New Lebanon Rehabilitation And Healthcare Center

Penalty

No penalty information released

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

Summary

Surveyors observed that the facility failed to prepare, store, and distribute food in a safe manner, as evidenced by the presence of a swarm of flying gnats and active black flies throughout the kitchen areas during multiple observations. During an initial tour, a dietary manager confirmed an ongoing issue with fruit flies and gnats in the kitchen, and further observations during meal preparation revealed active black flies present while staff prepared meals. The dietary manager acknowledged the presence of these pests and confirmed that all 96 residents received their meals from the affected kitchen. Review of the facility's food handling policy indicated that food should be stored, prepared, handled, and served to minimize the risk of foodborne illness, but these standards were not met during the survey period. All 96 residents in the facility were potentially affected, as they received food prepared in the kitchen where the pest issues were observed. The deficiency was identified during complaint investigations and confirmed through staff interviews and policy review.

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 resident with multiple medical conditions, including multiple sclerosis, obstructive sleep apnea, obesity, hypertension, anemia, anxiety, PTSD, asthma, major depressive disorder, and COPD, requested a copy of her medical records from the facility. The resident, who was cognitively intact and dependent on staff for medication administration but independent in some activities of daily living, made her request to the Medical Records Manager (MRM). The MRM informed the resident that the copier was broken at the time of the request and stated that copies would be provided once the copier was repaired. Despite the copier being repaired, the MRM did not follow up with the resident or provide the requested records. The copied records remained in the office, and the resident did not receive them. Facility policy confirmed that residents have the right to access their medical records at any time. This failure to provide the requested records was confirmed through interviews, observation of the undelivered records, and review of 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

The facility failed to thoroughly investigate and document grievances related to missing personal items for a resident. The resident, who was cognitively intact and had multiple medical diagnoses including morbid obesity, type II diabetes, anxiety disorder, and stage III chronic kidney disease, reported that several items of clothing had gone missing while residing in the locked unit. Despite providing detailed lists of missing items to Social Services, and the family also communicating concerns to the Administrator, the facility did not conduct a comprehensive investigation or follow up with the resident or her family to resolve the issue. The resident's concerns were not entered into the facility's grievance log, and there was no documented inventory of her personal items in the medical record. Interviews with staff revealed that Social Services received multiple lists of missing clothing from the resident over several days and attempted to locate some items in the resident's room and laundry, marking off what was found. However, Social Services did not follow up on the remaining missing items, assuming the issue was resolved when it was not mentioned again. The Administrator also acknowledged being informed of the missing items by the resident's family but did not pursue further investigation or communication after initially requesting a list of missing items from the family, which was not received. The Director of Nursing confirmed that the resident's concerns were not documented in the grievance log as required by facility policy. Facility policy required immediate action and a timely investigation upon receipt of any grievance, whether oral or written, to prevent further violations. Despite this, the facility did not document or investigate the resident's repeated reports of missing clothing, nor did it communicate outcomes or resolutions to the resident or her family. The lack of follow-up and documentation resulted in the resident and her family having to replace the missing items themselves, with the value of the lost clothing estimated at around $600.

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 who required assistance with activities of daily living, specifically bathing and personal hygiene, consistently received showers as scheduled. One resident with morbid obesity, diabetes, anxiety disorder, and chronic kidney disease, who was cognitively intact and required maximum assistance with bathing, went up to 12 weeks without a shower while residing in a locked unit. Documentation confirmed a lack of shower records for this resident over a two-month period, and the resident reported repeated refusals by night shift staff to provide showers, despite complaints to the DON. Another resident with multiple chronic conditions, including multiple sclerosis and morbid obesity, was scheduled for showers twice weekly but did not always receive them, as confirmed by both the resident and the DON. A third resident, who was cognitively intact and required substantial staff assistance with bathing, missed a scheduled shower due to short staffing and reported not being shaved regularly, which was corroborated by observation and lack of documentation. Facility policy required staff to provide necessary services for hygiene, including bathing and grooming, for residents unable to perform these tasks independently.

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 resident with diagnoses including schizoaffective disorder, hypertension, dementia without behavioral disturbances, and bipolar disorder was admitted to the facility and assessed as having severely impaired cognition. The resident was identified as high risk for elopement, with an elopement evaluation and care plan in place that included interventions such as redirection, distraction, prompt response to alarms, and restrictions on leaving the unit. Despite these interventions, the resident exhibited repeated exit-seeking behaviors, including attempts to open doors, pushing on exit doors, and trying to jump a fence in the smoking area. Staff notes documented multiple incidents where the resident attempted to leave the facility, and on one occasion, another resident succeeded in opening a door, nearly allowing the high-risk resident to exit. On the day of the deficiency, the resident continued to aggressively seek exits, and staff interventions, including non-pharmacological measures and administration of medications, were not effective in preventing these behaviors. The resident was on frequent staff checks but was not placed on one-on-one supervision despite escalating behaviors. Later that day, the resident successfully eloped from the mental health unit, triggering an alarm. Staff were unable to determine the direction the resident had taken, and a search was initiated. The resident was found approximately one hour later, hiding in bushes about 50 feet from the facility, and was returned without injury. Interviews with staff, including an LPN and the DON, confirmed that the resident had not been placed on one-on-one supervision until after the elopement occurred, despite multiple prior attempts to leave and clear documentation of high elopement risk. The facility's elopement policy was found to only address procedures following an elopement, not preventive measures. This sequence of events demonstrates a failure to provide adequate supervision and interventions to prevent the elopement of a resident assessed as high risk.

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 safe and appropriate respiratory care by not using a non-rebreather mask according to professional standards for a resident with impaired respiratory status. The resident, who had diagnoses including type II diabetes, stage III kidney disease, and unspecified dementia, was ordered to receive oxygen at 5 liters per minute via non-rebreather mask after experiencing low oxygen saturation levels. Staff interviews revealed that the non-rebreather mask did not fit the resident properly due to multiple skin folds, requiring staff to hold the mask in place. Additionally, the mask was administered at a flow rate of 5 liters per minute, which is below the standard practice of 10 to 15 liters per minute as outlined by the National Institute of Health guidelines. Nursing staff involved were either unaware of the correct flow rate for non-rebreather masks or followed the provider's order without verifying the standard of care. The nurse practitioner who gave the order was not aware that the facility's oxygen concentrators could deliver up to 10 liters per minute and based the order on incorrect information about equipment capabilities. The facility did not have a policy specific to the use of non-rebreather masks, contributing to the improper administration of oxygen therapy for the 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

A deficiency was identified when a resident with diagnoses including schizoaffective disorder, hypertension, dementia without behavioral disturbances, and bipolar disorder did not receive prescribed medications as ordered. The resident, who had severely impaired cognition and required supervision with activities of daily living, was admitted to the facility and had physician orders for lorazepam 1 mg and trazodone 50 mg to be administered at bedtime. Review of the Medication Administration Record (MAR) showed that lorazepam was not administered from 08/08/25 through 08/10/25, and trazodone was not administered on 08/08/25 and 08/09/25, as ordered by the physician. The Director of Nursing confirmed that there was no documentation to support that the resident received these medications on the specified dates. Facility policy requires that medications be administered in a safe and timely manner, and as prescribed. The failure to administer these medications as ordered was confirmed through medical record review, staff interview, and policy review.

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 proper storage of medications for two residents. For one resident with paraplegia, schizophrenia, depression, encephalopathy, and hypotension, surveyors observed a medicine cup containing two tablets left on the bedside table. There was no physician order, assessment, or care plan documentation supporting the resident's ability to keep medications at the bedside. The facility's policy required drugs to be stored in their original packaging or dispensing system, which was not followed in this instance. For another resident with encephalopathy, COPD, diabetes mellitus, and psychosis, an unopened insulin flexpen labeled for the resident was found in the top drawer of the medication cart, despite a pharmacy label indicating it should be refrigerated until opened. An LPN confirmed the insulin flexpen was not refrigerated. Facility policy required medications needing refrigeration to be stored in a refrigerator located in a secure area, which was not adhered to 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 facility failed to maintain a pest-free environment, as evidenced by multiple observations and interviews involving three residents. One resident with a history of psychosis, schizophrenia, and narcolepsy was observed in bed with flying insects on his sheet and privacy curtain, which was confirmed by the Activities Director. Another resident, who was cognitively intact and diagnosed with alcohol-induced pancreatitis, essential tremor, and major depressive disorder, had fly paper hanging from the ceiling with several dead insects and kept a fly swatter in bed. This resident reported a significant fly problem, stating that a nurse had provided the fly trap about a month prior, and described the area under his bed as a "graveyard" for dead insects. Staff and the Administrator confirmed the presence of the fly paper and dead insects, with the Administrator noting that the facility did not supply such pest control devices. A third resident, also cognitively intact and with diagnoses including cerebral infarction, diabetes mellitus, psychotic disorder, vascular dementia, and hypertension, was observed with multiple gnats and flies in his room. The resident stated that flies or gnats were always present in his room. Further observation confirmed flies on his comforter and gnats on his pillow, which was verified by a housekeeper. These findings demonstrate a lack of effective pest control measures in the facility, directly affecting the living conditions 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

The facility failed to notify the local health department of a COVID-19 outbreak that occurred from November 16, 2024, to December 24, 2024. The facility's infection control log and map confirmed the outbreak during this period. An interview with the Administrator on December 30, 2024, revealed that the facility was unaware of the requirement to contact the local health department and did not notify them of the outbreak. The directive from CMS, QSO-20-39-NH, dated May 08, 2023, requires facilities to contact their health department when responding to COVID-19 transmission. The facility's policy, dated September 2022, also mandates the use of surveillance tracking tools for infections and reporting outbreaks to public health authorities. This deficiency was investigated under Complaint Number OH00160332.

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 medication as ordered for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including schizophrenia, anxiety, and bipolar disorder. The resident exhibited signs of agitation, anxiety, and confusion, prompting a physician to order a dose of Haldol 5 mg intramuscularly. However, the nurse on duty, RN #111, was unable to access the medication from the Omnicell automatic dispensing cabinet, despite having access to it. Consequently, the resident was sent to the hospital, where they received the prescribed medication. The medical record review revealed that the nurse did not document the physician's order for Haldol in the resident's records. The Director of Nursing was not informed of the resident's transfer to the hospital until the following day and confirmed that other nurses were available to assist in accessing the medication. The facility's policy mandates that medications be administered safely and timely, as prescribed, which was not adhered to in this instance. This deficiency was investigated under Complaint Number OH00158398.

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 control procedures during medication administration, as observed during a complaint investigation. A registered nurse (RN) was seen preparing and administering medications to a resident without following proper infection control protocols. Specifically, the RN placed metformin and metoprolol tablets directly into her bare hands before transferring them to a medication cup, which is against the facility's policy that mandates the use of infection control procedures such as handwashing and antiseptic techniques. The resident involved in this incident had a complex medical history, including a right above the knee amputation, diabetes mellitus, asthma, schizoaffective disorder, and chronic respiratory failure. The resident was cognitively intact and required partial to moderate assistance with daily activities. The deficiency was noted as ongoing noncompliance from a previous survey, indicating a repeated failure to follow established infection control procedures during 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 ensure that resident rooms were free from flies and gnats, affecting two residents out of the three reviewed for environmental conditions. Resident #11, who was cognitively intact but dependent on assistance for various activities and frequently incontinent, was observed holding a fly swatter due to the presence of flies and gnats in her room. Similarly, Resident #13, who had moderate cognitive impairment and required substantial assistance, was found in a room with several flies and gnats, a strong urine odor, and a sticky substance on the floor, indicating a lack of cleanliness. Interviews with staff, including an STNA and an LPN, confirmed the ongoing issue of flies and gnats in the rooms of Residents #11 and #13. The pest control invoices reviewed showed treatments were provided for common areas but did not initially include individual resident rooms until a later date. This deficiency was part of a complaint investigation and represented ongoing noncompliance from a previous survey.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to maintain sufficient levels of nursing staff, resulting in Immediate Jeopardy when only three LPNs and two STNAs were on duty to care for 105 residents. This staffing shortage affected the ability to provide routine care, monitoring, medication administration, and response to urgent needs. The lack of adequate staffing led to potential serious harm and negative health outcomes for residents, as they were unable to receive necessary care and supervision. Resident #41, who was in a persistent coma state and dependent on staff for all care, was not attended to until several hours after the shift began. The STNA responsible for Resident #41 had 20 residents to care for and was unable to provide timely care due to the overwhelming workload. Similarly, Resident #4, who required assistance with meals and had impaired skin integrity, was left unattended for nearly an hour with her lunch tray untouched, and her wound dressing was not properly maintained. Resident #50 was found with dried food on his chest and a soaked incontinent brief, indicating a lack of timely care. The facility's staffing assessment did not adequately address the needs of specialized units, such as the memory care and mental health units. Interviews with staff revealed that the facility consistently operated with insufficient staff, leading to incomplete care and supervision. The facility's administrator and staff were aware of the staffing issues but were unable to resolve them due to budget constraints and lack of agency staff.

Removal Plan

• Staffing levels will be increased to five nurses on day shift and four nurses on night shift, STNA's staffing levels will be increased to eight STNA's on first shift and six nursing assistants on night shift.
• Staffing levels will be increased by increasing hours for current staff, reassigning staff from sister facilities and signing contracts with two temporary staffing agencies. The shift charge nurse will authorize the use of the agency staff.
• The charge nurses will be provided with the agencies phone numbers and will be educated to call agency when there are call offs and our staff will not pick up open shifts.
• RDO #224 will develop a bonus structure for new hires.
• RDO #224 will develop a bonus structure for staff that will pick up extra shifts.
• RDO #224 will develop a bonus structure for staff who refer new candidates.
• Human Resource (HR) Director #6 will call all applicants for the last 60 days to re-offer interviews.
• The Director of Nursing (DON) or designee will conduct resident assessments to identify those with pressure ulcers and extensive assist from two staff members with ADL to prioritize their care and ensure immediate needs are addressed.
• RDO #224 or designee will notify residents and their representatives about the staffing situation, the steps that are being taken to address the issue and what they can expect in terms of care.
• An ad hoc quality assurance (QA) committee meeting will be held to review the plan.
• [NAME] President of Human Resources (VPHR) #800 or designee will develop and implement a long-term plan to recruit and retain qualified staff including offering competitive wages, benefits and professional development opportunities.
• RDO #224 or designee will review staffing levels daily and adjust as necessary depending on new admissions/discharges and significant changes. This may involve hiring additional permanent staff or adjusting the staff to resident ratio based on acuity levels.
• RDO #224 will educate the administrator, the DON and HR Director #6 on the appropriate staffing levels to meet the residents needs and to adjust the staffing levels depending on new admissions/discharges and significant changes.
• RDO #224 or designee will interview four residents and four direct care members to ensure appropriate staffing levels and quality of care.
• The data collected from the above audits and feedback will be used to make ongoing adjustments to the staffing plan and care protocols, ensuring compliance and that residents receive high-quality care. The audits will be submitted weekly to the QA committee for trending, tracking and recommendations.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to provide adequate care and services to prevent and timely identify pressure ulcers and injuries for three residents, resulting in Immediate Jeopardy and serious life-threatening harm. Resident #37 developed six facility-acquired deep tissue pressure injuries and was hospitalized for osteomyelitis. Resident #86 developed unstageable pressure ulcers to the coccyx, left heel, and left lateral ankle, also requiring hospitalization for osteomyelitis. Resident #4 initially developed moisture-associated skin damage, which healed, but was later found to have an unstageable pressure ulcer to the coccyx. Resident #86 was admitted with diagnoses including a fracture and paraplegia, and was at risk for developing pressure ulcers. Despite being cognitively intact and requiring assistance with various activities of daily living, the facility failed to document turning and repositioning, and there were no shower sheets for a period. The resident developed multiple pressure wounds, which were not promptly identified or treated, leading to hospitalization for sepsis and osteomyelitis. Resident #37, with a history of peripheral vascular disease and diabetes, was at high risk for pressure wounds. The facility did not complete a Braden Scale assessment for nearly three years and delayed implementing an air mattress despite the resident's high risk. This resulted in the development of multiple pressure ulcers. Resident #4, with a history of psychosis and dementia, developed an unstageable pressure ulcer to the coccyx after initially having moisture-associated skin damage. The facility's failure to implement timely interventions and conduct regular skin assessments contributed to the worsening of the resident's condition.

Removal Plan

• Wound Nurse Practitioner assessed Resident #86's wounds and ordered new treatments as indicated.
• The Director of Nursing reviewed Resident #86's record and Resident #86 had the following interventions in place: Foley Catheter, Air mattress, Apply protective barrier cream after incontinent episodes and as needed, Assist with turning and repositioning as needed, Encourage Resident #86 to reposition self if able, Encourage/assist as needed to elevate heels off the mattress as tolerated, Pressure redistribution device in chair, Pressure reducing boots to bilateral feet as tolerated. May remove for care, Resident #86 uses half side rail for repositioning and bed mobility.
• The DON or designee implemented the following interventions for Resident #86: Limit time in chair to three hours, then back to bed for two hours before getting up again, ROHO cushion to wheelchair, Side to side turns only every two to three hours, which will be signed off in the treatment administration record when completed.
• WNP assessed Resident #4's wounds with no new orders given.
• The DON reviewed Resident #4's record and Resident #4 had the following interventions in place: Assist with turning and repositioning as needed, Pressure reduction mattress, Provide incontinence care as needed, Place washcloths in bilateral hands, clean hands between washcloth replacements, Assist with toileting needs, Provide perineal care after each incontinent episode; apply house barrier cream, Pressure relieving boots to be worn for prevention as tolerated.
• The DON or designee implemented the following interventions for Resident #4: Air mattress, ROHO cushion to wheelchair, Turn and reposition side to side every two to three hours, which will be signed off in the treatment administration record when completed, Pressure relieving boots to both heels.
• WNP assessed Resident #37's wounds and ordered new treatments as indicated.
• The DON reviewed Resident #37's record and Resident #37 had the following interventions in place: Apply protective barrier cream after incontinent episodes and as needed, Assist with turning and repositioning every two hours and as needed, Encourage/assist as needed to elevate heels off the mattress as tolerated, Provide a non-irritating surface to reduce friction or shearing forces, Provide incontinence care every two hours and as needed, Air mattress, Encourage Resident #37 to reposition self if able, Resident #37 uses half side rail for repositioning and bed mobility, Wheelchair with standard cushion with Dycem under cushion when out of bed for comfort and positioning.
• The DON or designee implemented the following interventions for Resident #37: No shoes until healed, Pressure reducing boots to bilateral feet.
• Residents with turn and reposition interventions had a physician order, and it would be signed off in the treatment administration record when completed.
• The DON or designee completed a skin assessment on all residents to ensure all pressure areas had been identified and treatment initiated.
• The DON or designee audited all residents with orders for splints to ensure the skin around it is checked on the daily basis for signs of pressure.
• The DON or designee audited all residents to ensure each resident had a shower sheet completed in the last seven days.
• The DON or designee audited all residents to ensure all residents had an updated quarterly Braden Assessment.
• The DON or designee audited all residents with moderate, high risk, and very high-risk Braden scores to ensure appropriate interventions are in place to prevent new pressure ulcers or worsening of present pressure ulcers.
• President of Clinical developed a Skin/Wound Clinical Program Best Practice that included the following: A shower sheet addressing the resident's skin condition must be completed with each shower to timely identify new areas, A skin assessment must be accurately completed by the floor nurse weekly, to timely identify new areas, Any time a resident is at risk for skin breakdown, appropriate interventions must be implemented immediately to prevent new development or worsening of pressure ulcers, Any time there is a new pressure area identified; a wound care treatment must be immediately initiated.
• The nursing staff were educated by the DON or designee on the facility Skin/Wound Clinical Program Best Practice.
• An ad hoc Quality Assurance Committee Meeting was held to review the plan.
• Weekly for four weeks, the DON or designee will review four residents to ensure shower sheets were completed with each shower.
• Weekly for four weeks, the DON or designee will review four skin assessments to ensure that the assessments were completed accurately.
• Weekly for four weeks, the DON or designee will review four residents at risk for skin breakdown to ensure appropriate interventions were implemented.
• Weekly for four weeks, the DON or designee will review all new pressure ulcers to ensure a treatment was initiated immediately.
• Weekly for four weeks, the DON or designee will review the residents with splints to ensure that the skin around it is checked daily for signs of pressure.
• The audits will be submitted weekly to the QA Committee for tracking, trending, and recommendations.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to administer care and services effectively, impacting all 105 residents. During the annual, extended, and complaint surveys, deficiencies were identified in several areas, including activities of daily living assistance, wound care, range of motion needs, accident prevention, catheter care, nutritional needs, gastrostomy tube care, and pressure ulcer treatment. These deficiencies resulted in an Immediate Jeopardy situation. Additionally, the facility was found deficient in maintaining sufficient staffing levels, which also led to an Immediate Jeopardy. The review of QAPI sign-in sheets revealed inconsistencies in the Director of Nursing (DON) role, with multiple individuals filling the position since September 2023. The sheets also lacked evidence of the governing body's involvement in QAPI meetings. An interview with the RN MDS Coordinator indicated that she was asked to serve as Interim DON but did not assume the responsibilities of the position. She did not attend QAPI meetings or address concerns, as she was informed it was unnecessary. The lack of consistent nursing management affected the continuity of care, contributing to missed resident care issues.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to maintain an effective governing body to oversee its operations, as evidenced by the lack of consistent leadership in the Director of Nursing (DON) position and insufficient involvement in Quality Assurance Performance Improvement (QAPI) meetings. The QAPI sign-in sheets for several dates revealed multiple individuals serving as DON, indicating significant turnover in this critical role. Additionally, the sign-in sheets lacked documentation of the governing body's participation in these meetings, which is a key responsibility outlined in the facility's Governing Body Policy and Procedure. Interviews with staff further highlighted the issues stemming from this instability. A physician confirmed the significant turnover in nursing management, while the President of Operations expressed concern over staffing levels. An RN MDS Coordinator reported being asked to fill in as Interim DON but stated she did not assume the responsibilities of the position and was not involved in QAPI meetings. This lack of consistent nursing management was reported to have affected the continuity of care and contributed to resident care issues being overlooked.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both regular operations and emergencies. The assessment, dated 2023 and 2024, was signed by the Administrator, the Director of Nursing (DON), and the Medical Director, but it did not include staffing needs for each resident unit or time frames for adjustments based on changes in the resident population. The assessment also lacked direct care staff involvement and did not address staffing determination on weekends. Additionally, the document was missing a completion signature and a date reviewed with the Quality Assurance Committee, and there was no information in the revision history page. An interview with the Administrator confirmed that the facility assessment was incomplete and did not meet the new requirements effective from August 8, 2024. The Administrator acknowledged that the facility did not have a policy related to the development of their facility assessment. This deficiency has the potential to affect all 105 residents in the facility, as the assessment did not adequately address the specific staffing needs required for specialized units or include residents in the assessment process.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure appropriate and adequate oversight by the Medical Director, which had the potential to affect all 105 residents. The Medical Director, identified as Physician #232, was unaware of the severity of identified concerns despite being a member of the Quality Assurance and Performance Improvement (QAPI) committee. Physician #232 admitted to not always providing the facility with completed documentation related to resident visits. Additionally, there was no evidence of the Medical Director's participation in addressing identified concerns and overall coordination of resident care and services. The facility's policy, dated September 2021, required the Medical Director to meet periodically with nursing and other professional staff to discuss clinical and administrative issues, care problems, and offer solutions, which was not adhered to.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to make good faith attempts to correct identified concerns as part of their Quality Assurance and Performance Improvement (QAPI) program, affecting all 105 residents. During the annual, extended, and complaint surveys, deficiencies were identified in areas such as activities of daily living assistance, wound care, range of motion needs, accident prevention, catheter care, nutritional needs, gastrostomy tube care, and pressure ulcer treatment. These deficiencies resulted in an Immediate Jeopardy situation. Additionally, the facility was found deficient in maintaining sufficient staffing levels, which also led to an Immediate Jeopardy. The review of the facility's QAPI program revealed a lack of documentation regarding efforts to address these deficiencies, including the absence of goals or measures to track improvement. Interviews with staff, including the RN MDS Coordinator and the Regional Clinical Nurse, highlighted a lack of involvement and action in addressing these concerns. The RN MDS Coordinator, who was asked to fill in as the Interim DON, had not participated in QAPI meetings or addressed concerns, as she was informed it was unnecessary. The Regional Clinical Nurse confirmed that staffing had been an ongoing concern since February 2024, with no documented attempts to increase staffing levels.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure proper infection control precautions were followed in several instances, affecting all 105 residents. In the laundry room, a staff member was observed sorting soiled linens without wearing the appropriate personal protective equipment (PPE), such as a plastic-coated jacket and goggles, which were available for use. This oversight was confirmed during an interview with the staff member. Resident #41, who was in a persistent coma state and dependent on enteral nutrition and tracheostomy care, was supposed to be under enhanced barrier precautions (EBP). However, an LPN entered the resident's room without donning a gown, despite signage indicating the need for EBP. The LPN was unaware of the requirement, and the Director of Nursing confirmed that EBP was necessary for the resident's tracheostomy and g-tube care, even though there was no active physician order for it. In another instance, an LPN failed to apply a gown while handling a urinal for Resident #205, who had an indwelling catheter and was under EBP. The LPN did not know the reason for the EBP. Additionally, a state-tested nurse aide (STNA) did not perform hand hygiene between handling meal trays and assisting residents with eating, even after touching food and residents directly. The STNA believed hand hygiene was unnecessary unless food was touched, which was contrary to the facility's policy as confirmed by the Director of Nursing.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to thoroughly investigate resident-to-resident altercations, affecting six residents reviewed for abuse. The incidents involved residents with various diagnoses, including dementia, schizophrenia, and other cognitive impairments. The facility's Self-Reported Incidents (SRI) lacked proper documentation and follow-up, as evidenced by the absence of staff statements and resident interviews in the investigation folders. One incident involved a possible altercation between two residents, where one was alleged to have bruised the other. However, the facility's investigation concluded there was no bruising, yet the investigation folder lacked documentation of any investigative steps taken. Another incident involved a resident pulling another by the coat and gumming her finger, with no new orders given after notifying families and a nurse practitioner. Again, the investigation folder lacked documentation of the investigation process. A further incident involved a resident hitting another, leading to the aggressor being placed on one-to-one supervision and transferred to the hospital. Despite these actions, the investigation folder still lacked documentation of the investigation, including staff statements or follow-up with the residents involved. The Regional Director of Operations confirmed the absence of necessary documentation in the investigation folders, which is contrary to the facility's policy on abuse investigation and reporting.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to provide timely care and services for residents dependent on staff for activities of daily living (ADL), affecting four residents. Resident #41, who was in a persistent coma state and dependent on staff for all care, did not receive incontinence care until 11:30 A.M., despite the staff's arrival at 7:00 A.M. The State Tested Nurse Aide (STNA) responsible for Resident #41 had a heavy workload, managing 20 residents, which delayed the provision of care. The Director of Nursing confirmed that incontinent residents should be checked and changed every two hours. Resident #4, diagnosed with dementia and other conditions, was not transferred out of bed for months due to staffing issues. The resident required a Hoyer lift for transfers and assistance with feeding, but the STNA assigned to the memory care unit was responsible for 18 residents, delaying care. Similarly, Resident #6, with a neurocognitive disorder, was not transferred out of bed regularly and had to wait 39 minutes for feeding due to staffing constraints. The STNA reported that Resident #6 had only been out of bed three times in the last three months. Resident #50, with severe cognitive impairment and dependent on staff for ADLs, was found with dried food on his chest and a soaked incontinent brief. The STNA covering the resident's area had not been able to attend to him since the start of the shift due to insufficient staffing. The facility had only two STNAs covering multiple units, leading to inadequate care for Resident #50. This deficiency was investigated under Complaint Number OH00155787.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure that residents did not have smoking equipment in their rooms, affecting three residents. Resident #51, who has emphysema and vascular dementia, was observed with cigarettes and a lighter in his room, despite being an unsupervised smoker according to his care plan. The care plan also indicated that smoking materials should be stored by the facility and distributed during designated smoking times. However, Resident #51 stated he kept his smoking materials in his room, and an LPN confirmed this practice, indicating a lack of adherence to the facility's smoking policy. Resident #68, who is cognitively intact, was observed vaping in her room, contrary to the facility's policy that prohibits smoking in rooms. The resident admitted to smoking in her room, and an LPN verified this occurrence, acknowledging that residents are allowed to keep smoking supplies but are not permitted to smoke in their rooms. Additionally, Resident #77, who resides in the memory care unit and is moderately cognitively impaired, was found with multiple cans of tobacco and was observed chewing tobacco in his room. The facility's administrator was unaware of Resident #77's tobacco use, highlighting a gap in monitoring and policy enforcement. This deficiency was investigated under a specific complaint number.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure that call lights were within reach for a resident, which affected one of the four residents reviewed for accommodations of needs. The resident in question, admitted with multiple diagnoses including chronic obstructive pulmonary disease, asthma, type 2 diabetes with polyneuropathy, hypertension, anxiety, and depression, had impaired cognition but no impairments in bilateral upper extremities. The resident required supervision for eating, total staff dependence for toileting and transfers, and maximal assistance for bed mobility. The care plan included interventions to assist with activities of daily living and encouraged the resident to use the call light when assistance was needed. During an observation, the resident was found lying in bed, verbally calling out for assistance, with the call light not within reach. The call light was attached to a plastic switch in the center of the bedroom wall, and the head of the bed was positioned away from the center of the room. Interviews with a State tested Nurse Aide and the Maintenance Director confirmed that the call light was not within reach and was not long enough for the resident to access. The facility's policy required nursing staff to check call lights daily and ensure they were within reach of residents capable of using them.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to adhere to proper procedures for the transfer or discharge of a resident, specifically Resident #100, who was discharged without appropriate documentation and notice. Resident #100, who was cognitively intact and required varying levels of assistance with daily activities, was discharged from the facility without receiving a formal discharge notice. The resident's progress notes did not indicate any formal discharge notice, and there was no discharge order listed in the resident's physician orders. The insurance company issued a notice of adverse determination, stating that the resident's continued stay could not be approved due to a lack of need for skilled nursing care, but the facility did not provide the required 30-day written notice of discharge. The Social Services Director (SSD) and Social Services Aide (SSA) informed Resident #100 that she must leave the facility the day after receiving the insurance denial letter. Despite the resident's protests and claims of having nowhere to go, the facility did not assist in finding alternative accommodations, and the discharge assessment inaccurately listed a homeless shelter as the discharge location. The facility's policy requires a 30-day written notice for discharge, which was not provided in this case, leading to the deficiency. The facility's failure to follow its own policy and regulatory requirements resulted in the improper discharge of Resident #100.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to provide timely notification to a resident regarding their transfer or discharge, as well as the reasons for the move. This deficiency affected a resident who was discharged to a homeless shelter without receiving a formal discharge notice. The resident, who was cognitively intact, had been admitted to the facility with diagnoses including spinal stenosis, polyneuropathy, and major depressive disorder. Despite the resident's cognitive status and need for assistance with various activities of daily living, there was no record of a formal discharge notice being provided. The resident received an insurance termination letter indicating that their stay would no longer be covered, and the facility's Social Services Director informed the resident that they must leave the following day. The resident expressed distress and disagreement with the decision, and there was no evidence of discharge planning or arrangements for follow-up care. The facility's policy required a thirty-day written notice for discharge, which was not adhered to in this case. Interviews with facility staff confirmed that the resident did not receive the required notice and was not provided with alternative living arrangements, leading to their discharge to a homeless shelter.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to adequately prepare and orient a resident for a safe and orderly discharge, affecting one resident out of three reviewed for transfer or discharge. The resident, who was cognitively intact, required assistance with various activities of daily living. Despite this, there was no formal discharge notice provided to the resident, and the discharge process was not properly documented in the resident's progress notes. The resident received an insurance termination letter, which led to a confrontation with the social services staff, as the resident was not informed about the discharge process or given adequate time to prepare for the transition. The resident was discharged to a homeless shelter without follow-up doctor's appointments or a clear discharge plan. The facility's policy required a thirty-day written notice for discharge, which was not provided. The social services director confirmed that the resident was told to leave the next day and that the facility does not find places for residents to go. The discharge location was inaccurately documented as a homeless shelter, and the resident's friend picked her up without a clear understanding of her living arrangements post-discharge.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to notify the state mental health authority regarding significant changes in the condition of residents requiring mental health or intellectual disability services, specifically in the context of the Pre-Admission Screening and Resident Review (PASARR). This deficiency affected two residents. Resident #04, who was admitted to hospice care for senile degeneration of the brain, had multiple mental health diagnoses that were not reflected in the PASARR. Despite the resident's severe cognitive impairment and admission to hospice, there was no significant change PASARR or notification to the state mental health authority. Similarly, Resident #79, who had schizoaffective disorder, was transferred to a psychiatric hospital due to behavioral issues and medication refusal. The facility did not complete a significant change PASARR or notify the state mental health authority of this transfer until two months later. Both cases were verified during an interview with the facility's Administrator, Social Service Designee, and Social Service Assistant, confirming the lack of timely notifications and updates to the PASARR.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to revise care plans in a timely manner and did not conduct care conferences as required, affecting three residents. Resident #46, diagnosed with Parkinson's disease, type two diabetes mellitus, epilepsy, and paraplegia, had a care plan that was not updated after experiencing urinary tract infections, despite receiving new medication orders. Additionally, Resident #46 only had two care conferences documented in the last 12 months, contrary to the policy requiring quarterly conferences. Resident #77, with diagnoses including dementia and major depressive disorder, eloped from the facility, but the elopement care plan was not initiated until several weeks later. This delay in care planning was confirmed by the Regional Clinical Nurse, indicating a failure to address the resident's elopement risk promptly. Resident #92, who had multiple psychiatric and medical diagnoses, was identified as at risk for elopement upon admission. Despite several elopement attempts documented in progress notes, the care plan for Resident #92 was not revised to include new interventions. The Regional Clinical Nurse verified that no new interventions were implemented following these incidents, highlighting a lack of timely response to the resident's behavior.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to provide appropriate catheter care for a resident with multiple health conditions, including Parkinson's disease, type two diabetes mellitus, epilepsy, and paraplegia. The resident, who was dependent on toileting and had an indwelling catheter, was observed receiving improper catheter care from a State tested Nurse Aide (STNA). The STNA did not follow the facility's catheter care policy, which requires maintaining a clean technique when handling the catheter, tubing, or drainage bag. Specifically, the STNA cleaned the catheter tubing incorrectly by moving away from the urethra and back up, and failed to change gloves after providing care, subsequently touching the bed controller with soiled gloves. The resident's medical record indicated a history of urinary tract infections (UTIs), with recent antibiotic treatments prescribed for UTIs. The facility's policy on catheter care emphasizes the use of standard precautions and clean techniques, which were not adhered to during the observed care. The failure to follow proper catheter care procedures potentially contributed to the resident's recurrent UTIs, as evidenced by the need for multiple antibiotic treatments. The deficiency was identified through observation, record review, and interviews, highlighting a lapse in adherence to established care protocols.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure that a physician approved the admission of residents in writing, affecting three residents out of five reviewed for physician services. Resident #58, who was admitted with multiple diagnoses including schizophrenia, severe intellectual disabilities, and type two diabetes mellitus, had no documentation of physician approval for admission. The resident required assistance with various activities of daily living and had severely impaired cognition, as noted in the admission Minimum Data Set (MDS) assessment. Similarly, Resident #85, admitted with diagnoses such as schizoaffective disorder and a history of traumatic brain injury, also lacked written physician approval for admission. This resident was cognitively intact and required minimal assistance with daily activities. Resident #92, with a complex medical history including schizophreniform disorder and major depressive disorder, was also admitted without documented physician approval. This resident was cognitively intact and required assistance with several daily activities. The Regional Clinical Nurse confirmed the absence of written physician approval for these admissions during an interview.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to provide medically related social services to a resident who was being discharged, which resulted in a deficiency. The resident, who was cognitively intact, required assistance with various activities of daily living and was discharged without a formal discharge notice. The resident's insurance company issued a termination letter, stating that the resident's continued stay could not be approved as the resident did not meet the criteria for skilled nursing care. Despite this, the facility did not provide a 30-day written notice of discharge as required by their policy. The Social Services Director (SSD) and Social Services Aide (SSA) informed the resident that she must leave the facility the following day and offered assistance in getting her into a homeless shelter. The resident expressed distress and verbal aggression, claiming that the facility staff had not helped her and accused them of fabricating the insurance termination letter. The resident was eventually picked up by a friend, but the SSD did not know where she went to live, although the discharge assessment inaccurately listed a homeless shelter as her discharge location. The facility's policy required a 30-day written notice for discharge, which was not provided to the resident. The SSD and SSA's job descriptions included responsibilities for effective and safe discharge planning, which were not fulfilled in this case. The facility's failure to adhere to its own discharge policy and provide adequate social services support led to the deficiency identified in the report.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure that laboratory tests were obtained according to physician orders for two residents. Resident #16, who had multiple diagnoses including severe dementia and schizoaffective disorder, had an order for Depakote levels to be drawn every six months. However, a review of the resident's medical records from September 2023 to July 2024 showed no evidence of these tests being conducted. This was confirmed by an interview with a Corporate Registered Nurse, who verified that the Depakote levels were not obtained as ordered. Similarly, Resident #77, who had diagnoses including dementia and type two diabetes mellitus, was ordered a basal metabolic panel (BMP) laboratory draw every two weeks. However, the resident's laboratory results indicated that no labs had been completed since July 11, 2024, despite the physician's order. This was also confirmed by the Corporate Registered Nurse. The facility's policy on diagnostic services requires that all requests for such services be ordered by a physician and carried out as instructed, which was not adhered to in these cases.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to schedule a timely oral surgeon appointment for a resident with dental concerns. The resident, who was admitted with Alzheimer's disease, type II diabetes mellitus, and bipolar disorder, was cognitively intact and required assistance with daily activities. The resident's care plan indicated a risk for altered nutritional status due to a history of mouth sores, necessitating a referral to dental services. On 07/24/24, the in-house dentist recommended an oral surgeon referral for the extraction of tooth #15. However, the referral process was delayed, with the first attempt to contact the oral surgeon made on 08/07/24, and further follow-up on 08/21/24, but no appointment was scheduled by that date. Interviews and observations revealed that the resident experienced pain and had multiple cavities in the left upper back teeth, with significant tooth damage. The delay in scheduling the oral surgery was attributed to a lack of communication within the facility regarding the need for referrals. The facility's ancillary services policy, dated September 2021, stated that ancillary services would be provided in accordance with applicable statutes and standards, but this was not adhered to in this case, resulting in the deficiency.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure that residents in the memory care unit received drinks according to their preferences and requests in a timely manner. This deficiency was observed in the case of a resident with multiple diagnoses, including schizophrenia, protein calorie malnutrition, COPD, alcohol abuse, tachycardia, and dementia. The resident was on a mechanically altered diet with thin liquids and was at risk for altered nutritional status and dehydration. On the evening of the observation, the resident requested coffee but was informed that none was available, as the kitchen had not sent enough coffee cups or coffee to the unit. Interviews with staff revealed that the kitchen only sent one coffee carafe and six cups, which was insufficient for the nine residents who wanted coffee with their meals. The staff had previously requested a coffee maker for the unit but were told it was not permitted. The Dietary Manager confirmed that only one carafe was sent and was unaware of the need for additional supplies until informed by rumors about the surveyors' focus. The manager also noted that residents tend to hoard mugs, leading to shortages. No message was received from the unit staff requesting additional coffee or mugs on the evening in question.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure that the medical records for a resident were complete and accurately documented. This deficiency affected a resident who was admitted with acute transverse myelitis in demyelinating disease of the central nervous system and major depressive disorder. The resident was cognitively intact and required varying levels of assistance with daily activities. However, there was no documentation in the resident's medical records indicating that the resident was ordered to be sent to the hospital on a specific date. Additionally, the progress notes lacked any record of the resident leaving the facility or being transferred to the hospital. Furthermore, there was no documentation that the resident's representative was informed of the hospital transfer until the representative called the facility to inquire about the resident's status.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure that residents received pneumococcal vaccinations as ordered, affecting two residents out of five reviewed for immunizations. Resident #38, who was admitted with diagnoses including schizophrenia, type two diabetes, peripheral vascular disease, and Charcot's joint, was assessed with moderate cognitive impairment and was dependent on assistance for daily activities. Despite the resident's representative consenting to the pneumococcal vaccinations, the medical record review revealed that the Prevnar 20 vaccine was not administered as ordered. Similarly, Resident #71, admitted with diagnoses such as suicidal ideation, hyperparathyroidism, hypertension, type two diabetes, osteoarthritis, and obesity, also had moderate cognitive impairment and required assistance with daily activities. The resident's representative consented to the pneumococcal vaccinations, but the Prevnar 20 vaccine was not administered as ordered. The Director of Nursing confirmed that both residents were ordered the pneumococcal vaccine but did not receive them. The facility's policy on pneumococcal vaccines stated that residents would be offered the vaccine and assessed for eligibility, but the policy did not ensure the vaccines were administered as ordered.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure the privacy and dignity of a resident, identified as Resident #5, who was cognitively intact but dependent on staff assistance for various activities of daily living. The resident was observed multiple times lying in bed with her buttocks exposed to the hallway, and the privacy curtain was not pulled to prevent visibility from the hall. This lack of privacy was confirmed by the Activities Manager, who noted that the resident was unable to reach the curtain to close it herself. Additionally, the resident was given a fly swatter to fend off flies, which were present in her room due to her refusal to shower, as stated by the Activities Manager. Further observations revealed that the resident was also surrounded by gnats while she was asleep, a situation confirmed by an LPN. The facility's policy on dignity, which emphasizes care that promotes residents' well-being and self-esteem, was not adhered to in this instance. The policy explicitly prohibits demeaning practices and requires staff to treat residents with dignity and respect, which was not the case for Resident #5, as evidenced by the repeated exposure and presence of insects in her room.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to notify a resident's representative of a change in condition, specifically when the resident was transferred to the hospital. The medical record for the resident, who was cognitively intact and required varying levels of assistance for daily activities, did not document the transfer to the hospital. Additionally, there was no record of the resident's physician or representative being informed of this transfer. The deficiency was confirmed during interviews with the resident's representative and a regional clinical nurse, who acknowledged the lack of documentation regarding the notification. The facility's policy mandates notifying the resident, their physician, and representative of changes in medical or mental condition, including hospital transfers. This non-compliance was investigated under a specific complaint number.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure the Minimum Data Set (MDS) assessments were completed accurately for three residents. Resident #41, who was in a persistent coma state and dependent for all care, was incorrectly coded in the MDS as consuming food by mouth, despite being NPO and receiving tube feeding. This discrepancy was confirmed by an MDS Registered Nurse during an interview. Resident #77, diagnosed with dementia and other conditions, was inaccurately assessed as not having wandering behaviors in the MDS, despite a history of wandering and a care plan indicating a risk for elopement. This error was also verified by the MDS Coordinator. Resident #62, with Alzheimer's disease and other diagnoses, was inaccurately documented in the MDS as having no dental issues, despite having multiple cavities and broken teeth, which were observed and confirmed by a Licensed Practical Nurse. The resident had been referred to an oral surgeon, but the MDS did not reflect the resident's dental condition. The facility's policy on MDS completion and submission timeframes was not adhered to, leading to these inaccuracies. This deficiency was investigated under Complaint Number OH00156885.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #62, who was cognitively intact, had multiple dental cavities and broken teeth, yet the care plan did not include interventions for these dental concerns. Despite the resident's complaints of tooth pain and the observations confirming the dental issues, the care plan remained unupdated. Similarly, Resident #04, who had severe cognitive impairment and was dependent on all activities of daily living, had contractures in her hands that were not addressed in the care plan until much later. Observations showed that interventions like placing towels in her hands were not consistently implemented, and the care plan lacked these interventions until a specific date. Resident #77, with moderate cognitive impairment, required a care plan for psychotropic drug use, which was not initiated in a timely manner. The resident's admission MDS assessment had triggered the need for such a care plan, but it was delayed by several months. Interviews with staff confirmed the oversight in updating and implementing the necessary care plans for these residents. The facility's policy on comprehensive, person-centered care plans was not adhered to, resulting in these deficiencies.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure proper wound care and transportation for residents, as well as timely addressing changes in condition. Resident #86 missed a follow-up appointment due to the facility's transportation issues, as the facility van was broken down. This resulted in the rescheduling of appointments, affecting the resident's continuity of care. Similarly, Resident #87 missed a neurologist appointment due to the same transportation issues, with the facility lacking a policy on transportation for appointments. Resident #303 experienced a failure in wound care management. Upon admission, the resident had discharge instructions for daily dressing changes, which were not followed. The dressing on the resident's left lower leg had not been changed since admission, despite the hospital's discharge instructions. The oversight was confirmed by the LPN, who noted that the order for dressing changes was not transcribed or implemented, leading to a lapse in care. Additionally, Resident #87's psychiatric needs were not adequately addressed. Despite having a history of self-harm thoughts and a previous suicide attempt, there was no follow-up by facility staff after recent expressions of self-harm thoughts were communicated to the psychiatric nurse practitioner. The Director of Social Services confirmed that no new interventions were implemented to address these concerns, indicating a failure to respond to the resident's mental health needs.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to maintain a safe environment, affecting a resident who was reviewed for environmental safety. The resident, who was cognitively intact and required set-up assistance for various activities, fell while engaging in an activity outside the facility. The fall was attributed to an uncovered pipe in the grassy area near the facility's sign. The Maintenance Director was informed about the uncovered pipe only after the incident occurred. Upon observation, the pipe was identified as a city-owned water pipe, approximately nine inches wide, and was left uncovered, posing a safety hazard.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to maintain an environment free from pests, affecting two residents. Resident #5, who has cervical disc disorder with myelopathy and contractures, was observed on multiple occasions with flies and gnats flying around and landing on her body while lying in bed. Staff interviews confirmed the presence of these pests, and there were no known interventions to reduce them in the resident's room. The resident required significant assistance with daily activities, including bed mobility, and the presence of pests was noted over several days. Resident #4, diagnosed with psychosis, dementia, major depressive disorder, and schizoaffective disorder, was also affected by the pest issue. This resident had impaired skin integrity with a pressure area on the coccyx, and observations revealed flies in her room and on her body near the wound. Staff interviews verified the presence of flies near the wound. A review of pest control invoices showed no treatment for gnats, flies, or flying insects during the specified visits, despite the facility's policy to provide an environment free of pests.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to ensure that residents were seen by a physician upon admission, affecting three residents. Resident #87, who was admitted with diagnoses including acute transverse myelitis and major depressive disorder, was seen by a Certified Nurse Practitioner (CNP) on 05/14/24, but there was no documentation of a physician or medical director visit since admission on 05/13/24. This was confirmed by a Licensed Practical Nurse (LPN) during an interview. Similarly, Resident #58, admitted with multiple diagnoses such as schizophrenia and type two diabetes mellitus, was only seen by a nurse practitioner for the establishment of care. Resident #92, with diagnoses including schizophreniform disorder and major depressive disorder, was also only seen by a nurse practitioner upon admission. The facility lacked a policy on physician visits, as confirmed by a Regional Clinical Nurse, and the physician stated that the nurse practitioner establishes care before he sees the residents.

Penalty

Fine: $145,6608 days payment denial

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

Summary

The facility failed to post nurse staffing information in a clear and visible place, which is a requirement for ensuring transparency and accessibility for residents and visitors. During an observation, it was noted that no staffing information was available, and this was confirmed by the Administrator. The Facility Scheduling Coordinator admitted to being unaware of the requirement and had not posted the information for three weeks since assuming the scheduling position. The facility's policy, dated September 2021, mandates daily posting of the number of nursing personnel responsible for direct care, including details such as facility name, current date, resident census, and the total number of registered nurses, licensed practical nurses, and certified nurse aides.

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 supervision for a resident who had an order for a supervised Leave of Absence (LOA), resulting in the resident leaving the facility unsupervised. The resident, who had medical diagnoses including epilepsy, right-sided hemiplegia due to cerebral infarction, and moderate cognitive impairment, was initially allowed to go on LOA independently. However, this order was later changed to require supervision by the resident's parents. Despite this, the resident signed out of the facility alone and was later found in the community, having almost been hit by a car. Interviews revealed that the resident's mother had previously informed the facility that the resident should not go on LOA unsupervised. The former Director of Nursing (DON) confirmed that an order for supervised LOA was in place, but was unaware of the independent LOA order. The incident was reported by a community member, prompting facility staff to retrieve the resident. The deficiency was identified during a complaint investigation, indicating ongoing 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 proper supervision and assistance with meals for Resident #20, who has a history of vascular dementia, anxiety, spastic hemiplegia, and dysphagia. The resident's care plan required one-on-one feeding assistance, use of a sippy cup, small bites, and specific swallowing techniques as recommended by Speech Therapy. On the day of the incident, Resident #20 was left unsupervised in the dining room with three bowls of food in front of him, which led to a choking incident. During the observation, Resident #20 was found in distress, appearing to choke with a red face and unable to breathe or cough. Another resident called for help multiple times before a State Tested Nursing Assistant (STNA) entered the room and provided assistance. The STNA admitted to leaving the dining area to retrieve a zip lock bag for another resident, confirming that she was supposed to supervise and assist Resident #20 with his meals. This deficiency was identified during a complaint investigation.