Irondale Post Acute

Penalty

Inspection fine: $50,400

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 a resident with bilateral hand contractures received consistent services and assistance to maintain range of motion. Resident #25 was admitted without bilateral hand contractures, but later evaluations showed limited motion in both wrists and fingers, and occupational therapy placed him on a restorative splint and brace program with bilateral upper extremity orthotics daily as tolerated. The OT discharge summary stated the prognosis to maintain his current level of function was good with consistent staff follow through. Documentation in the resident’s EMR showed inconsistent application of the bilateral hand splints. The record also showed gaps in restorative documentation, including no documentation of splint placement for a period in December 2025 and no documentation explaining why the resident refused the restorative program on three consecutive days in January 2026. A later joint mobility evaluation showed the resident’s right wrist, right fingers, and left fingers had worsened compared with the prior assessment, and OT documented that he was working with PT and OT to return to prior range of motion. During survey observations, the resident was seen in a wheelchair without resting hand splints on either hand, and he was unable to extend his fingers independently. The resident’s care plan identified limited physical mobility related to bilateral hand and wrist contractures and included interventions for gentle ROM and supportive devices, but the observations and record review showed the contracture prevention devices were not consistently in place. Staff interviews reflected confusion about responsibility for restorative nursing, splint application, and documentation of the program.

Penalty

Inspection fine: $50,400

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 comfortable and homelike environment in the secured unit. During an environmental tour, surveyors observed multiple areas of disrepair in the common area at the secure unit entrance, including black marks on the ceiling, unfinished sheet rock patches, areas needing stippling, a dirty black ceiling around the air vent, unpainted wall areas, brown spots on the ceiling, a loose cover base, sheet rock damage, and multiple floor tiles with missing top laminate. In the dining room area, surveyors observed red marks or drops on the ceiling at the entrance to a resident room, brown water-stained areas, black debris around the ceiling vent, sheet rock damage around the vent, and multiple unpainted wall areas and unpainted sheet rock patches in the hallway and under the nurses' station window shelf. Surveyors also observed multiple resident rooms in the secured unit with maintenance and cosmetic issues. One resident room had chipped paint on the entrance door frame, loose cover bases at the bathroom entrance, a missing towel bar, a black plunger standing upright and not bagged, a torn plastic toilet seat, and exposed rough wood on the bathroom door. Another resident room had seven unpainted sheet rock patches, sheet rock damage near the bed by the window, and an unpainted section of wall by the window, along with a missing section of cover base, chipped paint on the door frame, a nonfunctional light over the sink, a wooden leg used to hold up the sink, and a black plunger standing upright in the bathroom. Additional resident rooms were observed with loose or torn cover bases, chipped paint around sinks and door frames, torn linoleum flooring, cracked bathroom tile, black marks on bathroom doors, sheet rock damage on room corners, scraped and cracked paint, missing glove box and towel bar covers, grey areas on floor tiles, mismatched paint, small holes in walls, a missing heater control cover, missing horizontal blinds, wood damage on cabinets, and chipped paint on a metal heater cover. The maintenance director stated he was responsible for building maintenance, tracked improvements on a spreadsheet, knew about the repairs needed in the secured unit, and said the repairs were being prioritized, but he did not have a specific end date for when the repairs would be completed.

Penalty

Inspection fine: $50,400

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 two residents were kept free from physical abuse by each other. The deficiency involved a resident with schizophrenia, anxiety disorder, repeated falls, cognitive communication deficit, muscle weakness, and drug-induced subacute dyskinesia, and another resident with schizoaffective disorder, bipolar type, muscle weakness, and muscle wasting and atrophy. Both residents were identified in the report as having behavioral and psychiatric histories relevant to the incident. According to the investigation, one resident reported that her roommate approached her and hit her on the shoulder, causing pain. The other resident later reported that her roommate had hit her on the collarbone and said she had severe pain in that area. Both residents were interviewed, and each described physical contact by the other. The facility documented that neither resident had visible injuries, bruising, or signs of distress at the time of assessment, and both were placed on 15-minute checks and psychosocial monitoring. The record review showed that the resident identified as the assailant had a behavior care plan noting a long history of paranoia, delusions, hallucinations, and verbal and physical aggression, with religious and persecutory themes. The care plan and antipsychotic medication plan documented the need to monitor for aggression and hallucinations, but the report states the care plan failed to address appropriate supervision when the resident was in her room and failed to include specialized strategies to de-escalate those psychiatric triggers. Staff interviews also confirmed that both residents had known behavioral concerns and that the altercation occurred between them.

Penalty

Inspection fine: $50,400

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 protect one resident from misappropriation of property when a significant amount of money was reported missing from his room. The resident, who had diagnoses including delusional disorder, generalized anxiety disorder, depression, diabetes, asthma, paraplegia, hypertension, gout, and cellulitis, was documented as cognitively intact with a BIMS score of 15 out of 15. He reported that money given to him by his sister was missing, and the facility’s investigation identified that $389.00 was located in his wallet while the remainder was not found. The resident’s account of the event was that a female nurse entered his room while assisting him with toileting care, handled his robe and wallet, and money was missing from the wallet after the nurse returned it to his nightstand and later removed his wet pajama bottoms. The police report documented that the resident said a nurse took $700.00 from his wallet, and the resident later told surveyors that a female nurse took money from his wallet during morning care. The resident’s representatives also reported that he said a lady woke him, took his gown with the wallet in it, and removed the money while it was being taken to laundry. The facility’s investigation documented interviews with the resident, his sister, staff, and others, and noted that the resident’s sister confirmed she had given him $1,000.00. However, the investigation did not document how the resident and his money were kept safe beyond notifying police, did not clearly state whether the allegation was substantiated or unsubstantiated, and did not show that the resident was asked who he thought took the money or how he believed it went missing. The facility later stated it could not verify the money had been in the resident’s possession, despite the resident’s consistent statements to police, surveyors, and representatives, and despite the sister’s confirmation that she had given him the money.

Penalty

Inspection fine: $50,400

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 Resident #8 was free from unnecessary psychotropic medication use because his continued use of Seroquel was not appropriately monitored and reviewed by the interdisciplinary team for ongoing medical necessity and gradual dose reduction. The resident was an older adult with diagnoses including unspecified dementia, hypertension, atrial fibrillation, muscle weakness, lack of coordination, unsteadiness on feet, and cognitive communication deficit. His MDS showed severe impairment in cognitive skills for daily decision making, dependence for several activities of daily living, and use of a wheelchair. The assessment also documented that he was prescribed an antipsychotic medication and that a gradual dose reduction was not attempted. Observations showed the resident sleeping in his bed during multiple extended periods, while staff offered activities to other residents in the common area but did not offer activities to him. His care plans identified depression risk, anxiety and agitation, wandering and exit-seeking, and antipsychotic medication use related to delusions causing agitation, anxiety, and exit-seeking. The record also showed PHQ-9 results with varying scores, including moderate depression earlier in the year and minimal depression later, but there was no documentation that social services attempted to obtain input from family or staff about his mood until late in the review period, and no documentation addressing the PHQ-9 findings or what follow-up, interventions, or services were offered. The physician orders continued Seroquel 50 mg twice daily for dementia with behaviors, with monitoring orders tied to behaviors such as verbal aggression, refusing care, wandering, exit-seeking, restlessness, and delusions. However, the MAR and TAR review from October 2025 through February 2026 showed no behaviors documented. The record also did not show that the IDT reviewed the resident’s Seroquel use on at least a quarterly basis to determine whether continued use was justified or whether a GDR was indicated. Staff interviews confirmed that psychotropic medications were supposed to be reviewed quarterly by the IDT, but documentation of the resident’s September 2025 psychotropic review and any discussion or recommendation for GDR could not be produced.

Penalty

Inspection fine: $50,400

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

Summary

The facility failed to thoroughly investigate allegations of abuse involving two residents after one resident reported that her roommate had bopped her on the shoulder and the roommate later gave a conflicting account that the resident had struck her on the collarbone. The facility documented interviews with the two residents, several residents on the unit, and staff who did not work on the unit at the time of the incident, but it did not interview staff who were present during the altercation. The investigation also documented that RN #4 completed skin assessments for both residents, but RN #4 was not interviewed as part of the investigation. The assistant director of nursing stated she was present in the building when the incident occurred and that both residents came to her office reporting the altercation, but her evaluation was not documented in the EMR. Resident #51 was cognitively intact with diagnoses including schizophrenia, anxiety disorder, repeated falls, cognitive communication deficit, muscle weakness, and drug-induced subacute dyskinesia. She told surveyors that her roommate approached from behind and hit her on the right shoulder, causing severe pain, and that she reported the incident to staff. Resident #12 had diagnoses including schizoaffective disorder, bipolar type, muscle weakness, and muscle wasting and atrophy, and had moderate cognitive impairment. She told surveyors that she touched her roommate on the shoulder and that the roommate hit her on the collarbone. The facility concluded the allegation was unsubstantiated because there were no witnesses, despite both residents describing physical contact. The facility also failed to thoroughly investigate an allegation that Resident #27’s money was misappropriated. The resident, who had diagnoses including delusional disorders, generalized anxiety disorder, paraplegia, diabetes, asthma, hypertension, and depression, reported missing money from his room. The facility interviewed the resident, his sister, and some staff, searched the room, checked laundry, and reviewed security footage, but the investigation did not document the date of key interviews, what questions were asked, whether laundry staff were interviewed, or whether the allegation was substantiated or unsubstantiated. The investigation also did not document how the resident and his money were kept safe beyond notifying police, and it did not include nursing staff even though the police report and resident interview indicated a female nurse took money from the resident’s wallet during toileting care.

Penalty

Inspection fine: $50,400

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 activity programs that met the interests and supported the physical, mental, and psychological well-being of one resident reviewed for activities. The resident was admitted with diagnoses including schizoaffective disorder, bipolar type, muscle weakness, and muscle wasting and atrophy, and her MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15. Her preferred language was Russian, and the assessment documented that it was very important for her to keep up with the news, listen to music she liked, participate in favorite activities, go outside for fresh air, and take part in religious services or practices. The resident told the surveyor, through a Russian translator, that she did not participate in most activities because she could not understand them and that she had no one-on-one activities planned. She said she loved music, enjoyed playing the piano, and would like weekly scheduled piano sessions as part of her activity program. She also stated that the facility’s daily chronicle and activity schedule were printed in English. During observations, she was found lying in bed with no television or music in her room, no activity calendar posted in her room, and no individualized activity supplies present. Surveyors observed that she was not invited to a country cart activity or a fitness activity while those programs were occurring in the activity room. Record review showed her communication care plan addressed her Russian language barrier and called for translation services and activities that accommodated her communication abilities, and her activities care plan called for a monthly activity calendar in her room and staff check-ins with additional activity supplies as needed. However, the calendar was not posted in her room, there was no one-on-one activity program scheduled, and the activity director stated that all activities were offered in English and that the resident’s interest in playing the facility piano had not been incorporated into her activities.

Penalty

Inspection fine: $50,400

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 Resident #25 received treatment and care in accordance with orders and the comprehensive care plan. Resident #25 was admitted with multiple diagnoses including frontotemporal neurocognitive disorder, multiple myeloma, bilateral knee osteoarthritis, type 2 diabetes, epilepsy, chronic kidney disease, atherosclerotic heart disease, encephalitis, Pick's disease, stiffness of unspecified joint, reduced mobility, muscle weakness, and difficulty walking. The resident's mental status was significantly impaired, and he was rarely or never understood. The skin integrity care plan identified an abrasion to the right side of the back and included interventions such as treatment as ordered, education, padding of wheelchair arms, and providing a pillow to the right side of the high-back wheelchair as tolerated. On 1/31/26, staff identified an open area to the right side of the resident's back measuring 8 cm by 1.5 cm, described as linear with a pink, moist wound bed and dark brown discoloration around the area. The wound was cleansed and dressed, and the physician was notified. A wound care physician later documented the wound as an abrasion to the right flank with epithelial tissue and discoloration of the periwound. However, the hydrocolloid treatment order from the wound tracker form was not entered into the resident's EMR until 2/11/26, even though the wound care physician said the order had been made on 2/4/26 and should have been communicated to floor staff and entered as a physician order. The facility also failed to consistently follow the positioning intervention intended to prevent further skin injury. Observations on 2/10/26 and 2/11/26 showed the resident sitting in a wheelchair without a pillow on the armrest or behind his back, despite the care plan calling for a pillow to the right side of the wheelchair for positioning. Staff interviews showed that some nurses and CNAs knew the resident had a back abrasion and that a pillow was an intervention, but one CNA stated no one had educated her on the interventions in place. The wound care physician stated that if the resident was in his wheelchair for three hours without a pillow on his right side, the facility was not following the ordered interventions.

Penalty

Inspection fine: $50,400

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

Summary

The facility failed to ensure proper treatment and assistive devices were provided to maintain hearing abilities for one resident with hearing impairment. Resident #13, who had diagnoses including COPD, unspecified dementia, bipolar disorder, anxiety disorder, and cognitive communication deficit, reported that her hearing aid had been broken for over a year and that she relied on staff and visitors writing notes to communicate. During observations, she had no hearing aid in either ear and used a notepad and pen to communicate, including when a CNA wrote to her and she responded verbally. The resident and her representative both stated that the hearing aid had been broken for some time and that the facility had made no effort to repair or replace it. Staff interviews confirmed that the resident had difficulty hearing without her hearing aids and often needed written communication. Record review found no documentation in the EMR showing the facility was attempting to assist her with obtaining new hearing aids, and the social services director stated he could not find recent audiology documentation for the resident.

Penalty

Inspection fine: $50,400

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 medications and biologicals were stored and labeled according to accepted professional principles in two medication carts and one medication refrigerator. On one secured unit, a medication cart contained morphine 20 mg/ml that had expired on 1/15/26. On Castle Rock unit, the medication room refrigerator was observed unlocked while it contained resident medications, including a locked narcotic box. The locked narcotic drawer on the medication cart also contained oxycodone HCl oral solution 5 mg/5 ml that had been discontinued on 11/18/25. During interviews, CNA-Med #2 stated the expired morphine should have been discarded and should not have been administered, and said nurses and CNA-Meds were responsible for removing expired medications from carts. LPN #1 stated the discontinued oxycodone should have been removed from the cart and that the medication refrigerator should be locked because it contained narcotic and non-narcotic resident medications. The consultant pharmacist stated the refrigerator on each unit should have a locked door, while RN #3 stated she checked the pharmacy label for expiration dates before administering medications. The ADON stated staff administering medications were expected to review the expiration date on the medication bottle and discard medication accordingly.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with a feeding tube did not receive tube feeding administration as ordered by the physician. Upon admission from the hospital, the resident had diagnoses including pneumonia, muscle weakness, acute respiratory failure, dysphagia, protein calorie malnutrition, and cerebral infarction. The resident was assessed as having mild cognitive impairment and required assistance with daily activities. The care plan specified the need for tube feedings due to swallowing difficulties, with interventions including elevating the head of the bed, providing tube feeding and water flushes per physician orders, and monitoring nutritional intake. Despite these documented needs, the physician's orders for enteral feeding were not entered into the resident's computerized physician orders (CPO) until five days after admission. The hospital discharge summary included specific instructions for continuous enteral feeding and water flushes, but there was no documentation in the electronic medical record (EMR) indicating that these orders were followed from the time of admission until they were entered into the CPO. As a result, the resident did not receive the prescribed tube feeding during this period. Interviews with facility staff confirmed that the admitting nurse did not transcribe or verify the hospital discharge orders with the facility physician upon admission. The registered dietitian and regional clinical resource both stated that it was the responsibility of the admitting nurse to ensure all physician orders, including those for tube feeding, were entered and initiated. The failure to do so resulted in the resident missing necessary nutritional support as ordered by the physician.

Penalty

Inspection fine: $46,270

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 a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically in the case of a resident with a high risk for elopement. The resident, who had a history of impulsive behaviors, cognitive impairment, and multiple medical conditions including bipolar disorder, chronic heart failure, and a traumatic brain injury, was admitted to the secured unit after being assessed as high risk for elopement. Despite the resident's repeated exit-seeking behaviors, verbalizations of wanting to leave, and documented behavioral episodes such as refusing care, throwing food, and expressing distress, the facility did not implement or follow individualized interventions for supervision and monitoring as outlined in the care plan. On the day of the incident, the resident exhibited escalating agitation, refused his meal, and attempted to contact family without success. Staff failed to provide increased oversight or frequent checks during this period, and the resident was left unmonitored for approximately four hours before being discovered missing. The facility's investigation revealed that the resident eloped by overriding the window safety mechanism and climbing over a gate in the secured courtyard. The absence of consistent monitoring and failure to respond to the resident's behavioral cues resulted in the resident being missing for approximately 46 hours before being located at a homeless shelter. Documentation and staff interviews confirmed that the care plan lacked specific interventions to address the risk of elopement and that staff did not consistently implement the existing interventions. The facility's records also showed a pattern of the resident expressing a desire to leave, refusing medications, and exhibiting aggressive or impulsive behaviors, yet these were not met with appropriate or timely interventions to ensure his safety. Additionally, the facility did not have an effective evacuation plan in place. Observations showed that evacuation routes were not clearly posted, and the primary emergency egress for the secured unit was padlocked, with staff unaware of the key's location. Staff interviews indicated a lack of training and understanding of evacuation procedures, and the physical barrier of the padlocked gate prevented accessible egress in an emergency. These failures created a hazardous environment for all residents, as staff were not prepared to safely evacuate residents in the event of an emergency, and the environment was not adequately maintained to prevent accidents or ensure resident safety.

Removal Plan

• The padlock and the latch on the outdoor fenced storage areas were removed by the NHA.
• The facility map of the egress routes were posted by the life safety/maintenance resource for all halls.
• The facility was toured by the life safety resource to identify and ensure all egress exits were unlocked and accessible.
• All residents were reviewed by the director of nursing (DON) and clinical resource for elopement risk and care plans were updated as needed.
• Education with the NHA and the IDT (interdisciplinary team) initiated by clinical resource on keeping facility egress routes unlocked and accessible.
• All staff education initiated by DON/designee on specific evacuation routes, keeping egress exit for emergency exits for the secured unit unlocked and accessible, the codes for the exit doors and the facility evacuation map postings.
• Education on the emergency operations procedure quick reference guide initiated which showed initial employee expectations and responsibilities.
• Window security devices will continue to be monitored until window alarms are in place.
• Window alarm installation to be initiated for the secured unit.
• All staff were to be educated on evacuation procedures during orientation.
• Staff education initiated by the DON/designee on the need for safety checks and monitoring during a behavioral episode to prevent further occurrences and where to locate resident elopement care plans.
• Staff were educated that although residents may request to be left alone or to have their door closed, it does not eliminate the facility's obligation to ensure the safety of the resident; staff needs to verify that the resident was safe and present.
• Increased monitoring will be completed on a case by case basis dependent upon situation and if warranted the resident will be placed on 15-minute checks.
• Behavioral episodes could include verbal outbursts, physical aggression, increased exit-seeking behaviors, tearfulness, statements about leaving/going home and pacing.
• The facility will be completing a headcount on the secured unit every two hours by floor nurse, nursing management, or designee.
• Headcount to be completed on paper audit form for a minimum of 12 weeks or until substantial compliance has been achieved.
• The DON, or designee, will complete random audits three times per week for 12 consecutive weeks.
• The audit will include: Staff interview: Does staff member know evacuation route? Observation: All egress routes are unlocked and available in case of emergency? Staff interview: Does staff know to provide safety checks and increased monitoring during a resident behavioral episode? Increased monitoring will be completed on a case by case basis dependent upon situation and if warranted the resident will be placed on 15-minute checks. Behavioral episodes can include verbal outbursts, physical aggression, increased exit-seeking behaviors, tearfulness, statements about leaving/going home and pacing. Staff interview: Does staff know how to access the resident's elopement care plan? Staff interview: Does staff know the codes to the exit doors? Additional comments and/or interventions if issues noted on audit form.
• Audit records will be reviewed by the risk management/quality assurance committee monthly until such time consistent substantial compliance has been achieved as determined by the committee.

Penalty

Inspection fine: $46,270

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 an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to accident and hazard prevention. The QAPI committee did not identify or address issues involving resident elopement and emergency preparedness, including the lack of supervision necessary to prevent a resident from leaving the facility unsupervised and the absence of a system to ensure staff followed emergency evacuation procedures. These deficiencies resulted in situations that rose to the level of immediate jeopardy, where a serious adverse outcome was likely. Record review revealed that the facility had a history of similar deficiencies, with previous citations for failure to prevent accidents and hazards, including falls and elopement. Despite having a QAPI policy and procedure in place, the committee did not recognize or prioritize these high-risk areas for process improvement. The facility's QAPI meetings focused on standard issues such as falls, infections, and hospitalizations, but did not address elopement or emergency egress concerns until after they were identified by surveyors. Interviews with facility leadership, including the medical director, NHA, and DON, confirmed that the QAPI committee met regularly and included required members, but had not previously identified elopement or emergency preparedness as areas needing attention. The medical director had not provided recent education to staff or reviewed policies related to these issues. The lack of systematic identification and prioritization of these high-risk concerns contributed to the facility's failure to prevent immediate jeopardy situations related to resident safety.

Penalty

Inspection fine: $17,345

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

Summary

A deficiency occurred when a wheelchair-bound resident, who was dependent on staff for mobility and positioning due to bilateral below-the-knee amputations and other significant medical conditions, was not properly secured during transportation in the facility's van. The van driver failed to anchor the resident's wheelchair and did not apply the necessary restraints. As a result, when the van accelerated, the wheelchair tipped backward, causing the resident to fall onto the floor with the wheelchair landing on top of her. The incident resulted in the resident sustaining multiple serious injuries, including fractures of the cervical and thoracic vertebrae, multiple rib fractures, an epidural hemorrhage, and significant pain, requiring hospitalization in the ICU. Interviews and record reviews confirmed that the resident reported not feeling properly secured in the van and recounted that the driver had previously driven erratically. Another resident also reported that the same van driver had not anchored her wheelchair or applied seatbelts during transportation. Staff interviews revealed that proper procedures for securing wheelchairs included anchoring at four points and using both a lap seatbelt and a shoulder strap, but these procedures were not followed by the van driver involved in the incident. The facility's investigation noted that the van and its equipment were inspected and found to be functioning properly, indicating that the failure was due to staff action rather than equipment malfunction. The van driver was unable to confirm whether the wheelchair had been anchored prior to departure, and the facility was unable to determine how the incident occurred if the wheelchair had been properly secured. The resident required a rigid cervical collar and additional support following the incident, and her care plan was updated to reflect her new needs.

Penalty

Inspection fine: $8,338

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 a high fall risk, remained free from accidents. The resident sustained a fall on September 6, 2024, which resulted in a hip fracture that went unidentified until September 12, 2024. The fall was not reported by the staff present at the time, leading to a delay in the identification and treatment of the injury. The resident, who had severe impairment for daily decision-making and required supervision for safety with transfers, was found to have fallen in the doorway of her room. Despite the presence of a CNA and an LPN, the fall was not reported, and the resident was moved without a proper assessment for injuries. The resident exhibited signs of a change in condition, including lethargy, weakness, and bruising, which were documented in the days following the fall but were not immediately linked to the fall incident. The facility's failure to report and assess the fall resulted in the resident not receiving timely medical attention for her hip fracture. The resident's condition deteriorated over several days, with increased bruising and swelling observed, leading to the eventual discovery of the fracture through an x-ray. The lack of immediate reporting and assessment by the staff present at the time of the fall contributed to the delay in treatment and the resident's prolonged discomfort.

Removal Plan

• A thorough investigation of the incident was conducted.
• The facility reviewed the camera footage which revealed Resident #1 sustained a fall.
• CNA #3 and LPN #2 were identified in the video and interviewed.
• LPN #2 denied knowing anything about Resident #1's fall and was terminated.
• CNA #3 verified Resident #1 sustained a fall.
• All of the nursing staff were educated by the assistant director of nursing related to the facility fall policy, reporting a fall and documenting a fall.
• The facility continued to hold Quality Assurance and Performance Improvement (QAPI) meetings to address concerns.
• The facility reviewed their current fall policy to ensure appropriate procedures were in place to prevent falls/potential harm and reporting a fall.
• All staff were re-educated on the fall policy and procedure.
• All staff that were present at the time of the investigation were provided further education.
• The DON would ensure all newly hired staff would receive education on the fall policy.
• The education given included identifying neglect, reporting a fall, RN assessment for injuries, neurological checks if there was a head injury or the fall was unwitnessed, and documenting the fall.
• The facility would review falls and discuss them in the monthly Quality Assurance and Performance Improvement (QAPI) meeting for three months.