Exira Care 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 enough nursing staff every day to meet resident needs and failed to have a licensed nurse in charge on each shift. Survey findings showed repeated delays in answering call lights for four residents. Resident #1, who had severely impaired cognition, dementia, anxiety, hospice status, and required assistance with most ADLs, had 34 call light requests answered more than 15 minutes after initiation, including 11 over 20 minutes and 6 over 30 minutes. The resident’s relative stated the call light had been on for 23-24 minutes before staff responded. Resident #2, who had intact cognition and diagnoses including cancer, heart failure, and a left leg fracture, had 23 call light requests answered more than 15 minutes after initiation, with 12 over 20 minutes and 3 over 30 minutes. The resident’s relative stated staff frequently came, turned the call lights off, left, and did not return. Resident #5, who had intact cognition and diagnoses including hypertension, diabetes, seizure disorder, and asthma, had 7 call light requests answered more than 15 minutes after initiation, including 3 over 20 minutes and 1 at 30 minutes. The resident stated staff did not always come when he pulled the call light. Resident #6, who had severely impaired cognition, dementia, arthritis, and required extensive assistance with ADLs and mobility, had 4 call light requests answered more than 15 minutes after initiation, with all 4 over 20 minutes and 2 over 30 minutes. Staffing records showed a TNA assigned alone to a resident hall, an agency CNA orienting a newly hired CNA, and no documented staff assignment for one resident hall on another date. Staff and the DON confirmed staffing shortages, delayed call light response times, and that the TNA should not have been assigned alone. In the locked memory care unit, staff also reported delayed response to requests for assistance, including a resident fall response taking about 5 minutes and a nurse request that went unanswered until the surveyor was present.

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 dignity for two residents by leaving one resident’s blood-stained sheets on the bed for 4 1/2 hours and by reaching across another resident’s face to retrieve a clothing protector during mealtime. Resident #6 had severely impaired cognition with a BIMS score of 00, diagnoses of non-Alzheimer’s dementia and arthritis, and required extensive assistance with ADLs and mobility. The resident also had an ADL self-care deficit related to dementia and was at risk for infection related to a suprapubic catheter. On 5/03/26 at 10:20 AM, the resident’s bed had dried, red stains on the bottom half of the sheets while he was sitting in his room in a wheelchair, and the stained sheets remained in place at 12:31 PM. By 3:10 PM, the sheets no longer had the dried, red stain. Resident #7 had a BIMS score that could not be obtained because she was rarely or never understood, with diagnoses including a stroke without residual deficits, one-sided severe weakness, and bilateral hearing loss. She was dependent with all ADLs and mobility, and her care plan directed staff to work with nursing staff to provide maximum comfort. During a dining observation, a CNA reached directly in front of the resident’s face from one side of the table to the other, grabbed a clothing protector, placed it on the resident, then walked around and assisted her with eating. Staff later stated that reaching across someone’s face to access an item would be offensive, embarrassing, and disrespectful, and the DON stated the residents’ dignity should always be maintained.

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 baths for 2 of 3 residents who required bathing assistance. Resident #1 had severely impaired cognition with a BIMS score of 02 out of 15 and diagnoses including non-Alzheimer's dementia, anxiety, and hospice. Her care plan directed staff to provide a sponge bath when a full bath or shower could not be tolerated. Bath documentation showed she received baths on several dates in March 2026, but she missed scheduled baths on 3/13/26 and 3/27/26, and she received only one bath during a 13-day period from 3/06/26 through 3/19/26. The facility did not provide her bath log for April 2026. Resident #3 had a BIMS score of 00 out of 15 and diagnoses of Alzheimer's disease and non-Alzheimer's dementia. Her care plan directed staff to attempt to participate and provide assistance with bathing. Bath documentation for March 2026 showed she received baths on several dates, but she missed a second weekly bath during the 1st, 2nd, 3rd, and 5th weeks of the month. The facility did not provide her bath log for April 2026. Staff stated the resident-assigned CNA or bath aide was responsible for bathing residents, that baths were sometimes missed due to staffing shortages, and that CNAs take turns as bath aides. The DON stated staff should complete the task and document it appropriately.

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 appropriately complete assessments for 3 of 3 residents who fell at the facility. Resident #1 had severely impaired cognition with a BIMS score of 01, diagnoses including non-Alzheimer's dementia, anxiety, and hospice, and care plans noting impaired cognitive function and a fall risk related to assistive devices and a history of falls. After an unwitnessed fall on 8/02/25, the neurological assessment flow sheet documented movement of all extremities but lacked pupil response, hand grasp strength, and pain assessment while the resident was documented as sleeping. After another fall on 9/22/25, neurological checks were initiated, but the flow sheet lacked the signature of the staff who performed the assessments. After a fall on 10/20/25, the neurological assessment flow sheet lacked completed level of consciousness, pupil response, hand grasp strength, extremity movement, pain, and vital signs assessments. Resident #6 had a BIMS score of 00, diagnoses of non-Alzheimer's dementia and arthritis, and required extensive assistance with ADLs and mobility. His care plan identified acute on chronic pain risk and fall risk related to altered mobility, chronic confusion, history of falls, poor safety awareness, relocation stress, and weakness. After he was found sitting on the floor next to his bed on 12/06/25, neurological checks were initiated due to the unwitnessed fall. The neurological assessment flow sheet documented assessments from 9:30 PM through 11:15 PM, but no further neurological assessments were documented from 11:45 PM through 12:45 PM the next day. Resident #7 could not complete a BIMS because she was rarely or never understood and had diagnoses including stroke without residual deficits, one-sided severe weakness, and bilateral hearing loss. She was dependent with all ADLs and mobility, and her care plan identified impaired visual function and fall risk. After she was found on the floor beside her bed on 8/04/25, the incident note did not indicate that neurological checks were initiated. A later neurological assessment flow sheet included 30-minute vital signs from 3:30 AM through 5:30 AM, but did not include pupil response, motor function, or pain assessments during those times. Staff interviews showed an LPN could not verbalize the neurological assessment frequency guidelines and stated all columns on the form must be completed, while the ADON stated unwitnessed falls required an initial assessment and neurological checks every 15 minutes x4, every 30 minutes x2, every hour x4, then every shift for 72 hours; the DON stated staff should follow the policy.

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 use a gait belt during transfers for two residents who required assistance with mobility, and it failed to lock a wheelchair during a transfer for one of those residents. Resident #3 had severely impaired cognition with a BIMS score of 00 out of 15, diagnoses of Alzheimer's disease and non-Alzheimer's dementia, and was dependent for all ADLs and all forms of mobility except moderate assistance with eating. Her care plan identified her as a fall risk related to chronic confusion and directed staff to use 2-person assistance or a mechanical standing lift for transfers as needed to promote safety. Resident #4 had severely impaired cognition with a BIMS score of 01 out of 15, diagnoses of non-Alzheimer's dementia, fibromyalgia, and macular degeneration, and used a wheelchair for mobility. Her care plan identified her as a fall risk related to assistive devices for ambulation, chronic confusion, and poor safety awareness and directed staff to use 1-person assistance with transfers. On 5/03/26, Staff A, a TNA, wheeled Resident #3 and Resident #4 to their rooms and transferred both residents from their wheelchairs to their beds without using a gait belt. Staff A stated she used the same method for both transfers, including grabbing the resident's pants and under an armpit to assist the resident into a sitting position on the bed, and said she was still in training and not certified. Later that day, Resident #4 was transferred from her wheelchair to her bed by Staff N and Staff G while the wheelchair remained unlocked, and the resident stood up without staff assistance or a gait belt. Staff interviews indicated gait belts are required for 1-assist weight-bearing transfers, and the facility's Safe Resident Handling/Transfers policy stated that mechanical lifting equipment or other approved transferring aids, which may include gait belts, are to be used based on resident needs to prevent manual lifting except in medical emergencies.

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 competent staff by allowing a Training Nurse Aide (TNA) who was not yet certified to transfer two residents and to apply a leg immobilizer to a resident with a left leg fracture. Resident #2 had diagnoses of cancer, heart failure, and a left leg fracture, was non-weight bearing, and required maximal assistance with most ADLs and all forms of mobility. The resident stated that Staff A, TNA, applied her leg immobilizer by herself, and the Social Services Coordinator later adjusted the immobilizer and confirmed it was on incorrectly. The Director of Nursing stated that TNAs should not be applying or removing leg immobilizers. Staff A also transferred Resident #3 and Resident #4 without using the transfer methods described in their care plans. Resident #3 had severely impaired cognition, diagnoses of Alzheimer's disease and non-Alzheimer's dementia, and a care plan directing staff to use 2-person assistance or a mechanical standing lift for transfers as needed. Resident #4 had severely impaired cognition, diagnoses of non-Alzheimer's dementia, fibromyalgia, and macular degeneration, and a care plan directing 1-person assistance with transfers. Staff A wheeled both residents to their rooms and transferred them from wheelchair to bed by grabbing their clothing and under an armpit, stating she was off training but not certified yet and that her trainer had shown her this method. The facility also assigned a CNA without documented state-required dementia training to the Memory Care Unit on multiple dates, and the DON stated staff should know and maintain their scopes of practice and complete their educations timely.

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 perform hand hygiene while assisting with meals for 2 of 3 residents who were dependent with eating. Resident #3 had an MDS assessment showing a BIMS score of 00 out of 15, indicating severely impaired cognition, with diagnoses of Alzheimer's disease and non-Alzheimer's dementia. The assessment showed the resident required moderate assistance with eating and was dependent with all other ADLs and all forms of mobility. An undated care plan directed staff to attempt to participate and provide assistance with eating. Resident #6 also had an MDS assessment showing a BIMS score of 00, indicating severely impaired cognition, with diagnoses of non-Alzheimer's dementia and arthritis. The assessment showed he required supervision with eating, moderate assistance with oral and personal hygiene, maximal assistance with upper body dressing, and was dependent with all other ADLs and mobility. During a continuous dining observation, a TNA assisted Resident #6 with eating, then moved to Resident #3 and spooned food into that resident's mouth, then returned to Resident #6 and continued feeding him without sanitizing her hands between touching each resident's utensils. Later, a CNA washed her hands at the sink and then returned to Resident #3, who was holding the spoon used after the TNA had touched Resident #6's utensils. The facility's hand hygiene policy stated staff were to perform hand hygiene between resident contacts, and the DON stated staff should have performed hand sanitization between residents and followed the hand hygiene policy.

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 adequately supervise residents in the locked Chronic Confusion or Dementing Illness (CCDI) unit for 1 of 6 residents. Resident #30 was severely cognitively impaired, had delusions, used a walker, and required supervision for transfers and toileting. Her diagnoses included CVA, dementia, and asthma. Her care plan identified her as an elopement risk who was disoriented to place, wandered aimlessly, had communication problems, was rarely understood, had poor safety awareness, and needed staff to distract her from wandering, offer diversions, and anticipate and meet her needs. Progress notes documented multiple behavioral and safety-related incidents involving the resident, including hitting staff with a hanger, being found sitting on the floor in her room on more than one occasion, and being combative toward staff and other residents. During observation in the CCDI unit, residents were seen in common areas without staff present, including one resident in a recliner and another in a high-back chair with her legs on a walker. Resident #30 walked out of her room with her walker, appeared confused, and expressed not knowing where her family was and asking where she sat. Staff later stated that she needed close supervision, and the DON agreed it was a problem to leave residents unattended in the CCDI unit. The facility policy stated there would be at least one member of the nursing staff on the unit at all times and one CNA with appropriate CCDI training on the unit at all times.

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 adequate urinary catheter care for 2 residents. One resident had chronic urinary tract infections and an order to record urinary output every shift, but staff did not consistently document output. The resident also had an indwelling catheter related to urinary retention, and the record showed multiple days in which no urine output was documented. The DON acknowledged that catheter output had not been monitored as it should have been. For the second resident, who had dementia, diabetes, BPH, urinary retention, edema, and an indwelling suprapubic catheter, the physician placed a new 24 French catheter and directed staff not to put more than 10 ml in the balloon. The catheter order entered into the electronic record did not include that specific balloon-volume instruction. Staff stated they would either call the doctor for clarification or follow the amount listed on the catheter package, and one RN demonstrated that the package directed use of 30 ml. The DON stated she was not aware of the specific 10 ml instruction and said it should have been entered with the order. During observation, the second resident was found in a recliner with a heavily soiled brief, leaking from the catheter, and blood at and around the catheter site. The chart lacked documentation that the nurse assessed or addressed the issue, and staff interviews showed the catheter site soreness had not been passed on in report. The facility policy required recording output in the medical record and reporting changes such as odor, color, blood, mucus, or leaking, but the record showed missed output documentation on multiple days for both residents.

Penalty

No penalty information released

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

Summary

The facility failed to consistently monitor meal and supplement intakes for a resident with weight loss. Resident #6 had diagnoses including stroke, hyponatremia, non-Alzheimer's dementia, and hemiplegia, and had a BIMS score of 13 indicating intact cognition. The resident reported being on a mechanical soft diet and receiving a supplement, and the EHR showed a weight decrease from 147 pounds to 133 pounds, a 9.52% loss. The clinical record also showed dietician documentation of weight warnings, ongoing weight loss, and meal intake around 50% with frequent refusal of meals and supplements. Review of facility documentation showed incomplete charting of meal and supplement intake for Resident #6. In July 2025, intake documentation was present for only 9 of 31 days, with no charting for supper meals or supplements except for one day. In August 2025, there was no documentation for meal or supplement intake on the first day, and no supper entries for the next three days. Staff interviews confirmed that meal intakes were supposed to be documented in the staff charting room, and the DON and ADON stated that documenting meal intakes was required. The Administrator stated the facility did not have a policy related to monitoring meal intakes, and the dietician stated she expected meal intakes to be monitored and charted to communicate effectively with the physician for residents with weight loss.

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

Pharmaceutical services were not provided with accurate medication administration documentation for 2 of 13 residents reviewed. For one resident with a BIMS score of 14 and diagnoses including atrial fibrillation, coronary artery disease, heart failure, benign prostatic hyperplasia, septicemia, and diabetes mellitus, the April 2025 MAR showed that on April 18 and 19 there was no documentation for administration of 16 different morning medications. The resident was totally dependent on staff for toileting hygiene, dressing, and transfers, had an indwelling catheter, and the care plan indicated use of antidepressant medication and diuretic therapy with staff to administer medications as ordered. For another resident with a BIMS score of 3 and diagnoses including cancer, anemia, hypertrophy of kidney, macular degeneration, and arthritis, the May 2025 MAR/TAR showed that on May 19, 20, and 21 there was no documentation for 10 different morning medications. The resident required substantial assistance for dressing, was totally dependent for transfers, was frequently incontinent of bowel and bladder, and was on hospice services related to end stage disease. Staff interviews indicated the medication documentation was not always accurate, and the DON stated the facility had identified that some documentation was not being completed.

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 adequately supervise a cognitively impaired resident, leading to the resident leaving the building without staff knowledge. The resident, who had a history of mild cognitive impairment, hallucinations, and delusions, was last seen by staff at approximately 12:45 PM. The door alarm sounded at 1:01 PM, but the responding staff member only took a few steps outside, did not see anyone, and returned inside without conducting a thorough search or notifying other staff members. At 1:30 PM, another staff member found the resident in the driver's seat of a car in the parking lot, with the car running and the doors locked. The resident had a Brief Interview of Mental Status (BIMS) score of 8, indicating mild cognitive impairment, and had been experiencing hallucinations and delusions. The resident's care plan noted poor safety awareness and dementia that could lead to wandering, but lacked specific interventions for wandering or exit-seeking behavior. The resident had a history of wandering and was known to be more confused than usual on the day of the incident, possibly due to a Fentanyl patch for back pain. Staff interviews revealed that the door alarm response was inadequate, as the staff member who responded did not conduct a thorough search or initiate a head count. The facility's policies for door alarm response and missing resident procedures were not followed, contributing to the resident's unsupervised exit from the building. The incident highlighted gaps in staff response and communication, as well as deficiencies in the resident's care plan regarding wandering and elopement prevention.

Removal Plan

• Immediate education and coaching with staff on the facility's door alarm response procedure.
• All door alarms and wander guard alarms were checked for proper functioning.
• Elopement drills were completed successfully.
• Staff completed door response education. The facility updated the wandering assessment in their Electronic Health Record (EHR) to be completed on admission, 72 hours after admission and quarterly.
• Elopement drills will continue every quarter, alternating shifts for three quarters and reviewed at Quality Assurance (QA) meetings. If the drill is not successfully completed, they will increase the frequency to weekly.

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 accurate completion of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. The resident, who was admitted on May 2, 2024, was observed with a wanderguard on her left ankle during a dining room observation. However, the MDS assessments, including the admission, quarterly, and significant change assessments, did not document the use of a wander/elopement alarm, despite the resident's history of wandering and high elopement risk. The care plan and elopement risk assessment checklist indicated the use of a wanderguard due to the resident's dementia and poor safety awareness. Staff interviews revealed that multiple Certified Nursing Assistants (CNAs) were aware of the resident wearing a wanderguard but were unsure of the duration. The Director of Nursing (DON) acknowledged the oversight in the MDS assessments, which should have documented the use of the wanderguard. The deficiency was identified through observations, clinical record reviews, and staff interviews, highlighting the discrepancy between the resident's documented care plan and the MDS assessments.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the care plans for two residents included necessary interventions for staff to follow in the event of wandering or elopement behaviors. Resident #1, who had a history of mild cognitive impairment and various medical conditions, including moderate dementia with psychotic disturbance, was not provided with a care plan that addressed her wandering and exit-seeking behaviors. Despite having a wanderguard, her care plan lacked specific interventions for staff to implement when she exhibited these behaviors. This oversight became evident when Resident #1 eloped from the building and was found in a staff member's car, an incident that was not documented in her care plan. Resident #3, with severe cognitive impairment and a history of daily wandering, also had a care plan that failed to include interventions for wandering or exit-seeking behaviors. Although Resident #3 utilized a wander/elopement alarm, the care plan did not provide guidance for staff on how to manage her wandering tendencies. The resident's progress notes indicated frequent wandering and agitation, with staff needing to redirect her multiple times. Despite these behaviors, the care plan did not reflect specific strategies to address her wandering. The Director of Nursing acknowledged that the care plans were not updated to include interventions for wandering or elopement risks. The care plans were supposed to be revised quarterly and as needed, but this did not occur for the two residents in question. The lack of appropriate interventions in the care plans for residents at risk of wandering or elopement represents a significant deficiency in the facility's care planning process.