Page Rehabilitation And Healthcare Center

Penalty

No penalty information released

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

Summary

The facility failed to provide restorative nursing services as specified in the care plan for a resident, resulting in a fracture. The resident, who had diagnoses including necrotizing fasciitis, osteoarthritis, a previous displaced fracture of the right tibia, and bilateral foot drop, required substantial to maximal assistance for bed mobility and transfers. The care plan and therapy recommendations specified that the resident should perform active range of motion (AROM) exercises independently, with encouragement to spend less time in bed, and did not recommend passive range of motion (PROM) to be performed by restorative aides. On the day of the incident, a restorative CNA was providing range of motion exercises to the resident's lower extremities. During the session, the aide assisted the resident by lifting her right leg and bending her knee, which was not in accordance with the AROM-only recommendation. Both the resident and the aide heard a popping sound, and the resident immediately experienced severe pain. The incident was reported, and initial x-rays were negative, but subsequent evaluation by an orthopedic specialist revealed a closed fracture of the lateral tibial plateau. Interviews with facility staff, including the Director of Rehabilitation and a physical therapist, confirmed that only AROM was recommended and that restorative aides were not trained or authorized to perform PROM. The physical therapist indicated that the aide should not have had hands-on involvement during AROM, and the Director of Rehabilitation acknowledged that PROM could result in fractures, especially in residents with conditions such as osteoporosis or decreased strength. The deviation from the care plan and improper technique during restorative care directly led to the resident's injury.

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 follow proper sanitation and food handling practices to prepare, distribute, and serve food in a safe and sanitary manner. During an initial kitchen tour with the Food Service Manager, the surveyor observed a delivery person bringing milk into the kitchen without head or facial hair covered, and the Food Service Manager stated the beard should have been covered. The Food Service Manager also stated he did not wear a beard covering because it was itchy. The Administrator later stated that no one should be in the kitchen without hair being covered, whether preparing food or not, consistent with the facility policy requiring staff to have hair off the shoulders and facial hair properly restrained. The kitchen and food service areas were observed to be dirty and poorly maintained. The walk-in refrigerator door, floor area, and door jamb had dirt, buildup, and black bio growth. The juice machine area had a damaged and dirty wall and black bio growth on the floor. The ceiling and air vents over the drink area, food prep area, and steam table had dust and black bio growth. Appliances, stainless steel tables, the steam table, walls, and floors had food, grease, and grime buildup. A dirty cooler was stored under a coffee maker, and a large dead insect was observed on the floor in the dry storage room. The Food Service Manager stated maintenance was responsible for cleaning the ceiling tiles and vents, and the Maintenance Director stated his department tried to clean them quarterly, with the last work order for cleaning ceiling vents above the juice machine dated June 19, 2025.

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 homelike and sanitary environment by not properly storing residents’ personal care items in shared spaces and by leaving several rooms and bathrooms in unsanitary condition. During initial rounds, a resident had a nebulizer and mask left uncovered on the bedside table next to personal care items, and in the bathroom there was a wash basin and a urinal on the handrail without a name and uncovered, with another uncovered wash basin on the opposite handrail. Another resident had a BiPAP machine with the mask hanging from the dresser and not bagged. An LPN confirmed that the items should have been bagged. Additional observations showed a resident’s bathroom with large drops of blood on the floor, and on the secured memory care unit another resident’s bathroom had a strong foul urine odor, a toilet seat stained with large black and brown stains, flying bugs in the room, two toothbrushes uncovered on top of a paper towel holder, and a soiled wash basin on the floor. Later observations found the BiPAP mask still uncovered and hanging from the dresser, and another resident’s bed had crumbs at the bottom of the sheets, a wet fitted sheet from the center to the foot of the bed, and sheets and pillowcase soiled with blood stains. The DON stated that nebulizer and BiPAP/CPAP masks should be stored in a plastic bag when not in use, and the Administrator stated that personal care items such as wash basins and urinals should be labeled with a resident name and placed in a plastic bag.

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 a resident received treatment and care in accordance with physician orders and the plan of care for post-surgical left heel care. Resident #60 was admitted with osteomyelitis of a chronic non-pressure wound to the left heel with a grafted surgical incision, and orders were in place for an air mattress, heel boots, pressure reduction cushion at all times, and to float both heels above the bed surface using pillows and wedges when in bed, with bilateral heel boots at all times. During observation, the resident was seen in bed with heel boots on at one point, but no pillows or wedges were used to elevate the legs. On another observation, the resident was in bed with no heel boots on, no leg elevation, and the bandaged grafted heel resting directly on the mattress. The resident stated staff did not always put the boots on, especially during shift change, and later said he was unsure whether they had been on overnight. The TAR had already been signed by an RN indicating the heels were floated and the bilateral heel boots were on for the shift, yet the resident was again observed without the boots and with the heel on the mattress. The DON acknowledged the boots were supposed to be on at all times and placed them on the resident after the observation.

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 follow physician orders for positioning devices for two residents with limited ROM and mobility. Resident #116, admitted with vascular dementia, muscle wasting and atrophy, and schizoaffective disorder, had an active order for a knee orthosis to address right knee flexion contracture, improve ROM, reduce skin breakdown, and support functional transfers. Survey observations on multiple occasions showed the resident seated in a high-back wheelchair without any brace or orthotic on the right knee. When the Memory Care Unit Manager was asked to demonstrate the device, he stated the resident did not have one and did not have an order, then later confirmed the order existed but said he had never seen her with the device and could not explain who was responsible for verifying and updating physician orders. Resident #39, admitted with cerebral infarction, syncope with collapse, vascular dementia, and right-sided hemiplegia, had a care plan intervention for a right upper extremity resting hand splint and a physician order for the splint to be worn nightly and removed before breakfast with daily skin checks. Review of the treatment record showed no documentation for the splint, and a PT evaluation noted the resident reported having a splint but staff did not assist with donning it. An RN confirmed the active order existed but said the order entry did not include a schedule in the electronic record, so it did not appear on the TAR, and stated the resident was not having the splint applied and could not say when it was last used.

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

Medication storage was not maintained safely and securely for one resident who was reviewed for medication management. The facility policy stated that medications and biologicals are to be stored safely, securely, and properly, and that the medication supply is accessible only to nursing personnel, pharmacy personnel, or other staff lawfully authorized to administer medications. The resident involved was an alert and oriented male admitted on 6/22/25 with diagnoses including acute and chronic respiratory failure, COPD, and morbid obesity. During observation on 9/8/2025, the resident had a bottle of horse chestnut supplement, cortisone cream, Afrin nasal spray, and Refresh eye drops on the bedside table in his room. The resident stated that family and friends brought the items in and that he used them when needed. A unit manager later confirmed the medications were at bedside, stated she had written orders for them to be at bedside except for the horse chestnut supplement, and said the resident could have the medications but they should be in a locked box; however, the facility did not have any locked boxes, so she told him to keep them in his top drawer. The resident later stated the medications had been taken and said he did not have the locked box and had been instructed by the nurse to keep the medications in the dresser drawer.

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 individualized interventions and provide adequate supervision to prevent avoidable falls for a resident with multiple risk factors, including cerebral infarction, muscle wasting, impaired mobility, and cognitive deficits. The resident experienced four falls over a short period, each time attempting to go to the bathroom independently. Despite being identified as at risk for falls and having care plans that included interventions such as keeping the call light within reach, encouraging use of the call light, providing lateral fall pads, and ensuring a safe environment, documentation showed inconsistent implementation of these interventions. There was also conflicting information regarding the resident's continence status and the frequency of toileting assistance provided. The facility's records lacked evidence that staff consistently provided timely incontinent care or regular toileting, particularly in the hours leading up to the falls. After each fall, care plans were updated with additional interventions, such as posting signs to remind the resident to call for help, using nonskid footwear, and checking the resident every 15 minutes post-fall. However, there was no documentation that these interventions were reliably implemented. Staff interviews confirmed gaps in documentation and uncertainty about whether new interventions were carried out as planned.

Plan Of Correction

Corrective action will be accomplished for those residents found to have been affected by the deficient ice. Resident #2 no longer resides at the facility. You will identify other residents having the potential to be affected by the same deficient practice. What corrective action will be taken? A resident in the facility will be re-evaluated for bowel and bladder function by August 1st, 2025, by the facility nurse management. Based on the evaluation, the resident will be placed on the proper bowel and bladder program (toileting, check and change routinely, etc.) to ensure that bowel/bladder needs are being met appropriately. The program will then be triggered in point of care for the CNA's to document on every 2 hours or as directed. Facility nurse management will review each bladder evaluation upon admission, quarterly, and during significant changes to ensure that the evaluation is completed appropriately and that the bowel/bladder program is appropriate and meets the needs of the resident. Facility IDT will review each resident with a fall for the past 3 months, ongoing, and complete an analysis as needed. The analysis will include a root cause analysis to determine the underlying factors contributing to the falls. The facility will implement a plan of action based on the root cause analysis, including interventions to prevent future falls. The nurse management will monitor the effectiveness of these interventions over the next 30 days and then weekly for 90 days. Each resident with a fall will be reviewed in the morning clinical meeting daily and in the weekly risk management meeting as part of the facility policy. The facility will also review the documentation related to the fall, including the lack of timely toileting (6 hours before the fall), and ensure that appropriate prevention interventions are in place. An interview was held with Resident #2 regarding multiple falls. Riding toileting to prevent falls should have been implemented, and the resident should have been toileted more frequently before bed, with routine checks and documentation of the 15-minute checks to ensure fall prevention. The root cause analysis was completed, and the facility will implement appropriate corrective actions based on the findings. The DON/RN will oversee the implementation of these actions and ensure ongoing monitoring. The nursing staff will be re-educated on conducting risk assessments and completing timely documentation by August 1st, 2025. They will also be trained on the importance of timely toileting and fall prevention strategies. The Director of Nursing (DON) and Regional Director of Nursing will evaluate the effectiveness of the interventions, conduct audits, and implement continuous quality improvement measures. The results of these evaluations will be reviewed by the facility administrator, and recommendations will be made for ongoing practice improvements. The Nurse V shift will monitor the implementation of the fall prevention program, and the results will be reviewed during the weekly clinical meetings. The facility will ensure that all staff are aware of and adhere to the updated policies and procedures related to fall prevention and resident safety.

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 individualized interventions and adequate supervision to prevent avoidable falls for a resident with multiple risk factors. The resident had a history of cerebral infarction, muscle wasting and atrophy, difficulty walking, lack of coordination, aphasia, and impaired vision. The resident was always incontinent of bladder and bowel, required assistance of two staff for transfers and ambulation, and was identified as being at risk for falls due to impaired cognition, medication use, poor safety awareness, cardiac disease, and decreased mobility. The care plan included interventions such as anticipating needs, ensuring the call light was within reach, and using fall pads, but these interventions were not consistently or effectively implemented. The resident experienced multiple falls over a short period. Each fall investigation revealed that the resident was attempting to ambulate to the bathroom independently, despite being care planned for assistance. Documentation showed inconsistent and infrequent toileting, with significant gaps between toileting times, sometimes up to 11 hours. The fall investigations did not address the lack of timely toileting or incontinent care prior to the falls. Additionally, there were inconsistencies in the bowel and bladder assessment, with conflicting information about the resident's continence status. After each fall, the care plan was updated with new interventions, such as posting signs, ensuring nonskid footwear, and implementing 15-minute checks post-fall. However, there was no documentation that these interventions, particularly the 15-minute checks, were actually implemented. The Director of Nursing was unable to provide evidence that the required checks were performed. The lack of consistent implementation and documentation of individualized interventions contributed to the resident's repeated falls.

Plan Of Correction

What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #2 no longer resides at a facility. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Each resident in the facility will be re-evaluated for bowel and bladder function by August 1st, 2025, by the facility nurse management. Based on the evaluation, the resident will be placed on the proper bowel/bladder program (toileting, check and change routinely, etc.) to ensure that bowel and bladder needs are being met appropriately. The program will then be triggered in the point of care for the CNA to document on every 2 hours or as directed. The facility nurse management will review each bowel/bladder evaluation upon admission, quarterly, and with significant change to ensure that the evaluation is completed appropriately and that the bowel/bladder program is appropriate and meets the needs of the resident. The facility IDT will review each resident with a fall for the past 30 days by August 1st, 2025, and each fall going forward to ensure that root cause analysis was completed and that toileting needs are being met where needed. Interventions will be implemented according to findings upon review. The facility management will also review each fall for the past 30 days by August 1st, 2025, and each fall going forward to ensure that safety checks were complete as care planned and forms are present with the root cause analysis audit. What measures will be put into place or what systematic changes will be made to ensure that the deficient practice does not recur? The nurse management team will be re-educated by the Regional Director on completing bowel/bladder evaluations, conducting root cause analysis for falls, and implementing appropriate interventions based on the root cause analysis (toileting, 15-minute checks, etc.) along with the fall prevention policy and procedure on July 24th, 2025. The nursing staff (nurses and CNAs) will be re-educated by the Staff Educator/Designee by August 1st, 2025, on completing bowel/bladder evaluations, conducting root cause analysis for falls, implementing and completing appropriate interventions (toileting, 15-minute checks), and the fall prevention policy and procedure. This re-education will include documentation of the toileting program in the point of care for the CNAs. The DON/Risk Manager will complete an audit of each resident who has a fall to ensure that the root cause analysis was completed, interventions were placed according to the root cause analysis, safety check sheets are completed as ordered, and any testing needs are being met as care planned based on bowel and bladder programs. The Nurse Management team will complete an audit each shift to monitor the documentation and the toileting programs for individual residents. How will the corrective action be monitored to ensure the deficient practice will not recur? The results of the audits will be forwarded to the Administrator and the Director of Nursing for review. The audit will then be forwarded to the monthly Quality Assurance Meeting for further review and recommendations. The audits will continue daily for 30 days and then weekly for 90 days. Each resident with a fall will be reviewed at the morning clinical meeting daily and continue to be reviewed in the weekly at-risk meeting indefinitely as part of the facility policy and procedure. Date of Compliance: August 1st, 2025

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 protect a resident's right to be free from abuse and neglect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The incident occurred when the CNA was attempting to provide care to the resident, who was in a wheelchair. During this interaction, the resident became agitated, pushed against the CNA, and bit her. A Social Worker Assistant witnessed the CNA hitting the resident in response to being bitten. The Social Worker Assistant intervened, took the resident away, and reported the incident to the facility's Administrator. The resident involved in the incident had been admitted to the facility with diagnoses including major cognitive impairment and was residing in a secured unit for individuals with memory care needs. The resident's cognitive abilities were severely impaired, as indicated by a low score on the Minimum Data Set (MDS) assessment. Following the incident, the resident was unable to recall the event due to her advanced cognitive impairment but did report having pain in the area where she was allegedly hit. The facility's investigation into the incident included reviewing witness statements and interviewing staff. The CNA involved denied hitting the resident, claiming the Social Worker Assistant was lying. However, the facility's investigation concluded that the allegation of abuse was verified. The CNA was immediately suspended, and the incident was reported to law enforcement and Adult Protective Services. The resident's daughter, who is also her Health Care Surrogate, was informed of the incident and provided background on her mother's condition and care needs.

Plan Of Correction

This plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The CNA was suspended on. The CNA was terminated on. The CNA was reported to the Nurse Aide Registry on. The resident was evaluated by the Psych APRN and The Care ARPN on. New orders were received for 50mg every 6 hours as needed for or. 2. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; All residents residing in the Burroughs unit had the potential to be affected. The CNA involved worked full time on that unit only. Skin evaluations were completed on every resident on the Burroughs unit on. There were no abnormal findings indicating any type of or neglect. The CNA was suspended on and terminated on. All staff were re-educated on the policy and procedure, customer service and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. Knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. All staff were re-educated on the policy and procedure, customer service and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. Knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. Daily knowledge checks and audits will assess staff adherence to the education provided starting on. These will.

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 Certified Nursing Assistant (CNA) was reported to have hit a resident during an incident that occurred in the doorway of the resident's room. The Social Worker Assistant witnessed the CNA hitting the resident and immediately intervened, taking the resident away and escorting the CNA to the Administrator's office. The CNA claimed that the resident had been cursing and bit her, but denied hitting the resident. The Social Worker Assistant documented the incident, stating that she saw the CNA hit the resident and heard the resident exclaim that they had been hit with something hard. No other staff witnessed the incident, and the facility's investigation verified the allegation against the CNA. The resident involved in the incident was described as mostly pleasant but sometimes combative during care. The resident's daughter, who is also her Health Care Surrogate, mentioned that her mother had been diagnosed with a condition approximately 12 years ago and had sustained injuries that led to her admission to the facility for rehabilitation. The resident was later transferred to the memory care unit for increased supervision. Following the incident, the resident began experiencing distress, prompting the Unit Manager to contact the Advanced Practice Registered Nurse (APRN) on call.

Plan Of Correction

The CNA was suspended on and terminated on. All staff were re-educated on the policy and procedure, customer service, and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. Knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON, and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule, and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. All staff were re-educated on the policy and procedure, customer service, and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. The training will be provided every Tuesday as knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON, and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule, and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. Daily knowledge checks and audits will assess staff adherence to the education provided starting on. These will be completed by the IDT team on an ongoing random basis on all shifts. Social Services is completing daily random audits with residents and/or family members regarding and neglect.

Penalty

Inspection fine: $179,790

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 a resident from neglect, resulting in the resident's elopement and subsequent death. The resident, diagnosed with dementia and psychosis, exhibited paranoid behaviors and expressed a desire to leave the facility. Despite these changes in behavior, the facility did not re-evaluate the resident's elopement risk or update the care plan to ensure adequate supervision and safety measures were in place. On multiple occasions, the resident expressed fears of being under attack and requested evacuation, which was reported to the facility by the resident's son and law enforcement. However, the facility did not take appropriate action to address these concerns. Staff observed the resident outside the building but failed to intervene or notify others. Eventually, the resident was found deceased in a parking lot half a mile from the facility. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's change in mental status and the need for increased supervision. The facility's investigation concluded that there was no neglect, despite evidence of the resident's expressed intent to leave and the failure to implement necessary safety measures. The Director of Nursing acknowledged that the resident's risk for elopement was not re-evaluated, and the care plan was not updated to prevent unsafe wandering and elopement.

Penalty

Inspection fine: $179,790

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 recognize and adequately supervise a cognitively impaired resident, leading to a tragic outcome. The resident, who had a history of dementia, bipolar disorder, and other psychiatric conditions, exhibited new symptoms of paranoia and expressed a desire to leave the facility. Despite these clear signs of distress and intent to elope, the facility did not reassess the resident's risk for elopement or update the care plan to ensure adequate supervision. On multiple occasions, the resident communicated his fears and intent to leave, including calling his son and law enforcement, claiming he was under attack and needed evacuation. The facility was notified of these incidents, yet failed to take appropriate action to prevent the resident from leaving unsupervised. Staff members, including the DON and other nursing staff, did not communicate the resident's change in condition or the need for increased supervision, resulting in a lack of coordinated response to the resident's acute behavioral changes. Ultimately, the resident was able to exit the facility without intervention from staff, despite being seen outside by multiple employees. The lack of a clear policy on resident supervision outdoors and the failure to recognize the resident's elopement risk contributed to the resident's ability to leave the premises. Tragically, the resident was later found deceased, highlighting the severe consequences of the facility's failure to provide adequate supervision and intervention for a vulnerable resident.

Penalty

Inspection fine: $179,790

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 an elopement incident involving Resident #999, who was one of three residents reviewed for elopement. The resident, diagnosed with Bipolar disorder and paranoia, expressed to his son and law enforcement his intent to leave the facility, believing he was under attack. Despite these warnings, the facility did not reassess the resident's elopement risk or update his care plan with nonpharmacological interventions to ensure his safety. On the day of the incident, the resident was reported missing, and later found deceased in a parking lot half a mile from the facility. The facility's investigation into the incident was inadequate, as it did not address the failure to reassess the resident's risk for elopement following the onset of paranoid behavior. The facility's systemic corrective actions were insufficient, lacking documentation of behaviors and appropriate actions to ensure resident safety with the onset of new behaviors that could lead to elopement. The facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify and address these deficiencies, creating a likelihood of unsafe wandering and elopement among cognitively impaired residents. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not recognize the resident as an elopement risk, despite alerts from the resident's son and law enforcement. The DON admitted that the resident's risk for elopement was not re-evaluated, and the care plan was not updated. The facility's failure to implement effective corrective actions and adequately supervise the resident contributed to the incident, resulting in a determination of isolated ongoing Immediate Jeopardy.

Penalty

Inspection fine: $179,790

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

Summary

The facility failed to maintain a safe, clean, and comfortable environment for residents across all observed units. During an initial tour, several deficiencies were noted, including improperly stored bedpans and urinals on the floor of shared bathrooms, holes and missing tiles in walls, rusted and dirty faucets, and unlabeled personal items scattered in shared spaces. Additionally, food crumbs, garbage, and rust-covered furniture were observed in resident rooms, along with dead insects and dirt accumulation in various areas, including the memory care dining room and the secured unit's refrigerator. Further observations revealed issues with the facility's equipment and storage practices. The ice machine in the memory care unit kitchen area was covered in a white film and rust, with a water collection tray and waterspout showing signs of neglect. Expired milk was found in the refrigerator, and the bottom of the freezer contained a dried yellow substance. The Director of Nursing acknowledged the lack of a policy for storing personal items, although staff had been recently educated on proper storage practices. These findings indicate a widespread failure to ensure a sanitary and homelike environment for residents.

Penalty

Inspection fine: $179,790

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 were stored securely and administered properly, as observed during a survey. In one instance, a resident had a potassium pill left in a clear plastic medication cup on her bedside table, which she was waiting for someone to break in half. The resident did not have an order to self-administer medications, and the Unit Manager RN confirmed that the pill should not have been left with the resident. In another instance, an Albuterol Sulfate inhaler was found unattended on a bedside table while the resident was not in the room. The resident had not been assessed to self-administer the medication and had no physician order to do so. Additionally, a round orange pill was found on the floor outside a room, and a large white pill was observed on the floor of the Ford unit near the sitting room entrance. Despite being informed of the pill on the floor, a housekeeper did not attempt to remove it, and the Unit Manager RN had to be notified to remove it. These observations indicate a failure to adhere to the facility's medication administration policy, which requires medications to be administered safely and not left unattended or improperly stored.

Penalty

Inspection fine: $179,790

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

Summary

The facility failed to maintain an effective pest control program, resulting in a sanitary environment compromised by pests across all observed units. During an initial facility tour, live crawling insects were found in cups within the secured memory care unit, and dead insects were observed in various locations, including resident rooms and common areas. Photographic evidence was obtained to document these findings. Residents reported frequent sightings of large crawling insects, often referred to as 'waterbugs,' in their rooms and common areas, with some residents noting that insects had even contaminated their food and personal spaces. The facility's pest control policy, revised in November 2019, assigns the Maintenance Department the responsibility of coordinating pest control with an external company. Despite monthly visits from the pest control company and the application of insecticide around the building's foundation, the facility's pest sighting logs from July to December 2024 documented ongoing pest issues. Interviews with residents and staff revealed that while some residents reported pest sightings to staff, others did not, assuming staff were already aware. The Maintenance Director confirmed the presence of pest logbooks at nursing stations and stated that the pest control company reviews these logs during their visits. However, there was no proactive inspection by maintenance staff to identify pest issues within the facility.