Bria Of Woodriver

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 call lights were answered in a timely manner for multiple residents, despite a policy directing staff to respond to resident calls as soon as possible. Interviews and record reviews showed that six residents, several of whom were cognitively intact and required assistance with activities of daily living such as toileting, hygiene, dressing, and transfers, reported frequent and prolonged delays in call light response. One resident who uses a wheelchair and needs substantial/maximal assistance stated that call lights are typically unanswered for at least 30 minutes or more and that this concern is repeatedly raised at Resident Council meetings without improvement. Another cognitively intact resident who can perform most tasks independently reported that residents regularly complain that staff are on their phones, do not want to work, and fail to answer call lights. Additional residents with moderate cognitive impairment and functional limitations described waiting long periods for toileting assistance, including one resident who reported feeling embarrassed after wetting the bed because staff did not respond quickly enough to the call light. Another wheelchair-bound resident needing partial to moderate assistance with ADLs stated it was not uncommon to wait about forty minutes, especially at night, for staff to respond. Other residents reported that staff “do not want to work” and that call lights are often unanswered for an hour or more, causing stress when help is needed. The Ombudsman confirmed receiving numerous complaints and making several visits regarding delayed call light response, noting the problem persisted. Resident Council minutes and written grievances over several months documented repeated reports of call lights remaining on for over an hour on all shifts, staff sitting at the desk while call lights and doorbells rang, and concerns that nurses were not assisting CNAs with answering call lights. The DON acknowledged awareness of some complaints and stated an expectation that call lights be answered within 10–15 minutes, while the written policy required answering resident calls as soon as possible.

Penalty

Fine: $70,755

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 prevent elopement for two residents, both of whom had identified elopement risk and/or cognitive or psychiatric conditions. One resident (R2) had multiple diagnoses including dementia with agitation, schizophrenia, major depressive disorder, aphasia, chronic respiratory failure, facial weakness after stroke, and unsteadiness on feet. His MDS documented severe cognitive impairment and need for assistance with transfers and supervision or touching assistance for wheelchair mobility. R2’s care plans repeatedly identified him as high risk for elopement and falls, with interventions including use of a wander guard, monitoring of its function and placement every shift, replacement every 90 days, redirection from exits, and assistance with ADLs. Multiple elopement risk assessments over many months rated him as high risk. On the night of his elopement, R2 exited through the front door around 2:05 AM in his wheelchair. Facility video and external agency camera footage showed him leaving the front lobby, moving toward a neighboring assisted living facility, remaining in that area for a period, then traveling along the road and out of camera view. Staff on duty did not identify him as missing until approximately 8:00 AM, despite expectations from leadership and multiple staff interviews that residents should be rounded on and visually seen at least every two hours to confirm safety. Night staff, including the assigned CNA and LPN, reported they did not lay eyes on R2 for extended periods, relied on verbal assurances rather than direct observation, and in one case mistook his roommate for him during rounds. Staff also reported they were not informed that R2 was at risk for elopement, were unaware of an elopement risk binder, and did not initiate a head count or elopement process when they could not locate him. R2 was ultimately located by police approximately 4.4 miles away from the facility in his wheelchair. The report also documents systemic issues with the facility’s elopement prevention systems and door alarms. Although R2’s care plan required a wander guard, multiple medication administration notes in the weeks before and after the elopement documented that his wander guard was not in place or not available on several dates, and staff noted he frequently removed it. Leadership and staff gave conflicting accounts about whether R2 had a wander guard the night of the elopement and whether he was considered an elopement risk. The front lobby door alarm did not sound at the nurse’s stations like other exits, and several key staff, including the DON, HR, and RNC, were unaware that the front door alarm could not be heard from the nursing stations. The maintenance director confirmed that the front and north doors were set differently due to high traffic and that the front door alarm only sounded locally at the door. Staff interviews further showed inconsistent knowledge of elopement risk identification, reliance on residents knowing door codes, and lack of clear rounding policy at the time, all contributing to the failure to supervise and prevent R2’s elopement. A second resident (R4) was also identified as at risk for elopement due to delusions and stated intent to leave, with care plan interventions including 1:1 as needed, 15–30 minute checks as needed, and use and monitoring of a wander guard. R4 eloped through the front door and was found across a busy two-lane road approximately 500 feet from the facility entrance. The report attributes both residents’ elopements to the facility’s failure to ensure the environment was free from accident hazards and to provide adequate supervision, including failure to consistently implement care-planned elopement interventions, failure to ensure functioning and properly monitored wander guards, and failure to maintain an effective door alarm system that alerted nursing staff when at-risk residents approached or exited through the front door.

Penalty

Fine: $283,46021 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 ensure that staff were educated and competent in providing necessary care and services for residents with tracheostomies, as required by each resident's written plan of care. Multiple residents with tracheostomies experienced repeated episodes where staff were unable to perform routine tracheostomy care, such as suctioning, cleaning, and tube changes. In several cases, residents were sent to the hospital for issues that should have been managed within the facility, including removal of mucus plugs, tracheostomy replacement, and management of secretions. Documentation revealed that staff did not perform suctioning when residents exhibited symptoms such as secretions or emesis from the tracheostomy, and there was a lack of documentation of interventions to prevent repeated tracheostomy dislodgement in one resident. One resident was found unresponsive, and staff performed CPR incorrectly by bagging the resident's mouth instead of the tracheostomy, as they were unaware of the correct procedure. Staff interviews confirmed that neither the LPNs nor CNAs had received training on tracheostomy care or emergency response for residents with tracheostomies. The local fire department and paramedics reported frequent calls to the facility for non-emergent tracheostomy issues, such as suctioning and cleaning, which they considered routine care that should be managed by facility staff. In several instances, emergency responders found that the facility lacked necessary equipment, such as suction tips, and that staff were not using available equipment properly. The deficiency was further evidenced by staff statements indicating a lack of formal or routine training on tracheostomy care, with some staff expressing discomfort and lack of knowledge in providing such care. The facility's own documentation and job descriptions required staff to remain current in facility policies and procedures, including specialized care needs such as tracheostomy care. Despite this, the facility assessment indicated that tracheostomy care was a service provided, yet staff were not adequately prepared to deliver this care, resulting in repeated hospital transfers and, in one case, a resident death.

Removal Plan

• Tracheostomy in-service was completed
• All nurses, including agency nurses, were educated

Penalty

Fine: $283,46021 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

Nursing staff failed to provide safe and appropriate respiratory care for residents with tracheostomies, as evidenced by a lack of knowledge, skills, and necessary supplies. Multiple staff members, including RNs, LPNs, and CNAs, reported not having received training on tracheostomy care or CPR for residents with tracheostomies. During emergencies, staff were unable to properly ventilate residents with tracheostomies, as they did not know how to use the bag-valve-mask (BVM) with a tracheostomy tube and instead attempted to ventilate via the mouth, which is not appropriate for these residents. In several cases, staff were unable to suction or replace tracheostomy tubes due to lack of training or proper equipment, resulting in inadequate airway management. Two residents with tracheostomies, both full code, experienced respiratory distress and required CPR. In both cases, staff did not provide ventilation through the tracheostomy tube during resuscitation efforts, and only performed chest compressions or attempted to bag over the mouth. There were multiple reports of staff not having the correct tubing or not knowing how to attach the BVM to the tracheostomy. Both residents died in the facility, with death certificates pending. Other residents with tracheostomies were sent to the hospital for issues such as secretions, mucus plugs, or tracheostomy tube dislodgement, which could not be managed by facility staff due to lack of training or supplies. Emergency medical services and local fire department personnel reported frequent calls to the facility for non-emergent tracheostomy care needs, such as suctioning or cleaning, which should have been managed by facility staff. In several instances, EMS had to use their own equipment to suction residents, as the facility lacked necessary supplies like suction tips. Staff interviews confirmed that there was no routine or formal training on tracheostomy care, and some staff expressed discomfort or lack of proficiency in caring for residents with tracheostomies. The facility's own policy required routine tracheostomy care and suctioning as needed, but this was not consistently provided.

Removal Plan

• Tracheostomy in-service was completed and all nurses, including agency nurses, were educated prior to the start of their next scheduled shift.

Penalty

Fine: $283,46021 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 provide Cardiopulmonary Resuscitation (CPR) according to accepted professional standards for two residents with tracheostomies who were full code status. In both cases, staff did not provide adequate respiratory ventilation through the residents' primary airway, the tracheostomy, during resuscitation efforts. Instead, staff attempted to provide ventilation via the mouth or did not provide ventilation at all, despite the presence of bag valve masks (BVMs) in the room, which were not compatible with the tracheostomy or staff did not know how to use them properly. For the first resident, who had chronic obstructive pulmonary disease, asthma, and a tracheostomy, staff initiated CPR after the resident was found unresponsive and cyanotic. However, they were unable to attach the BVM to the tracheostomy and instead covered the tracheostomy with a gloved hand and attempted to bag via the mouth, ultimately providing only chest compressions without ventilation. For the second resident, who had anoxic brain damage, paraplegia, respiratory failure, and a tracheostomy, staff also failed to ventilate through the tracheostomy. Staff attempted to bag via the mouth, not realizing the need to ventilate through the tracheostomy, and were unfamiliar with the correct procedure and equipment. Interviews with staff revealed a lack of knowledge and training regarding CPR for residents with tracheostomies, as well as issues with equipment availability and compatibility. The facility's own policies required that residents with tracheostomies receive care to maintain a patent airway and that CPR be performed per BLS guidelines, but these were not followed. Both residents died following these events, and the failures were confirmed through interviews, record reviews, and observations by surveyors.

Removal Plan

• Staff were inserviced on performing CPR on residents with tracheostomies
• CPR Policy was reviewed
• CPR equipment was verified as available in the Facility
• CPR audits were initiated
• QAPI Meeting was held

Penalty

Fine: $283,46021 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

A deficiency occurred when staff failed to report a resident's significant change in condition to nursing staff for timely assessment and intervention. The resident, who had a history of anoxic brain damage, paraplegia, respiratory failure, and tracheostomy status, was noted by two CNAs to have dilated pupils, cool skin, decreased responsiveness, and increased muscle stiffness during care. Despite these notable changes from the resident's baseline, neither CNA informed the nurse on duty about the observations. Approximately 15-20 minutes after the initial observations, one of the CNAs returned to check on the resident and found the individual unresponsive. The CNA then notified the nurse, who arrived after a short delay, and CPR was initiated. Multiple staff members, including a paramedic and other CNAs, later confirmed that the resident was cold to the touch and already stiffening during resuscitation efforts, indicating a significant lapse in timely recognition and response to the change in condition. Interviews with staff, including the DON and Medical Director, confirmed that facility policy requires staff to report any change in a resident's condition to a nurse, and if the assigned nurse is unavailable, to another available nurse. However, the CNAs involved did not communicate the observed changes, and the facility's policy did not specifically address communication protocols between nurse aides and licensed nursing staff. This failure to report and respond to the resident's change in condition resulted in a delay in assessment and intervention.

Removal Plan

• Clinical and agency staff were in-serviced on timely assessments
• Notification of Change Policy was reviewed
• QAPI meeting was held
• 24 hour reports were reviewed for change in condition

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 timely access to a resident's medical records as required, specifically for one resident whose records were requested by an attorney. The process for handling medical record requests was disrupted when the staff member responsible for medical records was terminated, and the responsibility was transferred to the Business Office Manager, who was coordinating with the Regional Medical Records person. There was confusion and lack of communication regarding the receipt and processing of the request, with the Administrator and other staff members unaware of the outstanding request until much later. Documentation shows that the attorney's office made multiple attempts to request the records, including sending faxes, making phone calls, and mailing the request. The facility's fax numbers and process for handling requests contributed to the delay, as one fax number went directly to a copier/fax machine and was not monitored as closely as the secure fax/email. The previous medical records staff member indicated that she had started processing the request but was terminated before completion, and the request was not properly handed off or tracked. The facility's own policies require that all medical record requests be given to the Administrator and outline steps for processing such requests, including verification of authority and notification of costs. However, these procedures were not followed, resulting in a significant delay in providing the requested records. The deficiency was identified through interviews, record reviews, and documentation of the multiple attempts made by the attorney's office to obtain the records.

Penalty

Fine: $48,620

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 written wound care orders for a resident who was admitted with third-degree burns on the right foot, type 2 diabetes, and recent surgical aftercare. Upon admission, the resident's hospital discharge summary and care plan included specific instructions for wound care, including the use of bacitracin and xeroform dressings, daily washing, and dressing changes. However, documentation and interviews revealed that these orders were not consistently followed. The Treatment Administration Record (TAR) showed no wound care was signed off for two consecutive days, and there was no PRN order for wound care in the TAR. Staff interviews indicated confusion about the wound care orders, with some nurses expressing discomfort or lack of familiarity with the severity of the wounds, and others admitting to not performing wound care as required. The resident and family members reported that wound care was rarely performed, dressings were not changed or washed as ordered, and wound care was sometimes conducted in unsanitary conditions, such as on the floor of the resident's room. The wound care nurse admitted to removing a dressing that was supposed to remain in place and to not having the required bacitracin ointment available, substituting A&D ointment without notifying the provider or obtaining new orders. Communication lapses were evident, as the facility did not inform the hospital or the Director of Nursing about the lack of bacitracin, and the wound care nurse did not consistently document wound care in the TAR, instead making late entries in progress notes due to computer issues. As a result of these failures, the resident's wounds declined, leading to infection, increased pain, and ultimately hospital readmission for wound cellulitis and additional surgical intervention. Laboratory results showed elevated white blood cell counts, and wound cultures were positive for multiple organisms. The resident, his family, and clinical staff all described a pattern of missed or improperly performed wound care, lack of adherence to physician orders, and inadequate documentation, which directly contributed to the resident's deteriorating condition and need for further hospitalization.

Penalty

Fine: $48,620

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 a history of third-degree burns to the right foot, type 2 diabetes mellitus, and recent skin graft surgery was admitted to the facility with specific wound care and pain management orders. The resident's care plan included interventions to provide treatment as ordered, and physician orders were in place for acetaminophen and oxycodone to be administered as needed for pain. Upon admission, the resident's wound care orders from the hospital specified that the xeroform dressing on the donor site (left thigh) should be left in place, washed daily, and not removed until healed. Despite these orders, a wound care nurse attempted to remove the xeroform dressing from the resident's thigh, causing the resident to experience severe pain and bleeding. The nurse did not pre-medicate the resident prior to the dressing removal attempt, and only stopped after the resident expressed extreme pain and refused further care. The nurse later discovered the correct wound care instructions, which indicated the dressing should not have been removed. Documentation and interviews confirm that the resident was not provided adequate pain management before the procedure, and the wound care was not performed according to the physician's orders. The resident reported significant distress, stating that the dressing was removed without proper pain control, resulting in severe pain and bleeding. Staff interviews corroborated that the resident was in extreme pain during the dressing removal and that pain medication was only administered after the incident. The facility's pain management policy emphasizes the importance of addressing pain as reported by the resident, but this was not followed in this instance, leading to unnecessary suffering.

Penalty

Fine: $73,575

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 assess, monitor, and treat a change in condition for a resident, leading to a delay in treatment and subsequent hospitalization. The resident, who had Alzheimer's Disease and Dementia, was admitted with a history of influenza and was on oxygen therapy, which she frequently refused. Despite her refusal to use supplemental oxygen and a noticeable decline in her condition, including reduced meal intake and weight loss, there was a lack of documentation and communication regarding her deteriorating state. The resident's vital signs showed concerning changes, such as low blood pressure and oxygen saturation, yet there were no nursing notes or assessments documenting these changes or any notification to the physician. Staff interviews revealed that the resident was not eating well, appeared sluggish, and was not her usual self, but these observations were not adequately documented or communicated to the medical team. The resident was eventually sent to the hospital with altered mental status, hypotension, and dehydration, where she was diagnosed with pneumonia, acute on chronic hypoxic respiratory failure, and other conditions. The facility's policies required notification of the physician for significant changes in a resident's condition and documentation of any unusual events or changes. However, these protocols were not followed, as evidenced by the lack of documentation and communication regarding the resident's decline. The Director of Nurses acknowledged the oversight in monitoring the resident's weight loss and meal intake, and the Medical Nurse Practitioner confirmed that they were not informed of the resident's decline, which contributed to the delay in addressing her medical needs.

Penalty

Fine: $73,575

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 identify, assess, and monitor pressure ulcers, and provide the physician-prescribed treatment for four residents. One resident developed a pressure ulcer of unknown stage while at the facility and did not receive treatment for 23 days, during which time it became unstageable. Another resident developed three pressure ulcers while at the facility, including a sacral pressure ulcer that became infected. The facility's records failed to document necessary assessments and treatments, and there were inconsistencies in the treatment administration records. For one resident, the facility's records did not document a Braden Scale assessment before a certain date, and there was a lack of documentation regarding the monitoring, assessment, or treatment of a pressure ulcer for several weeks. The resident's treatment administration record showed that the resident refused dressing changes multiple times, and there were discrepancies between the treatment recommendations and the documented orders. Another resident's records failed to document an admission assessment, and there were inconsistencies in the documentation of skin conditions and pressure ulcers. The facility's staff did not consistently follow the prescribed treatment orders, and there were instances where treatments were not administered as ordered. The facility's policy required that pressure injuries be evaluated and documented weekly, but this was not consistently done. Additionally, there were communication issues between the wound nurse practitioner and the facility staff, leading to delays in implementing treatment recommendations. The facility's failure to adhere to its own policies and procedures contributed to the deficiencies in pressure ulcer care.

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 its Abuse Policy and Prevention Program concerning a case of drug diversion involving a resident who was unable to communicate due to impaired cognition. The incident involved the disappearance of Lorazepam, a medication provided by hospice, which was scheduled to be administered every six hours. The medication was last administered at 6 AM by the midnight nurse, and it was discovered missing during the evening shift on January 10th. The facility's policy required an immediate investigation and notification to local law enforcement if there was a reasonable suspicion of a crime, but this was not done in a timely manner. The Director of Nursing (DON) and the Administrator reviewed video footage, which was inconclusive in identifying the individual responsible for the medication's disappearance. However, the footage showed an agency nurse spending an unusual amount of time with the narcotic box open and going in and out of a hospice resident's room. Despite these observations, the facility delayed notifying the police, as the DON believed she needed to complete her investigation before contacting law enforcement. This delay was contrary to the facility's policy, which required immediate reporting of suspected crimes. The incident report was eventually filed with the local police department, but not until several days after the medication was confirmed missing. The police report indicated that the facility had narrowed down the suspect to one nurse and had video footage of the incident. The delay in reporting the incident to law enforcement was acknowledged by the Administrator, who stated that the notification should have been completed more promptly. The facility's failure to adhere to its policy resulted in a deficiency in handling the drug diversion incident appropriately.

Penalty

No penalty information released

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

Summary

The facility failed to inform local law enforcement in a timely manner regarding the suspected misappropriation of a narcotic medication, Lorazepam, for a resident who was unable to communicate due to impaired cognition. The incident was initially identified on January 11, 2025, when it was discovered that a card of Lorazepam was missing. The medication was last administered at 6 AM by the midnight nurse, and upon further investigation, it was found that a card was missing from the narcotics count. The facility's Director of Nursing (DON) and other staff reviewed video footage, which was inconclusive, and attempted to locate the missing medication without success. The facility's policy required immediate reporting to local law enforcement when there was a reasonable suspicion of a crime. However, the DON delayed notifying the police until January 15, 2025, as she believed she needed to complete her investigation first. The facility's administrator later clarified that the policy was to report incidents of suspected crime immediately, regardless of the completion of an internal investigation. The delay in reporting was acknowledged by the administrator, who stated that the notification to the police should have been completed more timely. The facility's abuse policy and prevention program outlined the requirement to contact local law enforcement when there is a reasonable suspicion of a crime, especially if it involves serious bodily harm. In this case, although the resident did not suffer a negative outcome, the failure to report the suspected misappropriation of medication in a timely manner constituted a deficiency in the facility's adherence to 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 provide three meals daily at regular times for four residents, as required by their policy. Resident 6, who was admitted with hemiplegia and hemiparesis, reported a significant delay in receiving dinner, which took over two hours to be served. This incident was documented in a grievance, highlighting the issue of staff being on their phones instead of attending to meal service. Resident 7, diagnosed with moderate protein calorie malnutrition and oral dysphagia, also reported that meals were consistently late, creating uncertainty about meal times. Resident 8, with protein calorie malnutrition and ileostomy status, filed a grievance after not receiving breakfast despite being present in the dining hall, indicating a lack of communication among kitchen staff. Resident 10, with chronic obstructive pulmonary disease and chronic kidney disease, similarly reported that meals were always late. The Director of Nursing and the Administrator both acknowledged the expectation for residents to receive three meals a day served on time, as per the facility's policy. The policy specifies that meals should be served at regular times comparable to normal mealtimes in the community, with breakfast at 7:30 AM, lunch at 11:30 AM, and dinner at 5:30 PM. However, the grievances and resident statements indicate a failure to adhere to these scheduled meal times, resulting in dissatisfaction and unmet nutritional needs for the residents involved.

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 obtain a physician's order for the removal of surgical staples from a resident's right hip incision. The resident, who was admitted with a diagnosis of right hip fracture, had staples removed from the incision site without a documented physician's order in the medical record. A nurse's progress note indicated that staples were removed and steri-strips applied, but later documentation revealed that a staple was left in the incision, causing discomfort to the resident. The Director of Nurses confirmed the absence of a physician's order for the staple removal and stated that staff are expected to have such an order before performing the procedure. The facility's policy requires physician orders to be followed as written, and any questions about the order should be clarified with the physician.

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 colonoscopy for a resident, identified as R2, despite a physician's order dated 9/10/24. R2, who has a diagnosis of Ulcerative Colitis and a history of colon resection surgery, was sent to the hospital with a bowel obstruction that was cleared before returning to the facility. R2 expressed concern about not having had a colonoscopy in 5 or 6 years, which was confirmed by his Power of Attorney (POA), who emphasized the importance of the procedure given R2's medical history. The Director of Nurses (DON) acknowledged difficulties in scheduling the colonoscopy due to unreturned calls from doctors' offices. Despite being aware of the POA's concerns, the appointment had not been made. The facility's administrator confirmed the absence of a policy on radiology/diagnostic services, which may have contributed to the delay in scheduling the necessary procedure for R2.

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 the development of pressure ulcers and provide appropriate care for residents at risk or already suffering from pressure ulcers. For Resident 1, who had multiple health conditions including diabetes, dementia, and impaired mobility, the facility did not implement the necessary interventions as outlined in the care plan. Despite being at risk for pressure ulcers, Resident 1 was observed on a regular mattress instead of a low air loss mattress, which was part of the care plan. The resident developed a stage 2 pressure ulcer on the left heel, which worsened to an unstageable ulcer, and a new stage 3 ulcer on the right buttock, along with a deep tissue injury on the coccyx. The facility staff failed to document these new ulcers and did not obtain treatment orders promptly. Resident 2, who was severely cognitively impaired and dependent on staff for mobility, also suffered from inadequate pressure ulcer care. The resident developed an unstageable pressure ulcer on the coccyx and a deep tissue injury on the right heel. The facility's treatment administration records showed that prescribed treatments were not consistently documented as completed. Additionally, there was confusion regarding the diagnosis of a Kennedy ulcer, which was not confirmed by the physician or nurse practitioner. The facility's policies on skin management and pressure injury treatment were not followed consistently. The staff failed to implement prevention protocols, such as regular turning and repositioning of residents, and did not ensure that treatment orders were obtained and documented for new skin impairments. These lapses in care and documentation contributed to the worsening of pressure ulcers in both residents, highlighting significant deficiencies in the facility's wound care management.

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 opened medications were labeled with open dates for five residents, as observed during a survey. On the specified date, an LPN was observed with a medication cart containing insulin pens for three residents, none of which were labeled with the date they were opened. The LPN, who was an agency nurse, stated she was unaware that insulin pens needed to be dated upon opening and did not know when the pens were initially opened. Another LPN, who was new, was also observed with a medication cart containing an undated insulin pen for a different resident. She similarly stated she was unaware of the requirement to date insulin pens upon opening. The Director of Nurses (DON) expressed that all staff are expected to date insulin pens when opened, as they expire after 28 days, but was not aware of the undated pens in the medication carts. The facility's policy requires medications to be stored safely and properly, following manufacturer recommendations.

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 food served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. Observations during meal times revealed that food was served on Styrofoam plates without proper insulation, leading to cold meals. Residents, including those who were cognitively intact and those with moderate cognitive impairment, consistently reported dissatisfaction with the temperature and quality of the food. Complaints were made during resident council meetings and through a special food committee, but no improvements were noted over a period of at least six months. During a breakfast service, it was observed that trays were not distributed promptly, resulting in further cooling of the food. Additionally, the kitchen ran out of bowls, causing a delay in meal service. A sample tray taken after the last tray was distributed showed that the food was not visually appealing, with a gray and yellowish hue, and lacked flavor. Temperature checks revealed that only one out of six food items was within the acceptable temperature range, with others being significantly below the required 135°F. The facility's policies on food preparation and dining services were not adhered to, as evidenced by the repeated complaints and observations of cold food. Meeting minutes from the food committee indicated ongoing issues with food temperatures, but no documentation was available for recent months. Staff interviews corroborated the residents' complaints, highlighting a persistent problem with food quality and service that had not been addressed effectively by the facility.

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 policies and guidelines for four residents, leading to deficiencies in infection prevention and control. For Resident 54, multiple staff members, including CNAs and a wound nurse, entered the resident's room, which was under enhanced precautions, without wearing the required gowns. During wound care, the wound nurse did not change gloves or perform hand hygiene after removing old dressings, increasing the risk of cross-contamination. Resident 20 experienced a similar issue when a wound nurse did not wash her hands or apply disinfectant between changing gloves while treating open and bleeding wounds. This lack of proper hand hygiene before donning new gloves posed a risk of infection. Additionally, Resident 58's wound care was compromised when the wound nurse failed to change gloves or perform hand hygiene between cleansing different pressure ulcers, despite the resident having a diagnosis of osteomyelitis in one of the wounds. For Resident 65, an LPN administered medication via a g-tube without performing hand hygiene or wearing a gown, as required by the facility's Enhanced Barrier Precautions policy. The LPN mistakenly believed that only the resident's roommate required precautions. The facility's policy mandates the use of gowns and gloves during high-contact resident care activities, which was not followed in this instance.

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 residents from resident-to-resident physical abuse, as evidenced by incidents involving three residents. One resident, who is severely cognitively impaired and diagnosed with Alzheimer's Disease, Schizoaffective Disorder, and Psychosis, was involved in an altercation with another resident. This altercation resulted in the cognitively intact resident hitting the impaired resident on the head with a cane, causing a hematoma. The incident was reported to the Director of Nursing, and the police were called, but no report was generated. The facility's abuse policy defines physical abuse as the infliction of injury that requires medical attention, which occurred in this case. Another incident involved a moderately cognitively impaired resident with diagnoses of Schizoaffective Disorder, Depression, Schizophrenia, and Major Depression Disorder. This resident was involved in an argument with the severely cognitively impaired resident over belongings, leading to a physical altercation where hair was grabbed, and a scratch was inflicted. The facility's failure to prevent these incidents and protect the residents from harm highlights a deficiency in their abuse prevention and intervention measures.

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 the elopement of a resident, identified as R71, who was at high risk for elopement due to multiple medical conditions, including chronic ischemic heart disease, cognitive communication deficit, and anxiety disorder. R71 was known to be exit-seeking and had a history of wandering, as documented in the care plan and physician order sheet. Despite having a wander guard in place, R71 managed to leave the facility on at least two occasions, as confirmed by staff interviews and video footage reviewed by the facility administrator. On one occasion, R71 was found at an apartment building next to the facility after being reported missing by staff. The wander guard alarm was supposed to alert staff when R71 approached the doors, but it was noted that the resident was able to exit the building by hanging on the access door, which opened after 15 seconds. Staff were not immediately aware of R71's absence, and it was only after a search and a call from 911 that the resident was located and returned to the facility. The facility's policy on elopement and unsafe wandering prevention emphasizes the importance of securing the environment and responding immediately to door alarms. However, the report indicates that the staff did not effectively monitor or respond to the alarms, allowing R71 to elope. The failure to ensure adequate supervision and secure the environment contributed to the resident's ability to leave the facility unsupervised.

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 timely incontinent care for a resident, identified as R54, who was always incontinent of urine and frequently incontinent of bowel. The resident's care plan aimed to keep her clean, dry, and odor-free, with interventions to provide incontinence care when needed. However, during an observation on September 11, 2024, it was noted that the resident's incontinent brief was heavily soiled with yellow urine, and the pad underneath was also stained. A CNA, V13, who was responsible for the resident's care, could not recall the last time the resident was checked, indicating a lapse in the two-hourly checks that were supposed to be conducted as per facility policy. Interviews with other CNAs and the Director of Nursing confirmed that incontinence checks were expected to be performed every two hours. Additionally, the resident's son reported finding his mother wet on previous occasions and mentioned that she had been hospitalized with sepsis and dehydration. The facility's policy on incontinence care, dated September 2023, emphasized the importance of keeping residents dry, comfortable, and odor-free to prevent skin breakdown, which was not adhered to in this instance.

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 investigate an allegation of abuse for a resident who reported incidents involving Certified Nursing Assistants (CNAs). On a specific date, the resident stated that she had been scratched on the back with a call light by one CNA and attacked by another. She reported these incidents to the administrator, who then involved the police, resulting in one CNA being jailed. However, a progress note from an earlier date documented the resident's complaint about a night CNA being rough and rude, but no further action or investigation was recorded. The facility's policy mandates that any incident, allegation, or suspicion of abuse, neglect, or mistreatment must be reported immediately to the administrator or a designated individual in their absence. Despite this policy, the administrator was not informed of the resident's earlier complaint, and no investigation was initiated at that time. This oversight indicates a failure to adhere to the facility's abuse prevention and reporting protocols, as the staff did not report the resident's allegations as required.

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 report an allegation of abuse involving a resident, identified as R73, who was part of a sample of 40 residents reviewed for abuse. On a specific date, R73 reported to the administrator that she had experienced incidents with some CNAs, including being scratched on the back with a call light and being attacked by another CNA. Despite R73's alert and oriented status, as documented in her Minimum Data Set, the facility did not report the allegation of abuse as required by their policy. The facility's policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or a designated individual in their absence. However, the administrator stated that neither the staff nor the Director of Nursing informed her of R73's allegations. The facility's policy also requires that all incidents be documented and reported to the Illinois Department of Public Health within specified timeframes, depending on the severity of the incident. In this case, the failure to report the allegation of abuse was a violation of the facility's abuse prevention policy.

Penalty

No penalty information released

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

Summary

The facility failed to provide routine medications in a timely manner for four residents, resulting in missed doses of critical medications such as insulin, antihypertensives, and anticoagulants. Resident 1, who was admitted with multiple serious conditions including pulmonary hypertension and congestive heart failure, did not receive several prescribed medications on a specific date due to the facility's pharmacy being located 274 miles away. The nurse's notes indicated that the medications were not available upon the resident's arrival. Resident 2, admitted with conditions such as thoracic aortic aneurysm and major depressive disorder, also missed several doses of important medications over two days. The nurse's notes documented that the medications were awaiting delivery from the pharmacy, and the resident was eventually sent to the emergency department for evaluation due to complaints of discomfort and dehydration. Similarly, Resident 3 did not receive a medication for excessive secretions, and the pharmacist noted issues with the prescription fill due to either diagnosis or insurance problems. Resident 4, with a complex medical history including cerebral infarction and diabetes, did not receive multiple medications due to awaiting pharmacy delivery. The facility's staff, including a nurse practitioner and the director of nursing, acknowledged the issues with medication availability, citing problems with pharmacy location and access to the automated medication dispensing machine. Agency nurses reported not having access to the dispensing machine, which further contributed to the delay in medication administration.

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 competent licensed nurse to administer medication to a resident, leading to a deficiency in medication administration. A resident, who was cognitively intact, had a care plan in place for pain management, which included administering Acetaminophen as needed. On a specific date, the resident requested pain medication at 2:30 AM, but it was not administered until 5:30 AM by a CNA, who was not licensed to give medications. The resident reported the incident to the day shift nurse, and it was noted that the medication was not properly documented in the Medication Administration Record by the responsible RN. The Director of Nursing and the Administrator were informed of the incident, and the CNA admitted to administering the medication. The RN involved was an agency nurse, and the facility decided not to allow her to return. The facility's policy on medication administration requires that all medications be administered by licensed personnel, which was not followed in this case, leading 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 administer intravenous (IV) medications as ordered for one resident, identified as R2, who was admitted with serious infections requiring specific IV antibiotics. Upon admission, R2 had orders for Tigecycline and Voriconazole to be administered every 12 hours. However, there was a delay in obtaining these medications from the pharmacy. The facility's progress notes indicate that the pharmacy was contacted about the IV antibiotics, and it was communicated that one of the antibiotics would not be available until the following day. Additionally, the pharmacy later informed the facility that they could not provide Voriconazole due to its hazardous nature and their inability to mix it. Despite receiving Tigecycline from the pharmacy on the evening of June 13, 2024, the facility did not administer the medication as ordered, and there was no documentation explaining the omission. The Director of Nursing acknowledged that the Tigecycline should have been administered since it was available. Consequently, R2 did not receive any antibiotics for 48 hours after leaving the hospital, which was confirmed by the medical assistant for the infectious disease doctor. The facility's medication administration policy requires documentation and notification if medications are not given as ordered, 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 prevent employee-to-resident abuse, resulting in a resident, R2, experiencing both physical and mental abuse. R2 was found with bruising under both eyes and on her left forearm, and she reported feeling scared and unsafe in the facility. The incident occurred when R2 was in her wheelchair and was not ready to go to bed due to pain in her feet and not needing much sleep. Despite her protests, two staff members, identified as V12, an LPN, and V15, a CNA, forcibly put her to bed using a mechanical lift, during which R2 was yelled at and physically handled, causing her distress and injury. R2's medical history includes diagnoses such as osteoarthritis, schizophrenia, bipolar disorder, generalized anxiety disorder, and insomnia, among others. She is cognitively intact, as indicated by her BIMS score of 15. The incident was reported to another LPN, V13, who documented R2's account of the abuse, including being yelled at and physically pulled by her wrists, resulting in a bruise and a small cut. The police were notified, and an investigation was initiated, confirming the abuse allegations. The facility's investigation corroborated R2's claims, with evidence including camera footage showing V12 and V15 entering R2's room with a sit-to-stand lift. Despite R2's resistance and her expressed desire not to go to bed, the staff members forced her into bed, violating her rights. The facility's abuse policy affirms residents' rights to be free from abuse, yet this incident highlights a significant failure in protecting those rights.

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 complete incontinent care to prevent urinary tract infections (UTIs) for a resident with a history of UTIs and other medical conditions. During an observation, a CNA did not perform hand hygiene after changing gloves and did not clean the resident's right side during incontinent care. The resident's care plan indicated a need for total assistance with toileting, and the facility's policy required cleaning from front to back, which was not followed. The resident was later admitted to the hospital with a UTI, altered mental status, and other conditions, and had a positive urine culture for E. Coli. The resident's medical records documented multiple hospital admissions related to UTIs and other complications, including acute metabolic encephalopathy, seizure, sepsis, fecal impaction, and hypoxemia. The Director of Nurses acknowledged that staff should complete incontinent care for any incontinent resident. The facility's incontinence care policy emphasized the importance of keeping residents dry, comfortable, and odor-free, and required proper perineal cleaning, 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 have enough CNAs working to meet the needs of the residents, as evidenced by the experience of one resident (R3). On the night of 4/29/24, R3, who is continent of bowel and bladder if assisted by staff, was unable to reach her call light or cell phone and was not checked on by staff throughout the night. As a result, R3 was left soaked in urine until she managed to call the facility around 5:00 AM. The CNA who responded, V7, confirmed that they were short-staffed and busy. R3 experienced chafing from lying in urine all night, although it had cleared up by the time of the interview. R3's cognitive status was confirmed to be intact with a BIMS score of 15. Interviews with staff members, including an LPN and multiple CNAs, corroborated the issue of short staffing, particularly on night shifts due to call-offs. The facility's Director of Nurses (DON) stated that they use a staffing grid based on census and attempt to cover shifts with their own staff or agency CNAs when someone calls off. However, the CNA schedule documented only three CNAs working on several nights, including the night of 4/29/24. The facility was unable to provide a staffing policy, further highlighting the deficiency in meeting the required staffing levels to ensure resident care.

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 medications were administered as ordered by the physician for one resident (R3). R3 reported that she was denied her medication and experienced a delay in receiving her prescriptions, which she had been getting delivered to her home before moving to the facility. The resident was without her medications, including pain medication, muscle spasm medication, heart medications, and seizure medications, for about three days. The resident's Medication Administration Records (MAR) for March, April, and May 2024 documented multiple instances where medications were not given, including Trileptal, Amlodipine, Atorvastatin, Jardiance, Lamictal, Lisinopril, Coreg, Metformin, Baclofen, and Venlafaxine. Progress notes indicated ongoing issues with medication delivery from the pharmacy and communication problems between the facility and the pharmacy. The Director of Nursing (DON) stated that when a medication is not available, the nurse is supposed to call the pharmacy to resolve the issue. However, the documentation showed that medications were frequently not given or not available, and the reasons were not always clearly documented. The facility's Medication Administration policy requires that if a medication is ordered but not present, the nurse should check for misplacement, call the pharmacy, and obtain it from a contingency or convenience box if available. If the physician's order cannot be followed, the physician should be notified, and a note should be made in the resident's record. These steps were not consistently followed, leading to the deficiency in medication administration for R3.

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 install the correct bed rail and obtain consent from the resident or their representative prior to the installation and use of bed rails for four residents. Observations revealed that residents had bed rails installed without documented consent. For instance, one resident with a diagnosis of weakness and hemiparesis was observed using a bed rail without prior consent. Another resident with a cerebral vascular accident diagnosis had a grab bar installed without consent. Similar deficiencies were noted for two other residents who had bed rails installed without documented consent, despite their medical conditions requiring such assistance for bed mobility and transfers. Interviews with the facility staff, including the administrator and the MDS/restorative nurse, confirmed that the facility had not been obtaining the necessary consents for bed rail use. The facility's policy on bed rails, dated October 2021, mandates that all residents be assessed for bed rail use upon admission and significant change, and that consent should be obtained. However, this procedure was not followed, leading to the deficiency. The administrator acknowledged the oversight and mentioned that they were now in the process of obtaining the required consents.