Jerseyville Nsg & Rehab Center

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 adequately evaluate, implement, and monitor the effectiveness of fall interventions for a resident with a history of falls, dementia with agitation, and severe cognitive impairment. The resident required substantial assistance for mobility, was assessed as a high fall risk on multiple occasions, and had a care plan that included interventions such as bed and chair alarms, fall mats, and keeping the bed in the lowest position. Despite these interventions, the resident experienced multiple falls, including a final incident resulting in severe injuries such as a depressed skull fracture, orbital and maxillary fractures, scalp laceration, and multiple brain hematomas. Staff interviews and record reviews revealed that the alarms intended to alert staff to the resident's movements were not effective, as the resident was able to turn them off. The care plan was not consistently updated to reflect the resident's changing needs or the ineffectiveness of certain interventions. For example, the use of a self-release belt was not documented as added to the care plan, and the bed and chair alarms, as well as the fall mat, were already in place prior to the final fall but were not effective in preventing the incident. Staff also reported that the resident was often left unsupervised in her room, and the visual indicator for high fall risk was not present outside her door at the time of the incident. Observations and interviews further indicated that the resident was found on the floor with significant injuries, and the alarms did not sound at the time of the fall. The facility did not have a formal alarm policy, and staff acknowledged that the interventions in place were not always appropriate or effective for the resident. The lack of effective monitoring and adaptation of interventions contributed to the resident's ability to attempt to get out of bed unassisted, ultimately resulting in a fatal fall.

Penalty

Inspection fine: $40,97038 days payment denial

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

Summary

The facility failed to ensure that its door alarms were sufficiently loud to be heard from areas away from the 200 hall exit door, and did not maintain the outside gate latch in working order. This deficiency was identified when a resident with severe cognitive impairment and a history of wandering was able to elope from the facility. Multiple staff and family members reported that the alarm on the 200-hall exit door could not be heard from the 100/300 hall nurse's station until they were much closer to the door, and even then, it was difficult to discern the type of alarm. At the time of the incident, there were no staff present at the 200 hall nurse's station, and the only therapy staff in the building was located at the front of the facility, away from the exit door in question. The resident involved had severe cognitive impairment, Alzheimer's Disease, and was ambulatory with supervision. On the day of the incident, the resident's son was visiting and, after briefly leaving the resident unattended, discovered she was missing. Staff and the son searched the facility and only became aware of the exit when they heard the alarm faintly while approaching the 200 hall. The resident was ultimately found outside the facility, in the roadway behind the building, by a bystander and family members. It was also noted that the gate to the fenced area outside the 200-hall door was not latched, allowing the resident to leave the premises. Interviews with staff and the resident's family confirmed that the alarm was not functioning at an adequate volume and that the gate latch was broken at the time of the incident. Staff also indicated that the alarm was not always audible from key locations within the facility, and the maintenance director acknowledged recent issues with the alarm system. The facility's elopement prevention policy required assessment and interventions for residents at risk, but the failure to maintain effective alarm audibility and secure exits directly contributed to the resident's elopement.

Penalty

Inspection fine: $40,97038 days payment denial

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

Summary

The facility failed to ensure that the latch on the courtyard gate was in proper working order, resulting in a resident being able to exit the facility without staff supervision. On the date of the incident, a resident's son and an LPN went outside to the fenced-in courtyard and discovered that the gate was neither locked nor latched. The resident was later found outside the facility by a member of the public, who contacted the facility to report the situation. The resident's son expressed concern about the safety of the facility, specifically citing the unsecured back fence as a reason for feeling unsafe and deciding to take his mother home. Interviews and record reviews confirmed that the latch to the gate off the 200-hall exit door was broken at the time of the incident. The Director of Nursing acknowledged that the latch was not functioning and stated that staff were told it was not required to be latched. Facility policy indicates a commitment to maintaining an environment free from accident hazards and prioritizing resident safety and supervision. At the time of the incident, there were 50 residents residing in the facility.

Penalty

Inspection fine: $31,603

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 timely report and treat a change in condition for a resident with a complex medical history, including dementia, multiple fractures, and a high risk for falls. After a witnessed fall, the resident complained of pain, particularly when transferring, sitting, or standing, but the facility did not promptly notify the physician or obtain appropriate diagnostic testing for the new pain. Instead, staff attributed the pain to the recent fall and continued to administer routine Tylenol, while the resident's daughter repeatedly voiced concerns about the nature and persistence of the pain. Despite ongoing complaints and behavioral signs of pain, such as increased agitation and combativeness during transfers, the staff did not escalate the issue or seek further medical evaluation. The resident's daughter reported her concerns to both nurses and CNAs, but was told the pain was expected after a fall. The physician was not informed of the resident's increased pain or potential new injury, and the plan became to wait for an upcoming orthopedic appointment rather than pursue immediate assessment. The resident remained in pain for several days without a new evaluation or intervention. Eventually, at the orthopedic appointment, the resident was diagnosed with a right inferior pubic ramus fracture, which had gone unrecognized and untreated for eight days. Interviews with staff confirmed that the physician was not notified of the change in condition, and the Director of Nursing stated that she would have expected nurses to report such changes. The facility did not provide a change in condition policy for review.

Penalty

Inspection fine: $31,603

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 ensure that fall prevention interventions were consistently in place for a resident with a significant history of falls and multiple risk factors. The resident, who was severely cognitively impaired and required substantial assistance with activities of daily living, had diagnoses including a displaced fracture of the left femur, emphysema, dementia, and tremors. The care plan specified the use of bed and chair alarms at all times, as well as other interventions such as scheduled toileting, non-skid socks, and increased supervision. Despite these documented interventions, the resident experienced an unwitnessed fall in her room after attempting to get out of bed without assistance. At the time of the fall, the bed alarm was not in place as required by the physician's order and care plan. Staff interviews confirmed that the alarm was not always in use, and the Director of Nursing acknowledged that the bed alarm was not in place at the time of the incident. The incident report and progress notes documented that the resident was found on the floor with a laceration to her finger and was incontinent at the time of the fall. The facility did not provide a fall prevention policy when requested. The failure to ensure that required fall prevention interventions were in place directly contributed to the resident's fall.

Penalty

Inspection fine: $61,78917 days payment denial

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

Summary

The facility failed to provide progressive fall interventions and complete a fall investigation for a resident, resulting in a displaced fracture of the greater trochanter of the left femur. The resident, who was severely cognitively impaired and required substantial assistance for activities of daily living, had a history of falls and was at high risk for further incidents. Despite multiple falls occurring on specific dates, the care plan was not updated with new interventions to prevent future falls. The resident's care plan included various interventions such as staff assistance with toileting, use of non-skid socks, and encouragement to use a walker. However, after falls on several occasions, including one where the resident tripped over a walker, the facility did not document new interventions or adequately investigate the incidents. The resident experienced pain and bruising, and despite being sent to the hospital, no x-rays were initially performed to assess potential injuries. The facility's fall policy required assessment and management of falls through prevention, investigation, and implementation of interventions. However, the facility did not adhere to this policy, as evidenced by the lack of documented interventions following the falls and the absence of a thorough investigation into the incidents. The Director of Nursing acknowledged the need for interventions after every fall, but these were not consistently implemented or documented in the resident's care plan.

Penalty

Inspection fine: $61,78917 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 obtain monthly weights for two residents, R13 and R41, which resulted in significant weight loss for R13. R13, who was admitted with diagnoses including cerebrovascular disease and depression, experienced a 15.6% weight loss from November 8, 2024, to February 26, 2025. R13's care plan required monthly weight monitoring, but weights were not recorded for December 2024 or January 2025. R13 was on a mechanically altered diet and required substantial assistance with eating, yet the facility did not adhere to the care plan's weight monitoring requirements. R41, who was on isolation for COVID-19, reported receiving cold meals and expressed uncertainty about recent weight changes. R41's care plan also required monthly weight monitoring due to a diagnosis of moderate protein-calorie malnutrition. However, the last recorded weight for R41 was on December 14, 2024, with no subsequent weights documented. The facility's scale was reportedly broken for about six weeks, contributing to the lack of weight monitoring. The Registered Dietitian (RD) confirmed that no weights were recorded for January 2025 and expressed concern about potential undetected weight loss and malnutrition. The facility's policies required monthly weight monitoring to assess nutritional status and intervene as necessary, but these procedures were not followed. The administrator acknowledged the requirement for monthly weights, yet the facility failed to comply, leading to the deficiency.

Penalty

Inspection fine: $61,78917 days payment denial

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

Summary

The facility failed to ensure that food was prepared, stored, and distributed in a manner that prevents foodborne illness, potentially affecting all 48 residents. During observations, it was noted that a dietary aide did not check the dish machine sanitizer level. The refrigerators contained items such as a cardboard box of lettuce with sticky, red spatters, an opened container of whipped cream without a date, and various other food items that were not labeled or dated. Additionally, the air conditioner above the toaster was covered in dust, and there were crumbs on a rack of pots and pans next to the stovetop. Further observations revealed that the wall next to the stovetop was spattered with a brown substance, and multiple dented cans of vegetable broth were stored with other cans. In the freezers, there were unlabeled and undated items such as breaded meat patties, pancakes, French fries, and garlic bread. A container of barbecue sauce that required refrigeration after opening was left in the dry storage room. The resident refrigerator contained fast food items that were not labeled or dated. The facility's policies require food to be covered, labeled, and dated, which was not adhered to, as confirmed by the administrator.

Penalty

Inspection fine: $61,78917 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 serve meals in a timely manner for four residents reviewed for nutritional services. Lunch was scheduled to be served at 12:00 PM, but the cook began plating food at 12:13 PM and continued until 1:03 PM. The trays were then taken to the nurse's station to wait for CNAs to deliver them to residents' rooms. The meals were delivered between 1:19 PM and 1:25 PM, significantly later than the scheduled time. A CNA noted that meals are always late, and the administrator acknowledged that while dining room residents are served first, the hall trays should not be delayed. The facility lacks a policy regarding the timeliness of meal service.

Penalty

Inspection fine: $61,78917 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 protect residents from abuse, as evidenced by two incidents involving residents R15 and R4. Resident R42, who has severe cognitive impairment and a history of aggressive behaviors, was involved in both incidents. In the first incident, R42 was found hitting R15, who is cognitively intact, while R15 was in bed. R15 reported being hit in the face, chest, and breasts by R42, who mistakenly believed R15 was in her room. This incident was documented by an LPN who responded to R15's cries for help. In the second incident, R42 approached R4 in the dining room and hit him in the back with a closed fist. R4, who is also cognitively intact, was eating lunch when the attack occurred. R42's actions were reportedly motivated by jealousy, as she accused R4 of bringing another woman into the dining room. The facility's abuse prevention policy defines abuse as the willful infliction of injury or harm, and these incidents demonstrate a failure to adhere to this policy.

Penalty

Inspection fine: $61,78917 days payment denial

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

Summary

The facility failed to investigate allegations of abuse involving two residents. In the first incident, a Licensed Practical Nurse (LPN) documented that while passing medicine, they heard a resident calling out and found another resident standing beside the bed, hitting the first resident and telling them to leave the room. Despite this, the facility administrator confirmed that no abuse investigation was conducted for this incident. In the second incident, an LPN was informed by a Certified Nursing Assistant (CNA) that a resident had left their wheelchair, approached another male resident, and hit him on the back. When questioned, the resident accused the male resident of bringing another woman into the dining room. Again, the facility administrator confirmed that no abuse investigation was conducted. The facility's Abuse Prevention Program Policy mandates that all incidents involving abuse, neglect, or misappropriation must result in an investigation, which was not followed in these cases.

Penalty

Inspection fine: $61,78917 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 serve meals at a desirable temperature to two residents, R14 and R41, as observed during a survey. On February 25, 2025, food temperatures were checked after the last resident tray was served, revealing that while the hamburger and ground hamburger were at acceptable temperatures of 169 and 156 degrees respectively, the French fries and vegetable medley were at lower temperatures of 107 and 123 degrees. R14 expressed dissatisfaction with the food, stating it was cold, tasted bad, and was often served late, sometimes as late as 2:00 PM. R14's Minimum Data Set (MDS) indicated a BIMS score of 15, showing cognitive intactness. R41, who was in isolation for COVID-19, reported receiving cold food that tasted horrible. R41's Face Sheet documented a diagnosis of Moderate Protein Calorie Malnutrition, and the MDS showed a BIMS score of 14, indicating cognitive intactness. The facility's administrator, V1, acknowledged issues with food temperatures due to non-heated meal carts and mentioned ongoing efforts to acquire new carts. The Resident Council Minutes from February 11, 2025, also noted complaints about food not being hot. The facility's Meal Services Temperatures Policy requires hot food to be above 165 degrees and mandates corrective actions if temperatures are not met, but these standards were not adhered to in this instance.

Penalty

Inspection fine: $61,78917 days payment denial

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

Summary

The facility failed to ensure the proper use of personal protective equipment (PPE) for two residents who were on isolation due to Covid-19. One resident, admitted with type 2 diabetes mellitus and chronic obstructive pulmonary disease, tested positive for Covid-19 and was placed on isolation. However, a Certified Nursing Assistant (CNA) was observed in the resident's room without wearing a gown or gloves, and her mask was improperly positioned below her nose. The CNA justified her lack of PPE by stating she was only passing water. Additionally, the resident's room door was left open, which is against isolation protocols. Another resident, diagnosed with dementia, depression, and anxiety, also tested positive for Covid-19 and was on droplet isolation precautions. Despite this, the resident was seen sitting in the hallway with her mask pulled down below her chin. The facility's administrator stated that staff are expected to follow proper isolation precautions, which include wearing a mask, gown, and gloves in rooms with droplet precautions. The facility's Isolation Precautions Policy supports these measures, indicating a failure to adhere to established protocols for infection control.

Penalty

Inspection fine: $61,78917 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 accommodate the needs of a resident, identified as R34, by not providing access to a sink in the resident's bathroom, which hindered the resident's independence. On February 25, 2025, R34, who is cognitively intact and uses a wheelchair, reported being unable to access the sink in the bathroom to brush his teeth. The bathroom layout, with a toilet riser and grab bars, obstructed wheelchair access to the sink. R34's care plan, dated October 11, 2022, indicated the need for assistance with activities of daily living and environmental adaptations to maximize safety and independence. The Director of Nursing was unaware of this issue until it was brought to her attention during the survey.

Penalty

Inspection fine: $61,78917 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 post its licensed and unlicensed staffing information responsible for resident care, which has the potential to affect all 48 residents residing in the facility. During a tour of the facility, it was observed that the staffing information was not posted as required. The Director of Nursing indicated that the daily staffing was posted in the employee break room, but the only information available there was the daily assignment sheets for Certified Nurses Assistants and Nurses. These sheets did not include the census or the total number and actual hours worked per shift for the staff responsible for resident care. The Regional Director of Clinical Operations acknowledged the lack of compliance with the policy on daily staff posting and mentioned that this was something they would be implementing.

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 assess and monitor the gastrostomy tube site for a resident, leading to a deficiency in care. The resident, who was moderately cognitively impaired and had a diagnosis of dysphagia and adult failure to thrive, was receiving tube feeding for nutritional support. Despite this, the resident expressed confusion about the necessity of the tube and reported that it had been accidentally removed. The facility's records indicated that the tube was not in place for several days before staff became aware of the situation. Multiple staff members, including nurses and a certified nursing assistant, were involved in the oversight of the resident's care. The resident had informed staff that the tube was out, but there was a lack of immediate action to address the issue. The resident was sent to the hospital for possible reinsertion of the tube after it was discovered missing post-dialysis. An emergency medical technician noted that the tube site was scabbed over, suggesting it had been out for longer than reported, raising concerns about neglect. The facility's policies on enteral feeding tube placement and monitoring were not followed, as evidenced by the lack of documentation and assessment of the tube site. The facility's procedures required checking the tube placement each shift, which was not adhered to, leading to the resident's tube being out for an extended period without proper monitoring or intervention. This failure to follow protocol resulted in the resident requiring hospital observation and potential surgical intervention for tube reinsertion.

Penalty

Inspection fine: $80,78919 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 protect residents from sexual abuse, specifically involving two residents with moderate cognitive impairment who were unable to consent to sexual relations. The deficiency was identified when the facility first noticed inappropriate sexual behaviors between the two residents but did not implement interventions to protect one of the residents from potential abuse. Despite being aware of the situation, the facility allowed the residents to continue interacting without adequate supervision or separation, leading to multiple incidents of inappropriate sexual behavior. The residents involved had diagnoses of dementia and other cognitive impairments, which affected their ability to make informed decisions. The facility's records indicated that the residents were in a relationship, and their families were informed and seemingly accepting of the relationship as long as it was consensual. However, the facility did not take sufficient steps to assess the residents' capacity to consent or to prevent potential abuse, as evidenced by repeated incidents where the residents were found in compromising situations. Staff members were aware of the ongoing interactions between the residents but failed to take appropriate action to prevent further incidents. The facility's documentation and communication with the residents' families and medical professionals were inadequate, as they did not report the incidents to local law enforcement or conduct thorough investigations. The facility's inaction and lack of effective interventions contributed to the continuation of inappropriate behaviors, resulting in a deficiency in protecting residents from abuse.

Removal Plan

• R3 room move to the 200 Hall. R4 room remained on the 300 Hall.
• R3 and R4 were both care planned to maintain supervision when in public areas together. R3 and R4 were care plans to not be in either person's room together.
• R4 was discharged home via AMA per POA.
• The Abuse Assessment was completed for all residents to determine if the resident is at risk of abuse or displays behaviors that would be indicative of potential abuse occurring completed by V1, Administrator.
• All residents identified as at risk for abuse had a care plan developed with interventions to prevent occurrence of abuse completed by V1, Administrator.
• The Administrator, Director of Nursing, and the MDS Coordinator assessed all residents to determine if any other residents were having sexual relationship in the facility. No other resident identified as having a sexual relationship with any resident.
• The Director of Nursing and/or designee educated all staff on what to do when a resident is at risk for abuse or displays behaviors that would be indicative of potential abuse occurring.
• Education will be ongoing to ensure that no employee works prior to receiving education by the Director of Nursing.
• Education will be provided to all new hires prior to working by the Director of Nursing.
• The Director of Nursing, Administrator and/or Social Service Director will assess residents BIMS score for the ability to consent to relationships. If unable to consent, the POA or decision maker will be notified and care plan updated.

Penalty

Inspection fine: $80,78919 days payment denial

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

Summary

The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident with moderate cognitive impairment. The resident, identified as R5, eloped from the facility sometime after 3:00 AM and was found by a passerby at 6:20 AM. The incident occurred because the door alarm was not activated, as another resident had turned it off. Staff did not notice R5's absence until a round was conducted at 5:00 AM, and an immediate search was initiated both inside and outside the facility. R5 had a history of moderate cognitive impairment, with a BIMS score of 11, and was known to have confusion and forgetfulness. The resident's care plan included interventions for a wander guard and observation of whereabouts, but these measures were not effectively implemented. R5's elopement assessment indicated a risk of elopement, as the resident had previously questioned the need to be at the facility and displayed behaviors suggesting an attempt to leave. Despite these indicators, the facility did not take sufficient precautions to prevent the elopement. Staffing issues were also highlighted, with reports indicating that the number of staff on duty was insufficient to supervise the residents adequately. The layout of the building further complicated supervision, as residents were scattered across different areas, making it difficult for staff to monitor them effectively. The facility's failure to ensure the door alarms were functioning and to provide adequate supervision contributed to the resident's elopement, resulting in Immediate Jeopardy.

Removal Plan

• R5 was immediately placed on 15-minute checks and moved to the 200 Hall for closer supervision.
• R5's care plan was reviewed and updated to reflect interventions regarding elopement risk by the MDS Coordinator.
• R5 was discharged home with R5's emergency contact.
• The Elopement Assessment was completed on all residents by V1, Administrator.
• All residents identified at risk for elopement care plans were updated with interventions, as well as the facility's Code Yellow Binder by V1, Administrator.
• All staff were in-service on the facilities Elopement Prevention Policy to reflect on what to do in the event of a missing person. All staff Education will be ongoing to ensure that no one works prior to being in-service by the Director of Nursing.
• All policies and procedures related to elopement and missing person were reviewed to ensure appropriate by V26, Regional Director and V1, Administrator.
• The Maintenance Director audited all exit door to ensure alarms are functioning properly.
• Door alarm code was changed and staff in serviced by the maintenance director on new code and not giving out the code to family members or residents.

Penalty

Inspection fine: $80,78919 days payment denial

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

Summary

The facility failed to investigate allegations of potential abuse to prevent further sexual abuse for two residents with moderate cognitive impairment, who were unable to consent to sexual relations. The report details multiple incidents where one resident displayed sexual behaviors towards another, including fondling and being found in compromising situations with their pants down. Despite these incidents, the facility did not conduct thorough investigations or implement effective interventions to prevent further occurrences. The report highlights several documented incidents involving the two residents. One resident was observed entering male residents' rooms and engaging in inappropriate behaviors, while the other resident was found in similar situations with female residents. Progress notes indicate that these behaviors were ongoing, with staff documenting the incidents and notifying family members and the administrator. However, there was a lack of formal investigations or comprehensive interventions to address the behaviors and protect the residents involved. The facility's Abuse Prevention Program Policy mandates that any incident or allegation of abuse should result in an investigation. Despite this policy, the Director of Nursing confirmed that no investigations were conducted for the incidents involving the two residents, except for one on a specific date. The facility's response was limited to documenting the incidents in progress notes and notifying medical professionals and family members, without taking further action to prevent recurrence.

Penalty

Inspection fine: $80,78919 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 implement its abuse policy to protect a resident's right to be free from sexual abuse by a known male with sexual behaviors. This deficiency involved two residents, both diagnosed with dementia, who were in a relationship that included holding hands and kissing. Despite the facility's awareness of the residents' cognitive impairments and the need to keep them apart, the staff did not effectively prevent them from being alone together. On two occasions, the residents were found with their pants and underwear off in one of the resident's rooms, indicating a failure to maintain adequate supervision and separation. The facility's administrator acknowledged the difficulty in keeping the residents apart and admitted that neither resident had the cognitive capacity to consent to a sexual relationship. The facility reported only one of the incidents to the state agency and did not report any incidents to local law enforcement, as they were uncertain if the situation constituted abuse. The facility's abuse prevention policy requires immediate reporting and investigation of any incident or suspicion of abuse, which was not fully adhered to in this case.

Penalty

Inspection fine: $80,78919 days payment denial

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

Summary

The facility failed to maintain adequate staffing levels, particularly during the night shift, which compromised the ability to meet the needs of all 47 residents. On the night of October 3, 2024, only two CNAs and one LPN were on duty, which was insufficient to provide necessary care and supervision. The CNAs were also required to perform laundry duties, further detracting from their ability to focus on resident care. Staff expressed concerns about the inability to answer call lights promptly and supervise residents, especially those at risk for falls. Despite these challenges, management cited financial constraints as a reason for not increasing staff levels. Interviews with staff and residents highlighted the impact of inadequate staffing on resident care. A CNA reported that the current staffing levels made it difficult to provide timely care and supervision, particularly for residents at risk of falls. An LPN contracted to work at the facility expressed surprise at the low staffing levels and noted the difficulty in supervising residents due to the building's layout. Residents also voiced concerns, with one resident mentioning missed showers and delayed responses to call lights, which they attributed to the lack of staff. The facility's Director of Nurses (DON) acknowledged the staffing challenges but maintained that the current staffing ratios were based on the number of residents. The DON indicated that additional staff would be added once the census increased to 50 residents. However, the facility's assessment and staffing calculations suggested a need for more nursing hours than were being provided. The facility's layout and the distribution of residents across different halls further complicated the ability to provide adequate supervision and care, as noted by both staff and residents.

Penalty

Inspection fine: $80,78919 days payment denial

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

Summary

The facility failed to report potential sexual abuse involving two residents, both diagnosed with dementia, to the local police department and the State Agency. An incident occurred where one resident was found in another resident's room with their pants down, and the other resident was on top of them. Despite the residents' Power of Attorneys being informed and expressing no concerns if the relationship was consensual, the facility did not notify law enforcement or the residents' physicians about the potential abuse. The facility's records indicate multiple incidents involving inappropriate sexual behavior between the two residents and other residents. These incidents included one resident being found with their hand down another resident's shirt and another incident where a resident was observed with their hand on another resident's leg. Despite these occurrences, the facility did not conduct thorough investigations or report these incidents to the appropriate authorities, as required by their Abuse Prevention Program Policy. Interviews with facility staff revealed that they were aware of the incidents but did not take the necessary steps to report them. The Director of Nursing and the Administrator acknowledged that only one incident was reported to the State Agency, and none were reported to local law enforcement. The facility's policy mandates immediate reporting of such incidents to both the state survey agency and local law enforcement, 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 address and monitor a urinary tract infection (UTI) in a timely manner for a resident, identified as R2, who was part of a sample of six residents reviewed for UTIs. R2 had multiple diagnoses, including a UTI, and was frequently incontinent of urine and bowel. The resident's care plan included monitoring for skin integrity and toileting needs, but there was a delay in obtaining and processing the necessary lab work to confirm and treat the UTI. The resident's family expressed concerns about the facility's handling of the UTI, noting that the facility would not test for a UTI unless the resident developed a fever. The family believed that the resident still had a UTI and that there was a delay in ordering and receiving lab results, which led to a serious infection. The facility's progress notes indicated multiple attempts to obtain a urine sample and confusion over lab orders, resulting in a delay in diagnosis and treatment. The Director of Nursing acknowledged a mix-up in the lab orders, which contributed to the delay in obtaining a culture and sensitivity report. The hospital lab manager confirmed that the facility did not order the correct lab work initially, leading to the delay. The facility's Laboratory Report Policy required nurses to ensure all labs were performed as ordered and to notify physicians of results, but this process was not followed, resulting in the deficiency.