Kimes Nursing And Rehab Llc

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 ensure that a resident was free from significant medication errors when an agency LPN did not follow proper medication administration procedures. The LPN prepared and administered evening/bedtime medications for two roommates at the same time, in a dark room, by popping both residents’ pills into separate cups labeled with their names. The LPN later admitted that she prepared both residents’ medications together and that the room was dark when she administered the medications. One resident, who was not ordered any benzodiazepines or opioid pain medications, was instead given medications that were ordered for his roommate, including Xanax 2 mg PO, Percocet (Oxycodone/Acetaminophen) 10–325 mg PO, and Gabapentin 800 mg PO. The resident who received the wrong medications had a history that included dementia with Lewy Bodies, neurocognitive disorder, mood disorder, major depressive disorder, anxiety disorder, CHF, hypertension, cirrhosis, muscle weakness, difficulty walking, and insomnia. His active orders included medications such as Abilify, Aspirin, Atorvastatin, Vitamin D, Plavix, Aricept, Fluoxetine, Lactulose, Magnesium Oxide, Melatonin, Remeron, Potassium Chloride, Sennosides, and Tamsulosin, with PRN orders for Acetaminophen, artificial tears, Mucinex, and Zofran. He had no orders for benzodiazepines or opioids. On the evening in question, the LPN documented administering his scheduled evening/bedtime medications around 8:44 P.M. and noted that he complained of being tired after a room change earlier that day. Shortly thereafter, his roommate complained to a CNA that his pain medications did not feel like they had worked, stating he could usually tell within 10 minutes when they took effect, suggesting concern that he had not received his usual medications. The facility also failed to timely identify and correlate the reported medication mix-up with the resident’s subsequent change in condition. Around 8:53 P.M., the LPN found the resident lethargic but responsive to touch and able to follow simple commands, with vital signs within acceptable ranges. The resident’s wife reported that he had not awakened during her visit. Despite the roommate’s report that he believed the medications had been mixed up and the LPN’s own acknowledgment that both residents’ medications had been prepared together, the LPN did not notify a physician of a possible medication error or seek medical guidance at that time. Throughout the night, the resident remained lethargic, and staff noted that something seemed “off,” but no provider was contacted until approximately 1:15 A.M., when the resident was found unresponsive, hypotensive, and bradycardic. EMS was then called, and the resident was transferred to the hospital with an altered mental status and unresponsiveness. Hospital evaluation, including a urine drug screen, showed the presence of benzodiazepines and oxycodone, which matched medications ordered for the roommate and not for the resident, confirming that a significant medication error had occurred and contributed to the resident’s serious deterioration in condition. Additional documentation from EMS and the hospital further described the resident’s condition following the error. EMS records indicated that the resident was unresponsive with pinpoint pupils, hypotension, bradycardia, and a Glasgow Coma Scale score of seven, and he received multiple doses of Narcan and Atropine en route. The ED provider note documented hypotension, bradycardia, poor responsiveness, and initial miotic pupils with partial response to Narcan, and the clinical impression included acute encephalopathy and unresponsiveness. The hospital history and physical described acute hypoxic respiratory failure and multifocal pneumonia, with progressive respiratory decline requiring endotracheal intubation and ICU admission. These findings, together with the positive urine drug screen for benzodiazepines and oxycodone in a resident without orders for those medications, were included in the facility’s investigation file as evidence of the significant medication error and its impact on the resident’s condition. The facility’s internal investigation gathered statements from the involved LPN, another LPN who assessed the resident, and a CNA. The agency LPN confirmed that she had prepared both roommates’ medications at the same time, in the dark, and that the roommate later complained that his medications did not feel effective. The second LPN reported that the resident’s condition appeared abnormal and that she eventually insisted he be sent out when he no longer responded as before. The CNA reported that the resident initially seemed at his baseline but later became more lethargic and took a “drastic turn” after his wife left. The DON acknowledged that the incident was possibly medication-related and that the resident’s transfer to the hospital for unresponsiveness was logged as an incident. Collectively, these actions and inactions—improper preparation and administration of medications, failure to promptly recognize and act on the reported medication mix-up, and delayed notification of a physician despite progressive lethargy—constituted the deficiency in ensuring the resident was free from significant medication errors.

Removal Plan

• The Vice President of Clinical Services created a performance improvement plan (PIP), presented it to the Director of Nursing (DON), and the DON assigned the Assistant Director of Nursing (ADON) to assist with medication audits designed to address medication pass performance criteria.
• The DON began an investigation for a possible medication error requiring a resident to be sent to the hospital.
• The DON interviewed the nurse involved and obtained the nurse’s statement of the incident.
• The DON interviewed the nurse working the night of the event and obtained the nurse’s statement.
• The DON interviewed the CNA who worked with the resident the night of the event.
• The DON interviewed the resident’s roommate to obtain a statement.
• The facility provided education on proper medication administration and the five rights of medication administration.
• The DON initiated an in-service on safe medication administration techniques and change of condition with nurses currently on shift regarding the possible medication error.
• The facility implemented a plan for the DON/designee to educate nurses on changes of condition and the five rights of medication administration followed by medication administration audits.
• The facility completed education for all current full-time licensed nurses and implemented a plan for new and agency nurses to be educated upon hire/scheduling by unit managers.
• The facility continued the process for an agency nurse resource guide binder to be available for agency staff to review.
• The DON/ADON began auditing changes in condition per the established schedule, with results reviewed through QAPI and issues addressed as needed.
• The DON/ADON began medication audits per the established schedule, including audits of resident identification/picture identification availability, with results reviewed through QAPI and issues addressed as needed.
• The DON conducted interviews with nurses who had worked prior to the incident/event.
• The ADON completed skin checks and health assessments on residents with low BIMS scores to identify changes in condition or possible medication adverse effects.
• The Vice President of Clinical Services and DON reviewed current policies and procedures for medication administration and change in condition.
• The physician assessed the roommate resident for possible medication adverse effects and reviewed medications for the affected resident.
• The DON reviewed the agency staff process and provided report forms to nursing staff at the beginning of shift to inform nurses how residents take their medication, and identified additions needed to the process including five rights and change in condition policy/education.
• Social Services conducted resident interviews regarding life satisfaction, abuse/neglect, and comfort reporting concerns.
• The DON completed a one-on-one in-service with the nurse involved on safe medication administration and change in resident conditions.
• The DON initiated an in-service for nursing staff on when to notify the DON regarding accidents/incidents, significant changes, medication errors, and emergencies, and implemented education upon hire for new nurses.
• The facility placed the nurse involved on the Do Not Return list.
• The facility implemented a requirement for all residents to have a picture in their chart and completed an immediate audit to verify compliance.
• The physician reviewed medications for the affected resident upon return from the hospital.
• The provider reviewed and approved all medications and documents for the affected resident.
• Social Services interviewed residents to identify concerns about receiving other residents’ medications.
• The facility implemented a plan to discuss the incident at the next QAPI meeting and to review audit results through QAPI with issues addressed as 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 notify the state survey agency of changes in administrative personnel, specifically changes in the Administrator position, affecting all 59 residents in the facility. Review of the Enhanced Information Dissemination and Collection (EIDC) website showed that neither the current Administrator nor the interim Administrator who served from November 2025 through January 2026 were listed as required. In an interview, the current Administrator confirmed that the facility had not informed the state survey agency of these changes in administrators, including the current Administrator. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was 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 maintain an effective training program for staff, affecting all 59 residents in the facility. Record review of personnel files showed that one CNA hired on 12/19/25 did not have documented training in compliance and ethics, the quality assurance program, effective communication, or behavioral health. Another CNA hired on 10/08/25 did not have documented training in compliance and ethics, the quality assurance program, or behavioral health. During an interview on 03/04/26 at 3:04 P.M., the HR staff member confirmed that the required training had not been completed for these CNAs. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791.

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 timely identify and report a significant change in condition for a cognitively intact resident, and to properly correlate that change to a suspected medication error. The resident had multiple diagnoses including dementia with Lewy Bodies, mood and anxiety disorders, CHF, hypertension, cirrhosis, and insomnia, but his MDS showed he was cognitively intact, had no communication issues, and was not ordered any benzodiazepines or opioids. His active orders included antidepressants, antipsychotic adjunct therapy, dementia medication, cardiac and GI medications, sleep aids, and bowel regimen, with PRN orders limited to acetaminophen, artificial tears, Mucinex, and Zofran. He did not have any orders for Xanax, oxycodone, or other narcotic pain medications. On the evening in question, an agency LPN prepared bedtime medications for the resident and his roommate at the same time, popping both residents’ pills into separate labeled cups at the medication cart. She crushed the cognitively intact resident’s pills in pudding and later gave the roommate’s pills whole, acknowledging that the room was dark when she administered the roommate’s medications. The roommate later reported that he believed he had received his roommate’s medications and that his own usual large gabapentin pill and the bitter-tasting oxycodone were missing from what he was given. He stated he did not experience his usual pain relief within 10–15 minutes and complained to staff that he had not received his correct medications. He also reported telling staff that his roommate had been given his medications and that this was why the roommate became unresponsive, and he stated that no one from the facility assessed him or investigated his report of a medication mix-up. After the agency LPN administered the bedtime medications, the resident complained of being tired following a room change and was assisted to bed. Around 8:53 p.m., the resident’s wife arrived and reported that he had not awakened during her visit. The LPN found him lethargic but able to follow commands, with vital signs within normal limits, and attributed his condition to fatigue from the move. Throughout the night, the LPN and another LPN noted that “something seemed off,” but they continued to attribute his lethargy to the room change and sleepiness. The resident’s condition progressively worsened; by approximately 1:15 a.m. he was more lethargic, then unresponsive to verbal and painful stimuli, with hypotension and borderline oxygen saturation. Only at that point was the on-call physician notified and EMS summoned. EMS and hospital records documented hypotension, bradycardia, unresponsiveness, pinpoint pupils, administration of Narcan and Atropine, and a urine drug screen positive for benzodiazepines and oxycodone—medications not ordered for the resident but ordered for his roommate. Despite these findings and the roommate’s contemporaneous statements, the DON reported she did not substantiate a medication error and did not clearly link the resident’s change in condition to a medication mix-up, reflecting a failure to promptly recognize, correlate, and report the suspected medication error and associated change in condition to the physician. Hospital documentation further described the resident as presenting with acute encephalopathy, acute hypoxic respiratory failure, shock, and unresponsiveness with pinpoint pupils and low blood pressure and heart rate. The ED and ICU notes referenced multiple doses of Narcan, a positive urine drug screen for benzodiazepines and oxycodone, and family and roommate concerns that the resident had received his roommate’s medications, including opioids and gabapentin. Subsequent hospital records from a tertiary facility noted that the encephalopathy was likely multifactorial on a background of Lewy Body dementia, with possible contributions from polypharmacy and anoxic brain injury in the setting of prolonged downtime and suspected receipt of the roommate’s opioids and gabapentin, though this could not be definitively confirmed. Within the facility, however, the change in condition was initially attributed to fatigue from a room move, the resident was allowed to remain in a progressively worsening state for several hours before EMS was called, and the facility did not substantiate or clearly document a medication error despite objective toxicology findings and consistent reports from the roommate and family. The facility’s internal investigation collected staff statements, MARs for both residents, controlled drug records, and hospital records. The agency LPN acknowledged that she prepared both residents’ medications at the same time and that it was possible she could have popped pills into the wrong cup or grabbed the wrong cup when crushing medications, though she denied intentionally giving the wrong medications. Another LPN recalled the roommate saying that the agency nurse had given the lethargic resident his pills, and that EMS administered Narcan due to pinpoint pupils. The DON confirmed that the resident’s urine drug screen was positive for benzodiazepines and oxycodone, and that the roommate was ordered Xanax and oxycodone at bedtime, but she stated she could not be certain the resident did not receive these drugs from another source and therefore did not substantiate a medication error. This sequence of events demonstrates that the resident’s significant change in condition was not promptly recognized as potentially medication-related, was not timely reported to the physician when first observed, and was not adequately correlated with the suspected medication error despite contemporaneous reports and objective toxicology findings.

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 report an allegation of misappropriation of resident property to the state as required by regulation and facility policy. Resident #10 was admitted with diagnoses including muscle weakness and hypertension, and her care plan and MDS documented intact cognition with no behaviors or history of making false allegations. A grievance report documented that the resident’s son had brought five lottery tickets to the resident; when he returned, the resident reported that one ticket, which she stated was a $250 winner, was missing while the other four tickets remained present but were not winners. According to the grievance documentation and interviews, the resident’s son searched the room, including dressers, drawers, and the trashcan, but could not locate the winning ticket. The social worker then assisted in searching the room without success. Resident #10 confirmed that her son had brought her four or five scratch-off tickets, that one was a $250 winner, and that she later noticed the winning ticket was missing after leaving the room for an activity and returning. She stated she did not throw the ticket away, did not see anyone else throw it away, and did not witness another resident or staff member take it, but believed someone must have taken it. Multiple staff members, including CNAs, RNs, agency nurses, and the ADON, were interviewed; several recalled seeing lottery tickets on the resident’s bedside table on various days, but none could confirm the number of tickets or what happened to the winning ticket. Interviews with facility leadership established that the situation was recognized as a potential misappropriation. The social worker stated that allegations of abuse or misappropriation would be reported to the state by the Administrator or DON. The Administrator acknowledged that a missing lottery ticket worth $250 constituted an allegation of misappropriation that should have been reported to the state and stated that such allegations should be reported immediately, but confirmed he did not report it and was unsure of his responsibility. The DON stated that allegations of misappropriation are to be reported to the state immediately upon suspicion or discovery, but confirmed she had not reported the allegation and had not been informed of the situation until later in the week. Review of the facility’s Abuse Investigation and Reporting policy showed that all reports of misappropriation must be promptly reported to appropriate agencies, with allegations reported within two hours, which did not occur 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 the facility’s failure to provide scheduled showers and personal care to dependent residents who required assistance with activities of daily living (ADLs). One resident with dementia, muscle weakness, diabetes, and impaired mobility had a care plan dated 08/27/25 indicating a need for assistance with self-care, ADLs, and mobility, with a goal to remain clean, dry, dressed, groomed, and free of odors. Interventions included dependent shower assistance by one helper, and an MDS dated 11/18/25 showed the resident required maximum assistance for bathing. The shower schedule showed this resident was to receive showers on Mondays and Fridays on dayshift, but shower records revealed missed showers on 02/20/26 and 02/27/26. Another resident with hypertension and cancer had a care plan dated 08/15/25 indicating dependence on staff for bathing/showering due to pain, limited mobility, limited range of motion, and weakness, with a goal to maintain current ADL function. An MDS showed this resident was dependent on staff for bathing and had refused care on four to six days during the review period. The shower schedule indicated showers on Tuesday and Friday dayshift, but shower records showed missed showers on 12/26/25 and 12/30/25. A third resident with hypertension, osteoarthritis, impaired mobility, weakness, cognitive deficits, and pain had a care plan dated 10/13/25 requiring assistance with self-care, ADLs, and mobility, including assistance as needed with showers twice weekly or per preference and partial assist with showers. The MDS indicated moderate assistance was needed for bathing/showering, and the shower schedule listed Tuesday and Friday nightshift. Shower records showed this resident did not receive showers on 10/21/25, 11/06/25, 11/13/25, 11/25/25, and 11/28/25. In an interview on 03/04/26 at 1:10 P.M., the ADON confirmed these residents were not provided scheduled showers and that there was no other documentation to show the showers were given.

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 ordered non-pressure wound care treatments were completed as prescribed for one resident. The resident was admitted with type II diabetes and hidradenitis suppurativa, and an MDS assessment documented moisture associated skin damage (MASD). A care plan identified the resident as being at risk for skin impairment due to weakness, cognitive deficit, incontinence, impaired mobility, thin and fragile skin, falls, and autoimmune disease, with goals and interventions that included keeping the skin clean and dry, using lotion on dry but not broken skin, monitoring and documenting skin injuries, and following facility protocols for treatment. An order dated 11/18/25 directed daily wound care including cleansing with chlorhexidine wash, applying clindamycin gel to the wound, covering with an ABD pad, and applying nystatin powder to the peri-wound area; this order remained in effect until 12/19/25. Record review of the treatment administration record for 12/2025 showed that this daily wound care was not completed on 12/11/25, 12/12/25, 12/16/25, and 12/18/25. A subsequent order dated 12/19/25 revised the daily treatment to include cleansing with chlorhexidine wash, applying clindamycin gel, applying calcium alginate, covering with an ABD pad, and applying nystatin powder to the peri-wound. The treatment administration record for 12/2025 showed missed treatments on 12/21/25, 12/25/25, 12/30/25, and 12/31/25, and the record for 01/2026 showed missed treatments on 01/03/26, 01/04/26, and 01/05/26. In an interview, the ADON confirmed that these treatments were not completed as ordered and stated there was no reason they should not have been completed and no additional documentation explaining the omissions. This deficiency was investigated under Complaint Number 2722441.

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 implement fall-prevention interventions as outlined in residents’ care plans for residents identified as high fall risks. For one resident with multiple diagnoses including osteoporosis, gait abnormalities, cognitive impairment, and a history of multiple falls, the fall risk assessment identified her as high risk and her care plan required that her walker be kept within reach when she was in her room. During observation, the resident was lying in bed with her wheelchair at the bedside, but no walker was within reach as required by her fall-prevention care plan. A CNA who had been working at the facility for about four months reported being familiar with this resident, acknowledged that the resident was a fall risk with a history of falls, and stated that the resident was supposed to wear non-skid socks or shoes when ambulating and primarily used a wheelchair. However, the CNA was not aware that the resident had a walker and confirmed, upon returning to the room, that no walker was kept within the resident’s reach despite this being an active intervention in the resident’s fall-risk care plan. For a second resident with multiple conditions including hemiplegia, muscle weakness, reduced mobility, and total incontinence, the fall risk assessment also identified her as high risk for falls, and her care plan required that she be provided with a reacher/grabber and encouraged to use it, particularly if she dropped items on the floor. Observation found this resident in bed with an air mattress, perimeter overlay, assist bars, and call light within reach, but without a reacher/grabber in reach as specified in her care plan. The resident stated she had a reacher/grabber “around there somewhere” but confirmed it was not within reach, and a reacher/grabber was later observed stored on a nightstand in an area of the room not accessible to her. An LPN, new to the facility, confirmed that the reacher/grabber was part of the resident’s fall-prevention interventions and that it was not within the resident’s reach at the time of observation. The facility’s fall policies required identification and implementation of interventions based on resident-specific risks, but the required interventions were not in place for these residents at the time of surveyor observations.

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 appropriate use of personal protective equipment (PPE) for a resident on transmission-based precautions (TBP) for Covid-19. During a medication pass on the North hall, an RN entered the room of Resident #30, who verbally reported it was her tenth and final day of isolation for a positive Covid-19 test, wearing only an N-95 particulate respirator and gloves. The RN did not don a gown before entering, despite the facility’s Covid-19 policy requiring a NIOSH-approved N-95 or higher respirator, gown, gloves, and eye protection for healthcare providers entering the room of a patient with suspected or confirmed Covid-19 infection. Observation after the medication pass showed a PPE cart outside the resident’s room and a Droplet Precautions sign that was not prominently displayed, as it was resting diagonally on the handrail, partially obscured by equipment stored in the hallway. Record review showed Resident #30 was admitted on an earlier date with diagnoses including congestive heart failure, chronic kidney disease, hypertensive heart disease, and morbid obesity. Nursing progress notes documented that on a prior date the resident was tested for Covid-19 due to headache, chills without fever, and sore throat, and the test was positive. However, the active physician’s orders did not include a specific order for TBP for Covid-19 or the duration of isolation, only an open-ended order allowing Covid-19 testing as needed. In an interview, the RN confirmed she knew the resident was in isolation for Covid-19, acknowledged that a gown was required PPE for entering the room, and stated she did not wear a gown because none were available in the PPE cart and she did not check other carts. She also acknowledged that the Droplet Precautions sign was not clearly visible or posted on the door where it would be easily seen when the door was closed.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain and implement its infection prevention and control program, including required COVID-19 precautions, during an active outbreak that affected all residents. Surveyors observed a sign at the facility entrance stating that staff and visitors were required to wear N95 masks at all times due to a current COVID-19 outbreak. Despite this, four of five night-shift staff members, including two LPNs and two CNAs, were observed inside the facility without any masks. One LPN acknowledged she had a resident on her unit with COVID-19 and confirmed staff were supposed to wear masks at all times. Another CNA stated she was unsure whether staff were required to wear masks at all times and reported working on the LTC unit. A second LPN, who also had a resident with COVID-19 on his unit, stated he did not believe masks worked, was not aware staff were to wear masks, and said he would only wear a regular mask, not an N95, when entering a COVID-positive resident’s room. Another CNA reported being unclear about mask use outside resident rooms and stated that staff had become more relaxed about mask use at night after several residents had COVID-19. Further observations showed improper use of personal protective equipment (PPE) for residents on isolation for COVID-19. A CNA delivering a breakfast tray to a resident on droplet/contact precautions for COVID-19 donned a gown, gloves, and an N95 mask but did not wear eye protection while providing care and handling items in the room. Upon exiting, she removed her gown and gloves, performed hand hygiene, and applied a new N95 mask, later stating she was new and did not know eye protection was required for entering the room of a resident with COVID-19. An RN confirmed that staff were required to wear eye protection when entering such rooms. Record review showed that one resident had tested positive for COVID-19 and was placed on isolation, and another resident later tested positive and was placed on droplet/contact isolation. Facility infection tracking logs documented that 18 residents had tested positive for COVID-19 over a defined period, with all but one remaining in the facility. The facility’s written COVID-19 policy required source control (mask use) for individuals in areas experiencing a SARS-CoV-2 outbreak and specified that staff entering rooms of residents with suspected or confirmed COVID-19 must use an N95 mask, gown, gloves, and eye protection, which was not consistently followed in practice.

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 received showers according to their preferred schedules, as documented in their care plans. Three residents with severe cognitive impairment and dependent on staff for bathing did not receive showers on multiple scheduled days. Medical records and care plans indicated that these residents were to receive showers twice a week, with specific days assigned for each individual. Shower records revealed that the scheduled showers were missed on several occasions for each resident. Interviews with CNAs, LPNs, and RNs confirmed that showers were not completed when there were staffing challenges. Staff reported that, during periods of inadequate staffing, priority was given to other essential care tasks such as turning, changing, and assisting residents with eating, resulting in showers being omitted. The Acting DON confirmed that residents' shower preferences were obtained on admission and that the missed showers were accurately reflected in the records. Family members of one resident expressed concern about the resident's hygiene, noting a decline in cleanliness and the importance of showering to the resident. The deficiency was identified during an investigation under specific complaint numbers.

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 appropriate and timely pressure ulcer care for two residents, resulting in deficiencies in wound management and prevention. For one resident with a history of congestive heart failure, respiratory failure, diabetes, and stage four kidney disease, a physician's order was in place to treat a pressure ulcer on the left heel. However, during wound care, a registered nurse mistakenly treated the right heel, which no longer had a pressure ulcer, instead of the left heel as ordered. The nurse confirmed the error after it was pointed out, and the facility's policy required adherence to physician orders for wound treatment. Another resident, admitted after hip replacement surgery and with stage three kidney disease and hypertension, was identified as being at risk for skin breakdown. Initial skin assessments were inaccurately dated, and the resident developed pressure ulcers on the right upper buttock and coccyx, which later merged into a larger wound. Treatment for these ulcers was not initiated until several days after the wounds were first noted, despite physician orders being obtained. Additionally, deep tissue pressure injuries were identified on both heels, but treatment was delayed by a day after the injuries were discovered and orders were received. Interviews with nursing staff and the Director of Nursing confirmed that documentation was not completed on the correct dates and that treatments were not started promptly as required by facility policy. The facility's Skin Integrity Management Policy specified that treatment plans should be established and implemented for residents with pressure ulcers, but these procedures were not consistently followed for the affected residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely and appropriate reporting of an allegation of physical abuse involving a resident with chronic respiratory failure, dementia with psychotic disturbance, and psychosis. The incident occurred when two CNAs were providing care to the resident, who became combative. One CNA reportedly responded to the resident's attempt to bite by pushing and smacking the resident's head. This incident was witnessed by the other CNA, who did not report it immediately. The abuse was not reported to the local law enforcement agency or the resident's family, and the facility's Administrator unsubstantiated the allegation due to a lack of evidence. The facility's policy requires immediate reporting of abuse allegations to a supervisor, with subsequent notifications to the physician, resident's family, Ombudsman, and local law enforcement. However, the report indicates a delay in reporting the incident, as the witnessing CNA did not report it until several hours later, and the Administrator did not notify the necessary parties. The deficiency was identified during the investigation of a complaint, highlighting non-compliance with the facility's abuse prevention 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 offer pneumococcal immunizations to residents, as evidenced by the review of medical records, vaccination consent forms, and staff interviews. This deficiency affected four out of five residents sampled for immunization review. The residents involved had various medical conditions, including heart disease, diabetes, dementia, renal disease, and respiratory failure. The immunization records for these residents showed either no record of receiving a pneumococcal vaccine or an unknown type of vaccine administered years prior. Additionally, there were no physician orders for the pneumococcal vaccine for these residents. The facility's Vaccine Administration Record (VAR)/Informed Consent form allowed residents or their responsible parties to indicate their wish to receive vaccinations, including COVID-19, influenza, and others. However, the forms for the affected residents did not indicate a request for the pneumococcal vaccine. An interview with the Director of Nursing (DON) revealed that there was no specific consent form for the pneumococcal vaccine, and the facility relied on residents or their families to write in their request for this vaccine. The DON acknowledged that there was no proof that the affected residents were asked about receiving the pneumococcal vaccine, highlighting a gap in the facility's vaccination consent process.

Penalty

No penalty information released

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

Summary

The facility failed to provide a bed-hold notice to a resident's representative when the resident was transferred to the hospital. This deficiency was identified during a review of the medical records of a resident who was admitted to the facility with diagnoses including dementia with behavioral disturbances, unspecified intellectual disability, generalized anxiety disorder, restlessness and agitation, and hypernatremia. The resident was transferred to the hospital due to an elevated sodium level, and although the resident's sister was informed of the transfer, there was no documentation that she was provided with a bed-hold notice as required by the facility's policy. The facility's policy mandates that residents or their representatives be informed of the bed-hold policy upon admission and prior to any transfer for hospitalization or therapeutic leave. In this case, the resident's medical record lacked evidence of compliance with this policy, as confirmed by the Social Service Director. The director was unable to find any documentation indicating that the resident's representative received the necessary bed-hold notice within the required timeframe, highlighting a lapse in the facility's adherence to its own procedures.

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 Pre-Admission Screening and Resident Review (PASARR) documents were accurate regarding a resident's current conditions and diagnoses. This deficiency was identified during a review of records and staff interviews, affecting one resident. The resident in question had a range of diagnoses, including anxiety disorder, schizoaffective disorder, dementia, and several other medical conditions. Despite having a documented diagnosis of anxiety disorder since July 2021, the PASARR completed in January 2022 did not list this diagnosis. This discrepancy was confirmed during an interview with the Marketing Director, who acknowledged the absence of the anxiety diagnosis on the PASARR document.

Penalty

No penalty information released

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

Summary

The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident #36, who has a complex medical history including end-stage renal disease, diabetes, heart disease, and other serious conditions, was prescribed the anticoagulant medication Eliquis for acute deep venous thrombosis. Despite the critical nature of this medication, the facility did not create a care plan to manage the resident's anticoagulant therapy. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan for the resident's Eliquis use. Similarly, Resident #10, who has diagnoses including heart disease, diabetes, dementia, and anxiety disorder, did not have a specific and patient-centered care plan for managing anxiety. The resident's most recent assessment indicated a need for partial assistance with certain activities, yet the care plan failed to address the anxiety disorder and its specific symptoms. This lack of a tailored care plan was also verified by the Director of Nursing, highlighting a gap in the facility's approach to individualized resident care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the availability of hospice records for Resident #109, which is crucial for continuity of care. The resident, who was admitted with multiple diagnoses including dementia and heart failure, was receiving hospice services with a prognosis of less than six months. Despite the care plan indicating the need for hospice services and documentation, the facility did not have the necessary hospice certification, care plan, or assessment in the resident's medical record. Interviews with the LPN confirmed that the required hospice documentation was not present. Additionally, the facility did not apply compression stockings as ordered by the physician for Resident #32, who was experiencing chronic left lower extremity edema. The resident, who had dementia and other mobility issues, was ordered to have compression stockings applied daily. However, observations revealed that the resident was not wearing the stockings, and the care plans did not address the edema or the use of compression stockings. Interviews with the CNA and LPN indicated a lack of awareness and adherence to the physician's orders, with the LPN acknowledging that the treatment administration record was inaccurately initialed to reflect compliance. These deficiencies highlight lapses in the facility's adherence to care plans and physician orders, impacting the quality of care provided to residents. The absence of hospice documentation and the failure to apply prescribed compression stockings demonstrate a lack of coordination and communication among the facility's staff, affecting the residents' care and well-being.

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 fall prevention interventions as per the care plans for two residents at risk for falls. Resident #33, who had a history of falls and fractures, was admitted with a care plan that included using a visual reminder to prompt the use of a call light for assistance. Despite this, the resident experienced a fall resulting in a right hip fracture, as the visual reminder was not present in the room. The Director of Nursing confirmed the absence of the visual reminder, which was supposed to be in place following an interdisciplinary team review after the resident's previous fall. Resident #38, diagnosed with severe cognitive impairment and requiring substantial assistance, was also affected by the facility's failure to adhere to fall prevention measures. The care plan for this resident included the use of dycem in the wheelchair to prevent falls. However, during an incident, the dycem was not in place, leading to the resident being found on the floor. The Director of Nursing verified that the dycem was not in the wheelchair at the time of the fall, contrary to the care plan requirements.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the PTSD and to minimize triggers and/or re-traumatization. This deficiency affected one resident, identified as having PTSD/trauma, within a facility census of 51. The resident had a range of pertinent diagnoses, including chronic PTSD, heart failure, morbid obesity, Alzheimer's disease, and other mental health disorders. Despite being cognitively intact and using a walker for mobility, the resident's medical record lacked an assessment or care plan for PTSD. Interviews with the Registered Social Worker and the Director of Nursing confirmed the absence of a PTSD care plan or assessment, with the staff unaware of the resident's PTSD triggers or history.

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 adhere to infection prevention guidelines by not wearing appropriate personal protective equipment during wound care for a resident. The resident, who was cognitively intact and used a wheelchair, had a right lateral heel unstageable pressure ulcer and was on enhanced barrier precautions due to their medical condition. The precautions required staff to wear gloves and gowns during high-contact activities such as wound care. However, during an observation, a State Tested Nurse Aide (STNA) assisted with the resident's wound care by only wearing gloves and not a gown, despite the clear signage on the resident's door indicating the need for enhanced barrier precautions. The STNA was observed holding the resident's leg in the air for at least two minutes without wearing a gown, and her clothing was in contact with the side of the bed. This action was in direct violation of the facility's Enhanced Barrier Precautions policy, which mandates the use of gloves and gowns for high-contact resident care activities to prevent the spread of multi-drug resistant organisms. The STNA confirmed in an interview that she did not wear a gown, acknowledging the resident was on enhanced barrier precautions.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was not treated with an antibiotic prior to the return of culture and sensitivity (C&S) results. This deficiency affected a resident who was being reviewed for a urinary tract infection (UTI). The resident had a complex medical history, including neurocognitive disorder with Lewy bodies, dementia, Alzheimer's disease, and other conditions. The resident's care plan included monitoring for signs and symptoms of UTI and ensuring proper toileting and pericare. On a specific date, the resident exhibited increased lethargy, unformed speech, and had not voided in 12 hours, prompting the physician to order a straight catheterization, urinalysis (UA) with C&S, and Rocephin, an antibiotic, for three days. The UA/C&S results, collected the day after the antibiotic was started, suggested probable contamination and recommended a repeat test if clinically indicated. Despite this, the resident had already completed the three-day course of Rocephin by the time the results were received. The Director of Nursing confirmed that the resident was treated with antibiotics before the UA/C&S results were available. The physician decided not to repeat the UA, as the resident's behavior had returned to baseline.

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 physician-ordered pressure reduction devices for two residents, leading to deficiencies in pressure ulcer care. Resident #109, who was admitted with multiple diagnoses including a stage I pressure ulcer, was observed without the physician-ordered off-loading boot and air mattress. Despite orders to use these devices to prevent further skin breakdown, they were not in place during multiple observations on the same day. The resident's care plan included interventions such as an air mattress and off-loading boot, but these were not executed as required. Similarly, Resident #45, who had a history of pressure ulcers and required substantial assistance with mobility, was found on an alternating air mattress set incorrectly to a weight of 450 pounds, despite weighing only 133 pounds. The care plan and physician orders specified the use of an alternating air mattress, but the incorrect setting was confirmed by an LPN who was unsure of the correct weight setting. This oversight was later corrected by a Registered Nurse Clinical Compliance Specialist. These deficiencies were identified during a complaint investigation.