West Woods Of Bridgman

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 adequately assess and respond to an acute change in condition for one resident, including failure to follow provider orders for diagnostic testing and failure to promptly activate 911 EMS when the resident became unresponsive and hypotensive. The resident was an elderly female with bipolar disorder, dementia, and delusional disorder who had been evaluated by a nurse practitioner two days prior for fatigue, poor appetite, right flank/low back pain, and lower abdominal tenderness. The NP suspected a UTI and hand‑wrote orders on a Doctor’s Orders sheet for CBC, CMP, and urinalysis with C&S if indicated. These orders were to be entered into the EMR by clinical care coordinators, but the Infection Prevention Manager later confirmed that no such orders were entered and no labs or UA were completed, and there were no results in the lab system. During the overnight shift, multiple CNAs reported that the resident was her usual self at the beginning of the shift but later became very lethargic, unable to keep her eyes open, and then completely unresponsive. CNAs stated they notified the nurse, and that two RNs (one being newly oriented) repeatedly assessed the resident, took vital signs several times, and made numerous phone calls. One CNA recalled that one RN wanted to send the resident to the hospital while the other RN was not convinced this was necessary. The orienting RN reported that both nurses assessed the resident and noted fluctuating vital signs, pain, lack of responsiveness except to painful stimuli (sternal rub), cold hands, and difficulty obtaining pulse oximetry readings. She contacted the on‑call PA, who agreed the resident required hospital evaluation, and she documented that the focus at that time was on facilitating transport and maintaining safety while awaiting transfer. The orienting RN described that she and the other RN were the only two nurses in the building that night and that she was being trained on the transfer process, including completing a transfer checklist and packet. She stated she had already transferred another resident earlier in the shift and had learned that 911 arrived quickly and would not wait for incomplete paperwork, so for this resident she took extra time to complete all transfer forms, call the family, and call report to the ED before calling 911. She reported asking the other RN whether they should call 911 and being told to finish the packet while the other RN went to eat. She then completed the electronic transfer form, including documenting last vital signs and that report was called to the ED, but she did not call 911 and believed the other RN would do so. EMS and 911 records show an abandoned 911 call from the facility, a return call in which staff stated there was no emergency, and subsequent calls from the local ED and ambulance service indicating the facility had called the ED with report on an unresponsive resident but had not sent the patient. EMS ultimately received a dispatch at approximately 5:37 a.m. for a 77‑year‑old female in cardiac arrest, arrived to find the resident unconscious but with spontaneous respirations and a pulse, and documented that no CPR or ventilations were in progress on arrival. The resident was transported emergently to the hospital, where she was found comatose, hypotensive, tachycardic, cool and cyanotic, and later died the same day. The PA who had been contacted by the facility stated that, based on the nurse’s documentation, the resident should have been sent to the hospital right after their call and that he would not have told staff to delay transfer. Additional interviews with leadership clarified that the DON expected nurses to assess residents with a change in condition, call the on‑call provider, complete transfer forms, and call 911 EMS for transport, with immediate transfer for an unresponsive resident. The DON acknowledged that night shift staffing could be as low as two nurses and that she believed there was little to do after evening med pass. The Infection Prevention Manager stated she did not receive any call from the facility during the overnight hours and arrived at work as EMS was taking the resident out on a stretcher. The Nursing Home Administrator reported there was no phone outage on the dates in question, although the facility’s voice‑over‑IP phone system could go down and be switched to another Wi‑Fi connection, and staff were expected to use personal cell phones if needed. 911 service records documented that when 911 returned the abandoned call from the facility, staff told them there was no emergency, and only after subsequent calls from the ED and ambulance service was EMS dispatched for the resident described as unresponsive and in cardiac arrest.

Removal Plan

• All licensed nurses were re-educated that 911 EMS must be called without delay for any resident exhibiting signs of an acute decline, including but not limited to unresponsiveness, hypotension, altered mental status, respiratory distress, or other emergent conditions.
• Staff were instructed that contacting the emergency department or hospital does not replace activation of 911 EMS.
• Emergency response protocol reeducation requiring immediate activation of 911 followed by notification of the supervisor or administrator on call.
• The monthly on call schedule was posted at the nurse's station.
• The Director of Nursing or designee are available 24 hours a day, 7 days a week to support clinical decision-making during all shifts.
• Re-education will be completed in person or by telephone prior to staff’s next scheduled shift being worked.
• No licensed staff will be allowed to start a shift or give care until education is completed.
• Medical director was notified.
• Facility health care providers will enter their own orders into the electronic medical record.
• A facility wide review of all current residents was initiated to identify those at risk for acute clinical decline.
• All residents exhibiting signs of deterioration were immediately assessed and transferred via EMS per the emergency response protocol.
• A licensed nurse will conduct a chart review of all current residents for change in condition and follow through with health care practitioner orders.
• All licensed nurses will receive education prior to their next worked shift, including those on leave of absence upon return.
• Agency licensed nurses will be educated and will complete a competency test prior to their shift worked.
• The facility change in condition policy was reviewed by the interdisciplinary team and updated to clearly require activation of 911.
• Emergency condition decision-support tools were implemented at the nurse's station.
• Leadership oversight was implemented to review all emergency transfers.

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 sufficient licensed nursing staff on the night shift to meet resident needs and maintain residents’ highest practicable well-being, which contributed to a delayed emergency transfer for a resident who experienced an acute change in condition and later died. The facility used a corporate staffing matrix based solely on census, without documented consideration of resident acuity, despite a facility assessment stating that staffing levels would be based on acuity and diagnoses. On the night in question, the census was 75, and the staffing matrix and facility assessment both indicated there should be three nurses on the night shift; however, only two nurses (one of whom was still in orientation) were on duty for the entire overnight shift after a scheduled nurse called in. The DON acknowledged that the facility often worked with only two nurses at night and believed three nurses were not needed after the evening medication pass, and the staffing manager confirmed that when there was a call-in, a day-shift nurse might stay over only long enough to complete the evening medication pass, leaving the night shift short. Resident #1 was a female resident with bipolar disorder, dementia, and delusional disorder. On the cited night, two residents, including Resident #1, required transfer to the hospital. CNA interviews described that staffing on nights was frequently short, with only two nurses and five CNAs at times, and that the south and east (back) units had higher-acuity residents, many of whom required two staff for care. CNAs reported that when CNAs working 8‑hour segments left mid‑shift, remaining CNAs were left with 15–16 residents each, and that residents sometimes waited 20 minutes or more for call lights to be answered, especially when showers were being completed. One CNA stated that once staff were in the back units, they did not go to other parts of the building due to the high acuity and needs of those residents. During the night in question, the two nurses on duty were RN V, who was still completing orientation, and RN P, who was assisting RN V with orientation tasks, including learning how to transfer a resident to the hospital. According to RN V, around 3:00 a.m. two residents, including Resident #1, needed to be transported to the hospital. RN V reported that she had earlier transferred another resident that night and had learned that EMS would not wait if paperwork was not ready, so she took extra time to complete all transfer paperwork correctly for Resident #1. She stated she asked RN P whether they should call 911, and RN P told her to finish the paperwork while RN P went to eat and would help afterward. RN V believed RN P called 911; however, she later stated she did not call 911 herself. RN P, in contrast, initially stated she did not call 911 and then expressed uncertainty about who had called. Documentation by RN V, entered later that morning, indicated that at 3:16 a.m. the PA was notified of Resident #1’s change in condition (hypotension, lethargy, cool skin, significant bilateral lower-extremity edema, and fluid-filled blisters on the heels), that the PA agreed the resident required hospital evaluation, and that the hospital was notified and preparations for transfer were initiated. EMS and 911 records showed that 911 received a call at 3:20 a.m. for another resident, with that call clearing at 5:01 a.m., and that an abandoned call from the facility occurred at 5:24 a.m., which was returned and staff reported no emergency. At 5:29–5:30 a.m., the local emergency department and the ambulance service contacted 911, reporting that the facility had called the hospital with report on a patient over an hour earlier but the patient had not arrived, and that the facility had reported difficulty reaching 911 due to phone issues. A subsequent call detail report documented that 911 initially closed the call after being told there was no emergency, then reactivated it when the ambulance service called back with information that a 77‑year‑old female at the facility was hypertensive, unresponsive, and in cardiac arrest, and that the facility said they could not get through to 911. EMS was dispatched around 5:37 a.m. and arrived to find the resident unconscious but breathing with a pulse, on oxygen via nasal cannula, with no CPR or ventilations in progress. EMS documented severe hypoxia requiring escalation of oxygen support and transported the resident to the emergency department. Hospital records indicated that upon arrival to the emergency department, the resident was comatose, hypotensive, tachycardic, cool, and cyanotic, and was intubated, with crushed pill remnants noted in the back of the throat and concern for polypharmacy versus aspiration of medication. The resident was found to have a UTI and developed complications including unstable SVT, cardiogenic shock on top of sepsis, and DIC, ultimately leading to death later that day. The facility’s own data for the date of the incident showed that, with a census of 75, 35 residents required two or more staff for care such as transfers. Multiple CNAs and nurses reported that night shifts were often short-staffed, that there were not enough nurses to cover nights, and that they frequently did not get lunch breaks. The combination of working with only two nurses instead of the three indicated by the facility’s matrix and assessment, the high acuity and dependency of many residents, and the orientation status of one of the two nurses on duty contributed to delays and confusion in arranging timely EMS transport for Resident #1 after an acute change in condition.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide and monitor an effective training program for a newly hired RN, specifically related to emergency procedures and hospital transfers, which contributed to a delayed response to a resident’s acute change in condition and emergent transfer. The facility’s DON and NHA stated that new nurses receive five days of training and an orientation checklist that includes emergency procedures, hospitalization, transfer forms, and emergency access for rapid transport. However, the DON acknowledged that the checklist does not have to be completed before being returned and that the orientation checklist for the involved RN had not been turned in, leaving the DON unaware of which training items had been completed. The orientation checklist for this RN was not provided to surveyors by the time of exit. The newly hired RN reported that she started at the end of the prior month and had not completed all of her training, including training on transferring a resident to an acute care hospital. On the night in question, she had to transfer two residents to the hospital for changes in condition and stated she had never done this before. She reported that another RN was assisting her with the orientation training checklist and with completing the paperwork, steps, and packet required for a hospital transfer. The assisting RN confirmed that the new RN appeared overwhelmed and unfamiliar with the transfer process and that she tried to help with the required paperwork. The new RN stated that she asked whether they should just call 911 for the resident and was told by the assisting RN to finish the paperwork while the assisting RN went to eat and would help again afterward. During this same shift, EMS and 911 records show multiple calls associated with the facility and a delay in EMS activation for the resident who was ultimately found unresponsive. 911 records documented an abandoned call from the facility, a return call from 911 during which facility staff reported no emergency, and subsequent calls from the local emergency department and ambulance service indicating that the hospital had received report on a patient from the facility but had not yet received the patient. EMS documentation for the resident later transported described dispatch for a cardiac or respiratory arrest, arrival to find the resident unconscious, minimally responsive, hypoxic, and requiring escalating oxygen support and eventual transfer to the emergency department. Hospital records documented that the resident, an older adult with dementia with psychotic features, major depressive disorder, and atrial fibrillation on Eliquis, was brought in unresponsive, hypotensive, tachycardic, cool, and cyanotic, and was intubated for airway protection. The combination of incomplete orientation, lack of verified competency in emergency transfer procedures, and the facility’s failure to ensure the new RN was effectively trained and monitored in these processes led to a delay in treatment and emergent hospital transfer for this resident. The DON confirmed that she did not know which emergency procedure and transfer-related training items the new RN had completed because the orientation checklist had not been returned. The Licensed Nurse Orientation and Skill Check form included items such as emergency procedures, hospitalization, transfer form from the electronic record, and emergency access for rapid transport, but there was no evidence these competencies had been completed or validated for the new RN. The new RN’s own statements that she had never transferred a resident to the hospital before, had not yet completed all of her training, and did not complete the first transfer’s paperwork correctly further demonstrate that the facility did not maintain an effective training and monitoring process for new nurses in critical emergency and transfer procedures, contributing to the deficient practice identified by surveyors.

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 develop and implement a person-centered care plan addressing a resident’s C6 cervical fracture and ordered Aspen collar use. The resident, a male admitted with diagnoses including a displaced fracture of the sixth cervical vertebra, syncope, collapse, and weakness, had a history and physical dated 12/6/25 documenting a syncopal episode with a fall, head strike, neck pain, and a scalp laceration requiring sutures. MRI showed an anterior superior vertebral body fracture, and he was stabilized in an Aspen collar with a recommendation for continued collar use and follow-up imaging. An after-visit summary dated 12/12/25 directed that the Aspen collar be worn at all times, and a provider note dated 12/15/25 confirmed the C6 fracture and Aspen collar, noting the resident was seen heading to therapy in the collar. Despite these documented orders and clinical findings, review of the resident’s care plan revealed no care plan related to the cervical fracture or the use of the Aspen collar. Interdisciplinary documentation on 12/16/25 described the resident as alert and oriented with some confusion, continuously removing the Aspen collar despite education to keep it in place per provider orders, and being unsteady, requiring assistance of two for bed mobility, transfers, and ambulation. During interviews, the Infection Prevention Manager/RN and the DON both confirmed there was no care plan in place for the C6 fracture or Aspen collar and stated that a care plan should have been created at admission by the assigned clinical care coordinator/RN responsible for the resident’s unit.

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 related to administration of metoprolol succinate ER. The resident, a female with bipolar disorder, dementia, and delusional disorder, had a physician’s order for metoprolol succinate ER 25 mg by mouth once daily for hypertension, with instructions to hold the medication if the systolic blood pressure was less than 110 or the pulse was less than 60, and to notify the physician. Review of the Medication Administration Records (MARs) for October, November, and December 2025 showed multiple instances where the resident’s systolic blood pressure was documented below 110, yet the metoprolol was still administered on those dates. Specific blood pressure readings below the ordered parameter included systolic values of 107, 102, 106, 107, 94, and 107 in October; 103, 106, 100, 100, 108, 105, and 109 in November; and 103, 104, 104, 106, 109, and 104 in December, all with documentation that the medication was given. The resident’s medical record contained no documentation that any provider was notified when blood pressure readings were outside the ordered parameters. In interviews, an LPN stated that medications with hold parameters should not be given if vital signs are outside those parameters. The physician assistant and nurse practitioner both reported that, based on the written order, the metoprolol should have been held whenever the systolic blood pressure was below 110, and the nurse practitioner did not recall being notified of any holds. The DON stated her expectation that medications be given per physician orders and acknowledged that if the provider was not contacted and the medication was given when blood pressure was outside parameters, it constituted a medication error.

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 complete required annual performance evaluations for two CNAs out of five reviewed, resulting in potential for unidentified CNA performance concerns, lack of training related to performance review outcomes, and potential unmet care needs. Documentation provided by the NHA showed that one CNA hired on 8/24/24 had no performance evaluation completed, and another CNA hired on 3/9/15 had their last documented performance evaluation on 3/19/24, with no current annual review. During interviews, the NHA acknowledged that these two CNAs did not have completed performance reviews and stated that the DON was responsible for completing evaluations while HR was responsible for tracking due dates. The DON reported she was unaware that she was responsible for CNA performance evaluations and had not completed any since starting in her role about five months earlier. The Regional Clinical Support confirmed that performance evaluations were expected annually on each employee’s hire-date anniversary, and no evaluations for the two CNAs were available by the end of the survey. A cited reference from a healthcare performance review resource noted that performance reviews lead to improved performance, greater productivity, and a better overall experience for patients. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the report focused solely on staff performance evaluation practices and related documentation and interviews.

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 a certified nurse assistant (CNA) completed the required 12 hours of in‑service training needed to ensure continued competency. Interview and record review showed that one CNA, identified as CNA F, was hired on 8/24/24 and, as of the time of survey, had completed 0 hours of in‑service training. A list of assigned in‑service trainings for this CNA documented that none of the assigned trainings had been attempted. The Nursing Home Administrator (NHA) reported that in‑services were assigned at the beginning of the year and monthly, and that CNAs were notified electronically when new training was assigned. The NHA confirmed that CNA F did not have 12 hours of completed in‑service trainings and stated that the Human Resources staff member responsible for maintaining the list of employees and training completions was unavailable during the survey. This deficiency resulted in the potential for a decrease in resident safety, as the facility did not ensure that this CNA had the required in‑service education, including dementia care and abuse prevention, as required for ongoing competency.

Penalty

7 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 care and services that promote dignity and respect for multiple residents, as evidenced by prolonged call light response times and unmet personal care needs. Several residents, all with significant physical or cognitive impairments requiring assistance with personal care and toileting, reported waiting extended periods—ranging from 30 minutes to several hours—for staff to respond to their call lights. In some cases, residents remained in soiled briefs or with full urinals for hours, causing discomfort and distress. Family members also observed and reported these delays, noting that staff sometimes turned off call lights before completing the requested assistance and occasionally forgot to return to fulfill the resident's needs. Staff interviews corroborated the residents' and families' accounts, with multiple CNAs and an LPN acknowledging that residents frequently complained about long call light wait times. One CNA admitted to turning off call lights before completing the task, intending to return later, while the facility's orientation materials specifically instructed staff not to turn off call lights until the resident's need was met. Despite these guidelines, the practice of prematurely turning off call lights persisted, leading to further delays and unmet care needs. The affected residents had diagnoses such as major depressive disorder, paraplegia, muscle weakness, paralysis, and cognitive communication deficits, making timely assistance with toileting and hygiene essential. The failure to respond promptly to call lights and to provide necessary personal care services resulted in residents experiencing discomfort and a lack of dignity, as well as frustration and concern from both residents and their families.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a therapy evaluation was completed for a resident upon readmission following an inpatient hospital stay. The resident, who had diagnoses including muscle weakness and required assistance with personal care, was discharged from the facility, hospitalized, and then readmitted. Upon return, the resident reported feeling weaker and more easily fatigued than before her hospitalization. Despite hospital discharge documentation and orders explicitly stating the need for occupational and physical therapy evaluation and treatment at the receiving facility, no therapy evaluation was conducted after her readmission. Interviews with facility staff revealed that the therapy manager and clinical care coordinator did not consider hospitalization alone as a reason to screen for therapy services, and believed that if a resident returned at their baseline, no therapy referral was necessary. However, hospital records indicated the resident required further skilled occupational therapy, and discharge instructions included orders for therapy evaluation and treatment at the facility. The interim director of nursing confirmed that the resident was not evaluated by therapy upon readmission, contrary to expectations.

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 develop a person-centered care plan for two residents, leading to deficiencies in their care. Resident #8, who is bed-bound and requires assistance with personal care, was observed unkempt and unshaven on multiple occasions. Despite being scheduled for showers twice a week, during which shaving was expected to occur, Resident #8 remained unshaven. Interviews with staff revealed that Resident #8 preferred to be shaved by a family member, a preference that was not documented in his care plan. The care plan lacked interventions related to his preferences or refusals for care, and staff were unaware of these preferences, leading to inconsistent care. Resident #32, diagnosed with major depressive disorder, PTSD, and generalized anxiety disorder, had a care plan that did not address his PTSD diagnosis. The care plan focused on the potential for acute condition changes but lacked specific interventions related to PTSD. Interviews with staff indicated a lack of awareness of Resident #32's PTSD diagnosis and the absence of documented triggers or interventions to manage his condition. This oversight resulted in staff being unprepared to address his needs, potentially leading to angry outbursts and stress. The facility's policy on care planning emphasizes the importance of person-centered care, including understanding resident preferences and documenting refusals of care. However, the care plans for both residents did not reflect these principles, resulting in deficiencies in meeting their individual needs. The lack of documentation and communication among staff contributed to the failure to provide appropriate and consistent care for these residents.

Penalty

No penalty information released

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

Summary

The facility failed to update the transfer status of a resident, resulting in a skin tear. The resident, who was cognitively intact, was initially admitted with diagnoses including unsteadiness on feet and difficulty walking. After a hospital stay, the resident was readmitted to the facility, and therapy assessed that her transfer status required a change from a one-person assist to a two-person assist due to increased weakness. However, this change was not updated in her care plan, leading to a skin tear during a transfer when a CNA followed the outdated care plan. Interviews revealed that the therapy director communicated the need for a change in transfer status to nursing staff, but the care plan was not updated accordingly. The CNA involved in the transfer was unaware of the change and relied on the care plan, which still indicated a one-person assist. The incident highlighted a breakdown in communication between therapy and nursing staff, as well as a failure to update the care plan to reflect the resident's current needs.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate nail care to a resident who was dependent on staff for activities of daily living. The resident, who was bed-bound and required total care, was observed on multiple occasions with long and soiled fingernails. Despite being scheduled for showers twice a week, during which nail care was supposed to be provided, the resident's nails remained unkempt. Observations on different days confirmed the resident's unshaven and unkempt appearance, indicating a lack of personal care. Interviews with staff, including CNAs and the Director of Nursing, revealed that nail care was expected to be performed during the resident's scheduled showers. However, despite documentation indicating that a shower was completed, the resident's nails were still long and dirty. The Director of Nursing acknowledged the deficiency upon observation, confirming that the resident's nails should have been trimmed during the shower. This indicates a failure in the facility's process to ensure the resident's personal care needs were met as per their care plan.

Penalty

No penalty information released

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

Summary

The facility failed to implement the use of gait belts during transfers for two residents, leading to potential injury risks. Resident #268 was admitted with diagnoses including unsteadiness on feet and required assistance with personal care. After a hospital readmission, her care plan indicated a one-person assist for transfers. However, a therapy screen revealed increased weakness, necessitating a two-person assist, which was not updated in her care plan. On a specific date, during a transfer without a gait belt, Resident #268 sustained a skin tear, highlighting the failure to adjust her care plan and use appropriate transfer aids. Resident #61, diagnosed with a neurocognitive disorder and a history of falls, required maximal assistance for transfers. Observations revealed that staff frequently transferred Resident #61 without using a gait belt, despite his impaired mobility. During one instance, a CNA assisted him to the toilet by placing her arms around his torso without a gait belt, as reported by a family member who regularly observed such practices. Interviews with staff, including the Therapy Director and Clinical Care Coordinator, confirmed that gait belts should be used for all transfers unless a mechanical lift is employed. The facility lacked a specific gait belt policy, relying on it as a standard of care. Additionally, a review of staff training revealed gaps in gait belt education, with some staff not receiving current training, contributing to the deficiency in safe transfer practices.

Penalty

No penalty information released

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

Summary

The facility failed to identify and implement interventions for PTSD triggers for a resident, leading to the potential for retraumatization and mental distress. The resident, who was admitted with diagnoses including major depressive disorder, PTSD, and generalized anxiety disorder, was cognitively intact as per a recent assessment. Despite having a care plan that mentioned the potential for acute condition changes related to PTSD, there were no specific interventions addressing the PTSD diagnosis. Additionally, a trauma-informed care life event screening identified past traumatic events, but no further trauma assessments were conducted by the facility staff. The Social Services Director (SSD) was initially unaware of the resident's PTSD diagnosis and any related triggers, despite the resident's history of physical aggression and past traumatic experiences, including abuse and significant personal losses. The resident had displayed aggressive behavior at the facility, such as breaking a window and threatening staff. The SSD later confirmed the PTSD diagnosis and the resident's history of violence but still lacked knowledge of specific PTSD triggers. This lack of awareness and intervention contributed to the deficiency in providing trauma-informed care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the Quality Assessment and Process Improvement (QAPI) meetings included the Medical Director as a mandatory attendee at least quarterly. This deficiency was identified through a review of the QAPI meeting sign-in sheets for January and February 2024, which revealed the absence of the Medical Director. Additionally, the Infection Control Meeting sign-in sheets, used for QAPI meetings in March and April 2024, also showed the Medical Director's absence. During an interview, the Nursing Home Administrator acknowledged that the Medical Director did not attend the meetings for four consecutive months, failing to meet the requirement of attending at least one meeting per quarter. The facility's Quality Assurance Performance Improvement Plan Policy, reviewed in May 2024, lists the Medical Director as a required attendee for these meetings.

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 use of personal protective equipment (PPE) for enhanced barrier precautions, which was observed in two residents. Resident #1, who had diagnoses including cerebral infarction and type 2 diabetes, was cognitively intact and required enhanced barrier precautions during high-contact care activities. Despite signage indicating the need for PPE, Certified Nurse Assistants (CNAs) L and S did not wear gowns or gloves while providing care to Resident #1. CNA S was unaware of the meaning of the signage, while CNA L acknowledged the requirement but did not comply. Resident #18, diagnosed with cerebral palsy and aphasia, required enhanced barrier precautions due to a gastrostomy tube. However, there was no signage on the door to indicate the need for PPE. Licensed Practical Nurse (LPN) BB confirmed the necessity of PPE when handling the tube. The Clinical Care Coordinator/Registered Nurse (CCC/RN) and the Director of Nursing (DON) both stated that enhanced barrier precautions were expected for residents meeting the criteria, yet these precautions were not properly implemented for Residents #1 and #18.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received care in accordance with professional standards of nursing practice, leading to an overdose of blood thinner medication. The resident, who had a history of atrial fibrillation and high blood pressure, was admitted with specific medication orders for warfarin. However, the facility transcribed the orders incorrectly, leading to the administration of an incorrect dosage. The hospital discharge summary specified a complex dosing schedule for warfarin, which was not accurately transcribed by the facility. Interviews with facility staff revealed a breakdown in the medication verification process. The nurse practitioner assumed that the pharmacy had correctly dosed the warfarin and did not verify the orders herself. The admission process involved multiple checks by different nurses, but these checks were not documented or retained, leading to a lack of accountability. The Clinical Care Coordinator noted that the order for pharmacy dosing of warfarin was not entered until days after the resident's admission, indicating a delay in the medication review process. Family members expressed concerns about the resident's medication regimen shortly after admission, highlighting the oversight in medication administration. Despite the facility's protocol for triple-checking medication orders, the failure to accurately transcribe and verify the warfarin dosage resulted in a significant medication error. The lack of effective communication and documentation among the healthcare team contributed to this deficiency, as noted in the review of nursing fundamentals.

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 administer medications at the correct dose as per the physician's order for a resident, leading to a significant medication error involving an overdose of Warfarin, an anticoagulant. The resident, who had a history of atrial fibrillation and hypertension, was discharged from a local hospital with specific instructions for Warfarin dosing. However, the facility transcribed the orders incorrectly, resulting in the resident receiving 4.5 mg of Warfarin daily instead of the prescribed 2 mg or 2.5 mg. This error was not identified or corrected promptly, leading to a critically high INR level of 8.19, which was reported to the facility. Despite the critical lab results indicating a dangerously high INR, the facility did not take immediate action to address the overdose. The results were faxed to the pharmacy, but there was no documented follow-up with the provider regarding the critical lab results or the pharmacy's recommendation to administer Vitamin K. The resident's INR remained critically high, and there was a delay in obtaining a stat lab draw to reassess the INR levels. The lack of timely intervention and communication with the provider contributed to the resident's prolonged exposure to the risk of bleeding due to the Warfarin overdose. Interviews with facility staff revealed a breakdown in the medication administration and monitoring process. The nurse practitioner did not review the Warfarin orders closely, and the admission process failed to ensure accurate transcription and verification of medication orders. The facility's procedures for handling critical lab results and coordinating with the pharmacy and provider were inadequate, leading to a failure to address the resident's critical condition promptly. This deficiency highlights significant lapses in medication management and communication within the facility.