Alden Estates Of Orland Park

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 prevent fall incidents and failed to provide a safe transfer using a mechanical lift for a resident with morbid severe obesity, vascular dementia, depression, anxiety, hypertension, and a BIMS score of 9/15 indicating moderate cognitive impairment. The resident had a care plan identifying her as at risk for falls due to cognitive and functional deficits, with an intervention to assess for anxiety and agitation prior to transfer. The facility’s fall management policy required assessment of hazards and risks, development of a plan of care, and implementation of resident interventions to minimize fall incidents and injuries. On 4/23/26, the resident fell while being transferred with a mechanical lift. Nursing documentation stated a nurse entered the room and found the resident lying on the floor on her left side with sling pads underneath her, complaining of back and head pain. The nurse contacted the physician, notified the DON, and the resident was sent to the hospital. The hospital record stated the resident came to the ED after falling out of the mechanical lift and reported right-sided head and back pain; EMS noted she had received Ativan before being placed in the mechanical lift. Staff interviews described the transfer as involving the resident becoming agitated, screaming, and moving during the lift transfer. Two CNAs were assisting, with one operating the lift and the other spotting the resident, but the resident was described as heavy, hard to position, and actively flailing her arms and legs while suspended. Staff reported the mechanical lift began to tilt, the bed frame was lifted, and the resident fell onto the mattress and then to the floor with the mattress. The DON and Administrator stated the resident’s movement caused the lift to tip during the transfer.

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 supervision and fall prevention measures for a resident with advanced vascular dementia and a known history of falls, resulting in the resident exiting through an emergency stairwell door and falling down a flight of stairs. On the morning of 3/23/26, a CNA observed the resident attempting to get out of bed without assistance, recognized the resident as a fall risk, and transferred the resident to a wheelchair, then brought the resident to the nurses' station. At that time, all staff, including the nurse, were rounding on residents, leaving no one at the nurses' station to monitor the resident. The nurse reported that the resident self-propelled the wheelchair down the middle hallway, exited the unit via an emergency exit door, and that he only became aware of the situation when he heard the door alarm and went to locate its source. When staff responded to the alarm, the CNA found the resident at the bottom of the stairwell with the wheelchair, and the falls report documented the resident in a supine position with the wheelchair over the lower extremities, grimacing and guarding extremities. The hospital record from that day documented an unwitnessed fall down a flight of stairs, diffuse bruising, inability to tolerate movement of the left arm, a comminuted distal right femur fracture extending into the joint space, and a comminuted left humeral head and neck fracture with mild displacement, with surgical repair of the right femur performed. The resident’s care plans prior to the incident identified the resident as at risk for falls due to a history of falls, weakness, impaired cognition, use of assistive devices, narcotic and psychotropic medications, and advanced vascular dementia with significant cognitive decline, unpredictable behaviors, poor safety awareness, and impaired memory and decision-making. The nurse stated there were no fall precautions in place for the resident at the time of the incident, despite these identified risks and the resident’s need for constant redirection when in a wheelchair.

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 deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and assistive devices to prevent accidents, including elopement and falls. One cognitively impaired resident with known exit-seeking behavior was allowed to elope from the facility without staff awareness, and multiple residents at risk for falls did not have care-planned fall prevention interventions consistently implemented. The elopement resident had a BIMS score of 6 indicating severe cognitive impairment, diagnoses including dementia, and a documented history of exit-seeking and wandering behaviors. The resident had an electronic alert band ordered and applied due to exit-seeking behavior, and the care plan identified the resident as at risk for elopement with an intervention to utilize an electronic alert band. Despite this, the resident was last seen in bed around 2:15–2:30 a.m. and subsequently left the building through the front door without staff knowledge. Police found the resident walking alone on a nearby street and returned the resident to the facility around 3:36 a.m., at which time staff documented that the facility had been unaware the resident had left. Staff interviews and observations revealed that the electronic alert system did not function effectively as an audible warning at the nurse’s station. A CNA reported not hearing any alarm when the resident exited, explaining that the sound of the alarm was located between a set of double doors and could not be heard when those doors were closed. The CNA confirmed that the last time she saw the resident, the resident was in bed with eyes closed and appeared to be sleeping. A former LPN stated she only became aware of the elopement when police arrived at the front desk and informed her that the resident had been found outside the facility. The administrator confirmed that the root cause of the elopement was that the electronic alert alarms could not be heard at the nurse’s station and acknowledged that when the system was initially tested, staff only checked the alarm audibility while standing between the double doors, and no one had checked whether the alarm could be heard outside those doors. The social services director confirmed that the resident’s elopement risk care plan had been initiated months earlier due to comments about wanting to leave and wandering behavior, and acknowledged that the interventions in place were not effective since the resident was able to elope. The facility also failed to implement fall prevention interventions as care-planned for several residents at risk for falls and dependent on staff for transfers. One resident with diagnoses including CHF, Type 2 DM, and dependence on enabling machines and devices had an MDS indicating dependence for sit-to-stand and toilet transfers, and a care plan requiring two staff and use of a total body (Hoyer) lift for transfers. Despite this, a CNA was observed transferring this resident from a wheelchair to a toilet using a stand lift alone, and she acknowledged that two staff should perform the transfer but stated she proceeded alone due to short staffing. The restorative nurse and PTA confirmed that if a resident is care-planned for two-person mechanical lift transfers, that plan must be followed for safety. Additional residents at risk for falls were observed with their beds at waist height despite care-planned interventions requiring beds to be maintained in the lowest appropriate position. One resident with hemiplegia and hemiparesis, dependent on staff for transfers and identified as at risk for falls, had a care plan specifying mechanical lift for transfers and ensuring the bed is in the lowest position. During observation, this resident was found lying in a bed at waist height. When questioned, the LPN confirmed the resident was a mechanical lift transfer and acknowledged that the bed was elevated to waist height and should be in the lowest position for safety. Another resident with paraplegia, dependent on staff for chair/bed transfers and at risk for falls, also had a care plan intervention to ensure the bed is in the lowest position. This resident was likewise observed in a bed at waist height, and the LPN confirmed the bed height. The DON stated that beds are to be in low position but noted that some residents prefer higher beds and do not allow staff to lower them, indicating that care-planned fall prevention interventions were not consistently maintained as required by facility policy and resident care plans.

Removal Plan

• Reassessed R75 for elopement risk after the elopement occurred and determined resident remained an elopement risk.
• Located R75 and returned resident to the facility.
• Completed a head-to-toe assessment for R75 with no signs of injury noted.
• Updated R75’s care plan to address the elopement event.
• Notified R75’s family member and Primary Care Physician/Medical Director of the elopement.
• Reviewed facility policies related to the occurrence (Elopement, Routine Resident Checks, Incidents/Accidents, Alarms, electronic alert band, Wanderers, Changes in Condition).
• Updated the Wanderguard policy to include considering alternative interventions in the event of equipment failure (e.g., room change to a more secure floor).
• Updated assessments and care plans for residents at risk for elopement.
• Placed R75 on 1:1 supervision pending move to a more secured unit.
• Moved the only other resident requiring electronic monitoring to a higher/more secured unit.
• Reassessed all residents for elopement risk.
• Implemented a process that all new admissions will have an elopement risk assessment completed per MDS schedule (within 7 days of admission, annually, and as needed).
• Reviewed and updated care plans for residents identified at risk for elopement on admission.
• Placed pictures of at-risk residents in binders at all nursing stations and the receptionist desk.
• Evaluated at-risk residents with active exit-seeking behaviors for possible room change to a more secured unit to limit access to the front entrance door.
• Evaluated at-risk residents to determine whether an electronic monitoring bracelet is appropriate.
• Conducted staff interviews to identify further potential risk.
• Conducted Code drills on all shifts to assess staff knowledge and preparedness.
• Reeducated all staff and managers on routine resident checks, exit seeking, incidents/accidents, elopement policy/procedure, and location of elopement-risk binders.
• Administered staff competency quizzes on elopement.
• Reeducated staff and managers on elopement risk and reporting behaviors/changes related to elopement risk to the appropriate discipline.
• Reeducated reception staff on monitoring front doors, resident safety, and proper Code Green procedure.
• Educated all staff on the electronic monitoring system.
• Implemented monitoring of exit doors by staff when unalarmed.
• Assigned receptionist to monitor the front entrance door.
• Required the receptionist to arm the door and required first-floor nurses to monitor the door when the receptionist is not present.
• Implemented alarm panel checks with a signed monitoring sheet by first-floor staff to ensure door alarms are activated when doors are not monitored by staff.
• Implemented weekly checks of exterior door alarms by the Maintenance Director and EVS Supervisor to ensure alarms are working and doors are secured.
• Met with R75’s daughter to discuss and implement new interventions.
• Initiated a work order to add an annunciator panel to the first-floor nurses station to amplify the alarm.
• Added elopement training to annual abuse training to ensure staff knowledge of elopement plans.
• Started QAA compliance audits using an elopement and door-check audit tool with review at monthly QAPI meetings.
• Assigned IDT members to complete audits and submit them to the Administrator for oversight of completion.
• Started review of audit results regarding elopement and door alarm working condition with the IDT with review at monthly QAPI.
• Implemented an Administrator daily audit to confirm the exterior front door alarm is activated each day by the receptionist prior to leaving.
• Added to new-hire orientation education on elopement and administration of competency quizzes.
• Established that the facility Quality Assurance Team/IDT will meet at least monthly to review elopement-risk residents, trends/patterns, and implement action steps.
• Held an emergency QA meeting with the IDT and Medical Director to discuss the elopement and approve the Removal Plan.
• Assigned ongoing monitoring of the Removal Plan to the Administrator, DON, ADON, and Social Services.

Penalty

Inspection fine: $57,35016 days payment denial

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 deficiency involves the facility’s failure to provide adequate supervision and monitoring, including maintaining visual oversight, for residents assessed as at risk for falls, in accordance with their care plans and assessed needs. One resident with dementia, a history of falls, orthostatic hypotension, syncope, and severely impaired decision-making was housed on a locked dementia unit and identified as at risk for falls. This resident had an unsteady gait, wandered, and exhibited behaviors of trying to get up and walk unassisted. Despite being at the nurse’s station in a wheelchair prior to the first fall, the resident was later found on the floor in a staff bathroom located within a locked nurse’s closet that required a code to enter. Staff reported that the closet door was usually kept closed and coded, and a nurse stated that someone must have left the door open. The fall was unwitnessed, and the resident sustained a scalp laceration requiring staples. Subsequently, the same resident experienced another fall in the dining room. The resident’s care plan identified her as at risk for falls due to history of falls, weakness, impaired balance and mobility, impaired cognition, wandering, and hypotension, with interventions including monitoring for attempts to get out of a chair or ambulate without an assistive device and cueing the resident accordingly. Progress notes and behavior charting documented that the resident was restless, crying, yelling, attempting to ambulate unsafely without staff assistance, and that interventions such as walking her around the unit and offering activities did not fully resolve these behaviors. On the day of the dining room fall, staff brought the resident to the dining area in a wheelchair and locked the wheelchair at the table. Multiple staff were present in the dining room but reported they did not actually see the fall. Statements indicated that the resident stood up from the wheelchair, walked around the table, and fell before staff could reach her, resulting in a left femur fracture. Another resident with dementia, impaired short- and long-term memory, unsteady gait, use of a rollator, history of falls, and multiple risk factors including hypertension medications, antidepressants, seizure history, COPD, and occasional incontinence was also assessed as at risk for falls. This resident required supervision or touching assistance for sit-to-stand transfers and, according to a nurse, required monitoring every fifteen minutes and should not be left alone in her room unless asleep. The nurse reported that the resident was kept near the nursing station for monitoring and that the resident was forgetful and needed encouragement to use her rollator. On the day of the incident, the nurse last saw the resident in her room sitting on the bed or rollator seat, then later heard the resident yelling and found her on the floor by the window, with a hematoma on the top of her head, lip bleeding, and complaints of arm pain. The fall was unwitnessed, the resident’s walker was not near her, and she stated she had been going to answer a telephone that was not present in the room. Hospital records documented an unwitnessed fall with head injury, lip laceration, scalp abrasion, a right supracondylar humerus fracture, and intracerebral hemorrhage. These events occurred despite facility policies stating a commitment to proactively identify residents at risk for falls, plan preventive strategies, and assess and monitor the resident’s environment to manage potential hazards. The facility’s fall management policies stated that hazards and risks would be assessed, plans of care developed and implemented, and the environment monitored to minimize fall incidents and injuries. However, in these cases, residents with known dementia, impaired cognition, unsteady gait, and documented fall risk were able to access unsafe areas or ambulate without adequate supervision. The first resident accessed a staff-only bathroom through a coded nurse’s closet and fell without staff present, and later ambulated around a dining room table and fell while staff were in the room but without continuous visual oversight. The second resident, who staff acknowledged should not be left alone in her room unless asleep and required frequent monitoring, was left unsupervised in her room, ambulated without her rollator, and sustained an unwitnessed fall with significant injuries. These circumstances demonstrate that the facility did not consistently maintain the level of supervision and environmental control described in residents’ assessments, care plans, and facility policies for fall prevention.

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 administer medications as ordered by the physician for one resident, who had multiple complex medical diagnoses including chronic kidney disease, heart failure, dementia, and other serious conditions. The resident was not cognitively intact, as indicated by a BIMS score of 6. Review of the medication administration record (MAR) for October showed that scheduled doses of Carvedilol and Sodium Zirconium Cyclosilicate (Lokelma) were not documented as given on two separate dates. The MAR had blank boxes for these medications, with no documentation indicating whether the medications were administered or the reason for omission. Interviews with nursing staff and the Director of Nursing (DON) confirmed that facility policy requires immediate documentation of medication administration or the reason for withholding a dose. Staff acknowledged that a blank box on the MAR means the medication was not given, and if a medication is held, the reason must be documented. The DON and staff could not provide a reason for the missing documentation or confirm whether the medications were actually administered. Progress notes for the relevant dates did not contain any entries explaining the omissions, and the assigned nurses either could not recall the events or admitted to possibly forgetting to document. Facility policies and job descriptions reviewed by surveyors further confirmed the requirement for accurate and timely documentation of medication administration and reasons for any missed doses. Despite these policies, there was no evidence in the resident's records to explain the missed or undocumented doses, and staff interviews did not clarify the circumstances. The deficiency was identified based on the lack of documentation and failure to follow established procedures for medication administration and record-keeping.

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 effective supervision and monitoring of residents in the dining room, resulting in an accident involving a resident assessed to be at risk for falls. The resident, who had multiple diagnoses including chronic hepatic failure, hepatic encephalopathy, Alzheimer's disease, dementia, and impaired mobility, was left unsupervised in the dining room after lunch. Staff interviews revealed that there was no clear protocol requiring staff to remain in the dining room for supervision, and the LPN assigned to monitor the area was seated at the nurse station, unable to maintain visual supervision of the resident. The resident was found on the floor in the dining room by another staff member, with no staff present in the room at the time of the fall. The resident was alert but in pain and was subsequently sent to the hospital, where she was diagnosed with a right femoral neck fracture. The care plan for this resident identified her as a fall risk, with interventions including supervision and removal from common areas after meals, but these interventions were not followed at the time of the incident. Staff interviews indicated a lack of communication regarding the resident's fall risk status, and the LPN monitoring the dining room was not informed of the resident's specific needs. The facility's fall management policy emphasized proactive identification and supervision of residents at risk for falls, but this policy was not effectively implemented, leading to the unwitnessed fall and 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 ensure that the designated Infection Preventionist (IP), who also served as the Assistant Director of Nursing (ADON), participated in the Quality Assessment and Assurance (QAA) Committee meetings as required. Record review of QAA meeting sign-in sheets for several dates showed no documented attendance by the IP, despite the individual having assumed the IP role months prior. This was confirmed by the Assistant Administrator, who acknowledged the absence of the IP from these meetings and affirmed that participation is a standing requirement for the IP. Facility policy and the job description for the Infection Preventionist Nurse both specify participation in QAA meetings as a responsibility. The facility census indicated that 174 residents resided in the facility at the time of the deficiency. The lack of IP participation in QAA/QAPI programming was identified through interviews and record review, with the Assistant Administrator confirming the deficiency and its inconsistency with both facility policy and regulatory requirements.

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 resident with multiple diagnoses, including encephalopathy, end stage renal disease, and chronic obstructive pulmonary disease, who was cognitively intact, reported an incident involving a certified nursing assistant (CNA) while care was being provided to his roommate. The resident stated that the CNA entered between the beds to turn off the call light, became upset when questioned, and shook the side of the resident's bed. The resident recorded the incident on video, which showed an unseen person shaking the bed for several seconds, followed by an argument between the resident and the individual. The resident reported the incident to facility leadership, and a police report was filed. A roommate confirmed being present in the room but did not witness the event, only hearing the resident yelling. The facility's initial and final reports indicated that the staff member involved was identified, but the allegation could not be substantiated, and the CNA was allowed to return to work on a different unit. The facility's abuse policy affirms residents' rights to be free from abuse, including physical actions such as those described in the incident.

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 timely notify a resident's family after a fall that required transportation to a local hospital for evaluation. The incident involved a resident who fell from his wheelchair, resulting in a bruise to the right side of his head, an abrasion to his face, and blood on his lips/mouth area due to biting his lip during the fall. The resident was transported to the hospital for evaluation on the night of the incident. However, the resident's mother was not notified of the fall or the hospital transfer until several hours later, after the resident had already returned to the facility. The Director of Nursing confirmed that family should be notified immediately after a resident falls and if a resident is being sent to the hospital for a change in condition. The facility's policy on change of condition also mandates that the responsible party be notified of changes in a resident's condition. Despite these protocols, the Licensed Practical Nurse on duty only notified the resident's mother after the resident had returned from the hospital, failing to inform her at the time of the fall and subsequent hospital transfer.

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 proper assessment and documentation following a fall incident involving a resident, identified as R2. On 12/18/24, R2 was observed on video falling out of bed at 10:20 AM. Two staff members, including a Wound Certified Nursing Assistant (CNA), entered the room and moved R2 back to bed without conducting a nurse assessment. The CNA involved did not recall notifying a specific nurse, and there was no documentation of the fall or any assessment in R2's clinical records for that day. The Director of Nursing (V2) stated that all falls should be documented, and a nurse should perform a full body assessment before moving the resident. However, the facility lacked a specific policy or procedure for staff to follow after a resident falls. The facility's Fall Risk Assessment Policy from 8/2020 requires a nurse to complete an Occurrence Report and initiate post-occurrence documentation, which was not adhered to in this case.

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 schedule a resident's doctor appointments as per the physician's orders for one of the residents reviewed for quality of care. The resident, who was admitted with diagnoses including major depressive disorder, chronic pain syndrome, history of traumatic brain injury, and injury to the peripheral nerves of the thorax, had specific orders from their physician to follow up with a pain specialist at a rehabilitation hospital. These orders were documented on 10/18/23 and again on 1/10/24, yet the facility did not schedule the required appointments. Interviews with facility staff, including the Unit Manager and the Administrator, confirmed that the appointments were not scheduled as ordered. The resident's Primary Care Physician and Nurse Practitioner for Pain Management both expressed expectations that the facility would arrange these appointments. The facility's appointment policy indicates that assistance should be provided to residents in scheduling appointments, yet this was not adhered to in this case.

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 proper food storage and labeling practices in the kitchen, which could lead to foodborne illness among the 152 residents receiving dietary services. During an inspection, it was observed that the walk-in cooler contained several food items, such as shredded cheese, liquid eggs, and various pureed foods, that were not labeled or dated. Additionally, some items were stored improperly, with raw foods placed above cooked foods. The kitchen supervisor acknowledged the importance of labeling and dating food items but was unable to specify the expiration periods for different foods. The facility lacked a policy on how to date opened food items or determine their expiration. In the dry storage area, several dented cans of food were found, including cans of sliced pears, fruit cocktail, chocolate pudding, and tomato sauce. The corporate executive and kitchen supervisor both stated that dented cans should not be used as they could pose a risk of contamination. However, the facility's policy on dented cans was not being followed, as these compromised cans were not separated or marked as unusable. The walk-in freezer also contained several items without proper labeling or dates, such as pie crusts, pastries, waffles, and chicken tenders. A non-English speaking staff member was unable to answer questions about proper food storage and labeling. Additionally, the facility's sanitization practices were inadequate, with only one log being maintained for both the three-compartment sink and the red sanitization buckets, despite the need for separate logs. The dietary aide confirmed that only one log was used, and the corporate executive noted that separate logs should be maintained to ensure proper sanitization levels.

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 care for residents dependent on staff for activities of daily living (ADLs), as evidenced by multiple observations and interviews. One resident, who was cognitively intact and dependent on staff for toileting hygiene, reported that staff skipped washing her perianal area during incontinence care, leading to a diaper rash. Despite the resident's request for water to be used during cleaning, staff continued to use wipes, which the resident believed contributed to her skin irritation. The facility's policy required the use of water and soap for perineal care, but this was not followed, resulting in reddened and inflamed skin for the resident. Other residents were observed with unmet personal hygiene needs, such as facial hair and dirty fingernails. One resident had an accumulation of chin hairs, while another had a dark substance under her fingernails, both of whom required substantial assistance for personal hygiene. The Director of Nursing acknowledged that female residents should not have facial hair and that fingernails should be clean to prevent infections. However, these hygiene tasks were not consistently performed, as evidenced by the continued presence of facial hair and dirty fingernails over several days. Additional residents were found with long, dirty fingernails and facial hair, indicating a lack of regular personal hygiene care. One resident had long, jagged fingernails with a brown substance underneath, and another had a full beard despite expressing a desire to have it shaved. These observations highlight the facility's failure to adhere to its policies on nail care and shaving, which require residents to have clean, well-trimmed nails and facial hair removed to improve appearance and morale. The facility's inaction in providing necessary ADL assistance resulted in multiple residents experiencing unmet hygiene needs.

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 properly store medications and remove expired medications from stock, affecting five residents. During an observation, it was noted that a resident's oral and rectal medications were stored together in the same drawer, which is against infection control protocols. Both the Assistant Director of Nursing and a Registered Nurse confirmed that rectal medications should not be stored with oral medications due to potential infection control issues. The resident had an active order for a rectal medication, which should have been stored separately in the treatment cart. Another deficiency was observed when a bag of Daptomycin, an intravenous antibiotic, was found in the medication room refrigerator with an expiration date that had already passed. The Assistant Director of Nursing acknowledged that expired medications should be sent back to the pharmacy and that the expired medication was still being administered to a resident for osteomyelitis. The facility's policy requires that medications be stored under proper conditions and that expired medications be removed. Additional issues included a resident having unsupervised access to nicotine gum, which was not securely stored, and another resident's zinc oxide medication being left on a bedside table instead of being locked in the medication cart. Furthermore, a bottle of Nystatin powder was found in a resident's room without an order for it to be stored there, and the Director of Nursing confirmed that medications should be secured unless there is a specific order allowing bedside storage. These observations indicate a failure to adhere to medication storage policies, potentially compromising 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 adhere to infection control practices during blood glucose monitoring and dining services, affecting five residents. On October 1, 2024, an LPN did not clean the glucometer after testing a resident's blood glucose level before using it on another resident. This practice was contrary to the facility's policy, which required cleaning and disinfecting the glucometer after each use to prevent cross-contamination. Interviews with other staff members, including another LPN and the Director of Nursing, confirmed that the glucometer should be cleaned between residents to prevent infection, especially since blood is involved. During a lunch service, a CNA was observed handling multiple residents' food and utensils without performing hand hygiene between tasks. The CNA touched a resident's plate and glass, refilled the glass from a communal carton of thickened water, and then proceeded to serve other residents without cleaning her hands. This action violated the facility's hand hygiene policy, which mandates handwashing after contact with potentially contaminated items and between resident interactions. The facility administrator acknowledged that the CNA should have cleaned her hands to prevent the spread of infectious organisms.

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 call lights were within reach for dependent residents, affecting three residents in the sample. One resident, who was diagnosed with functional quadriplegia and cognitive communication deficit, was found with her call light on the floor, making it inaccessible. Despite being able to use the call light, she could not find it. The Director of Nursing confirmed that call lights should be within reach, as per the facility's policy. Another resident, with a care plan indicating a risk for falls due to weakness and hemiplegia, repeatedly had his call light under the bed and out of reach. Nurses entered and exited his room without ensuring the call light was accessible. A third resident, who required assistance with daily activities and was at risk for falls, was left without her call light within reach after being assisted to bed by a CNA. She reported that this was a recurring issue, forcing her to yell for help when she could not reach the call light.

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 written documentation of bed hold notifications to residents and/or their representatives when residents were transferred to the hospital. This deficiency was identified in three out of five residents reviewed for discharge and hospitalization. Specifically, the facility did not provide bed hold notifications for residents who were transferred to the hospital for various medical conditions, including elevated troponin levels, sepsis, and complications from a fall. The facility's policy requires that a bed hold notification be given to the resident or their representative at the time of transfer and that the Ombudsman be notified via a monthly transfer log. Interviews with the facility's Administrator and Director of Nursing revealed that the required bed hold assessments were not completed for the affected residents, and there was uncertainty as to why the nurses did not perform this task. The facility's policy, dated December 2018, mandates that the bed hold policy be documented and communicated to the resident and their representative within 24 hours of transfer. Additionally, the Ombudsman should be informed of all hospital transfers and therapeutic leaves. The failure to adhere to these procedures resulted in a deficiency in the facility's compliance with its own policies and regulatory requirements.

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 intravenous medications were administered by qualified staff, specifically Registered Nurses (RNs), as per their policy. A resident, identified as R165, was admitted with several diagnoses including orthopedic aftercare following surgical amputation, acute osteomyelitis, type 2 diabetes, and cellulitis. The resident had physician orders for intravenous antibiotics, Daptomycin and Ceftriaxone. However, these medications were administered by Licensed Practical Nurses (LPNs) instead of RNs, which is against the facility's policy. The Director of Nursing (DON) confirmed that only RNs should handle intravenous medications, yet multiple LPNs were documented as having administered these medications over several dates. The Medication Administration Record (MAR) for R165 showed that LPNs administered Daptomycin and Ceftriaxone on numerous occasions throughout September and October. This included instances where LPNs flushed the midline PICC and changed the cap, tasks that should have been performed by RNs. The facility's policy, dated January 2022, clearly states that administration of intravenous fluids through central venous access should be done by a licensed nurse trained in the procedure, implying RNs. This discrepancy between policy and practice led to the deficiency noted in the report.

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 have a skin alteration worsening assessed by a physician for a resident, identified as R16, who was reviewed for quality of care. On October 1, 2024, R16 reported having a diaper rash, and during incontinence care, CNAs observed reddened and inflamed skin from R16's lower back to upper thigh areas, including the perineal area and folds. Despite applying barrier cream to the perianal area, the CNAs did not apply it to the perineal area or folds. R16 expressed discomfort, describing a burning sensation. The Wound Care Coordinator, V34, noted that R16 was not being seen for wound rounds and emphasized the need for CNAs to alert the staff nurse for evaluation. V34 identified the condition as incontinence-related and suggested notifying the doctor for treatment evaluation. The LPN, V21, who had been caring for R16, admitted to not notifying a doctor about the skin alteration, despite the area not improving. V21 was unable to find any progress notes regarding the last physician evaluation of the wound. Although the doctor was aware of the rash and had ordered creams, there was no documentation of a recent physician assessment. The Wound Care Physician, V44, confirmed not being consulted for R16 and stated that MASD is usually managed by the primary care provider unless it does not improve, in which case he would be consulted. R16's medical history includes heart failure, COPD, and Type 2 diabetes mellitus, with a cognitive status noted as intact. The resident's care plans lacked specific interventions for the skin condition, despite a care plan indicating potential for skin integrity alteration. The facility's policy requires documentation of non-pressure skin alterations weekly and the development of a care plan for actual or potential skin integrity issues, which was not adhered to in R16's case.

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 services to a resident as recommended in the admission restorative nursing assessment. The resident, identified as R152, was admitted to the facility and had been there for about four months without receiving any therapy services, despite being assessed for restorative therapy. The assessment indicated that R152 had no impairment in his extremities but was completely dependent on staff for toileting hygiene and bed mobility, with goals to improve to only requiring substantial assistance. The Restorative Nursing assessment recommended Passive Range of Motion (PROM), Active Range of Motion (AROM), and Bed Mobility/Walking programs, but the resident's Minimum Data Set (MDS) showed he received no such services in the previous seven days. The Restorative Registered Nurse (V7) acknowledged that R152 was not on any restorative programs and mentioned that the resident did not want to participate regularly because he was alert. However, there was no documentation of the resident's refusal of services. The resident's care plan indicated an ADL Functional Performance Deficit with goals to improve functioning, but it did not document any restorative therapies being offered or refused. Additionally, the Electronic Health Record (EHR) task section did not show any reference to restorative therapy programs being ordered, offered, or refused. The facility's policy requires that residents be assessed and provided with individualized restorative programs, which were not documented or implemented for R152.

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 a safe and supervised environment for three residents, leading to potential accident hazards. One resident, identified as R221, was observed in a wheelchair without non-skid socks or eyeglasses, despite being a fall risk due to conditions like metabolic encephalopathy and Parkinson's with dyskinesia. The staff acknowledged the oversight, as the resident was supposed to have non-skid footwear for safety. Another resident, R222, was found in a cluttered room with furniture and a mat improperly placed, which could impede safe movement. This resident, who has cognitive deficits and poor balance, was at risk for falls, and the care plan required a floor mat next to the bed, which was not followed. Additionally, a third resident, R142, who has moderate cognitive impairment and multiple health issues, was found with disinfectant spray cans within reach, contrary to the facility's policy on chemical storage. The policy mandates that chemicals be kept inaccessible to residents, stored in locked areas, or under constant supervision. The presence of these chemicals in the resident's bed and on the overbed table posed a safety risk, as they were not secured or monitored by staff.

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 manage the dressing of a PICC line for a resident, identified as R165, who was admitted with multiple diagnoses including orthopedic aftercare following surgical amputation, acute osteomyelitis, type 2 diabetes, and cellulitis. The resident's physician orders required a transparent sterile dressing change weekly and as needed, with checks on the IV site every eight hours for signs of infection. However, observations on October 1st and 3rd revealed that the PICC line dressing, dated September 29th, was soiled with bloody drainage, indicating it had not been changed as required. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the dressing should be changed weekly or as needed if soiled. The facility's own IV Care Reference Guide and policy on Central Venous Access Catheter Device: Dressing Change also stipulated that dressings should be changed daily if covered with gauze and not visible. Despite these guidelines, the dressing remained unchanged, leading to a deficiency in the care provided to the resident.

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 oxygen supplementation as ordered by the physician for a resident, identified as R42, who was admitted with diagnoses including chronic obstructive pulmonary disease and dependence on supplemental oxygen. The physician's order specified oxygen at 4 liters per minute via nasal cannula continuously. On October 1st, R42 was observed in bed with a nasal cannula connected to an oxygen compressor set to 0 liters, resulting in a blue tongue and shallow respirations. The assigned RN, V6, stated she did not turn off the oxygen supply and was unaware of who did. By October 3rd, the oxygen was set correctly at 4 liters, and R42's condition improved with a pink tongue and regular breathing. The facility's policy allows only RNs, LPNs, or RTs to administer oxygen, while CNAs may only adjust or reapply the nasal cannula or mask.

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 an accurate Record of Receipt for a controlled medication for a resident, identified as R324. During an observation of the medication cart, a handwritten note was found in the Controlled Drug Receipt/Record/Disposition Form book, which lacked essential information such as the medication's name, quantity on hand, quantity received, and licensed nurses' signatures. The resident had a box of Morphine Sulfate 30 mL in the locked box on the medication cart, but the narcotic count sheet was incomplete. The Director of Nursing acknowledged the absence of the appropriate narcotic count sheet and emphasized the importance of including the medication name to prevent medication errors. R324 was admitted with diagnoses including palliative care, vascular dementia, atherosclerotic heart disease, atrial fibrillation, and hypertension. The resident had an active order for Morphine Sulfate Solution 20 mg/mL to be administered as needed for moderate pain. The facility's Controlled Drug Documentation Policy requires a proof-of-use form for each controlled medication, which was not properly followed in this instance. The policy also mandates that controlled substances be counted and verified every shift by two licensed nurses, with any discrepancies reported to the Director of Nursing immediately.

Penalty

Inspection fine: $10,0366 days payment denial

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 adequate safety measures for a resident at risk for wandering, resulting in the resident eloping from a locked unit and exiting the facility without supervision on two separate occasions. The resident, who was cognitively impaired with diagnoses including moderate vascular dementia and unspecified psychosis, was able to leave the facility unnoticed by staff. On the first occasion, the resident left the facility, walked past a pond and across a thoroughfare, and was found in a movie theater parking lot over an hour later. The facility was unaware of how the resident managed to exit the locked unit. The resident's history showed a pattern of exit-seeking behavior, including standing by the elevator and attempting to board it. Despite being assessed as at risk for elopement, the facility did not effectively monitor or prevent the resident from leaving the premises. On the second occasion, the resident again managed to leave the facility, walking past the receptionist and into the parking lot. The receptionist did not notice the resident leaving and failed to call a code green for resident elopement. The facility's policies and procedures for managing elopement and monitoring residents at risk were not adequately followed or enforced. The resident's care plan and risk assessments were not updated in a timely manner to reflect the resident's exit-seeking behaviors. The lack of supervision and failure to activate door alarms contributed to the resident's ability to elope from the facility, resulting in Immediate Jeopardy being declared.

Removal Plan

• Resident was reassessed for elopement risk after the elopement occurred and deemed an elopement risk. The resident elopement risk assessment was reviewed by Memory Care Director with no changes warranted.
• Resident was located and returned to the facility. A head-to-toe assessment was completed by the assigned nurses, with no signs of injury on either occurrence.
• The Resident care plan was updated pertaining to the elopement that occurred, by the Memory Care Director and further reviewed and updated by the MCD.
• The DON, Administrator, ADON, and Medical Director reviewed the facility policies related to the occurrence: Elopement, Routine Resident Checks, Exit Seeking, and Incidents/Accidents. No changes were made.
• The Memory Care Director and Social Service Director updated the assessments and care plans for elopement risk residents. The assessments were completed.
• The Administrator initiated further education that a resident exhibiting exit seeking behaviors should be placed on enhanced monitoring including 15 minute checks and 1:1 supervision until the behavior subsides or alternate measures are put into place. Staff were educated to alert the nurse of exit seeking behaviors who would then implement increased intervention.
• All residents were reassessed for elopement risk and completed.
• All new admissions will have an elopement risk assessment that will be completed within 24 hours upon admission and interim care plan will be initiated based off the assessment, and will be reassessed every three months, and as needed by MCD.
• All residents that are identified as-risk for elopement during admission had a review of their care plan and updates were made where applicable, completed and further reviewed.
• Pictures of at-risk residents were placed in a binder on all nursing stations and the receptionist desk which was completed and reviewed by MCD.
• All residents determined to be at-risk for elopement and with active exit-seeking behaviors will be evaluated for a possible room change to the secured unit to limit access to the front entrance door.
• Interviews were conducted by the Administrator with staff to determine further potential risk and completed. Additional interviews were initiated and completed to further identify any potential risk factors.
• All staff and managers are being reeducated on routine resident checks, exit seeking, incidents/accidents, elopement policy and procedure and where to locate the at risk of elopement binders. The reeducation was provided and was completed.
• All staff and managers are being reeducated on elopement risk and reporting behaviors or changes in factors related to elopement risk to appropriate discipline. This was started and completed.
• All reception staff were reeducated on monitoring the front doors and resident safety and proper procedure for code green completed.
• Exit doors will be monitored by staff when unalarmed. The receptionist will monitor the front entrance door. Door will be armed by receptionist and monitored by 1st floor nurses through the duration of that time.
• Exterior door alarms will be checked daily by the maintenance director and EVS Supervisor to ensure they are in working order and secured. Completed and checked again.
• After initial elopement resident was placed on 15 minute checks for 24 hours. During that time the facility met with daughter and discussed new interventions. A plan was established and implemented.
• 1:1 Visual monitoring was initiated by staff for the resident. Intervention will remain in place until the facility's wandering management system is installed and determined to be effective to prevent further incident.
• Elevator monitor was initiated. Elevator will remain monitored 24 hours a day until wandering management system is installed and determined to be effective to prevent further incident.
• A review of compliance using Quality Assurance Audit tool for elopement started by the Administrator. The Audits will be done daily for two weeks then twice weekly for four weeks, then monthly, and evaluated at the monthly QAPI meeting to determine compliance. Audits to be completed by members of the IDT team and turned into Administrator who will ensure audits are being completed.
• A review of results of audit regarding elopement and door alarm working condition with the facility's interdisciplinary team started. Audits will be done weekly for four weeks, then monthly, and then randomly by Administrator/designee until goal is attained. Results of these audits will be reviewed at the monthly QAPI to determine compliance.
• Administrator to Audit daily that exterior front door alarm is being activated each day by receptionist prior to leaving.
• A facility wandering management system install was initiated.
• During orientation of new hires, the facility Business Office Manager will educate newly hired staff on elopement and conduct competency quizzes.
• The facility Quality Assurance Team/ IDT including Medical Director, Administrator, Social Services, DON, ADON and facility consultant shall meet at least monthly to review elopement risk residents, trends, patterns and develop and implement action steps as necessary.
• The QA meeting is held monthly, then quarterly and as needed. An emergency QA meeting was held by the Administrator with the Interdisciplinary Care Team and Medical Director. The Elopement from the facility were discussed along with the Removal Plan. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator, DON, ADON, and Social Services.

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 stand-by assistance to a resident who required assistance to ambulate, resulting in the resident falling and fracturing her nasal bone. The resident, who had a history of falls and was at risk for further incidents, was ambulating in the dining room with a rolling walker when she tripped and fell, striking her nose on the floor. Despite the resident's care plan indicating the need for supervision during ambulation, staff members were not adequately informed or did not adhere to the requirement for stand-by assistance. The resident's medical history included conditions such as hypertension, Alzheimer's disease, atrial fibrillation, type 1 diabetes mellitus, and chronic obstructive pulmonary disease. The care plan, initiated prior to the incident, highlighted the resident's risk for falls and included interventions such as monitoring changes in her ability to navigate the environment and encouraging the use of a wheelchair. However, these interventions were not effectively communicated or implemented by the staff, leading to the resident's fall and subsequent injury. Interviews with staff members revealed a lack of awareness and communication regarding the resident's need for stand-by assistance. Several staff members, including CNAs and memory care aides, were not informed of the requirement to walk alongside the resident during ambulation. The facility's policy on fall management emphasized the need to assess hazards, develop a care plan, and implement appropriate interventions, but these measures were not adequately followed, contributing to the deficiency.