5 CMS Surveys
Inspection Report — Apr 17, 2025
Complaint Investigation
Date: Apr 17, 2025
Visit Reason
Investigation of a complaint received on 2025-04-17 about medication administration, infection control, and medication regimen review.
Complaint Details
Oxygen administration above physician order and improper equipment maintenance: established. Medication Regimen Reviews not reviewed or maintained: established. Duplicate vitamin D therapy: established. Medication administration errors including crushing capsules and failure to document refusals: established. Failure to perform hand hygiene during care: established.
Findings
Four deficiencies were established related to oxygen administration and equipment maintenance, medication regimen review and unnecessary medications, medication administration errors, and infection prevention and control practices.
Deficiencies (5)
F 0695 Provide safe and appropriate respiratory care for a resident when needed: Resident #65 was administered oxygen at 3 L/min despite physician order for 2 L/min, oxygen tubing was not changed weekly as required, and nebulizer equipment was not properly cleaned or stored.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines: The facility failed to ensure Medication Regimen Reviews were reviewed, addressed by the physician, and maintained in the clinical record for four residents, resulting in potential for unnecessary medications and adverse effects.
F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: Resident #90 received duplicative vitamin D therapy with both vitamin D2 and D3 concurrently during June 2024, increasing risk of toxicity.
F 0759 Ensure medication error rates are not 5 percent or greater: Medication administration errors occurred in four residents including crushing potassium chloride capsules against physician orders, failure to document medication refusal or notify physician, and improper medication preparation.
F 0880 Provide and implement an infection prevention and control program: Staff failed to perform hand hygiene between residents during fresh water pass and catheter care, resulting in potential cross-contamination of infectious organisms.
Inspection Report — Apr 24, 2024
Complaint Investigation
Date: Apr 24, 2024
Visit Reason
Investigation of a complaint received on 2023-09-28 about misappropriation of narcotic medication.
Complaint Details
Misappropriation of narcotic medication for Resident R266: established.
Findings
One violation was established related to failure to prevent misappropriation of narcotic medication by a nurse who was terminated for refusal to submit to drug testing.
Deficiencies (1)
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: the facility failed to prevent misappropriation of narcotic medication for Resident R266 due to a nurse signing out medication not administered and refusing drug testing, resulting in termination.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN H | Registered Nurse | Named in the established violation for misappropriation and refusal to submit to drug testing. |
Inspection Report — Apr 24, 2024
Complaint Investigation
Date: Apr 24, 2024
Visit Reason
Investigation of complaints received about medication misappropriation, failure to report injuries, incomplete investigations, pressure injury care, staffing data reporting, and QAPI committee compliance.
Complaint Details
Medication misappropriation by RN H: established. Failure to report injuries of unknown source for Residents R87 and R34: established. Incomplete investigation of Resident R34 incident: established. Inadequate pressure injury care for Resident R109: established. Inaccurate staffing data submission to CMS: established.
Findings
Five deficiencies were established related to medication misappropriation by a nurse, failure to report injuries of unknown source, incomplete investigation of a resident incident, inadequate pressure injury assessment and monitoring, and failure to submit accurate staffing data to CMS. Additionally, the facility failed to ensure the QAPI committee met quarterly with required members.
Deficiencies (5)
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: Registered Nurse H signed out a PRN Norco medication for Resident R266 but did not administer it, and refused drug testing leading to termination.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: The facility failed to report injuries of unknown source for Residents R87 and R34 to the state agency.
F 0610 Respond appropriately to all alleged violations: The facility failed to conduct a thorough and complete investigation for an incident involving Resident R34.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: The facility failed to assess, monitor, and document pressure injuries for Resident R109, including lack of physician documentation and treatment orders.
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 report Payroll Based Journal information accurately and missed submission deadlines.
Report Facts
Date of survey completed: Apr 24, 2024
Date of discipline: Feb 10, 2023
Date of policy revision: Oct 7, 2021
Date of policy revision: Oct 16, 2021
Date of education completion: Oct 11, 2024
Date of corrective action monitoring: Apr 16, 2024
Date of incident: Mar 3, 2024
Date of incident: Nov 29, 2023
Date of MDS assessment: Dec 20, 2023
Date of pressure injury identification: Mar 7, 2024
Date of pressure injury assessment: Mar 18, 2024
Date of nurse progress note: Apr 3, 2024
Date of skin assessment observation: Apr 24, 2024
Date of PBJ staffing data quarter: Oct 1, 2024
Date of QAPI plan update: Apr 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN H | Registered Nurse | Named in medication misappropriation and drug testing refusal findings |
| RN C | Registered Nurse | Interviewed regarding PBJ data submission and resident care |
| LPN J | Licensed Practical Nurse | Reported resident R266's medication discrepancy |
| LPN I | Licensed Practical Nurse | Noted medication discrepancy for resident R266 |
| RN G | Registered Nurse, Risk Manager | Reviewed QAPI policy and attendance |
| LPN D | Licensed Practical Nurse | Performed skin assessment for resident R109 |
| CNA E | Certified Nursing Assistant | Assisted with skin assessment for resident R109 |
| CNA F | Certified Nursing Assistant | Witnessed resident R87 prior to fall |
Inspection Report — Apr 20, 2023
Complaint Investigation
Date: Apr 20, 2023
Visit Reason
Investigation of a complaint received about medication storage, dietary services, adaptive equipment, infection prevention, and infection control surveillance.
Complaint Details
Medication storage deficiencies: established. Dietary service deficiencies: established. Adaptive equipment deficiencies: established. Infection prevention program deficiencies including Water Management Plan: established. Infection control surveillance failure for potential UTI in resident R23: established.
Findings
Multiple deficiencies were found including improper labeling and storage of medications, failure to serve planned meal items, lack of adaptive eating equipment for residents, failure to develop a comprehensive Water Management Plan for Legionella control, and failure to ensure infection control surveillance for a resident with a potential urinary tract infection.
Deficiencies (4)
F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. The facility failed to label multi-dose insulin and ophthalmic medications properly and had loose pills in medication carts.
F 0800 Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. The facility failed to follow the menu and did not serve planned meal items according to 13 resident tray cards out of 20 meals observed.
F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. The facility failed to provide adaptive equipment during meal service for two residents, resulting in increased difficulty with nutritional consumption.
F 0880 Provide and implement an infection prevention and control program. The facility failed to develop a comprehensive Water Management Plan to address Legionella control and failed to ensure infection control surveillance for a resident with a potential urinary tract infection.
Inspection Report — Mar 8, 2023
Complaint Investigation
Date: Mar 8, 2023
Visit Reason
Investigation of a complaint received on 2023-02-26 about sexual abuse and medication storage.
Complaint Details
Sexual abuse of Resident #3 by Resident #2: established. Missing controlled substances and potential drug diversion: established.
Findings
Two deficiencies were found: failure to protect residents from sexual abuse and failure to ensure secure inventory and tracking of controlled substances resulting in missing medication.
Deficiencies (2)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect Resident #3 from sexual abuse by Resident #2, who was severely cognitively impaired and engaged in inappropriate sexual contact despite care plans and monitoring.
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to ensure secure inventory and tracking of controlled substances, resulting in missing hydrocodone/acetaminophen for Resident #9 and potential drug diversion.
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