Evercare At University

Penalty

Fine: $158,110

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 a facility failed to protect a non-verbal, severely cognitively impaired resident from sexual abuse by another resident. The first incident took place when a CNA observed a male resident with his hand inside the female resident's diaper in a public area. The CNA intervened, removed the male resident, and reported the incident to two LPNs. However, the incident was not reported to law enforcement or the Department, and no immediate interventions were implemented to prevent further contact between the two residents. The following day, the same male resident entered the female resident's room, pulled down her brief, applied shaving cream to her, and stated his intent to have sex. Staff discovered the male resident in the female resident's room with his pants down and shaving cream on his hands. The female resident was found lying in bed, non-responsive, with shaving cream on her buttock. The male resident was subsequently sent to the hospital for evaluation, but prior to this, he was not placed under enhanced supervision and was able to move freely throughout the facility. The female resident involved was non-verbal, unable to communicate, and severely cognitively impaired, making her unable to consent to any sexual activity. The male resident had a documented history of inappropriate contact with peers and staff, and his care plan reflected this risk. Despite this, the facility did not implement measures to prevent further abuse after the initial incident, nor did they promptly report the abuse as required by policy. The failure to act resulted in a second incident of sexual abuse the following day.

Removal Plan

• V1 and V2 were in-serviced on abuse and neglect by V41
• Department heads were in-serviced on abuse and neglect policy and procedure by V1
• 24 hour reports were reviewed
• 24 hour report audits were initiated
• Interviews with staff members were initiated to ensure staff know who to report abuse and neglect to
• Root cause analysis was completed for abuse and neglect

Penalty

Fine: $158,110

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

Summary

The facility failed to follow its abuse prevention policy in the case of a non-verbal, severely cognitively impaired resident who was unable to consent to sexual activity. On one occasion, a CNA observed another resident with a history of inappropriate contact attempting to get into bed with the non-verbal resident. The day prior, the same resident was observed with his hand inside the non-verbal resident's diaper in a public area. Despite these incidents, the facility did not report the initial allegation to law enforcement or the Department, nor did they implement interventions to prevent further abuse. Staff interviews revealed that after the first incident, the involved resident was not placed under enhanced supervision and continued to have access to the non-verbal resident. The care plan for the non-verbal resident did not address risk of abuse or neglect, and the facility's response to the initial report was limited to internal review of surveillance footage, which did not fully capture the incident. The administrator acknowledged being notified but did not take further action, stating that it did not cross her mind to report the allegation since she believed nothing had happened. Subsequently, the resident with a history of inappropriate behavior entered the non-verbal resident's room, removed her incontinence brief, and applied shaving cream to her, admitting to staff that he wanted to have sex. The incident was only reported to law enforcement after an anonymous call. The facility's own abuse prevention policy requires immediate reporting and investigation of abuse allegations, but these procedures were not followed, resulting in repeated abuse of a vulnerable resident.

Penalty

Fine: $158,110

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

Summary

The facility failed to investigate an allegation of sexual abuse involving two residents, one of whom was severely cognitively impaired and non-verbal, dependent on staff for mobility, and unable to communicate or consent. A certified nursing assistant observed one resident with his hand inside the diaper of the cognitively impaired resident and reported the incident to an LPN, who then notified the facility administrator. The administrator reviewed video surveillance but, upon not seeing anything, did not pursue a further investigation. The care plan for the cognitively impaired resident did not address risk of abuse or neglect, and the other resident's care plan, which noted a history of inappropriate contact, was not updated with interventions until after a subsequent incident. The day following the initial uninvestigated allegation, the same resident was found in the room of the cognitively impaired resident, attempting to get into bed with her. Documentation and staff interviews confirmed that the resident admitted to entering the room and attempting sexual contact. The facility's abuse prevention policy requires prompt and thorough investigation of all abuse allegations, but this was not followed. Additionally, a police report was filed by an anonymous caller who alleged that multiple incidents of abuse were occurring and not being reported by the facility.

Penalty

Fine: $158,110

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

Summary

The facility failed to provide adequate supervision and protection for a severely cognitively impaired, non-verbal resident with a history of psychosis and dependence for mobility. The resident's care plan did not address the risk of abuse or neglect, despite her vulnerability. Another resident, who was cognitively intact but had a documented history of inappropriate contact with peers and staff, was not placed on enhanced supervision or restricted from moving freely about the facility after an initial incident of inappropriate contact was observed. On one occasion, a CNA observed the resident with a history of inappropriate behavior with his hand inside the vulnerable resident's diaper, claiming to be checking it. This incident was reported to the LPN and the facility administrator, but no immediate action was taken to increase supervision or separate the residents. The following day, the same resident was found in the vulnerable resident's room, attempting to get into bed with her, with his pants down and shaving cream on his hands. Staff found shaving cream on the vulnerable resident's buttock, and the resident admitted to wanting to have sex with her. The vulnerable resident was non-verbal and unable to consent to sexual activity. Despite staff and psychiatric documentation of the incidents and the resident's admission of intent, the facility did not implement interventions to prevent further contact or abuse after the initial event. The facility's abuse prevention policy states a zero-tolerance approach and the need to protect residents from abuse, but this was not followed, resulting in repeated incidents of sexual abuse and lack of adequate supervision for both residents involved.

Penalty

Fine: $158,110

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 facility failed to report an allegation of sexual abuse involving a resident with severe cognitive impairment and dependent mobility. The incident occurred when a certified nursing assistant (CNA) observed another resident, who had a history of inappropriate contact, with his hand inside the dependent resident's diaper while she was seated in her wheelchair. The CNA immediately informed an LPN, who then notified the facility administrator. Despite being notified, the administrator did not report the allegation to authorities, stating that nothing had happened. The resident who was the subject of the allegation had diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis, and was documented as severely cognitively impaired. The care plan for this resident did not address risk of abuse or neglect. The facility's own abuse prevention policy requires prompt reporting and investigation of abuse allegations, but this protocol was not followed in this case. The incident was later reported to local police by an anonymous caller, not by the facility.

Penalty

No penalty information released

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

Summary

The facility failed to notify a resident's representative of a fall incident. The resident, who was admitted with osteoporosis, pain, and dementia, was documented as severely cognitively impaired and required partial assistance with bed mobility and transfers. After an unwitnessed fall, the resident was found with a hematoma on the right side of her head. The family member listed as the emergency contact and durable power of attorney was not informed of the fall due to an incorrect contact number being on file. Staff attempted to call the family member, but the voicemail box was not set up, and it was later discovered that the number used was incorrect. The family member only became aware of the resident's fall and resulting injuries upon visiting the facility and observing visible bruising. Interviews with staff confirmed that the contact information was not accurate, and as a result, the family was not notified in a timely manner. The facility's policy requires that medical care problems, including accidents, be communicated to the resident's family or legal representative efficiently and effectively, which did not occur 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

A deficiency occurred when the facility failed to provide and document physician-ordered wound care for a resident with multiple wounds and significant medical history, including paraplegia, pressure ulcers, and bilateral lower limb amputations. The resident's care plan and physician orders specified daily wound treatments for the left posterior thigh and bilateral stumps, as well as new abdominal wounds. However, the Treatment Administration Record (TAR) showed multiple dates where these treatments were not documented as completed. Additionally, wound care orders for new abdominal wounds were not entered into the system, resulting in a lack of documented treatment for those areas. Interviews with facility staff confirmed that treatments should be documented in the TAR and that it was the responsibility of the nursing staff to enter and carry out physician orders in a timely manner. The facility's own policy requires accurate and timely documentation of care provided. The failure to document and provide ordered wound care was directly observed through record review and staff interviews, confirming the deficiency.

Penalty

No penalty information released

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

Summary

A resident with paraplegia, bilateral below-knee amputations, and a history of pressure ulcers was admitted with two pressure ulcers and was identified as being at risk for impaired skin integrity. The resident's care plan and wound consultant report documented the presence of a Stage 3 pressure ulcer on the left proximal thigh, with specific physician orders for wound care, including cleansing with normal saline, application of gentamycin and silver alginate, and covering with a silicone bordered foam dressing to be performed daily and as needed. Review of the Treatment Administration Record (TAR) revealed that the prescribed wound care treatments were not documented as completed on multiple dates. Interviews with the DON confirmed that treatments should be documented in the TAR and that nurses are expected to enter orders promptly, provide treatments as ordered, and document them when completed. Facility policies require accurate and timely documentation of all treatments administered, but this was not done for the resident's pressure ulcer care on the specified dates.

Penalty

Fine: $66,285

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

Summary

A deficiency occurred when staff failed to assess and appropriately treat a significant change in condition for a resident with multiple complex medical diagnoses, including end stage renal disease, heart failure, and dependence on oxygen therapy. The resident, who was cognitively intact, began experiencing respiratory distress, with oxygen saturation levels dropping to 76% despite being on supplemental oxygen. Staff did not document vital signs in the medical record, did not notify the physician, and did not initiate timely interventions or transfer to a higher level of care, despite the resident's ongoing complaints of shortness of breath and visible distress. Certified nursing assistants and licensed nursing staff reported that they typically only took and documented vital signs if specifically asked, and in this case, vital signs were either not taken or not properly recorded in the electronic medical record. The nurse on duty interpreted the resident's distress as a panic attack, attempted to calm her, and did not escalate care or notify the physician as required by facility policy. The resident's family was called to assist, but upon arrival, found the resident in severe respiratory distress and called 911 themselves. Emergency Medical Services found the resident cyanotic, with a pulse oximetry reading of 50%, and required advanced airway management and intubation en route to the hospital. Facility documentation and interviews confirmed that the care plan did not address the resident's oxygen use or respiratory issues, and there was no evidence that the physician was notified of the resident's deteriorating condition. The facility's change of condition policy required timely communication with the physician and family in the event of significant changes, but this was not followed. The failure to assess, document, and respond to the resident's acute respiratory distress resulted in a delay in emergency intervention and transfer to the hospital.

Removal Plan

• Admin/DON were inserviced by VP of Clinical
• Admin inserviced IDT team
• Current staff inserviced on change of condition and notifying nurse. Change of condition, notifying MD, document vitals, SBAR, head to toe assessment, full set of vitals, and continued vitals.
• Last 30 days of change of conditions in residents have been reviewed to ensure that no other issues have been identified.
• All residents with change of condition reviewing medical records.
• Review of policy and procedures have been completed with MD. Reviewed & updated.
• Initial change of conditions in residents nurse will notify MD and follow MD orders at the time of change of condition.
• Noted change of condition where oxygen levels are below 92%, titrate it up 1L, recheck q 30 mins until O2 can reach 92%, if distress is noted notify MD. If no, change in condition MD is to be notified again. Standing order provided by MD. Being completed by VP of clinical, Director of Nursing, MD, and administrator.
• All working staff have been in-serviced on change of condition policy and procedure. Currently all staff on shift have been in-serviced. Total facility staff in-serviced at 75%. 100% completion will be done. Being Completed by IDT team, DON, administrator, and/or designee by start of next worked shift.
• No staff will work before being in serviced on change of condition. Ongoing - Being completed by IDT team, DON, administrator, and/or designee by start of next working shift.
• A Quality assurance tool was implemented; daily audit of the 24 hour report and dc notices for change of conditions, vitals, dc notes, and MD notification if there is a noted change of condition. Audits to continue daily to ensure that change of condition is documented. Audits complete by: DON/Designee
• Root Cause Analysis completed for Change of Condition

Penalty

No penalty information released

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

Summary

The facility failed to report a hip fracture of unknown origin for a resident who was reviewed for abuse. The resident, who was admitted with diagnoses including quadriplegia, muscle contractures, protein calorie malnutrition, and dementia, was moderately cognitively impaired and required substantial assistance with mobility. On a specific date, the resident experienced a change of condition and was sent to the hospital, where imaging revealed a fracture of the distal femur. The hospital indicated that the injury required a higher level of care. Despite being informed of the fracture, the facility delayed reporting the incident to the proper authorities. The facility's staff, including the LPN, DON, and ADON, were notified of the fracture, but the report was not made until the X-ray results were received. The facility's policy requires reporting known or suspected instances of abuse or serious bodily injury within two hours, but the report was delayed as the staff awaited confirmation of the fracture's nature. The facility's administrator acknowledged the delay, stating that they typically wait for X-ray confirmation before reporting, which led to a failure to comply with the immediate reporting requirements outlined in their abuse prevention policy.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate tracheostomy care and supplies for a resident, identified as R4, who was admitted with chronic respiratory failure and hypoxia. R4 required intermittent oxygen therapy, suctioning, and tracheostomy care, but the care plan did not address these needs. On one occasion, R4 pulled out his tracheostomy tube, and the staff, including LPN V10, were unable to locate a replacement tube or the original tube. Emergency Medical Services (EMS) were called, but they also could not find a replacement tube, and the facility staff were unaware of the availability of a spare tube. Upon R4's return from the hospital, it was noted that the tracheostomy size had changed to a 5.5 mm cannula, but the facility did not have the correct size available. Instead, larger cannulas were found in R4's room, which were not suitable for his tracheostomy. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were unaware of the change in tracheostomy size, and the facility had not ordered the correct supplies. This lack of appropriate supplies and communication led to inadequate care for R4's tracheostomy needs. Additionally, the facility's documentation practices were insufficient. R4's Medication Administration Record indicated that tracheostomy care was performed only once in 13 days, despite physician orders for daily care. The DON and Administrator acknowledged that care should be documented immediately after it is performed, but this was not consistently done. The facility's failure to provide necessary tracheostomy care and supplies, along with inadequate documentation, resulted in a deficiency in the quality of care provided to R4.

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 physician visits were completed within the required timeframes for three residents. Resident 1 was admitted with diagnoses including hypothyroidism, hypertension, and type 2 diabetes mellitus with diabetic chronic kidney disease, but there was no documentation of a physician visit within the first 30 days of admission. Resident 2, admitted with cerebrovascular disease, epilepsy, and intellectual disabilities, was only seen by a physician once in the past six months. Similarly, Resident 5, who was admitted with vascular dementia, protein calorie malnutrition, and cerebral infarction, had only one documented physician visit over the last six months. The facility's policy requires that residents be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The administrator acknowledged the lack of compliance with this policy, attributing it to the previous medical director's subpar performance. A new medical director has been appointed, and some residents have expressed interest in changing their primary care provider due to dissatisfaction with the previous 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 a Registered Nurse (RN) was scheduled for at least 8 consecutive hours a day, 7 days a week, which had the potential to affect all 99 residents residing in the facility. The nursing staff schedules provided by the administrator, V1, for the dates February 1 to February 27, 2025, revealed multiple days where there was no RN coverage for 8 consecutive hours. Specifically, on 16 different days within this period, the facility did not meet the required RN coverage. V1 acknowledged the requirement for eight hours of consecutive RN coverage per day and mentioned that the Director of Nurses (DON), V2, would sometimes come in if there was no RN coverage. However, V1 confirmed that the facility did not have a policy specific to RN coverage.

Penalty

No penalty information released

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

Summary

The facility failed to properly store and label medications, as well as discard expired medications, which could potentially affect all 99 residents. During an inspection of the Medication Storage Room, it was found that there were open bottles of Meclizine with expired dates, and a Licensed Practical Nurse (LPN) confirmed that these were stock medications that should have been discarded. Additionally, the inspection of a medication cart revealed open and partially used bottles and vials of medications, such as Sodium Bicarb and Lispro, without proper labeling or open dates. The facility's policy requires that all medications be securely stored, labeled with the resident's name and open date, and discarded according to manufacturer guidelines. Furthermore, the report highlights an incident where an LPN retrieved a resident's medication from the cart without locking it, leaving it unattended during administration. This is contrary to the facility's policy, which mandates that medication carts be locked when not in use. The Director of Nurses stated that each resident should have their own labeled and dated medication, and that multi-dose vials or injection pens should not be used. The facility's policies on medication storage and administration were not adhered to, leading to these deficiencies.

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 proper food storage, labeling, and hygiene practices, which has the potential to affect all 99 residents. Observations revealed that pork roast was improperly thawing in a refrigerator with a slightly open door, and chocolate pudding cups were not labeled or dated. The Dietary Manager, V12, was observed drinking from an open energy drink container in the food preparation area, which is against facility policy. Additionally, V12 did not perform hand hygiene between glove changes, and the Evening Cook, V13, failed to wear a hair restraint, perform hand hygiene, or change gloves while handling food. The Maintenance Director, V14, also entered the kitchen without a hair restraint, further violating the facility's hygiene policy. The facility's policies require that all food be covered, labeled, and dated, and that staff wear hair restraints and perform hand hygiene as specified. Despite these policies, the Dietary Manager acknowledged the lapses in practice, indicating a lack of adherence to established procedures. These deficiencies were observed during a survey, highlighting significant non-compliance with professional standards for food safety and hygiene.

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 infection prevention and control program by not utilizing Personal Protective Equipment (PPE) and neglecting proper hand hygiene practices during care for residents with transmission-based precautions. Observations revealed that staff did not wear gowns or gloves while providing care to residents with pressure ulcers, catheters, and gastroenteric tubes. For instance, a wound nurse and certified nursing assistants were seen performing wound and catheter care without PPE, and a CNA was observed using the same gloves for multiple tasks without performing hand hygiene. The facility's policy on Enhanced Barrier Precautions (EBP) was not followed, as staff were unaware of the need for PPE for residents with chronic wounds or indwelling medical devices. The Director of Nursing/Infection Preventionist initially stated that no residents required EBP, despite evidence to the contrary. This lack of awareness and adherence to policy was further highlighted when a regional nurse consultant pointed out the necessity of EBP for certain residents, prompting the Director to compile a list of residents needing EBP. Additionally, the facility's medication administration and perineal care policies were not consistently followed. Staff failed to perform hand hygiene between glove changes during medication administration and incontinence care. This was observed when a licensed practical nurse changed gloves without washing hands and a CNA did not cleanse a resident's thighs or perform hand hygiene between glove changes during incontinence care. These lapses in protocol demonstrate a systemic issue in maintaining infection control standards within the facility.

Penalty

No penalty information released

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

Summary

The facility failed to provide secure storage for residents' smoking materials, including cigarettes, lighters, and vapes, and did not supervise residents during smoking times. This deficiency was observed in eight residents who were reviewed for smoking. These residents were found to keep their smoking materials in their pockets or rooms without any locked storage, contrary to the facility's policy that requires all smoking materials to be stored in a secure area. The facility's policy also mandates that all smoking sessions be supervised by staff, which was not adhered to, as residents were observed smoking outside without staff supervision. Several residents, including those with conditions such as Peripheral Vascular Disease, Hypertension, Acute Respiratory Failure with Hypoxia, Emphysema, COPD, Bipolar Disorder, and Metabolic Encephalopathy, were found to be smoking independently without any documented interventions for safe smoking in their care plans. For instance, one resident on oxygen was seen removing his nasal cannula to smoke, and another resident with no fingers was found with an electronic cigarette hanging around his neck. Despite their medical conditions, these residents were assessed as independent smokers, and their care plans lacked specific interventions to ensure their safety while smoking. Interviews with facility staff, including the Social Services Director and Certified Nursing Assistants, revealed that smoking assessments were not integrated into the computer system and that staff relied on the residents' cognitive abilities to manage their smoking materials safely. The Social Services Director stated that residents were trusted to store their smoking materials securely, and staff checked to ensure residents were not smoking in their rooms. However, the lack of secure storage and supervision during smoking times indicates a failure to comply with the facility's smoking policy, potentially compromising resident safety.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper documentation of blood sugar levels for a resident with type 2 diabetes, which is crucial for tracking, trending, and monitoring the chronic condition. The resident reported not receiving an insulin shot at lunch, and although the Medication Administration Record indicated that the insulin was administered, the blood sugar level was not documented. The Licensed Practical Nurse (LPN) acknowledged the absence of documentation and noted that there was no place in the Electronic Medical Record to record the blood sugar levels until the order was modified. The Director of Nursing confirmed that documenting blood sugar levels is standard practice, but as of the survey, the facility had not provided a policy for such documentation.

Penalty

No penalty information released

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

Summary

The facility failed to provide complete incontinent care for two residents, R94 and R27, as observed during a survey. R94, who is always incontinent of bowel and bladder, was assisted by a CNA who did not cleanse all necessary areas during incontinent care. Specifically, the CNA cleansed R94's penis but failed to cleanse the scrotum, inner thighs, and buttocks before applying a new brief. This incomplete care was observed despite the facility's policy requiring thorough cleansing and drying of all areas. Similarly, R27, who is also always incontinent of bowel and bladder, did not receive complete care during an observed session. The CNA cleansed R27's groin and labia but did not spread the labia apart for thorough cleaning, nor did she dry the washed areas. Additionally, the CNA did not cleanse R27's bilateral hips or thighs and failed to dry the rectal area after cleansing. These actions were contrary to the facility's perineal care policy, which mandates washing, rinsing, and drying all relevant areas without contamination.

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 adequately monitor and document the behaviors of a resident for whom psychotropic medications were prescribed. Specifically, the behavior tracking for the resident, initiated in October 2024 for physical aggression and anxiety, was found to be completely blank for February 2025. Despite the resident receiving Lorazepam as needed for anxiety, there was no documentation of behavior episodes or the effectiveness of the medication. The resident's care plan indicated the need for behavior tracking and consultation with pharmacy and medical director for dosage reduction, but these steps were not followed. Additionally, the facility did not follow up on pharmacy recommendations regarding the resident's medication. The Director of Nursing was aware that ongoing PRN antianxiety medications should not be used without proper documentation and evaluation. However, the facility's policies on psychotropic drug management and behavior management were not adhered to, as evidenced by the lack of documentation and follow-up on pharmacy recommendations. The facility's policies require PRN orders for psychotropic drugs to be limited to 14 days, with a documented rationale for any extension, which was not observed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that preventative health vaccines, specifically Respiratory Syncytial Virus (RSV) and Pneumonia (PNU) vaccines, were administered to residents who had given consent and wished to receive them. Two residents, identified as R8 and R78, were affected by this deficiency. R8's consent forms for both RSV and Pneumococcal vaccines were signed by their Power of Attorney on October 22, 2024, but the second pages of these forms were left blank, indicating that the vaccines were not administered. R8 has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), which makes receiving these vaccines particularly important. R78, who was admitted to the facility in October 2024, expressed a desire to receive the PNU vaccine and signed the consent form on October 23, 2024. However, the second page of the form was also left blank, and R78 reported not receiving the vaccine. The Assistant Director of Nursing (ADON) confirmed that R8 had not received the vaccines despite having signed consent forms. The Director of Nursing (DON) mentioned that a clinic was held in January 2025, but R78 was reportedly sick at the time, which may have prevented her from receiving the vaccine. The facility's policy requires documentation in the resident's medical record indicating whether the immunizations were received, refused, or contraindicated, but this was not completed for these residents.

Penalty

Fine: $77,550

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 assess blood sugar levels for a resident with diabetes, leading to a critical health incident. The resident, who was admitted with diagnoses including diabetes, was supposed to receive insulin as per the physician's orders. However, the Medication Administration Record (MAR) showed that the resident did not receive the scheduled insulin 13 times over a six-day period. The reasons documented for not administering the insulin included the resident's blood sugar levels being too low and the resident being asleep. Despite these occurrences, the physician was not notified, and there was no documentation of blood glucose checks at the time of the resident's condition change. The resident experienced a significant change in condition on December 8, 2024, becoming unresponsive and requiring emergency medical intervention. Emergency Medical Services (EMS) found the resident with a critically low blood glucose level of 24 and administered Glucagon before transporting the resident to the hospital. The hospital records indicated that the resident had Type 2 Diabetes Mellitus with hypoglycemia and noted that the resident's insulin might not be necessary given the HgbA1c results. The facility's failure to conduct an HgbA1c test in November, as ordered, and the lack of communication with the physician about the frequent holding of insulin doses contributed to the resident's acute condition. Interviews with facility staff revealed inconsistencies in following standing orders and a lack of proper documentation and communication with the physician. The Director of Nursing acknowledged that staff were not diligent in documenting when insulin was held or when the physician was notified. The Nurse Practitioner stated that she was unaware of the frequency with which the insulin was held and emphasized the importance of being informed to make necessary adjustments to the insulin dosage. The facility's policy on medication administration was not adhered to, as the licensed nurse did not document the reasons for holding the medication or notify the physician as required.

Penalty

Fine: $77,550

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

Summary

The facility failed to implement necessary interventions to address a significant weight loss for a resident, identified as R2, who experienced a 20% weight loss over a four-month period. R2 was admitted with diagnoses including metabolic encephalopathy, vascular dementia, diabetes, and unspecified calorie protein malnutrition. Despite having a care plan in place to prevent malnutrition and dehydration, the facility did not update the care plan to address the significant weight loss. The resident's weight decreased from 170 pounds to 136 pounds between September and December, and the facility did not document how the initial weight was obtained upon admission. The facility's dietician recommended health shakes with all meals on September 12, 2024, but the order for these shakes was not documented until October 18, 2024, over a month later. The resident's meal intake records showed that she consumed less than 25% of her meals on numerous occasions, although she did consume her health shakes. The facility's policy required that significant weight changes be communicated to the dietician and physician, but there was no documentation that the dietician was notified of the resident's weight loss after the initial assessment, nor was there evidence that the physician was informed. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's weight loss. The Director of Nursing stated that weight fluctuations should be reported to the physician, but there was no evidence this occurred. The dietician noted that she was rarely notified of residents needing assessment and had to rely on her own reports. The Nurse Practitioner was unaware of the resident's weight loss, and there was no documentation of follow-up by the medical doctor. The facility's policy on significant weight gain or loss was not adhered to, resulting in a failure to provide appropriate nutritional interventions for the resident.

Penalty

Fine: $77,550

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 significant changes in a resident's condition, specifically regarding weight loss and blood glucose levels. The resident, who was admitted with diagnoses including metabolic encephalopathy, vascular dementia, diabetes, and unspecified calorie protein malnutrition, experienced a 20% weight loss over three months and a 10.5% weight loss in the last month. Despite this significant weight loss, there was no documentation that the resident's physician was informed. The Director of Nursing stated that either she or the nurse caring for the resident would notify the physician of such fluctuations, but this did not occur. Additionally, the resident was sent to the hospital due to a change in condition, where it was discovered that her blood glucose level was critically low at 24. The facility's records showed that the resident did not receive her scheduled insulin 13 times over a six-day period, with reasons documented as "Not Administered: Other" or "Not Administered: another comment with the blood glucose level documented." The resident's physician was not notified of these missed insulin doses, and the facility's staff did not document any communication with the physician regarding the resident's blood sugar levels or the decision to hold insulin doses. The facility's policy requires notifying the physician of significant changes in a resident's condition, but this was not adhered to in the case of the resident's weight loss and insulin administration. The Nurse Practitioner stated that she was not aware of the frequent withholding of insulin and that she would have adjusted the insulin dose if she had been informed. The lack of communication and documentation regarding the resident's condition and treatment changes contributed to the deficiency identified by the surveyors.

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 locate and/or replace missing clothing and personal items for a resident, as reported by the resident's family member. The family member stated that the resident lost clothes, jackets, a new pair of white leather shoes, hearing aids, and two blankets. Despite the family member's efforts to provide replacements, these items continued to go missing. The Social Services Director and the Administrator were unaware of the missing items, and there was confusion about whether a grievance had been filed. The family member confirmed that they had not received any missing items back from the facility, nor had they been contacted for reimbursement. The facility's grievance records indicated that some items were found and returned to the resident's room, but the white shoes were not located. The facility's policy requires missing items to be reported to the Social Service Department or appropriate staff, with a Concern Report to be filled out if necessary. However, the grievance regarding the missing items was not provided by the facility, and there was a lack of documentation and follow-up on the missing items, leading to the deficiency in honoring the resident's right to a safe, clean, comfortable, and homelike environment.

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, identified as R9, from verbal abuse by a staff member, specifically a Dietary Aid, during an incident in the dining room. R9, who has a complex medical history including joint replacement surgery, bipolar disorder, and diabetes, was involved in a verbal altercation with the Dietary Aid. The incident began when R9 requested his meal in the dining room, and the Dietary Aid responded with a dismissive attitude, leading to a heated exchange. R9 reported feeling threatened when the Dietary Aid allegedly picked up a glass with the intent to throw it at him, although staff intervened before any physical harm occurred. The incident was documented in R9's progress notes and an incident report, which detailed the verbal disagreement between R9 and the Dietary Aid. The report included statements from R9, the Dietary Aid, and other staff members who witnessed the event. The Dietary Aid was described as having a confrontational attitude, and R9 admitted to calling the Dietary Aid derogatory names during the argument. Staff members intervened by separating the two parties and ensuring R9 felt safe afterward. The facility's investigation concluded that the allegation of abuse was unsubstantiated, attributing the incident to R9's behavior and the Dietary Aid's need for customer service training. Despite the conclusion, the incident highlights a failure in the facility's Abuse Prevention and Prohibition Program, which mandates zero tolerance for abuse and requires staff to protect residents from verbal and mental mistreatment. The Dietary Aid involved in the incident no longer works at the facility.

Penalty

No penalty information released

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

Summary

The facility failed to initiate and thoroughly investigate an alleged violation of abuse involving a resident and a dietary aid. The incident occurred when the resident, who has attention deficit issues, reported that the dietary aid was verbally abusive, screamed, and threatened to throw a glass at him. The dietary aid was subsequently fired, but the facility's investigation concluded that the allegation of abuse was unsubstantiated, attributing the incident to a verbal disagreement initiated by the resident's behavior. Interviews with staff and other residents revealed that the dietary aid and the resident were involved in a loud argument in the dining room, with both parties exchanging harsh words. Staff intervened and separated them, and the dietary aid was asked to leave the dining room. The Director of Nursing was not present during the incident and was unsure of the dietary aid's employment status afterward. The facility's administrator reviewed camera footage and determined that no physical harm occurred, and the issue was deemed a customer service problem rather than abuse. The facility's Abuse Prevention and Prohibition Program mandates a zero-tolerance policy for abuse, neglect, and mistreatment, requiring staff to report and prevent such incidents. However, the investigation into this incident was not thorough, as the facility did not substantiate the abuse claim despite conflicting accounts from staff and the resident. The lack of a comprehensive investigation and clear documentation of the incident led to the deficiency in handling the alleged abuse case.

Penalty

No penalty information released

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

Summary

The facility failed to administer prescribed medications to a resident, identified as R2, who was reviewed for medication administration among a sample of 17 residents. R2's medical history includes conditions such as Osteomyelitis, Gastroesophageal Reflux Disease, Peripheral Vascular Disease, Chronic Kidney Disease, and Type 2 Diabetes. The resident's care plan, updated on October 24, 2024, indicates chronic pain related to several conditions, with interventions including reporting pain to a nurse and conducting pain assessments. R2 had an order for oxycodone, a Schedule II medication, to be administered twice daily. However, the medication administration records from October 1 to October 31, 2024, show multiple instances where the medication was not administered, with reasons cited as item unavailability, waiting on a prescription, or medication not being in stock. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that most medications are typically in stock, but there were occasional delays when a medication was not available. The Director of Nursing was unaware of the specific reasons for the missed doses of oxycodone for R2, as they had recently started working at the facility. The facility's medication administration policy states that medications should be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner. Despite this policy, the facility failed to ensure the timely administration of R2's prescribed pain medication, leading to a deficiency in pharmaceutical services.

Penalty

No penalty information released

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

Summary

The facility failed to administer medication as ordered by the physician for a resident diagnosed with Vascular Dementia with severe agitation. During an incident on January 2, 2024, the resident exhibited violent behavior, prompting the Director of Nursing (DON) to assist a nurse in administering a PRN medication. Instead of consulting the Medication Administration Record (MAR), the DON relied on the nurse's verbal information and administered 2ml of Haldol. The physician's order specified a dosage of 2mg of Haldol, which was not followed. The physician was present during the incident and observed the resident's behavior before and after the medication was given. The facility's Medication Administration policy requires verification of the physician's order with the MAR and the pharmacy label before administering any medication. This protocol was not followed, resulting in a medication error. The Nurse Practitioner confirmed the error, noting that the amount of Haldol administered was insufficient to cause harm, although it did not significantly alter the resident's behavior. The incident highlights a failure to adhere to established medication administration procedures, leading to a significant medication error.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate pain management for two residents, R4 and R7, resulting in significant discomfort and inability to participate in therapy. R4, who was admitted with a diagnosis of low back pain and a stage 4 pressure ulcer, did not receive the prescribed Hydrocodone-acetaminophen for several days after admission. Despite the medication being ordered to be administered every 8 hours as needed, R4's Medication Administration Record (MAR) showed no administration of the pain medication until a week after admission. The delay was due to the facility's inability to obtain a hard script from the hospital, as the discharging hospitalist was unavailable. R7 was observed in pain, moaning, and unable to participate in therapy due to abdominal pain rated at 7 out of 10. Despite being given Tylenol, R7 continued to experience pain, and no abdominal assessment was performed by the nurse. R7's care plan included a diagnosis of multiple conditions that could contribute to pain, and interventions were outlined to manage pain, including administering medication as ordered and assessing pain every shift. However, R7's pain medication was not available because the script had not been received from a physician, as confirmed by the Director of Nursing (DON). The facility's pain management policy requires timely interventions and medication administration as ordered, 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 implement fall interventions for a resident who was reviewed for falls. The resident, who has a history of cerebrovascular accident (CVA) and weakness on the left side, was admitted to the facility and was noted to be alert and oriented. Despite these conditions, the resident experienced a fall on two separate occasions. On the first occasion, the resident was found lying on the ground next to the bed after attempting to pick up a phone, resulting in bruising and a call for an ambulance. There was no fall event documented for this incident, and no interventions were put in place afterward. The second fall occurred the following day, with the resident again found on the floor. An event report was created, and fall mats were listed as an immediate intervention. However, the initial care plan provided to the surveyor was undated and blank, lacking documentation of the resident's musculoskeletal history and fall risk. The Director of Nursing confirmed that no fall interventions were in place for the resident and that no fall event or investigation was completed for the first fall. The facility's policy on fall evaluation and prevention was not followed, as it requires evaluation of fall risk and development of interventions upon admission, as well as completion of an accident/incident report and notification of the physician following a fall.

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 medications as ordered for two residents, R4 and R7, leading to a deficiency in pharmaceutical services. R4, who was admitted with a diagnosis of low back pain and a stage 4 pressure ulcer, did not receive his prescribed pain medication, Hydrocodone-acetaminophen, until several days after admission. Despite the medication being ordered to be administered every 8 hours as needed, R4's Medication Administration Record (MAR) shows no administration of the pain medication until a week after admission. The delay was due to the facility not receiving the necessary hard script from the hospital that discharged R4, despite multiple attempts to obtain it. Similarly, R7 did not receive pain medication because the script had not been received from the physician. The Director of Nursing (DON) acknowledged the expectation that residents should have pain medication as ordered, yet the facility's policy on medication administration was not adhered to, as it requires medications to be administered per the order of the attending physician or licensed independent practitioner. This failure to provide timely pain management as per physician orders constitutes a deficiency in the facility's pharmaceutical services.

Penalty

No penalty information released

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

Summary

The facility failed to provide additional nourishment as ordered for a resident diagnosed with vascular dementia and protein-calorie malnutrition. The resident's physician had ordered Ensure protein shakes to be provided at each meal, but observations revealed that the supplement was not consistently included on the resident's dietary card or meal tray. The resident's family confirmed that the supplement was often missing, and the dietary manager acknowledged a system glitch that led to the omission of the supplement from the dietary card. Additionally, the facility did not ensure timely distribution of ice water to residents. Observations showed that several residents did not have access to water or ice, and staff interviews revealed that due to staffing shortages, hydration had not been provided during the evening shift. The regional corporate nurse was unaware of the issue, and family council minutes had previously noted the need for more frequent ice passes.

Penalty

Fine: $16,920

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

Summary

The facility failed to implement and update interventions to prevent falls for four residents, leading to multiple incidents of falls. Resident R2, who is alert and oriented, experienced several falls, including a significant one on 09/06/2024, resulting in a laceration requiring stitches. Despite being at high risk for falls, as indicated by a fall risk score of 21, the facility did not update R2's care plan with new interventions following the fall. Observations revealed that non-skid strips were not present in R2's room, and the care plan had not been revised since 07/10/2024, despite the fall on 09/06/2024. Resident R1, who is cognitively impaired, also experienced multiple falls, with the most recent documented on 09/09/2024. The care plan for R1 was not updated with new interventions after this fall, and observations showed that the bed was not in the lowest position, and a floor mat was missing, contrary to the care plan's instructions. Additionally, R1's room lacked the prescribed reclining high-back wheelchair, indicating a failure to adhere to the care plan's interventions. Residents R4 and R5 also experienced falls without appropriate updates to their care plans. R5, who is cognitively impaired, had falls on 07/23/2024 and 09/26/2024, with no progressive interventions documented after these incidents. Similarly, R4, who is alert and oriented, had falls on 08/20/2024 and 10/03/2024, but the care plan was not updated with new interventions after the first fall. The facility's policy on fall prevention was not followed, as evidenced by the lack of updated interventions and incomplete fall risk assessments for these residents.

Penalty

Fine: $16,920

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 resident with the prescribed narcotic pain medication, Hydrocodone-Acetaminophen, for 10 out of 30 days in September 2024. The resident, who was admitted with diagnoses including stable and unstable burst fractures of the lumbar vertebrae and unspecified osteoarthritis, was ordered to receive this medication three times daily. However, the Medication Administration Record (MAR) indicated that the medication was unavailable from September 1 to September 4 and again from September 21 at the 8:00 PM dose until September 26 at the 8:00 PM dose. During these periods, the resident did not receive the prescribed Hydrocodone-Acetaminophen, nor was the alternative pain management option of Acetaminophen 650 mg or Voltaren Arthritic Pain Gel administered. The resident's daughter expressed frustration over the situation, noting that the staff mentioned they were waiting for a new prescription from the doctor. She observed her father experiencing spasms and jerking motions during a visit on September 26, indicating he was in pain. Despite having regular Tylenol available, the daughter stated it was ineffective for her father's pain. The resident himself, who has moderate difficulty hearing, confirmed experiencing some pain but was unsure if the facility had informed him about the unavailability of his pain medication. Interviews with facility staff revealed that the issue was not with the pharmacy but rather with obtaining the necessary prescriptions from the physician. The Licensed Practical Nurse (LPN) mentioned that it is the nurse's responsibility to ensure medications are refilled before they run out, but sometimes multiple calls to the physician are required. The Regional Nurse Consultant acknowledged the oversight and mentioned that the facility is working on implementing processes and educating nurses to prevent such occurrences in the future. The facility's pain management policy emphasizes the importance of accurate assessment and management of residents' pain, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to document necessary assessments and complete treatments as prescribed for a resident with a foot wound. The resident, who had been at the facility for a month, reported that his foot bandage had not been changed regularly, and he had not been seen by a doctor for his wound. The Treatment Administration Record (TAR) showed missing documentation for several dates when the treatment was supposed to be completed. The Director of Nursing confirmed the missing documentation and noted that the wound appeared inflamed, prompting a referral to Wound Management, which was delayed due to a communication issue. The resident's care plan did not address the monitoring of the foot wound, and the wound log lacked essential documentation such as the onset date and classification of the wound. The facility's Wound Report for Quality Assurance showed no improvement in the wound's condition over several weeks. The resident was eventually seen by Wound Management, which noted the wound's measurements and changed the treatment plan. The facility's Wound Management Policy outlined the necessary documentation and treatment procedures, which were not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that medications were readily available for administration per physician's orders, affecting the well-being, comfort, and pain control of three residents. Resident 1, who was admitted after back surgery, experienced significant pain due to a delay in receiving prescribed Oxycodone. Despite having a prescription, the medication was not delivered until three days after admission, during which time the resident suffered from moderate pain and sleep disturbances. The Director of Nursing acknowledged that the nurse should have contacted the doctor immediately to obtain the prescription and ensure timely delivery. Resident 4 also experienced a lapse in pain management due to the unavailability of her scheduled Hydrocodone medication. The resident, diagnosed with arthritis and cervical spinal stenosis, missed multiple doses over several days. The Licensed Practical Nurse reported the issue to the Medical Director but was unable to administer the medication as it was unavailable. The Director of Nursing was unaware of the situation until informed and confirmed the medication was not available as prescribed. Resident 8 faced similar issues with the availability of Hydrocodone, which was not administered as needed due to a lack of supply. The Assistant Director of Nursing noted the challenges in obtaining controlled medications and mentioned a new process to initiate prescription refills before running out. The facility's Pain Management Policy emphasizes the importance of timely interventions to manage pain, which was not adhered to in these cases, leading to inadequate pain management for the residents involved.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that medications were readily available for administration per physician's orders for three residents. Resident 1, who was admitted after back surgery, experienced a delay in receiving her prescribed pain and sleep medications, Clonazepam and Oxycodone, due to a lack of proper prescription transmission to the pharmacy. This resulted in the resident experiencing significant pain from the time of admission until the medications were finally delivered. The Director of Nursing was unaware of the issue until it was brought to her attention, indicating a lapse in communication and procedure. Resident 4 also experienced a lapse in receiving her scheduled pain medication, Hydrocodone, for several days. The Licensed Practical Nurse noted that the medication was unavailable, and the resident was not aware of the missed doses. The Director of Nursing confirmed the absence of the medication and acknowledged that it should have been administered as prescribed. This situation highlights a failure in medication management and inventory control within the facility. Resident 8 faced a similar issue with the unavailability of Hydrocodone, which was prescribed for chronic pain management. The Assistant Director of Nursing mentioned difficulties in obtaining controlled medications due to the requirement of handwritten prescriptions. The facility's policies on receiving and managing controlled substances were not effectively followed, leading to residents experiencing unnecessary pain and discomfort due to the unavailability of their prescribed medications.

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 residents' rights to communication and self-determination by not providing adequate phone access for residents and their families. Observations and interviews revealed that the facility's phone was often not answered during evening hours, leading to busy signals or transfers to an answering service. This issue was noted during multiple attempts by a surveyor to contact the facility by phone, as well as through interviews with family members of residents who expressed frustration over their inability to reach the facility or speak with their loved ones after certain hours. The deficiency was further highlighted by the facility's lack of a receptionist and the absence of a phone policy, as acknowledged by the facility's administrator. Additionally, the administrator admitted that they did not have access to the answering machine to retrieve messages. This lack of phone access and communication capability potentially affects all 86 residents in the facility, as it impedes their right to make and receive phone calls in private, as outlined in the Illinois Ombudsman Long-Term Care Program Residents' Rights.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper wound care and adherence to physician orders for a resident with pressure ulcers. The resident, who is severely cognitively impaired and dependent on staff for all activities of daily living, developed an unstageable pressure ulcer on the right posterior thigh. The care plan required treatments to be administered as ordered, with regular monitoring and documentation of wound healing. However, observations revealed that the resident was not repositioned as frequently as required, and the wound was not covered with a dressing as ordered. The resident's care plan and physician orders specified that the resident should lie down after every meal to reduce pressure on the buttocks and be repositioned every two hours. Despite these orders, the resident was observed sitting in a wheelchair for extended periods without being repositioned. Additionally, the wound on the right posterior thigh was found uncovered and without a dressing, contrary to the treatment orders. The facility's wound management policy required documentation of new pressure injuries and regular wound assessments, but there were inconsistencies in the documentation and treatment of the resident's wounds. Interviews with staff revealed a lack of consistent wound care practices and documentation. The treatment nurse did not return to complete the dressing change, and the LPN had to perform the treatment during the day shift because the dressing was off. The facility's wound management policy emphasized the importance of following physician orders and maintaining proper documentation, but these protocols were not consistently followed, leading to inadequate care for the resident's pressure ulcers.

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 pain management for a resident, identified as R3, during the dying process. R3's baseline care plan did not address pain management, despite a pain assessment indicating that R3 was experiencing pain. The facility did not provide requested pain assessments, and there were no vital signs noted in R3's records. Hospice progress notes indicated that R3 was experiencing worsening symptoms, including muscle spasms and restlessness, which were not adequately managed by the facility staff. The hospice nurse advised the facility nurse to administer morphine and lorazepam to manage R3's symptoms, but the facility nurse was reluctant to do so unless R3 requested the medication. This reluctance persisted even after the hospice nurse explained the necessity of administering the medication due to R3's condition, which included signs of terminal restlessness and respiratory distress. The facility nurse's decision to withhold medication was based on her judgment and concerns about potential risks, despite the hospice nurse's guidance and the family's reports of R3's pain. R3's daughter reported that her father was in pain and that the facility nurse initially administered pain medication but later refused, citing concerns about losing her license. Another nurse eventually administered the medication, which helped calm R3. The facility's pain management policy required regular pain assessments and documentation, but these were not adequately followed, contributing to R3's unmanaged pain during his final hours.

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 four residents, resulting in severe pain for two of them. Resident 1, who has multiple diagnoses including quadriplegia and chronic pain, did not receive any of his morning or noon medications on a specific day. This led to his pain level reaching a 10 before he finally received his pain medication in the afternoon. The Medication Administration Record (MAR) confirmed that the medications were not administered as ordered, and no pain assessment was completed during the day shift. Resident 2, who has chronic kidney disease and other serious conditions, also did not receive any of his medications on the same day. Despite informing the Administrator and seeking help from other nurses, he did not receive his essential medications for high blood pressure and chronic liver disease. The MAR confirmed the absence of nurse initials, indicating the medications were not administered. Resident 3, who suffers from multiple conditions including chronic pain and diabetes, did not receive any medications or blood sugar checks on the same day. His family members reported his severe pain and lack of medication to the facility staff, but no action was taken. The MAR confirmed the medications and blood sugar tests were not administered. Additionally, Resident 12, who has type 2 diabetes and congestive heart failure, did not receive his morning medications or insulin, as confirmed by the MAR. The facility's policy on administering medications was not followed, leading to these deficiencies.

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 sufficient staffing on 5/20/24, resulting in four residents not receiving their medications and blood glucose testing. The daily assignment schedule did not document a licensed nurse assigned to the B hall, and multiple CNAs confirmed that no nurse was present on the B hall for the entire day shift. Residents on the B hall did not receive their medications, and some were in pain due to the lack of care. The Administrator was informed of the issue but was unable to resolve it, as the facility did not have a contract with a staffing agency to provide additional nurses. One resident reported to the Administrator that he had not received his medications, including those for high blood pressure and chronic liver disease, but no action was taken. Another resident's daughter and wife both confirmed that he did not receive his pain medication, causing him significant discomfort. The CNAs on duty also reported that they were unable to get assistance from the other nurses, who stated they were not allowed to pass medications for the B hall. The facility's policy on staffing, dated August 2022, states that sufficient numbers of nursing staff should be available 24/7 to provide competent resident care services. However, on 5/20/24, this policy was not followed, leading to a significant lapse in care for the residents on the B hall. The Regional Director confirmed that a licensed nurse should have been available to pass medications to the residents on the B hall.

Penalty

Fine: $70,250

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 fall interventions and precautions were in place for one resident (R7) who was at high risk for falls. R7 had a history of falls and multiple diagnoses, including dementia, COPD, hypertension, peripheral vascular disease, and rhabdomyolysis. Despite being cognitively intact and requiring supervision for certain activities, R7's care plan included a bed alarm and instructions to use a call light for assistance. However, during observations, the call light was found on the floor and out of R7's reach, and the bed alarm cord was positioned in a way that could cause entanglement, posing additional fall risks. R7 was also observed wearing regular socks instead of non-slip socks, further increasing the risk of falls. Interviews with staff confirmed that R7 could use the call light when needed, but the call light was not consistently placed within her reach. The facility's policy on fall prevention emphasized the importance of providing an environment free of accident hazards and ensuring that all interventions and precautions are in place. However, the staff failed to adhere to these guidelines, as evidenced by the improper placement of the call light and the hazardous positioning of the bed alarm cord. The administrator acknowledged that staff should ensure all interventions and precautions are in place before leaving a resident's room.