Elevate Care South Holland

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 follow professional standards of practice by not carrying out physician orders for a wound culture for one resident and not documenting ordered skin assessments for five residents. One resident with a history including Alzheimer’s disease, gastrostomy, adult failure to thrive, hypothyroidism, seizures, kidney cancer, and stage 3 and stage 4 pressure ulcers had a positive wound culture in January for Klebsiella pneumonia and Enterococcus faecalis. The infectious disease nurse practitioner stated she had ordered repeat wound cultures and believed they were not collected. Record review confirmed three physician orders for wound cultures dated 2/7/2026, 2/18/2026, and 3/18/2026, with the DON later confirming that the cultures ordered on 2/7/2026 and 2/18/2026 were not completed and that the 3/18/2026 order was not completed because the resident was in the hospital. The DON stated the purpose of the wound culture was to obtain appropriate antibiotics and acknowledged it was not standard practice to fail to follow physician orders, and that the nurses who received the orders had no explanation for not carrying them out. The deficiency also includes failure to document weekly skin assessments as ordered for five residents with multiple complex medical conditions, including quadriplegia, dementia, CKD, dysphagia, muscle wasting, osteoarthritis, hyperlipidemia, pressure ulcers, heart failure, colostomy, anemia, and depression. Active physician orders for these residents required weekly showers and skin assessments on specified days, with acknowledgment of completion, documentation of refusals or absences, and documentation of any new skin issues on a nursing skin assessment form, along with physician and family notification. Review of shower sheets for January, February, and March for these residents showed no documentation of skin assessments, and there was no skin assessment documentation elsewhere in the medical records. Staff interviews confirmed that the expected practice was for CNAs to notify nurses to perform skin checks before showers and for nurses to conduct head-to-toe skin assessments, documenting them on the CNA shower sheet. The wound LPN and treatment nurse both stated that nurses were supposed to perform and document skin assessments as ordered, and that any skin alterations should be documented on the shower sheets. The DON stated that showers were to be completed per schedule and documented in the MAR, with shower sheets signed by nurses and collected by wound care, but also stated that nurses were not required to document the condition of the skin on the shower sheet or in the resident record and only needed to initial the MAR. The facility’s physician order processing policy required licensed nurses to confirm and complete instructions for physician orders, and RN/LPN job descriptions required completion of record-keeping forms and informative charting that reflects care provided and resident response, but these requirements were not met in the cited instances.

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 provide scheduled showers and to complete and document ordered skin assessments for multiple dependent residents. Surveyors observed and interviewed residents, staff, and a family member, and reviewed records including physician orders, MDS assessments, care plans, and shower sheets. For one resident with quadriplegia who had resided in the facility for about three years, the resident reported that CNAs did not change her regularly, that she rarely got out of bed, and that she did not receive her scheduled showers, instead receiving bed baths most of the time despite preferring showers. When CNAs arrived to take her for a shower and were questioned, they could not state when her last shower occurred and indicated that showers were documented on shower sheets kept in a binder. The resident’s family member also reported that the resident did not receive twice-weekly showers as scheduled and was not assisted with oral care, despite having an active physician order for twice-weekly showers with concurrent skin assessments and documentation, including instructions to document refusals or absences and to complete a NUR Skin Assessment Form for new skin issues. For several other residents, review of shower sheets over a three‑month period showed repeated failures to provide showers as ordered and to document showers, bed baths, refusals, or skin assessments. One resident with advanced cognitive impairment, multiple comorbidities, and existing pressure ulcers had physician orders for twice‑weekly showers and skin assessments, but shower sheets showed that in January the resident received 3 of 9 scheduled showers, in February 3 of 8, and in March 2 of 5, with one shower documented on a day when the resident was actually hospitalized, which an LPN confirmed meant the shower could not have occurred. Another resident, dependent for all ADLs and with dementia and multiple medical conditions, had orders for twice‑weekly showers and skin assessments, yet shower sheets showed no showers or bed baths documented for January and only partial completion of scheduled showers in February and March. A further resident with dysphagia, dementia, G‑tube feeding, and a sacral area of maceration observed during wound care had orders for twice‑weekly showers and skin assessments; although this resident’s shower sheets showed more frequent showers in February and March, the presence of a saturated incontinence brief at the time of wound care and the lack of separate skin assessment documentation highlighted that skin assessments were only recorded on shower sheets. Another cognitively intact resident with a history including a stage 4 sacral pressure ulcer and dependence on staff for most ADLs reported being in bed all the time, receiving bed baths “not too often,” and having had only one shower “a long time ago.” This resident also stated that her hair had not been combed in over a year despite asking staff to wash it. Review of her shower sheets showed that in January she received 3 of 8 scheduled showers plus 2 on non‑scheduled days, in February 3 of 8, and in March 5 of 9. Staff interviews revealed that the facility’s process required CNAs to take residents to the shower room on scheduled days, pull the call light for a nurse to perform a head‑to‑toe skin check before the shower, and complete a CNA Shower Sheet for every scheduled shower day, documenting whether a shower, bed bath, or refusal occurred and any skin changes, with the nurse signing off. The wound LPN stated that if there was no shower sheet, the shower was not done, that nurses only documented their head‑to‑toe skin assessments on the CNA Shower Sheet and nowhere else, and that if a resident did not receive a shower or bed bath and did not get a head‑to‑toe skin assessment, there were risks of additional skin breakdown, new skin abnormalities, infection due to uncleanliness, emotional impact, and overall poor care. Another CNA confirmed that it was mandatory to have a shower sheet for every resident on every scheduled shower day and that the nurse was required to fill out and sign the sheet. When surveyors requested documented skin assessments for the affected residents, none were provided, despite physician orders and facility policy requiring regular bathing and skin monitoring. Facility policy titled “Bathing – Shower and Tub Bath,” revised 1/31/2018, stated that the purpose was to ensure residents’ cleanliness to maintain proper hygiene and dignity, and that a shower, tub bath, or bed/sponge bath would be ordered according to resident preference two times per week or according to preferred frequency and as needed or requested. The combination of resident and family reports, staff statements, shower sheet reviews, and the absence of separate skin assessment documentation demonstrated that the facility did not consistently provide the ordered showers or bed baths, did not consistently perform or document the required weekly skin assessments, and did not follow its own policy and physician orders for residents who were dependent on staff for ADL 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 deficiency involves the facility’s failure to obtain ordered wound cultures needed to guide treatment of a resident’s infected pressure ulcer. The resident, an older adult with severe cognitive impairment, Alzheimer’s disease, hypothyroidism, adult failure to thrive, a gastrostomy, and multiple pressure ulcers including a stage 4 sacral ulcer, was dependent on staff for all ADLs and was frequently incontinent of bowel. Hospital records from late March documented a necrotic sacral wound requiring excisional debridement of skin, soft tissue, and muscle, with CT imaging showing a sacral decubitus ulcer extending to bone and initial wound cultures growing Klebsiella pneumoniae, Enterococcus faecalis, and Proteus mirabilis. The resident was treated with IV antibiotics and discharged on oral antibiotics. Within the facility, wound assessments in early and mid-March documented an unstageable sacral pressure ulcer with heavy serosanguineous exudate and increasing wound size, and noted that the resident was not on antibiotics at those times. The infectious disease nurse practitioner, who had followed the case since January, documented that a January wound culture was positive for Klebsiella pneumoniae and Enterococcus faecalis and that subsequent labs in February showed trending increases in WBC, platelets, neutrophils, ESR, and CRP, with concern for worsening skin and soft tissue infection. In response, the practitioner started additional antibiotics and explicitly reordered wound cultures on multiple dates (2/7, 2/18, and 3/18) to further evaluate the infection and guide therapy, and progress notes referenced awaiting wound culture results while trending labs and following wound care recommendations. Despite these orders, the facility did not obtain the ordered wound cultures. The infectious disease nurse practitioner stated that a repeat wound culture had been ordered but did not believe it was collected, and that the resident’s ongoing antibiotic treatment was based on the January culture, with the wound initially improving and then stopping improvement. The DON confirmed that wound cultures ordered on 2/7 and 2/18 were not completed and that there were no results because the cultures were never obtained, and that the 3/18 order was not completed because the resident was in the hospital. The DON stated that the purpose of the wound culture was to obtain appropriate antibiotics for the wound and that it was not standard practice to fail to follow a prescriber’s order, yet the nurses who received and confirmed the orders could not provide a reason for not carrying them out. Facility policy on physician order entry and processing required licensed nurses to confirm and complete prescriber orders, and RN/LPN job descriptions required adherence to standards and regulations to ensure quality care, but these requirements were not met 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 deficiency involves the facility’s failure to provide individualized fall interventions and adequate supervision for a high fall-risk resident, resulting in two bed falls within one week. The resident was an older adult with chronic respiratory failure, tracheostomy with ventilator dependence, prior brain damage, gastrostomy, and anxiety disorder, and was dependent on staff for all ADLs, including rolling in bed. A fall risk assessment on admission scored the resident at 71, indicating high risk for falls. The MDS showed no BIMS score and documented total dependence for functional status. The care plan for safety stated the goal that the resident would remain free of falls and included use of a hi-low bed in the lowest position and, after ER evaluation, that the resident would be reviewed for appropriate interventions and have bilateral upper body wedges placed upon return from the hospital. Despite this high-risk status and care plan language, staff interviews and records show that the only consistent intervention in place before and after the first fall was keeping the bed in the lowest position, with mittens on the resident’s hands. The first fall occurred around midnight when a CNA summoned an LPN, who found the resident prone on the floor next to the bed with the bed in the lowest position; no injuries were noted, and the resident was returned to bed via a four-person transfer. The resident was then sent to the hospital, where records documented evaluation for gross hematuria following the reported fall. Upon readmission later that night, documentation and multiple staff interviews indicate the resident did not have bed rails, wedges, or bolsters in place, and some staff were unsure whether the resident was even identified as a fall risk or what fall interventions were ordered. Shortly after the resident’s readmission, a second fall occurred around midnight. A CNA again summoned the LPN and respiratory therapist, who found the resident prone near the bedside with no pulse and no visible chest rise; a code blue was initiated, and EMS was called. EMS documentation indicated that on their arrival the resident had stable vital signs and strong pulses and remained stable during transport. Hospital records from this second event noted an abrasion over the left frontal scalp and a CT scan without acute soft tissue abnormality or skull fracture. The resident’s family member reported that the resident had previously suffered a cardiac arrest and lost control of his body, and stated that although they had requested bed rails, bed bolsters, or other assistive devices to prevent falls, none were provided. The facility’s fall prevention policy required individualized assessment and implementation of appropriate safety interventions and supervision for residents at risk of falls, but interviews with CNAs, respiratory therapists, and the DON showed uncertainty about the resident’s fall-risk status and lack of additional fall-prevention measures beyond a low bed and mittens.

Penalty

Inspection fine: $68,6401 days payment denial

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

Summary

The deficiency involves the facility’s failure to provide a resident’s medical record to the resident’s Power of Attorney/Healthcare Representative (POA/HCR) in a timely manner after a formal request was made. The medical records staff member (V5) acknowledged receiving a request from the resident’s POA in October 2025, along with a completed application and identification. V5 stated that additional documents were needed to process the request and that attempts to reach the POA by phone were unsuccessful. Despite this, no certified letter or other documented follow-up was sent to inform the POA of the missing documents, resulting in the requested records not being provided. The resident’s admission record dated 1/20/2026 shows diagnoses including chronic ischemic heart disease, heart failure, renal dialysis, and pressure ulcers. The record also reflects a State of Illinois compliant authorization for release of patient information dated 10/1/2025 and a request for information dated 1/20/2026. The facility’s Medical Record Policy states that an organized, accurate, and complete written record will be maintained for each resident in accordance with applicable state and federal guidelines and that records are to be readily accessible. Despite this policy, the resident’s records were not made accessible to the POA/HCR as requested, leading to the cited deficiency.

Penalty

Inspection fine: $68,6401 days payment denial

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

Summary

The deficiency involves the facility’s failure to ensure ongoing revision and updating of individualized care plans in accordance with residents’ conditions and treatments. For one resident with diagnoses including Alzheimer’s disease, dementia, adult failure to thrive, type 2 diabetes mellitus, and chronic ischemic heart disease, surveyors observed the resident lying in bed with oxygen in use at 2L via nasal cannula. The oxygen tubing had no label with a date, there was no physician order for oxygen administration in the active orders, and there was no care plan addressing oxygen use. The DON acknowledged that oxygen use should have a physician’s order and that the tubing should be labeled with a date, and the Administrator was informed that there was no care plan for the oxygen therapy. Another resident, an older adult with multiple diagnoses including chronic respiratory failure with hypoxia, tracheostomy and ventilator dependence, gastrostomy, left femur fracture with routine healing, essential hypertension, seizure disorder, anxiety disorder, depressive disorders, generalized edema, left hip pain, diaphragmatic hernia, and delirium, was identified as being at high risk for falls per a Fall Risk scale. The resident’s fall care plan, initiated for high fall risk with problems such as gait/balance issues, poor communication/comprehension, decreased safety awareness, and adverse behaviors, contained dated interventions such as keeping furniture locked, educating the resident to use the call light, and bilateral floor mats. However, on subsequent dates, entries of 11/29/25 and 12/1/25 documented “no intervention” instead of updated fall-prevention measures after falls. The DON stated that the fall care plan should be updated after each fall with appropriate interventions, and the Administrator stated that his expectation is that care plans be updated after appropriate interventions are discussed, indicating that this did not occur as required by facility policy for comprehensive care plans.

Penalty

Inspection fine: $68,6401 days payment denial

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

Summary

The deficiency involves the facility’s failure to implement and maintain fall prevention measures for a resident identified as high risk for falls. The resident is an adult with multiple complex medical conditions, including chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, gastrostomy, a prior displaced intertrochanteric fracture of the left femur with routine healing, essential hypertension, seizure disorder, anxiety disorder, adjustment disorder with depressed mood, major depressive disorder, generalized edema, left hip pain, diaphragmatic hernia, and delirium due to a known physiological condition. A facility incident report shows that on 10/21/25 the resident was found lying on the floor on the left side, reported left lower extremity pain, and an x‑ray revealed an acute intertrochanteric fracture of the proximal left femur, after which the physician ordered transfer to the hospital. The resident’s fall risk scale dated 10/26/25 identifies the resident as high risk for falling, and the care plan dated 2/27/25 documents high fall risk related to gait/balance problems, poor communication/comprehension, decreased safety awareness, and adverse behaviors, with interventions including keeping furniture locked, educating the resident to use the call light, and bilateral floor mats added on 10/21/25. On 1/20/26 at 1:00 PM, the resident was observed in bed with only one floor mat on the right side of the bed and no floor mat on the left side, despite the care plan intervention for bilateral floor mats. At that time, the Assistant DON stated she had moved the left-side floor mat to place the bedside table so the resident could eat lunch and that she would return after the resident finished eating, leaving the resident in the room unsupervised. Later that day at 2:42 PM, the DON acknowledged that the resident should have been out of bed in a wheelchair in a highly visible area for monitoring because of the high fall risk. The facility’s Fall Prevention Program policy, revised 11/21/17, requires assessment of fall risk, implementation of appropriate safety interventions, and incorporation of fall interventions into the care plan, including informing nursing personnel of residents at risk and maintaining safety interventions for those residents. The record review also shows that after the addition of bilateral floor mats on 10/21/25, entries dated 11/29/25 and 12/1/25 list “no intervention,” indicating no documented changes or additions to fall interventions following the resident’s fall.

Penalty

Inspection fine: $68,6401 days payment denial

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

Summary

The deficiency involves the facility’s failure to ensure that a resident’s ordered continuous enteral tube feeding was administered as prescribed. During an observation, the resident reported having a tube feeding and stated that he did not want the tube feeding running while he was eating, but also reported that the nurse had not started his tube feeding at all that day. The admission record documented that the resident had chronic respiratory failure, a tracheostomy, a history of liver transplant, a gastrostomy tube, and seizures. An order summary for enteral feeding directed Nepro 1.8 at a rate of 45 ml/hour for 24 hours, with a total volume of 1,080 ml, and the care plan included an intervention to administer tube feeding as ordered. Interviews with facility staff confirmed expectations that tube feedings be administered according to the physician’s order or adjusted by the nurse practitioner if needed to accommodate resident preferences. One staff member stated that all tube feedings were expected to be given as ordered or adjusted by the nurse practitioner, and another staff member acknowledged that the resident refused tube feeding during meals but stated that the feeding was expected to be administered when the resident was not eating by mouth. The facility’s enteral nutrition policy required nursing staff to follow enteral nutrition guidelines, ensure continuous drip feedings were administered appropriately, and closely monitor tube feeding tolerance and intake to ensure nutritional goals were met, including confirming that enteral nutrition was delivered as ordered by the physician. Despite these policies and orders, the resident’s tube feeding was not initiated as ordered on the day observed.

Penalty

Inspection fine: $68,6401 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

Surveyors identified that a resident with diagnoses including Alzheimer's disease, dementia, adult failure to thrive, type 2 diabetes mellitus, and chronic ischemic heart disease was receiving oxygen therapy without a corresponding physician order or care plan. On observation, the resident was found lying in bed with oxygen running at 2 liters via nasal cannula, and the oxygen tubing lacked a date label indicating when it had been changed. During interviews, the Wound Care Coordinator stated that oxygen tubing should be labeled with the date to ensure cleanliness and for infection control, and the DON acknowledged that oxygen administration requires a physician order and that tubing should be dated. The facility’s oxygen therapy policy, last revised 12/1/2021, requires verification of a physician order prior to oxygen administration and directs staff to discard disposable masks, cannulas, and tubing after use in accordance with an equipment change schedule, which was not followed in this instance. The deficiency centers on the facility’s failure to follow its own oxygen therapy policy and physician order requirements, resulting in oxygen being administered to the resident without an active physician order, without a documented care plan for oxygen use, and with unlabeled oxygen tubing that did not comply with the facility’s infection control and equipment change procedures.

Penalty

Inspection fine: $68,6401 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 medications were administered as ordered by the physician for two residents. One resident with chronic respiratory failure, tracheostomy, liver transplant, G-tube, seizures, and other conditions reported around midday that he had not received his morning medications, stating the nurse had told him they would be given with his noon medications, but as of after 12:30 p.m. he still had not received them. The LPN responsible stated she was running late and had not had a chance to administer the morning medications, acknowledging they should be given within one hour before or after the scheduled start time and that she would notify the nurse practitioner of the late administration. The nurse practitioner stated that this resident’s medications, including continuous Nepro tube feeding, Keppra, metoprolol, and tacrolimus, should be administered as ordered and that administering both morning and noon medications together could cause gastrointestinal upset, loose stools, and abnormal medications. The resident’s care plan directed staff to administer medications as ordered, and the facility’s medication administration policy required medications to be given in accordance with prescriber orders and within 60 minutes of the scheduled time. For a second resident with multiple diagnoses including chronic respiratory failure with hypoxia, tracheostomy and ventilator dependence, gastrostomy, left femur fracture, hypertension, seizures, anxiety disorder, depressive disorders, generalized edema, hip pain, diaphragmatic hernia, and delirium, there were concerns regarding documentation of medication administration. This resident had orders for ferrous sulfate in the morning, valproic acid oral solution twice daily, and clonazepam three times daily, with a care plan to give medications as ordered. Around midday, the resident was in bed and stated he was unsure if he had received his medications, although he usually did. The LPN assigned to this resident later stated she was supposed to sign off medications immediately after administering them and could not explain why she had not documented administration when she reported giving the medications at 9:00 a.m. This conflicted with the facility’s policy requiring proper and timely documentation of medication administration.

Penalty

Inspection fine: $68,6401 days payment denial

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

Summary

The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during wound care and oxygen administration for a resident with multiple chronic conditions, including Alzheimer’s disease, dementia, adult failure to thrive, type 2 diabetes mellitus, and chronic ischemic heart disease. The resident had active physician orders for wound care to the right buttock, sacrum, and both heels, specifying cleansing with normal saline or wound cleanser, patting dry, applying betadine where ordered, and covering with appropriate dressings, as well as use of a low air loss mattress. During an observation of wound care, the wound care nurse (V3) cleansed the sacral wound area and then applied a clean dressing without performing hand hygiene in between steps. V3 then changed the dressing on the right heel, again without performing hand hygiene between tasks, contrary to the facility’s Dressing Change (Clean/Non-Sterile) policy, which requires removal of soiled gloves, handwashing or use of alcohol-based hand gel, and then application of clean gloves before proceeding. In addition, the resident was observed lying in bed with oxygen in use at 2 L via nasal cannula, and the oxygen tubing had no label indicating the date it was changed. V3 stated that oxygen tubing should have a label with the date to indicate when it was changed for infection control purposes. The DON (V2) acknowledged that hand hygiene is required between wound dressing changes and that oxygen use should have a physician’s order and the tubing should be labeled with the date, consistent with the facility’s Oxygen Therapy policy, which requires disposable cannulas and tubing to be discarded after use in accordance with an equipment change schedule. These observations demonstrate that the facility did not follow its own infection control and treatment policies during wound care and oxygen administration for this resident.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its own policies and procedures, as well as manufacturer guidelines, regarding the use and maintenance of Low Air Loss Mattresses (LALM) and the implementation of physician-ordered wound care interventions for three residents with pressure ulcers. Observations revealed that LALMs were not set to the correct weight settings based on resident weights, with one resident's mattress set at 250 pounds despite weighing only 121.1 pounds. Additionally, another resident's LALM was found to have a malfunctioning static mode, and alternating pressure was not observed as required. Multiple layers of linen and a disposable brief were used on top of the LALM for one resident, contrary to manufacturer instructions, potentially impeding the mattress's effectiveness. Record reviews and staff interviews indicated that physician orders for wound care were not consistently transcribed into the Physician Order Sheets (POS) and Treatment Administration Records (TAR), resulting in treatments not being administered as prescribed. For example, one resident's order for cleaning a sacral wound with Dakin's solution was omitted, and another resident did not receive the prescribed Calcium Alginate for wound care. In some cases, discontinued treatments such as Collagen were still being applied to healed wounds, and appropriate dressings like foam island or hydrocolloid were not used as ordered. Care plans for residents with pressure ulcers included interventions such as ensuring LALMs were functioning properly and set to appropriate settings, but these interventions were not consistently implemented. Staff interviews confirmed a lack of awareness or adherence to current physician orders and manufacturer guidelines. The deficiencies were identified through direct observation, interviews with wound care nurses, and review of medical records, highlighting failures in following established protocols for pressure ulcer prevention and treatment.

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

Surveyors observed that the ice scoop for the cooler box on the 2nd floor was stored inside the cooler box rather than in a separate container outside the box, as required by facility policy. This was confirmed during observations with both a Certified Nursing Assistant and the Director of Food Services, who each acknowledged that the scoop should be kept outside the cooler box to prevent contamination. Additionally, a resident reported consistently finding the scoop inside the cooler when retrieving ice. Review of the facility's policy indicated that the ice scoop should be cleaned daily and stored outside the ice bin, either covered or in a holder on the side of the bin. The failure to follow this procedure was directly observed and confirmed by staff and a resident.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's right to be free from physical abuse by an employee. A severely cognitively impaired resident was allegedly physically assaulted by an LPN, resulting in the resident experiencing pain. The incident was witnessed by a visitor who reported seeing the LPN punch the resident twice. The visitor attempted to record the incident but only captured the aftermath. The LPN was removed from the facility following the report. The resident involved is an elderly female with a diagnosis of unspecified dementia, among other conditions. Her cognitive impairment was severe, as indicated by a BIMS score of 3. At the time of the incident, the resident was in the common area and reportedly interfered with another resident's oxygen tubing, which led to the alleged physical altercation with the LPN. The resident later reported pain in her right scapula, which was a new complaint following the incident. The facility's response included assessing the resident for injuries, which showed no visible signs of harm, although the resident did report pain. The facility's abuse prevention policy emphasizes the prohibition of abuse and the importance of creating a secure environment for residents. However, the actions of the LPN, as described, were deemed unwarranted and punitive, failing to adhere to the facility's policy and resulting in a deficiency in protecting the resident from abuse.

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 transfer a resident to the hospital after a new onset of pain and abnormal x-ray results indicated an acute fracture. The resident, who had a history of osteoarthritis, syncope episodes, radiculopathy, Raynaud's syndrome, and a previous fall with a right hip fracture, experienced new-onset pain in the right hip. An x-ray revealed a poster superior dislocation of the right prosthetic femoral head with an acute fracture of the posterior right acetabular wall. Despite these findings, the nurse who received the x-ray results did not assess the resident or take further action beyond relaying the results to the medical doctor, who did not provide new orders at that time. The Director of Nurses later reviewed the x-ray results and recognized the acute fracture, but there was a delay in transferring the resident to the hospital for five days. During this period, the resident experienced increased pain. The medical doctor eventually instructed the facility to send the resident to the hospital after being informed of the x-ray results and the possibility of a new fracture. The resident was transferred to the hospital for evaluation of the right hip prosthesis dislocation and increasing pain, but the delay in response to the x-ray findings and the resident's condition constituted a deficiency in 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 provide a safe environment during incontinence care, resulting in a resident falling and sustaining a left hip fracture. The resident, who has severe cognitive impairment and is at high risk for falls due to decreased mobility and balance, was standing next to his bed when a CNA was providing incontinence care. The CNA removed the resident's adult brief and began cleaning, during which the resident unexpectedly urinated. The CNA moved back to avoid the urine, and the resident, wearing only socks, attempted to walk towards the CNA but slipped in the urine and fell. The incident report and subsequent interviews reveal that the resident was found on his back near the bed, with a wet floor identified as a predisposing environmental factor. The resident was not wearing non-skid footwear, and there was nothing for him to hold onto for stability. An x-ray confirmed an acute nondisplaced left femoral intertrochanteric fracture, requiring surgical intervention. The facility's fall preventive program emphasizes the use of professional standards of practice to ensure resident safety, 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 provide appropriate pain management for a resident who required Hydrocodone-acetaminophen PRN, resulting in the resident experiencing extreme pain for about one day. The resident, who was cognitively intact and had undergone a lumbar laminectomy, reported being in severe pain for two to three days without relief from a pain patch and muscle relaxant. The resident's pain was not alleviated because the nurse did not refill the Hydrocodone-acetaminophen prescription when there were only five pills left, leading to a lapse in medication availability. The pharmacy required a new prescription for the medication, which was received and a thirty-day supply was sent to the facility. However, the medication was not removed from the nexus, and the Control Drug Receipt/Record form with the nurse's signatures was not available. Despite the resident's complaints of pain and requests for Hydrocodone-acetaminophen, the facility failed to administer the medication, and the resident refused alternative medications offered. The facility's Pain Assessment Policy indicates that medication should be administered at the patient's request, but this 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 was found to have committed a deficiency by forging a family member's signature on an admission contract without permission. This incident involved a resident's family member, who was the emergency contact and representative for the resident. The family member reported receiving an admission packet via email that contained her unauthorized signature. The admission coordinator admitted to electronically signing the family member's name on the admission contract to meet a corporate deadline, acknowledging the wrongdoing and stating that the signed package was discarded, although a copy was automatically emailed to the family member.

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 policy regarding the placement of a urinary catheter drainage bag in a privacy bag, compromising the dignity of a resident. The incident involved a resident diagnosed with benign prostatic hyperplasia, chronic heart failure, and urine retention. During an observation, the resident's urinary catheter drainage bag was found not placed in a privacy bag and was visible to anyone entering the room. The LPN acknowledged that the CNA might have improperly positioned the drainage bag, which should have been either placed in a privacy bag or moved to a less visible location. The Director of Nursing confirmed that the facility's policy requires urinary catheter drainage bags to be placed in privacy bags to prevent exposure.

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 enteral feeding according to the physician's order for a resident requiring tube feeding. During an observation round, it was noted that the resident's tube feeding was hanging but not connected or turned on as per the physician's order, which specified that the feeding should be on at 9 AM. A Licensed Practical Nurse (LPN) confirmed that the feeding should have been turned on. The Director of Nursing (DON) also acknowledged that the tube feeding should have been administered according to the physician's order. The resident's admission record indicated a diagnosis requiring attention to gastrostomy, with an order for enteral feeding of Nepro at 55 ml/hour via pump for 21 hours a day, starting at 9 AM. The facility's policy on medication administration requires that medications, including enteral feedings, be administered as prescribed by 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 ensure that the oxygen humidifier bottle used by a resident was labeled with the appropriate date. During an observation, it was noted that a resident using oxygen via nasal cannula with a portable concentrator had an undated humidifier bottle attached. A Licensed Practical Nurse (LPN) acknowledged that the humidifier bottle should be labeled with the date to inform staff when it needs to be changed. The Director of Nursing (DON) confirmed that the oxygen humidifier bottle should be labeled with the date and changed weekly. The resident involved had a medical history of Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with Hypoxia, and an Anxiety Disorder. The facility's policy requires that all disposable respiratory equipment be labeled with the date when placed in use, and the humidifier bottle should be changed weekly and as needed.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper infection control practices during a blood glucose monitoring procedure for a resident under Enhanced Barrier Precautions (EBP). On 12/10/2024, an LPN entered a resident's room, which had signage indicating EBP, and performed hand hygiene before putting on gloves. However, the LPN did not wear the required PPE gown while conducting the blood glucose check, during which blood was visibly present. After completing the procedure, the LPN removed her gloves, performed hand hygiene, and exited the room. The LPN acknowledged that both gloves and a gown should have been worn during the procedure. The Director of Nursing confirmed that in EBP rooms, the required PPE includes gloves and a gown, and emphasized the importance of using both during blood glucose monitoring for infection control. The resident involved had a diagnosis of Type 2 Diabetes Mellitus without complications and was under EBP due to enteral feeding, tracheostomy, and compromised skin integrity. The facility's policy on EBP, dated 1/15/2024, mandates the use of PPE, including gowns and gloves, for high-risk activities where contact with blood, bodily fluids, skin breakdown, or mucous membranes is expected.

Penalty

Inspection fine: $29,328

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 notify the physician or nurse practitioner of a sacral wound culture result indicating a high amount of bacteria, specifically greater than 100,000 pseudomonas aeruginosa, for a resident with a stage three sacral pressure ulcer. This oversight affected one of the three residents reviewed for notification of abnormal lab results. As a result, the resident did not receive any antibiotic treatments and was hospitalized two weeks later with a diagnosis of sacral osteomyelitis. The resident was admitted with multiple diagnoses, including sepsis, a stage three sacral pressure ulcer, quadriplegia, anemia, muscle wasting, and adult failure to thrive. A wound assessment documented signs of infection, and a wound culture was ordered. However, the results were not communicated to the appropriate medical personnel. Interviews with staff revealed a lack of clarity and follow-up regarding the culture results, with several staff members, including the wound care coordinator and infectious disease nurse practitioner, unaware of the results. The facility's policy required that test results be reported to the ordering physician to ensure prompt and appropriate action. Despite this, the culture results were not communicated, and no new antibiotic treatments were documented for the resident after the culture was reported. The resident's condition worsened, with the pressure ulcer progressing to stage four, and the resident was eventually diagnosed with sacral osteomyelitis, highlighting the failure to act on the abnormal lab results.

Penalty

Inspection fine: $29,328

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 resident, resulting in the resident leaving the facility unauthorized. The resident, who had a history of substance abuse and alcohol use, was assessed to have supervised pass privileges and was not deemed capable of unsupervised outside pass privileges. Despite this, the resident exited the facility through the front lobby entrance without staff intervention and was gone for approximately fourteen hours without staff knowledge of their whereabouts. The incident occurred when the resident, who was non-weight bearing on the right lower extremity and had significant physical impairments, was last seen ambulating in the hallway with a walker. Staff members, including a CNA and an RN, noted the resident's absence during routine checks and medication pass. The resident was seen on camera leaving the facility with a male companion, who was carrying the resident's belongings. The receptionist, who was supposed to monitor the front desk, did not recognize the resident and failed to stop them from leaving. Interviews with staff revealed a lack of communication and urgency regarding the resident's absence. The RN and Social Service Coordinator did not express concern when the resident was reported missing, and the receptionist was unaware of the resident's identity. The facility's policy required a doctor's order for a resident to leave on a pass, which was not obtained in this case. The resident's departure was not reported to public health as an elopement, as the facility considered the resident cognitively intact and not at risk for elopement.

Penalty

Inspection fine: $16,801

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

Summary

The facility failed to provide adequate supervision for a resident diagnosed with dementia, resulting in the resident being left unsupervised during a transportation appointment. The resident, who had a BIMS score of 5 indicating cognitive impairment, was dropped off by a transportation company without a staff escort, despite being identified as not capable of unsupervised outside pass privileges. The resident was later found by family members attempting to navigate a street in a wheelchair, highlighting a significant lapse in supervision and communication between the facility, transportation service, and family. The incident was compounded by a lack of immediate action from facility staff when the resident's absence was reported. The unit clerk, who was aware of the situation, did not notify the appropriate nursing staff or management, delaying the implementation of the facility's missing resident protocol. This inaction contributed to the resident being unsupervised for an extended period, increasing the risk of harm. Additionally, the facility failed to adhere to its fall prevention protocols for two residents, resulting in one resident sustaining a laceration requiring sutures after falling from a wheelchair. The facility did not complete accurate fall risk assessments or implement individualized interventions based on the root causes of falls. This oversight led to repeated falls for the residents, indicating a systemic issue in the facility's fall prevention measures.

Removal Plan

• R1 reassessed without any adverse negative outcome.
• R1's appointment has been rescheduled.
• All facility contracted Medi-car and ambulance companies were contacted and reviewed facility's expectations during transportation, including ensuring the resident is safely transferred and reported to the receiving appointment staff.
• All residents with scheduled appointments have the potential to be affected by the alleged deficiency.
• The facility has conducted a comprehensive review to identify any other residents with scheduled appointments and has established corresponding staff escorts.
• The facility has conducted a comprehensive review to identify residents with a BIMS under 11 and those which cannot safely access the community independently, additionally, each resident is reviewed for additional factors such as behaviors, physical challenges and assistive devices as appointments arise to ensure a facility escort is assigned.
• The Unit Clerk will communicate upcoming appointments 72 hours prior to appointment date with confirmed staff escort name to nursing staff during morning meeting utilizing the appointment communication log.
• Emergency QA meeting conducted.
• Residents with upcoming scheduled appointments will be evaluated by nursing and social service departments to ensure resident is cognitively appropriate for independent community access.
• Family members of residents with upcoming scheduled appointments who require an escort, will be contacted to, optionally, assist with escorting/accompanying residents during transport if available. If family is not available, the facility will ensure a staff escort will accompany residents for all non-contracted transportation companies for residents who have been determined to require an escort.
• The Director of Nursing or designee educated the facility transportation coordinator/unit clerk on communicating upcoming appointments 72 hours prior to appointment date, including the name of the confirmed staff escort communicated to nursing staff during morning meeting utilizing the appointment communication log.
• Facility has developed a Transportation Communication Form which is being provided to all transportation companies at the time of scheduled resident appointments, which communicates pertinent transportation information, including resident drop off points, contact information for physician office and facility, to ensure resident safety.
• The Director of Nursing or designee educated the facility staff on the new Transportation Communication Form to be provided to transportation drivers at the time of resident pick-ups for scheduled appointments.
• The Director of Nursing or designee educated the facility staff who may accompany residents on appointments that Escort must call the facility to inform/confirm resident's arrival to appointment location office/Suite with Unit Clerk immediately to verify safe arrival. Knowledge check to be completed with staff escort prior to leaving the facility for verification/clarification.
• The Director of Nursing or designee educated the facility staff on immediately implementing the missing resident policy and procedure once a resident has been identified as missing.
• Staff, including agency, not present in the facility will be educated prior to starting their next shift. This training will be ongoing for new hires in the orientation process and has been added to the agency staff orientation folder.
• The Director of Nursing or designee will audit 3 random residents with scheduled appointments twice a week for 3 months or until compliance has been determined thereafter, to ensure safe transport and delivery of cognitively impaired residents to scheduled appointments.
• The Director of Nursing or designee will audit 3 random staff, twice a week for 3 months, for knowledge checks of previous education related to missing resident policy and Transportation Communication Form to ensure safe transport and delivery of residents who have been determined to require a staff escort to scheduled appointments.
• Findings of the quality review audits will be brought to the facility QA meeting until such time as the committee has determined substantial compliance has been achieved and recommends ongoing monitoring.

Penalty

No penalty information released

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

Summary

The facility failed to perform dressing changes and daily assessments of a resident's sacral wound as ordered for two days and did not address a foul odor in the wound for six days. This resulted in an abscess/infection forming behind the sacral wound, which required surgical drainage while the resident was hospitalized. The sacral wound developed a foul odor that was not identified at the facility, affecting one of three residents reviewed for pressure sore prevention and treatment. The resident, who had multiple diagnoses including urinary tract infection, peripheral vascular disease, hemiplegia following a cerebral infarction, and chronic ischemic heart disease, had a care plan that included monitoring and treating a sacral pressure ulcer. Despite the care plan, the facility did not perform the required dressing changes on specific dates and failed to document or address the foul odor emanating from the wound. The wound, initially documented as stable and showing no signs of infection, eventually declined, growing in size and developing necrotic tissue. Interviews with the wound care nurse, wound physician, and other nursing staff revealed that the dressing change frequency was revised based on family requests, and there was a lack of awareness and documentation of any signs of infection. The facility's policy required daily checks of dressings for signs of infection and proper documentation, which were not followed. The resident was eventually sent to the hospital, where a CT scan revealed abscess formation, necessitating surgical intervention and a course of IV antibiotics.

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 develop an effective plan of care for a dementia resident (R1) assessed to be at high risk for falls. Despite being identified as a high fall risk, there was no documentation of the specific monitoring required for R1. This lack of monitoring led to R1 suffering a right-sided pelvic fracture after attempting to self-ambulate to the bathroom and falling. The incident was only reported by another resident (R3) a couple of days later, and staff were unable to determine the exact circumstances of the fall due to R1's severe cognitive impairment and confusion. Interviews with staff revealed that R1 was impulsive, had poor safety awareness, and often attempted to get up without assistance, but there was no set monitoring schedule documented for high fall risk residents like R1. Another resident (R2) also experienced a fall resulting in a laceration to the head that required hospital treatment. R2, who had spinal stenosis, weakness, and lack of coordination, fell off the bed while being changed by a CNA. The CNA admitted to holding R2 with one hand while attempting to provide pericare with the other, which led to R2 sliding off the bed and hitting their head on the floor. The incident report and interviews with staff confirmed that R2 needed substantial assistance with bed mobility and could not turn over in bed without help. The fall occurred because R2 was positioned too close to the edge of the bed during care. The facility's failure to ensure adequate supervision and safe bed mobility practices for these high-risk residents resulted in significant injuries. The lack of a documented monitoring schedule for high fall risk residents and improper handling during direct care contributed to these incidents. The facility's fall prevention program policy stated that residents should be checked approximately every two hours or as per the care plan, but this was not effectively implemented for R1 and R2, leading to their injuries.