Evercare At Stearns

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 protect residents from resident‑to‑resident abuse, resulting in multiple physical assaults by one cognitively impaired resident against other cognitively impaired residents. The resident identified as the aggressor had a documented history of dementia with behavioral disturbance, traumatic brain injury, agitation, aggression, and prior violent episodes, including physically aggressive behavior toward his wife at home, attempts to elope, and an incident in which an RN was knocked to the ground during a prior hospitalization. His MDS showed severe cognitive impairment (BIMS 0) and physical behavioral symptoms directed toward others, such as hitting or pushing, occurring 1–3 days and placing him at significant risk for physical illness or injury. His care plan noted a history of physical aggression toward staff related to dementia and identified him as at risk for abuse/neglect due to impaired cognition and need for ADL assistance. One incident involved this resident entering another resident’s room and assaulting him with a walker. The victim in this event had Alzheimer’s disease and dementia with behavioral disturbance, was severely cognitively impaired, resistive to care at times, and dependent on staff for most ADLs. Progress notes documented that staff heard a resident screaming for help and then observed the aggressor hitting this resident with a walker. The victim was found with a head injury and was transported to the ED, where he was diagnosed with a physical assault and a 2‑cm scalp laceration that required repair with staples. This event occurred despite both residents being care planned as at risk for abuse/neglect related to dementia and impaired cognitive skills. A second incident occurred when the same aggressive resident entered another male resident’s room after using a shared bathroom. The victim, who had severe cognitive impairment, dementia without behavioral disturbances, anxiety, and required assistance with ADLs, reported that he approached the aggressor to tell him he was in the wrong room. The aggressor then stood up and struck him across the face with an open hand. Staff heard the victim scream from the dining area and, upon his arrival at the nurse’s station, observed redness to the right side of his face around his eye. An IDPH final report confirmed that the physical altercation occurred, that a small red area was present near the right eye, and that both residents resided on the memory unit. A third incident involved the same aggressive resident entering a female resident’s room and striking her in the face with a cane while she was asleep in bed. This victim had dementia with agitation, restlessness and agitation, anxiety disorder, paroxysmal atrial fibrillation, severe cognitive impairment, and required assistance with ADLs. Her care plan identified her as at increased risk for abuse and neglect related to dementia with behavioral disturbances. Progress notes documented that yelling was heard, and when staff arrived, they saw the aggressor standing over her holding a cane. The resident sustained a laceration to the right side of her jawline, reported pain at 8/10, and was noted to be frantic but resting quietly after the event. An IDPH final report documented that the LPN heard yelling, found the aggressor standing over the resident with a cane, and observed bleeding from the jawline laceration. Interviews with staff and facility leadership further described the aggressor’s unpredictable and unprovoked aggressive episodes. A resident aide stated that he could become agitated quickly, did not like redirection, and staff never knew when he would become aggressive. An LPN reported hearing a scream, running to the room, and seeing the aggressor standing over the female resident with a cane raised to strike again, noting that he became aggressive when he believed someone was in his room or personal space. The social service director stated she was not aware of his aggression when he was accepted, while the DON stated that she and the SSD had visited him in the hospital, found him calm and cooperative, and were told by hospital staff that he had been cooperative except for the initial ER incident. The administrator and DON both acknowledged that the aggressor was very protective of what he believed was his bed, that he would have an issue if he saw someone on it, and that all residents were at risk because staff never knew when he would “go off.” Despite the facility’s written Abuse Prevention and Prohibition Program stating that the facility screens for potentially abusive residents during pre‑admission and maintains adequate staffing to meet residents’ needs, these resident‑to‑resident assaults occurred, demonstrating a failure to ensure residents were free from abuse by other residents. The facility’s Abuse Prevention and Prohibition Program also stated that the facility is committed to protecting residents from abuse by anyone, including other residents, and that it conducts ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences. However, the documented history of the aggressor’s dementia with behavioral disturbance, prior aggression toward caregivers, and multiple in‑facility assaults on other residents shows that, in practice, residents were not adequately protected from resident‑to‑resident abuse. The combination of the aggressor’s known behavioral risks, the severe cognitive impairment and dependence of the victims, and the repeated episodes of physical assault within the memory unit formed the basis of the cited deficiency for failure to ensure residents were free 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

A deficiency occurred when the facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident. One resident, diagnosed with severe dementia and dependent on staff for all activities of daily living, was found in bed and unable to communicate or participate meaningfully in assessments. Another resident, with moderate cognitive impairment and a history of confusion and inappropriate sexual behaviors, was observed by an LPN kneeling next to the first resident's bed with her pants down and her hand in the other resident's buttocks region. The LPN witnessed the resident placing her finger near the other resident's rectum and immediately intervened. The resident who initiated the contact had a documented history of dementia, confusion, and previous sexual behaviors, including self-stimulation and confusion about boundaries. Despite these known risks, the resident was able to access and interact with the other resident, who was incapable of providing consent or resisting advances due to her cognitive and physical limitations. The incident was witnessed by staff, and the resident was unable to explain her actions clearly, offering inconsistent explanations such as attempting to help or being cold. The affected resident's medical records confirmed severe cognitive impairment, total dependence on staff, and inability to communicate. Staff interviews and documentation indicated that the resident could not report or describe the incident. The facility's failure to prevent this interaction resulted in inappropriate physical contact of a sexual nature, violating the resident's right to be free from abuse and neglect.

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 operationalize its abuse policy and procedures for two residents with cognitive impairment. An incident occurred in which one resident, who had a history of working as a CNA and was now a resident with some confusion and dementia, was found by an LPN on her knees next to her roommate's bed with her pants down and her hand in the buttocks region of her roommate, who also had severe dementia and was non-communicative. The LPN observed the resident placing her middle finger near the roommate's rectum, with both residents and the bedding soiled with fecal matter. The LPN immediately intervened, separated the residents, and notified management and authorities. Despite the eyewitness account and documentation by the LPN, the facility's internal investigation concluded that no inappropriate contact had occurred, attributing the incident to a misunderstanding and the resident's confusion. The administrator and DON expressed doubt that abuse had occurred, citing the resident's prior CNA experience and confusion, and did not fully address the eyewitness statement or the police report, which described digital manipulation of the roommate's vagina and anus. The facility's documentation did not include a statement from the non-communicative resident or a thorough account of the LPN's observations in the final report. The facility's abuse policy outlines steps for investigation, including interviews with witnesses and review of relevant documentation. However, the investigation omitted key details from the eyewitness account and did not document the incident in the roommate's nursing notes. The facility requested past noncompliance for F600 abuse, despite the lack of findings in their internal investigation and the presence of conflicting evidence from staff and police reports.

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 all alleged violations were thoroughly investigated for two residents with dementia who were involved in an incident of possible abuse. The incident involved one resident being found on her knees next to her roommate's bed, with her pants down and her hand in the area of the other resident's buttocks. The eyewitness, an LPN, reported observing the resident placing her finger near the roommate's rectum and immediately intervened. The roommate was non-communicative and unable to provide a statement due to severe dementia. The incident was reported to management, police, and family members, and both residents were separated and monitored. Despite the eyewitness account and the police report describing digital manipulation of the roommate's vagina and anus, the facility's internal investigation concluded that nothing inappropriate had occurred. The investigation relied heavily on the resident's history as a former CNA and her confused statements, as well as the lack of physical injuries or behavioral changes in the roommate. The facility did not document any findings that addressed the eyewitness's detailed account or the police report, nor did they provide documentation of steps taken to address the specific alleged violation. Nurses' notes for the roommate did not mention the incident, and interviews with staff indicated a lack of clarity about the nature of the incident and the actions taken. The facility's abuse policy outlines steps for investigating alleged incidents, including reviewing documentation, interviewing witnesses, and assessing residents. However, the investigation in this case did not address key evidence, such as the eyewitness's statement and the police report, and failed to document a thorough review of the incident. The lack of comprehensive documentation and failure to address all aspects of the allegation resulted in a deficiency related to the facility's responsibility to thoroughly investigate and respond to alleged violations.

Penalty

Fine: $89,3007 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 prevent abuse and neglect for four residents reviewed for abuse, resulting in both physical and psychosocial harm. One resident, who was moderately cognitively impaired, was observed in a physical altercation with his roommate, who had a documented history of aggression. The altercation involved striking with closed fists and pushing, yet there was no documentation of the incident in the medical record for two consecutive days. The resident reported feeling scared, unsafe, and unable to protect himself, and had previously informed the Social Services Director about his fear and ongoing issues with his roommate. Despite this, the two residents remained roommates, and the incident was not promptly reported to facility administration or documented by the staff present, including a safety aide who witnessed the event. Another incident involved two severely cognitively impaired residents in a locked dementia care unit. One resident entered another's room, became agitated, and struck the other resident multiple times, resulting in a scratch to the upper lip and reported hits to the face, stomach, and leg. Staff intervened after hearing a commotion, separated the residents, and sent the aggressor for evaluation. Interviews with staff indicated that the aggressor was wandering and appeared confused, believing the other resident was involved with his wife. The care plans for the involved residents did not consistently identify risk for abuse or include appropriate interventions. Across these incidents, there was a lack of timely documentation, reporting, and care planning to address known risks of aggression and abuse. Staff, including RNs and safety aides, were either unaware of the altercations or failed to report them to administration. The facility's failure to implement and document interventions for residents with histories of aggression or cognitive impairment contributed to repeated episodes of resident-to-resident abuse and harm.

Penalty

Fine: $89,3007 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 resident with a history of cerebral infarction, dysphagia, dementia, major depressive disorder, anxiety disorder, trigeminal neuralgia, and morbid obesity was admitted with significant ADL deficits and was always incontinent of bowel and bladder. The care plan included interventions for skin integrity, such as frequent skin assessments, use of a pressure redistribution mattress, regular turning and repositioning, and application of barrier creams after each episode of incontinence. Physician orders specified weekly skin checks and daily application of barrier cream for incontinence dermatitis, with additional instructions for cleansing and protecting the peri-area and buttocks. Despite these orders and care plan interventions, staff failed to consistently identify and treat the resident's developing wounds. Observations revealed that during incontinent care, the resident's buttocks were severely reddened with open sores and bleeding, and no moisture barrier cream was applied. Certified Nursing Assistants (CNAs) did not report the worsening skin condition to the nursing staff, and the wound nurse was unaware of the resident's excoriated and bleeding wounds until informed by surveyors. Documentation showed that previous wounds had been marked as healed, and there were no ongoing wound notes or timely reassessments after the discontinuation of wound management specialist services. Interviews with staff confirmed that the expected protocol was not followed: CNAs were supposed to report changes in skin condition and apply barrier cream, but this was not done. The wound nurse and DON both stated they were not made aware of the resident's deteriorating skin condition until after the surveyor's observation. The lack of communication and failure to follow established wound care protocols resulted in the resident experiencing severe excoriation, open wounds, and pain.

Penalty

Fine: $89,3007 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 maintain resident privacy and dignity for four residents during personal care activities, as observed and documented by surveyors. In multiple instances, certified nursing assistants (CNAs) provided incontinence care or toileting assistance without ensuring that window blinds, privacy curtains, or room doors were closed, resulting in residents being exposed to view from outside the building or to their roommates. For example, one resident with severe cognitive impairment and total dependence on staff for toileting was left exposed to the outside patio and parking lot during incontinence care, as the blinds and privacy curtain were not closed. Another resident, cognitively intact but dependent on staff for toileting, was also exposed to the outside during care, and expressed that she would be embarrassed if her private areas were visible to others outside her room. Additional incidents included a resident being assisted with toileting in a bathroom with the door open, exposing his buttocks and scrotum to his roommate, who later stated discomfort with witnessing such exposure. Another resident with severe cognitive impairment and frequent incontinence was left with his perineal area exposed during care, as both the blinds and curtain were left open until a CNA realized and closed the blinds. In each case, the facility's own policy required staff to provide privacy and avoid unnecessary exposure during personal care, but these procedures were not consistently followed. Residents involved had significant medical conditions such as cerebral infarction, dementia, hemiplegia, and morbid obesity, and were dependent on staff for activities of daily living, including toileting and incontinence care. Interviews with residents and family members confirmed that such exposure would be embarrassing and was not acceptable to them. Staff and the Director of Nursing acknowledged that privacy should be maintained at all times, including closing blinds, curtains, and doors during care, but these expectations were not met during the observed incidents.

Penalty

Fine: $89,3007 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 a safe environment and adequate supervision for four residents, resulting in multiple falls and injuries. One resident with diagnoses including brain neoplasm, dementia, and lung neoplasm was identified as a high fall risk and had a care plan with multiple interventions such as non-slip footwear, signage, and a bolstered mattress. Despite these interventions, the resident experienced at least twelve falls, including one that resulted in a skin tear to the right knee. Observations revealed the resident was frequently not wearing non-slip socks or shoes, the call light was found on the floor, and the bolstered mattress was not in place as care planned. Staff interviews confirmed the expected interventions were not consistently implemented, and the resident’s family expressed concerns about inadequate supervision and missing safety equipment. Another resident with severe cognitive impairment and a history of wandering was care planned as an elopement risk and resided on a secured unit. However, observations showed the resident wandering into other residents’ rooms without staff intervention, and another resident reported the need to keep their door closed to prevent this. The care plan interventions, such as providing supervision and diversional activities, were not observed to be consistently followed during the survey. Two additional residents, both high fall risks with cognitive impairments, were observed being transferred by CNAs who did not use gait belts as required by their care plans and facility policy. Although staff stated they use gait belts for transfers, direct observation showed that gait belts were not used on the residents during transfers, despite being carried by the staff. Facility policies and care plans specified the use of gait belts to promote safety, but these were not adhered to during the observed transfers.

Penalty

Fine: $89,3007 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 observed multiple failures in the facility's medication storage and labeling practices. During inspections of medication carts and storage rooms, numerous instances were found where drugs and biologicals were not properly labeled, such as opened multi-dose insulin pens without open dates and vials of Lorazepam stored in unlabeled or improperly labeled bags. Expired medications, including Lorazepam, were found in unlocked refrigerators, and staff confirmed these should have been destroyed but were not. Additionally, some medications lacked pharmacy labels or had handwritten names, and there were medications present for individuals not currently residing in the unit. Medication carts were found to be physically compromised, with missing drawers creating large openings that exposed narcotic lock boxes. These carts were observed unattended in hallways, with the narcotic drawers accessible to residents, including those who were mobile and cognitively impaired. Staff interviews confirmed that the carts had been in this condition for extended periods, and that narcotics could be accessed through the openings. The facility's Director of Nursing and other staff acknowledged awareness of these issues, including the lack of double-lock security for controlled substances and the absence of narcotic count sheets for expired medications. Further deficiencies were identified in the management of emergency kits (E-kits). Kits were found unsealed, unlocked, and missing required inventory documentation. Staff were unclear on the procedures for retagging and inventorying the kits after use, and there was confusion regarding the presence and use of medications within the kits. The lack of proper labeling, security, and documentation for both routine and emergency medications was confirmed through staff interviews and direct observation, in violation of the facility's own medication storage policy.

Penalty

Fine: $89,3007 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 timely and complete incontinent care for four residents who were dependent on staff for toileting and personal hygiene due to conditions such as cerebral infarction, hemiplegia, impaired mobility, and severe cognitive impairment. Multiple residents reported not being cleaned or changed for extended periods, with some stating they had not received care since early morning hours. Observations confirmed that residents remained wet or soiled for several hours, and staff did not consistently provide care in accordance with the residents' care plans and physician orders, which required frequent and thorough incontinent care to maintain skin integrity and prevent complications. Direct observations of care revealed that staff did not fully cleanse all affected areas during incontinence care. For example, staff were seen wiping only parts of the groin and buttocks, leaving stool or urine on the skin, and failing to dry the area or apply prescribed moisture barrier creams. In some cases, open sores and reddened skin were noted, and care was performed in a manner that caused further skin breakdown. Additionally, privacy measures were not always observed, as window blinds were left open during care, exposing residents to potential view from outside. Interviews with staff indicated inconsistent understanding and implementation of proper incontinent care procedures, including the frequency of checks and the thoroughness of cleaning. The facility's own policy required washing the entire perineal area and all areas affected by incontinence, but this was not consistently followed. The Director of Nursing confirmed the expectation for timely, complete care and privacy, which was not met in these instances.

Penalty

Fine: $89,3007 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 safe and appropriate respiratory care for four residents who required oxygen therapy. Observations revealed that humidified water bottles were not attached to oxygen concentrators for these residents, and nasal cannulas or oxygen tubing were not dated as required. In several instances, oxygen tubing was found lying on the floor, and portable oxygen tanks were left free-standing without proper stands or containers. These deficiencies were noted despite physician orders and facility policy specifying the need for humidification at certain flow rates, regular tubing changes, and proper labeling. One resident with a history of COPD, respiratory failure, and dependence on supplemental oxygen was observed multiple times without a humidified water bottle attached to the concentrator and with undated nasal cannula. During care, this resident was laid flat and had her oxygen removed, resulting in visible shortness of breath. Another resident, who did not have a physician order for oxygen, was found using an oxygen concentrator without a humidified water bottle and with undated nasal cannula. Additional residents with diagnoses including acute respiratory failure and CHF were also observed using oxygen without humidification and with undated tubing. Interviews with staff, including the DON and LPN, confirmed that nurses are responsible for attaching humidified water bottles and dating nasal cannulas, and that portable oxygen tanks should not be left free-standing. The facility's own policy requires weekly tubing changes, dating of tubing, and the use of humidification as clinically indicated. Despite these policies and staff expectations, the required procedures were not consistently followed for the residents reviewed.

Penalty

Fine: $89,3007 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 maintain a clean, homelike environment for two cognitively intact residents, as evidenced by multiple observations and resident interviews. One resident reported that the facility was filthy, with overwhelming odors and insufficient staff to maintain cleanliness, stating that housekeeping only lightly mopped the floors without scrubbing. Another resident described persistent odors of urine and feces throughout the building and mentioned a leak during heavy rain. Both residents' assessments confirmed their cognitive intactness at the time of the interviews. Surveyors observed dirty and sticky dining room floors on several occasions, along with strong urine odors in various areas of the facility, including the dining room and resident hallways. Staff interviews revealed that CNAs would notify housekeeping of cleaning needs or use air freshener themselves, while the housekeeping supervisor stated that rooms were cleaned daily and air freshener was used for odors. The facility's cleaning protocol outlined daily cleaning tasks, but observations and resident reports indicated these were not effectively implemented, resulting in an environment that did not meet standards for cleanliness and comfort.

Penalty

Fine: $89,3007 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 report allegations of abuse involving four residents, as required by regulation and facility policy. In one incident, two residents with moderate cognitive impairment were observed physically striking each other, with one resident repeatedly hitting the other and both engaging in aggressive behavior. Despite the altercation being witnessed by a safety aide and other staff, there was no documentation of the event in the medical records, no report made to the Illinois Department of Public Health (IDPH), and the residents remained roommates. The administrator and registered nurse were not made aware of the incident until it was brought to their attention by a state surveyor, and the safety aide did not report the incident as abuse. Another resident with a history of physical aggression exhibited agitated and aggressive behaviors, including yelling, cursing, and pushing another resident's wheelchair. These behaviors were documented in progress notes, but the incidents were not reported or investigated until days later, when the DON became aware and reported them to IDPH. The nurse documented the events as late entries, and the DON stated that she would have expected immediate reporting of abuse. A separate incident involved a resident with Huntington's Disease and a history of abuse, whose roommate, a resident with severe cognitive impairment, was found standing by her bed holding a pillow. Although no physical contact occurred and the residents denied any harm, the CNA who observed the event was concerned. The facility's investigation concluded that there was no reportable issue, and no separation of the residents or report to IDPH occurred. The facility's abuse prevention policy requires immediate reporting of alleged violations, but this was not followed in these cases.

Penalty

Fine: $89,3007 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 investigate allegations of abuse involving one resident who was observed to be angry, agitated, and verbally aggressive toward other residents and staff. Progress notes documented that the resident was yelling and cursing at others, and staff intervened to redirect and calm the resident. Despite these documented incidents of verbal altercations, there was no evidence that an abuse investigation was initiated for the events that occurred on two separate dates. The incidents were only reported to the Director of Nursing several days later, and the required investigation had not been conducted as of the time of the survey. Interviews with facility staff confirmed that the incidents were reported late and that the Director of Nursing was not made aware of the situation until days after the events occurred. The facility's own Abuse Prevention policy requires immediate initiation of an investigation upon any finding of abuse or neglect, but this was not followed. Documentation also indicated that the nurse entered progress notes as late entries, further delaying the reporting and investigation process.

Penalty

Fine: $89,3007 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 refer a resident for a Pre-Admission Screening and Resident Review (PASARR) after the resident was diagnosed with serious mental disorders. The resident was admitted with diagnoses including heart valve replacement, atrial fibrillation, and congestive heart failure, and later received additional diagnoses of severe dementia with agitation, dementia with psychotic disturbance, and schizoaffective disorder, depressive type. Despite these new diagnoses, the resident's PASRR Level I screening from a previous date indicated no serious mental illness or intellectual/developmental disability, and no further screening was conducted after the significant change in the resident's mental health status. The resident's care plan documented risks related to impaired cognitive skills, mental health diagnoses, and behaviors such as physical aggression and elopement risk, with the resident residing on a secured unit. The facility's policy required notification to the state-designated mental health or intellectual disability authority when a resident experiences a significant change in mental health status, but this was not done. The social worker acknowledged missing the re-evaluation and only began gathering documentation for the PASARR after the deficiency was identified.

Penalty

Fine: $89,3007 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

Certified Nurse Assistants (CNAs) failed to follow proper hand hygiene and glove removal protocols during the care of a resident with severe cognitive impairment, Alzheimer's disease, and frequent incontinence. During an observed episode, the resident had saturated his incontinence brief and pants with urine and had a small amount of stool present. After providing peri care, one CNA did not perform hand hygiene after removing gloves, while another CNA failed to remove her gloves and perform hand hygiene after handling the resident's soiled clothing. This CNA then touched the resident's wheelchair handles, the resident's hands, body, and gait belt, and assisted the resident from bed to wheelchair without changing gloves or performing hand hygiene. Both CNAs also touched the resident's door handle upon leaving the room without performing hand hygiene. Interviews with other CNAs indicated that they were aware of the facility's policy requiring hand washing before donning gloves and after removing them, as well as after handling soiled linen and before touching other surfaces or residents. The facility's policy, dated 2016, specifically states that hands must be washed before and after glove use, and that gloves should be changed often as they become contaminated. The observed actions of the CNAs were inconsistent with both the facility's policy and the stated practices of other staff members.

Penalty

Fine: $115,595

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 provide timely treatment for a resident who experienced a significant change in condition. The resident, who was cognitively intact and required assistance with activities of daily living, became unresponsive and did not receive medical treatment for several hours. This delay in care resulted in the resident experiencing cardiac arrest and severe septic shock, necessitating emergency medical intervention and hospitalization. The deficiency was identified as an Immediate Jeopardy situation, beginning when the facility did not assess or monitor the resident's declining condition, failed to notify the physician of the resident's decline, and did not obtain timely medical treatment. Despite multiple staff members observing changes in the resident's condition, including increased incontinence, refusal to eat, and unresponsiveness, the necessary actions to address these changes were not taken. The resident's condition continued to deteriorate, leading to a critical medical emergency. Interviews with staff and review of records revealed that the resident's change in condition was not appropriately communicated or acted upon. Staff members, including CNAs and LPNs, noted the resident's unusual behavior and decline but did not ensure that the resident received the necessary medical attention. The facility's failure to follow its own policies for change in condition and physician notification contributed to the delay in treatment and the resident's subsequent medical crisis.

Removal Plan

• Emergency QA held with interdisciplinary team to establish a system that addresses any resident in distress and or unresponsive will be treated timely and without delay.
• Charge nurse will notify the MD, DNS, and or Administrator to ensure immediate action is taken.
• Root Cause analysis completed related to staff failure to immediately notify and transfer resident to hospital when change in condition arose.
• DNS and or Designee performed Inservice to Licensed Nurses to ensure that shift to shift report is done.
• Facility suspended V5 (LPN) and V9 Speech Therapist for not responding or making any effort to assist R3 when unresponsive.
• DNS and Regional Clinical Operations Nurse will begin in-servicing All Staff in person or by phone.
• In-service to include notification of any change in condition to charge nurse and Director of Nursing.
• Licensed nurses will notify physician if resident is unresponsive or in acute distress to call 911 and notify physician, DNS, and or Administrator and resident's responsible party.
• Staff will not be allowed to work unit until in-service completed.
• DNS and or designee will do 100% visual assessment to ensure all current residents are in stable condition and not in acute distress.
• DNS and or designee will do 100% audit of vital sign equipment to ensure each unit has a working vital sign equipment readily available.
• DNS and Unit Managers will visually monitor every resident to ensure residents are not in distress and in stable condition.
• DNS and Unit Managers will monitor that each unit has vital sign equipment, and it is in working condition.
• Policy regarding this IJ related to F684 was reviewed at the Emergency QA meeting.

Penalty

Fine: $115,595

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 of a resident's change in condition and unresponsive episode, which was a significant deficiency. The resident, who was cognitively intact and required assistance with activities of daily living, experienced a decline in condition over several days, culminating in an unresponsive episode. Despite being a full code with advance directives requesting life-sustaining measures, the resident did not receive timely medical treatment. The resident became unresponsive at 9:00 AM, but medical intervention was delayed until 4:00 PM, resulting in the resident being hospitalized with a diagnosis of cardiac arrest and severe septic shock. Interviews and record reviews revealed that the resident had been exhibiting changes in condition, such as refusing medication and meals, increased incontinence, and a decline in mobility and alertness. Staff members, including CNAs and nurses, noticed these changes and reported them to the nursing staff and the Director of Nursing. However, the nurse on duty misinterpreted the resident's condition as behavioral rather than a medical emergency, leading to a lack of timely assessment and intervention. The nurse practitioner was not informed of the resident's unresponsive state, and the physician was not notified of the significant changes in the resident's condition. The facility's failure to assess, monitor, and provide timely treatment was identified as the root cause of the deficiency. The resident's power of attorney expressed concern over the delayed response and inadequate care, highlighting that the resident had been in distress for days before the unresponsive episode. The facility's policy on notification of a change in condition was not followed, as significant changes in the resident's condition were not communicated to the physician or responsible parties in a timely manner.

Penalty

Fine: $115,595

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 neglected to provide necessary medical services to a resident, resulting in medical neglect. The resident, who was cognitively intact and required assistance with activities of daily living, exhibited a significant decline in condition over the course of five and a half hours. Despite being unresponsive and showing signs of severe distress, including foaming at the mouth and shallow breathing, the resident did not receive timely emergency medical treatment. The resident's care plan indicated a full code status, yet there was a delay in recognizing the need for emergent medical intervention. The report details multiple failures in communication and assessment by the facility's staff. The resident's change in condition was noted by several staff members, including CNAs and a speech therapist, who reported the resident's unusual behavior and physical decline to the nursing staff. However, these concerns were not adequately addressed. The nurse practitioner was notified of the resident's refusal to take medication and food, but was not informed of the resident's unresponsiveness earlier in the day. The nurse on duty failed to follow up on the resident's condition and did not call for immediate medical assistance, mistaking the symptoms for behavioral issues. The facility's Director of Nursing and other staff members were involved in the resident's care but did not take appropriate action until the resident's condition had severely deteriorated. The resident was eventually transferred to the hospital after emergency services were called, but only after a significant delay. The facility's policies on change in condition and physician notification were not followed, contributing to the resident's medical neglect and subsequent hospitalization for cardiac arrest and severe septic shock.

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 resident-to-resident abuse involving four residents, as observed in two separate incidents. In the first incident, a male resident with severe cognitive impairment and multiple medical conditions, including dementia, unintentionally hit a female resident with his walker. This occurred after the female resident, who also had cognitive impairments and used a wheelchair, pushed the male resident's walker out of her way in a crowded area. The incident was captured on facility cameras, showing no intention to harm, and resulted in no significant injuries, although precautionary x-rays were taken. In the second incident, a male resident who had been admitted less than 24 hours prior, and who was severely cognitively impaired, was involved in a physical altercation with another male resident. The new resident mistakenly believed he was in his own room and reacted aggressively when the other resident attempted to enter. This resulted in the resident being hit in the head and sustaining a black eye, a skin tear, and bruising. Staff intervened quickly, and both residents were assessed, with one being sent for psychiatric evaluation. The facility's abuse prevention policy emphasizes protecting residents from abuse by anyone, including other residents. However, in these cases, the facility's actions were insufficient to prevent the incidents, despite the cognitive impairments of the residents involved. The facility's investigation concluded that there was no intent to harm in either case, but the incidents highlight a failure to adequately protect residents from potential 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 prevent significant medication errors related to insulin administration for four residents. Resident R41, who has a history of type 1 diabetes mellitus and other health issues, experienced a fall due to low blood sugar levels. The Medication Administration Record (MAR) for R41 did not document the units of insulin administered on multiple occasions, including the day of the incident. The Director of Nursing acknowledged the inconsistency in charting due to the use of agency nurses, which led to a lack of documentation on the insulin units given. Resident R42, diagnosed with type 2 diabetes mellitus and chronic kidney disease, also had incomplete documentation in the MAR regarding the units of insulin administered. The Licensed Practical Nurse (LPN) responsible for R42's care stated that there was no designated area in the MAR to record the insulin units, leading to inconsistent documentation practices. Similarly, residents R104 and R16, both with type 2 diabetes mellitus, had numerous instances where the MAR did not document the insulin units administered. The LPNs involved in their care reported that the MAR lacked a specific section for recording insulin units, resulting in incomplete records. The facility's Insulin Injection Policy requires documentation of the type, amount, time, and site of insulin injections, which was not adhered to in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to administer medications as ordered for a resident who was supposed to receive Tylenol 500 mg three times daily at specific times due to chronic pain. The resident reported that while regular nurses administered the medication on time, agency nurses often missed doses. The resident's medical history includes chronic pain and a wedge compression fracture of the fourth lumbar vertebra. The physician's orders clearly stated the administration times for the medication, which were not consistently followed, leading to missed doses in April and June. The Director of Nursing acknowledged the missed doses and explained that the administration times were adjusted to accommodate the resident's preferences. Despite this adjustment, the expectation was for all nurses, including agency staff, to adhere to the physician's orders. The facility's policy on medication administration emphasizes adherence to prescribed orders and proper documentation, which was not followed in this case, as evidenced by the missing Medication Administration Records for April.

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 insulin timely as prescribed by the physician for one resident (R2). R2, who has diagnoses including type 2 diabetes mellitus, did not receive the 8:00 PM dose of Basaglar insulin on 2/23/24 because the medication was not in stock. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the insulin was administered later that evening when it arrived from the pharmacy, but this administration was not documented in R2's Medication Administration Record (MAR) or Progress Notes. The facility's 24 Hour Nursing Report did document that the insulin was given at approximately 9:45 PM, but there was no documentation of physician communication regarding the late administration in the Progress Notes for February 2024. The Facility's Medication Administration policy requires that medications be administered as prescribed and documented in the resident's MAR or treatment record. The DON stated that she expects staff to follow this policy but felt that the order to resume insulin when received covered the administration time. However, she did not believe it was necessary for staff to document when the physician was contacted, whether the medication arrived, or whether it was administered. This lack of documentation and timely administration of insulin constitutes a failure to meet the pharmaceutical needs of the resident as prescribed by the physician.