The Eleanor Nursing Care Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.

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 sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.

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 maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.

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 that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene 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 deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.

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 maintain a clear, consistent, and promptly implemented grievance process, as required by its own policy and state regulations. The facility’s undated Grievance/Complaint Procedure policy designates the Administrator as the Grievance Officer and requires that grievances be fully documented, investigated, and that complainants be informed orally and in writing of the results within ten working days. Surveyors found that this process was not followed, and that there was no effective system to track grievances or demonstrate the facility’s response and rationale. One resident involved, Resident #114, had diagnoses including type 2 diabetes mellitus without complications, Wernicke’s encephalopathy, and cognitive communication deficit, and was documented as having severe cognitive impairment and needing partial to moderate assistance with toileting, bathing, and dressing, with bowel incontinence. A Concern Form dated 06/16/2025 recorded that the resident’s representative reported finding the resident the previous day in a soiled brief, in a gown, with no sheets on the bed, wrapped in a throw cover, and with a wheelchair containing a towel soiled with feces. The form contained only the description of the concern and no documentation of investigation, follow-up, resolution, notification to the representative, or staff signatures. The Director of Social Work and the Director of Nursing each confirmed that this concern was not completed, investigated, or resolved, and could not explain why, noting they were not employed at the facility at that time. Additional deficiencies were identified through resident interviews and record review. One resident reported filing a grievance about a staff member allegedly sleeping on an overnight shift; the corresponding grievance form showed a staff response and an undated disciplinary action, but there was no documentation of any follow-up with the resident who filed the grievance. At a Resident Council meeting, multiple residents stated that they were unaware of the grievance process, that there was poor or little follow-up when complaints were made, and that they did not know what happened after submitting grievances. Staff interviews revealed confusion about who collected grievance forms from locked boxes and who was responsible for tracking and resolving grievances. The Director of Social Work acknowledged that the grievance policy needed review, that there was no log to track grievances, and that the grievance binder contained grievances only from 2025 and none from 2026. The Administrator and Director of Nursing both indicated that the process for collecting, tracking, and responding to grievances was unclear and that no tracking system was in place.

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 antibiotic treatment in accordance with physician orders, professional standards of practice, and the comprehensive care plan. A resident admitted with acute urinary tract infection, Parkinson's disease, and Lewy body dementia had a care plan for urinary tract infection that included administering medications as ordered. The physician ordered Amoxicillin 500 mg to be given every eight hours for six days (at 6 AM, 2 PM, and 10 PM), for a total of 18 doses. Review of the February 2025 Medication Administration Record showed that three scheduled doses of Amoxicillin were omitted on 2/16 at 2 PM and on 2/17 at 2 PM and 10 PM, resulting in only 15 of 18 doses being administered. There was no documentation on the Medication Administration Record or in the nurse's notes explaining why these doses were not given. During interviews, the LPN Unit Manager stated that if there was no documentation on the MAR, the medication was not given, acknowledged that the omissions were preventable, and noted that nurses were expected to check at the end of their shift to ensure medications were signed or that a note was entered if a medication was refused. The DON stated that the expectation was that there be no omissions on the medication or treatment administration records and that, if a medication was not administered, the medication nurse should document the reason in a progress note or on the MAR or treatment administration record.

Penalty

No penalty information released

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

Summary

Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards and its own policies for a resident at high risk for skin breakdown. On admission, the resident had peripheral vascular disease with a nonhealing right transmetatarsal amputation, diabetes mellitus, osteomyelitis, deep tissue injuries to both heels, a right groin wound, a right foot/toe amputation wound, and coccyx excoriation. The admission assessment and MDS identified the resident as at risk for pressure ulcers, with care plans calling for skin integrity interventions such as daily CNA skin checks, pressure-reducing devices, turning and repositioning, offloading extremities, and weekly wound rounds. Hospital discharge instructions also required timely follow-up with primary care, wound care center, infectious disease, and vascular surgery. Despite these identified risks and orders, multiple physician-ordered treatments and monitoring interventions were not documented as completed. Weekly skin checks ordered starting 04/21/2025 had no documentation on the April and May Treatment Administration Records (TARs). Orders dated 04/25/2025 for zinc oxide to the buttocks every shift and bilateral heel booties with offloading every shift were missing documentation on 7 of 42 shifts in April and 48 of 93 shifts in May. An order to apply foam dressing to the left heel every other day lacked documentation from 05/01/2025 to 05/14/2025. Later wound care orders dated 05/28/2025 for daily betadine and dressing to the left heel and hydrocolloid to the sacral ulcer every other day were also not documented as completed for multiple days in June, including 06/01/2025–06/06/2025 and on 5 of 16 days after 06/14/2025. In addition to missing treatment documentation, there was a lack of wound assessments and wound round documentation over an extended period. From 04/21/2025 until 06/18/2025, there were no documented wound assessments or evidence that the resident was seen on wound rounds, and nursing and medical progress notes from 04/29/2025 to 06/06/2025 lacked information about the sacral ulcer, including when it developed or any wound measurements. When the resident was reassessed after a hospital stay, the re-entry MDS documented two Stage 3 and one unstageable pressure ulcers present upon admission, and a 06/18/2025 wound care note described a Stage 3 sacral wound and pressure injuries on both heels. During interviews, an LPN Unit Manager acknowledged numerous dates where ordered wound treatments were not documented and could not confirm whether care was provided, citing workload and being the only nurse on the unit. The DON confirmed awareness of poor documentation and could not verify that ordered wound care was completed, and the Medical Director acknowledged not ordering an initial wound care consult and was unaware that wound treatments were not documented as completed.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide dialysis services consistent with professional standards of practice for a resident receiving hemodialysis. The facility’s policy on care of residents receiving hemodialysis, last reviewed in May 2025, required nursing staff to complete pre- and post-dialysis assessments, including documenting pretreatment information and post-treatment vital signs and access site assessments in a hemodialysis communication book. For a resident with heart failure, chronic kidney disease, and cirrhosis who received dialysis three times per week, surveyors found that from mid-March to late April 2026, only fifteen days had dialysis sheets in the communication book, and ten of those were incomplete, missing either the pre- or post-dialysis assessment. There was no documentation elsewhere in the electronic medical record to show that these required assessments had been completed. The facility also failed to ensure that the resident consistently attended scheduled dialysis treatments due to an ongoing elevator problem. Dialysis treatment records from September through October 2025 showed that the resident was scheduled but absent on at least one occasion due to a “facility issue,” and an elevator repair invoice documented repair work on the second and third floor elevator doors in October 2025. Interviews with a former employee, the resident, nursing staff, and the receptionist/transportation scheduler indicated that the elevator frequently malfunctioned, causing residents, including this hemodialysis resident, to miss one or more dialysis appointments. The resident reported missing dialysis sessions because the elevator was down and then having to attend dialysis on consecutive days, and staff confirmed that the resident was moved from an upper floor to a first-floor unit specifically because of missed dialysis appointments related to the elevator being out of service.

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 sufficient nursing staff to meet the needs of residents as outlined in its own facility assessment. The assessment, reviewed by Quality Assurance and Performance Improvement, specified that each unit should have a Charge LPN and a medication nurse on the day shift. However, staffing assignment sheets and direct observations revealed that on multiple dates, including the observed date, only one nurse was assigned per unit, each responsible for approximately 30 residents. This staffing pattern was consistent across several dates within a one-month period for all units, including the rehabilitation, long-term, and dementia units. As a result, there were instances where medications were administered late due to the insufficient number of nurses available to provide timely care. Interviews with nursing staff, the staffing coordinator, the interim DON, and the administrator confirmed the discrepancy between the facility's staffing plan and actual staffing practices. Staff reported frequently working alone on units, and the staffing coordinator acknowledged that units were sometimes staffed with only one nurse if additional staff were unavailable. The interim DON and administrator both agreed that the facility assessment required two nurses per unit on the day shift, but staffing records showed this was not consistently achieved. There was no indication that staff were aware of habitual lateness among nurses, but the lack of adequate staffing directly contributed to delays in medication administration and did not align with the facility's documented 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 provide a safe, clean, and comfortable environment for residents, as evidenced by multiple observations of environmental deficiencies across several units. Surveyors noted visible dark water stains on ceiling tiles in numerous resident rooms, community areas, and bathrooms. Additional issues included torn window curtains, missing ceramic tiles under bathroom sinks, and makeshift repairs with sheet rock that did not adequately cover gaps. Noisy exhaust fans and sinks producing banging and rattling noises were also observed. These deficiencies were not systematically tracked or documented, and the maintenance binders intended for reporting such issues were inconsistently used, with entries often lacking specifics, dates, or resolution information. Interviews with the Director of Maintenance revealed the absence of a formal system to track or prioritize maintenance needs, relying instead on informal verbal reports and personal recollection. During a walkthrough, the Director of Maintenance was unable to specify the extent of needed repairs or provide timelines for completion. Furthermore, a significant plumbing incident involving a burst pipe in the Physical Therapy room was not formally documented, and the Director of Maintenance was unaware of the event, its cause, or its resolution. These lapses in maintenance reporting and follow-through contributed to the ongoing unsafe and uncomfortable environment for residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that its facility-wide assessment accurately reflected the resources and staffing needed to care for residents, as required. The assessment, reviewed by Quality Assurance and Performance Improvement, documented that each unit should have a Charge LPN and a medication nurse on the day shift. However, staffing assignment sheets for multiple dates over approximately one month showed that several units, including the rehabilitation, long-term, and dementia units, were often staffed with only one nurse per unit during the day shift, despite each unit housing about 30 residents. This staffing pattern was observed repeatedly, and on several occasions, a single nurse was responsible for medication administration and resident care, which led to medications being administered late. Interviews with nursing staff, the staffing coordinator, the interim DON, and the administrator confirmed that the actual staffing did not match the facility assessment. Staff reported frequently working alone on units, and the staffing coordinator acknowledged that units were sometimes staffed with only one nurse if additional staff were unavailable. The interim DON and administrator both agreed that the facility assessment called for two nurses per unit on the day shift, but staffing records showed this was not consistently achieved. There was no indication that staff were aware of any habitual lateness among nurses, but the discrepancy between the assessment and actual staffing contributed to delays in medication administration.

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 sufficient nursing staff to meet the needs of all residents, as required by their own Facility Assessment and staffing policy. Review of staffing schedules over a two-month period revealed multiple instances across all three shifts and units where the number of certified nurse aides (CNAs) fell below the facility's minimum requirements. Staff interviews confirmed that callouts were frequent, and the facility did not utilize agency staff, relying instead on internal pools and offering bonuses to cover gaps. Despite these efforts, there were repeated occasions when units operated with fewer CNAs than needed, particularly on weekends and during evening shifts. Staff reported having to work double shifts, skip breaks, and work into the next shift to complete resident care tasks, with some units experiencing only one CNA on duty at times. Resident acuity data indicated a high number of residents requiring extensive assistance, including mechanical lifts, help with eating, and total or extensive assistance with toileting. Staff consistently reported that the workload was heavy and that the reduction in CNA staffing from four to three per unit made it difficult to complete all required cares. Staff also noted that tasks were rushed, and resident care was sometimes incomplete, especially when callouts reduced staffing below even the minimum guideline. Supervisory staff acknowledged that low staffing levels could negatively affect resident care and that complaints about staffing had been raised by both staff and residents. Resident Council meeting minutes documented ongoing concerns from residents about delayed call bell responses, insufficient assistance with activities of daily living, and staff inattentiveness, particularly on weekends. These concerns were raised repeatedly over several months, with no documented evidence that the facility addressed or responded to them. During interviews, residents confirmed that they had to wait a long time for care and that their concerns about staffing had been expressed in previous meetings. The Administrator acknowledged awareness of these concerns and stated that incentives were offered to attract and retain staff.

Penalty

No penalty information released

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

Summary

Surveyors identified multiple deficiencies related to the facility's failure to provide a safe, clean, comfortable, and homelike environment for residents across all three residential units. One resident was unable to hang clothing in their closet for over six months due to a missing closet bar, despite repeated requests by the resident's family representative to both the Director of Social Work and the Director of Maintenance. The Director of Social Work recalled discussing the issue at a care plan meeting and with maintenance, but could not confirm if a formal work order was submitted, while the Director of Maintenance did not recall the request. Another resident reported the loss of approximately $45 from their wallet, which was kept on their bedside table. This resident was not provided with a lock box and was unaware of what a lock box was, although the Director of Social Work stated that lock boxes were offered and discussed at resident council meetings, but could not confirm if this resident had been offered one. Environmental observations revealed that heating and air conditioning radiator units throughout the facility were heavily soiled with dust, debris, and black stains, and had bent, crushed, and rusty conductor fins. Several rooms and dayrooms on all floors were affected. Additionally, one room was missing closet doors, leaving clothing exposed. The 3rd Floor dayroom was found to have inadequate lighting, with only a portion of ceiling fixtures illuminated during resident activities and meals, resulting in a dim environment. The 3rd Floor was also noted to be noisy due to a defective call bell system that emitted a continuous beeping noise, which was audible throughout the unit and originated from a wall-mounted intercom near the medication room. The Director of Plant Operations confirmed the beeping was constant and had not been resolved by the call bell vendor. The facility lacked a formal system to track maintenance and repair requests, relying instead on logbooks and verbal communication between staff and the Director of Plant Operations. Maintenance staff were responsible for addressing issues, but there was no documentation to indicate when repairs were completed or if outside vendors were needed. Housekeeping was responsible for cleaning radiator units quarterly, but observations indicated this was not sufficient to maintain cleanliness. The ongoing environmental and safety issues were not addressed in a timely or effective manner, resulting in a failure to uphold residents' rights to a safe and homelike environment.

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 timely notification of resident representatives or emergency contacts when two residents were transferred to the hospital. In the first case, a resident with end stage renal disease, respiratory failure, and atrial fibrillation was sent to the hospital for perma-catheter placement and later admitted for hypotension and end stage renal disease. Although the resident's family member was listed as the emergency contact, there was no documented evidence that the representative was notified at the time of transfer. The resident reported that their family was not contacted until days later, and documentation showed that the family member was only called after the resident returned to the facility. In the second case, another resident with diagnoses including sepsis, viral encephalitis, and chronic lymphocytic leukemia was admitted to the hospital for medical issues. The family member, listed as the emergency contact, stated they were not notified by the facility and only learned of the hospitalization from the hospital itself. There was no documentation of representative notification in the medical record. Facility policy required timely notification of residents and their representatives regarding transfers or discharges, but this was not followed in these instances.

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 required written notifications of transfer or discharge, including bed-hold policies and appeal rights, to residents, their representatives, or the ombudsman for two residents who were hospitalized. For one resident with end stage renal disease, respiratory failure, and atrial fibrillation, there was no documented evidence of discharge notices or bed-hold notifications for three separate hospitalizations, nor was there evidence that the ombudsman was notified of one of these hospitalizations. The facility's policy requires that such notifications be provided in writing and in a language and manner understood by the resident and their representative, and that the ombudsman be notified at the same time as the resident and representative. For another resident with diagnoses including sepsis, viral encephalitis, and chronic lymphocytic leukemia, there was no documented evidence of a discharge notice or bed-hold notification when the resident was sent to the hospital. Additionally, the resident's family member, listed as the emergency contact, reported not being contacted by the facility regarding the hospitalization and only learned of it from the hospital. These findings were confirmed through interviews and record reviews, which revealed the absence of required documentation in the medical records for both 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 ensure that the Comprehensive Care Plans for three residents were updated to reflect their current condition following falls, as required by facility policy and state regulations. Specifically, after each resident experienced a fall, there was no documented evidence that the care plans were revised to include the details of the incident or to add new interventions to address the increased risk or to evaluate the effectiveness of existing interventions. The facility's own policies require care plans to be updated after significant changes in a resident's condition, including falls, and to document any new or modified interventions. One resident with end stage renal disease, atrial fibrillation, and peripheral vascular disease experienced a fall while being transported to hemodialysis. Although the incident was documented in progress notes and an accident report, the resident's care plan was not updated to reflect the fall or any new interventions. Another resident with peripheral vascular disease, anxiety disorder, and a history of cerebrovascular accident had an unwitnessed fall from bed, but the care plan last reviewed several months prior did not include this event or any new interventions. A third resident with chronic obstructive pulmonary disease, iron deficiency anemia, and an aneurysm also experienced an unwitnessed fall out of bed, and while the fall risk score was updated, there was no evidence of new interventions or a revised care plan following the incident. Interviews with facility leadership, including the acting DON, Regional Director of Operations, and Regional Nursing Coordinator, confirmed that care plans were not updated after the falls for these residents. The staff were unable to provide any documentation showing that the care plans reflected the falls or any subsequent changes in interventions, despite facility policy requiring such updates.

Penalty

Fine: $130,725

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

Summary

The facility failed to provide a functioning call system for residents on Unit 3, which includes the Dementia/Long Term Care Unit. On 9/10/2024, it was observed that the centrally located audible call bell system was not operational, and the interim system using tap bells was ineffective. The tap bells were not audible at the central nursing station or throughout the hall, affecting 37 residents. Specifically, Resident #31, who was at moderate risk for falls, was found sitting on the toilet without access to a functioning call bell, as the bathroom call bell was neither audible nor visual, and the tap bell was out of reach. The facility's policy required that each resident have a call bell within reach, but this was not adhered to. The issue with the call bell system began in April 2024, and despite a contract proposal being signed, the contractor did not receive the necessary down payment until late August 2024, delaying repairs. Interviews with staff revealed a lack of awareness about the non-functioning call bell system, and there was no documented evidence of increased monitoring or updated care plans to address the residents' ability to contact staff during this period. The deficiency was further highlighted by the lack of documented evidence of tap bell function and placement logs, as well as care plan updates from April to September 2024. Interviews with various staff members, including CNAs, LPNs, and the Director of Maintenance, confirmed the ongoing issues with the call bell system and the absence of effective interim measures. The facility's failure to ensure a working call system posed an immediate jeopardy to the health and safety of residents on Unit 3.

Removal Plan

• The facility assigned two to four staff members as monitors to make continuous rounds on Unit 3.
• Monitoring logs for room rounds were presented to the survey team by the facility with no negative findings.
• Staff education regarding room rounds on Unit 3 was conducted with 90.2% completion.
• Unit 3 residents were assessed for the ability to use the call bell system. Three residents were assessed by therapy as not being able to use a call bell.
• The Policy and Procedure titled Alternate Call Bell System for use during a Partial or Full Call Bell System Downtime was initiated.
• The Temporary Alternative Call Bell System was installed in Unit 3 rooms with a receiver located at the desk.

Penalty

Fine: $130,725

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 safe, clean, comfortable, and homelike environment for residents in two of its three units during a recertification survey. Observations revealed several environmental deficiencies, including missing or broken floor molding, rusted and scratched heaters, damaged sheetrock with large gouges, and dirty, dusty floor tiles. Additionally, there was a strong odor of urine in the Unit 3 hallway, and residents' wheelchairs were found to be dusty, with ripped armrests and caked-on food. One of the two passenger elevators was out of service, limiting accessibility for residents and staff. Interviews with facility staff revealed that maintenance issues were supposed to be recorded in a maintenance book checked three times daily. However, the Maintenance Director indicated that they had to prioritize repairs and were working with contractors on a renovation plan. The wheelchairs were supposed to be cleaned by nursing staff at night, but no cleaning schedule was provided despite requests. The Administrator confirmed that the facility was undergoing renovations, with the first floor completed and the second floor pending. Staff were expected to update the maintenance book with needed repairs.

Penalty

Fine: $130,725

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

Summary

The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving Resident #84, who exhibited escalating aggressive behaviors. Despite documented incidents of aggression starting on 9/16/23, including physical attacks on staff and other residents, the facility did not implement effective interventions to manage these behaviors. Resident #84, who was admitted with schizophrenia, bipolar disorder, and other conditions, was noted to have moderate cognitive impairment and a history of physical aggression. The care plans in place included maintaining a daily routine and providing emotional support, but these measures were insufficient to prevent further incidents. On 9/22/23, Resident #84 punched a staff member and another resident, leading to their hospitalization. Upon return, no new interventions were implemented, and the resident continued to exhibit aggressive behaviors, including hitting and scratching other residents. On 10/7/23, Resident #84 attacked multiple residents, causing injuries and necessitating hospitalization for both Resident #84 and one of the victims. The facility's records lacked evidence of interventions to address these aggressive behaviors effectively. Interviews with staff revealed a lack of adequate supervision and documentation of interventions. The Corporate LPN mentioned possible undocumented interventions, while the Director of Nursing acknowledged the need for increased supervision. The Medical Director was unaware of Resident #84's psychiatric history and noted staffing limitations that prevented 1:1 supervision. These deficiencies highlight the facility's failure to protect residents from abuse and implement necessary interventions to manage aggressive behaviors.

Penalty

Fine: $130,725

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 alleged violations of abuse, neglect, or mistreatment involving three residents to the State Agency within the required two-hour timeframe. For Resident #104, there was no documented evidence that an injury of unknown origin, reported by the family as bruises on the resident's hands, was communicated to the state agency. The facility's policy mandates immediate reporting of such incidents, but the necessary Accident and Incident report was not found, and the injury was not reported as required. Resident #45 reported an allegation of staff-to-resident abuse, which was not communicated to the State Agency until three days after the incident. The resident described being pulled by a nurse aide, resulting in bruises, and informed their son, who contacted the police. Despite the initiation of an investigation by the facility, there was no evidence of timely reporting to the state agency, as confirmed by interviews with the current Director of Nursing and the Administrator. For Resident #73, an incident of resident-to-resident abuse was reported late to the State Agency. The resident reported being hit by their roommate, resulting in visible injuries, but the report was not sent to the Department of Health until over five hours after the incident occurred. The Director of Nursing, who was not employed at the time of the incident, acknowledged that the report should have been made within the two-hour timeframe.

Penalty

Fine: $130,725

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 dignified experience for three residents during a recertification survey. A Registered Nurse was observed standing over two residents, who required assistance with eating, while feeding them their meals. This action was contrary to the facility's policy and staff interviews, which indicated that staff should be seated and facing residents during mealtime to provide a personal experience. Another resident was observed in the dining room wearing a hospital gown and a sweatshirt without pants, indicating a lack of appropriate clothing. The resident expressed a desire to wear their own clothes but did not have any available. The facility's policy was to provide clothing from a donation box within 24 hours of admission, but there was no record of this being offered to the resident. Staff interviews revealed that the resident had been without proper clothing since admission, and the issue was not addressed promptly. Additionally, a Certified Nurse Aide referred to residents needing assistance with eating as 'feeders,' which was deemed inappropriate by the Director of Nursing. The aide was unaware that such terminology was not allowed, highlighting a lack of awareness and training regarding respectful communication with residents.

Penalty

Fine: $130,725

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 had the right to organize and participate in resident groups, specifically the Resident Council meetings. During a Resident Council meeting, several residents reported that it had been months since they last attended a meeting because they were unaware of who should be assisting them. The facility lacked documented Resident Council minutes for several months, from April to July 2024, indicating that meetings were not held regularly during this period. The Administrator and Director of Nursing acknowledged that they were aware of the irregularity in holding Resident Council meetings when they started working at the facility. They confirmed that there was no staff liaison assigned to assist with the meetings, and there was no President of the Resident Council prior to the survey. A meeting was scheduled in August 2024 to introduce the new administration to the Resident Council members, but the absence of regular meetings and proper documentation led to the deficiency.

Penalty

Fine: $130,725

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 was found to have significant deficiencies during a recertification survey, primarily due to a lack of communication and documentation between the facility's administration and its governing body. The survey revealed that there was no established process or frequency for the administrator to report to the governing body, and the method of communication was not recorded. This lack of communication led to the governing body being unaware of critical issues, such as the non-functional call bell system on the third floor, which had been out of service since April 2024, and the absence of a plan to address this issue. Additionally, the facility failed to document any Quality Assurance Performance Improvement (QAPI) meetings or actions taken to resolve the call bell system problem. The survey also uncovered that the facility had only one working elevator for over a year, and this issue was not reported to the Department of Health. The QAPI meeting agendas from March and July 2024 did not mention the non-working elevator or call bells. Interviews with the facility's staff, including the Administrator, Director of Maintenance, and Corporate Director of Nursing, revealed a lack of awareness and documentation regarding these issues. The Administrator, who had been in the position for about a month, was unaware of the duration of the elevator problem and whether it had been reported to the Department of Health. Further interviews with the Corporate Administrator and Regional Director of Maintenance indicated that there were informal weekly calls with the facility owner to discuss issues, but no formal documentation of these discussions existed. The Regional Director of Maintenance did not consider the elevator issue as a loss of service since one elevator was operational. Attempts to contact the facility owner were unsuccessful, and the Assistant Chief Operating Officer, who worked closely with the facility operator, was also unaware of the exact timeline of the call bell system failure.

Penalty

Fine: $130,725

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 Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to address issues impacting resident safety, specifically regarding the malfunctioning centralized call bell system. Since April 2024, the call bell system had been out of service, leaving residents on the 3rd Floor Unit unable to call for assistance from their rooms or bathrooms. This deficiency also affected family members visiting residents and staff working in shower rooms, as they were unable to summon help when needed. Despite the ongoing issue, there was no documentation of meetings or plans to address the problem until September 2024. The facility was cited for Immediate Jeopardy at F919 due to the lack of an effective plan to ensure resident safety in the absence of a functioning call bell system. Additionally, the facility was cited for having only one working elevator and failing to notify the Department of Health about this ongoing issue. The QAPI meeting agendas from March and July 2024 did not mention the non-working elevator or the call bell system, and there was no evidence of monitoring the interim plan using tap bells for effectiveness and safety. The facility also did not document any input from residents, representatives, or direct care staff, nor did they inform the Governing Body or facility operator about the call bell system issues. Interviews with facility staff revealed that the Corporate Director of Nursing and the Corporate LPN were aware of the call bell issue in April 2024 and had implemented temporary measures such as tap bells and increased rounding. However, they were unsure if these measures were documented or if ongoing education and assessments were conducted. The call bell contractor confirmed that the facility first contacted them in April 2024, but work did not begin until September 2024 due to delays in receiving a deposit. The Corporate Administrator and Assistant Chief Operating Officer were also interviewed, revealing a lack of formal documentation and communication regarding the call bell issue with the facility owner.

Penalty

Fine: $130,725

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 comprehensive care plans for two residents were reviewed and revised as required. Resident #31, who was at moderate risk for falls, did not have their care plan updated to reflect current interventions to prevent falls. Despite the resident's fall on 8/27/24, there was no documented evidence that the care plan was updated to address the resident's ability to contact staff while the call light system was not functioning. The facility's call bell system had been malfunctioning since mid-April, and temporary tap bells were provided, but these were not placed in bathrooms, leaving residents without a means to call for help when needed. Resident #88, who was admitted with diagnoses including type II Diabetes Mellitus and absence of leg below the knee, did not have documented evidence of quarterly care plan meetings or updates since 2/27/24. The resident expressed anxiety due to the lack of a Social Worker to assist with housing needs and had not attended a care plan meeting in a long time. The Corporate Social Worker confirmed that the resident should have had two additional care plan meetings, but there was no documentation of these meetings or invitations to the resident or their representative. The facility's failure to update care plans and ensure proper communication and documentation of care plan meetings led to deficiencies in the care provided to these residents. The lack of updated interventions for Resident #31's fall risk and the absence of care plan meetings for Resident #88 highlight the facility's non-compliance with regulatory requirements for comprehensive care planning.

Penalty

Fine: $130,725

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 was found to have insufficient nursing staff to meet the needs of residents on all shifts, as revealed during the Recertification and Abbreviated Survey. Residents reported during a Resident Council meeting that the facility was short-staffed, particularly on weekends and various shifts, leading to delayed responses to call bells. Family members also noted the absence of staff during visits, and an analysis of staffing schedules from June to September 2024 showed the facility frequently fell below its minimum staffing levels. The Facility Assessment documentation confirmed that the staffing levels were inadequate for the facility's capacity of 120 residents. Interviews with staff further corroborated the deficiency in staffing. Several Certified Nurse Aides (CNAs) and Licensed Practical Nurses (LPNs) reported working excessive hours, often covering double shifts due to the lack of sufficient staff. The Director of Nursing and the Staffing Coordinator acknowledged the staffing challenges, noting that the facility did not have contracts with outside agencies and faced difficulties retaining staff due to its location. Despite offering bonuses, the facility struggled to maintain adequate staffing levels, leading to burnout among current staff. The deficiency in staffing resulted in residents experiencing delays in receiving care, such as infrequent bed linen changes, limited access to ice, and extended wait times for pain medication. The facility's staffing plan, which aimed for 3-4 CNAs on the day shift, 2-3 on the evening shift, and 1-2 on the night shift, was not consistently met. This inadequacy was highlighted by multiple instances where the actual staffing fell short of these targets, impacting the quality of care provided to residents.

Penalty

Fine: $130,725

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

Summary

The facility failed to thoroughly investigate alleged violations involving abuse, mistreatment, or neglect for a resident with severely impaired cognition and multiple diagnoses, including anxiety disorder and dementia. The resident's family reported observing bruises on the resident's hands on multiple occasions, which led to x-rays being performed. However, there was no documented evidence that the facility initiated an investigation into the injuries of unknown origin, as required by their policy. Additionally, the resident's Skin Integrity Care Plan was not updated to address the bruising, and there was no Abuse/Victim Care Plan in place. Interviews with facility staff, including the Administrator and Director of Nursing, revealed that no Accident and Incident reports were located for the resident, despite the requirement to report and investigate injuries of unknown origin immediately. The Medical Director noted that the resident was combative and had fragile skin, which could lead to bruising during care. However, there was no documented evidence that regular skin assessments were conducted as per physician orders, and the facility failed to communicate with the family about the resident's bruising.

Penalty

Fine: $130,725

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

Summary

The facility failed to ensure adequate supervision and a safe environment for Resident #102, who had a history of exit-seeking behaviors and was at risk for elopement. Despite being assessed as high risk for elopement and having a wander guard placed on their wrist, Resident #102 frequently removed the device. There was no documented physician order for the wander guard, and the resident's behaviors and safety measures were inconsistently documented by the nursing staff. The resident's care plan included interventions such as 15-minute checks and 1:1 supervision, but these were not consistently implemented or documented. On the night of the incident, Resident #102 eloped from the facility and was found by the police at an address away from the facility. The nursing supervisor had observed the resident in bed during rounds, but later, the Certified Nurse Aide (CNA) on duty heard an alarm and assumed it was the supervisor. The CNA did not check the stairwell due to being the only staff on the unit and did not realize the resident was missing until informed by the supervisor. The facility's alarm system was reportedly faulty, and the resident was not adequately monitored despite their known risk for elopement. Interviews with staff revealed systemic issues, including the lack of a physician's order for the wander guard, inadequate staffing, and failure to follow protocols for monitoring high-risk residents. The Medical Director and Corporate Director of Nursing acknowledged that residents assessed as high risk for elopement should not be placed near exit doors and should have proper safety measures in place. The facility's failure to implement and document appropriate interventions and supervision contributed to the resident's elopement.

Penalty

Fine: $130,725

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 each resident received an accurate assessment reflective of their status, as evidenced by the case of a resident with chronic obstructive pulmonary disease and neuromuscular dysfunction of the bladder. The resident's 8/8/24 Quarterly Minimum Data Set Assessment inaccurately documented their vision and oxygen use. Despite being cognitively intact, the resident was noted to have highly impaired vision and required continuous oxygen, as per the 5/27/24 Physician Order and the 8/24 Administration Record. However, the assessment incorrectly indicated that the resident could see fine details and did not use oxygen. During an observation on 9/06/24, the resident was found in bed with oxygen administered at 3 liters via nasal cannula, struggling to locate food on their tray and calling for help due to their impaired vision. The Minimum Data Set Coordinator admitted to overlooking the resident's vision impairment and oxygen use in the assessment, despite the administration record showing inconsistent documentation of oxygen use. This oversight led to the inaccurate coding of the resident's assessment, highlighting a deficiency in the facility's assessment process.

Penalty

Fine: $130,725

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 a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their medical needs. Resident #40, who was admitted with conditions including Parkinson's Disease and Peripheral Vascular Disease, developed a pressure ulcer that was not adequately documented or addressed in their care plan. Despite being readmitted with an unstageable pressure ulcer, there was no evidence in the medical record of a care plan to manage this condition. Observations and interviews revealed that the resident was not being repositioned frequently enough, and the care plan should have been initiated by the Registered Nurse upon the resident's return from the hospital. Resident #19, diagnosed with Type II Diabetes Mellitus, Major Depressive Disorder, and Atrial Fibrillation, was prescribed psychotropic medications but lacked a care plan with interventions to address the use of these medications. The nursing care plan for psychiatric drug use had a goal for maintaining the resident's psychosocial well-being but did not include specific interventions. The Minimum Data Set Coordinator acknowledged the absence of interventions, attributing it to being called away and not completing the plan. These deficiencies highlight a lack of comprehensive care planning for residents with specific medical needs.

Penalty

Fine: $130,725

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

Summary

The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards of practice. Resident #401, who was admitted with a diagnosis of pressure ulcer on the left heel, did not receive consistent documentation of treatments and weekly skin checks as per the physician's order and care plan. The physician's order for Santyl application to the left foot wound was not documented on several occasions, and there was no evidence of follow-up on the wound care team's recommendations for heel booties and an air mattress. Observations revealed that Resident #401 was not consistently using heel booties or an air mattress, as recommended by the wound care team. The resident was seen with an air heel lift boot, which was not ordered by a physician, and the boot was often not secured properly, leading to inadequate offloading of pressure from the heel. Interviews with staff, including a physical therapist and a licensed practical nurse, confirmed that the recommendations for offloading and the use of an air mattress were not implemented, and there was a lack of awareness and follow-up on the wound care team's notes. The deficiency was further highlighted by the lack of communication and documentation within the facility. The wound care team's recommendations were not entered into the electronic medical record in a timely manner, leading to a delay in implementing necessary interventions. Staff interviews indicated a lack of clarity on who was responsible for updating care plans and ensuring that physician orders were followed, contributing to the failure to provide adequate care for Resident #401's pressure ulcer.

Penalty

Fine: $130,725

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

Summary

The facility failed to ensure proper nutrition and hydration care for a resident with a significant weight loss of 9.79% over six months. The resident, who was admitted with conditions such as Chronic Obstructive Pulmonary Disease and Adult Failure to Thrive, had a care plan that required meal intake monitoring and assistance due to impaired vision. However, the facility did not consistently monitor the resident's meal intake as per the care plan, and the resident was not reassessed to determine the necessary level of assistance during meals. Observations revealed that the resident often did not consume food on multiple days, and there were instances where the resident was left unattended during meals, leading to inadequate nutrition intake. Interviews with staff, including a Registered Dietician, Occupational Therapist, and Certified Nurse Assistants, highlighted a lack of communication and documentation regarding the resident's needs and meal consumption. The staff were unaware of the resident's visual impairment, which affected their ability to feed themselves. The Occupational Therapist acknowledged the resident's vision problems and suggested methods like the clock method or divided plate, but these recommendations were not documented or communicated effectively to the nursing staff. The lack of consistent assistance and monitoring contributed to the resident's continued weight loss and inadequate nutrition management.

Penalty

Fine: $130,725

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

Summary

The facility failed to provide appropriate respiratory care to a resident, as evidenced by the administration of oxygen at a rate inconsistent with the physician's order. The resident, who was admitted with diagnoses including Coronary Artery Disease, Congestive Heart Failure, and Asthma, had a physician's order for continuous oxygen at 2 liters per minute. However, observations on multiple occasions revealed that the resident was receiving oxygen at 3 liters per minute via nasal cannula, contrary to the prescribed amount. The deficiency was further highlighted during an interview with a registered nurse who acknowledged that the oxygen concentrator was set between 2.5 to 3 liters per minute, rather than the ordered 2 liters per minute. The nurse admitted that during rounds, they only checked on the residents' well-being and did not verify the oxygen concentrator settings unless administering medications. This oversight led to the resident receiving an incorrect oxygen dosage, which was not documented in the Medication Administration Record for the specified date.

Penalty

Fine: $130,725

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 licensed pharmacist performed a monthly drug regimen review and reported irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing. This deficiency was identified during a recertification survey conducted from September 5 to September 17, 2024. The survey revealed that for three residents, there was no documented follow-up for drug regimen reviews from March to August 2024. Specifically, Resident #89, who had diagnoses including Metabolic Encephalopathy and Type 2 Diabetes, had no documented follow-up for drug regimen reviews despite irregularities being noted in reports from March to August 2024. Similarly, Resident #83, diagnosed with Dysphagia and Dementia, also lacked documented follow-up for the same period, and Resident #19, with diagnoses including Chronic Obstructive Pulmonary Disease and Type II Diabetes Mellitus, had no documented evidence of follow-up for irregularities noted in March and April 2024. Interviews with the Director of Nursing revealed that the facility had not been receiving the Drug Regimen Reviews until they started working at the facility in July 2024. The Director of Nursing stated that the pharmacist should send the Drug Regimen Reviews via email, and these should be handed to the medical providers for a response, with any ordered interventions put in place. However, there was no documented evidence in the electronic medical records or the Drug Regimen Review binder that the facility's medical provider received, reviewed, or acted upon the pharmacy drug regimen reviews for the residents in question.

Penalty

Fine: $130,725

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 all drugs and biologicals were labeled and stored according to professional standards, as observed during a recertification survey. In one instance, a resident with diagnoses of hepatic encephalopathy, hypothyroid, and neoplasm of the breast had a cup containing approximately ten pills left unattended on their bedside table while they were in the bathroom. The resident was unable to recall the purpose of all the medications, which included Aldactone, Vitamin E, Ursodiol, Tramadol, Propranolol, Amlodipine, Gabapentin, and Acidophilus. A Licensed Practical Nurse admitted to leaving the medications at the bedside due to a busy schedule, acknowledging that it would have been better to secure the medications in the medication cart until the resident returned. In another instance, a resident with chronic obstructive pulmonary disease, hypertension, and pressure ulcers had a bottle of Dakins' solution and a tube of Silver Sulfadiazine left on their bedside table. These items were intended for wound care, as per the physician's order, but were not stored securely. The same Licensed Practical Nurse stated that such treatments should be locked in the treatment cart and could not explain why they were left in the resident's room. These observations indicate a failure to adhere to proper medication storage protocols, as required by professional standards.

Penalty

Fine: $130,725

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 timely dental services for Resident #70, who was admitted with conditions including Dementia, Major Depressive Disorder, and Cerebrovascular Accident. The resident, who had no natural teeth and performed oral care independently, reported not having seen a dentist since admission. Interviews revealed that the facility's protocol was for residents to be seen by a dentist upon admission and as needed. However, despite transitioning to long-term care, the resident had not been evaluated by a dentist. The Licensed Practical Nurse and Director of Nursing acknowledged the oversight, indicating a lapse in communication and procedure adherence, as the Social Worker did not inform the team of the resident's need for a dental evaluation.

Penalty

Fine: $130,725

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

Summary

The facility failed to ensure proper food storage in accordance with professional standards for food service safety during a recertification survey. Observations revealed open and undated food items in the walk-in refrigerator, including chicken and tuna salads that exceeded their storage duration, and expired low-fat milk and orange juice boxes. In the walk-in freezer, there were boxes of frozen chicken thighs without expiration dates, one of which was open to air. Additionally, the dry food storage contained loose Mac orzo and egg noodle pastas in plastic bags without expiration dates. These findings indicate a lack of adherence to the facility's policy on food receiving and storage, which mandates labeling, dating, and discarding of opened items within specified timeframes. Interviews with the Food Services Director highlighted a lack of oversight and communication regarding food storage practices. The director acknowledged the expired items and the failure to discard them, attributing it to staff oversight. They also mentioned that the frozen chicken thighs were received without expiration dates and that a notification had been sent to the vendor without response. Furthermore, the director admitted to forgetting about a code system for identifying expiration dates, which was left by the previous director. This oversight contributed to the improper storage and handling of food items, as staff were not adequately informed or reminded of the necessary procedures.

Penalty

Fine: $130,725

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 establish and maintain an effective infection prevention and control program, as evidenced by the lack of enhanced barrier precautions for two residents with pressure ulcers. Resident #3, who has quadriplegia and a community-acquired pressure ulcer, was observed receiving care without staff wearing personal protective equipment (PPE). Additionally, there were no signs indicating the need for enhanced barrier precautions or PPE bins outside the resident's room. Interviews with staff revealed a lack of awareness and training on enhanced barrier precautions prior to the survey, despite the facility's policy requiring such measures. Resident #63, diagnosed with a stage 4 sacral pressure ulcer, was also subject to inadequate infection control practices. During a wound care observation, two LPNs were seen performing a dressing change without wearing the required PPE, despite recent in-service training on enhanced barrier precautions. The LPNs were unaware of the signage indicating the need for enhanced barrier precautions and the absence of a PPE cart outside the resident's room. The facility's infection control practitioner was unable to explain the lack of compliance with the established policy.

Penalty

Fine: $130,725

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

Summary

The facility failed to ensure proper notification procedures were followed for two residents regarding their transfer or discharge. For one resident, who was discharged to another facility in July 2024, there was no documented evidence that the Office of the State Long-Term Care Ombudsman was notified of the discharge. The facility's policy required such notifications to be sent, but interviews with the Director of Nursing and the Regional Manager of Operations revealed that they could not verify if the notification was sent. This oversight indicates a lapse in adhering to the facility's policy and state regulations. Another resident, who was transferred to a hospital in June 2024 due to seizures, did not have their Health Care Proxy notified of the transfer. The facility's policy required immediate notification of the resident's representative in such cases, but there was no documentation in the electronic medical record to confirm this occurred. Interviews with the Health Care Proxy and facility staff, including a Nurse Practitioner and a Registered Nurse, confirmed that the notification was not made, highlighting a failure in communication and documentation processes within the facility.

Penalty

Fine: $130,725

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 received the necessary assistance for bathing, resulting in deficiencies in personal hygiene for two residents. Resident #104, who was admitted with diagnoses including Anxiety Disorder, Dementia, and Hypokalemia, did not receive 41 scheduled showers between May 2023 and September 2023. Despite having a care plan that required extensive assistance with bathing, there was no documented evidence of showers being provided as scheduled. Interviews revealed that staff shortages and lack of documentation contributed to the failure to provide showers, with a complainant noting the resident's unkempt appearance and the need to provide personal hygiene products themselves. Resident #105, admitted with diagnoses including Epileptic Seizures, Overactive Bladder, and Spondylolisthesis, did not receive 12 scheduled showers between December 2023 and January 2024. Additionally, there was no documented evidence of skin checks being performed as per physician orders. Interviews with staff indicated that insufficient staffing and chaotic conditions on the unit hindered the ability to provide showers and document care. The Director of Nursing acknowledged the responsibility of Nurse Managers to ensure showers were given and documented, highlighting a systemic issue in monitoring and recording resident care.

Penalty

Fine: $130,725

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 physician reviewed the total program of care for two residents, leading to deficiencies in their care plans. Resident #102, who was assessed at high risk for elopement, did not have a physician order for the placement and function check of a wander guard, despite having one placed on their wrist. The resident's care plan and medical progress notes indicated the presence of a wander guard, but there was no documented physician order for it. Interviews with staff, including a Licensed Practical Nurse and the Medical Director, confirmed that a physician order was required for residents with wander guards, and this oversight occurred during the admission process via telehealth. Resident #104, admitted with severe cognitive impairment and a diagnosis of malignant neoplasm of the supraglottis, did not receive follow-up care as per hospital discharge instructions. The discharge summary recommended an oncologist follow-up within 1-2 weeks and a repeat CT scan within 3-6 months, but there was no evidence of these actions being taken in the resident's physician orders and progress notes. The Medical Director acknowledged the oversight, stating that the focus was on the resident's current condition rather than following the discharge instructions, and emphasized the need for reviewing orders to ensure compliance with hospital discharge summaries.

Penalty

Fine: $130,725

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 each Certified Nurse Aide (CNA) received the required twelve hours of in-service education per year based on their individual performance review. This deficiency was identified during a Recertification Survey conducted from September 5 to September 17, 2024. The survey revealed that eight CNAs did not have documented evidence of performance reviews completed at least once every 12 months. The facility's assessment indicated that education was primarily provided by the Director of Nursing/Staff Educator, with several sessions scheduled to accommodate all shifts. However, there was no documentation to support that the CNAs received the mandatory education as required by regulation. Interviews conducted during the survey further highlighted the deficiency. The Director of Nursing acknowledged that CNA education was previously managed by the corporate team but stated that they would take over the responsibility moving forward. CNAs interviewed could not recall receiving the required 12 hours of in-service training or having performance evaluations. One CNA mentioned receiving in-service education on specific topics but could not remember the duration, while another CNA recalled signing off on in-services without recalling the content or duration. This lack of documentation and recall indicates a failure in the facility's process to ensure compliance with the regulatory requirements for CNA education and performance evaluations.

Penalty

Fine: $130,725

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 free from significant medication errors, as observed during the Recertification Survey and Abbreviated Surveys. Specifically, two residents experienced multiple medication omissions. Resident #105, who had intact cognition and was taking nine or more medications for various conditions including hypertension, anxiety, and depression, had numerous instances where medications were not administered as documented in the Medication Administration Record (MAR). These omissions included critical medications such as antihypertensives, antibiotics, antidepressants, and thyroid hormones, with no documented reasons for the omissions. Additionally, Resident #19, diagnosed with chronic obstructive pulmonary disease, type II diabetes mellitus, and major depressive disorder, experienced multiple missed doses of insulin, a crucial medication for managing blood sugar levels. The MAR for September 2024 showed several instances where insulin was not administered, and no reasons were documented for these omissions. Interviews with nursing staff revealed that medication administration was often delayed or omitted due to staffing issues, with only one nurse available on the unit at times, leading to incomplete documentation in the MAR. Interviews with facility staff, including the Corporate Director of Nursing and the Medical Director, highlighted systemic issues in medication administration and documentation. The Director of Nursing acknowledged the problem of medication omissions and the need for improvement. The Medical Director emphasized the importance of insulin administration for Resident #19 and noted that they were not informed of the missed doses. The facility's policy requires that all medication administrations be documented immediately, and any omissions be reported to the appropriate supervisory staff, which was not consistently followed in these cases.