Cityview Healthcare And Rehabilitation

Penalty

No penalty information released

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

Summary

The deficiency involves failure to store and maintain food and food service areas in a clean and sanitary manner in accordance with professional standards and facility policy. During a kitchen tour, surveyors observed a moderate amount of dried white splatter on the backside of the stove, and a tray between the stove top and oven that contained various food items, such as corn, with dried brown stains underneath once the tray was removed. Additionally, the silver plate portion of the wall to the right of the three-compartment sink had a moderate amount of various dried food splatter. The Dietary Manager confirmed these observations. Further observations on nursing units showed additional sanitation and food storage issues. On one nursing unit refrigerator, surveyors found a moderate amount of dried brown splatter throughout the interior and on the inside door shelves, and the freezer contained various stains and food debris; a Licensed Social Worker confirmed these findings and stated that night shift staff were responsible for cleaning the refrigerator. On another nursing unit refrigerator, surveyors observed a tray of five peanut butter and jelly sandwiches, a dessert dish with fruit covered with a plastic lid, and a half-full pitcher of orange juice, all without labels or dates, as well as two pitchers of frozen water in the freezer also without labels or dates; an LPN confirmed these findings. Review of the facility’s sanitation policy showed that food service areas were required to be maintained in a clean and sanitary manner and kept free from litter and protected from pests, which 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 deficiency involves the facility’s failure to maintain a clean, sanitary, and well‑maintained environment in resident rooms and common areas, as identified through multiple observations and staff and resident interviews. During an environmental tour with the ADON, surveyors observed structural damage such as a hole in a bathroom ceiling, a hole in a wall with a cable cord fed through it, cracked floor tiles in several rooms, a cracked window in a dining room, missing ceiling tiles exposing wiring and a water pipe, missing window blinds, and a detached baseboard heating/cooling cover. Additional findings included a detached soap dispenser left on top of a closet, multiple water‑stained ceiling tiles in numerous rooms and hallways, cracked tile around a shower drain, missing covers on overhead lights, rusted air vents, and cracked vanity bases with pieces on the floor. The ADON verified all of these findings during the tour. Further observations showed multiple cleanliness and sanitation issues. These included a heavily soiled wedge pillow with visible dirt and debris, a torn, worn, and discolored pillow without a pillowcase, torn and tattered upholstery on chairs and wheelchair armrests with exposed padding, a torn and debris‑containing fall mat, and privacy curtains in multiple rooms with varying degrees of staining. Floors in several areas, including resident rooms and dining rooms, were described as dirty, sticky, or with significant staining and dirt accumulation, and crumbs and dirt were noted under a radiator in a dining room. A personal mini‑refrigerator in a resident room had gnats flying around it and contained leftover fast food items. A radiator vent in another resident’s room was heavily dusty, which the resident stated had been that way for a while; the housekeeper confirmed the condition and reported that the available duster did not clean the vents well. The housekeeping supervisor and housekeeper verified the environmental and cleanliness findings during interviews. This deficiency was investigated under Complaint Number 2688708.

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 maintain resident rooms and common areas at comfortable temperatures to ensure a safe, clean, comfortable, and homelike environment, including safe supports for daily living. During resident interviews, one resident reported that his room was often too warm, another stated his room was really warm, and a third resident said she frequently had to tell staff that her room was too warm. On the same day, observations and temperature measurements conducted on the Blue Sky Living Unit (400 Hall) between 8:45 A.M. and 9:15 A.M. with an LPN showed multiple resident rooms and common areas with elevated temperatures: one room measured 88°F, others measured 85.6°F, 86.5°F, 84.6°F, 83.5°F, 81.6°F, and 83.3°F, the hallway measured 82.6°F, and the dining room measured 81.9°F. The LPN confirmed all recorded temperatures at the time of discovery. This deficiency was determined to have the potential to affect all 24 residents residing on the Blue Sky Living Unit (400 Hall), out of a total facility census of 91 residents, and was investigated under Complaint Number 2688708.

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 ordered large portions received meals consistent with those diet orders and the facility’s own portion policy. Resident Council minutes over several consecutive months documented repeated resident complaints about not getting what they were supposed to get, not having enough food on their plates, and menus not matching what was served. During a lunch meal observation, the Dietary Manager served two servings of the main entrée for large portion diets but only one 4-ounce serving of each side item (baked beans and vegetables or rice and green beans), despite the facility policy defining a large portion as 1.5 times the standard portion for all components. Review of the diet order report showed that 34 residents were ordered large portions at meals. Surveyors observed that a resident on a large portion renal diet received one hamburger on a bun and single 4-ounce servings of rice and green beans, and another resident on a large portion regular diet received one sausage on a bun and single 4-ounce servings of baked beans and California blend vegetables. The Regional Dietary Manager confirmed these residents did not receive large portions as ordered. The facility’s policy on large, small, and double portions specified that large portions are a modest increase above the standard portion (1.5 times) and should be measured consistently using predetermined guidelines, such as 1.5 scoops instead of one scoop. The Dietary Manager acknowledged misunderstanding the policy, believing it meant a double entrée while still providing only standard portions of side items. The Activity Director, who began in December, confirmed that residents consistently complained in Resident Council about not receiving enough food. This deficiency was investigated under two complaint numbers and had the potential to affect 34 residents receiving large portions.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a dignified living environment for a cognitively intact resident who witnessed a physical altercation between staff members. Resident #17, admitted with paraplegia, end stage renal disease, and mental health diagnoses including anxiety disorder and major depressive disorder, had a BIMS score of 15, indicating intact cognition. The resident reported observing a physical fight between staff members a couple of months prior, though he did not want to discuss details and stated the fight could have been avoided. Staff interviews confirmed that a physical altercation occurred between CNA #501 and Laundry Aide #619 on the facility elevator, beginning as yelling and shoving and then becoming more physical, with the elevator doors opening during the incident such that it was likely the resident witnessed part of the fight. The DON confirmed the location and nature of the altercation and acknowledged that it was likely the resident saw part of the incident when the elevator doors opened and other staff intervened. Both involved staff confirmed they were in a physical fight following a prior verbal altercation and that the elevator doors opened during the incident, though they were unsure if residents witnessed it. The Administrator and HR Director denied knowledge of a physical fight or suspensions, stating only that the staff were sent home after a verbal altercation and declined to share investigative findings. Review of personnel records for the two staff members showed no documentation of disciplinary actions related to a physical fight, despite the employee handbook stating that threats or actual physical violence are not permitted and may result in termination. Timesheet reviews showed both staff were absent from work for several days following the incident, consistent with their reports of being suspended, but without corresponding documentation, contributing to the finding that the facility failed to ensure residents were provided with a dignified living 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 deficiency involves the facility’s failure to notify the resident’s legal guardian of a significant change in condition and hospitalization, as required by facility policy. A resident with dementia, schizoaffective disorder (depressive type), impulse disorder, HIV, and generalized anxiety disorder was admitted on 11/08/23 and had a documented guardianship letter indicating that the resident’s sister was the legal guardian. On 01/07/26 at 9:38 A.M., the resident reported shortness of breath, with vital signs showing blood pressure 127/65 mmHg, temperature 99.0°F, respirations 16, and oxygen saturation of 74%. An LPN notified the physician, applied 2 liters of oxygen per order, and called EMS for transfer to the hospital, documenting that the guardian was notified. A subsequent progress note at 3:44 P.M. documented that the resident was admitted to the hospital for acute respiratory hypoxic failure related to possible pneumonia, and the RN Unit Manager documented that the guardian was notified of the admission. However, in interview, the RN Unit Manager stated she called the resident’s sister (the legal guardian) around 2:00 P.M. to follow up after the transfer, while the LPN reported that she had notified the resident’s mother by telephone of the change in condition and transfer, believing the mother to be the guardian. The Licensed Social Worker confirmed that the sister was the legal guardian and stated that the guardian had given approval to contact the resident’s mother, but was unable to provide evidence of this conversation. The facility’s January 2026 “Notification of Change in Condition” policy required the nurse to notify the resident’s physician and legal representative when there was a significant change in status, and this was not followed for the legal guardian at the time of the change in condition and transfer.

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 protect residents from abuse, specifically resident-to-resident physical abuse, despite clear behavioral histories and observable warning signs. For one resident, identified as Resident #64, the medical record showed cognitive intactness with mild depression, a history of mood distress and anxiety, and a care plan focused on emotional support and alternative therapies. On 03/22/26, a progress note documented an abrasion on Resident #64’s forehead. Another resident, Resident #80, had diagnoses including psychoactive substance abuse, PTSD, anxiety, depression, bipolar disorder, and a history of restlessness and agitation. Her care plan documented moderate to intense anger, poor listening skills, defensiveness, and verbally aggressive behavior, with interventions to administer medications as ordered and to anticipate and remove triggers for agitation. According to the self-reported incident and witness accounts, Resident #80 entered Resident #64’s room after reportedly becoming upset, told the roommate to be quiet, and threw a can of shaving cream toward Resident #64, resulting in an abrasion to his head. A CNA’s witness statement and an LPN’s interview confirmed that Resident #80 went into the room, instructed the roommate to “shush,” and threw the shaving cream can at Resident #64’s head, after which she fell while returning to her wheelchair. Resident #80 reported that she was extremely upset, retrieved the shaving cream, entered the room, got out of her wheelchair, and threw the can at Resident #64, though she claimed it missed. Resident #64 stated he did not smoke, denied provoking Resident #80, and reported that she entered uninvited and caused the injury to his forehead. Despite these accounts and the documented injury, the Administrator stated he could not substantiate resident-to-resident abuse because he believed Resident #80 did not have logical common sense to think it through, indicating the facility did not recognize or classify the event as abuse in accordance with its own definition of willful infliction of injury. A second incident involved Resident #11 and Resident #102, both cognitively intact per their MDS assessments and able to understand and make themselves understood. Resident #11 had schizoaffective disorder, used a wheelchair, required supervision or touch assist for transfers, and was care planned to reside in the Connections Community due to aggressive behaviors related to schizophrenia. On 11/27/25, documentation showed Resident #11 had a scratch to the cheek and a reddened area, and a progress note recorded that he alleged an altercation with a peer, after which the residents were separated and the physician notified. An SRI described that Resident #102 went to Resident #11’s room, blocked the doorway, refused to move when asked, and then hit Resident #11 in the face; however, the facility later marked this allegation as unsubstantiated, stating evidence indicated abuse, neglect, or misappropriation did not occur. Resident #102’s record showed schizoaffective disorder and major depressive disorder, with care plans noting behavior problems including aggression, destruction of property, refusal of medications, pouring and drinking urine, and sexual inappropriateness. A psychiatric note shortly before the incident documented decreased behaviors and aggression while on medications. Progress notes indicated that Resident #102 had been on a leave of absence with family and remained on leave over several days. An LPN interview revealed that on the day of the altercation, she witnessed Resident #11 attempting to enter his room while Resident #102 blocked the doorway and then punched Resident #11 in the face without provocation. The same LPN reported that Resident #102 had been aggressive all day, cussing at staff and residents, yelling, refusing medications, and that his sister reported he had not taken his medications during the leave of absence; he also refused medications upon return. Despite these documented behaviors and the witnessed physical strike, the facility did not implement new interventions for Resident #102 in response to his medication refusal and escalating aggression and concluded the allegation of abuse was unsubstantiated, contrary to the facility’s policy requiring ongoing assessment, care planning, and monitoring for residents with aggressive behaviors. The facility’s abuse policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and clarified that “willful” meant the individual acted deliberately, not that they intended to cause harm. The policy also required ongoing assessments and care planning for residents with verbally or physically aggressive behaviors and those who wander into other residents’ rooms. In both incidents, residents with known behavioral and psychiatric histories engaged in deliberate physical acts—throwing an object and punching another resident—that resulted in documented injuries or skin alterations. Nonetheless, the facility’s investigations concluded that the allegations were unsubstantiated and did not reflect the policy’s definition of abuse or its prevention requirements, demonstrating a failure to ensure residents were free from abuse and to use appropriate assessment and care-planning processes for residents with known behavioral risks.

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 protect two residents from physical abuse by another resident with a known history of physical aggression related to mental illness. One resident had severely impaired cognition, bipolar disorder with psychotic features, a history of traumatic brain injury, and exhibited verbal behaviors directed at others. Another resident had intact cognition but carried diagnoses including schizophrenia, borderline personality disorder, obsessive compulsive disorder, and bipolar disorder. The aggressive resident had a care plan in place since admission identifying potential for physical aggression and interventions such as counseling on conflict management, walking away from peers, and seeking staff assistance when conflicts arose. On one occasion, staff witnessed the aggressive resident strike a cognitively impaired resident in the dining room. The injured resident reported being hit in the face by the aggressor. A general note documented a skin tear to the left chin, and the resident was sent to the hospital, where a thick layer of dermal glue was applied and bruising to the left eye was noted. Although the self-reported incident and investigation confirmed that the aggressor hit the resident, the written witness statements and investigation did not document what object was used. In a later interview, the DON stated that the resident had been hit with a [NAME] that had a wooden handle and rubber head, and staff believed the object was obtained from a maintenance cart. On a separate occasion, the same aggressive resident struck another resident in the back of the head in a hallway following an argument over a composition notebook, which was later found in the aggressor’s room. A housekeeper reported seeing the argument that resulted in the aggressor hitting the other resident, and a CNA described the aggressor as very aggressive that morning. The injured resident sustained a laceration to the back of the head, was sent to the hospital, and returned with two staples in the crown of the head and a CT scan showing no additional anomalies. In an interview, this resident confirmed being hit in the head with a rock by the same aggressor and expressed relief that the aggressor was no longer present. These events demonstrate that the facility did not prevent physical abuse between residents despite prior knowledge of the aggressor’s behavioral risks and existing care plan interventions.

Penalty

Inspection fine: $26,685

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

Summary

A resident with diagnoses including schizophrenia, dementia, muscle weakness, and difficulty walking, who resided on a secured unit due to aggressive behaviors and risk for wandering, was able to access a locked soiled utility room containing a laundry chute on the third floor. The resident subsequently fell through the laundry chute to the facility's basement, where he was found inside a laundry bin by the Maintenance Director. The only points of entry to the basement laundry chute room were the chute itself and a locked door, confirming the resident's path of entry. At the time of discovery, the resident had visible injuries including bleeding around the mouth and eye, and a large bump on the hand. Staff interviews and record reviews revealed that the lock on the third-floor soiled utility room had been malfunctioning for approximately a week prior to the incident, and staff, including the former administrator, had been made aware of the issue. Despite the resident's known risk for wandering and the requirement for supervision, the resident was able to leave the secured unit undetected during lunch service. Documentation and investigation into the incident were incomplete and inconsistent, with discrepancies in staff accounts and a lack of comprehensive assessment or immediate summoning of emergency services prior to moving the resident from the scene. The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent the accident. The resident sustained multiple traumatic injuries, including a C6 compression fracture, an acute T4 anterior fracture, and multiple rib fractures, requiring hospitalization and subsequent transfer to a long-term acute care hospital. The incident affected one of three residents reviewed for accidents, and the facility census at the time was 88.

Removal Plan

• Instructed Licensed Practical Nurses (LPN) #283, #291, #303, and #342 to conduct head counts of their units to ensure all residents were accounted for and had not wandered off their units.
• Checked the soiled utility room containing the laundry chute on the 200 unit to determine if the door was locking properly.
• Checked the soiled utility room containing the laundry chute on the 400 unit to determine if the door was locking properly.
• Checked the soiled utility room containing the laundry chute on the 300 unit to determine if the door was locking properly.
• Coordinated an ad hoc Quality Assurance (QA) meeting to discuss the incident with Resident #51. A root cause analysis was performed, and the team discussed a plan to prevent the incident of a resident wandering into secured places and/or off the unit.
• Decided to re-educate staff on the importance of ensuring the utility room doors were latched and always locked, after each entry and exit, as well as installing an extra lock on each (laundry) chute access on each unit.
• Additional staff training would include ensuring residents on secured units were always supervised and present on their units, ensuring maintenance work orders and all work orders would be placed into TELS (an electronic method for placing, tracking, and communicating work orders that are needed) and emergency orders would be additionally communicated to the Administrator.
• RCSRN #401 and Unit Manager (UM) LPN #287 conducted wandering assessments on 87 current residents.
• Identified 15 residents who triggered as high risk for wandering; the remaining 72 in-house residents were identified as low risk for wandering.
• Installed padlocks on the laundry chute access doors on all three resident care units.
• The DON, ADON #279, UM LPN #253, UM LPN #287, and RCSRN #401 educated all staff on the importance of ensuring utility room doors where the laundry chutes were contained were latched and always locked after each entry and exit.
• Staff were educated that an extra lock had been applied to the chute access doors on each unit and ensuring the padlocks were in a position after each use.
• Staff were additionally educated on ensuring residents on secured units were supervised and ensuring maintenance work orders were placed into TELS and emergency orders communicated to the Administrator.
• All staff education was completed.
• Implemented a plan that all new hires would be educated during orientation by the Administrator or designee on ensuring utility room doors were secured when not in use, the process for submitting maintenance work orders, and ensuring emergency orders were communicated to the Administrator.
• Additional new hire training would ensure laundry chute doors would be always locked when not in use.
• The DON or designee began ongoing audits for all three soiled utility rooms in which the laundry chute access was contained, five days per week, for a duration of four weeks to ensure all doors and chutes were locked and secured appropriately. The results of the audits would be reviewed in the facility's QA meetings.
• The DON or designee implemented ongoing, every shift head counts at the end of each nursing shift to ensure all residents were accounted for. The DON or designee would complete these head counts every shift, seven days per week, for a duration of four weeks. The results of the audits would be reviewed in the facility's QA meetings.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe, clean, and homelike environment for multiple residents on the third floor nursing unit, as evidenced by direct observations, interviews, and record reviews. In one resident's room, there was a persistent puddle of water on the floor due to a leaking ceiling and a disconnected sink drain, which had been ongoing for two to three months. The sink and counter were partially pulled away from the wall, and both the soap and paper towel dispensers were missing, with visible wall damage where they had been ripped off. The room also lacked a cover for the light bulbs above the sink and the thermostat, and the bathroom door would not stay closed, requiring a trash can to keep it shut. These issues were confirmed by housekeeping staff, the DON, and the maintenance supervisor, who indicated that some of the problems had not been reported or addressed in a timely manner. Additional observations on the same unit revealed widespread stained ceiling tiles in several residents' rooms and a broken light cover in another room. In one resident's room, the shared bathroom was found to be dirty, with urine stains and a strong odor, which was confirmed by both the resident and an LPN. The facility's housekeeping policy required rooms and bathrooms to be clean, free of odors, and for dispensers to be checked and replaced as needed, but these standards were not met in the observed areas. The facility also failed to ensure that phone calls were answered in a timely manner, which had the potential to affect all residents. There were documented instances where phone calls to the facility went unanswered for extended periods, including one call that rang 28 times without being answered and another that rang 18 times before being picked up. Staff interviews revealed that there was no receptionist on night shift, and nursing staff were sometimes too busy to answer the phone, despite the expectation that calls should be answered within three rings. This issue was further highlighted by a fire department incident report noting a delay in entering the building due to no one being at the front desk.

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 scheduled activities and did not implement care planned interventions for several residents, resulting in unmet psychosocial and recreational needs. Multiple observations and interviews revealed that activities listed on the facility's activity calendars, such as manicures, cards, hydration carts, bingo, and group discussions, were not conducted as scheduled across various nursing units. Staff and residents consistently reported that activity staff were often absent, and scheduled activities were not provided, with some staff attributing this to activity aides being off work or reassigned to supervise smoke breaks. Additionally, documentation of resident participation in activities was inconsistent or missing, with activity aides lacking access to the electronic system and resorting to informal paper records, which were not always maintained or transferred to the official record. Several residents with cognitive and physical impairments, including those with hemiplegia, schizoaffective disorder, dementia, and paraplegia, expressed feelings of boredom, isolation, and disappointment due to the lack of activities and outings. Residents reported that they were not encouraged or assisted to attend activities, were not taken outside except for smoke breaks, and had not participated in planned community outings such as zoo trips, which were canceled due to lack of transportation. Some residents noted that broken recreational equipment, such as video games and air hockey tables, further limited their options for engagement. Interviews with staff confirmed that activities were not provided as scheduled, and that there were no activities on weekends or during certain shifts, leading to increased resident boredom and behavioral issues. Review of care plans and medical records for affected residents showed that interventions to encourage participation in activities, socialization, and outings were not implemented. Residents' preferences for specific activities, outdoor time, and pet therapy were not honored, and there was little evidence of one-to-one or self-directed activity participation. The facility's own policy required the provision of meaningful experiences and a variety of activities, but observations and documentation revealed that these standards were not met. The lack of consistent activity programming and failure to follow care plans had the potential to affect all residents in the facility.

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 timely and appropriate incontinence care for two residents who were dependent on staff for all activities of daily living. For one resident with diagnoses including senile degeneration of the brain, Parkinson's Disease, and paranoid schizophrenia, observations revealed the resident was wearing two incontinence briefs, both soaked with dark yellow urine and containing a moderate amount of hard brown feces. Staff noted the resident had not been changed in a while, and the resident cried out in pain during care, with visible redness on the inner buttocks. Additionally, one CNA failed to change soiled gloves or perform hand hygiene before applying a clean brief, contrary to facility policy. For another resident with dementia, anxiety disorder, and adult failure to thrive, staff observed a large amount of dark yellow urine in the incontinence brief, which appeared to have been present for some time. The resident was also found with a folded blanket and a reusable chux pad under the buttocks, with the blanket showing dried urine. Staff indicated these items were likely used for added protection against incontinence, but this was not in line with standard practice. During care, the resident was left uncovered from the waist down while a CNA left the room to gather supplies. Both incidents were observed to be inconsistent with the facility's incontinence care policy, which requires cleansing with perineal wash, proper glove use, hand hygiene, and changing linens and clothing as needed. The deficiencies were identified through observation, interview, and record review, and affected two out of three residents reviewed for incontinence 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

Staff failed to follow physician orders and care plan interventions for Enhanced Barrier Precautions (EBP) for a resident with a feeding tube. The resident, who had diagnoses including unspecified dementia, anxiety disorder, and adult failure to thrive, was dependent for activities of daily living, frequently incontinent of urine, always incontinent of bowel, and received the majority of nutrition via a PEG tube. Physician orders and the care plan required the use of EBP, including donning gowns and gloves during high-contact care activities such as incontinence care and tube feeding management. During observation, two CNAs and an LPN provided incontinence care and managed the resident's tube feeding without donning isolation gowns, despite clear signage and facility policy requiring this PPE for such activities. The staff's clothing came into contact with the resident, bed, and linens during care. Interviews confirmed that the staff did not wear the required gowns, and the LPN was unaware that a gown was necessary for tube feeding care. The facility's policy, updated in 01/2025, specified that EBP must be used for residents with indwelling medical devices, including feeding tubes, during high-contact care activities.

Penalty

Inspection fine: $26,685

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 comprehensive, individualized, and effective interventions to meet the behavioral health care needs of a resident with significant psychiatric history. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, dementia, anxiety, antisocial personality disorder, hallucinations, body dysmorphic disorder, and a history of suicide attempts, was found unresponsive in a communal shower room due to a self-inflicted injury. This incident occurred after an LPN provided the resident with a pair of scissors to cut his hair, without reviewing the resident's care plan or providing supervision. The resident's care plan included supervision while shaving and noted a history of self-harm and suicidal ideations. Despite this, the LPN did not check the resident's care plan or Kardex before giving the scissors, which were described as safety scissors with a rounded blunted end. The resident was left unsupervised with the scissors, leading to a self-inflicted injury that resulted in significant blood loss and ultimately, the resident's death. Interviews with staff revealed that there was no indication or concern that the resident was suicidal at the time, and no behaviors or statements suggested self-harm intentions. However, the facility lacked a policy addressing suicidal behavior, residents at risk for self-harm, or sharp object safety, which contributed to the incident. The root cause analysis concluded that the incident was due to the LPN providing the resident with a sharp object, which should not have occurred.

Removal Plan

• Resident #93 was noted with acute blood loss, Emergency Medical Services (EMS) was notified, and Resident #93 was transported to a local emergency room (ER) by local EMS providers.
• LPN #500 was immediately provided 1:1 verbal education by the DON on not providing sharp objects to residents.
• LPN #500 was suspended by the Administrator following the incident, pending a thorough investigation. LPN #500 was permitted to return to work.
• The Director of Nursing (DON), ADON #270, Unit Manager #267, Housekeeping Supervisor #283, Human Resource Manager #262, Licensed Social Worker (LSW) #246, Central Supply #317 and Admissions Director #216 completed a whole house sweep for sharp objects with no sharp objects noted.
• All residents were assessed, and medical records were reviewed (including psychiatric/provider notes) to identify those residents who had self-harm and/or suicidal ideation history. In addition, those who could be, were interviewed, related to suicidal ideation/self-harm. Eleven residents (#100, #15, #16, #28, #33, #38, #40, #101, #57, #61, and #102) were identified as at risk for self-harming behaviors. Care plans and associated Kardex's were reviewed by Regional Clinical Support Nurse #244.
• All staff were interviewed regarding any knowledge of residents exhibiting any signs, symptoms, or behaviors which could be indicative of suicidal ideations. This was completed by the Administrator.
• Regional Clinical Support Nurse #244 educated all facility interdisciplinary team members (IDT) on updating care plans for resident(s) who have suicide ideations/self-harm and pulling them to the Kardex.
• All staff were educated by the DON/Designee on reviewing residents' Kardex, ensuring residents were free and safe from self-harm, and assisting and providing supervision to residents as deemed necessary.
• The Administrator completed a quality assessment and performance improvement (QAPI) and a root cause analysis with the Medical Director, DON, ADON #270, Regional Clinical Support Nurse #244, Medical Records #317, Human Resources Manager #262 and LSW# 246. The facility root cause analysis identified the nurse (LPN #500) gave Resident #93 a sharp object and should not have. The facility corrective action plan involved mitigating the risk and availability of sharp objects and identifying those residents at risk for self-harm or suicidal ideations.
• The DON/Designee began random, ongoing resident audits on care plans for residents with a history of suicidal ideations and/or self-harm. The ongoing audits were completed four times weekly for a total of six weeks.
• The DON/Designee began random, ongoing audits of staff competencies regarding staff utilization of the resident Kardex's. The audit reviewed five random staff members four times weekly for a total of four weeks.
• The Administrator held a QAPI meeting with the DON, ADON, Medical Director, Activities Director #201, Medical Records Coordinator #317, Human Resource Manager #262, Regional Clinical Support Nurse #244 and LSW# 246 to discuss the findings of the facility audits.

Penalty

Inspection fine: $26,685

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 an incident of potential neglect involving a resident to the State Agency as required. The resident, who had a history of schizoaffective disorder, bipolar disorder, dementia, and other mental health conditions, was found in a critical state with significant blood loss from the groin area. The resident was transported to a hospital where he was pronounced deceased. The facility's investigation revealed that the incident was caused by a Charge Nurse providing the resident with a sharp object, specifically a pair of safety scissors, without supervision, despite the resident's care plan indicating the need for supervision during activities like shaving. The resident's care plan highlighted several mental health issues, including a history of self-harm and suicidal ideations, and required supervision for certain activities due to these conditions. Despite this, the LPN provided the resident with scissors without consulting the care plan or providing supervision. The LPN believed the resident was independent in activities of daily living and did not exhibit aggressive behaviors, which led to the decision to give the scissors. The facility's administrator confirmed that the incident was not reported to the State Agency, believing it to be an accident and not reportable. The facility's policy required the investigation of all alleged violations involving abuse, neglect, and injuries of unknown source, but the administrator did not consider the incident as such. This oversight represents a deficiency in the facility's compliance with reporting requirements for incidents of potential neglect.

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 protect residents from resident-to-resident physical abuse, affecting five residents. Resident #2, who was severely cognitively impaired, was involved in multiple incidents of aggression towards other residents. On one occasion, Resident #2 kicked Resident #23 in the leg, and on another, hit Resident #21 in the face over a dispute involving a television remote. Additionally, Resident #2 hit Resident #20 in the head, causing him to fall to the floor. These incidents highlight a pattern of aggressive behavior by Resident #2 towards other residents. Resident #22, who was cognitively intact, was involved in an incident where he scratched Resident #2 in the face. This occurred as Resident #2 attempted to punch Resident #22, and Resident #22 acted in self-defense. The facility's records indicate that Resident #2's aggressive behavior was a recurring issue, necessitating intervention to prevent further incidents. The facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property emphasizes the right of residents to be free from abuse. However, the incidents involving Resident #2 demonstrate a failure to uphold this policy, as multiple residents were subjected to physical aggression. The facility's response to these incidents included immediate interventions, but the deficiency lies in the initial failure to prevent the abuse from occurring.

Penalty

Inspection fine: $25,847

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 environment free from potential accident hazards when smoking materials were not secured, leading to unsafe smoking practices in resident rooms. This deficiency was observed when Resident #38, who required staff supervision and a smoking apron, was found alone in his room with a strong cigarette odor and visible smoke. The room, shared with Resident #37, had cigarette ashes on the bathroom floor, burn marks on the toilet seat and toilet paper holder, and cigarette butts in a trash can. Resident #37, who was away from the facility at the time, had been previously observed smoking in the room. Resident #37 had impaired cognition and was assessed to require supervision while smoking, as documented in his care plan and a Last Chance Agreement. Despite these measures, the facility did not prevent him from smoking unsupervised in the room. Resident #38, with intact cognition, also required supervision and a smoking apron while smoking, yet was found in a room with evidence of smoking. The presence of oxygen in a nearby room further heightened the risk of potential harm. The facility's policy stated that smoking was only permitted in designated areas and that smoking materials should be kept locked. However, the facility did not have effective systems in place to ensure compliance with these policies, as evidenced by the presence of smoking materials in the residents' room and the lack of adherence to supervision requirements. This oversight posed a significant risk to the safety of the residents and the facility.

Removal Plan

• Conduct room sweeps on all resident rooms for the presence of smoking materials.
• Search Resident #37's room and secure any smoking materials identified.
• Search Resident #38's room and person and secure any smoking materials identified.
• Assess Resident #32, Resident #37, and Resident #38 for injuries.
• Re-educate all staff on the facility smoking policy and procedure related to supervision of residents who smoke.
• Re-educate all 64 residents who smoke on the smoking policy, which includes residents smoking only in designated areas, securing smoking materials, and other applicable policies.
• Perform a root cause analysis to determine residents may have purchased and brought back smoking materials without staff knowledge and policies and procedures for securing smoking materials had not been adhered to.
• Complete an audit of the smoking assessments for all 64 residents who smoke to ensure accuracy and update care plans as needed.
• Complete a skin assessment on all residents who smoke.
• Provide all staff two questionnaires to ensure education is effective.
• Update the procedure for securing smoking materials when a resident leaves and returns to the facility, to include signing out smoking materials and signing them back in.
• Educate all staff and residents on the updated procedure.
• Audit smoking material sign out/sign in sheets to ensure smoking materials are returned.
• Complete room audits on all residents who smoke, and throughout the facility, to ensure residents have no smoking materials in their rooms and are adhering to the facility's smoking policy.
• Hold an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee meeting to review the root cause analysis and corrective action plan.

Penalty

Inspection fine: $25,847

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 meals were served at an appropriate temperature and were palatable, affecting all residents except one who did not receive food from the kitchen. During a lunch meal service observation, an LPN noted that the meal tray contained a red watery substance, a mixture of meat and beans, and a bag of chips, which she described as 'slop.' The ice cream on the tray was melted, and residents complained about the food quality and portion sizes. Interviews with two residents confirmed that the food was often awful and insufficient. Further observations included a meal test tray that left the kitchen and was received cold and lacking flavor. The meal consisted of scrambled eggs, bacon, toast, and grits. The Assistant Director of Nursing verified these findings. Resident Council meeting minutes from August and September 2024 also documented concerns about the food, including meat being too hard and food not being properly cooked. This deficiency was investigated under Complaint Number OH00158177.

Penalty

Inspection fine: $25,847

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 resident call lights were in working order and accessible to residents, affecting 14 residents. During an interview, an Activities Aide observed that some resident rooms had call light cords that were only two to three inches long, making them unreachable for residents in bed. Additionally, several rooms had non-functioning call lights, and no alternative call light system was implemented. The Activities Aide confirmed that the call lights had been non-functional for several weeks. Further interviews revealed that a Certified Nursing Assistant was aware of the non-functioning call lights in several rooms, and this was verified through observation. The Maintenance Director acknowledged that the call light system had not been functioning properly for two to three weeks and had only recently received parts to begin repairs. The Maintenance Director also confirmed the issue with the short call light cords, which would prevent residents from reaching them while in bed. This deficiency was investigated under Complaint Number OH00158177.

Penalty

Inspection fine: $25,847

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

Summary

The facility failed to maintain a clean and sanitary environment, affecting two residents. Resident #39 reported a persistent water leak in his room, which had been ongoing for several weeks. Despite informing the Administrator and maintenance, the issue remained unresolved, leading to water accumulation on the floor. Observations confirmed the presence of a large puddle and stained, odorous bed linens, which had not been changed for an extended period. Housekeeping staff acknowledged the water issue, and a CNA confirmed the condition of the linens but did not change them until prompted. The Maintenance Director later identified the leak's source after several weeks of investigation. Resident #46's room was found to have a strong odor of stool and urine, with the toilet containing a large amount of waste and dried stool on the seat. A CNA verified these findings and expressed reluctance to flush the toilet due to concerns about potential overflow, indicating a lack of immediate action to address the unsanitary condition. This deficiency was investigated under Complaint Number OH00158177.