Forest City Rehab & Nrsg Ctr

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 treatment and care according to provider orders and resident preferences by not scheduling a urology appointment for one resident after an abnormal lab result. The resident’s prostate specific antigen (PSA) lab result dated 5/14/25 showed a high value, and the nurse practitioner documented on the lab result form that the resident should be referred to urology. An order dated 5/16/25 for a referral to urology related to the high PSA was present on the resident’s active Order Summary Report as of 5/19/25. The DON confirmed that the nurse practitioner had written for the resident to see a urologist and stated that the referral should have been placed in the medical appointment scheduler’s mailbox so the appointment could be made. The medical appointment scheduler reported that no urology appointment had been scheduled for the resident and that there were no entries in the appointment schedule book, stating he believed the appointment was not made because he was never notified of the order or referral. Review of the resident’s electronic medical record by the DON showed no indication that the resident had seen a urologist. This sequence of events demonstrates that despite a documented high PSA result and a corresponding provider order for a urology referral, the internal process for communicating and acting on the referral order failed, resulting in the resident not receiving the ordered urology consultation.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident’s property from misappropriation by staff. The resident had a diagnosis of schizoaffective disorder and was documented as having expired on a specified date. After the resident’s death, the resident’s sister-in-law reported that multiple charges were made to the resident’s bank account by an LPN, including a $1,000 PayPal transfer to the LPN. Bank statements showed that beginning the day after the resident expired, 34 charges totaling $4,910.79 were made from the resident’s account, including the $1,000 PayPal charge. The sister-in-law also reported that the LPN had the resident’s cell phone at her home. The Administrator stated he first became aware of the situation when police arrived and informed him of the allegations. A police officer reported that the LPN admitted to making purchases using the resident’s bank account after the resident expired, using bank information saved on a phone, and admitted to having the resident’s cell phone at her residence. The LPN claimed the resident had told her she could have the money in his bank account after paying for his cremation and could keep the cell phone, but there was no documentation of this agreement and no witnesses. Facility policy defined misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent and stated residents have the right to be free from misappropriation, and the employee handbook stated staff should never borrow or take money or personal belongings from residents.

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 identify, document, and update nutritional interventions for a resident with known risk factors and a history of weight loss, resulting in severe weight loss. The resident had multiple diagnoses including diabetes, atherosclerosis of the aorta, asthma, hypothyroidism, GERD, cataracts, dysphagia, lack of coordination, and gait/mobility abnormalities, and was assessed as having moderate cognitive impairment and requiring supervision to eat. The care plan, initiated months earlier, identified risk for weight gain/loss related to diabetes and hypothyroidism and directed staff to monitor and document meal intake percentages at all three meals and to refer to the physician/dietitian if there was a 5% weight loss over 30 days or 10% over 180 days. The facility’s weight summary showed a weight of 128 pounds in July and 113.6 pounds on 1/6/26, with no subsequent facility weight obtained before the resident’s hospital admission on 1/16/26, when the hospital documented a weight of 80 pounds and severe protein-calorie malnutrition. From 1/6/26 onward, documentation of the resident’s food intake was incomplete and inconsistent despite clear indications of poor intake. The facility’s meal intake records showed the resident consumed 0–25% of breakfast and lunch on 1/6/26 with no entry for the evening meal, no documented intake at all from 1/7/26 through 1/10/26, and refusals to eat on 1/11, 1/13, and 1/15. On 1/12, the resident ate 0–25% at breakfast and lunch, with no entry for the evening meal. A psychiatry note dated 1/15/26 recorded staff reports that the resident had not been eating and that after the family placed a spending limit on the resident’s food delivery app card, she reportedly stopped eating. A dietary progress note on 1/15/26, based only on chart review and not an in-person assessment, stated that the resident’s intakes had been poor, that she required 1:1 supervision with meals, and that she was on appetite stimulants and multiple nutritional interventions, but it did not prompt a new weight or updated interventions in response to the recent decline in intake. Multiple staff interviews confirmed that the resident’s intake had declined significantly when her ability to order outside food was reduced, and that this change was not followed by timely weights, consistent intake documentation, or notification to the provider or dietitian. CNAs reported that the resident disliked facility food, often refused substitutes, and had markedly decreased intake after her food delivery spending was limited; they stated they reported this to nurses, but intake documentation remained sparse or missing for several days. Nursing staff, including an LPN and an RN, acknowledged that when a resident stops eating, a weight should be obtained and the provider and dietitian notified, and that in this case no weight was entered after 1/6/26 despite visible weight loss and very low or refused intakes. The dietary manager and dietitian both stated they were not made aware of the extent of the poor or undocumented intakes, and the resident was not discussed in nutritional risk meetings during the period in question. The DON reviewed the intake records and characterized the charting as completely unacceptable, noting that CNAs are expected to document every meal and that such documentation is essential to monitor whether residents are meeting nutritional needs. The facility’s own weight policy called for a systematic interdisciplinary effort to identify and track residents with significant changes in appetite and decreased oral intake in the last seven days, but this process was not effectively implemented for this resident between 1/6/26 and 1/16/26.

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 complete thorough initial and ongoing skin assessments for a resident at risk for skin breakdown who had documented redness to the buttocks and peri-area. The resident had multiple diagnoses including diabetes, atherosclerosis of the aorta, asthma, hypothyroidism, GERD, cataracts, dysphagia, lack of coordination, and gait/mobility abnormalities. A facility assessment showed moderate cognitive impairment, dependence on staff for toilet hygiene, substantial to maximal assistance needs for personal hygiene, and supervision for bed mobility. An order dated 12/16/25 directed application of zinc barrier cream to the buttocks twice daily and as needed for incontinence, and a care plan initiated the same day identified impaired skin integrity related to incontinence with erythema, excoriation, and skin breakdown to the peri-area and buttocks. Despite these identified risks and care needs, the electronic medical record contained no documented nursing skin assessment of the buttocks from 12/16/25 until the resident’s transfer on 1/16/26. A progress note on 12/25/25 stated that zinc barrier cream to the buttocks and perineal area continued and that the area remained stable, but did not include wound classification, size, tissue description, or drainage. A shower sheet dated 1/6/26 documented redness to the buttocks, yet there was still no corresponding nursing skin assessment with detailed wound characteristics. When the resident was sent to the hospital on 1/16/26 for abnormal labs, the emergency department record documented a sacral ulcer. Staff interviews confirmed the lack of thorough and ongoing skin assessments. A CNA reported the resident had a “real red area” on her buttocks and that barrier cream was applied, and stated CNAs report skin issues to nurses. The RN who sent the resident to the hospital acknowledged she did not inspect the resident’s skin before transfer, had last seen the resident’s bottom 3–4 days earlier, noted redness and irritation, and admitted she did not document skin assessments, only the barrier cream on the treatment record without size or description. The DON confirmed there were no skin/wound assessments since 12/16/25 except for a brief 12/25/25 note and stated she would expect location, appearance, and size to be charted. The wound care nurse described documenting only what she saw visually and monitoring without consistent, detailed assessments, and acknowledged the resident had persistent redness to the peri-area and buttocks and that it was possible the wound opened. The facility’s wound policy required weekly assessment and documentation of any skin impairments by the wound nurse or designee, which was not followed for this resident.

Penalty

No penalty information released

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

Summary

A staff member with a beard was observed preparing pureed bread and vegetables in the kitchen without wearing a beard covering, as required by facility policy. The Dietary Manager was present in the kitchen during this time but did not ensure the staff member wore the appropriate beard restraint. The staff member continued to prepare and puree food for the noon meal without donning a beard cover, despite acknowledging that facility policy mandates beard coverings when preparing food. The facility's Food Safety and Sanitation policy, dated 9/17/23, specifies that beard restraints should be worn at all times during food preparation.

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 was identified when a resident with a suprapubic indwelling urinary catheter was repeatedly observed in public areas, including the dining room and from the hallway while in bed, with their urinary drainage bag visible and not covered by a privacy bag. The urine in the collection bag was visible to others on multiple occasions. The facility's Director of Nursing confirmed that privacy bags should be used to maintain resident dignity, and the facility's dignity policy specifies the use of privacy coverings for urinary catheter bags as an example of promoting dignity and respect.

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 adaptive utensils to a resident who required them for independent feeding due to a history of cerebrovascular accident (CVA) and bilateral carotid stenosis. The resident's care plan specified the need for built-up silverware at meals, and meal tickets confirmed this requirement. However, during observations on two consecutive mornings, the resident was given only standard or plastic utensils and was seen attempting to eat with these, resulting in difficulty managing his food. Staff interviews confirmed the resident's need for weighted utensils to assist with eating and to promote strength in his affected hand. The facility's policy also indicated that adaptive eating equipment should be provided to residents who need them to promote feeding independence.

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 as-needed (PRN) psychotropic and anti-psychotic medications had appropriate stop or duration dates for three residents reviewed for pharmacy services. Specifically, one resident had an order for haloperidol as needed every 8 hours, and two residents had orders for lorazepam as needed at varying intervals. All of these orders had documented start dates but lacked required stop or duration dates. According to the facility's own policy, as-needed psychotropic and anti-psychotic medications are limited to 14 days, but this was not reflected in the orders reviewed. The Director of Nursing confirmed that PRN psychotropic and anti-psychotic medications require a stop date.

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 catheter care for two residents with urinary catheters, as observed through multiple instances where catheter drainage bags were not properly positioned. For one resident with a history of prostate cancer and obstructive and reflux uropathy, the catheter bag was repeatedly found resting on the seat of a wheelchair next to the bed, which was lower than the seat, resulting in the bag being below the level of the bladder. This improper positioning prevented urine from draining into the bag. The resident subsequently developed blood in the urine, was diagnosed with a urinary tract infection, and was started on antibiotics. Staff interviews confirmed that catheter bags should be positioned below the bladder to ensure proper drainage and prevent complications. Another resident with diagnoses including type 2 diabetes mellitus, obstructive and reflux uropathy, and benign prostatic hyperplasia was observed on several occasions with the urinary catheter bag not placed in a dignity bag and the lower half of the collection bag lying on the floor. Staff interviews and facility policy confirmed that catheter bags and tubing should not touch the floor to prevent infection. The facility's own catheter care policies were not followed in both cases, as the drainage bags were not maintained in appropriate positions to ensure proper urine flow and infection control.

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 by the physician, resulting in a medication error rate of 7.14% based on 28 observed opportunities with 2 errors. In one instance, a resident with type two diabetes mellitus and diabetic neuropathic arthropathy was ordered to receive 15 units of Humalog insulin via pen three times daily. The LPN administering the insulin did not prime the insulin pen and needle by wasting two units prior to injection, contrary to facility policy and standard practice. The LPN stated that she only primes the pen when opening a new one, not with each administration. The facility's policy requires priming the pen with two units before every use to ensure the correct dose is delivered. In another case, a resident with an order for cetirizine 10 mg daily for allergies was instead given loratadine 10 mg by an LPN. The DON confirmed that cetirizine and loratadine are different allergy medications. The facility's medication administration policy requires verification of the right medication, dose, route, time, and resident identity before administration. These failures resulted in the facility exceeding the acceptable medication error rate threshold.

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 a resident was not provided a snack outside of scheduled meal service times, despite expressing a desire for a bedtime snack. The resident reported not receiving snacks and stated that when a request was made, the Dietary Manager responded that only diabetic residents receive snacks. Interviews with facility staff, including an LPN, the Dietary Manager, and the Dietitian, confirmed that snacks are only provided to diabetic residents or those with weight loss, and that no snacks are offered to other residents in the evening. Review of the resident's diet order and care plan showed no restrictions or physician orders prohibiting snacks outside of scheduled meal times.

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 pressure injury treatments were completed and properly documented for two out of three residents reviewed for pressure injuries. For one resident with a stage 4 pressure ulcer on the left lower back and multiple comorbidities including diabetes, COPD, and peripheral vascular disease, the Treatment Administration Record (TAR) showed that prescribed wound care treatments were not signed off as completed on several weekend dates. The wound care nurse confirmed that treatments should be documented after completion and that if not documented, it is considered not done. The resident's care plan required wound management per treatment orders, and facility policy mandated that staff initial the TAR after each administration. Similarly, another resident with a stage 3 pressure ulcer on the right ankle, along with diagnoses such as right-sided hemiplegia, obesity, and traumatic brain injury, had wound care treatments that were not signed off as completed on multiple weekend dates. The wound care nurse again confirmed the lack of documentation and reiterated the importance of following treatment orders. The care plan for this resident also required wound care per treatment orders, and the facility's policy specified that physician-ordered treatments must be documented on the TAR after each administration.

Penalty

No penalty information released

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

Summary

The facility failed to follow its abuse prevention policy in the case of one resident with a history of mental illness and prior abuse. After the resident returned from the hospital and made an allegation of assault against a staff member, the required immediate reporting to the administrator and to the Department of Public Health was not completed within the policy's specified timeframe. The administrator was notified via text message by the LPN, but did not respond, and the nurse did not follow up with a phone call as required. The administrator did not initiate the investigation or report the allegation to the state agency until the following day, missing the two-hour reporting window outlined in the facility's policy. Additionally, the staff member accused of abuse continued to have contact with the resident after the allegation was made, contrary to the policy that requires immediate removal of the accused from resident contact pending investigation. The administrator did not interview the resident about the incident, and the LPN did not gather further details from the resident. The initial and final abuse investigation reports were not sent to the state agency until days after the incident, further demonstrating a failure to follow established procedures for timely reporting, investigation, and protection of the resident during the investigation process.

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 immediately report an allegation of abuse involving a resident with a history of mental illness and prior abuse. The resident, identified as being at risk for abuse and/or neglect, returned from the hospital and made a statement accusing a staff member of assault. This statement was heard by a CNA, who relayed it to an LPN shortly after the resident's return. The LPN then texted the Administrator/Abuse Coordinator about the allegation, but did not receive a response. The Administrator was not informed in person until the following day and acknowledged that the report to the state survey agency was delayed. The Director of Nursing later confirmed that there was no record of a timely report being sent to the state agency regarding the abuse allegation, and the initial report was only sent several days after the incident. The facility's policy required immediate reporting of all abuse allegations, but this protocol was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to immediately investigate an allegation of abuse and did not immediately suspend the alleged perpetrator while the investigation was ongoing for one resident. The resident, who had a history of mental illness and prior abuse, returned from the hospital and made a statement identifying a staff member as the person who assaulted her. This statement was relayed to a nurse, who then informed the administrator via text message, but the administrator did not respond at that time. The nurse did not interview the resident for further details, and the administrator did not speak to the resident about the allegation upon being notified the next day. The alleged perpetrator continued to work until later in the day when they were identified and sent home. Documentation shows that the staff member involved wrote a statement about the incident, and the resident's care plan indicated a risk for abuse, instructing staff to follow facility policy for all suspected or reported instances. Despite these protocols, the facility did not act immediately to investigate the allegation or remove the alleged perpetrator from duty, as confirmed by interviews with staff and review of time cards. The initial and final abuse allegation investigations were sent to the state agency several days after the incident.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of sexual abuse within the required timeframe to the Illinois Department of Public Health (IDPH). After a resident was discharged home, her daughter reported to facility staff that the resident had alleged being sexually assaulted during her stay. The daughter initially contacted the facility regarding a missing cell phone and, during the conversation, mentioned the allegation of sexual abuse. This information was relayed to the facility administrator by the admissions staff. Despite being informed of the allegation, the administrator did not immediately report the incident to IDPH, believing that reporting was unnecessary since the resident was no longer at the facility. The facility's own policy requires that allegations of abuse be reported to IDPH immediately, but not later than two hours after the allegation is made if it involves abuse or serious bodily injury. The report to IDPH was ultimately made two days after the initial allegation was received, exceeding the required reporting timeframe.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that food was served at a temperature that met resident satisfaction, affecting four residents who were reviewed for food temperatures. Observations and interviews revealed that residents consistently received food that was cold by the time it was served. One resident reported that the Dietary Manager informed him that the food temperature met state requirements, but it was still cold when served. Another resident mentioned frequently needing to reheat his food in the microwave, while a third resident expressed a preference for warmer food but chose to eat it cold. A fourth resident noted that the food was usually cold upon receipt, and using the microwave to reheat it would result in long wait times due to the number of residents needing to do the same. During an observation on the second floor, it was noted that the dietary aide had forgotten the thermometer initially but later checked the food temperatures. The recorded temperatures for various food items, including regular and pureed textures, were below the facility's policy requirement of maintaining a minimum temperature of 135 degrees Fahrenheit on the steam table before serving. The temperatures ranged from 104 to 129 degrees Fahrenheit, indicating a failure to adhere to the facility's food safety and sanitation policy, which contributed to the residents' dissatisfaction with the food temperature.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper food temperatures and prevent cross-contamination during meal service on the second floor, affecting all 94 residents residing there. Observations revealed that various food items, including shredded chicken, rice, and corn, were held at temperatures below the required 135 degrees Fahrenheit on the steam table. Residents reported that their food was often cold by the time it was served, with some resorting to reheating their meals in a microwave. The Dietary Manager was unaware of the required holding temperatures and confirmed that there was no temperature log for the second floor steam table. Additionally, cross-contamination risks were identified when a dietary aide was observed using the same gloves to handle multiple food items and surfaces without changing gloves or performing hand hygiene. The aide touched containers, the steam table, and various food items, including cheese and lunch meat, without using tongs or changing gloves. The facility's policy requires proper handwashing techniques and glove changes to prevent the spread of infection and cross-contamination, which were not followed in this instance.

Penalty

Fine: $7,760

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 and treat a resident's pressure injuries in a timely manner, leading to the deterioration of the resident's condition. The resident, who was admitted with multiple medical conditions including sepsis, diabetes, and stage 2 pressure ulcers on both buttocks, did not receive the prescribed wound treatments consistently. The resident's treatment orders, which required wound care twice daily, were not followed, resulting in missed treatments over a ten-day period. There was no documentation of the resident refusing treatment, and the initial wound assessment was delayed by a week. The wound care nurse, V3, confirmed that the resident's wounds were not assessed upon admission, and the admitting nurse failed to identify the existing pressure injuries. The Director of Nursing, V2, acknowledged that the wound treatment orders were entered but not initiated as required. The Licensed Practical Nurse, V4, who was covering the wound care position, did not perform the necessary assessments due to the resident's admission occurring after her shift. The facility's policy mandates that wound assessments should be conducted within 24 hours of admission, but this was not adhered to in this case. The lack of timely wound assessment and treatment contributed to the resident's pressure injuries worsening from stage 2 to an unstageable condition. The facility's wound policy emphasizes the importance of systematic wound care to promote healing and prevent deterioration, but the failure to implement these practices resulted in the resident's condition deteriorating. Interviews with staff, including the Nurse Practitioner, V5, highlighted the necessity of following treatment orders and documenting any refusals, which was not done in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident had his prescribed medications when leaving the facility on an overnight pass. The resident, identified as R1, did not have his medication strip available when he left the facility with his power of attorney (POA). The nurse's notes did not document that R1 left the building, and a handwritten note given to R1's POA indicated that the medication strip was not available. The medications that R1 was supposed to receive during his time away included several psychotropic and other medications for conditions such as schizophrenia, hypertension, and anxiety. The Director of Nursing (DON) explained the procedure for sending medications with residents who leave the facility, which involves using small envelopes to label and send the medications. However, the LPN involved, V4, stated that the medication strip was not in the medication cart and did not know which specific medications were supposed to be given to R1. V4 also mentioned that she did not have access to the medication machine and did not check if the medications were available there. The facility's guidebook and policy on administering medications emphasize the importance of ensuring medications are sent with residents when they leave for extended periods.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of abuse to the administrator for one of the residents reviewed for abuse. The incident involved a resident who allegedly reported to her daughter that she was pushed by a Certified Nursing Assistant (CNA) after receiving a ham sandwich. The daughter's report was communicated to the facility's scheduler, who did not inform the administrator. The administrator was unaware of the incident until an interview conducted by surveyors. Upon reviewing video footage, the administrator found no contact between the CNA and the resident. The facility's Abuse Prevention policy requires employees to report any incident or suspicion of abuse to the administrator immediately, which was not followed in this case.

Penalty

Fine: $210,355

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 resident with a history of embolic strokes received physician-ordered anticoagulants, leading to significant medication errors. Resident R167, who had a history of strokes due to embolism, was readmitted to the facility with a physician's order for Xarelto, an anticoagulant. However, the medication was not administered as prescribed due to issues with obtaining it from the pharmacy, resulting in the resident missing six doses. This failure contributed to R167 experiencing an acute embolic stroke, requiring emergency transport to the hospital, where the resident later passed away. The deficiency also involved another resident, R116, who was prescribed Rivaroxaban for atrial flutter. The facility failed to administer the anticoagulant for five days due to delays in receiving the medication from the pharmacy. This lapse in medication administration was documented in the resident's electronic Medication Administration Record (eMAR), which showed that the medication was on order but not delivered. The facility's policies and procedures for administering medications were not followed, leading to these significant medication errors. Interviews with facility staff, including the Director of Nursing and Licensed Practical Nurses, revealed a lack of access to the automated medication dispensing system and confusion about the availability of medications. The Director of Nursing admitted to not being aware of the medication's availability and the issues with the automated system. The facility's failure to ensure timely administration of anticoagulants as ordered by physicians resulted in Immediate Jeopardy, highlighting a breakdown in the medication management process.

Removal Plan

• All licensed nursing staff have been re-educated to ensure residents admitted have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available. Education includes an emphasis on the importance of securing medications, such as blood thinners/anticoagulants.
• The Administrator re-educated licensed clinical management nursing staff on the process to follow-up with pharmacy when authorization is required.
• A system is in place to ensure commonly available medications are available through pharmacy, back up pharmacy and the backup medication dispensing system.
• Re-education is completed by Administrator/DON/MDS/clinical management directors. All licensed nursing staff have been contacted via phone by the Administrator/DON/MDS/or clinical management directors and prior to the beginning of the next shift worked and will sign education sheets ensuring the licensed nursing staff was re-educated.
• A house audit was completed which consisted of the Director of Nursing ensuring that all residents prescribed blood thinners are receiving the prescribed medications, per physician orders.
• New licensed nursing staff hired are educated to ensure residents admitted to the facility have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available.
• On the spot education for licensed nursing staff is being conducted to ensure residents admitted have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available.
• A weekly audit of 5 residents will continue for four months to ensure residents have all medications are available, including blood thinners and all medications are received in a timely manner, per physician orders.
• The DON or designee perform QAPI audits of 5 residents a week for 4 months to ensure medications are administered as prescribed.
• An analysis of the audits are presented through QAPI quarterly. QAPI Audits are completed using direct observation, resident interview and medical record review.
• A root cause analysis was completed to determine process breakdown, barriers and process improvement. The root cause analysis was completed by the IDT which included the Administrator, clinical management licensed staff, pharmacy representation, corporate clinical staff and the medical director.
• All QAPI audits will be analyzed and reviewed in quarterly QAPI. This is overseen by the medical director and administrator. QAPI will determine if further audits will continue after the completion of 4 months.

Penalty

Fine: $210,355

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 appropriately follow up on a report of a stage 1 pressure injury for a resident, leading to the progression of the injury to a stage 3 pressure ulcer. The resident, who was admitted with severe cognitive impairment and was dependent on staff for personal hygiene and mobility, was at risk of developing pressure ulcers. Despite a reddened area being noted by a CNA during a bed bath, no nursing progress notes or skin assessments were found until the injury had progressed to a stage 3. The facility's policy required thorough weekly examinations by a licensed nurse, but the initial assessment and documentation were not completed in a timely manner. Another resident, who returned from the hospital with a deep tissue injury to the right heel, did not have the prescribed off-loading boot in place during a care and dressing change. The resident's care plan required maintaining off-loading heel boots and repositioning every 1-2 hours, but these interventions were not consistently implemented. The facility's policy on pressure ulcer and skin condition assessment did not adequately address pressure ulcer prevention, contributing to the oversight in care. The facility's failure to implement timely interventions and follow established protocols for pressure ulcer prevention and care resulted in the progression of pressure injuries for two residents. The lack of documentation and communication among staff members further exacerbated the situation, as necessary notifications and assessments were not completed as required by the facility's policies.

Penalty

Fine: $210,355

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 adequate nutritional care for a resident, identified as R103, who experienced significant weight loss. R103, a male resident with schizophrenia, major depressive disorder, and anxiety disorder, was not weighed or assessed by a dietitian for nine months following a notable weight loss. Observations revealed that R103 was pale, cachectic, and his meals were often untouched and out of reach, indicating a lack of proper nutritional monitoring and intervention. Interviews with facility staff, including an LPN, ADON, and Restorative Nurse, highlighted a lack of clarity and responsibility regarding nutritional monitoring and interventions for R103. The LPN admitted to not checking if residents received the correct diet, while the Restorative Nurse mentioned inconsistent weight monitoring and documentation. The Dietary Manager confirmed that no nutritional assessment had been conducted since January 2024, and there were no documented interventions to address R103's weight loss. The Dietitian, who had been at the facility for 2 to 3 months, was unaware of R103's weight concerns and emphasized the importance of regular weight monitoring and re-approaching residents who refuse to be weighed. Despite a care plan intervention to weigh the resident monthly and refer to a dietitian if significant weight loss occurred, no actions were taken in 2024 to address R103's nutritional needs. The facility's policy required regular weight monitoring and dietitian review, but these were not followed, leading to the deficiency.

Penalty

Fine: $210,355

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 enhanced barrier precautions for a resident with a pressure injury. A Certified Nursing Assistant (CNA) was observed providing care to a resident with a stage III pressure injury on the coccyx without wearing a gown, despite the requirement for enhanced barrier precautions, which include wearing a gown and gloves during high-contact care activities. The CNA was unaware of the wound's status, and there was no enhanced barrier precaution sign on the resident's door or an isolation cart in the hallway. The Director of Nursing confirmed that enhanced barrier precautions should be in place for residents with wounds to prevent contamination and spread of infection. Additionally, the facility failed to follow proper infection control procedures during incontinence care for another resident. A CNA was observed discarding soiled linen on the floor and not changing gloves after providing care, which is against the facility's policy. The CNA carried soiled linen through the hallway without bagging it and did not change gloves before assisting the resident into a wheelchair. The Director of Nursing stated that soiled linen should be bagged and gloves changed after care to prevent contamination, as per the facility's policies on linen handling and perineal care.

Penalty

Fine: $210,355

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 handle food in a manner that prevents cross-contamination, as observed during a lunch service on the first floor. The Dietary Manager, V32, stated that the noon meal included an open face turkey sandwich and alternatives such as hamburgers and grilled cheese sandwiches. During the lunch service, the cook, V33, was observed handling hamburger patties with gloved hands that had previously touched potentially contaminated surfaces, including handles, bags, and food containers. V33 did not change gloves between tasks, resulting in a layer of grease on the gloves, which then transferred to slices of bread and the tops of plates, leaving grease streaks. The facility's Food Safety and Sanitation policy, revised in September 2023, requires that single-use gloves be changed as soon as they become dirty or torn and before beginning a different task. V32 acknowledged that V33 should have used tongs or changed gloves to prevent cross-contamination. This failure to adhere to the facility's policy on glove use has the potential to affect all residents residing on the first floor, as noted in the facility's resident census, which showed 81 out of 164 residents live on that floor.

Penalty

Fine: $210,355

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 an involuntary transfer to the hospital for a resident with severe cognitive impairment. The resident, identified as having multiple diagnoses including stroke, nicotine dependence, and chronic obstructive pulmonary disease, was admitted to the facility from the hospital. Shortly after admission, the resident expressed a desire to leave Against Medical Advice (AMA) but was deemed unsafe to do so due to disorientation and confusion. The decision was made to involuntarily transfer the resident back to the hospital for evaluation and treatment. The facility's records, including the social service note and progress notes, did not indicate that the resident's spouse, who was listed as the emergency contact and surrogate decision maker, was notified of the transfer. Interviews with facility staff, including the Social Services Assistant Director and the Director of Nursing, revealed that there was an assumption that the notification had been made, but no documentation was found to confirm this. The staff involved in the transfer process did not communicate effectively to ensure the resident's representative was informed. The facility's policy on changes in resident condition requires notifying the resident's responsible party of significant changes, including involuntary transfers. However, in this case, the policy was not followed, as evidenced by the lack of documentation and confirmation of notification to the resident's spouse. This oversight highlights a breakdown in communication and adherence to established procedures for notifying family members or representatives during critical events.

Penalty

Fine: $210,355

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 the accuracy of a resident's advanced directive, specifically for one resident reviewed for advanced directives. The resident's electronic medical record indicated a Do Not Resuscitate (DNR) status, which was consistent with the physician's orders dated April 17, 2024. However, the POLST (Practitioner Order For Life-Sustaining Treatment) form dated September 13, 2024, indicated the resident was a full code, creating a discrepancy between the documented code status and the POLST form. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the code status should be consistent across all documentation, including the electronic medical record, physician orders, and POLST form. The facility's policy requires that any changes in code status be communicated to nursing by social services, and that the POLST form should match the physician's orders. The inconsistency in the resident's code status documentation was identified during a review of the resident's records, highlighting a failure in the facility's process to ensure accurate and consistent documentation of advanced directives.

Penalty

Fine: $210,355

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 treatment orders and care for two residents with wound care needs. For the first resident, there was no evidence of a care plan addressing the management of an accordion drain for a liver abscess. The resident's dressing, placed at the hospital, had not been changed since admission to the facility. The facility's records lacked documentation of monitoring or changing the dressing for the liver drain, and there was a noted shortage of PICC line dressing change kits. Staff interviews revealed confusion about the necessity of dressing changes for the drain site, and the facility's policy on post-operative drains was not followed. The second resident had wounds on her left second toe and right dorsal foot, which were not properly assessed or dressed according to orders. The wound care nurse observed that the resident's wounds were not covered with the prescribed dressings, and an initial wound assessment was not conducted for the right dorsal foot wound. The resident's care plan did not address her history of these wounds, and the facility's wound policy, which requires documentation of wound assessments, was not adhered to. Both cases highlight a lack of adherence to treatment orders and facility policies, resulting in inadequate wound care management. The facility's failure to conduct initial wound assessments and ensure proper dressing changes for the residents' wounds contributed to the deficiencies identified during the survey.

Penalty

Fine: $210,355

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 resident with an indwelling urinary catheter had a catheter secure device in place, as observed during a survey. The resident, identified as R49, was found lying in bed without a catheter secure device, and the catheter tubing was pulled tightly to the left with the drainage bag secured to the lower part of the bed frame. Certified Nursing Assistants (CNAs) V28 and V29, who were providing a bed bath to the resident, were unaware of the absence of the secure device. The resident communicated through nodding that his catheter had come out twice, indicating a lack of securement. The Director of Nursing (DON), identified as V2, confirmed that the facility uses catheter secure devices to prevent trauma and tension on the catheter tubing and that these should be offered to all residents with catheters. The resident's care plan, dated prior to the observation, indicated a risk for complications related to catheter use but did not document the use of a catheter secure device or any refusal of such a device. The facility's catheter care policy, dated 2018, mandates that indwelling catheters be secured to prevent trauma, which was not adhered to in this instance.

Penalty

Fine: $210,355

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 date respiratory equipment for two residents, leading to potential contamination. For the first resident, a male with chronic obstructive pulmonary disease and other health issues, the oxygen tubing and CPAP mask were not marked with the date they were initiated, and the equipment was improperly stored. The oxygen tubing was found in contact with the floor, and the CPAP mask was hanging from a drawer knob, both uncovered. The Director of Nursing acknowledged that respiratory equipment should be stored in a baggie when not in use to prevent contamination and should be dated according to the facility's policy. For the second resident, a male with chronic obstructive pulmonary disease and obstructive sleep apnea, the nebulizer mask and tubing also lacked date markings. The CPAP facemask and tubing were found uncovered on the bedside table. The Director of Nursing confirmed that there were no orders to change the tubing, resulting in a lack of documentation. The facility's policy requires that oxygen equipment be changed and dated weekly and as needed, but this was not adhered to for these residents.

Penalty

Fine: $210,355

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 properly for two residents, leading to deficiencies in pharmaceutical services. Resident R62, who has a history of anxiety disorder, Type 2 Diabetes, emphysema, bipolar disorder, and hypertension, did not receive her prescribed diabetic medication, Trulicity, as scheduled in September 2024. The medication was not sent by the pharmacy, and the facility did not take timely action to resolve the issue, resulting in missed doses on two occasions. The Director of Nursing was unaware of the missed doses until later, indicating a lapse in communication and medication management. Resident R153, a Type 2 diabetic, did not receive his fast-acting insulin according to the manufacturer's instructions. An LPN administered the insulin without wiping the pen tip with alcohol, priming the pen, or holding the plunger button for the recommended duration, which could result in an incomplete dose. The Director of Nursing confirmed these steps were not followed, which are necessary to ensure the full dose of insulin is delivered. These actions demonstrate a failure to adhere to proper medication administration protocols, potentially compromising resident care.

Penalty

Fine: $210,355

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 date opened insulin pens for two residents, R153 and R166, which is a requirement for medication storage. During an inspection of the 200-hall medication cart, it was observed that R153's fast-acting insulin pen had a yellow sticker with sections for Date Open, Date Expire, and Initials, all of which were left blank. The pen showed signs of being opened, as indicated by a damaged red tamper seal and some insulin being dispensed. The LPN, V9, confirmed administering insulin from this pen earlier in her shift and acknowledged that the pen should have been dated upon opening. R153's Order Summary Report confirmed an active order for fast-acting insulin to be administered four times daily. Similarly, R166's long-acting and fast-acting insulin pens were found with blank yellow stickers for Date Open, Date Expire, and Initials, and no other dates were documented on the pens. The seals on these pens were also damaged, indicating they had been opened. V9 admitted to administering insulin from these undated pens and confirmed that they should have been dated when opened. R166's Order Summary Report showed active orders for both fast-acting and long-acting insulin. The Director of Nursing, V2, stated that insulin pens are supposed to be dated upon opening, as their potency degrades after 28 days, and mentioned that staff had been recently in-serviced on this procedure.

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 safe feeding recommendations for four residents, leading to potential safety hazards. Resident R2, diagnosed with dysphagia, bipolar disorder, and dementia, was observed being given potato chips by the Assistant Director of Nursing, despite being on a mechanical soft diet. The speech therapist confirmed that R2 should not have been given potato chips and required supervision due to swallowing difficulties. Similarly, Resident R3, with diagnoses including hemiplegia and dysphagia, was observed eating potato chips and a regular diet unsupervised, contrary to his care plan that required a pureed diet and 1:1 assistance during meals. Resident R6, diagnosed with dysphagia following cerebral infarction, was observed feeding himself a pureed diet rapidly without supervision, contrary to his physician's orders that required 1:1 supervision and cueing for swallowing safety. The speech therapist confirmed that R6 needed supervision to ensure safe eating practices. Resident R9, with chronic bronchitis and COPD, was observed feeding himself a whole sandwich in bed without assistance, despite his care plan indicating a need for a pureed diet and 1:1 hand feeding. The speech therapist noted that R9 should have been receiving the diet specified in his orders. The Director of Nursing acknowledged that all residents on altered diets require some level of supervision, and those needing 1:1 supervision should not be served food until staff are ready to sit with them. The facility's policies on pureed and mechanical soft diets emphasize the need for individualized dietary modifications based on residents' swallowing and chewing abilities. However, the facility failed to adhere to these policies, resulting in residents receiving inappropriate diets and inadequate supervision during meals.

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 were free from physical and sexual abuse by a resident (R1) with a history of aggressive and inappropriate behaviors. R1, who had a criminal background and diagnoses including dementia and cognitive communication deficit, exhibited escalating aggressive behaviors towards staff and other residents. Incidents included R1 punching another resident (R2) in the face, flipping a resident (R3) out of a chair, and exposing himself to a resident (R4). Despite R1's documented history of aggression and inappropriate behavior, the facility did not adequately assess or manage the risks posed by R1, leading to multiple instances of abuse and harm to other residents. R1's aggressive behaviors were documented in various notes and reports, including instances of physical aggression towards staff and residents, and sexually inappropriate behavior. R1's criminal history background check revealed felony convictions and a history of violent behavior. Despite these red flags, R1 was admitted to the facility and his aggressive behaviors were not effectively managed. Staff reported multiple incidents where R1 was physically and verbally aggressive, including trapping a CNA in his room while masturbating, placing a choke hold on staff, and throwing a can of pop at a CNA. These behaviors escalated to physical assaults on residents, including punching R2 and flipping R3 out of a chair. The facility's failure to adequately assess and manage R1's behaviors resulted in significant harm to other residents. R1's care plan and risk assessments did not accurately reflect the severity of his behaviors, and interventions were insufficient to prevent further incidents. The facility's abuse prevention policy was not effectively implemented, leading to multiple instances of abuse and harm to residents. The Immediate Jeopardy was identified and later removed when R1 was placed on 1:1 supervision and subsequently discharged from the facility with police involvement.

Removal Plan

• R1 no longer resides in the facility.
• R2 is at baseline and continues to reside safely in the facility.
• R3 is at baseline and continues to reside safely in the facility.
• R4 is at baseline and continues to reside safely in the facility.
• All staff are in the process of being re-educated on the abuse policy to ensure residents are free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place.
• The Administrator/DON/MDS/management directors will complete the education. All staff will be educated via phone prior to the beginning of the next shift worked and will sign education sheets on keeping from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place.
• A list of identified offenders was reviewed by Social Service staff to ensure a safety plan is in place, per the plan of care.
• New hires will be educated on ensuring residents are kept free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place during orientation.
• On the spot education on abuse training knowledge is completed to ensure compliance System: Education to be completed by the start of next scheduled shift.
• A weekly audit of 10 residents will continue to ensure residents free of physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place.
• Audits will be completed by Social Services Director or designee and an analysis presented through QAPI.
• Audits are completed using direct observation, resident interview and medical record review.
• A root cause analysis was conducted to identify barriers and further education needed.
• All audits will be analyzed and reviewed in quarterly QAPI. This is overseen by the medical director and administrator. QAPI will determine if the audits will continue at that time.

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 supervise a resident with known escalating behaviors of physical and sexual aggression. This resident, who had a history of aggressive and inappropriate behaviors, was not properly monitored despite multiple incidents of aggression towards staff and other residents. The resident's behavior included physical aggression such as punching another resident in the face and flipping another resident out of a chair, as well as sexually inappropriate behavior, including exposing himself to a female resident. Despite these incidents, the resident was only placed on 15-minute checks, which were inconsistently documented and not effectively implemented, leading to further incidents of aggression and sexual misconduct. The resident's medical history included diagnoses of dementia, cognitive communication deficit, and a history of criminal behavior, including felony convictions and substance abuse. The facility's records show that the resident exhibited aggressive behaviors shortly after admission, including physical aggression towards staff and other residents, and sexually inappropriate behavior towards a staff member. Despite these behaviors, the facility's response was inadequate, with inconsistent supervision and failure to implement effective interventions to manage the resident's behavior. Interviews with staff revealed that the supervision checks were not consistently performed or documented, and there was confusion among staff about who was responsible for monitoring the resident. The facility's policy on safety and supervision of residents was not effectively followed, leading to multiple incidents of aggression and sexual misconduct by the resident. The failure to provide adequate supervision and implement effective interventions resulted in the resident being able to continue exhibiting aggressive and inappropriate behaviors, ultimately leading to the resident being discharged with police involvement after sexually assaulting another resident.

Removal Plan

• R1 no longer resides in the facility.
• R2 is at baseline and continues to reside safely in the facility.
• R3 is at baseline and continues to reside safely in the facility.
• R4 is at baseline and continues to reside safely in the facility.
• All staff are in the process of being re-educated on the abuse policy to ensure residents are free from physical and sexual abuse and behavior management for residents with a safety plan in place.
• Education includes supervising residents with escalating behaviors, monitoring and placing interventions in place.
• A system is in place to ensure supervision checks are completed as identified by the facility.
• The form is reviewed daily by clinical management to ensure it is completed and accurate.
• The Administrator/DON/MDS/management directors will complete the education.
• All staff will be educated via phone prior to the beginning of the next shift worked and will sign education sheets on ensuring residents are free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place.
• A list of identified offenders was reviewed by Social Service staff to ensure a safety plan is in place, per the plan of care.
• New hires will be educated on ensuring residents are kept free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place during orientation.
• On the spot education on abuse training, identifying escalating behaviors, monitoring and placing interventions in place.
• A knowledge check is completed to ensure compliance.
• A system is in place to ensure supervision checks are completed.
• Education to be completed by the start of next scheduled shift.
• A weekly audit of 10 residents will continue to ensure residents free of physical and sexual abuse, staff identifying escalating behaviors, monitoring and placing interventions in place and a system is in place to ensure supervision checks are completed.
• Audits will be completed by Social Services Director or designee and an analysis presented through QAPI.
• Audits are completed using direct observation, resident interview and medical record review.
• A root cause analysis was conducted to identify barriers and further education needed.
• All audits will be analyzed and reviewed in quarterly QAPI. This is overseen by the medical director and administrator.
• QAPI will determine if the audits will continue at that time.

Penalty

Fine: $39,9655 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 identify, assess, and implement pressure wound treatment and prevention interventions for a resident, leading to the development of an additional Stage 2 pressure wound and the worsening of existing wounds. The resident was admitted with a Stage 3 pressure wound on the left heel and a wound on the sacrum, but the care plan did not include any treatment or prevention interventions. The resident did not receive any wound care treatments from the time of admission until several weeks later, and there was no documentation of a complete wound assessment during this period. The Wound Care Physician's evaluations indicated that the resident's wounds worsened over time, and a new Stage 2 pressure wound developed. The facility's Wound Care Nurse and Director of Nursing confirmed that wound care treatments were not documented and therefore likely not performed. The resident did not refuse wound care, and the lack of treatment was attributed to failures in the facility's processes and documentation. The facility's policy required weekly wound assessments and documentation, but these were not completed as required. The care plan was inadequate, lacking necessary interventions such as a turning/repositioning schedule and special mattress. The facility's staff acknowledged the deficiencies in wound care and documentation, which contributed to the resident's deteriorating condition.

Penalty

Fine: $39,9655 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 inform a resident's family/Power of Attorney (POA) of a significant change in the resident's condition and subsequent hospitalization. On 1/3/24, a resident (R1) was found to be lethargic, with an altered mental status, elevated heart rate, and low oxygen levels. Emergency Medical Services (EMS) were called, and R1 was transported to the hospital. However, the facility did not notify R1's POA, who later learned of the hospitalization from the hospital staff. Interviews with the facility's Licensed Practical Nurses (LPNs) and Registered Nurse (RN) confirmed that the standard procedure is to notify the family/POA and document this communication in the Nurse's Notes, but this was not done in R1's case. The facility's Change in Resident's Condition Policy, reviewed on 2/1/22, mandates that nursing or social service staff alert the family of a resident's change in condition and document the communication in the resident's medical record. Despite this policy, there was no documentation in R1's Progress Notes indicating that the family/POA was informed of the change in condition or the hospitalization. The lack of communication and documentation represents a failure to adhere to the facility's policy and ensure the family/POA was promptly informed of the resident's critical condition and transfer to the hospital.