident #98's MDS assessment failed to capture oxygen use and inaccurately documented anticoagulant medication use, which was confirmed as an error by the MDS Coordinator. Resident #91's MDS assessment inaccurately reflected the resident's dental status. The resident reported having upper dentures but lacked a denture cup, and the initial admission nursing assessment did not indicate the presence of dentures. Staff interviews and a review of the resident's hard chart and speech therapy evaluation failed to document the presence of dentures, which was later confirmed by the nurse unit manager and the Director of Nursing. Resident #129's discharge MDS inaccurately documented the discharge status, indicating the resident was discharged to a hospital instead of home. This error was confirmed by the MDS Coordinator. Additionally, Resident #54's MDS assessment failed to capture the resident's active diagnoses of depression and bipolar disorder, despite documentation in the medical record and physician orders indicating the resident was on antidepressant medication. The MDS Coordinator acknowledged the need to modify the MDS to reflect the correct diagnoses.

Penalty

Inspection fine: $157,2509 days payment denial

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

Summary

Facility staff failed to develop and implement comprehensive, person-centered care plans with measurable goals and non-pharmacological approaches for several residents. For Resident #63, the medical record review revealed that the resident had specific preferences for activities such as reading, listening to music, and attending religious activities. However, the current care plan did not address these preferences, and the Activity Director confirmed the absence of such a care plan during the survey. Despite an interdisciplinary care plan meeting, no documentation was provided to indicate that the resident's activity preferences were addressed prior to the survey exit date. For Resident #54, the medical record review showed that the resident was receiving multiple psychotropic medications, including antipsychotics, an antidepressant, and an anti-anxiety medication. The care plan for this resident did not include comprehensive, resident-centered measurable goals and interventions that addressed the use of these medications, the targeted behaviors for which they were prescribed, or non-pharmacological approaches. The Director of Nursing (DON) was made aware of these concerns but offered no further comments. Similarly, Resident #21's care plan was found to be inadequate. The resident, who had diagnoses including schizophrenia, major depressive disorder, bipolar disorder, and dementia, was receiving multiple psychotropic medications. The care plan did not specify the resident's behaviors for which these medications were prescribed and lacked non-pharmaceutical interventions. The DON was informed of these issues but did not provide any comments at the time of the survey.

Penalty

Inspection fine: $157,2509 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 interdisciplinary team meetings to review and revise care plans following each assessment. This was evident for several residents, including one who was admitted in February 2023 and had no documentation of a care plan meeting between June and September 2023. Another resident, admitted in 2022, had a care plan meeting in December 2023, but there was no documentation indicating that the care plan was updated to reflect a recent ENT appointment and recommendation for a hearing aid. Additionally, a resident admitted in 2020 had no care plan meeting scheduled after a December 2023 MDS assessment. The facility also failed to ensure that residents and their representatives had the opportunity to participate in the development, review, and revision of care plans. One resident, admitted in August 2023, was cognitively intact but was not invited to their care plan meeting. Another resident, with severe cognitive impairment, had a care plan that was not comprehensive and lacked specific, measurable goals. The facility did not evaluate the resident's progress or response to care plan interventions following quarterly assessments. Furthermore, the facility did not conduct care plan meetings for newly admitted residents. One resident, admitted in December 2023, had no documentation of a care plan meeting following their admission assessment. The Social Service Director acknowledged the oversight but could not provide additional documentation to confirm that the meeting had occurred. These deficiencies highlight the facility's failure to adhere to regulatory requirements for timely and comprehensive care planning.

Penalty

Inspection fine: $157,2509 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 develop and implement an activities program to meet the needs and preferences of residents. This deficiency was evident for four of the six residents reviewed for activities. Observations and medical record reviews revealed that residents were not engaged in meaningful activities that aligned with their documented interests and preferences. For instance, Resident #43, who enjoys music and religious programming, was found lying in bed without any engagement in these activities. The activity logs for Resident #43 only recorded leisure cart visits, which did not include the resident's preferred activities. Interviews with staff indicated a lack of knowledge and implementation of appropriate activities for this resident. Similarly, Resident #71, who has a diagnosis of dementia and enjoys quilting, children, television, music, and puzzle words, was observed not participating in any meaningful activities. The activity logs for this resident also failed to show engagement in their preferred activities. Staff interviews revealed that activities were not personalized based on the resident's preferences, and there was no rationale provided for this oversight. Resident #63, who has a diagnosis of Schizoaffective Disorder Bipolar type and lung disease, was observed in bed without any engagement in activities. The resident expressed a desire to attend activities and physical therapy. However, the care plan did not address the resident's activity preferences, and the activity logs only recorded occasional leisure cart visits. Staff interviews confirmed a lack of access to the resident's assessment and inadequate documentation of activity provision. Resident #91 also reported not participating in activities for a couple of months, despite enjoying bingo. The activity logs for this resident only recorded leisure cart visits, and there was no additional documentation to confirm participation in other activities.

Penalty

Inspection fine: $157,2509 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 the attending physician reviewed and responded to pharmacist-identified irregularities and recommendations in a timely manner. For Resident #65, a medication regimen review (MRR) was completed on 8/9/23 with a recommendation to attempt a gradual dose reduction of an antidepressant. However, the attending physician did not review or respond to this recommendation, and the antidepressant dose remained unchanged. The Director of Nursing (DON) confirmed that the MRR was not addressed with the provider, and the attending physician indicated that the nurses did not inform him of the MRR. For Resident #53, the facility did not have documentation of monthly pharmacy reviews for October, November, or December 2023 initially. Although the DON later provided documentation for November and December, the October review revealed a recommendation to discontinue a PRN medication, which was not addressed by the physician. The corporate nurse confirmed that there was no written policy or procedure specifying a timeframe for addressing MRR recommendations. The surveyor noted the failure to ensure pharmacy recommendations were addressed in a timely manner.

Penalty

Inspection fine: $157,2509 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 primary care and specialty provider notes were placed in the medical record for review by other healthcare professionals. This deficiency was evident in multiple cases, including residents with behavioral and emotional status issues, communication and sensory problems, insulin management, and facility-reported incidents. For instance, Resident #106 had an order for a psychiatric consult in July 2023, but no documentation was found to indicate the resident was seen until the psychiatric nurse practitioner provided notes later. Similarly, Resident #63's electronic health record lacked psychiatric notes for a visit conducted in January 2024, despite an order for a psych consult in September 2023. Resident #53's medical record revealed a lack of primary care physician notes since October 2023, despite a nurse's progress note indicating the resident was seen by the physician in November 2023. Additionally, Resident #59's record showed missing wound physician notes for November and December 2023, even though nursing progress notes indicated the resident was seen by a wound physician during those months. The facility provided multiple copies of primary care physician notes but failed to include the requested wound physician notes. Further deficiencies were noted in the records of Residents #184 and #183. Resident #184's medical record lacked progress notes from a nurse practitioner involved in the resident's care during an incident in August 2022. Similarly, Resident #183's record did not contain legible or typed notes from an oncologist for several appointments in 2023. The facility's failure to ensure that these critical medical notes were available in the residents' records hindered the ability of healthcare professionals to provide appropriate and timely care.

Penalty

Inspection fine: $157,2509 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 allegations of abuse to the State Agency, the Office of Health Care Quality (OHCQ), within the required timeframe of 2 hours. In the first instance, a resident reported being belittled and physically mishandled by a geriatric nursing assistant (GNA) during the night shift. The Nursing Home Administrator (NHA) was informed of the allegation at 11:17 AM on 1/10/24, but the report was not forwarded to the state agency until 7:28 PM the same day, exceeding the 2-hour reporting requirement. This delay was acknowledged by the Director of Nursing (DON) during a discussion on 1/24/24. In the second instance, another resident made an allegation of verbal abuse against a GNA on 12/19/23 at 9:00 PM. The facility's investigation documentation revealed that the allegation was not reported to the OHCQ until 1:07 PM on 12/20/23, again failing to meet the 2-hour reporting requirement. The DON confirmed that the Administrator was made aware of the accusation only on 12/20/23, which led to the delayed reporting. Both instances highlight the facility's failure to comply with timely reporting regulations for abuse allegations.

Penalty

Inspection fine: $157,2509 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 abuse allegations were thoroughly investigated for two residents. For the first resident, admitted in June 2023, a self-report indicated that during a meeting in July 2023, the resident and a family member reported that a night nurse had squeezed the resident's hand. However, the facility's investigation documentation did not include interviews with potential witnesses other than the resident and the nurse involved. There was no documentation of an interview with the geriatric nursing assistant assigned to the resident at the time of the alleged event, nor was there any information on whether the resident had a roommate. Despite the Nursing Home Administrator's indication that additional documentation would be sought, no further documentation was provided by the time of the survey exit on February 2, 2024. For the second resident, who had resided at the facility for several years, a self-report revealed that during an interview for another abuse investigation, the resident reported that an aide had been pulling and tugging on them while providing care on a specific date. The final investigation report was submitted to the licensing agency, but the facility's investigation documentation failed to show that any staff were interviewed before the conclusion of the investigation. When asked about the expectations for an abuse investigation when a resident provides a specific date but not a name, the Director of Nursing stated that everyone working that day would be interviewed. However, the investigation did not reflect this procedure, as no staff interviews were documented before the investigation's conclusion.

Penalty

Inspection fine: $157,2509 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 dependent resident was groomed in a manner that preserved the resident's dignity. Observations on two separate occasions showed that Resident #71 was lying in bed with facial hair on the chin and upper lip. The resident's Minimum Data Set (MDS) assessment indicated that they depended on staff for all self-care needs, including grooming and personal hygiene. The resident also had moderately impaired cognition and a diagnosis of dementia. Despite this, the resident's plan of care and Geriatric Nurse Aide (GNA) task documentation did not reflect a preference for facial hair, and the resident expressed a desire to have their facial hair shaved during an interview. Interviews with staff confirmed that Resident #71 depended on staff for all care needs and that the resident's facial hair should have been shaved according to their preference. Staff #49, a GNA, acknowledged the presence of facial hair and indicated they would shave it after the surveyor's intervention. The Nurse Manager and the Director of Nursing (DON) both stated that the resident's facial hair should have been shaved if it was not documented in the plan of care to leave it. This failure to groom the resident according to their preference resulted in a deficiency in maintaining the resident's dignity.

Penalty

Inspection fine: $157,2509 days payment denial

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

Summary

The facility failed to ensure that residents were informed of their right to formulate an advance directive. This deficiency was identified for two residents. One resident, admitted in August 2023, had no documentation in their medical record indicating they had been informed about their right to formulate an advance directive. The Social Service Director (SSD) confirmed that the social service assessment tool used at the time did not include a section for advance directives, although it has since been updated to include this information. The SSD also stated that social services did not provide residents with written information or assistance in formulating advance directives, instead directing them to external resources like the internet or banks for financial power of attorney (POA) information. Another resident, admitted in December 2023, also had no advance directive in place and was not provided with educational materials or state forms to complete one. The SSD confirmed that the facility's policy on advance directives was different from what they had been taught, indicating a lack of proper training and adherence to the facility's policy. The SSD acknowledged that residents were not given the necessary information or assistance to formulate advance directives, which is a violation of their rights.

Penalty

Inspection fine: $157,2509 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 Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This deficiency was identified for two residents who continued to stay in the facility after their Medicare coverage ended. The review of records showed that these residents did not receive the required SNFABNs, which are meant to inform them of their financial liability for non-covered services and their appeal rights. During interviews, the Social Services Director and a Social Service Coordinator both confirmed that they were unfamiliar with the SNFABN forms and did not issue them to residents. The facility's policy on Advance Beneficiary Notices states that an ABN should be issued prior to furnishing non-covered care, but this was not followed. The lack of awareness and failure to issue the SNFABNs led to the deficiency noted by the surveyors.

Penalty

Inspection fine: $157,2509 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 document the preparation and orientation given to residents to ensure an orderly transfer to an acute care facility. This deficiency was evident for one resident who was admitted in December 2023 and had multiple transfers to an acute care facility. On one occasion, the nurse documented a critical low lab and a physician's order for a blood transfusion, but there was no documentation that the resident received an explanation of the transfer or their understanding of it. On another occasion, the nurse documented a change in the resident's mental status and a recommendation for hospital transfer, but again, there was no documentation of an explanation given to the resident or their understanding. These concerns were discussed with the Director of Nurses, who offered no comments at that time.

Penalty

Inspection fine: $157,2509 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 new Preadmission Screening and Resident Review (PASRR) was completed when it was determined that a resident would remain in the facility for long-term care. The resident, who was originally admitted in June 2022 with a diagnosis of Schizoaffective Disorder Bipolar type, had a brief hospitalization in August 2023 and was readmitted to the facility. The initial PASRR indicated that the resident's stay would be less than 30 days, but no new PASRR was completed when it became evident that the resident would remain for a longer period. The PASRR form on file was incomplete, lacking a signature and date, and no previous PASRR was found in the electronic health record (EHR). The social service coordinator confirmed that the only PASRR present was dated 9/1/23 and lacked a signature. Despite requests, no documentation was provided to indicate that a new PASRR screen was completed in 2022 when it was evident that the resident would remain in the facility for more than 30 days. The psychiatric nurse practitioner confirmed that the resident had a past psychiatric admission but could not provide additional information regarding the dates. The social service director acknowledged that a new PASRR should be completed if a resident transitions to long-term care but was unable to provide evidence that this was done. The Director of Nursing was informed of the concern, but as of the survey exit, no documentation was provided to indicate that a new PASRR screen was completed. This deficiency was evident for one resident reviewed for PASRR during the survey.

Penalty

Inspection fine: $157,2509 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/or their representatives with a summary of the baseline care plan that included a summary of the resident's medications within 48 hours of admission. This deficiency was identified for two residents. For the first resident, the Director of Nurses stated that baseline care plans were developed upon admission and provided during the care plan meeting. However, a review of the resident's medical record revealed no documentation that a summary of the resident's medications had been provided. The Social Services Director confirmed that only the care plan was given, without any additional documents, including the medication summary. For the second resident, there was no documentation found to indicate that a care plan meeting had been conducted or that the resident had received a copy of the baseline care plan along with a summary of medications. The resident could not recall receiving these documents. The Social Services Director was made aware of the concerns but no additional documentation was provided by the time of the survey exit to indicate compliance with the requirement to provide the baseline care plan and medication summary within 48 hours of admission.

Penalty

Inspection fine: $157,2509 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 incontinent care to a dependent resident, as evidenced by multiple instances of missing documentation and reported neglect. Resident #282, who was admitted for rehabilitation and relied entirely on staff for activities of daily living, did not receive documented incontinent care on several shifts across multiple days. This issue was highlighted by the resident's family member, who noted that the lack of care was more frequent on holidays and weekends. Interviews with staff confirmed that the resident required incontinent care twice per shift, but documentation was missing for numerous shifts, indicating a failure to provide the necessary care. Further investigation revealed that Geriatric Nursing Assistant (GNA) #42 admitted to being too busy to complete all required documentation during shifts and sometimes carried over documentation to the next day. The GNA also acknowledged that there were shifts where incontinent care was not provided to all residents under their care. The Director of Nursing (DON) and Corporate Clinical Nurse (CCN) reviewed the incontinent care task sheets and confirmed the lack of documentation, with no additional information or documentation provided to address the concerns.

Penalty

Inspection fine: $157,2509 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 timely scheduling of vision and hearing appointments for two residents. Resident #68, who has diagnoses including dementia and heart failure, had an order for an in-house audiology consult for hearing aids on 12/1/23. However, by 1/10/24, there was no documentation indicating that the appointment had been scheduled or completed. The unit nurse manager and medical records clerk confirmed that the appointment was only scheduled on 1/17/24, indicating a delay in the process. The care plans did not reflect the ENT appointment or the need for a hearing aid, and the communication system for scheduling appointments appeared ineffective, as noted by the staff's reliance on a communication board that may not have been updated promptly. The Director of Nursing was made aware of this issue on 1/31/24. Resident #59, who is cognitively intact, reported not having seen an eye doctor for three years despite having an active order for an optometry appointment dated 10/7/22. The unit nurse manager confirmed that the resident had not had an optometry appointment since the order was placed and that an appointment was only scheduled on 1/17/24. This delay in scheduling was acknowledged by the unit nurse manager, who noted that the facility previously had an in-house provider but now makes outside appointments. The Director of Nursing was informed of this deficiency on 1/31/24.

Penalty

Inspection fine: $157,2509 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 splints for the prevention of contracture development were re-implemented for a resident after a brief hospitalization. Resident #63 was readmitted to the facility in August 2023, but the splint order was not re-established until January 2024. Observations and record reviews revealed that the resident's wrist brace was not being used as recommended, and there was no documentation indicating the splints had been used since the readmission. The Occupational Therapist confirmed the recommendation for the splints but was unaware that they had not been re-evaluated or used since the resident's readmission. Additionally, the facility failed to ensure that a resident with a limited range of motion received treatment and services as ordered by the attending provider. Resident #43 had contractures in both hands and was recommended to use palm protectors. However, observations showed that the resident only had a palm protector on the right hand, and staff interviews confirmed that the left hand was not being treated as ordered. The attending provider's order for palm protectors was not being followed, and the resident's care plan was not adequately implemented. These deficiencies were evident for two residents reviewed for positioning and mobility. The facility did not ensure that the necessary treatments and services were provided to prevent further decline in the residents' range of motion, leading to a failure in maintaining their physical health and well-being as required by their care plans and medical orders.

Penalty

Inspection fine: $157,2509 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 document and address a physician's recommendation for a resident to receive a urology consult. This deficiency was identified for a resident who was admitted with an indwelling urinary catheter. The resident had a physician consultation at a local hospital, but the facility did not obtain the written recommendation from the consultation. The progress notes inaccurately documented the referral information, leading to a delay in scheduling the urology appointment. The Director of Nursing (DON) confirmed the discrepancy between the progress note and the actual referral recommendation. Interviews with staff revealed that it was the responsibility of the resident's nurse to ensure that documentation from consulting physicians was obtained and available for review. The deficiency was further highlighted when the resident reported successful removal of the indwelling urinary catheter, which was confirmed by a urology consultation. The facility eventually scheduled the urology appointment, but the initial failure to document and act on the physician's recommendation led to a delay in appropriate care for the resident.

Penalty

Inspection fine: $157,2509 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 respiratory care equipment for a resident who required continuous oxygen via nasal cannula. An observation on 1/10/24 at 9:14 AM revealed that the tubing or nasal cannula was neither initialed nor dated, and the prefilled humidifier with sterile water attached to the resident's oxygen concentrator was empty. The resident mentioned that the night shift nurse had informed them that there were no more prefilled humidifier water bottles available. A subsequent observation at 10:55 AM confirmed that the humidifier bottle remained empty, and the RN present verified that the sterile water was finished. The facility's oxygen administration policy, reviewed on 1/17/24, stated that the humidifying jar should have enough water to bubble as oxygen flows through. Interviews with staff indicated that the night shift nurse was responsible for changing the humidifier water weekly, and it should have been replaced on 1/10/24. The unit manager expected nurses to change the humidifier water whenever it was low or empty and should have been notified if there was no supply. However, the unit manager was not made aware of the shortage of prefilled humidifier water bottles.

Penalty

Inspection fine: $157,2509 days payment denial

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

Summary

A facility provider failed to make their visit notes available after a visit with a resident. This was evident for one resident reviewed for provider visit note availability during a facility's revisit survey. The medical record review revealed that the resident received a new order for Ativan for Anxiety, but there was no evidence of a diagnosis of Anxiety in the resident's list of active diagnoses. An interview with the DON confirmed that the CRNP saw the resident but failed to provide a provider note detailing the visit. The surveyor expressed concern that the facility failed to place a provider visit note in the resident's medical record in a reasonable amount of time after the provider's visit.

Penalty

Inspection fine: $157,2509 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 recommendations from the psychiatric provider were reported to the primary care provider and did not report abnormal behaviors in a timely manner. This deficiency was evident in the case of a resident with a history of stroke, high blood pressure, diabetes, lung disease, and dementia. The resident had an order for a psychiatric consult in July, but there was no documentation indicating that the resident was seen as a result of this order. When the psychiatric nurse practitioner (NP) did see the resident on July 31st, the NP recommended starting a new medication, Buspar, for anxiety. However, there was no documentation to show that this recommendation was communicated to the primary care physician, and no order for Buspar was found in the medical record following the visit. The corporate nurse confirmed that the recommendation was not reviewed with the primary care providers, and no follow-up visits by the psychiatric NP were documented between August 1st and January 10th of the following year. Additionally, the facility failed to report abnormal behaviors exhibited by the resident in a timely manner. The resident was observed smearing feces on multiple occasions, a behavior that was documented by the Geriatric Nursing Assistants (GNAs) starting in mid-November. Despite this, the unit nurse manager was not aware of the behavior until January 11th, when it was first reported to her. The psychiatric NP was also not informed of the fecal smearing behavior until January 15th, when the resident was seen for an urgent visit. The NP noted that the resident had been smearing feces and deferred further medication adjustments until lab results were reviewed. The unit nurse manager confirmed that the resident's behavior had not been previously reported to her, and the psychiatric NP confirmed that she was not made aware of the behavior until the urgent visit. The facility also failed to hold an interdisciplinary care plan meeting for the resident since May of the previous year. The lack of communication and timely reporting of the resident's abnormal behaviors and the psychiatric NP's recommendations contributed to the deficiency. The Director of Nursing was made aware of these concerns, including the failure to follow up on the psychiatric NP's recommendation, the failure to notify the primary care provider, and the failure to report the incidents of fecal smearing to either the psychiatric or primary care provider.

Penalty

Inspection fine: $157,2509 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's drug regimen was free from unnecessary drugs by not specifying the duration for which a Lidocaine patch should be applied and failing to implement physician orders for blood pressure and pulse parameters before administering a blood pressure medication. For the Lidocaine patch, the order did not indicate the removal schedule, leading to the patch being applied for longer than the recommended 8 to 12 hours. This was evident in the treatment administration record (TAR) for multiple days in September 2023 and January 2024, where the patch was either left on for nearly 24 hours or not removed at all on certain days. The Director of Nurses (DON) was unable to provide an explanation for this oversight when questioned. Additionally, the facility did not follow the physician's order to monitor the resident's blood pressure and heart rate before administering Amlodipine Besylate, a medication for high blood pressure. The medication administration record (MAR) for December 2023 and January 2024 showed that the resident received the medication twice daily without any documentation of blood pressure and heart rate monitoring as required. This failure to adhere to the prescribed parameters for administering the medication was also discussed with the DON, who did not offer a response. These deficiencies indicate a lack of proper medication management and adherence to physician orders, potentially putting the resident at risk for adverse effects from both the Lidocaine patch and the blood pressure medication. The facility's failure to ensure accurate and timely removal of the Lidocaine patch and to monitor vital signs before administering Amlodipine highlights significant gaps in their medication administration processes.

Penalty

Inspection fine: $157,2509 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 that residents' medication regimens were free from unnecessary medications by administering psychotropic medications without adequate monitoring for behavior. This deficiency was evident for two residents. Resident #54, who was admitted with diagnoses including dementia, depression, mood disorder, and anxiety, received multiple psychotropic medications such as Aripiprazole, Olanzapine, Buspirone, and Escitalopram. The medical record review revealed that there was no evidence of monitoring for the specific behaviors that necessitated these medications, nor were there any documented person-centered, non-pharmacological approaches attempted to reduce or discontinue the psychotropic medications. Similarly, Resident #21, with diagnoses including schizophrenia, major depressive disorder, bipolar disorder, and unspecified dementia, was also administered multiple psychotropic medications, including Escitalopram, Mirtazapine, and Olanzapine. The review of Resident #21's medical record also failed to show evidence of behavior monitoring or the implementation of non-pharmacological interventions. During an interview, the Director of Nurses (DON) acknowledged the lack of a process for monitoring resident-specific behaviors and indicated that the facility no longer used behavior monitoring sheets, which contributed to the deficiency in monitoring and managing the use of psychotropic medications.

Penalty

Inspection fine: $157,2509 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 a medication error rate of less than 5 percent, resulting in a 9.6 percent error rate for three residents. For Resident #287, a nurse administered non-chewable Calcium + D tablets instead of the prescribed chewable form, which the resident attempted to chew and then spit out. The nurse acknowledged the error and indicated they would notify the physician to obtain the correct form of the medication. Resident #292 received crushed Metoprolol succinate 25 mg ER, an extended-release medication that should not be crushed, potentially leading to a large dose being administered all at once. The nurse practitioner confirmed the error and noted that each medication cart contains a list of medications that should not be crushed. Lastly, Resident #42 was administered a lidocaine patch instead of the prescribed Bengay Ultra strength pad, which the nurse confirmed as an error and stated they would notify the physician about it. These medication errors were reviewed with the Director of Nursing, who was aware of the incidents. The errors were identified through direct observation, interviews with the involved staff, and a review of the residents' medication orders. The errors included administering the wrong form of medication, crushing an extended-release medication, and applying an incorrect topical treatment. These actions led to a medication error rate significantly higher than the acceptable threshold of 5 percent.

Penalty

Inspection fine: $157,2509 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 locked carts where medications were stored, as observed in three out of nine carts during the survey. On 1/09/24 at 8:31 AM, an unlocked treatment cart was observed near the first-floor nurses' station. Nurse, Staff #19, confirmed the cart was unlocked and immediately locked it. On 1/10/23 at 7:44 AM, another unlocked treatment cart was observed on the first floor, which remained unlocked until 7:52 AM. Staff #16, RN, confirmed the cart was unlocked and contained prescription medications such as Hydrocortisone Butyral USP1% and Triamcinolone. Staff #16 acknowledged that the treatment cart should have been locked. On 1/24/24 at 6:22 AM, an unlocked medication cart was observed on the second floor outside of a room, with no nurse nearby. Nurse, Staff #62, was found down the hall and confirmed that the cart was one of the two carts they were responsible for that shift. Staff #62 immediately locked the medication cart. These observations indicate a failure to adhere to the requirement that all drugs and biologicals must be stored in locked compartments.

Penalty

Inspection fine: $157,2509 days payment denial

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

Summary

The facility failed to maintain a physical barrier between the clean and soiled areas of the laundry room, leading to potential cross-contamination. During a tour, it was observed that there was an opening between the clean and soiled areas with no door or physical barrier. Soiled linens were placed in open bins on the dirty side, and clean laundry was folded in the area where the dryers were located. Staff confirmed the lack of a physical barrier and the process of handling soiled and clean linens in the same space without separation. Additionally, the facility failed to properly clean or replace a dirty nebulizer mask for a resident with chronic obstructive pulmonary disease (COPD). The resident's nebulizer mask was observed lying bare on a machine, bedside table, and even on the floor without any covering. Interviews with staff revealed that the mask was not consistently placed in a plastic bag after use, and there was an instance where a mask that fell on the floor was picked up and placed in a bag without proper cleaning. The unit manager confirmed that the expectation was to change the mask if it fell on the floor, not just rinse it off or place it back in a bag.

Penalty

Inspection fine: $157,2509 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 notify a provider of a blood sugar level outside an order's acceptable range for a resident with type 2 diabetes. On 8/6/23, Resident #65 had a blood sugar reading of 450, and 8 units of insulin were administered as per the sliding scale order. However, the attending provider was not notified of the high blood sugar reading, contrary to the physician's order. Interviews with the attending provider, an LPN, and the Director of Nursing confirmed that the expectation was to notify the provider and the resident's representative of such a high reading, which was not done in this case. Additionally, the facility staff failed to notify the physician immediately following an accident that had the potential for requiring physician intervention. Resident #245, who had left-sided weakness following a stroke, experienced an unwitnessed fall on 1/22/24 at approximately 10:30 PM. The incident report and evaluations were not initiated until 1/24/24, and the physician was notified on 1/24/24 at 5:59 PM, two days after the fall. The resident had complained of pain in the left hip and had an X-ray ordered, which later revealed a fracture. The delay in notification was confirmed through interviews with the RN and the Director of Nursing.

Penalty

Inspection fine: $157,2509 days payment denial

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

Summary

The facility failed to notify residents and their representatives in writing of transfers or discharges, including the reasons for these moves. This deficiency was identified for two residents. Resident #132 was transferred to the hospital on two occasions for altered mental status, but there was no documentation indicating that the resident or their representative was notified in writing of these transfers. The Director of Nursing confirmed the absence of such documentation and acknowledged that the former administration did not send out the required notifications. A form is currently being developed to address this issue. Resident #241 was transferred to an acute care facility on two separate occasions. On the first occasion, the nurse documented the transfer due to a critical low lab and a physician's order for a blood transfusion, but there was no written notification provided to the resident or their representative. On the second occasion, the transfer form did not include a reason for the transfer, and there was no written notification sent with the resident. Interviews with the Director of Nursing, Social Service Director, and a registered nurse revealed confusion and lack of clarity regarding the responsibility for notifying residents and their representatives in writing. The facility's current process for notifying the Ombudsman of transfers and discharges was also found to be inadequate.

Penalty

Inspection fine: $157,2509 days payment denial

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

Summary

The facility failed to notify the resident and/or the resident representative in writing of the bed-hold policy upon transfer of the resident to an acute care facility. This deficiency was identified for Resident #132 and Resident #241. For Resident #132, the medical record review revealed that the resident was transferred to an acute care facility on two occasions for altered mental status. Although the resident representative was called, there was no written documentation that the bed-hold policy was communicated in writing. The Director of Nursing confirmed the absence of such documentation during an interview. Similarly, for Resident #241, the medical record review showed that the resident was transferred to an acute care facility for a blood transfusion due to a critical low lab result. While the resident's representative was informed verbally, there was no written documentation indicating that the bed-hold policy was provided. The Director of Nursing acknowledged that the facility did not have a specific bed-hold policy until recently, which contributed to the lack of written notification.

Penalty

Inspection fine: $157,2509 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 Guanfacine HCL as ordered by the physician for a resident with hypertension. The Medication Administration Record (MAR) indicated that the medication was not given on multiple occasions, and there was no documentation explaining why the medication was held or not administered. The Director of Nurses was unable to locate any documentation to justify the missed doses. The facility also failed to administer Lacosamide as ordered by the physician for a resident with a seizure disorder. The MAR showed that the medication was not given on several occasions due to it awaiting delivery from the pharmacy. The Director of Nurses could not provide documentation explaining why the medication was not available from the pharmacy, and the nurses who documented the codes no longer worked at the facility. Additionally, the facility failed to provide care and treatment in accordance with professional standards for a resident with multiple myeloma. The resident's anticancer medication, Pomalidomide, was not administered as ordered, and there was a lack of documentation and follow-up regarding the medication's availability and administration. The facility also failed to document and assess a resident with an unwitnessed fall in a timely manner. The resident complained of pain and was later found to have a hip fracture, but the necessary assessments and documentation were delayed by two days.