4 CMS Surveys
Inspection Report — Jan 23, 2025
Complaint Investigation
Date: Jan 23, 2025
Visit Reason
Investigation of complaints received about dignity, care plan implementation, care planning, assistance with eating, fall prevention, respiratory care, and medical record documentation.
Complaint Details
Dignified dining experience: established. Care plan implementation failures for skin protection and nutrition: established. Confusing nutrition care plan for Resident #344: established. Inadequate assistance with eating for Resident #5: established. Failure to use gait belt during ambulation for Resident #343: established. Inaccurate oxygen administration for Resident #4: established. Inaccurate meal intake documentation for Residents #5 and #30: established.
Findings
Multiple deficiencies were found including failure to provide dignified dining assistance, failure to implement care plans for skin protection and nutrition, failure to provide adequate assistance with eating, failure to use gait belts during ambulation resulting in a fall, failure to ensure accurate oxygen administration, and failure to accurately document meal intake.
Deficiencies (7)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: staff ignored residents during meals and engaged in personal conversations, resulting in diminished self-worth and frustration for Resident #14 and Resident #21.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: Resident #21 and Resident #30 were not consistently provided with geri sleeves and straw as required by their care plans, and heel protectors were not consistently applied for Resident #30, risking skin breakdown.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: Resident #344's nutrition care plan was confusing and inconsistent regarding diet and fluid restrictions, leading to potential mismanagement of fluid intake.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: Resident #5 did not receive adequate assistance with eating, resulting in potential negative physical outcomes due to insufficient monitoring and support.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Resident #343 was ambulated without a gait belt despite high fall risk, resulting in a fall and potential injury.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: Resident #4 did not consistently receive oxygen at the ordered flow rate due to confusion and inconsistent documentation of oxygen settings.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: Resident #5's meal intake was inaccurately documented prior to meal completion, and Resident #30's use of geri sleeves was inconsistently documented, resulting in inaccurate reflection of care provided.
Inspection Report — Feb 29, 2024
Complaint Investigation
Date: Feb 29, 2024
Visit Reason
Investigation of a complaint received on 2024-02-29 about medication administration, resident safety, feeding tube care, food safety, staffing data submission, infection prevention and control.
Complaint Details
Care plan for high-risk medication: not developed for Resident #32 — established. Medication administration documentation errors and unattended medications for Residents #1, #37, #145 — established. Unsafe wheelchair transport without footrests for Resident #6 — established. Improper feeding tube management including unauthorized use of de-clogger and cola for Resident #3 — established. Improper food labeling and storage — established. Incomplete staffing data submission for Q4 2023 — established. Infection prevention lapses including hand hygiene, equipment sanitation, PPE use, and failure to follow enhanced barrier precautions for Resident #3 — established.
Findings
Multiple deficiencies were found including failure to develop a comprehensive care plan for a high-risk medication, improper medication administration documentation, unsafe wheelchair transport practices, improper feeding tube management, inadequate food labeling and storage, incomplete staffing data submission, and lapses in infection prevention and control practices including PPE use and hand hygiene.
Deficiencies (7)
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The facility failed to develop and implement a person-centered comprehensive care plan for a high-risk medication for Resident #32.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality. The facility failed to follow professional standards for medication administration documentation and medication handling/storage, including documenting medications as given prior to administration and leaving medications unattended for Resident #1, #37, and #145.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The facility failed to ensure safe transport of Resident #6 in a wheelchair with footrests in place, resulting in potential for injury.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. The facility failed to ensure proper care related to tube feeding management for Resident #3, including use of a de-clogger and carbonated cola without physician orders or care plan interventions.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. The facility failed to properly label, date, and discard opened food products, increasing risk of food borne illness.
F 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. The facility failed to submit complete and accurate direct care staffing data for the 4th quarter of 2023.
F 0880 Provide and implement an infection prevention and control program. The facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. The facility also failed to perform hand hygiene between resident care, sanitize shared equipment between uses, wear appropriate PPE while sorting soiled laundry, and implement precautions per physician order for Resident #3 on enhanced barrier precautions.
Inspection Report — Jun 1, 2023
Date: Jun 1, 2023
Visit Reason
Investigation of a complaint regarding failure to follow the care plan resulting in injury to a resident.
Findings
The facility failed to follow the care plan for Resident #1, resulting in a fall with injury including a large hematoma and lacerations.
Inspection Report — Mar 15, 2023
Complaint Investigation
Date: Mar 15, 2023
Visit Reason
Investigation of a complaint received on 2023-03-15 about infection control and resident dignity.
Complaint Details
Inadequate PPE use and hand hygiene: established. Improper cleaning of resident equipment: established. Improper laundry handling: established. Staff fingernail hygiene issues: established. Resident dignity compromised: established. Failure to provide SNFABN: established. Missing MDS discharge assessments: established. Incomplete staff competency training: established. Food safety violations: established. Improper CPAP equipment cleaning: established.
Findings
Multiple infection control deficiencies were found including improper use of PPE, inadequate cleaning of resident equipment, improper laundry handling, and staff fingernail hygiene issues. Residents' dignity was compromised by staff actions. Several residents' equipment and care practices were not properly maintained or sanitized.
Deficiencies (11)
Failure to ensure proper PPE use and hand hygiene for residents on Enhanced Barrier Precautions, including staff not wearing eye protection properly or at all, and failure to gown and glove when required.
Resident shared equipment such as wheelchairs and tube feeding pumps were not cleaned or disinfected properly, with dried substances and splatters observed on equipment.
Failure to properly clean and sanitize shared medical equipment including blood pressure cuffs, pulse oximeters, and thermometers between resident uses.
Laundry was transported and handled without proper covering, increasing risk of contamination.
Staff wore artificial fingernails extending beyond fingertips, posing infection control risks.
Failure to maintain resident dignity, including exposing residents and feeding them in a child-like manner.
Failure to provide required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident, risking appeal rights.
Failure to submit required Minimum Data Set (MDS) discharge assessments for multiple residents, risking inaccurate tracking.
Failure to ensure annual competency training for Certified Nursing Assistants, with 5 of 32 not completing required training.
Food safety violations including uncovered and expired foods, moisture-damaged ceiling tiles, unclean equipment and surfaces, and improper sanitizer concentration without test strips.
Failure to clean CPAP masks and equipment properly, risking resident infection.
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