Merkel Nursing Center

Penalty

Fine: $204,535

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

Summary

The deficiency involves the facility’s failure to protect multiple residents from neglect by not providing sufficient, qualified staff and by allowing untrained aides to perform transfers and incontinence care alone, contrary to the facility assessment, policies, and care plans. Timecard review showed that on 34 of 84 shifts between early January and mid-February, only one direct care staff member was on duty, despite the facility assessment requiring at least two direct care staff and one nurse per shift when residents required mechanical lifts or two-person transfers. The AIT and ADON both acknowledged ongoing staffing shortages, frequent no-shows, and that resident care suffered because the facility was short staffed. The AIT stated it was not safe to have only one aide working on the floor and that policies requiring two staff for transfers and incontinent care were not always followed. One resident with dementia, severe cognitive impairment, and a care plan requiring two staff and a mechanical lift for transfers was dropped during a mechanical lift transfer performed by a single aide who was not certified and had no documented training or abuse/neglect education. The resident reported being dropped to the floor, then pulled back into the wheelchair and told not to report the fall; her roommate, who had moderate cognitive impairment, stated she saw the aide alone with the lift, heard the aide exclaim, and observed the resident and lift on the floor. The resident was later found dragging her leg, reported pain, and was hospitalized with a distal femur fracture requiring surgery. The aide later stated she had not been trained on mechanical lift use and denied transferring the resident alone, while another aide and a nurse gave conflicting accounts and denied assisting with the transfer. Another resident with severe cognitive impairment and a care plan requiring two-person mechanical lift transfers was observed being transferred by a single aide using a stand-and-pivot method without a mechanical lift. The aide admitted she was the only aide working, knew the resident required a mechanical lift and two staff, and stated she routinely transferred the resident this way because no help was available. A third resident, with moderate cognitive impairment and high fall risk, required prompt response to call lights and assistance with transfers and toileting. She activated her call light to request help to the restroom, but no staff were present in the hall or at the nurses’ station; after waiting, she attempted to go alone, urinated on herself, slipped, and was found on the floor by a hospice aide while the call light was still engaged. The AIT confirmed that only one aide was on duty that shift, that staff no-shows were common, and did not explain why she and the ADON, who were in the office, did not answer call lights. A fourth resident with moderate cognitive impairment, colon cancer, muscle weakness, and a high fall risk had multiple falls over several weeks, including two falls on the same day that resulted in rib fractures, pleural effusion, and hospitalization, and another fall causing a forehead injury. Progress notes documented repeated falls related to attempts to transfer or reach items independently, and the resident’s representative reported the resident was anxious and tried to get up on her own. The care plan for falls had not been updated with new interventions since several months prior, despite the series of falls. Timecards showed that during at least two of the resident’s falls, only one direct care staff member was on duty. A fifth resident with severe cognitive impairment, depression, anxiety, mixed bladder incontinence, and a care plan requiring staff assistance for toileting and checks/changes every two hours was left in wet clothing for approximately two hours after requesting help. She first asked the only aide on duty, who told her she was too busy. The resident was later observed crying in the hall and then sitting in the dining room with visibly wet pants. When she asked an RN to change her, the RN looked at her but did not acknowledge the request. The resident became upset and attempted to remove her wet clothes in the dining room, after which the ADON reprimanded her and told her to go to her room. She was not assisted with changing until about two hours after her initial request. The aide later stated she was working alone, was very busy, and acknowledged that being short staffed could lead to residents not getting the care they needed and could be considered neglect. Personnel file reviews showed that aides designated as nurse aides were not certified and lacked documented training, including mechanical lift training and, in at least one case, abuse/neglect training. The facility’s policies required two staff for mechanical lift transfers and prohibited aides from performing transfers and incontinent care alone, and the facility’s abuse and neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. The MD stated his expectation that residents be free from abuse and neglect, that policies be followed, and that residents’ needs be met by staff with the knowledge and skills to provide necessary care, and he confirmed that being dropped from a mechanical lift could cause the type of femur fracture sustained by one resident and that not following transfer policies could have led to injury for another resident. An Immediate Jeopardy situation was identified related to these failures.

Removal Plan

• Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse; if there are any mechanical lift residents, ensure a total of one LVN/RN and two direct care staff are in the building at all times; assess staffing requirements weekly based on census and resident needs; maintain two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
• Ensure DON and ADON verify that all agency or temporary direct care staff have documented training/credentials prior to working a shift (including checking the agency portal and obtaining CNA credentials from the sister facility) and ongoing.
• Assess Residents #5, #3, #2, and #16 for any further injury, pain, or emotional distress.
• Report Resident #1's fall to the state agency per reporting requirements.
• Assess and monitor Resident #1 for negative outcomes.
• Remove NA-A from resident care pending investigation.
• Complete investigation of the incident by AIT.
• Terminate NA-A as disciplinary action.
• Create an informational handout for incident reporting and mechanical lift use and review it.
• Provide an instructional mechanical lift demonstration for all staff by the facility's COTA.
• Review incidents within the last 30 days to identify other residents at risk.
• Re-educate all direct care nursing staff on shift on abuse/neglect policy (including safe transfer procedures and supervision expectations) with a signature sheet; require review for all direct care staff before start of first shift.
• Provide abuse/neglect and related education at an in-service with a signature page.
• Ensure the agency and sister facility only send CNAs.
• Require the charge nurse to verbally educate any agency and sister facility staff on call lights, mechanical lift, and abuse/neglect during shift report prior to the aide starting the shift; require verbal return instruction to determine competency.
• Re-educate all residents about their rights, abuse, neglect, and reporting.
• Review abuse, neglect, transfers, and reporting upon hire; provide monthly review at mandatory in-service; provide one-on-one education annually at staff hire anniversary; enforce that any violations of policy will result in termination.
• Require the charge nurse to initial, date, and log the name of each agency and sister facility staff member educated.
• Complete a mandatory all-staff in-service reviewing falls and fall prevention, reporting incidents, mechanical lift transfers, and abuse and neglect.
• Reinforce expectation that violations of abuse/neglect, mechanical lift, and reporting policies will result in disciplinary action up to and including immediate termination.
• Train all staff on falls and call light usage via phone calls with return instruction to ensure retention of information; prevent staff who do not answer the phone from returning to work until retrained; maintain a DON log of staff contacted and educated.
• Have DON/designee review all incidents daily for 30 days to establish a risk-of-incident analysis based on patterns of staffing and incidents.
• Conduct a monthly abuse/neglect audit for direct care staff and incidents and report to QAPI for 3 months.

Penalty

Fine: $204,535

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 keep the environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents for multiple residents at risk for falls. One resident with dementia, severe cognitive impairment, and a care plan requiring two staff for mechanical lift transfers was routinely transferred by a single aide using a mechanical lift. On one morning, the resident reported being dropped to the floor during a mechanical lift transfer performed by one nurse aide, who then pulled her back into the wheelchair and instructed her not to tell anyone. The resident later complained of pain in her left hip, leg, and foot, with internal rotation, redness, swelling, and inability to move the lower leg/foot, and was subsequently diagnosed with a distal femur fracture requiring surgery. The resident’s roommate, who had moderate cognitive impairment, stated she observed the aide alone transferring the resident with the mechanical lift, heard the aide exclaim, and saw both the resident and the lift on the floor, and further stated she had never seen two staff assist with that resident’s mechanical lift transfers. The facility’s own records and staff interviews showed that the resident’s care plan required assistance by two staff for transfers using a mechanical lift, and the facility’s mechanical lift policy required at least two nursing assistants for safe use. The nurse aide involved stated she had never been trained by the facility on mechanical lift transfers, although she knew two staff were required, and the facility could not locate her orientation/evaluation checklist or any documented training regarding resident care. Another nurse aide on the same shift reported she had not received training on mechanical lift use and did not recall assisting with the transfer, while the LVN on duty denied assisting and reported having previously voiced concerns about aides transferring residents alone. The ADON stated that nurse aides could not perform transfers without a CNA or nurse and that nurses were supposed to supervise aides to ensure they did not perform tasks they were not trained in, but there was no evidence this supervision or training occurred for the aide involved. The deficiency also includes failures related to supervision and staffing for two other residents at high risk for falls. One resident with heart failure, kidney disease, moderate cognitive impairment, and a care plan identifying high fall risk and the need for prompt call light response fell after using the call light for toileting assistance, waiting, then attempting to go to the bathroom alone, urinating on herself, slipping, and falling. At the time of this fall, timecards showed only one nurse aide was on duty as direct care staff; during observation, no staff were present in the hall or at the nurses’ station while the resident was on the floor with the call light activated, and a hospice aide not employed by the facility ultimately located staff. The aide on duty stated she was the only aide working, had difficulty getting everything done when working alone, and that being short staffed could lead to residents not getting the care they needed and could be considered neglect. Another resident with colon cancer, muscle weakness, moderate cognitive impairment, and a care plan identifying high fall risk related to weakness experienced multiple falls over a period of time, including several without injury and two with injury, one resulting in multiple rib fractures and hospitalization. The care plan for this resident had not been updated with new fall interventions since several months prior, despite repeated falls documented in the incident log. Progress notes described falls in the bathroom and between the bathroom and room, with the resident attempting to get on the commode or reaching down to pick up a phone and losing balance. The resident’s family representative reported the resident was anxious and tried to get up on her own. Timecards showed that at the time of two of this resident’s falls on the same day, only one nurse aide was on shift as direct care staff. The ADON later stated that interventions had been implemented for this resident but acknowledged they were not updated in the care plan or medical record.

Removal Plan

• Define direct care staff as any trained individual who demonstrates competency per the facility aide competency checklist (including NA enrolled in CNA class employed, CNA, LVN, RN) for providing direct care/ADL assistance.
• Ensure at least two direct care staff on the floor at all times in addition to one LVN/RN charge nurse.
• Ensure a total of one LVN/RN and two direct care staff are in the building at all times if there are any mechanical lift residents.
• Assess staffing requirements based on census and resident needs.
• Maintain two direct care staff whenever the facility has any residents who use a mechanical lift or are a two-person transfer.
• Ensure DON/ADON verify all agency or temporary direct care staff have documented training prior to working a shift.
• Obtain access to the current temporary agency portal to check staff credentials.
• Require the sister facility to send CNA credentials prior to staff working a shift.
• For Resident #1, assess immediately upon discovery, send to hospital, follow discharge orders, notify physician/ADON/administrator/responsible party, initiate neuro checks/monitoring, remove NA-A from resident care pending investigation, and terminate NA-A.
• For Resident #5, assess and send to hospital, place reminder posters to use call light, educate resident on call light use, and work with hospice and follow hospice physician orders.
• For Resident #3, assess, notify hospice/doctor/family/administrator, transfer to hospital for evaluation, and continue monitoring for post-fall outcomes (pain, emotional distress, injury).
• Complete a 100% audit of all residents requiring mechanical lift transfers and display the list at the nurses station.
• Notify all staff of the mechanical lift resident list and include it in shift report and in the shower sheet book for aides.
• Send a text message to all direct care staff about the locations of the mechanical lift list.
• Have the ADON review the mechanical lift transfer list during shift report.
• Continue monitoring Residents #3 and #5 related to incidents and staffing comparison.
• Educate Residents #3 and #5 on call light usage on the same day as their respective falls.
• Educate staff on call light response expectations via informational handout at the nurses station with signature confirmation prior to starting first shift.
• Provide call light education at an in-service with an in-service signature sheet.
• Provide nursing staff education about call light usage and falls (DON via phone calls) and track completion; prevent staff from starting next shift until educated.
• Require all direct care nursing staff to take a quiz prior to working as direct care staff; grade prior to shift; re-educate and retest failures; remove from care if they fail the subsequent quiz.
• Re-educate all RNs/LVNs/CNAs/NAs on mechanical lift policy including two-staff requirement via protocol handout with staff signatures.
• Conduct follow-up in-service with return demonstration of mechanical lift use (COTA).
• Add proper mechanical lift use to new hire packets and competency checklists for direct care staff.
• Provide agency and sister-facility direct care staff an educational handout prior to starting shift (abuse/neglect, call light usage, mechanical lift transfer, falls) directed by charge nurse; verify competency via verbal return and staff signature.
• Re-educate staff on falls and post-fall procedures with documented signatures prior to start of first shift.
• Train new direct care staff on call light expectations during on-the-floor training before providing resident care; verify competency via verbal return and orientation sheet initials.
• Conduct an audit of in-services (mechanical lift use, incident reporting, abuse/neglect, falls, call lights) to ensure all staff trained; restrict work until training completed with verbal return; complete audits and report to IDT/QAPI.
• Complete competency validations for mechanical lift use for 100% of direct care staff (COTA/ADON) with signature validation.
• Conduct regular random observations of lift transfers by charge nurses and DON/designee; document in a log; suspend/remove staff from care until correct return demonstration if noncompliance occurs.
• Post signage above mechanical lift resident beds to remind staff which residents require mechanical lift use.
• Reinforce mechanical lift policy with clear disciplinary consequences for non-compliance; require staff to sign in-service sheet acknowledging review prior to working first shift.
• Have charge nurse/designee monitor transfers on each shift for compliance; track checks in a log at the nurses station; review by ADON in QAPI.
• Monitor a mechanical lift transfer once per shift with charge nurse initials; if noncompliance noted, immediately re-educate and remove staff from duty until proper return demonstration completed.
• If non-compliance is noted during monitoring, terminate staff who performed mechanical lift improperly and assess the resident for pain or injury.
• Report monitoring results at monthly QAPI.

Penalty

Fine: $204,535

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

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skill sets to meet resident needs on 34 of 84 reviewed shifts, despite a facility assessment requiring at least two direct care staff and one nurse per shift. Timecard review showed that on multiple specified dates and shifts between early January and early February, only one direct care staff member was on duty, even though the facility had residents requiring mechanical lifts and two-person transfers. Interviews with leadership acknowledged that the facility was short staffed due to staff quitting, difficulty hiring in a rural area, and inability to compete with larger facilities and hospitals, and that resident care suffered because of being short staffed. One resident with a left femur fracture, severe cognitive impairment (BIMS score 00), and a care plan requiring two-person maximum assistance and two-person mechanical lift transfers was inappropriately transferred by a single NA without a mechanical lift. The NA reported she was the only aide working, knew the resident required a mechanical lift and two staff, but transferred him alone because no help was available and stated she routinely transferred him this way. Another resident with heart failure, kidney disease, severe cognitive impairment (BIMS score 07), and a care plan identifying high fall risk and the need for prompt response to call lights fell after using the call light for toileting assistance, waiting, then attempting to go to the restroom alone. Her call light was observed activated with no staff present in the hall or at the nurses’ station; she reported she always had to wait a while for staff to answer her call light and that she had fallen before. Timecards showed only one direct care staff was on shift at the time of this fall. A third resident with colon cancer, muscle weakness, and moderate cognitive impairment (BIMS score 09), who used a walker and wheelchair and required one-person assistance for transfers, had multiple falls over a short period, including two falls on the same day that led to hospitalization for rib fractures and pleural effusion. Progress notes described falls occurring while the resident attempted to get on the commode and when she was found on the floor between the bathroom and her room, with documentation of weakness and difficulty standing. The incident log showed numerous falls, and the care plan identified high fall risk related to weakness, but there were no updates to fall interventions since several months prior. Timecards indicated only one direct care staff was on duty during the falls that occurred that day. Another resident with depression, anxiety, severe cognitive impairment (BIMS score 01), partial/moderate assistance needs for transfers, and occasional incontinence waited approximately two hours to be changed after an incontinent episode. She was repeatedly told by the only aide on shift that the aide was too busy, was observed crying and still unchanged in the hall and dining room, and later had her request to an RN ignored before finally being changed about two hours after her initial request. The aide stated she had been working alone more often since other staff had quit, had difficulty getting everything done when working alone, and that being short staffed could lead to residents not getting needed care and could be considered neglect. Leadership interviews further linked these events to insufficient staffing. The AIT confirmed that on one of the key days only one aide was working because another did not show up, and acknowledged that it was not safe to have only one NA on the floor and that a resident should not have been transferred without a mechanical lift. The AIT stated her expectation was that residents be taken care of by whatever means necessary, while also acknowledging that policies and procedures were not always realistically followed. The ADON reported that the facility had been short staffed due to staff not wanting to work, staff quitting, and hiring challenges, and stated that resident care suffers because of being short staffed. The MD stated he was not aware the facility had been using so many uncertified aides and that the facility should have been using agency staff to ensure residents received care from qualified staff. These observations, interviews, and record reviews formed the basis for the Immediate Jeopardy determination related to insufficient nursing staff and resulting resident care failures.

Removal Plan

• Define direct care staff as any trained individual who demonstrates competency per the facility aide competency checklist (including NA enrolled in CNA training employed less than 120 days, CNA, LVN, or RN providing direct care).
• Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse; maintain a total of one LVN/RN and two direct care staff in the building at all times if there are any mechanical lift residents.
• Assess staffing requirements weekly based on census and resident needs; ensure two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
• Ensure all agency or temporary direct care staff have documented training prior to working a shift by checking credentials via the agency portal and obtaining sister-facility CNA credentials prior to shifts.
• Require two direct care nursing staff on each rotation.
• Utilize staffing agency and aides from the sister facility if the facility does not have enough qualified staff.
• Complete the facility assessment weekly to assess acuity and needs for direct care nursing staffing requirements.
• IDT will review the facility assessment policy for guidance on acuity levels and staffing needs.
• Follow the facility assessment to determine staffing needs.
• Assess Residents #5, #3, #2, and #16 for any further injury, emotional distress, or pain.
• Conduct an immediate review of staffing patterns to evaluate gaps in coverage and staffing needs.
• Contact temporary staffing agencies to meet staffing requirements.
• Use aides from the sister facility to cover staffing gaps until staffing agency assignments are filled.
• Implement temporary agency staffing to ensure two direct care staffing coverage.
• Request a copy of aide certification from the staffing agency.
• Conduct certification checks on all aides arriving from the sister facility.
• Charge nurse will verbally educate any agency and sister-facility staff during shift report (before starting) on call lights, mechanical lift, and abuse/neglect.
• Charge nurse will require verbal return instruction from agency/sister-facility staff before they start the shift to determine competency.
• Adjust the schedule to prevent only one direct care staff at any time, using temp agencies and sister-facility CNAs.

Penalty

Fine: $204,535

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

Summary

The deficiency involves the facility’s failure to ensure that nurse aides demonstrated competency in skills and techniques necessary to meet residents’ needs, particularly in the use of mechanical lifts and performance of transfers. The facility’s own Nurse Aide Orientation/Evaluation checklist, undated, stated that NAs could not perform tasks such as helping patients into a chair from bed or into a wheelchair by themselves. Despite this, multiple NAs were working full time without documented certification or evidence of mechanical lift training. Personnel files for several NAs (including NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, NA-L, and NA-P) lacked documentation of mechanical lift training, and some had no evidence of any orientation or evaluation checklist at all. One resident, identified as Resident #1, was directly affected when NA-A transferred the resident using a mechanical lift without the assistance of another CNA or nurse, contrary to facility policy and the stated requirement that at least two staff are needed for mechanical lift transfers. This incident resulted in Resident #1 sustaining a distal femur fracture. The facility’s policy titled “Lifting Machine, Using a Mechanical Lift,” revised July 2017, specified that at least two nursing assistants are needed to safely move a resident with a mechanical lift, and the nurse aide job description required that aides be enrolled in a state-approved competency training program and perform only services for which they had demonstrated competence. Interviews with staff further demonstrated the lack of competency and training oversight. NA-F and NA-G each stated they were not certified and had not been trained regarding two-person mechanical lift transfers, although they provided full resident care without restrictions. The AIT confirmed that the NA checklist defined what NAs were allowed to do and that transfers were not allowed to be done alone by NAs; she also verified that two-person mechanical lift transfers were not on the NA checklist and that she could not locate NA-A’s checklist or any training records. The ADON stated that NAs could not perform any transfers without a CNA or nurse and that even two NAs together could not perform these activities, indicating that nurses were supposed to supervise NAs to ensure they did not perform tasks for which they were not trained. The MD reported he was not aware that the facility had been using so many uncertified aides and stated his expectation that staff follow facility policy and work within their scope of practice. These findings led surveyors to identify an Immediate Jeopardy situation related to the lack of competent nursing staff and improper use of mechanical lifts.

Removal Plan

• Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse when there are any mechanical lift residents.
• Assess staffing requirements based on census and resident needs, ensuring two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
• Ensure DON and ADON verify that all agency or temporary direct care staff have documented training prior to working a shift.
• Provide immediate assessment and treatment for Resident #1 following the mechanical lift incident, including hospital transfer and following discharge orders.
• Conduct an immediate review of staffing credentials for all staff to identify uncertified aides.
• Move all uncertified staff to hospitality aide positions and utilize temporary staffing agency to meet certified aide requirements.
• Remove any direct care staff not meeting CNA requirements from assignments requiring certification.
• If aides are not certified, move them to hospitality aide positions or relieve them from duty and do not count them toward the two direct care staff count.
• Redefine aide requirements with clear definitions and assign titles accordingly to all aides.
• Ensure only certified nurse aides are assigned to CNA-required roles.
• Assign the AIT responsibility for scheduling CNAs for each shift and utilize temporary staffing agencies and sister facility aides to meet certified aide requirements.
• Verify active CNA certification prior to scheduling.
• Educate all staff on call light usage.
• Perform license verification checks for all direct care staff upon hire and thereafter, with AIT review for accuracy and completion.
• Train all direct care staff on falls and call light usage via phone calls with return instruction to ensure retention of information.
• Prevent staff who do not complete phone training/return instruction from returning to work their shift until retrained on falls and call lights.
• Have Administrator/DON review staffing roster to ensure compliance and use staffing agencies/sister facility aides if non-compliance is discovered.
• Provide all agency and sister facility direct care staff an educational handout prior to starting their first shift on the floor, directed by the charge nurse.
• Require agency and sister facility staff to sign a check-in sheet each shift confirming review of educational material.
• Verify competency through verbal return demonstration of information and staff signature.
• Review monitoring findings in QAPI.

Penalty

Fine: $204,535

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 designate and maintain a full-time (40 hours per week) registered nurse as the Director of Nursing (DON), as required by regulation and the facility’s own policy. Review of DON time clock records from mid-December 2025 through mid-February 2026 showed no evidence of 40 hours of DON coverage for 9 of 11 reviewed weeks. The records reflected only sporadic hours worked by the DON on a few specific days in January and February. At the time of survey entrance on 1/28/2026, the AIT, the owner, and the ADON each stated there was no DON present in the building. The DON later reported that 2/5/2026 was her first day working on the floor in the facility and that she had only completed online training prior to that date. The ADON stated during interview that the facility had not had a DON in the building 40 hours per week since mid-December 2025, that a DON had been hired but had not been in the building full-time, and that RNs working in the facility were not fulfilling DON duties and did not want to serve in the DON role. The ADON further stated that resident care had been affected because there was no Infection Preventionist, no one had conducted antibiotic stewardship, and care plans had not been updated. The AIT confirmed there was no full-time DON and that the newly hired DON had only completed online training and had not started full-time in the facility. The facility’s policy on the Director of Nursing Services, revised August 2006, specified that the DON is employed full-time (40 hours per week) and is responsible for multiple nursing leadership functions, including developing nursing objectives and standards, maintaining policies and procedures, coordinating services, staffing, staff training, participating in MDS and care planning, and ensuring care is provided according to residents’ assessments and care plans.

Penalty

Fine: $204,535

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

Summary

The deficiency involves the facility’s failure to ensure that nurse aides who worked more than four months were trained, competent, and had completed a state-approved nurse aide training and competency evaluation program (NATCEP) or competency evaluation, as required by 42 CFR §483.150(a) and (b). Review of employee files showed that multiple nurse aides (NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, and NA-L) were hired and worked full time for periods exceeding four months without being certified within the required timeframe. The facility’s own nurse aide job description required that nurse aides either have completed a state-approved training and competency evaluation program and hold a current state certificate, or be enrolled in an approved competency training program and perform only services for which they had demonstrated competence. Interviews with the involved nurse aides and the AIT confirmed that these staff members were not certified and had not completed all required components of the NATCEP. NA-A reported she had previously taken CNA classes and passed the written test but failed the skills test and never retook it. NA-C stated she had completed 40 hours of online CNA training and two in-person classes, but the facility stopped the CNA classes before she could complete certification. NA-F reported passing a written exam but failing the clinical exam and was waiting on additional training hours. NA-H stated she completed 60 hours of computer training but had not completed clinical hours due to lack of a site to complete that portion. The AIT acknowledged that none of the nurse aides were certified because they had not tested, and that a planned NATCEP at a sister facility had been cancelled. Despite these circumstances, the nurse aides continued to work full time beyond four months without the required certification or completed competency evaluation.

Penalty

Fine: $204,535

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 and maintain an infection prevention and control program that included an antibiotic stewardship component with antibiotic use protocols and a system to monitor antibiotic use for three consecutive months. Record review showed there was no infection tracking log or other evidence of an antibiotic stewardship program for December 2025, January 2026, and February 2026. The facility’s written policy, revised in September 2017, stated that surveillance of infections was intended to identify individual cases and trends of significant organisms and healthcare-associated infections, using standard definitions and including infections such as pneumonia, UTIs, C. difficile, and pathogens associated with serious outbreaks. During interviews, the ADON reported that she had previously performed infection prevention tasks, including tracking infections and maintaining a binder of residents who received antibiotics, but she was no longer responsible for tracking and trending infections after a previous DON was hired. She stated the previous DON’s last day was in mid-December 2025 and could not provide any evidence of antibiotic stewardship activities after her own prior tracking efforts. The AIT confirmed that both the previous and new DON had completed infection preventionist training and were designated as the facility’s IPs, but she was unable to provide any infection tracking or trending documentation for December 2025, January 2026, or the current month. The newly hired DON stated that the survey date was her first day working on the floor and that she was still in training, having only completed online training beforehand, and there was no documentation available to show that infection surveillance or antibiotic use monitoring had been conducted during the cited months.

Penalty

Fine: $204,535

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 designate a qualified Infection Preventionist (IP) who worked at least part-time and had completed specialized infection prevention and control training during the months of December 2025, January 2026, and February 2026. Record review showed that the DON had completed Nursing Home Infection Preventionist Training with a certificate dated 01/14/2026, but she did not begin working on the floor in the facility until 02/05/2026 and was still in training at that time. The facility’s policy titled “Surveillance for Infections,” revised September 2017, stated that the IP would conduct ongoing surveillance for healthcare-associated infections and other significant infections, but there was no evidence this surveillance was being conducted during the period when the DON position was vacant and when the new DON had not yet started working in the building. During interviews, the ADON reported that she had previously performed IP tasks such as tracking infections before the prior DON was hired, and that the prior DON’s last day was December 12, 2025. She stated there was no IP appointed when the DON position was vacant and acknowledged she could not provide any records showing recent infection tracking in the facility. The AIT confirmed that both the previous and new DONs had completed the infection preventionist program and provided the new DON’s IP certificate dated 01/14/2026. The AIT also reported that another staff member had infection control-related training, but the certificate provided, dated 10/25/2017, was for “Infectious Diseases and Infection Control” and was not a nursing-facility-specific IP training. The report states that this failure could affect residents by placing them at risk of infection spread due to the facility not appropriately recognizing and responding to communicable diseases and infections.

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 establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A and Nursing Aid B during incontinence care for a resident. The resident, an elderly female with vascular dementia, was dependent on staff for toileting hygiene. During an observation, CNA A and Nursing Aid B were seen performing hand hygiene and donning gloves before removing the resident's soiled brief. However, they did not perform hand hygiene or change gloves before placing a new brief on the resident, which is a breach of infection control practices. In interviews following the observation, both CNA A and Nursing Aid B acknowledged their failure to perform hand hygiene and change gloves, attributing it to nervousness and forgetfulness. The Assistant Director of Nursing (ADON) confirmed that the expectation was for staff to perform hand hygiene and don new gloves between handling soiled and clean items. The facility's infection control policy, last revised in August 2012, requires handwashing after contact with bodily fluids and after removing gloves, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to immediately inform a resident, consult with the resident's physician, and notify the resident's representative when there was a significant change in the resident's condition. This deficiency was identified for a resident who had returned from the hospital after being treated for a urinary tract infection (UTI). Despite the resident exhibiting symptoms of confusion, paranoia, and refusing medication, the facility did not notify the physician or nurse practitioner of these changes in condition. The resident, a female with a history of hypothyroidism, depression, insomnia, and hypertension, was admitted to the facility in June 2024. After being treated for a UTI at the hospital, she returned to the facility but continued to show signs of confusion and paranoia, including calling 911 multiple times and refusing medication and meals. Despite these ongoing symptoms, there was no evidence that the facility staff notified the resident's physician or nurse practitioner about the resident's condition. Interviews with facility staff, including LVNs and the physician, revealed that the physician and nurse practitioner were not informed of the resident's condition after her return from the hospital. The facility's policy required prompt notification of the physician in the event of a significant change in a resident's condition, but this protocol was not followed. The administrator acknowledged the failure to notify the physician and expressed concern about the potential harm to residents due to this oversight.

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 and implement comprehensive person-centered care plans for three residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental and psychosocial needs. Resident #6 and Resident #7, both smokers, did not have care plans addressing their smoking habits, despite assessments indicating they required supervision while smoking. Resident #6 was observed smoking under supervision, and Resident #7 was seen smoking independently, yet their care plans lacked specific interventions or goals related to smoking. Resident #10 did not have a care plan documented in the facility's electronic health record system, despite having diagnoses of depression, insomnia, and essential hypertension. The Director of Nursing (DON) acknowledged the care plans were disorganized when she assumed her position and was in the process of updating them. However, she had not reviewed or revised the care plans for Resident #6 and Resident #7, and was unaware of the absence of a care plan for Resident #10. The facility's policy required comprehensive care plans to be developed and implemented for each resident, consistent with their rights, and to include measurable objectives and timeframes. These plans were to be reviewed and revised by the interdisciplinary team after each comprehensive assessment and change in condition. The Administrator expressed that the lack of required information in the care plans or the absence of a care plan could lead to improper care and indicated a lack of training among the staff.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurate medical records for three residents regarding their smoking assessments, as required by professional standards and the facility's smoking policy. Resident #5, a female with moderate cognitive impairment and schizoaffective disorder, had a smoking safety screen indicating she required supervision while smoking due to dexterity and vision problems. However, her clinical record lacked additional smoking safety screens, and her care plan did not adequately address her smoking needs. Resident #6, a female with intact cognitive response and chronic obstructive pulmonary disease, also had incomplete documentation. Her smoking safety screen noted she smoked over ten cigarettes daily and required supervision, but her care plan did not address her smoking habits. Similarly, Resident #7, a female with severe cognitive impairment and psychotic disorder, had a smoking safety screen indicating she needed supervision and storage of smoking paraphernalia, yet her care plan did not reflect her smoking needs. Interviews with the DON and Administrator revealed that smoking assessments were overdue and not completed quarterly as required. The DON acknowledged the delay in updating assessments, and the Administrator confirmed that the lack of timely assessments could put residents at risk of harm. The facility's policy required quarterly re-evaluation of residents' ability to smoke safely, which was not adhered to, leading to the deficiency.

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 and follow its established smoking policy in the designated smoking area. On 10/09/2024, an observation revealed that a red, labeled, self-enclosed, covered smoking receptacle, intended for flammable ash only, contained non-flammable trash items such as a Cheez-it package and an aluminum soda can. Additionally, the receptacle was lined with a clear, plastic trash liner, which is against the facility's policy. This oversight was noted during a survey, highlighting a potential fire hazard due to the improper disposal of trash in a container meant solely for cigarette butts. Interviews conducted with the facility's Administrator and Environmental Supervisor revealed a lack of awareness and adherence to the smoking policy. The Administrator expressed concern upon being informed of the issue, acknowledging the fire hazard posed by the presence of trash in the smoking receptacle. The Environmental Supervisor, who had been with the facility for four years, admitted to not being familiar with the smoking policy and stated that the housekeepers were responsible for cleaning the ashtrays and ensuring cigarette butts were properly disposed of. The Environmental Supervisor also noted that the staff and residents did not use the receptacle correctly, contributing to the deficiency observed.

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 and implement a baseline care plan for a newly admitted resident within 48 hours, as required by their policy. The resident, a female with diagnoses including hypothyroidism, depression, insomnia, and essential hypertension, was admitted without a baseline care plan or comprehensive care plan documented in the facility's electronic health record system. This oversight was identified during a review of the resident's clinical records and confirmed through interviews with facility staff. The admitting nurse, who was responsible for creating the baseline care plan, was no longer employed at the facility at the time of the review. The Administrator acknowledged that the baseline care plans should be completed upon admission within the first 48 hours and monitored by the DON. The absence of a baseline care plan could lead to improper care for the resident, as it is essential for meeting the resident's immediate needs and ensuring continuity of 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 that comprehensive care plans were reviewed and revised by the interdisciplinary team after a significant change in condition for a resident. Specifically, the care plan for a resident was not updated following a fall that resulted in a lower left leg fracture. The resident, who had a history of moderate cognitive impairment and was at risk for falls, experienced a fall in the bathroom while attempting to get water for her denture cup. Despite the incident and subsequent diagnosis of a fibula fracture, the care plan was not revised to address the resident's new needs and prevent further injuries. Interviews with facility staff, including the Facility Owner and Administrator, revealed that the responsibility for updating care plans after significant changes in condition was understood to lie with the Director of Nursing (DON) and the administrator. The facility's policy required that care plans be reviewed and revised by the interdisciplinary team after each comprehensive assessment and change in condition. However, this policy was not followed, as the care plan was not updated after the resident's fall and injury, potentially placing the resident at risk for inadequate 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 maintain a Quality Assessment and Assurance (QAPI) committee with the required members, specifically the Medical Director (MD), for seven meetings reviewed. The MD did not attend the QAPI meetings in person or by phone for the months of August 2023, October 2023, November 2023, December 2023, April 2024, May 2024, and June 2024. This absence was confirmed through record reviews of sign-in sheets and interviews with the Administrator (ADMN), who acknowledged the MD's lack of participation during the meetings. The ADMN admitted to taking the sign-in sheets to the MD's office post-meeting for signatures and stated that the MD was informed about the meetings but did not actively participate. The facility's policy outlined that the QAPI committee should include the MD as a member, among other representatives from various departments. The ADMN recognized the failure to ensure the MD's presence and participation, which could potentially lead to unidentified quality deficiencies and improper care for residents.

Penalty

No penalty information released

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

Summary

The facility failed to treat two residents with respect and dignity during meal assistance, which compromised their quality of life. Resident #6, a female with multiple health issues including pressure ulcers, chronic kidney disease, and dementia, was assisted with her meal by the Director of Nursing (DON) who stood over her instead of sitting at eye level. This action was contrary to the facility's policy that emphasizes feeding residents with attention to safety, comfort, and dignity. Resident #18, a male with severe cognitive impairment and other health conditions, was assisted by the Activities Director (AD) who was distracted, engaging in conversation with another staff member and consuming her own food while assisting the resident. This lack of focus and attention during meal assistance was not in line with the facility's policy and could have negatively impacted the resident's dignity and meal intake. Interviews with the DON and AD revealed a lack of adherence to proper training and facility policies. The DON acknowledged that staff should have been trained to sit at eye level with residents and focus solely on them during meal assistance. The AD admitted to being distracted and not following the training she had received, which included maintaining focus on the resident and avoiding personal eating or conversations with other staff during meal assistance. Both staff members recognized that their actions could have led to a loss of dignity for the residents and potentially impaired their meal intake.

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 and implement comprehensive person-centered care plans for four residents, which led to deficiencies in meeting their assessed needs. For Resident #16, the care plan did not incorporate the correct code status and PASRR status, despite the resident having a DNR order and requiring PASRR services. The care plan was outdated and did not reflect the necessary updates to ensure the resident's needs were met. Resident #17's care plan lacked measurable objectives or interventions for tracheostomy care and feeding tube management. Although the resident had a tracheostomy and required tube feeding due to dysphagia, the care plan did not include specific interventions or goals to address these needs effectively. This oversight could potentially lead to complications related to the resident's nutritional and respiratory care. For Resident #19, the care plan did not include interventions for fall prevention, despite the resident being at high risk for falls due to impaired mobility, vision, and a history of dizziness. Similarly, Resident #24's care plan was not updated after the resolution of a urinary tract infection treated with Bactrim, leaving the care plan outdated and not reflective of the resident's current health status. These deficiencies in care planning could result in decreased quality of life and unmet needs for 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 maintain an environment free from accident hazards in two of the three halls reviewed, specifically the Back Hall and Front Hall. Observations revealed that hazardous items such as shampoo, wound cleanser, nail polish remover, shaving cream, disinfectant spray, and perineal and skin cleanser were not secured and were accessible to residents. These items were found in the Back Hall Shower room, which was propped open, and in the Back Hall bathroom, as well as in the Front Hall bathroom. The facility's policy requires that such items be locked and inaccessible to residents to prevent potential harm. Interviews with the Administrator (ADMN) and Director of Nursing (DON) highlighted a lack of staff education and monitoring as contributing factors to the deficiency. The ADMN stated that shower rooms should remain locked when not in use and that hazardous items should not be accessible to residents. The DON expressed concerns that residents could potentially ingest these items or suffer injuries if they leaked onto the floor. The facility's policy on hazardous areas emphasizes the importance of identifying and addressing potential hazards to ensure resident safety, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents requiring respiratory care were provided with oxygen administration consistent with professional standards of practice. Specifically, the facility did not post 'Oxygen in Use' signs on the doors of three residents who were receiving oxygen therapy. This oversight was observed during a survey, where Resident #2, Resident #14, and Resident #235 were all noted to be using oxygen without the appropriate signage on their doors. The absence of these signs could potentially place residents at risk of respiratory infection, as visitors and staff may not be aware of the oxygen in use. Resident #2, a male with cerebral palsy, paraplegia, muscle wasting, and moderate cognitive impairment, was observed sitting in a recliner with oxygen but without the necessary signage. Resident #14, a female with heart disease, COPD, and severe cognitive impairment, was found sleeping with oxygen therapy in use, also lacking the sign. Resident #235, a male with atherosclerotic heart disease and anxiety, was similarly observed with oxygen but no sign. The Director of Nursing acknowledged the deficiency, attributing it to a lack of communication and oversight, which could lead to visitors being unaware of the oxygen use, thus posing a risk to the residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that three nurse aides (NA B, NA C, and NA D) were either enrolled in or had completed an approved training course within four months of employment. NA B, hired on January 30, 2024, NA C, hired on September 15, 2023, and NA D, hired on March 15, 2024, were all working full-time without certification. During interviews, NA B confirmed he had not been certified or attended training courses. The Director of Nursing (DON) acknowledged the lack of certified nurse aides and cited the absence of cost-effective local training programs as a barrier. The facility's policy requires all newly hired personnel to attend a 10-hour orientation program within the first five days of employment, which is separate from the 75-hour Nurse Aide Training Program. The facility's assessment tool indicated a significant number of residents required staff assistance for daily activities, with staffing ratios of 2:35 during the day, 1-2:35 in the evening, and 1:35 at night. Despite the supervision by LVNs, the facility's failure to ensure nurse aides were certified within the required timeframe placed residents at risk of receiving care from individuals with unknown skill levels.

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 the prescribed menu for a resident on a pureed diet during two consecutive lunch meals. On July 29, 2024, the resident did not receive a pureed roll as indicated on the menu, and on July 30, 2024, the resident's tray was missing mashed potatoes, which were part of the planned meal. These discrepancies were observed during meal service and confirmed through interviews with the resident, who expressed confusion about the missing items. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Dietitian, and Director of Nursing (DON), revealed that the oversight was due to a lack of proper checks by nursing staff and hurried actions by kitchen staff. The dietitian acknowledged that the failure to provide all menu items could result in residents not receiving the necessary caloric intake. The DON attributed the issue to oversight by both kitchen staff and nurses, emphasizing the potential impact on residents' nutritional status.

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 professional standards for food service safety, as observed during a survey of the kitchen. Several deficiencies were noted, including the improper storage of ice scoops, which were found uncovered on the counter next to the ice machine. Additionally, an unopened bottle of buttermilk was discovered in the refrigerator past its expiration date. A tub containing four unopened bottles of wine was also found, with one bottle having spilled, resulting in a black substance at the bottom of the tub. Furthermore, chipped dinnerware, including a plate and a coffee cup, was observed being served to residents. Interviews with the Dietary Manager (DM) and the Dietician revealed that these issues were due to oversight and staff being in a hurry. The DM acknowledged that the ice scoops should have been covered and that expired food items, such as the buttermilk, should not have been in the refrigerator. The DM also noted that the spilled wine bottle should have been cleaned to prevent mildew growth. The Dietician confirmed that expired food items could make residents ill and that chipped dinnerware should be discarded. Facility policies reviewed indicated that items that cannot be sanitized or are hazardous due to chips or cracks should be discarded, and supervisors are responsible for ensuring food items are not expired.

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 establish and maintain an effective infection prevention and control program, as evidenced by the improper handling and storage of ice scoops. During an observation, it was noted that an ice scoop was left uncovered on the counter in the kitchen and another was found uncovered on a cart beside the ice chest at the nurses' station. This was contrary to the facility's policy, which requires ice scoops to be stored in a designated, clean, labeled, and dry location to prevent cross-contamination. During an interview, the Dietary Manager (DM) acknowledged that the ice scoops should have been covered and not left out, attributing the oversight to being in a hurry. The DM recognized that this failure could lead to cross-contamination and illness among residents, and accepted responsibility for ensuring proper procedures are followed.

Penalty

No penalty information released

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

Summary

The facility failed to conduct regular inspections of bed frames and bed rails, which are crucial for identifying potential entrapment risks. This deficiency was observed in four residents who utilized bed rails for mobility and safety. The residents had various medical conditions, including cerebral palsy, hemiplegia, and disorders affecting bone density, which necessitated the use of bed rails to assist with bed mobility and safety. Despite the presence of bed rails, there was no evidence of regular maintenance or assessment to ensure their safety and functionality. Interviews with facility staff, including the Maintenance Supervisor, ADON, and DON, revealed a lack of clarity and responsibility regarding the assessment of bed rails and mattresses for entrapment risks. The Maintenance Supervisor admitted to never having assessed the bed frames or rails for such risks and was not provided with the necessary tools to do so. Similarly, the ADON and DON were unaware of who was responsible for these assessments, and neither had performed them since their tenure at the facility began. The facility's policy on the proper use of side rails, dated December 2016, mandates an assessment to determine the risk of entrapment and the appropriateness of side rail use. However, this policy was not followed, as evidenced by the lack of documented assessments and inspections. The failure to adhere to this policy could potentially place residents at risk of injury due to entrapment, as acknowledged by the DON and ADMN during their interviews.

Penalty

No penalty information released

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

Summary

The facility failed to provide a working communication system that was easily within reach for a resident, identified as Resident #19, who was blind and had a history of falls. On the date of observation, the call light was found on the floor behind the resident's recliner, out of reach. The resident, who was moderately cognitively impaired with a BIMS score of 9, expressed that he relied on the call light for assistance but was unable to locate it due to his blindness. This oversight was noted during an observation and interview, where the resident confirmed the call light was not accessible. The Director of Nursing (DON) acknowledged that the expectation was for call lights to be placed within reach of residents to prevent falls and ensure they could call for assistance. The DON attributed the failure to staff not paying attention and emphasized that all staff were responsible for ensuring call lights were accessible. The facility's policy on Quality of Life- Accommodation of Needs, dated August 2009, supports providing access to assistive devices, such as installing longer cords, to ensure accessibility. The DON and Assistant Director of Nursing (ADON) were responsible for monitoring compliance during their rounds.

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 and implement written policies and procedures to prohibit and prevent abuse and neglect, specifically in the case of a staff member, NA B, who was reviewed for resident abuse. The deficiency was identified when the facility did not suspend or remove NA B from direct care duties during an investigation into allegations of abuse. This failure was highlighted by the fact that NA B continued to work in resident care positions even after allegations were made, potentially placing residents at risk. The incident involved a resident who reported that NA B had been rough with her during care, specifically when turning her over. The resident expressed that there was no justification for the rough handling and reported the incident to staff, although she could not recall to whom. Additionally, during a confidential group meeting, another resident stated that NA B was rude and rough, and she refused to have him care for her. The Ombudsman was informed of these allegations and demanded that NA B be restricted from certain residents' rooms, but NA B reportedly entered one of the rooms again after this directive. The Director of Nursing (DON) acknowledged being informed of the allegations by the Ombudsman and directed NA B not to enter specific rooms, yet he continued to work that night. The Administrator (ADMN) expected staff involved in abuse allegations to be suspended until the investigation was completed, which did not occur in this case. The facility's policy stated that employees accused of abuse should be reassigned or suspended until the investigation's results were reviewed by the Administrator, a step that was not followed, leading to the deficiency.

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, identified as being at risk for skin breakdown, received appropriate care to prevent pressure ulcers. Specifically, the facility did not perform weekly skin assessments for the resident, who had a history of hemiplegia and hemiparesis following a stroke, stage 2 pressure ulcer, cellulitis, and vascular dementia. The resident's care plan included interventions for preventing pressure ulcers, such as weekly skin assessments and adherence to facility protocols for skin breakdown prevention. However, these assessments were not conducted as required, which could lead to the development of pressure ulcers, infections, and worsening of wounds due to delayed treatment. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that they were unaware of why the skin assessments were not performed. The DON acknowledged that missing skin assessments could result in skin breakdown. The facility's policy on pressure ulcer prevention required risk assessments to be repeated weekly and upon any changes in condition, with daily skin inspections during personal care or activities of daily living. Despite these policies, the facility did not adhere to the required procedures, as evidenced by the lack of recent skin assessments 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

The facility failed to ensure that residents had the right to send and receive mail, including letters, packages, and other materials delivered through means other than a postal service, for all 11 residents reviewed during a confidential group meeting. This deficiency was identified during a group interview where residents reported not receiving their mail on weekends because the Office Manager (OM), who was responsible for picking up the mail, did not work on weekends. The OM confirmed in an interview that she was the only person with a key to the post office box and collected mail only from Monday to Friday. A review of the facility's undated policy on Nursing Home Residents' Rights revealed that residents are guaranteed rights under the federal Nursing Home Reform Law, which includes the right of access to individuals, services, community members, and activities inside and outside the facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the Activities Director (AD) was a qualified therapeutic recreation specialist or an activities professional meeting state licensing requirements. The AD assumed the position on June 6, 2024, but there was no evidence of certification or training in her employee file. During an interview, the AD confirmed she did not have her Activity Director certification and had been waiting for paperwork from the facility to begin classes for certification. The Administrator (ADMN) acknowledged the oversight during the hiring process and admitted it was his responsibility to ensure staff certifications. The ADMN expressed concerns that residents might not have their social needs met due to the AD's lack of certification. Additionally, the facility's job description for the Activity Director did not specify education requirements. During a follow-up interview, the ADMN mentioned that another staff member, who was certified as a therapeutic recreation specialist, had been training the current AD, but no evidence of this qualification was provided. The ADMN was unable to provide additional documentation during the exit conference.

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 daily staffing information was posted in a prominent place readily accessible to residents and visitors for three of the seven days reviewed. Specifically, on 07/29/2024, 07/30/2024, and 07/31/2024, there was no daily nursing staffing information posted at the nurses' station or any other location within the facility. During an interview, the Director of Nursing (DON) stated that staff had access to schedules on their phones and that if the public or families wanted to know which staff were working, they could ask a staff member. The DON admitted that daily staffing was not posted anywhere in the facility and was unaware that this was a required posting. This oversight could potentially place residents, their families, and visitors at risk of not having access to important staffing and facility census information.

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 and maintain an effective communications training program for new and existing direct care staff, as evidenced by the lack of communications training for the Director of Nursing (DON), Nursing Assistant B (NA B), and Nursing Assistant D (NA D). These deficiencies were identified during a review of personnel files, which revealed that none of these staff members received communications training during their new hire orientation. The DON was hired on June 25, 2024, NA B on January 30, 2024, and NA D on March 15, 2024, yet all lacked the necessary training. Interviews conducted during the investigation revealed that the Office Manager (OM) was not present during the onboarding of these employees and was unaware of why the training was not conducted. The Administrator (ADMN) expected that staff would receive communications training during the onboarding process but acknowledged that the OM hired at the time had implemented their own onboarding procedures, which led to the omission of the required training. The ADMN was unaware of the training deficiencies until the survey and recognized that this oversight could result in staff being unable to provide adequate care, potentially leading to injuries, accidents, and improper treatment for residents.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a training program to ensure that staff were adequately trained in the Quality Assurance and Performance Improvement (QAPI) program. Specifically, three staff members, including the Director of Nursing (DON), Nursing Assistant B (NA B), and Nursing Assistant D (NA D), were not provided with QAPI training upon their hire. This oversight was identified through a review of personnel files, which revealed that none of these employees had received the necessary training since their respective hire dates. Interviews conducted during the investigation revealed that the Office Manager (OM) was not present during the onboarding of these employees and was unaware of the lack of training. The Administrator (ADMN) acknowledged that the facility had hired a new OM who implemented changes to the onboarding process, which led to the omission of QAPI training. The ADMN admitted to being unaware of the training deficiencies until the survey and recognized that this failure could potentially impact the quality of care provided to residents, leading to possible injuries, accidents, and improper treatment.

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 training program to ensure that staff were adequately trained in behavioral health, as evidenced by the lack of training for the Director of Nursing (DON) and a Nursing Assistant (NA D). Both staff members, hired on different dates in 2024, did not receive the necessary behavioral health training upon their onboarding. This deficiency was identified through a review of personnel files, which showed no record of behavioral health training for these employees. Interviews with the Office Manager (OM) and the Administrator (ADMN) revealed that the OM was not present during the onboarding of these employees and was unaware of why the training was not conducted. The ADMN expressed an expectation for staff to receive communication training during onboarding and acknowledged that the newly hired OM had made inappropriate changes to the onboarding process, which led to the oversight. The facility's policy on orientation for newly hired employees, dated January 2008, outlines a comprehensive orientation program that includes a review of various facility policies and procedures. However, the facility assessment tool dated July 2024 indicated that the facility cared for at least one resident with behavioral health needs, requiring specific care interventions. The lack of behavioral health training for the DON and NA D could potentially impact the quality of care provided to residents with behavioral health needs, as the staff may not be equipped to manage psychiatric symptoms and behaviors effectively.