Country Lane Gardens Rehab & Nursing Ctr

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 activities that met individual residents’ assessed needs and preferences, and to make those preferences accessible to staff. For one resident admitted with COPD, bipolar disorder, alcohol dependence, and hypertension, the admission activity assessment documented that he did not respond to questions and there was no evidence that family was contacted to obtain preferences. His care conference indicated activity staff were to offer group activities and review the monthly calendar, yet activity documentation from admission through the first week showed only a single one-on-one “chatting” interaction by a nurse aide and no evidence he had been invited to group activities. Multiple observations over several days showed this resident either in bed or in a wheelchair in the hallway with no entertainment, even when craft activities were occurring in common areas. Activity staff later stated they were unable to document any activities for him and had no evidence he had participated in or been invited to activities since admission. Another resident, cognitively intact and with multiple chronic conditions including chronic respiratory failure, morbid obesity, COPD, sleep apnea, and several psychiatric diagnoses, was assessed as preferring room visits three times per week and not wanting to participate in activities outside her room. However, the assessment did not document that she was asked about interest in community activities. Activity logs over a three‑month period showed no activities outside her room and no community activities. Observations on several dates showed her lying in bed with no staff approaching to ask about activity participation. In interview, she confirmed that no community activities were offered and stated she would love to go out to eat or go shopping but that this was never offered. Activity staff confirmed they did not have access to residents’ activity assessments, were unsure of individual preferences unless residents told them directly, and that no community activities were scheduled; review of facility activity calendars over three months showed no community activities. A third resident with vascular dementia, anxiety disorder, and muscle weakness had an activity assessment and care plan indicating she did not wish to participate in group activities but preferred independent activities such as listening to music, doing word searches, attending church services, and receiving music, word search books, and crafting supplies. Observations over two days at multiple times showed her sitting in her room without any of her preferred independent activity items provided. Activity staff interviews revealed that one‑on‑one documentation was kept on paper in a book held by the activity coordinator, that individual preferences were obtained from the Activity Director or by learning from staff and residents, and that no activities had been provided for this resident during the week. A fourth resident with major depressive disorder, generalized anxiety disorder, schizoaffective disorder (including bipolar type), dementia, and restlessness/agitation had a care plan directing staff to encourage attendance at activities of interest and to provide preferred activities such as bingo, dancing, singing, writing and solving math problems, and going outside, while noting that the resident did not like coloring or drawing. Observations over two days showed this resident in their room with the door shut and not participating in activities while other residents in the common room engaged in coloring and drawing. Review of the resident’s activity task documentation over 30 days showed that activities offered were predominantly coloring, crafts, “chit chat,” or art, with participation often passive or refused. A 90‑day review of one‑on‑one activity documentation showed activities were not consistently offered and often recorded generic entries such as the resident being out of the room or “morning news,” with no entries for bingo, music, dancing, or outdoor activities. Activity staff reported that if residents did not want group activities they would offer one‑on‑one interactions such as talking or hand massages, that this resident struggled with group activities and was given one‑on‑ones, and that they identified music and talking as interests. Staff also confirmed they lacked access to residents’ activity evaluations, used paper tracking for some one‑on‑ones, and that community activities were not being conducted. The facility’s Activity Programs policy stated that programs are to be geared to individual needs and reflect residents’ schedules, choices, rights, interests, hobbies, and personal preferences, which was not supported by the documented practices and observations. The Administrator confirmed that the facility did not have consistent activity logs to verify when activities occurred and which residents participated. Activity staff further confirmed that they did not have access to residents’ activity evaluations to identify preferences and that some one‑on‑one activities were tracked only on paper for certain residents. Across the four residents reviewed, surveyors found a pattern of missing or incomplete assessment follow‑through, lack of documented invitations to activities, absence of preferred or community activities, and reliance on limited or generic activities such as coloring and crafts that did not align with documented or expressed preferences. These findings demonstrated that the facility failed to ensure activity preferences were available to aides and failed to complete activities according to resident preferences, contrary to its own Activity Programs policy.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean, sanitary environment free from pests on the C hall, affecting the room of Resident #42 and potentially all 12 residents residing on that hall. On two separate observations, live cockroaches were seen in Resident #42’s room. Resident #42 reported that he sees cockroaches all the time, that they sometimes crawl in his bed and keep him from sleeping, and that he sees them on the walls. A progress note dated 10/03/25 by LPN #182 documented that Resident #42’s room had been treated by an exterminator after insects and bugs were observed throughout the room. LPN #129 confirmed that there were currently live cockroaches in Resident #42’s room, and CNA #210 and CNA #132 reported seeing cockroaches crawling on his bedside table and in his bed when delivering his meal tray. Two other residents (#26 and #34) also reported seeing live cockroaches in the C hallway. Review of pest control invoices dated 09/18/25, 10/06/25, 11/14/25, 12/30/25, 01/09/26, 01/30/26, and 02/20/26 showed no documentation of cockroaches as a target pest, despite the ongoing observations and reports of cockroaches in Resident #42’s room and the C hallway. The facility’s pest control policy, last revised in May 2008, stated that the facility shall maintain an effective pest control program and an ongoing program to continuously eliminate insects and rodents, but the documented presence of cockroaches and lack of corresponding identification on pest control invoices demonstrated a failure to implement this policy effectively.

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 ordered non-pressure skin treatments and accurate documentation for two residents with significant cognitive and functional impairments. One resident, admitted with diagnoses including type II diabetes mellitus, morbid obesity, dementia, and rheumatoid arthritis, had a care plan identifying risk for red and/or open skin areas with interventions to follow facility protocols and monitor and document skin injuries. A progress note documented that this resident developed two open areas on the right gluteal fold, but from the date of discovery through several days afterward there were no corresponding physician treatment orders or treatments documented on the Treatment Administration Record (TAR) for these gluteal fold wounds. Subsequently, a weekly wound observation tool entry described an abrasion on the back of the right thigh, with measurements, assessment, and a treatment order to cleanse with normal saline and apply zinc barrier cream every shift and as needed. This order and documentation were entered under the right thigh rather than the right gluteal fold, and the medical record continued to lack a specific treatment order for the two open areas on the right gluteal fold. A later weekly wound observation tool entry indicated that a gluteal fold skin alteration acquired on the earlier date was healed, but did not specify the exact location or type of alteration. The ADON confirmed that the area discovered on the earlier date was on the right gluteal fold, that no treatment was ordered until several days later, that the site was incorrectly documented as the back right thigh for assessment and treatment, and that the healed-out documentation was completed on paper without a specific healed-out note for the skin alteration. The second resident, admitted with diagnoses including type II diabetes mellitus, dementia, and age-related osteoporosis, had a resolved care plan for three skin tears on the right anterior leg with an intervention to treat per facility protocol. Progress notes documented three skin tears with a treatment order obtained, and an initial physician order directed nightly cleansing of the right anterior leg skin tears with saline, patting dry, maintaining steri-strips daily, and using an abdominal pad and kerlix as needed. A subsequent physician order changed treatment for the right lower extremity skin tears to cleansing with normal saline and leaving open to air unless drainage was noted, but the original order was not clarified or discontinued, resulting in two concurrent treatment orders being carried out on the TAR. A wound care APRN later documented a new daily (and as needed) treatment order for the right anterior lower extremity skin tears without specifying treatment details, and no addendum or clarification was found. The TAR showed that both earlier treatment orders continued to be completed through the following weeks, and documentation reflected ongoing treatment even after the skin tear area had healed. A regional nurse confirmed that the initial order was not appropriate for skin tears, that two orders were active throughout the month, and that treatment continued after healing without clarification of the incomplete APRN order.

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 medications as ordered and to ensure appropriate pharmaceutical services for a resident with multiple complex diagnoses, including end stage renal disease on dialysis, type 2 diabetes mellitus, major depressive disorder, opioid dependence, anxiety disorder, and long-term antibiotic use. The resident had intact cognition per a recent MDS assessment. Physician orders included Amitriptyline 50 mg, two tablets at bedtime for depression; Sevelamer Carbonate 800 mg, two tablets before meals for hyperphosphatemia; and Reglan 5 mg by mouth three times a day for nausea. Review of the MAR showed that the mid-day dose of Sevelamer Carbonate was not administered on multiple dates, and there was no documentation explaining the missed doses on some of those days. On two dates, the record indicated the resident was at dialysis when Sevelamer was not given. Reglan was not administered twice on one date, and Amitriptyline was not administered on two separate dates. Progress notes did not document reasons for several missed Sevelamer doses, and there was no evidence that the physician was notified of the missed Sevelamer or Amitriptyline doses. The physician was not notified of the missing Reglan until two days after it was first not administered. Interview with a regional nurse confirmed that Reglan and Amitriptyline were not administered because the facility had run out of these medications, and Sevelamer was not administered because it had not been given before the resident left for dialysis, despite the resident eating lunch at dialysis and not receiving the medication there. The facility’s medication administration policy required medications to be administered in accordance with orders, but the documented omissions and lack of timely physician notification demonstrated that this did not occur for this resident.

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 failures in medication management and physician oversight, resulting in residents receiving unnecessary or improperly monitored drugs. One resident with dementia, muscle weakness, adult failure to thrive, and poly osteoarthritis was admitted with moderate cognitive impairment and required assistance with activities of daily living. After an emergency department visit, this resident was prescribed a lidocaine topical patch and tizanidine for pain and muscle spasms. These new medications were entered as verbal orders from an outside certified nurse practitioner but were never signed, and there was no documented communication with any facility provider about the new medications. Despite the lack of provider sign-off or documented oversight, nursing staff administered these medications along with multiple other antianxiety, muscle relaxant, and pain medications already ordered for the resident. Over several days, the resident received Xanax, baclofen, hydroxyzine, tramadol, Tylenol, lidocaine patch, and tizanidine. Subsequently, the resident experienced a fall and was noted to be slower to respond, with slurred speech. The on-call physician was notified, and the resident was sent to the emergency department, where documentation indicated a diagnosis of polypharmacy with muscle relaxants held and mental status improvement. Review of the medical record confirmed that the emergency room orders from the earlier visit were never signed by the ordering nurse practitioner, there was no documentation of communication with any facility provider regarding the new medications, and no in-house provider visits were documented during that period. The regional nurse confirmed that no documentation could be provided to show provider awareness or oversight of the new medications. A second resident with dementia, hypotension, anxiety disorder, mood disorder, major depressive disorder, and paraphilia had an active care plan for altered cardiovascular status related to hypotension, including medication as ordered by the physician. The physician ordered midodrine 15 mg three times daily with instructions to hold the medication if systolic blood pressure was greater than 110 mmHg. Review of multiple months of MARs showed that midodrine was repeatedly administered when the resident’s systolic blood pressure exceeded 110 mmHg at various morning, afternoon, and evening doses. The regional nurse verified that the resident had systolic blood pressure readings greater than 110 mmHg throughout the review period and that midodrine was not held as ordered. Facility policy required medications to be administered in a safe and timely manner and as prescribed, but the ordered parameters were not followed. A third resident with end-stage renal disease on dialysis, type 2 diabetes, major depressive disorder, opioid dependence, anxiety disorder, and long-term antibiotic use had a care plan for hypertension that included providing antihypertensive medication as ordered, monitoring for side effects, monitoring blood pressure as clinically indicated, and reporting signs of malignant hypertension. The physician ordered clonidine 0.1 mg, three tablets by mouth twice daily, with instructions to hold the medication for systolic blood pressure above 110 mmHg and pulse above 60 bpm. Review of the MAR and vital signs over a one-month period showed that clonidine was scheduled for administration at 10:00 a.m. and 10:00 p.m., but there was no evidence that blood pressure was checked for the evening dose and no evidence that heart rate was obtained at any time during the review period. The regional nurse later verified that the parameters in the order were incorrect and that the medication should have been held for systolic blood pressure below 110 mmHg and pulse below 60 bpm. The facility’s medication administration policy required medications to be administered in accordance with orders, but the required monitoring parameters were not followed or correctly applied.

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 with dementia and known histories of sexually inappropriate behaviors received adequate and effective behavioral health services, individualized interventions, monitoring, and supervision. One resident with moderately impaired cognition and a long history of sexually inappropriate behaviors had multiple documented incidents over several months, including oral sex with another resident, encouraging a male resident to rub her legs, kissing a male resident in her room, being observed with a male resident’s hands in her pants, repeatedly entering male residents’ rooms, and speaking in explicit sexual detail to her roommate. Her guardian repeatedly expressed concerns and requested increased safety measures, including a transfer to an all-female facility. The resident’s care plan included intermittent periods of one-to-one observation and every 15‑minute checks, but these heightened monitoring interventions were repeatedly started and then resolved, and the 15‑minute checks were discontinued in October without documented rationale or authorization from the psychiatric provider. Another resident with severely impaired cognition and dementia also had a documented history of sexually inappropriate behaviors. His care plan identified sexually inappropriate behavior after an encounter with another resident and included interventions such as behavioral health services, medication management, and one-to-one observation if sexually inappropriate behavior occurred. He was prescribed cimetidine (Tagamet) off-label to reduce sexual desire. Nursing notes documented multiple episodes of him touching himself inappropriately in common areas and being redirected to his room, as well as reports from his sister about sexually inappropriate behaviors at his offsite day program and concerns about the effectiveness of his medication. Despite these ongoing behaviors and concerns, after his room was changed to a secured unit due to inappropriate touching of a female resident, there was no documented evidence of increased monitoring, reassessment, or new interventions between the time of the move and the subsequent incident. The deficiency culminated when the resident with severely impaired cognition and the resident with moderately impaired cognition, both with known sexually inappropriate behaviors, were placed on the same secured unit without reassessment or revision of their behavioral health care plans related to monitoring and supervision. Direct care staff expressed concerns about moving the male resident with sexually inappropriate behaviors to a unit where residents were generally less cognitively aware and more vulnerable, but these concerns were either not communicated to management or not acted upon. No increased monitoring or individualized behavioral interventions were implemented for either resident after the room change. Several days later, staff discovered the two residents in the female resident’s bedroom with both residents partially undressed and engaged in sexual intercourse, confirming that the facility had not provided the necessary behavioral health services, individualized interventions, and supervision required by their conditions and histories. The facility’s own policies on dementia care and behavior assessment required the interdisciplinary team to identify resident-centered care plans, evaluate behavioral symptoms for safety risk, monitor for worsening symptoms, and adjust interventions based on changes in behavior and needs. However, the residents’ ongoing sexually inappropriate behaviors, repeated incidents, guardian concerns, and changes in placement were not accompanied by consistent reassessment, documentation, or adjustment of monitoring and supervision. The psychiatric mental health nurse practitioner reported she was not informed of continued sexually inappropriate behaviors after the male resident’s room change and did not authorize discontinuation of the female resident’s 15‑minute checks, indicating a breakdown in communication and failure to follow established behavioral health protocols that contributed directly to the incident.

Removal Plan

• The DON, Certified Nurse Practitioner (CNP) #900, and Resident #05's guardian were notified of the sexual incident with Resident #10; full body skin assessments were completed for Resident #05 and Resident #10.
• Resident #10's guardian was notified by the facility of the sexual incident with Resident #05; the facility requested permission to transfer Resident #10 out of the facility later that day.
• The facility submitted an initial SRI with an allegation of sexual abuse to the State Survey Agency regarding the incident between Resident #05 and Resident #10.
• Resident #05 and Resident #10 were visited and evaluated by Psychiatric Mental Health Nurse Practitioner (PMHNP) #905.
• Resident #05 was sent to the hospital for further medical evaluation and sexually transmitted disease and hepatitis screenings.
• Resident #10 was discharged to another facility.
• Resident #05 was discharged to another facility.
• MDS Nurse #273, ADON #339, and Wound Nurse #354 interviewed all residents with a BIMS score of 13 and above about inappropriate sexual encounters, reporting, and safety; all residents with a BIMS score of 12 and below had a skin assessment completed to identify any possible changes.
• MDS Nurse #273, ADON #339, and Wound Nurse #354 completed behavior assessments for all residents in the facility.
• RDO #490 and Corporate Quality Assurance Nurse (CQAN) #467 educated all staff on the facility dementia clinical protocol, resident routine checks, behavioral assessment, intervention, and monitoring, and the facility system change for sexually inappropriate residents (including pre-admission IDT review for sexual behaviors; care planning for residents with dementia or cognitively intact residents with sexual inappropriate behaviors; psychiatric follow-up; immediate notification to nursing management and psychiatric team; immediate placement on every 15-minute checks and/or one-to-one observation until deemed safe).
• ADON #339 and Regional Nurse #255 reviewed the last 72 hours of resident charting to identify documentation of sexual behaviors; five residents (#60, #61, #63, #64, and #65) were placed on every 15-minute checks for inappropriate comments to staff; orders and notifications were completed; direct care staff would complete observations with management completing checks if changes were needed; IDT/psychiatric/physician would determine discontinuation; at-risk residents would be reviewed weekly with changes prompting team discussion and plan of action.
• MDS Nurse #273 reviewed and confirmed all residents with sexual behaviors had care plans in place with appropriate interventions.
• An ad hoc QAPI meeting was held to review the system change for sexually inappropriate residents and education provided to staff (including Medical Director, Activities Director, HRD, Social Services Assistant, Regional Nurse, MDS Nurse, Receptionist, Wound Nurse, and CQAN).
• The facility created an audit tool to be reviewed weekly at standard of care meetings with the IDT to ensure residents were identified and interventions were in place; residents with a diagnosis of sexual behavior or any sexual behavior identified would be audited weekly; the system change would continue ongoing.
• The DON or designee would audit behavior documentation five times a week for four weeks to ensure interventions were in place.
• The medical records for Residents #60, #61, #63, #64, and #65 were reviewed and verified care plans were in place with acceptable interventions for inappropriate sexual behaviors and confirmed each resident was under the care of PMHNP #905.
• Direct staff members were observed providing adequate surveillance for Residents #60, #61, #63, #64, and #65 with no issues noted.
• Interviews with RN #191, LPN #504, and CNA #141 verified staff were educated regarding dementia clinical protocol, resident routine checks, and behavioral assessment/intervention/monitoring, and were knowledgeable of residents requiring increased surveillance and the procedure for resident checks.

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 a homelike environment by not providing consistently adequate hot water for resident bathing and laundry needs, affecting a census of 81 residents. During observation in one resident’s bathroom, surveyors found the faucet water to be only tepid, and the resident confirmed that the water was sometimes too cold. A CNA reported that the facility had experienced boiler issues at least once weekly since at least March 2025 and that nursing management instructed staff to reschedule resident baths and showers when hot water was not working, leading to resident complaints about postponed bathing. A walking tour with maintenance staff revealed that water temperatures in first-floor resident rooms were 95.4°F, which the maintenance staff acknowledged was below acceptable hot water temperatures. The housekeeping director also confirmed intermittent problems with hot water, stating that laundry was sometimes delayed because she had to wait for the water issue to be resolved. Resident interviews and record review further demonstrated the impact of the inadequate hot water. One cognitively impaired resident’s medical record showed that the resident declined a scheduled shower because the water was too cold. Additional residents reported that the hot water did not always get hot enough and that this affected their bathing schedules. Despite these ongoing issues and resident complaints, the administrator and regional director of operations stated they were not aware of the water temperature concerns reported by residents and direct care staff. This pattern of intermittent inadequate hot water for basic care needs and lack of awareness by facility leadership led to the cited deficiency under the residents’ right to a safe, clean, comfortable, 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 that residents were not physically restrained, as evidenced by the handling of a resident with a history of Type II Diabetes, morbid obesity, bipolar disorder, and depression. The resident exhibited aggressive behaviors, including yelling, swinging fists at staff, and attempting to enter other residents' rooms. Despite multiple attempts by staff to verbally de-escalate the situation and meet the resident's needs, these interventions were unsuccessful, and law enforcement was contacted on two occasions due to the resident's escalating aggression. During one of these incidents, staff used a bath sheet to physically restrain the resident in his wheelchair. The sheet was placed across the resident's torso and chest and held behind him by an LPN, preventing the resident from striking staff or other residents. This action was confirmed through interviews with staff members, including the LPN who held the sheet and a CNA who witnessed the event. The restraint was not documented in the resident's medical record, and there were no physician orders authorizing the use of a restraint. Facility policy defines a restraint as any device that a resident cannot remove in the same manner as it was applied and that restricts the resident's ability to change position or place. The use of the bath sheet in this manner met the facility's definition of a restraint. The internal investigation confirmed the use of the sheet as a restraint, although staff statements and progress notes did not consistently document this intervention.

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 notify the State Agency of an allegation of abuse involving a resident with diagnoses including Type II Diabetes, morbid obesity, bipolar disorder, and depression. The incident involved the use of a bath sheet held across the resident's torso and chest by staff to prevent the resident from harming others during a behavioral episode. Multiple staff interviews confirmed that the sheet was held by hand and not tied, and was used until police and EMS arrived. There was no physician order for a restraint, and the resident's medical record did not document any incident of restraint. The internal investigation by the Regional Administrator determined that the resident was not restrained, and as a result, the incident was not reported to the Ohio Department of Health as potential abuse. Facility policy requires immediate reporting of all allegations of abuse, neglect, or exploitation to the Administrator and the State Agency. The policy also defines abuse as the willful infliction of injury or unreasonable confinement, and specifies that a restraint is any device that a resident cannot remove and that restricts movement. Despite these policies, the facility did not report the incident as required, even though the use of the sheet could be considered a restraint and an allegation of abuse. This deficiency was substantiated during the survey and recited from a previous complaint survey.

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 residents were free from significant medication errors by not administering the full prescribed course of antibiotics to two residents. For one resident with chronic respiratory conditions, including COPD and chronic respiratory failure, the medical record showed that a 7-day course of Doxycycline was ordered and 14 pills were supplied by the pharmacy. However, after several days of administration, it was observed that there were eight pills remaining on the medication card when there should have only been five, indicating that three doses had been missed. The Acting Director of Nursing confirmed that only one dose was pulled from emergency stock and that there was no other source for the medication, verifying the missed doses. Similarly, another resident with diagnoses including schizoaffective disorder and chronic kidney disease was prescribed the same antibiotic regimen. Observations revealed that five pills remained on the medication card when there should have been only three, indicating that two doses were missed. The Acting Director of Nursing again confirmed the discrepancy and the importance of administering the full course of antibiotics. Facility policy required medications to be administered according to orders, but this was not followed, resulting in significant medication errors 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 implement its abuse policy by not accurately and promptly reporting an allegation of abuse involving a resident with multiple psychiatric and cognitive diagnoses. An incident was self-reported in which a resident alleged that an LPN spoke to her in an aggressive and inappropriate manner, making her uncomfortable. The facility's investigation was compromised by errors in documentation, including listing the wrong staff member as the alleged perpetrator and copying incorrect information into the self-reported incident (SRI) report. Additionally, the allegation was not immediately reported to the appropriate personnel as required by facility policy. In a separate incident, the facility did not thoroughly investigate an allegation of physical abuse between two residents, both with significant psychiatric and cognitive conditions. Documentation revealed that one resident pushed another, but the investigation lacked statements from the involved residents and did not clarify the sequence of events. Key witness statements and nursing notes were not included in the initial investigation materials provided to surveyors, and there was uncertainty about when and to whom the incident was reported. The facility's records were inconsistent, and the investigation did not fully address the reported physical altercation. Both incidents demonstrate failures in following the facility's abuse, neglect, and exploitation policy, which requires immediate reporting and thorough investigation of all allegations. The deficiencies included delayed reporting, inaccurate documentation, and incomplete investigative records, affecting multiple residents reviewed for abuse.

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 immediately and accurately report an allegation of emotional/verbal abuse involving a resident with schizoaffective disorder, generalized anxiety disorder, obsessive-compulsive disorder, delusional disorders, and dementia, who was cognitively intact at the time of the incident. The incident involved an LPN who spoke to the resident in a manner that made her feel uncomfortable, including taking her down the hallway and telling her it was none of her business to speak about the LPN to other staff. The resident reported feeling uncomfortable, and staff statements described the LPN's actions as intimidating and embarrassing, including snatching a juice cup and scolding the resident for coming out of her room to get juice. Multiple staff and resident statements described a hostile and uncomfortable environment during the incident, with the LPN's behavior being characterized as aggressive and dismissive. Other residents and staff witnessed the LPN's actions, and one CNA described the behavior as abusive. Despite these observations, the facility's investigation concluded that abuse did not occur, based on interviews and assessments that found no negative outcomes for the resident or others involved. The facility's reporting process was flawed, as the self-reported incident (SRI) was not submitted immediately, and the wrong staff member was listed as the alleged perpetrator in the SRI. The narrative in the SRI was also inaccurate, as it included information from another incident. The delay in reporting and inaccuracies in the documentation were confirmed by facility leadership, who acknowledged that the allegation was not reported immediately and that the SRI did not accurately reflect the incident or the correct staff member involved.

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 thoroughly investigate an allegation of physical abuse involving two residents, both of whom had significant cognitive impairments and complex medical histories, including schizoaffective disorder, dementia, and psychosis. Documentation revealed that one resident became agitated and, on multiple occasions, was observed yelling at and pushing another resident. Nursing notes and staff statements described the incident, but there were inconsistencies and missing information in the facility's investigation. Notably, the investigation did not include statements from the residents involved, despite the self-reported incident form indicating they could provide meaningful information. The facility's investigation relied on handwritten statements from staff, some of whom did not witness the incident directly, and omitted key statements that were later found on the unit manager's desk. The Regional Director of Operations was unable to clarify who initially reported the incident, to whom it was reported, or when the allegation was brought to their attention. Additionally, the facility's documentation did not align with the events described in nursing notes, and there was a lack of timely and complete reporting as required by facility policy. The facility's policy mandated immediate reporting of all allegations of abuse to the administrator or designee and to the state health department. However, the investigation was incomplete, with missing resident statements and unclear timelines regarding when the incident was reported. This deficiency was noted as a continuation of non-compliance from a previous survey.

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 discharge process for two residents was completed in a timely and thorough manner. For one resident with multiple diagnoses including anoxic brain injury, dementia, and psychiatric disorders, documentation showed that after several unsuccessful referrals to other nursing facilities, there was no further evidence of continued efforts or communication with the resident's guardian regarding the discharge process. The resident's care plan required all discharge planning to be documented, but there was a lack of documentation and communication after a certain date, as confirmed by both the guardian and the Social Services Director. For another resident with complex medical and psychiatric conditions, the facility initially communicated with the guardian about pursuing an assisted living waiver and possible discharge. However, after a certain point, there was no further documentation of progress or communication with the guardian regarding the discharge plan. The Social Services Director confirmed that there had been no recent contact or documentation about the discharge process for this resident. The facility's policy states that residents have the right to communication and support in exercising their rights, but this was not upheld in these cases.

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 only qualified personnel removed midline intravenous (IV) catheters for two residents who had received IV therapy for urinary tract infections. Both residents were cognitively intact and had midline IV catheters placed at the facility by an outside specialty nursing service. After completion of their IV antibiotic courses, a Licensed Practical Nurse (LPN) removed the midline IV catheters for both residents, despite lacking documented training or qualifications specific to midline or peripherally inserted central catheter (PICC) procedures. Review of the LPN's personnel file showed only basic IV training certification from 2014, with no evidence of midline or PICC-specific training. Facility policy and the Ohio Administrative Code specify that LPNs are not permitted to initiate or discontinue a PICC or any catheter longer than three inches, which includes midline catheters. Interviews with facility staff and the Regional Director of Clinical Services (RDCS) confirmed that the LPN was not qualified to remove the midline IV catheters and that there was confusion among staff regarding the scope of practice for LPNs in this area. The deficiency was identified through record review, staff and resident interviews, and policy review, which collectively demonstrated that the facility did not ensure nurses and nurse aides had the appropriate competencies to care for residents with midline IV catheters. The RDCS acknowledged a lack of IV training for staff and was unaware of the specific state regulations prohibiting LPNs from removing midline catheters. Both residents reported no discomfort or issues following the removal, but the removals were performed by unqualified personnel in violation of state regulations and facility policy.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with a history of cerebral infarction, glaucoma, vascular dementia, and anxiety disorder, who was noted to have impaired cognitive function and poor decision-making, was left unattended outside in the sun for several hours. The resident, who required substantial assistance for activities of daily living and was dependent on staff for toileting and transfers, was allowed outside after a social service assistant determined she could go out due to her high BIMS score. Staff were aware the resident had a habit of undressing in public and had previously refused to come inside from the courtyard. On the day of the incident, the resident was observed outside, undressed, and staff covered her with a gown. Despite being told by the administrator not to let the resident outside unsupervised after a similar incident the previous day, the resident remained outside for an extended period in temperatures ranging from 82 to 85 degrees Fahrenheit. The resident was found unresponsive in her wheelchair after several hours, with a body temperature of 107 degrees Fahrenheit and an oxygen saturation of 88 percent. She had developed second-degree burns and blisters on her arms and legs. Staff brought her inside, applied ice packs, and moved her to an air-conditioned area, but did not immediately notify a physician or call emergency services. Documentation of the incident was delayed, and there was no evidence of follow-up vital signs or timely physician notification. The resident was not transferred to the hospital for evaluation and treatment until approximately 24 hours after the incident, despite the severity of her condition. Interviews with staff revealed confusion about who authorized the resident to go outside and a lack of clarity regarding responsibility for monitoring her safety. The exit door keypad was broken, preventing the resident from re-entering the facility independently, and this issue had been ongoing for months. Staff did not consistently monitor the resident while she was outside, and there was a lack of immediate and appropriate intervention when her condition deteriorated. The failure to supervise the resident, monitor her condition, and provide timely medical intervention resulted in actual harm and was identified as a deficiency by surveyors.

Removal Plan

• Resident was sent to the ER for evaluation and treatment.
• Resident returned to facility with an order to follow up with the outpatient burn center.
• Resident has wound care orders in place to affected areas.
• Resident was reeducated on risks factors of prolonged heat and sun exposure.
• Policies and procedures were reviewed to ensure they were comprehensive and accurate: Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, Heat Related Illness, and Abuse Policy.
• Education was completed for all licensed staff on Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, Heat Related Illness, and Abuse Policy.
• The forecast of weather conditions with high and low temperatures was posted at the Second Floor Courtyard door, First Floor Courtyard door, and Smoking Area door.
• Staff were educated to reference the high temperature to the heat-related illness guidance and to educate all residents on risks of outside temperatures that day if they request to go outside.
• For temperatures of 80 degrees (Fahrenheit) or higher, staff will increase resident safety checks.
• If residents choose to remain outside, staff will offer additional safety interventions from the facility Excessive Heat policy, including additional education, ice water, move to shaded areas, etc.
• Resident's care plan was reviewed and updated to reflect the current resident's condition and needs.
• A post-education test on Heat Illness Education was administered to all staff and all staff successfully completed the post test.
• Head-to-toe assessments on all residents were initiated to ensure there were no negative outcomes from heat-related illnesses.
• The facility QAPI Committee reviewed the deficiencies, the plan of action, the policies and procedures related to Heat Related Illness, Change in Condition and Notification, and completed a root cause analysis.
• Outside thermometers were hung by the Administrator with the forecast posting so staff can see the actual temperature compared to the forecasted highs and lows.
• Staff were educated that if resident(s) will not come inside, they will immediately contact the Director of Nursing, Administrator and/or the Director of Social Services to assist bringing in the resident(s) to ensure their safety.
• Facility began reviewing change of condition via 24hr and 72hr report by DON/Designee. Audit will include notification, interventions, assessments.
• Facility began posting outside temperature listing which will be audited by Administrator/Designee.
• Facility began resident interviews regarding neglect for residents with BIMS of 13 or higher. Random residents will be interviewed by Administrator/Designee.
• Facility began random resident assessments on residents with BIMS of 12 or lower for signs of neglect. Random residents will be assessed by DON/Designee.
• Facility began random staff interviews on heat illness via posttest and what current outside temperature is that day by Administrator/Designee.
• All findings will be reviewed in QAPI.
• The Administrator and the DON will be responsible for the oversight of the monitoring/audits.
• Before residents are taken outside, by activities or other staff, they will check with charge nurse to determine which residents are able to go outside.
• The External Courtyard Keypad was repaired by the facility maintenance director and determined to be in working order.
• The Keypad will be audited for functionality by Administrator/Designee.
• All residents that go outside will be supervised by facility staff.
• Prior to taking residents outside, for activity or other reasons, staff will verify with charge nurses that residents are safe to go outside supervised based upon resident's current medical condition.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to timely identify and provide comprehensive, resident-centered interventions following an acute change in condition for a resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, dementia, and a history of weight loss. The resident, who required staff assistance with activities of daily living, was observed by staff to have an acute change in medical condition, including dusky colored hands and feet, limited food and fluid intake, lethargy, and the need for supplemental oxygen. Despite these significant changes, there was no documented assessment or intervention by licensed staff at the time these symptoms were first noted. Over the course of several days, the resident's condition continued to deteriorate, with ongoing poor oral intake and increasing lethargy. Multiple staff members, including CNAs, reported the resident's declining condition and abnormal physical findings to various nurses, but there was no evidence that a comprehensive assessment was performed or that the resident's medical provider was notified in a timely manner. Documentation was lacking regarding the resident's status, interventions provided, and physician notifications. The resident's care plan did not address hydration risk or the need for assistance with food and fluid intake, despite ongoing weight loss and poor appetite. The failure to assess and respond to the resident's change in condition resulted in a significant delay in medical intervention. The resident was ultimately transferred to the hospital only after a licensed nurse, returning from time off, discovered the resident in a severely compromised state. At the hospital, the resident was diagnosed with severe dehydration, acute kidney injury, and malnutrition, and subsequently passed away after being transferred to hospice care. The deficiency was identified through closed medical record review, interviews, and review of facility policies and procedures.

Removal Plan

• Resident #95 was transferred to the hospital and did not return to the facility. The resident expired.
• An audit was completed by DON/Designee on all residents who went out to the hospital to determine if any changes in resident conditions went unreported.
• The President of Clinical Operations reviewed the following policies and procedures to ensure they were comprehensive and accurate: Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, and Abuse.
• The Regional Director of Clinical Services, Regional Director of Operations and Administrator initiated education for all licensed staff on Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, and Abuse Policy. Education was completed for Licensed Practical Nurses (LPNs), Registered Nurses (RN), Certified Nurse Aides (CNAs), Activity Personnel, Dietary Staff, Housekeeping/Laundry Staff, Maintenance Staff, Administrative Staff. All staff were educated.
• The DON/Designee provided education for nursing staff on the POC alert function in Point Click Care (PCC) charting to identify potential condition changes and how alerts generate on the alert panel on PCC dashboard. Education was completed for Licensed Practical Nurses (LPNs), Registered Nurses (RNs) and Certified Nurse Aides (CNAs). This was provided in person and via phone before staff were allowed to work. Education included how alerts appear on the dashboard and are reviewed daily in morning clinical meetings. If reported changes were not addressed by the nurse, they were to report it to the DON. Education also included ongoing changes in conditions would be reported to the DON.
• The DON/Designee educated in person and via phone Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on the Change in Condition policy, which included when a change of condition was reported, new orders were obtained, entered in PCC/implemented, which would include appropriate monitoring, including oxygen therapy needs.
• Ongoing compliance would include new nurses in orientation upon hire.
• The Quality Assessment and Performance Improvement (QAPI) Committee, including the Administrator, Regional Director of Clinical Services, Social Services, Minimum Data Set (MDS) Nurse, Human Resources, Director of Nursing (DON), Activities Director, Assistant DON (ADON)/LPN, and Medical Director reviewed the facility plan of action, the policies and procedures related to Change in Condition and Notification and a root cause analysis was completed.
• A whole house audit was conducted on all current facility residents by the DON/Designee by reviewing 72-hour report for any change of condition and need for interventions and notifications and head to toe assessments by DON/Designee.
• The facility began audits on resident change in condition by reviewing the 24 hour and 72-hour reports which would be reviewed five times per week ongoing by DON/Designee. Audits would include Change in Condition and Notification. If adverse findings were noted, an immediate head to toe assessment would be completed and notification to physician.
• All findings would be reviewed weekly in QAPI. The Administrator and the DON would be responsible for the oversight of the monitoring/audits.
• Director of Nursing/Designee conducted an audit on all orders placed, including medications, treatments, monitoring, therapy, etc. for all residents. This audit concluded that all orders were appropriate, contained no errors, and provided necessary monitoring where needed.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate and necessary comprehensive, resident-centered care to a resident following a vascular procedure for arterial stenosis. After undergoing an angiogram and stent placement, the resident was discharged with physician orders to receive Plavix 75 mg daily and Aspirin 81 mg daily to maintain stent patency and prevent complications. However, the medical record revealed that the resident had not received Aspirin since the previous year, and Plavix was never administered after being ordered. There was also no care plan addressing the resident's post-procedure care, follow-up appointments, or transportation needs. The resident, who had multiple comorbidities including diabetes, peripheral vascular disease, dementia, and chronic kidney disease, required assistance with activities of daily living and had a history of arterial/ischemic ulcers. Despite the physician's orders and the resident's high risk for complications, the facility failed to arrange transportation for follow-up appointments with the vascular surgeon. The lack of a contract with a non-emergent ambulance service resulted in multiple missed appointments, and the facility did not reschedule or ensure the resident was evaluated by the vascular surgeon after the procedure. As a result of these failures, the resident's arterial wounds deteriorated, leading to the development of osteomyelitis in the left foot. The wounds showed signs of infection, including purulent drainage, necrotic tissue, and exposed bone. The resident ultimately required emergent transport to the hospital, where intravenous antibiotics were initiated for the treatment of osteomyelitis. Interviews with facility staff confirmed the missed medication administration and transportation issues, as well as a lack of awareness regarding the resident's missed follow-up care.

Penalty

No penalty information released

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

Summary

The facility failed to provide a comprehensive, resident-centered plan of care to prevent, identify, and treat weight loss and dehydration, resulting in actual harm to a resident with severe cognitive impairment and multiple comorbidities. This resident, who was at nutritional risk and required staff assistance with activities of daily living, experienced significant unaddressed weight loss and dehydration. Despite documented weight loss from 98 pounds on admission to 91 pounds over several weeks, there was no evidence of timely or effective interventions, such as ensuring the administration and documentation of ordered nutritional supplements, or the implementation of additional care plan interventions. The care plan did not address hydration needs or the resident's physical ability to consume food and fluids, nor did it reflect the need for staff assistance with eating and drinking in light of the resident's cognitive status and poor appetite. Meal intake records showed inconsistent and often minimal food and fluid consumption, with several days of no intake documented and no evidence that alternative food options or supplements were offered or accepted. There was also a lack of documentation regarding the reasons for poor intake or any attempts to address it. The resident's declining intake and condition were not communicated to the medical provider or registered dietitian, and weights were not consistently obtained as ordered. When the resident's condition deteriorated, staff failed to recognize or report the change in a timely manner, resulting in the resident being found in a severely debilitated state and subsequently hospitalized for severe dehydration and malnutrition. A second resident experienced significant weight loss without timely dietitian follow-up or implementation of recommended interventions. Despite documented weight loss exceeding 5% in one month, reweights were not completed as requested, and recommended nutritional supplements were not initiated promptly. Staff failed to document attempts to encourage intake or offer alternative supplements when intake was low. Facility policy required prompt reweighting, notification, and intervention for significant weight changes, but these steps were not consistently followed, contributing to the deficiencies identified.

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 eight consecutive hours of Registered Nurse (RN) direct care coverage on three specific dates within a seven-day period, as required by regulation. Staffing reports and staff time punch records confirmed that no RN was scheduled or present for the required hours on those dates. The Regional Director of Nursing (DON) was the only RN in the building and was providing resident care during these times. Interviews with the Regional DON and Staffing Coordinator confirmed that no other RNs were present on the identified dates. Additionally, the facility did not have a policy regarding RN coverage requirements, although the Administrator acknowledged awareness of the regulatory requirement for 8 hours of consecutive RN coverage daily and that the DON could not serve as the facility's RN coverage. This deficiency had the potential to affect all 94 residents in the facility. No specific details about individual residents' medical history or conditions at the time of the deficiency were provided in the report.

Penalty

No penalty information released

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

Summary

The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to ensure the highest practicable well-being of its residents. One incident involved a resident with confusion and poor decision-making who was left unattended outside in high temperatures, resulting in the resident being found unresponsive with a body temperature of 107°F, oxygen saturation of 88%, and second-degree burns. The physician was not notified for approximately 12 hours, and the resident was not transferred to the hospital for evaluation or treatment until about 24 hours after the incident. The Administrator was aware of the resident's tendency to go outside and had previously instructed staff on how to handle such situations, but was not present at the facility when the incident occurred. Another deficiency involved the facility's failure to provide physician-ordered medication and arrange necessary transportation for a resident following a stent procedure. The resident did not receive the required medication to prevent the stent from closing and missed follow-up appointments with a vascular surgeon due to the facility lacking a contract with a non-emergent ambulance transportation service. The Administrator acknowledged the absence of a transportation contract and was unaware of which or how many residents missed appointments during this period. This lapse resulted in the resident developing osteomyelitis of the foot. Additionally, the facility failed to prevent the misappropriation of resident property, specifically narcotic pain medications. There were multiple discrepancies in the documentation and handling of controlled substances, including missing medication cards, incomplete narcotic logs, and missing administration records. Staff interviews revealed that narcotics were frequently unaccounted for, and there was a lack of timely response from management when missing medications were reported. The facility's investigation into the missing narcotics was inconclusive due to missing records, and the required documentation and procedures for controlled substances were not consistently followed.

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 an effective governing body to oversee its operations, as evidenced by multiple lapses in management and oversight. The governing body, which included the administrator, director of nursing, medical director, and other regional and corporate leaders, did not ensure that policies and procedures were properly implemented or monitored. QAPI meeting minutes revealed that when the facility's transportation contract was dropped, there was no backup plan in place, and no evidence of follow-up meetings or attendance records to address the issue. This resulted in residents who required cot transport missing critical medical appointments, with no documentation of which residents were affected or how many appointments were missed. Medication management was also deficient, with QAPI minutes noting that nursing staff failed to follow medication pass policies. Audits were conducted, but there was no documentation of meeting attendance or thorough investigation into the issues. One resident developed osteomyelitis of the foot after not receiving physician-ordered medication post-stent procedure and missing follow-up appointments due to lack of transportation. The administrator confirmed the absence of a transportation contract for an extended period and was unaware of the full impact on residents. Additionally, the facility failed to thoroughly investigate allegations of missing narcotics, resulting in misappropriation of controlled substances for multiple residents. Documentation and inventory records for controlled substances were missing, and staff interviews revealed that required procedures for signing in and out medications were not followed. Residents reported not receiving pain medication as documented, and staff expressed concerns about ongoing issues with missing narcotics. The governing body and regional leadership were unaware of these significant care failures, and there was no evidence of comprehensive investigation or resolution of the incidents.

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 designated medical director implemented resident care policies, coordinated medical care, and participated in Quality Assurance and Performance Improvement (QAPI) meetings. Review of QAPI minutes and interviews revealed that the medical director did not attend or participate in QAPI meetings, and there was no documentation of attendance or involvement. Additionally, when the facility lost its contract with a non-emergent ambulance transportation service, there was no evidence of a backup plan or ongoing efforts to resolve the issue, resulting in residents missing critical medical appointments due to lack of transportation. One resident developed osteomyelitis of the foot after the facility failed to provide physician-ordered medication following a stent procedure and did not arrange necessary follow-up appointments with a vascular surgeon. The resident required cot transport, which was unavailable due to the lack of a transportation contract. Another resident experienced a significant change in condition that was not promptly assessed or treated by nursing staff, resulting in severe dehydration, acute kidney injury, and subsequent death after transfer to a hospice facility. There was no evidence that the facility identified or addressed the staff's lack of intervention prior to the survey. Additionally, the facility did not ensure proper communication and collaboration with an outside dialysis center regarding the care of a resident receiving hemodialysis. The resident had a critically low hemoglobin level and was prescribed Epoetin alfa, which was not administered as ordered due to unavailability from the pharmacy. The dialysis center was unaware of the Epoetin alfa order and administered a different medication from the same drug class. The medical director was not aware of the medication issues or the care provided by the dialysis center, and there was no evidence of coordination between the facility and the dialysis provider.

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 an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by incomplete documentation, lack of follow-through on action steps, and insufficient investigation into significant resident care issues. QAPI meeting minutes did not include attendance records, and there was no evidence that required weekly meetings between the administrator and transportation aide occurred to resolve transportation issues. The governing body was not involved in QAPI meetings, and regional leadership was unaware of critical care failures identified by surveyors. One resident developed osteomyelitis of the foot after the facility failed to provide physician-ordered medication following a stent procedure and did not arrange necessary cot transportation for follow-up appointments. The facility lost its contract with a non-emergent ambulance transportation service and did not secure a replacement, resulting in missed medical appointments for residents requiring cot transport. The administrator was unable to identify which or how many residents missed appointments during this period. Additionally, the facility did not thoroughly investigate allegations of missing narcotics, resulting in unaccounted controlled substances for multiple residents. Documentation for controlled substance administration and inventory was missing, and staff failed to follow required procedures for signing in and out medications. Despite reports and evidence of missing medications, the facility did not determine the extent of the issue or conclude its investigation, and education was provided to nursing staff without a comprehensive review of the problem.

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 resident medical records were complete and accurately documented for four residents. For one resident with anxiety disorder, hypertension, and COPD, Ativan was documented as administered on the medication administration record, but not signed out on the controlled substance administration record, as confirmed by the LPN/Unit Manager. Another resident with diabetes, end stage renal disease, and a left leg amputation received Tramadol, which was signed out on the controlled substance administration record but not documented on the medication administration record for multiple doses, as confirmed by the President of Clinical Operations. A third resident with peripheral vascular disease, dementia, and diabetes was observed wearing Prevalon boots, but there was no physician's order for the boots and they were not included in the plan of care, despite the boots being in use for several months. For a fourth resident with anxiety disorder, fibromyalgia, and chronic pain syndrome, Tramadol was signed out as administered on the controlled substance administration record but not documented on the medication administration record for several doses. These discrepancies were confirmed by facility leadership during interviews.

Penalty

No penalty information released

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

Summary

The facility failed to promptly address grievances related to resident care that were raised during a resident council meeting attended by nine residents. Concerns were voiced regarding untimely medication administration, staffing, and continuity of care. The meeting minutes referenced additional details on the back of the form, but no further information was provided, and there was no documentation specifying the exact nature of the concerns about staffing and continuity of care. There was also no evidence that the facility followed up to clarify or address these concerns, nor was there any documentation of actions taken in response. Requests for evidence of follow-up or action from the facility administrator on three separate occasions went unanswered.

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 notify a resident's representative when there was a significant change in the resident's physical status and when the resident was transferred to the hospital for treatment. The resident, who had diagnoses including cerebral infarction, glaucoma, vascular dementia, and anxiety disorder, was found slumped in a wheelchair after being outside in the courtyard. Staff noted the resident was unresponsive, with a high temperature of 107.5°F and an oxygen saturation of 88%. The resident was moved to an air-conditioned area, given oxygen, and ice packs were applied. Later, multiple blisters were found on the resident's arms and legs, which were treated and assessed by staff. Orders were obtained from a nurse practitioner for wound care, and the resident was eventually sent to the emergency room for evaluation approximately 24 hours after the incident. Despite these significant events, including the development of burns and the transfer to the hospital, there was no evidence that the resident's daughter, listed as the emergency contact, was notified by the facility. The daughter confirmed in an interview that she was not informed of the incident or the hospital transfer and only learned of the situation when contacted by the hospital. Facility policy required notification of the resident's representative in the event of significant changes or hospital transfers, but this was not followed in this case.

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

A deficiency occurred when a resident's narcotic pain medication, specifically Oxycodone, was diverted and unaccounted for, affecting one of three residents reviewed for narcotic pain medications. The resident involved had multiple diagnoses, including chronic kidney disease, diabetes, congestive heart failure, and bipolar disorder, and was cognitively intact. Physician orders indicated the resident was to receive Oxycodone 15 mg every six hours as needed for severe pain. Despite pharmacy records showing regular deliveries of Oxycodone, medication administration records and controlled substance inventory logs revealed significant discrepancies, with large quantities of medication unaccounted for and missing documentation. Staff statements and interviews indicated that the medication was signed into the narcotics log but not properly signed out when empty, and that the required documentation for both the administration and inventory of controlled substances was missing. Multiple staff members noted that the number of pills delivered and the number of cards and sheets signed in did not match, and that these discrepancies were not identified during shift change narcotic counts. One nurse reported that a full card of Oxycodone was missing within a week of delivery, and that the resident was left without pain medication. Additionally, there were inconsistencies in the documentation and handling of another controlled substance, Alprazolam, for a different resident, with only one card and sheet signed in for a delivery of 45 pills, when two should have been recorded. Interviews with staff and the resident confirmed that the resident did not receive pain medication as documented, and that the resident experienced significant pain and anxiety as a result. The facility's investigation was hampered by missing records, and staff reported a pattern of missing narcotics in the same hall. The facility's policy defined misappropriation of resident property as the deliberate misplacement or wrongful use of a resident's belongings without consent, and the events described in the report constitute a failure to protect the resident from such misappropriation.

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

A deficiency occurred when a resident with diagnoses including cerebral infarction, glaucoma, anxiety disorder, and vascular dementia was administered an antipsychotic medication (Haldol) without proper documentation or justification. The resident, who had intact cognition and required assistance with transfers, had no routine psychoactive medication orders. After returning from the hospital, the resident exhibited agitation and combative behavior, leading to a one-time order for Haldol and Ativan if needed for agitation and aggression. However, the medications were not administered at that time, and the resident later rested calmly. Over 24 hours later, an LPN administered Haldol to the resident after the resident attempted to hit the nurse during a dressing change. There was no documentation in the progress notes to indicate the reason for administering the medication at that time, and behavior tracking did not show any documented behaviors warranting its use. Facility policy required that antipsychotic medications only be used for specific conditions and after other causes of behavioral symptoms had been addressed. The Acting DON confirmed there was no evidence of imminent danger to self or others to justify the use of Haldol, and the only incident noted was the resident pulling a fire alarm earlier, with no further documentation.

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 report an allegation of missing narcotics involving two residents, both of whom had controlled substances prescribed and delivered, but discrepancies were found in the medication counts and documentation. One resident, with diagnoses including chronic kidney disease, diabetes, congestive heart failure, and bipolar disorder, was prescribed Oxycodone for severe pain. Despite pharmacy records showing regular deliveries of Oxycodone, staff discovered that a full card of the medication was missing, with only seven doses documented as administered out of thirty delivered. The controlled substance administration records and inventory count sheets for this medication were also missing, making it impossible to determine the exact amount unaccounted for. Staff communications revealed that concerns about the missing narcotics were reported to management, but there was no timely response or follow-up from supervisory staff. Additionally, a discrepancy was identified with another resident's Alprazolam delivery, where 45 tablets were delivered but only one card and one administration sheet were signed in, instead of the required two. This error in documentation could allow for medication to be removed without detection. Multiple staff interviews confirmed ongoing issues with narcotic counts and documentation, particularly involving the same nurse, and that these discrepancies were not properly identified during shift change counts. Staff also reported that missing narcotics had been an issue in the past, and that management did not conduct thorough interviews or investigations with all involved staff members. The facility's policy required that all allegations of misappropriation of resident property, including missing narcotics, be reported to the State Survey Agency within 24 hours. However, there was no evidence that the facility reported the missing narcotics to the State Survey Agency in a timely manner. Interviews with facility leadership confirmed that the incident was not reported as required, and that the investigation into the missing medications was incomplete, with no summary or conclusion documented.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the protection of residents during the investigation of alleged resident-to-resident abuse and did not thoroughly investigate an allegation of missing narcotics. In the case of a resident with a history of sexually inappropriate behavior, the care plan included interventions such as 1:1 supervision and frequent safety checks. However, after an incident where this resident was observed inappropriately touching another resident, documentation and staff interviews revealed that 1:1 supervision was not consistently provided, and records were falsified to indicate supervision had occurred when it had not. There were gaps in supervision, and staff responsible for 1:1 care did not complete or initial the required documentation, resulting in periods where residents were not protected as required. Regarding the missing narcotics, the facility failed to maintain accurate records and conduct a thorough investigation into the disappearance of controlled substances, specifically Oxycodone and Alprazolam, for two residents. Staff discovered discrepancies in the narcotic count sheets and administration records, with missing documentation and unaccounted-for medication. Despite reports to management, there was a lack of timely response and follow-up, and the facility was unable to determine the amount of medication missing due to incomplete records. Interviews with staff indicated ongoing issues with narcotic accountability, and some staff expressed reluctance to work in certain areas due to frequent incidents of missing medications. The facility's policies required prompt and thorough investigation of abuse and misappropriation of resident property, including maintaining evidence and documentation. However, the investigation into both the abuse incident and the missing narcotics was incomplete, with missing records, lack of documentation in resident progress notes, and no clear summary or conclusion of the investigations. The failure to provide required supervision and to maintain accurate medication records directly affected the safety and well-being of the residents involved.

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

A deficiency was identified when a resident with diagnoses including bipolar disorder, diabetes, chronic kidney disease, and congestive heart failure, who was dependent on staff for toileting and required substantial to maximal assistance with bathing, did not receive the necessary services to maintain good grooming and personal hygiene. The resident, who was always incontinent of bowel and bladder and had intact cognition, reported typically receiving only one shower per week and only when requested, despite preferring two showers per week. Review of shower documentation over a one-month period showed the resident received only six showers, and staff confirmed the resident had not been placed on the shower schedule, resulting in showers not being provided or offered twice weekly as required.

Penalty

No penalty information released

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

Summary

The facility failed to ensure ongoing communication and collaboration with an outside dialysis center regarding the dialysis care and services for a resident with end stage renal disease, diabetes, and a left leg below the knee amputation. The resident, who was cognitively intact, attended hemodialysis three times weekly at an external facility. A critically low hemoglobin level was identified, and orders were given for increased iron supplementation and weekly Epoetin alfa injections. However, the Epoetin alfa was not administered as scheduled on multiple occasions due to unavailability from the pharmacy, and there was no evidence that the physician was notified of these missed doses. Simultaneously, the dialysis center administered Mircera, a medication from the same drug class as Epoetin alfa, every two weeks, but was unaware of the facility's order for Epoetin alfa. Communication reports between the facility and the dialysis center were incomplete or delayed, and did not consistently document medications administered at the dialysis center. Interviews with staff and review of the contract confirmed that there was a lack of required collaboration and information exchange regarding the resident's dialysis-related medications and care.

Penalty

No penalty information released

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

Summary

The facility failed to implement appropriate behavioral health care and interventions for a resident with a complex medical and psychiatric history, including anoxic brain damage, dementia, bipolar disorder, major depressive disorder, PTSD, and substance abuse. The resident had a documented history of sexually inappropriate behaviors, and the care plan included interventions such as medication administration, behavioral health involvement as needed, monitoring for wandering, education on safe practices, and immediate removal from situations with 1:1 supervision when necessary. Despite these interventions being listed, staff interviews revealed that preventive measures were not in place prior to an incident where the resident engaged in inappropriate sexual behavior with another resident. Staff were unsure who witnessed the incident, and there was a lack of clarity regarding the implementation of preventive strategies before the event occurred. Following the incident, the resident was placed on 1:1 supervision for a short period and then on 15-minute checks, but no alternative or individualized behavioral interventions were documented prior to moving the resident to another unit. Psychosocial assessments for the involved residents were completed verbally but not documented at the time, and witness statements were used retrospectively for documentation. The deficiency was identified based on the lack of documented and implemented behavioral health interventions prior to the incident, as well as insufficient preventive measures to address the resident's 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 facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving two residents. For one resident with multiple sclerosis, anxiety disorder, and legal blindness, the physician's order for Ativan was reduced from two tablets to one tablet at bedtime. Despite this change, the controlled substance administration records showed that the resident continued to receive two tablets on several occasions, as the medication label was not updated and still indicated the previous dosage. Nursing staff, including a unit manager, confirmed that double doses were administered on specific dates, and this was acknowledged as a medication error. Another resident with diabetes, end stage renal disease, and a left leg amputation experienced several medication errors related to anemia management and pain control. The resident was prescribed Epoetin alfa weekly, but the medication was not administered on several scheduled dates due to unavailability from the pharmacy, and there was no evidence that the physician was notified of the missed doses. Additionally, the resident was receiving Mircera, a similar medication, at an outside dialysis center, but neither the facility nor the dialysis center was aware of the dual prescriptions. Furthermore, the resident received Tramadol, an opioid pain medication, at intervals shorter than prescribed, and the administration was not properly documented in the medication administration record. Facility policy required medications to be administered as prescribed, with verification of the correct resident, medication, dosage, time, and method, and for staff to document administration immediately. The observed failures included not updating medication labels, not notifying physicians of missed doses, lack of communication between the facility and dialysis center regarding medication administration, and improper documentation and timing of 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 notify a resident, her physician, and her family of abnormal radiology results following an incident that resulted in a left ankle fracture. The resident, who had diagnoses including end stage renal disease, heart failure, and toxic encephalopathy, was assisted by a CNA after experiencing difficulty standing from the toilet. During this assistance, the resident became unstable and was guided to the floor. Although the CNA reported the incident and the resident later complained of foot pain, there was no documented evidence that the nurse took immediate action or notified the physician at that time. Subsequent nursing notes indicated that the resident's physician eventually ordered an x-ray, which revealed an acute, minimally displaced fracture at the distal fibula, and new orders were given for orthopedic follow-up and non-weight bearing status. Interviews with the resident and her spouse revealed that they were not informed of the abnormal x-ray results until an aide inadvertently mentioned it. The administrator confirmed there was no documentation that the resident, her family, or her physician were notified of the fall or the abnormal radiology findings. Review of facility policy indicated that the nurse is required to notify the physician and the resident's representative in the event of an accident, injury, or significant change in condition, but this protocol was not followed in this case.

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 a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that accurate and clear advance directives were in place for a resident at the time of death. The resident, who had multiple complex diagnoses including severe cognitive impairment, was admitted to hospice care, and a change in code status from full code to DNR-CCA was initiated. However, there was no hospice documentation, including the updated advance directive, present in the facility's medical records at the time of the resident's death. Staff interviews revealed that nurses were aware a change in code status was pending but had not received the signed documentation from hospice. When the resident was found without vital signs, staff checked the electronic medical record and, finding no update, initiated CPR in accordance with the existing full code order. During resuscitation, hospice staff called to inform them of the new DNR-CCA status, leading to confusion and the cessation of CPR. EMS, also lacking documentation of the code status change, resumed CPR upon arrival. The facility's policies required that advance directives and DNR orders be clearly documented and accessible in the resident's medical record. Both the Administrator and DON confirmed that the necessary hospice documentation, including the updated advance directive, had not been received or filed in the facility. This lack of documentation led to confusion among staff during a critical event and resulted in actions that were not aligned with the resident's most current wishes.

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 all resident medical records were complete, specifically in the case of one resident with multiple complex diagnoses, including severe cognitive impairment, encephalopathy, dementia, and palliative care needs. Upon review of the resident's medical record following his death, it was found that there was no documentation explaining the circumstances of his expiration, what occurred prior to his death, or any actions taken to provide life-sustaining measures. The only notes present indicated that the resident had expired and that the body was released to the funeral home. Interviews with the Administrator, DON, and the LPN responsible for the resident's care confirmed that there was a lack of required documentation regarding the incident and death. The LPN acknowledged responsibility for documenting the event but confirmed that no such documentation was present in the medical record. Facility policy requires prompt and detailed documentation of changes in a resident's condition, including observations and actions taken, but this was not followed in this instance.

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 hospice records were present and accessible for a resident who had been placed on hospice services. Medical record review for this resident, who had multiple complex diagnoses including severe cognitive impairment, revealed that from the start of hospice care through a ten-day period, there were no hospice documents available in the facility. Specifically, there was an absence of the hospice plan of care, hospice progress notes, and documentation of the resident's code status. Interviews with the Administrator and DON confirmed that the facility did not have any hospice documentation on site, as hospice had not sent the required documents.

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

A deficiency occurred when a resident with a history of sexual trauma and multiple psychiatric diagnoses, including PTSD, was sexually assaulted by another resident. The assaulted resident required extensive to total assistance with most activities of daily living and had intact cognition. The incident took place in the resident's room, where the perpetrator entered and engaged in non-consensual sexual contact, including digital vaginal penetration and groping, despite the resident's verbal objections and distress. The event was discovered when a CNA entered the room and observed the perpetrator's hand near the resident's waist. Upon questioning, the resident disclosed that the perpetrator had touched her inappropriately and against her will. The resident reported pain and emotional distress, and a subsequent SANE exam confirmed internal injuries consistent with sexual assault. The resident's roommate was not present during the assault, and staff were not in the room at the time, allowing the incident to occur without immediate intervention. Following the assault, the resident experienced a significant decline in her mental health, including increased anger, depression, fear, flashbacks, nightmares, and anxiety, all of which were documented in psychiatric progress notes. The resident expressed fear of encountering the perpetrator again and reported feeling unsafe in her living environment. The incident was reported to facility management, law enforcement, and a SANE exam was conducted to document the injuries.

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 care plan and document a resident's sexually inappropriate behaviors and did not ensure that the physician or Certified Nurse Practitioner (CNP) addressed these behaviors. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic heart failure, bipolar disorder, and severely impaired cognition, exhibited repeated sexual behaviors towards other residents, including entering female residents' rooms without permission and inappropriate physical contact. Despite multiple documented incidents and a physician order for increased supervision, the resident's care plan did not address these behaviors, and there was no documentation in the medical record regarding a significant incident or the rationale for one-on-one supervision. Additionally, progress notes from the physician and CNP did not indicate awareness or management of the resident's behaviors, even though the CNP later confirmed knowledge of the incidents and interventions. Interviews with staff confirmed that the resident's behaviors were known but not documented or addressed in the care plan or medical record. The administrator verified the lack of documentation and care planning related to the resident's behaviors and confirmed that no medication interventions were attempted.

Penalty

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 allegation of resident-to-resident sexual abuse to the state agency, as required by both state regulations and facility policy. The incident involved two residents, one with severe cognitive impairment and behavioral issues, and another with a history of psychiatric disorders and sexually inappropriate behaviors. Multiple documented events indicated ongoing sexually inappropriate interactions between these two residents, including reports of oral sex, physical contact, and repeated attempts to enter each other's rooms. Staff were made aware of these incidents through progress notes, resident reports, and direct observation. Despite the repeated documentation of these behaviors and the involvement of various staff members, including LPNs, RNs, the Social Service Director, and the DON, there was no evidence that the facility submitted a self-reported incident (SRI) to the state agency regarding the sexual abuse allegations. The facility's own policy required notification of the Ohio Department of Health (ODH) within 24 hours of any alleged violations involving abuse, neglect, or exploitation. Interviews with facility leadership confirmed that no SRI was completed for these incidents. The medical records and care plans for both residents were updated to reflect the ongoing behaviors, and interventions such as 15-minute checks, education on safe sex practices, and behavior contracts were implemented. However, the lack of timely reporting to the appropriate authorities constituted a failure to comply with regulatory requirements for reporting suspected abuse, neglect, or theft, as well as a failure to follow the facility's own policies.

Penalty

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 thoroughly investigate an allegation of resident-to-resident sexual abuse involving two residents. Documentation shows that one resident, who had a history of inappropriate sexual behaviors and severe cognitive impairment, was reported by another resident to have received oral sex. Both residents involved denied any sexual contact when interviewed. Despite these denials, there were multiple documented incidents of sexually inappropriate behaviors, including attempts to enter female residents' rooms, physical contact such as rubbing another resident's legs, and being observed in intimate situations with another resident. The records indicate that staff were aware of ongoing sexually inappropriate behaviors between the two residents, as evidenced by repeated documentation of incidents and the implementation of 15-minute checks and behavior contracts. Both residents had complex medical and psychiatric histories, including cognitive impairment, bipolar disorder, and a history of sexually inappropriate behaviors. The facility's own policy required a thorough investigation of all alleged violations, including interviewing all involved parties and witnesses, but the report confirms that no such investigation was completed regarding the sexual abuse allegation between the two residents. Interviews with facility leadership, including the DON and Administrator, verified that an investigation into the alleged sexual abuse was not conducted. The facility policy mandates that an investigation be completed within five working days of notification, but this protocol was not followed. The lack of a thorough investigation into the allegation constitutes the deficiency cited in the report.

Penalty

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 accurately and timely identify and address sexually oriented behaviors involving two cognitively impaired residents, resulting in a deficiency related to ensuring residents' ability to consent to sexual activity and preventing potential incidents of resident-to-resident sexual abuse. Both residents involved had documented cognitive impairments, with one resident having a BIMS score indicating severe impairment and the other moderate impairment. Despite these impairments, both residents were observed engaging in sexual behaviors, including inappropriate touching in common areas and being found partially undressed together in a private room. Medical records and progress notes revealed that while both residents were able to recall and express that their interactions were mutual, there was no documented assessment of their capacity to consent to sexual activity. The psychiatric and behavioral health notes failed to include any evaluation or information regarding the residents' understanding of the nature and consequences of sexual activity or their ability to provide informed consent. Additionally, care plans and educational interventions implemented for both residents did not address or document how the facility determined their ability to consent to sexual activity. The deficiency was further evidenced by the lack of specific documentation in care plans regarding the nature of inappropriate behaviors, the absence of assessments related to consent, and the failure to address these issues in behavioral and psychiatric evaluations. The facility's actions did not ensure that the rights and safety of the cognitively impaired residents were protected in situations involving sexual activity, nor did they provide adequate documentation or assessment to support that the residents were able to consent to such interactions.

Penalty

Fine: $26,257

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

Summary

The facility failed to provide a comprehensive and individualized nutritional plan for a resident identified as being at nutritional risk. The resident experienced significant weight loss over several months due to the facility's failure to address her refusal to consume pureed foods. Despite being on a pureed diet, the resident was observed seeking food from vending machines and other residents, indicating hunger and dissatisfaction with her diet. The facility did not implement appropriate nutritional interventions or notify the physician and the resident's guardian about diet changes and the discontinuation of hospice services. The resident's medical history included chronic obstructive pulmonary disease, alcoholic liver disease, psychosis, hypertension, anemia, hyperlipidemia, schizoaffective disorder, major depression, and severe protein-calorie malnutrition. Despite these conditions, the facility did not adequately monitor her nutritional status or provide comfort foods that she preferred. The resident's weight continued to decline, and she was admitted to hospice services due to severe malnutrition. However, hospice services were discontinued due to a clerical error, and the facility failed to follow up with the resident's guardian or offer in-house palliative care. Throughout the period of weight loss, the facility did not document any new interventions or changes to the resident's care plan to address her nutritional needs. The resident's refusal to eat pureed foods was not adequately addressed, and there was no evidence that requests for alternative food items were implemented. The facility's inaction led to the resident's continued weight loss and negatively impacted her psychosocial well-being.

Removal Plan

• The RDO and Regional Director of Clinical Services educated the facility Administrator on the Weight Assessment Interdisciplinary Interventions policy and Resident Dietary Preferences.
• An emergency Quality Assurance Performance Improvement meeting was held with department heads to discuss notification of Immediate Jeopardy and initiation of abatement plan for corrective action.
• Transitions Hospice' Regional Care Coordinator had communications with Resident #9 and her guardian to sign new consents to enter hospice care.
• The facility Administrator contacted Resident #9's guardian to discuss Resident #9's wishes for comfort/pleasure foods and obtained a signed dietary waiver.
• Unit Manager notified facility CNP of new signed waiver for Resident #9 and a new order was received for comfort foods.
• The Administrator provided education to RD regarding updates to the Weight Assessment Interdisciplinary Interventions Policy and Resident Dietary Preferences.
• Notification was made to Resident #9's guardian by Administrator of Resident #9's new orders.
• The dietary department was notified of the resident's diet change, and a diet slip was completed for Resident #9 to receive comfort food items.
• Administrator developed an action plan for residents who voiced concerns regarding their diet type, including IDT meetings with residents and guardians to discuss diet concerns and changes.
• Resident #9's care plan was updated to reflect changes to Resident #9's diet to regular/comfort food.
• The facility policy for Weight Assessment and Interdisciplinary Intervention was updated.
• Education was completed by the Administrator to the facility department heads via phone message per group chat.
• The Administrator completed education to the facility staff on updated policy for Weight Assessments and Interdisciplinary Interventions as well as resident preferences for diet.
• Administrator, UM, and UM assessed 76 residents for weight loss and identified nine additional residents with weight loss to ensure their weight loss was not due to psychosocial issues from dislike of their current diets.
• Care conferences were completed with residents or guardians to review weights, diets and preferences to ensure residents' psychosocial status is maintained.
• The Administrator implemented a plan to complete weekly audits for all residents for weight loss, with a specific schedule for frequency of audits.

Penalty

Fine: $26,257

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 three residents were seen by a physician as required by regulations. Resident #68, who was admitted with multiple diagnoses including COPD, asthma, and severe morbid obesity, was not seen by a physician every 30 days for the first 90 days and then every 60 days thereafter. The resident was initially seen by the Former Medical Director on 07/14/23, but was not seen again until 05/14/24 by the current Medical Director. This lapse in required visits was confirmed by an interview with an LPN. Similarly, Resident #79, admitted with conditions such as chronic respiratory failure and severe protein calorie malnutrition, was not seen by a physician within the required timeframes. The resident was initially seen on 01/24/24 and not again until 05/14/24. Resident #9, with diagnoses including COPD and alcoholic liver disease, was also not seen by a physician as required, with a gap from 03/11/23 to 05/14/24. The facility's policy mandates physician visits every 30 days for the first 90 days and every 60 days thereafter, which was not adhered to in these cases.

Penalty

Fine: $26,257

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

Summary

The facility failed to implement enhanced barrier precautions for a resident with indwelling medical devices, as observed during a survey. Resident #59, who had a colostomy and a PICC line, did not have the required precautions in place, such as a sign on the door and a cart outside the door, as per the care plan dated 05/22/24. This was confirmed by interviews with a registered nurse and a unit manager, who acknowledged the absence of these precautions. Additionally, the facility did not ensure that vaccination consents were fully completed for two residents. Resident #59's vaccination declination form was incomplete, lacking specification of which vaccination was declined. Resident #9, who had a legal guardian, signed consent forms for flu and Covid-19 vaccinations without the guardian's awareness. Furthermore, the facility failed to track infectious organisms, as evidenced by incomplete logging of pathogens for residents who tested positive for UTIs over several months. This was confirmed by the Director of Nursing and a unit manager.

Penalty

Fine: $26,257

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 was treated with dignity and clothed according to his preference. Resident #59, who was admitted with diagnoses including chronic obstructive pulmonary disease, pneumonia, respiratory failure with hypoxia, and anorexia, was found to be wearing a hospital gown instead of his preferred clothing. Despite having intact cognition and requiring maximum assistance for dressing, the resident expressed dissatisfaction with wearing a hospital gown, stating it was thin and did not provide warmth. The care plan indicated that the resident needed maximum assistance with dressing, yet the facility did not provide him with adequate clothing options. Interviews revealed that the resident had only one shirt and one pair of pants listed in his personal belongings inventory, and he was not offered additional clothing from the facility's resources, such as the lost and found. The Activities Director was unaware if the resident had been offered extra clothing, and a State tested Nursing Assistant confirmed the resident's preference for sweatpants from the lost and found. The resident repeatedly expressed feeling cold and uncomfortable, highlighting the facility's failure to address his clothing needs and ensure his dignity and comfort.

Penalty

Fine: $26,257

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 was able to utilize her power wheelchair, impacting her dignity and autonomy. The resident, who has multiple medical conditions including chronic obstructive pulmonary disease, cerebrovascular accident with left-sided hemiplegia, and severe morbid obesity, was grounded from using her power wheelchair after incidents where she ran into other residents. The facility's occupational therapy and physical therapy departments did not have a goal for working with the resident on power wheelchair safety, and there was no documented evidence of rehabilitation services related to power wheelchair safety prior to the surveyor's request for evaluation and daily notes. The resident reported being incontinent and experiencing delays in staff response to her call light, which contributed to her being late for a scheduled smoking break and subsequently bumping into another resident. Interviews with facility staff revealed that the resident had not been offered therapy for wheelchair safety and that her refusals to participate in therapy were not documented. The resident expressed willingness to participate in therapy if it allowed her to attend smoking breaks on time. The facility had not made any modifications to the manual wheelchair to accommodate the resident's difficulty in propelling it with one arm and leg.