Bria Of Chicago Heights

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 from physical abuse by another resident when an altercation occurred in the dining room and the event was not substantiated as abuse during the facility’s investigation. The involved resident, R3, was an older male with a BIMS score of 8, indicating moderate cognitive impairment, and diagnoses including Type 2 diabetes and unspecified dementia with mood disturbance. During a confrontation in the dining room, R3 approached and invaded another resident’s (R9’s) personal space, and R9 hit R3 in the nose before staff could separate them. R3 was sent for a medical evaluation and returned to the facility. The facility’s abuse policy defines physical abuse to include hitting and similar acts, and the policy states the facility will promote resident security and prevention of mistreatment. The administrator, who served as the abuse coordinator, conducted the investigation and initially concluded the incident was unsubstantiated because he determined that R9 did not show intent to hurt R3, despite acknowledging that contact occurred and that R3 was hit in the nose. Police were notified and came to the facility but did not make a report. The administrator later stated that he should have substantiated the event. The surveyor was unable to obtain statements from the CNAs and social work aide who were first on the scene and separated the residents, despite attempts to contact them by phone. Months after the altercation, R3 experienced a separate incident in the dining room in which he collapsed and was taken to the hospital; this was confirmed as a different event from the altercation in which he was hit in the nose.

Penalty

Inspection fine: $47,740

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 residents at risk for falls were accurately assessed, placed on the appropriate fall prevention program, and supervised according to their identified needs. The facility policy required fall risk evaluations on admission, readmission, quarterly, after significant change, and after each fall, with residents scoring 10 or greater identified as high risk. The falling star program guidelines stated residents would automatically be placed on the program based on risk factors including a BIMS score of 0-7, unsteady gait, poor safety awareness, or a fall evaluation score of 10 or higher. For one resident with frontotemporal neurocognitive disorder, Alzheimer's disease, unsteadiness on feet, and gait abnormalities, the record showed a BIMS score of 5, a functional assessment requiring supervision or touching assistance for walking, and a fall risk assessment score of 10 on one assessment. A later fall risk assessment scored the resident at 8 but did not select confusion as warranted. The care plan identified the resident as high risk for falls related to recent fall, cognitive deficits, and psychotropic medication use, but the falling star program was excluded. On the day of the unwitnessed fall, staff reported the resident was seen moving toward the exit door, was followed to the room, sat on the bed, and was then left alone with the door closed. Later, staff found the resident with facial injuries, and the roommate stated the resident had fallen in the room. The resident was sent to the hospital and was found to have an anterior wedge compression fracture of the L1 vertebral body. For another resident with altered mental status, muscle weakness, reduced mobility, and hemiplegia and hemiparesis following cerebral infarction, the care plan identified the resident as high risk for falls and directed staff to keep the bed in the lowest position. During observation, the resident was lying in bed while the bed remained elevated and was not in the lowest position. A CNA seated in the hallway across from the room did not redirect or assist with lowering the bed. A third resident with morbid obesity, muscle weakness, reduced mobility, abnormal posture, hypertension, and altered mental status had a fall risk assessment scored incorrectly because elimination status was not marked and predisposing factors were not selected despite the diagnosis of hypertension. The DON later affirmed that this resident was likely high risk for falls due to diagnoses and inability to walk.

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 an injury of unknown origin to a resident and did not determine the cause of the injury. The resident, who had a history of stroke with hemiplegia, unsteady gait, and multiple psychiatric diagnoses, was found with swelling and discoloration to the left eye, bruising to the chest and right leg, scratches to the face and chest, and complaints of chest pain. These injuries were identified by emergency room staff after the resident was transported to the hospital for agitation. Staff interviews revealed that the resident had been involved in altercations with staff, including throwing rubbing alcohol and physically assaulting staff members, but no staff member reported witnessing or causing the injuries observed. Multiple staff members described escalating behavioral incidents involving the resident, including verbal and physical aggression. The nurse and assistant administrator intervened and monitored the resident after the incidents, but neither reported any visible injuries prior to the resident's transfer to the hospital. The nurse did not report the injury of unknown origin to the administrator as required by the facility's abuse policy. The resident later claimed that staff had assaulted him, but staff denied any physical altercation resulting in injury. The resident's medical record indicated minimal risk for aggression in prior assessments, with only one previous note of physical aggression months earlier. The facility's abuse policy required prompt reporting of suspicious injuries, but this protocol was not followed. The origin of the resident's injuries remained undetermined, and the facility did not take appropriate steps to investigate or report the injuries as required.

Penalty

Inspection fine: $95,940

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 a resident-to-resident physical assault, resulting in one resident being struck in the face with a shoe by another resident. The assaulted resident sustained a purple discoloration to the right eyelid and petechia above the eyebrow. The incident was reported by the injured resident to both the Assistant Administrator and her son, and photographic evidence of the injury was provided. The progress notes indicated a verbal altercation between the two residents, after which the aggressor was relocated to another room. However, there was no documentation in the medical record regarding the injury, and the injured resident was alert and oriented at the time of the survey. The Assistant Administrator acknowledged being informed of the incident and observing the injury but did not report the injury of unknown origin to the State Department, nor did he initiate an investigation into the allegation of physical assault. He also did not consult the Administrator for guidance. The Administrator was unaware of the injury and confirmed the lack of documentation and reporting. The facility's abuse policy affirms residents' rights to be free from abuse, neglect, and mistreatment, but the policy was not followed in this instance.

Penalty

Inspection fine: $95,940

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 appropriate treatment and care according to physician orders and resident needs in two key areas. For one dependent resident with a history of malignant neoplasm of the right breast, constipation, and chronic pain managed with daily narcotic medication, the facility did not effectively prevent the development of severe constipation. Despite being on a bowel regimen and having PRN medications available, the resident developed a large stool burden and was hospitalized with a diagnosis of Stercoral Colitis secondary to severe constipation. Staff interviews revealed that while the resident was known to be at risk for constipation and had a history of bowel concerns, there was a lack of effective monitoring, assessment, and documentation regarding bowel movements and the administration of PRN bowel medications. The Director of Nursing confirmed that interventions were not effective and that there was insufficient documentation of assessments or progress notes related to the resident's bowel status prior to hospitalization. Additionally, the facility failed to follow physician orders for monthly laboratory monitoring of seizure medication levels for two residents with seizure disorders. For one resident prescribed carbamazepine, monthly lab draws were ordered to ensure therapeutic levels, but there were missed months where no labs were drawn or documented, and no evidence that the physician was notified of the missed labs. The resident's medication level was found to be low on one occasion, and the nurse practitioner expected a follow-up lab, which was not completed. Similarly, another resident with orders for monthly levels of multiple seizure medications did not have documentation of these labs being completed or the physician being notified of missed tests. Facility policy requires that physician orders be followed as written, including appropriate contact or notification for labs or pharmacy needs. The lack of adherence to these orders and insufficient monitoring and documentation contributed to the deficiencies identified in the care of residents at risk for constipation and those requiring therapeutic drug monitoring for seizure management.

Penalty

Inspection fine: $95,940

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 administer influenza and pneumococcal vaccines, as well as to document education and refusals for these vaccines, affecting four out of five residents reviewed for immunizations. Specifically, the Infection Prevention Nurse reported that she was responsible for educating residents and obtaining consent or refusals, but could not provide documentation of education for residents who refused vaccination. Additionally, it was noted that an outsourced clinic administered the vaccines, but there was a lack of documentation regarding education and refusals, particularly for residents who declined the influenza vaccine during the 2024 influenza season. Medical record reviews revealed that some residents had orders for annual influenza and pneumococcal vaccines and had received education and consented to both, but only received the pneumococcal vaccine. For several residents, there was no documentation of education or offers for the vaccines, despite orders being present. Facility policies required documentation of education and refusals in the medical record, but this was not consistently done, resulting in incomplete records and failure to follow established procedures for immunization documentation and administration.

Penalty

Inspection fine: $95,940

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 its abuse policy and did not investigate an injury of unknown origin involving two residents. One resident reported being struck in the face with a shoe by another resident, resulting in a visible bruise and petechia. The incident was reported to the Assistant Administrator, who observed the injury but did not report it to the State Department or initiate an investigation as required by facility policy. The Assistant Administrator also did not consult the Administrator for guidance and assumed the matter was resolved by separating the residents involved. There was no documentation of the injury in the resident's medical record, and the Administrator was unaware of the incident until informed by surveyors. The facility's abuse policy requires immediate external reporting and investigation of any allegations or suspicions of abuse, neglect, or injuries of unknown origin. Despite these requirements, the injury was not reported or investigated for 44 days. The resident's family member confirmed that the incident had been reported to him and expressed concern that it should have been investigated. The lack of timely reporting and investigation represents a failure to adhere to established protocols for resident safety and abuse prevention.

Penalty

Inspection fine: $95,940

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 its abuse policy and procedures by not immediately reporting an injury of unknown origin involving two residents. One resident reported being struck in the face with a shoe by another resident, resulting in a bruise to the right eye and petechia above the eyebrow. The incident was reported to the Assistant Administrator, who observed the injury but did not report it to the State Department or initiate an investigation as required by facility policy. The Assistant Administrator also did not consult the Administrator for guidance and assumed the matter was resolved by separating the residents involved. There was no documentation of the injury in the resident's medical record, and the Administrator was unaware of the incident until informed by surveyors. The delay in reporting the injury of unknown origin lasted 44 days, and the facility did not follow its policy, which requires immediate external reporting of any allegations of abuse, neglect, or injury of unknown origin. The policy specifies that such incidents must be reported to the Department of Public Health immediately, or within two hours if serious bodily injury is suspected, and no later than 24 hours otherwise. The failure to report and investigate the incident as required affected two residents reviewed for reporting abuse and injury of unknown origin.

Penalty

Inspection fine: $95,940

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

Facility staff failed to accurately code the Minimum Data Set (MDS) for two of three residents reviewed. For one resident, interviews with the resident and the Wound Care Coordinator confirmed that the resident had never been diagnosed with or treated for a stage 3 pressure ulcer while at the facility. Despite this, the resident's MDS documented the presence of one unhealed stage 3 pressure ulcer. Review of the resident's current and previous physician order sheets showed no wound treatment orders, further supporting that no pressure ulcer care was provided. For another resident, the MDS indicated a planned discharge to the hospital. However, progress notes and interviews with facility staff confirmed that the resident left the facility against medical advice (AMA) and was discharged to the community, not the hospital. The MDS nurse acknowledged the error, stating that the discharge destination was incorrectly coded due to a misunderstanding of the resident's actual discharge status. Documentation, including a signed Release of Responsibility form, supported that the resident left AMA.

Penalty

Inspection fine: $95,940

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 refer a resident with documented diagnoses of major depressive disorder and schizoaffective disorder for a Level II preadmission screening and resident review (PASRR), as required. The resident was admitted with alcoholic polyneuropathy and liver disease, and their medical records included diagnoses of major depressive disorder and schizoaffective disorder. Despite these diagnoses, the initial PASRR Level I screen indicated no evidence of a serious mental illness or related condition, and no Level II screening was conducted. The Assistant Administrator confirmed that the resident's diagnoses should have prompted a new PASRR screening, but no additional screening was performed or documented during the survey.

Penalty

Inspection fine: $95,940

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 review and revise a resident's wound care interventions as required. A resident with a stage 3 pressure ulcer on the ankle, identified on 4/4/25, did not have the wound properly documented in the care plan until 5/29/25, despite the wound being present and later noted as healed on 5/23/25. The wound care nurse acknowledged that the care plan should specify the staging of the wound and differentiate between actual and at-risk skin impairments, but the care plan initially lacked this information. When the care plan was reviewed by the surveyor on the morning of 5/29, it did not include the stage 3 pressure ulcer or a history of the impairment, and the goal for wound care was not specified.

Penalty

Inspection fine: $95,940

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 its consultant pharmacist properly identified and reported the absence or inadequacy of indications for use of certain medications during the monthly drug regimen review, as required by facility policy. Specifically, for two residents, the pharmacist did not note irregularities in the use of apixaban and benztropine mesylate. One resident had an order for apixaban with the stated indication of tachycardia, but the medical record did not contain a diagnosis of tachycardia, and the resident's pulse rates were within normal limits. The Assistant Director of Nursing and the pharmacist both confirmed that apixaban is not used to treat tachycardia. Another resident had an order for benztropine mesylate with an unclear indication listed as "other symbolic functions." The pharmacist was unable to clarify what this diagnosis referred to and did not report any irregularities in the medication regimen review. The facility's consultant pharmacy services agreement requires the pharmacist to review each resident's medication regimen monthly, including ensuring that medications are prescribed for appropriate indications, but this process was not followed for the residents in question.

Penalty

Inspection fine: $95,940

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 its transmission-based isolation policy for two residents when one resident was found to have Extended-Spectrum Beta-Lactamases (ESBL) in the urine. Despite a physician order for contact isolation, census records show that the resident's roommate was not relocated during the period of isolation, even though open beds were available. The facility's policy requires that either the infected resident or their roommate be moved to prevent transmission, but this was not done according to the census documentation. Additionally, the order for contact isolation was not discontinued after the completion of treatment, contrary to facility policy, which states that isolation should end once treatment is completed. The residents involved included one with a history of dysuria, weakness, hernia, major depressive disorder, and ulcerative colitis, who required maximal assistance with toileting and was frequently incontinent. The roommate had diagnoses including Alzheimer's disease, dementia, bipolar disorder, and schizoaffective disorder, with moderately impaired cognition. The Infection Prevention RN confirmed that the roommate should have been moved and that the isolation order should have been discontinued after treatment, but these actions were not reflected in the records.

Penalty

Inspection fine: $95,940

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, as evidenced by the presence of rodents and flying insects in resident rooms. On one occasion, a resident was observed screaming after seeing a mouse in her room, and both she and another resident reported hearing mice days prior, prompting the Maintenance Director to place traps. A housekeeper later confirmed removing a mouse caught in a trap from under the resident's bed. Additionally, numerous flies were observed in another resident's room, particularly around soiled linen left on the floor, which was confirmed by both a CNA and a housekeeper. The facility's pest control policy requires the building to be kept free of insects and rodents, but these incidents demonstrate that the policy was not effectively implemented.

Penalty

Inspection fine: $95,940

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 staff thoroughly assisted and documented resident concerns and grievances during monthly resident council meetings over a five-month period. Review of resident council meeting minutes revealed no documented concerns, despite residents stating that issues were raised during the meetings. The president of the resident council specifically noted that concerns about nursing staff behavior during overnight shifts and suggestions related to food were discussed but not recorded in the minutes. Additionally, a review of the facility's grievance records showed only three listed concerns, none of which matched those mentioned by the resident council president. Interviews with the activity director confirmed that residents had voiced concerns during recent meetings, but these were not documented in the official minutes. The activity director stated she removes concerns from the minutes and gives them to Social Services, but could not recall the specific concerns raised. Residents also reported that their rights were not being reviewed during meetings. The facility's policy requires staff to document and address grievances, but the lack of documentation in both meeting minutes and grievance logs indicates this process was not followed.

Penalty

Inspection fine: $12,048

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 monitor and supervise a newly admitted resident with a known history of falls, confusion, and assessed to be at high risk for falls. This deficiency resulted in the resident sustaining a laceration to her left eyebrow that required hospital treatment with sutures after a fall in the facility hallway. The resident, a female with a history of dementia, hypertension, and hypothyroidism, was admitted to the facility and assessed as having impaired memory, unsteady gait, and a history of falls. Despite being identified as a high fall risk, the interim fall care plan did not include provisions for assistive devices. On the night of the incident, the resident was found on the floor with a laceration above her left eyebrow, which was not witnessed by staff. The resident was ambulatory with an unsteady gait and was continuously walking up and down the hallway, not yielding to redirection. The staff, including the CNA assigned to the resident, were not monitoring the hallway at the time of the fall as they were engaged in other duties. The facility's fall prevention policy requires individualized interventions for residents at risk, but these were not adequately implemented for the resident. Interviews with facility staff, including the DON, LPN, and CNA, revealed that the resident's fall risk was known, but the necessary supervision and monitoring were not provided. The fall coordinator stated that residents should be monitored during the night shift, with CNAs staying close to resident rooms and rounding every 1 to 2 hours. However, the CNAs were not monitoring the hallway during rounds, contributing to the lack of supervision that led to the resident's fall.

Penalty

Inspection fine: $12,048

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 residents from abuse by not ensuring adequate staff supervision in the dining area, particularly for residents with a history of aggression. This deficiency was evident in an incident involving two residents, one with a history of schizophrenia, delusional disorders, bipolar disorder, dementia, and legal blindness, and another with schizoaffective disorder and a history of aggressive behavior. The incident occurred in the dining hall where the two residents engaged in a verbal altercation that escalated into a physical confrontation, resulting in one resident being hit in the face and sustaining injuries. The facility's staff did not adequately monitor the residents in the dining area, which led to the altercation. Witnesses reported that there was only one Certified Nursing Assistant present during the initial stages of the incident, and she was unable to stop the altercation on her own. It took additional staff members to intervene and separate the residents. The lack of sufficient staff presence and supervision allowed the situation to escalate, resulting in one resident being sent to the hospital for evaluation and treatment of injuries sustained during the altercation. Interviews with staff members revealed that there were inconsistencies in the supervision of residents in the dining area. Some staff members stated that there should always be at least one staff member present, while others indicated that the presence of staff was not consistent, especially during shift changes. The facility's abuse policy states that residents who allegedly abuse another resident should be removed from contact with others during the investigation, but this was not effectively implemented in this case, contributing to the deficiency.

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 a cognitively impaired resident, who requires supervision and has a history of wandering, from leaving the facility without staff knowledge. This incident involved a resident diagnosed with Encephalopathy, Drug Induced Subacute Dyskinesia, Malaise, Reduced Mobility, Adjustment Disorder, Type 2 Diabetes Mellitus, Seizures, and Hypertension. The resident, who had a cognitive assessment score indicating moderate cognitive impairment, left the facility through his bedroom window without staff noticing. The resident was found days later at a fire station and subsequently transported to a hospital due to knee pain. On the day of the incident, staff noticed the resident was missing around 2:00 PM, and a code purple was initiated. Despite searching the facility and surrounding areas, the resident was not found until he presented himself at a fire station three days later. Interviews with staff revealed that the resident's window was not secured to prevent it from opening fully, allowing the resident to exit through it. The maintenance director confirmed that many windows in the facility were not equipped with safety mechanisms to prevent them from opening wide enough for a person to pass through. The facility's social services and nursing staff were unaware of the resident's high risk for elopement, as the resident's behavior and cognitive assessments were not adequately reflected in his care plan. The resident's elopement risk was not properly assessed, and preventive measures were not in place. This lack of awareness and preventive action led to the resident's unauthorized departure and subsequent absence from the facility for several days, during which he did not have access to his medications and was exposed to potential harm.

Removal Plan

• Identification of Residents Affected or Likely to be Affected: nine other residents were identified as wanderers and were added to the elopement list following the completion of the reassessment.
• All nine residents were also added to the elopement binder.
• The Care plans were reviewed and updated accordingly for all nine residents. Eight of the nine residents were moved to rooms with windows that lead to a courtyard and are not directly accessible to the exterior/exit areas of the facility. One resident refused the room change; however, her room is located directly across from social services office and her windows have been secured.
• There is a total of 11 residents on the elopement list/binder.
• The facility has a total of 81 windows, all 60 windows were secured to only open three inches except for 21 windows. The 21 windows were not secured because they do not lead/have access to exit the premises as they lead to the patio/courtyard which is within the facility. The maintenance director assessed and secured all external windows that are accessible to exit the premises.
• The Asst. Administrator initiated an in-service/training on elopement protocol to staff.
• The trainings on elopement prevention mentioned in the section are new and have been integrated in the facility's policies and procedures regarding elopement prevention.
• The facility does not utilize agency staff at this time, nonetheless, if the need arises in the future, the DON/ADON/Charge nurse will provide training on elopement prior to start of shift.
• The IDT (Interdisciplinary Team) which includes the DON (Director of Nursing), unit manager, social services director, activity director reviewed R6's care plans to ensure that wandering behavior and elopement risks are addressed. Resident was moved to another room, with window that opens to a secured courtyard. The window was secured so it does not open fully.
• R6's elopement assessment was completed by the social services director. R6 was added to the elopement binder. Nurse Practitioner also completed an evaluation upon return to the facility.
• R6 was placed on one-to-one supervision for 72 hours.
• Resident head count of the whole facility was completed by the DON/clinical managers. There was no concern identified.
• Headcount is done during shift change as part of the nurse-to-nurse shift reporting and when completing the midnight census.
• Elopement/Wandering assessment will be completed for all residents. The assessment will be completed by the DON (Director of Nursing), unit manager, Administrator and Social Services.
• Any resident who is identified with wandering behavior/ elopement risk will have care plans developed. This will be completed by the IDT.
• The elopement binders will be updated and will have elopement binders in all nursing stations, kitchen, front desk, and department head offices.
• The elopement binder is not new, but it is updated when a new resident is added to the binder. A resident is added to the binder when the resident is identified with exit-seeking behavior/risk for elopement.
• The Maintenance Director/Environmental staff will assess all windows of the facility and will secure windows and prevent the windows from fully opening to prevent a resident from using the window to exit the building.
• The Maintenance Director/MOD (Manager on Duty) will conduct rounds of all windows daily to ensure windows are always secure. The QAPI team conducted an Ad-Hoc QAPI meeting and decided to secure the windows to only allow 3-inch opening to prevent a resident from using the window to elope. An Ad-Hoc resident council meeting is scheduled to discuss the new standard of securing the windows in the facility.
• The facility utilized an L-bracket (also called corner brackets or angle braces) which is fastened to the window frame to prevent the window from fully opening and only allow the 3-inch opening. The residents are not able to tamper with the security of the windows.
• The Administrator will provide training to the IDT regarding development of care plans to address residents who are identified with exit-seeking /wandering behaviors and elopement risk.
• The DON/Administrator/Social Services Director will provide education to the staff. The education items include but not limited to: a) Code Purple b) Use of the elopement binders c) Exit-seeking behaviors and interventions d) Elopement risk and wandering and interventions e) Policy on missing resident f) Responding to alarms and g) Resident safety and supervision h) Reporting to the Administrator/Maintenance Director any concern related to windows.
• The training will be completed. Any staff who are not available, on vacation or leave of absence will have training completed at the start of their shift upon return to work.
• To measure knowledge retention, posttests will also be started. The Administrator/Director of Nursing/Social Services Director will conduct posttests of five random staff to evaluate knowledge retention. Five posttests per week for four weeks will be completed. The acceptable score of the post-test is 100%. Any staff who will not meet the acceptable score will receive additional training. The Administrator/Director of Nursing/Social Services Director will provide the staff with training on specific areas based on the results of the post tests.
• To ensure that all staff are trained prior to the start of their next shift if off duty, the DON/Administrator will notify the staff to meet with their supervisor/charge nurse/DON when they return to work. The supervisor/charge nurse/DON will ensure that the training is done before starting their work shift. The Administrator/DON/Social Services Director will provide the training. If the DON/Social Services Director are not available, a trained nurse will provide the training.
• The facility will conduct the same training quarterly for four quarters, and then annually thereafter. The training will also be included in the orientation of new employees.
• At this time, the facility is not utilizing agency. In the future, if the facility will use agency, the DON/Social Services Director/Administrator will provide the same training to the agency staff.
• Actions to Prevent Occurrence/Recurrence: Ad-Hoc QAPI meeting was completed which were participated by the leadership team which includes the Director of Nursing (DON), Unit Manager (UM), Risk Manager (RM), Social services Director (SSD), Admissions Director, Minimum Data Set (MDS) Coordinators, Maintenance Director, Business office Manager (BOM), Rehabilitation Manager, Human Resource Director and the Activities Director (AD). The Medical Director also participated via telephone. The QAPI team discussed the incident and the corrective actions to prevent similar events.
• Elopement drill will be completed by the Maintenance Director and Administrator. This will also be completed daily, for the seven days, and will be done at different shifts. After seven days, the elopement drills will be done weekly for three months, then monthly thereafter. The elopement drills will be completed per policy, as indicated above.
• All exit doors in the facility will also be checked by the Maintenance Director to ensure all doors were locked and secure and that delayed egress was functioning properly. Door checks will be completed daily, including weekends by the MOD-manager on duty/charge nurse. The door checks will be completed by Maintenance Director, or other members of the maintenance team. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed.
• The Maintenance Director/Environmental Service Director/MOD will also conduct window checks daily. Window checks will be completed daily, including weekends by the MOD-manager on duty/charge nurse. The window checks will be completed by Maintenance Director, or other members of the maintenance team. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed.
• Daily, the DON, clinical managers, and members of the IDT will hold clinical meetings and discuss new or worsening wandering/ exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring that appropriate clinical interventions are implemented to prevent an incident of elopement. The MOD (manager on duty)/charge nurse, DON will also conduct weekend clinical meetings to review new or worsening exit seeking/wandering behaviors and ensure interventions are in place to prevent elopement.
• New admissions will be reviewed by the DON, Risk Manager, Wound Nurse or MDS for elopement risk and any resident identified as being at risk will be updated into the facility elopement books.
• The QAPI team will hold a weekly Ad-Hoc QAPI meeting to discuss the elopement prevention program and review interventions to new/worsening wandering/exit-seeking behaviors. The QAPI team will determine if additional corrective actions are necessary based on concerns identified.
• The Administrator/Social Services Director/DON will conduct audits of the Elopement Binder daily for three months to ensure that identified elopement risk are included in the binder. Additionally, the Administrator/Social Services Director/DON will also review five residents weekly for three months to ensure that residents who are identified with new and/or worsening exit-seeking behaviors and wandering are being addressed in the care plans. After three months, the QAPI team will determine if additional monitoring or corrective actions are necessary.
• To evaluate the effectiveness of the removal plan, QAPI team will review results of the audits, posttests, door and window checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities.

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 effective pest control program, resulting in the presence of pests such as roaches and ants. Multiple residents reported seeing roaches in their rooms and hallways, with some residents stating they had to kill the pests themselves. Observations by the surveyor confirmed the presence of a dead bug in the dining room, and staff members also acknowledged seeing roaches and other pests. Despite having a pest control service scheduled twice a month, the facility did not adequately address pest sightings reported by residents and staff, as evidenced by the lack of documentation in the pest control logbook and the continued presence of pests. Interviews with staff and residents revealed that pest sightings were not consistently reported or documented, leading to delays in addressing the issue. The maintenance staff and administration were aware of the pest problem but did not take timely action to resolve it. The facility's pest control policy, which mandates an ongoing pest control program, was not effectively implemented, as shown by the recurring pest sightings and the lack of follow-up on reported incidents. The pest control service records indicated evidence of cockroaches, but the facility failed to maintain a pest-free environment for its residents.

Penalty

Inspection fine: $10,036

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 the State inspection survey results readily available and accessible to residents, family members, and legal representatives. During a Resident council meeting, all ten residents in attendance stated that they were unaware of the location of the State Inspection results binder and had not seen any signage indicating its location. The Office Manager also did not know where the binder was and could not locate it at the front desk. The Administrator and Assistant Administrator were unable to find the binder after searching for approximately five minutes. The facility's policy on Resident Rights states that residents have the right to examine the results of the most recent survey conducted by Federal or State surveyors, but this was not being upheld.

Penalty

Inspection fine: $10,036

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 label multi-dose medication in accordance with professional principles, as observed in the first-floor medication storage room. Two vials of opened, undated Tuberculin, Purified Protein (Mantoux) 5TU/0.1ml, 10 dose vial were found. The Director of Nursing (DON) confirmed that the multi-dose vials should be labeled with an open or accessed date and a discard date of 28 days unless the manufacturer specifies a different date. This failure has the potential to affect all 93 residents currently residing in the facility, as per the facility policy on the storage of medications. Additionally, the facility failed to discard expired glucagon from their emergency medication box, which has the potential to affect all 13 diabetic residents in the facility. The expired glucagon syringes were found in the emergency medication box, with expiration dates documented as past due. The DON stated that the pharmacy is responsible for removing expired medication, but the pharmacy consultant reported not checking the emergency medication box for expired medications. This oversight led to the presence of expired glucagon in the emergency medication box, which should have been discarded and replaced with non-expired medication.

Penalty

Inspection fine: $10,036

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 a resident's fall care plan by not placing the call light within reach. During an observation, the surveyor noted that the call light was clipped to the privacy curtain, approximately three feet away from the resident, making it inaccessible. The resident, who has a history of falls, confirmed that she could not reach the call light and had previously fallen when attempting to transfer to her wheelchair without staff assistance. Both a Certified Nurse Aide and a Licensed Practical Nurse verified that the call light was out of reach and acknowledged that it is the staff's responsibility to ensure call lights are accessible to residents. The resident's fall care plan, initiated on a previous date, specifically included an intervention to promote the placement of the call light within reach. Despite this, the call light was not positioned correctly, leading to a situation where the resident could not call for assistance. The facility's Fall Prevention and Management policy emphasizes the importance of creating a safe environment and implementing preventative strategies for residents at risk of falls. However, the failure to adhere to the care plan and policy resulted in the resident being unable to summon help, increasing the risk of further falls and injuries.

Penalty

Inspection fine: $10,036

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 their hypoglycemia protocol by not administering glucagon to a resident with a low blood sugar who was unresponsive. The resident, who has a history of type 2 diabetes, metabolic encephalopathy, and hemiplegia following a cerebral infarction, was found unresponsive with a blood sugar level of 45. Despite the protocol requiring glucagon administration for unresponsive residents with low blood sugar, the nurse did not administer glucagon because it was not available in the medication cart. Instead, the nurse called 911 and waited for the ambulance, which administered glucagon upon arrival. The resident's condition was first noticed by a CNA who found the resident unresponsive while passing breakfast trays. The nurse confirmed the low blood sugar and called for emergency assistance but did not follow the hypoglycemia protocol due to the unavailability of glucagon in the med cart. The nurse stated that glucagon is usually kept in the med cart but was not there at the time. The Director of Nursing confirmed that glucagon should have been administered and is stored in the emergency medication box in the medication room. The resident was transported to the hospital by paramedics, who found the blood sugar to be critically low at 20 and administered glucagon, which slightly improved the resident's responsiveness. The hospital records confirmed the resident was admitted with a diagnosis of hypoglycemia. The facility's policy clearly states that glucagon should be administered to unresponsive residents with low blood sugar, but this protocol was not followed in this case, leading to a delay in appropriate treatment for the resident.