Taylorville Care 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

The deficiency involves the facility’s failure to prevent an elopement of a resident identified as high risk for wandering and elopement, and the failure to ensure mechanical lift equipment and slings were in proper working order during transfers, resulting in two separate resident falls. One resident with severe cognitive impairment, dementia, poor decision-making skills, and a history of wandering and exit-seeking behaviors eloped from the building without staff awareness. This resident had a wander management system in place and was care planned and assessed as at risk for elopement. On the day of the incident, door alarms sounded and staff performed head counts on the halls, but they did not identify that this resident was missing. Staff statements indicate that alarms sounded, staff checked their assigned halls, and all residents on those halls were believed to be present, yet the eloping resident was not accounted for. The facility later learned of the elopement only after being contacted by staff from a nearby assisted living facility, who had been alerted by a community member who found the resident wandering in a ditch and then observed her walking down the road, confused and unable to state her name. Multiple interviews and written statements describe confusion among staff and residents about how the elopement occurred and how long the resident had been outside. A CNA reported taking two residents out for a smoke break and later learning from those residents that the eloping resident had been pushing on their wheelchairs trying to get out the door and that she had gotten out. Another resident reported that the eloping resident tried to push her and another resident toward the door and that she notified a nurse, who removed the eloping resident from the area; this resident later saw the eloping resident come through the door to the outside but did not see her afterward. A different resident recalled the eloping resident trying to push her and another resident to get outside and stated she went to get the nurse because the eloping resident was not supposed to go out without staff. Nursing staff, including the former ADON and an LPN, described hearing door alarms, going to the front desk, and conducting head counts when the cause of the alarm was not witnessed, but they did not determine who had set off the alarm and believed all residents were present. The facility’s own investigation notes reference a family member of another resident who knew the patio door code and used it to take her husband outside, and who was unsure whether the eloping resident may have followed her out, while also noting that this family member had memory loss and became more confused throughout the day. The second part of the deficiency concerns two separate incidents in which mechanical lift slings failed during transfers, causing residents to fall. One resident with paraplegia due to spina bifida, scoliosis, morbid obesity, and neurogenic bladder required total assist with a mechanical lift for transfers and was cognitively intact. This resident reported that during a transfer from a shower chair to bed, while suspended in the air by the lift, the sling straps broke and she fell, striking her face on the base of the lift. Progress notes and hospital records document that staff found her on the floor with her legs partially under the bed and the sling snapped and hanging from the lift, with a large amount of blood from a facial laceration, bruising and swelling around the right eye, and subsequent diagnosis of an acute nondisplaced fracture of the anterior right iliac wing. CNAs involved in the transfer stated that the sling was already under the resident, they did not inspect or test the straps before use, and that the sling loops or stitching came undone while the resident was in the air, causing her to fall. Another resident, severely cognitively impaired and dependent on staff for transfers, experienced a similar sling failure during a transfer from bed to wheelchair. Progress notes and a CNA witness statement describe that the resident was in a sling that appeared properly fitted, with straps and hooks intact and without noted fraying or breaks, when two of the sling straps on one side snapped as the resident was being lowered into the wheelchair, causing the resident to fall backward to the floor. The nurse assisting with the transfer eased the resident to the floor, and the resident sustained three skin tears to the left arm, discoloration, and a red spot on the left cheek from contact with the nurse’s knee. Staff interviews confirm that this earlier sling break occurred and that the same type of equipment was involved. The laundry supervisor stated that laundry staff were supposed to inspect every sling, discard damaged ones, and document inspections, but acknowledged that they were not documenting in the log as required and that she had been written up for this. The administrator confirmed that after the first sling-related fall, management checked with laundry about inspecting slings and not using bleach, and that after the second fall, staff were re-educated, indicating that prior to these incidents, sling inspection and maintenance practices were not being reliably documented or verified.

Removal Plan

• Resident returned to facility safely; skin assessment and vital signs completed upon return
• Resident placed on checks
• Wander management system checked for proper functioning
• Code to patio door changed
• All door alarms checked for proper functioning
• Staff education/in-service regarding elopement policy (resident supervision, redirecting exit-seeking residents, alarm response, and no sharing of door codes with non-staff members)
• DON/ADON to audit wander management system documentation on MAR/TAR
• Review and update care plans for residents at risk for elopement as needed
• Social Service Director to review the Code Yellow book to ensure completeness
• Code Yellow drills performed on each shift
• Administrator to review audits to ensure compliance
• Report trends to the QA committee and implement further corrective action as needed

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents with cognitive impairments. One resident, who was severely cognitively impaired and had a history of inappropriate sexual behavior, was observed by staff touching another resident's genital area while both were waiting to go outside to smoke. The touching occurred outside the clothing, and the second resident, who was moderately cognitively impaired and assessed as at risk for abuse and neglect, did not voice opposition at the time. Staff intervened upon witnessing the incident and separated the residents for closer observation. Documentation and interviews revealed inconsistencies in staff accounts regarding the nature of the touching, with some reports indicating the contact was outside the pants and others suggesting it may have been inside. The second resident did not recall the incident but, when questioned, expressed that she was comfortable with what had happened. Both residents had been observed interacting closely and holding hands prior to the incident. Staff noted that both residents exhibited confusion at times, raising concerns about their capacity to consent to sexual activity. The facility did not have a policy in place regarding consensual relationships between residents, and staff were uncertain about the appropriate procedures to follow in such situations. The facility's abuse prevention policy defined sexual abuse as non-consensual sexual contact and required evaluation of a resident's capacity for consent if there was reason to suspect incapacity. Despite these requirements, the facility failed to ensure adequate protections were in place to prevent abuse and to properly assess the residents' ability to consent, resulting in a deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to employ a Director of Food and Nutrition, resulting in the absence of a qualified food service manager to supervise the daily functions of the Food and Nutrition Services Department. During the survey, it was observed that there was no dietary manager present in the facility, and kitchen staff, including cooks and dietary aides, reported not having any supervision by management. The previous dietary manager had recently quit without notice, and the registered dietitian, who visits three times a month, had not been asked to take on additional duties in the interim. Facility policy requires a qualified food service manager to oversee daily planning, food procurement, storage, preparation, distribution, service, and staff supervision, but no such individual was present or fulfilling these responsibilities during the survey period. This deficiency had the potential to affect all 67 residents living in the facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that food was stored and prepared in a manner that prevents foodborne illness, as evidenced by multiple observations and staff interviews. A dietary aide was seen placing a plastic cup that had fallen on the floor back with clean dishes, contrary to facility policy requiring re-washing of dropped items. The same staff member was unaware of the need to check sanitizer levels or dish machine temperatures. In the dry storage area, a dented can of beef ravioli was stored with other cans, and there was no designated area for dented cans. An uncovered, unlabeled, and undated container of white powder (identified as thickener) was found next to the three-compartment sink. In the freezer, uncooked chicken was stored above vegetables and cooked turkey, and bacon was stored above waffles and pancakes, with no specific system for separating uncooked meats from other foods. In the walk-in refrigerator, pasteurized shell eggs were stored above milk, and there were containers of food that were either unlabeled, undated, or both. Food temperatures taken after meal service revealed that ham salad and pureed items were held at temperatures (55°F, 68°F, and 71°F) not consistent with safe food handling standards. The registered dietitian confirmed uncertainty about whether staff were checking food temperatures before serving and acknowledged the improper storage of uncooked animal proteins. Facility policies require proper labeling, dating, covering, and storage of food, as well as re-washing of any dishware that falls on the floor, but these were not followed as observed.

Penalty

No penalty information released

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

Summary

Surveyors identified that the facility failed to provide palatable and safe temperature meals to eight residents reviewed for food and nutrition services. Multiple residents reported that the food lacked flavor, was not at the correct temperature, and was of poor quality, with specific complaints about cold food and hard toast. During a Resident Council meeting, several residents expressed that the kitchen and food quality had declined. Direct temperature measurements of food items after service revealed that ham salad and pureed items were served at temperatures ranging from 55°F to 71°F, which were acknowledged by the Registered Dietitian as not appropriate. The facility's own policy requires food to be prepared and served in a palatable, attractive manner and at safe, appetizing temperatures, but these standards were not met as observed and reported.

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 promote dignity and treat residents in a respectful manner during care for three residents. One resident, who is cognitively intact and dependent on staff for mobility and hygiene due to a history of stroke and other medical conditions, reported that a CNA was rough during a shower, used a hoist that caused pain to his private area, and ignored his repeated requests to be repositioned. The resident also stated that after the shower, he was put to bed while still wet and that no staff or management followed up with him about the incident. The resident's mother reported the incident to the Social Service Director, who did not document the complaint in the grievance book or speak directly to the resident, but instead relayed the information to the Administrator. The Administrator confirmed that no investigation was conducted, no interviews were held with the resident or other staff, and the only documentation was a disciplinary write-up for the CNA involved. Another resident, who is moderately cognitively impaired but was alert and oriented during the interview, stated that the same CNA showed no respect during showers, although he did not report any abuse. This resident requires partial to moderate assistance with showering, with the CNA expected to provide less than half the effort as the resident is able to complete most of his own shower. The care plan for this resident indicated a need for limited assistance and participation in restorative programs to maintain function. A third resident, who is cognitively intact and independent with activities of daily living including showers, reported that the CNA did not allow residents to do as much for themselves as they were able during showers, instead performing the tasks herself. The care plan for this resident indicated supervision was only needed as required and that the resident was independent with transfers. These findings demonstrate a pattern of staff not honoring residents' rights to dignity, respect, and independence during care.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of verbal and physical abuse to the State Agency as required. A resident with a history of flaccid hemiplegia, dysphasia, hypertension, hyperlipidemia, epilepsy, and arthritis, who is cognitively intact and dependent on staff for mobility and hygiene, reported that a CNA was rough during a shower, causing pain and discomfort to his private area with the transfer sling. The resident stated that his complaints were ignored during the incident, and after being put to bed soaking wet, he informed his mother, who subsequently reported the incident to the facility's Social Service Director. Despite the report from the resident's mother, the Social Service Director did not document the concern in the grievance book or interview the resident, instead passing the information to the Administrator. The Administrator acknowledged receiving the complaint and issued a disciplinary write-up to the CNA but did not interview the resident, the CNA's coworker, or conduct a formal investigation into the allegation. The Administrator also confirmed that the incident was not reported to the State Agency as required by facility policy and federal regulations. The facility's own Abuse Prevention Program policy mandates immediate reporting of all alleged violations involving abuse, neglect, or mistreatment to the administrator and appropriate authorities, as well as a thorough investigation and a written report within five working days. In this case, the facility did not follow these procedures, as the allegation was neither reported to the State Agency nor properly investigated, and no documentation of the incident was made in the facility's grievance records.

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 by not conducting an investigation into allegations of physical and verbal abuse made by a resident against a CNA. The resident, who has diagnoses including flaccid hemiplegia, dysphasia, hypertension, and is dependent on staff for mobility and hygiene, reported that during a shower, the CNA used a hoist that caused pain to his private area, was rough, and made statements suggesting he had no rights. The resident's mother reported the incident to the Social Service Director, but no one from management spoke to the resident about the incident, and no investigation was initiated. Multiple interviews confirmed that the resident expressed discomfort and pain during the shower, and that he communicated this to the CNA, who did not reposition him or address his concerns. Other staff members and residents were aware of the resident's dissatisfaction with the CNA's care, and the resident's mother reiterated the details of the incident to facility staff. Despite these reports, the Social Service Director did not document the concern in the grievance book or speak directly to the resident, instead passing the information to the Administrator. The Administrator acknowledged that no investigation was conducted, no statements were collected from the resident or other staff, and the accused CNA was not suspended pending investigation. The facility's own policy requires immediate reporting, investigation, and protection of residents in such cases, including removal of the accused staff from resident contact. The failure to follow these procedures resulted in the deficiency cited by surveyors.

Penalty

No penalty information released

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

Summary

The facility failed to report an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions, including dementia and atrial fibrillation. The resident was on blood thinners, which increased the risk of bleeding. On February 2, 2025, a light bluish V-shaped bruise was observed on the resident's forehead by the Assistant Director of Nurses (ADON), who documented the finding as a late entry on February 4, 2025. Despite noticing the bruise, the ADON did not report it to the State Agency, as required by the facility's Abuse Prevention Policy. The policy mandates that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, must be reported immediately or within 24 hours if they do not involve serious bodily injury. The resident's condition worsened the following day, with changes in behavior such as not acting normally, needing assistance with feeding, and episodes of crying. The Licensed Practical Nurse (LPN) noted the bruise and contacted the resident's physician, who decided to send the resident to the emergency room. The emergency medical services (EMS) crew observed dried blood in the resident's nostrils and noted the resident's reluctance to disclose the cause of the injury. The EMS reported their concerns of potential elder abuse to the State Agency. The facility's administrator did not report the incident to the State Agency, attributing the resident's hospital transfer to a change in consciousness likely due to a urinary tract infection, rather than the bruise.

Penalty

No penalty information released

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

Summary

The facility failed to prevent, identify, obtain orders, and monitor pressure ulcers for two residents, resulting in significant deficiencies in care. Resident R14 went from 4/15/2024 until 4/30/2024 without treatment or monitoring of a stage 3 facility-acquired pressure ulcer. The initial identification of the ulcer was made by a CNA on 4/15/2024, but no physician was notified, and no orders were obtained until 4/30/2024. The wound was not measured or properly documented until 4/30/2024, when the Director of Nurses (DON) became aware of it. The resident's care plan and progress notes indicated that R14 was at moderate risk for pressure ulcers and required frequent monitoring and repositioning, which were not adequately performed during this period. The DON confirmed that the nurse who initially found the open area did not follow the expected protocol of notifying the doctor and obtaining an order for treatment. For Resident R71, multiple pressure ulcers were observed and documented, but there were significant lapses in care and monitoring. On 6/4/2024, the Assistant Director of Nurses (ADON) completed a dressing change for R71, but on 6/6/2024, it was observed that some pressure ulcers did not have dressings, and the resident was not properly offloaded or repositioned. The ADON failed to change gloves between dressing changes and did not cleanse one of the wounds before applying treatment. Additionally, R71 did not have heel protectors on, and the resident's positioning in bed was not conducive to preventing further pressure ulcers. The DON and ADON acknowledged these deficiencies and agreed that the resident should be turned every two hours and provided with heel protectors. The facility's Wound Management Program, dated 2/26/2021, did not document procedures for dressing changes, replacing missing dressings, cleansing wounds before treatment, and turning and positioning residents. This lack of clear procedures contributed to the inadequate care provided to R14 and R71, resulting in the development and worsening of pressure ulcers. Both residents were dependent on staff for mobility and toileting, highlighting the critical need for diligent monitoring and care to prevent pressure ulcers.

Penalty

No penalty information released

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

Summary

The facility failed to remove expired medication and glucose control solution from the refrigerator and medication cart, and did not date multi-dose insulin pens after opening. During an inspection, a vial of Tuberculosis (TB) solution was found open without a date, a bottle of Azithromycin oral suspension without a name or date, and an opened vial of Influenza vaccine with an expired date. Additionally, expired Bisacodyl medicated laxative suppositories were found in the refrigerator. These findings were verified by an LPN who acknowledged the errors and stated the TB solution should be disposed of 30 days after opening. Further inspection of the medication carts revealed multiple Lantus insulin pens without open dates, expired Aspirin tablets, and expired glucose control solutions. The RN on duty was unsure about the timing of quality control checks on glucometers and verified the expired dates on the solutions. The facility's policy requires medications to be dated upon opening and expired medications to be removed and destroyed. The DON and Administrator both stated their expectations for proper labeling and disposal of medications, but acknowledged lapses in adherence to these protocols.

Penalty

No penalty information released

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

Summary

The facility failed to properly store and label foods, secure hair during meal preparation and service, and utilize hand hygiene to prevent food contamination and/or borne illness. During an inspection of the standup freezer, it was found that an open box of frozen pancakes and multiple boxes of maple sausage links were not sealed or labeled with open dates. Similarly, the walking refrigerator contained an open gallon of milk without an open date, a bundle of celery not stored in a bag or container, and an open box of lettuce with an unsealed inner bag. The deep freezer in the storeroom also had an open container of strawberry cheesecake ice cream without an open date. The Dietary Manager admitted to not dating the ice cream when it was opened and acknowledged the expectation for open boxes to be dated and sealed properly to prevent food from falling on the floor. Additionally, the facility's kitchen staff did not adhere to proper hair covering protocols. The cook was observed wearing a hairnet but did not have a beard guard, while two dietary aides had hairnets that did not fully cover their hair. The Dietary Manager and Administrator both stated that they expected kitchen staff to have their hairnets on and fully covering their hair, and for those with beards to have them covered as well. The facility also failed to maintain proper hand hygiene practices. The cook was observed handling food and kitchen equipment without wearing gloves and did not perform hand hygiene before donning gloves. Similarly, a dietary aide was seen retrieving a gallon of milk and setting up meal trays without performing hand hygiene before putting on gloves. Both staff members continued to handle food and kitchen equipment without changing gloves or performing hand hygiene after touching various surfaces. The facility's Cleaning and Sanitation policy emphasizes the importance of frequent hand washing to prevent contamination, but this was not followed by the kitchen staff.

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 wheelchair brakes were locked and a gait belt was utilized during transfers for several residents. Specifically, two CNAs transferred a resident with moderate cognitive impairment and high fall risk without locking the wheelchair brakes, causing the wheelchair to move backward during the transfer. Another resident with severe cognitive impairment and a history of falls was also transferred without locking the wheelchair brakes, resulting in the wheelchair moving during the transfer. Both incidents were observed by surveyors, and staff acknowledged the expectation to lock wheelchairs during transfers but failed to do so in practice. Additionally, the facility did not adhere to its smoking supervision policy for a resident who was allowed to smoke unsupervised and keep smoking materials in her room, contrary to the care plan and facility policy. The resident's care plan initially required supervision, but it was later revised without proper reassessment. The resident was observed with cigarettes and a lighter in her room, and staff confirmed the resident kept smoking materials in her room despite the policy requiring them to be secured at the nurse's station. Furthermore, a CNA failed to use a gait belt while transferring a resident with Alzheimer's Disease and Dementia, who was dependent on staff for transfers and had cognitive impairments. The CNA relied on the resident's daughter's previous assistance without a gait belt, leading to an unsafe transfer. The facility's policy mandates the use of gait belts for weight-bearing residents during transfers, but this 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 adhere to proper infection prevention and control protocols, leading to multiple deficiencies. Certified Nurse's Aides (CNAs) were observed not performing hand hygiene before donning and doffing gloves, and not removing soiled linens, which resulted in residents being exposed to contaminated surfaces. For instance, a CNA transferred a resident with saturated pants without changing the soiled incontinent pad in the wheelchair, and another CNA operated a remote control without removing gloves after providing care. These actions were contrary to the facility's policies on hand hygiene and linen handling. Additionally, the Director of Nurses (DON) and Assistant Director of Nursing (ADON) were observed placing wound care supplies directly on a resident's bed and a soiled incontinent pad, instead of using a clean barrier. This practice was not in line with the facility's infection control policy, which mandates the use of clean surfaces for medical supplies. The ADON admitted to not following proper procedures, citing her recent transition from a hospital setting as a reason for the oversight. Further observations revealed that a Licensed Practical Nurse (LPN) did not perform hand hygiene before and after administering medications to residents. The LPN also failed to change gloves and perform hand hygiene between attempts to obtain a resident's blood sugar, contaminating the medication cart and other surfaces in the process. These actions were inconsistent with the facility's handwashing policy, which requires thorough hand cleansing before and after resident care to prevent the spread of infection.

Penalty

No penalty information released

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

Summary

The facility failed to notify the physician of high blood sugar results and a newly acquired pressure ulcer for two residents. One resident, who has Type 2 Diabetes Mellitus, had blood sugar levels over 260 on 21 occasions between 5/8/24 and 6/4/24, but the physician was not notified as required by the resident's care plan. Interviews with nursing staff revealed that they did not consistently follow the order to notify the physician, with one nurse admitting to not calling the doctor because she did not consider a blood sugar level of 260 to be high. The physician confirmed that he was unaware of the high blood sugar levels until he reviewed the resident's records during rounds on 6/8/24 and subsequently adjusted the insulin dosage. Another resident, who was at moderate risk for pressure ulcer development, acquired a stage 3 pressure ulcer on the left buttock that was first identified by a CNA on 4/15/24. However, the physician was not notified, and no treatment order was obtained until 4/30/24 when the Director of Nurses became aware of the wound. The wound was not measured or documented properly until this date. The facility's policy requires notifying the physician of changes in a resident's condition, but this protocol was not followed in these instances.

Penalty

No penalty information released

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

Summary

The facility failed to prevent verbal abuse for one resident, who reported that an aide poured water directly on him during a bed bath and later made a derogatory comment about him to another aide. The resident, who is cognitively intact and has diagnoses of Type 2 Diabetes Mellitus, Depression, and Anxiety, described the aide as a larger woman with curly black hair and a darker skin tone. The resident did not initially report the incident to facility staff but mentioned it to his wife. The administrator was notified of the allegations and initiated an investigation, which confirmed that the aide had made the derogatory comment, although she denied pouring a bucket of water on the resident. The aide admitted to calling the resident an offensive name under her breath, which the resident overheard. The aide was suspended pending the investigation, and the incident was reported to the Illinois Department of Public Health (IDPH). The facility's Abuse Prevention Policy mandates immediate reporting and thorough investigation of any abuse allegations, which was followed in this case. The administrator confirmed that the final report would substantiate the allegation of verbal abuse.

Penalty

No penalty information released

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

Summary

The facility failed to ensure their Abuse Prevention Policy was followed for two residents. In the first case, a CNA allegedly called a resident a derogatory name, which was overheard by another resident and reported by the resident's daughter. Despite multiple staff members being aware of the incident, it was not properly reported or investigated. The Director of Nursing and the Administrator both denied knowledge of the incident initially, and the matter was dismissed due to the reporting resident's confusion and hallucinations, as noted by the staff. In the second case, a resident reported that a CNA poured water directly on him during a bed bath and later called him a derogatory name. The resident's account was corroborated by the CNA's admission and another staff member's statement. However, the incident was not immediately reported to the Administrator, and the Director of Nursing was not informed until later. The CNA involved was suspended, and the incident was eventually reported to the state health department. Both incidents highlight a failure in the internal reporting and investigation processes as outlined in the facility's Abuse Prevention Policy. Staff members did not follow the required procedures for reporting and documenting allegations of abuse, leading to delays in addressing the issues and ensuring resident safety.

Penalty

No penalty information released

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

Summary

The facility failed to ensure standards of care for a resident with Type 2 Diabetes Mellitus by not monitoring blood sugars as ordered. The resident's care plan did not address the diabetes diagnosis, and blood glucose monitoring (Accu checks) was not performed before meals and at bedtime as ordered. Additionally, the resident's insulin was unintentionally omitted for a period. Interviews with staff, including a Registered Nurse, the Administrator, the Director of Nursing, the Assistant Director of Nursing, and another Registered Nurse, confirmed that the resident was not receiving the necessary blood sugar monitoring despite being on insulin and having a diabetes diagnosis.

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 timely and complete incontinent care for two residents. One resident, who is cognitively impaired and always incontinent of bowel and bladder, was found with saturated pants and an incontinent pad. The CNA responsible for his care failed to cleanse all necessary areas, including the thighs, upper buttocks, penis, and scrotum. The CNA admitted to forgetting to provide complete care. The resident's records indicate a diagnosis of Alzheimer's Disease and Dementia, and he is dependent on staff for toileting and transfers. Another resident, who is moderately cognitively impaired and dependent on staff for toileting and mobility, was found with a wet incontinent brief. The CNAs responsible for his care failed to provide any incontinent care before covering him up. The CNA admitted to forgetting to provide care altogether. The resident's records indicate diagnoses of Hypertension, Type 2 Diabetes Mellitus, and an unspecified open wound to the right foot.

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 physician's orders were accurately completed and implemented for a resident with Type 2 Diabetes Mellitus. The resident returned from hospitalization with an order for insulin glargine 50 units twice a day, but the facility did not administer this medication from 5/29/2024 to 6/5/2024. The Director of Nursing (DON) discovered the error on 6/5/2024, noting that the resident had not received any insulin during this period. The resident's blood sugar was recorded at 278, significantly higher than the normal range of 80-120. The DON clarified the correct dosage with the resident's physician and re-ordered the previous dosage of 28 units at bedtime, which was the dosage before the hospitalization. The Event Report and interviews with staff and the resident's daughter confirmed the significant medication error. The Assistant Director of Nursing (ADON) and the DON both acknowledged that missing the insulin for about a week constituted a significant medication error, with the potential for severe consequences such as Diabetic Ketoacidosis (DKA). The facility's policy on obtaining and following physician's orders was not adhered to, as the licensed personnel did not clarify or insert the correct order upon the resident's return from the hospital, leading to the resident missing critical diabetic medication for an extended period.

Penalty

Fine: $245,505

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

Summary

The facility failed to provide adequate supervision for residents who require supervised leave and have the potential for elopement. This deficiency was observed in two residents, R5 and R8, who were able to leave the facility unsupervised. R5, who has a history of dementia and other medical conditions, was found by local police 0.6 miles from the facility after leaving without staff supervision. R5 had informed a CNA of his intention to leave, but the staff did not take appropriate action to prevent his elopement. Similarly, R8, who is moderately cognitively impaired, was found by a citizen walking on the road a block from the facility. R8 had previously attempted to exit the facility multiple times on the same day, but staff failed to monitor her closely or implement an elopement care plan. The facility's door alarms were not functioning properly, contributing to the residents' ability to leave the facility undetected. The alarm on door B did not sound when the lights were turned off, and staff were unaware of this issue. Additionally, the facility was understaffed, making it difficult for staff to monitor residents effectively. The lack of a backup battery alarm on some doors and the absence of a policy for checking door alarms further exacerbated the situation. Staff were not adequately trained on how to respond to exit-seeking behavior, and there was no system in place to ensure that residents at risk of elopement were closely monitored. The facility's failure to provide adequate supervision and maintain functioning door alarms resulted in immediate jeopardy for the residents. The deficiency was identified by surveyors, who noted that the facility's in-service training for staff was insufficient to address the issue. The facility's elopement prevention policy was outdated, and staff were not aware of the procedures for handling exit-seeking residents. The lack of communication and coordination among staff members further contributed to the deficiency, putting all residents at risk.

Removal Plan

• Maintenance Director contacted the Door Alarm company, and the technician was onsite. The corridor light switch to A and B hall that controlled door alarm power and lights down A and B hallway was removed to prevent the power to door alarm from being disengaged.
• Door backup power system identified as not being on circuit for the generator. Electric Company on site to connect door alarm power to generator panel.
• Maintenance Director and Door alarm company technician checked all doors to ensure they were working properly and that alarms sounded as designed.
• Facility elopement policy reviewed and updated to have doors check daily. Maintenance Director will check door alarms per facility policy daily. Nurses will check door alarms at the beginning of every shift.
• All residents were re-assessed for accuracy by administrator, Director of Nursing, Assistant Director of Nursing, and Social Service Director, to identify residents who are at risk for elopement including residents that require supervised leave. Assessments were completed for all residents who have been identified as at risk based on the completed assessments. Revision to all identified residents' care plans to include person-centered interventions.
• Facility elopement policy reviewed and updated by Regional Director and Administrator regarding residents at risk for elopement and what staff are to do if residents display exiting seeking behaviors or verbalize the desire to leave.
• Maintenance Director educated by Administrator on checking door alarms daily to ensure they are in good working order.
• Nursing staff educated by Director of Nursing and Assistant Director of Nursing on checking door alarms at the beginning of every shift to ensure they are in good working order.
• All staff working in the facility were in serviced on safety and supervision of residents, code yellow/missing resident, work order process, elopement and door alarm checks by Director of Nursing and Assistant Director of Nursing and Administrator.
• Education to Licensed staff in the facility on completion of elopement observations and implementation of appropriate intervention if at risk by Director of Nursing and Assistant Director of Nursing and Administrator.
• All staff will be trained during the orientation and quarterly for 1 year regarding missing resident policy and door alarm response procedure.
• The facility will implement compliance adherence during quarterly QA meetings.

Penalty

Fine: $245,505

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 use alternatives to bed rails and did not adequately assess and monitor the risks associated with their use, leading to significant harm to residents. One resident, with a history of dementia and physical impairments, suffered a fractured arm after it became entrapped in the bed rail during care. The resident's care plan indicated a preference for bed rails to reduce anxiety, but there was no documented assessment of the risks versus benefits of their use. The incident resulted in a decline in the resident's physical condition, ultimately leading to hospice care and the resident's passing. Another resident, also with dementia and behavioral disturbances, was observed multiple times with her arm through the bed rail, posing a risk of injury. Despite the resident's documented history of hallucinations and agitation, there was no physician order for the use of side rails, and the facility failed to conduct a proper assessment of the risks associated with their use. The resident's care plan included the use of side rails for safety during care, but the facility did not adequately monitor or address the potential for entrapment. A third resident, who was immobile and dependent on staff for all mobility, had side rails installed at the request of the family without a proper assessment. The facility did not document any medical symptoms justifying the use of side rails, nor did they explore alternative methods to ensure the resident's safety. The lack of proper assessments and monitoring for all three residents highlights the facility's failure to comply with regulations regarding the use of bed rails, resulting in immediate jeopardy to resident safety.

Removal Plan

• Maintenance Director completed bed gap measurement and assessment for entrapment zones per FDA guidance for all residents' beds with side rails. All bed rails were in compliance.
• Maintenance Director completed side rail audit to ensure they are compatible with bed.
• Director of Nursing and Social Service Director audit of side rails used as a restraint or enabler with completed pre restraint assessment form, side rail assessment form, side rail usage assessment and side rail consent on all residents to ensure least restrictive alternatives.
• Director of Nursing and Social Service Director audit and update care plans for residents using side rails regardless of used as enabler or restraint and for any other residents with restraints other than side rails. Care plans include medical symptoms justifying use of restraint, type of restraint used, frequency, durations, circumstances for when it is to be used, interventions to address potential or actual complications from restraints use such as increase incontinence, decline in ADLs or ROM, increased confusion agitation or depression.
• Director of Nursing and Social Service Director audit completed of physician orders for side rails and correct as needed to include medical symptom being treated, type of restraint, frequency of releasing the restraint.
• Regional Director and Regional Director reviewed and updated Bed Rail Maintenance and Installation and Entrapment Prevention, Restraint Reduction Program, Restraint Policy, and Restraint Usage Guide.
• Education to clinical staff currently in the facility conducted by Administrator, Director of Nursing and Social Services Director on Restraint Policy, Restraint Reduction Program, and Restraint Usage Guide.
• Education to Maintenance Director completed by Corporate Director of Environmental Services.

Penalty

Fine: $245,505

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

Summary

The facility failed to notify the physician of a change in condition and delayed diagnostics for a resident, resulting in a delay of treatment and pain management for a right distal femoral fracture. The resident, who was severely cognitively impaired and dependent on staff for mobility and activities of daily living, was reported to have swelling and tenderness in the right knee by a CNA. The RN on duty received this report and ordered an X-ray, but the X-ray was delayed until the following day due to the service being busy. The resident's condition worsened, with increased pain and swelling noted by multiple CNAs and the RN. Despite these observations, the physician was not notified of the resident's increased pain or the delay in obtaining the X-ray. The resident's family was informed of the X-ray results, which indicated a probable distal femoral fracture, and requested that the resident be sent to the emergency department for further evaluation and pain management. The resident was eventually admitted to the hospital for pain management and treatment of the fracture. Interviews with staff revealed that there was a lack of communication and assessment regarding the resident's pain and condition. The Director of Nurses acknowledged that the physician should have been notified of the delay in diagnostics and the resident's increased pain. The facility's policy on changes in a resident's condition or status was not followed, as the physician was not informed of the significant change in the resident's physical condition.

Penalty

Fine: $245,505

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 timely treat an injury of unknown origin for a resident, resulting in ongoing pain and a delay in treatment for a fractured leg. The resident, who was severely cognitively impaired and dependent on staff for all mobility and activities of daily living, was admitted with diagnoses of dementia with anxiety and weakness of the left side. On May 2, 2024, a CNA reported swelling and tenderness in the resident's right knee, which was communicated to the RN on duty. An order for a knee X-ray was placed, but the X-ray was not conducted until the following day. Throughout May 2, 2024, multiple CNAs observed the resident in significant pain, with swelling and redness in the knee. Despite these observations, the resident was not sent to the emergency department immediately. The RN on duty assessed the resident and decided to wait for the X-ray scheduled for the next morning, believing the situation was not as severe as it turned out to be. The resident's family was informed and agreed to monitor the situation until the X-ray could be performed. On May 3, 2024, the X-ray revealed a probable distal femoral fracture, and the resident was subsequently sent to the emergency department for further evaluation and pain management. The delay in obtaining the X-ray and addressing the resident's pain was acknowledged by the facility's staff, including the Director of Nursing and the Administrator, who admitted that the physician should have been notified of the increased pain and delay in the X-ray. The facility's policy on changes in a resident's condition or status was not adequately followed, contributing to the deficiency.

Penalty

Fine: $245,505

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, document, and treat pressure ulcers for a resident, leading to the development of a new ulcer and the worsening of existing ones. The resident, who was admitted with dementia and left-side weakness, was severely cognitively impaired and dependent on staff for mobility and daily activities. Despite having no documented pressure ulcers upon admission, the resident developed a deep tissue injury and a Stage II pressure ulcer, which were not properly documented or treated until several days later. The facility's records show inconsistencies and delays in obtaining physician orders for pressure ulcer treatment. The resident's medication administration records indicated open areas during skin checks, but there were no corresponding wound documentation or treatment orders until days later. Interviews with staff revealed a lack of awareness and communication regarding the resident's pressure ulcers, with some staff members unaware of the ulcers' existence before the resident's hospitalization. Observations during a survey revealed improper wound care practices, such as using the same gauze pad to clean multiple ulcers. The facility's wound management policy was not followed, as there was a failure to document new skin conditions, measure wounds accurately, and obtain timely treatment orders. The facility's Director of Nurses and other staff acknowledged the deficiencies, noting that the pressure ulcers worsened due to inadequate turning and repositioning of the resident.

Penalty

Fine: $245,505

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

Summary

The facility failed to provide adequate pain management for a resident, identified as R6, who suffered from a leg fracture. R6, who was severely cognitively impaired and dependent on staff for mobility and daily activities, was admitted with diagnoses of dementia with anxiety and weakness of the left side. Despite having physician orders for pain medications such as Aleve and Motrin, R6 did not receive any PRN pain medication when she reported a pain scale of 4 on May 3, 2024. The facility's records indicate that R6 experienced pain and swelling in her right knee, which was reported by CNAs to the nursing staff, but adequate pain management was not provided. On May 2, 2024, CNAs observed swelling and tenderness in R6's right knee and reported it to the RN, who ordered an X-ray. However, the RN did not send R6 to the emergency room despite her wincing in pain with movement. The X-ray results, received on May 3, 2024, indicated osteoarthritis and a probable distal femoral fracture. The resident's family requested that R6 be sent to the emergency department for further evaluation and pain management, which was eventually done after the family expressed concerns about R6's pain and requested additional X-rays. Interviews with staff and family members revealed that R6 exhibited signs of pain, such as screaming and grimacing, during care. Despite these observations, the facility did not adequately address R6's pain, and the physician was not promptly notified of the increased pain. The facility's policy on pain prevention and treatment required regular pain assessments, but it appears that these were not effectively implemented in R6's case, leading to a delay in appropriate pain management and medical evaluation.

Penalty

Fine: $245,505

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

Summary

The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate care and supervision. Residents reported extended wait times for assistance with activities of daily living, such as being taken off a bedpan or being laid down in bed, due to a lack of available Certified Nursing Assistants (CNAs). For instance, one resident was left on a bedpan for 45 minutes, while another had to wait for two CNAs to assist with being laid down, highlighting the staffing shortages during night and weekend shifts. Additionally, the report details an incident where a resident was found outside the facility by local police after leaving without staff knowledge. The resident, who was moderately cognitively impaired, managed to exit the building and was later returned by police. The staff on duty were unaware of the resident's departure, and the facility was unable to send someone to retrieve the resident due to insufficient staffing levels. This incident underscores the lack of supervision and monitoring of residents, particularly those with cognitive impairments. The facility's staffing schedules revealed that there were only three CNAs and two nurses available for 72 residents during certain shifts, which was insufficient to meet the residents' needs. The facility administrator acknowledged the staffing shortages and the inability to fill open shifts, leading to staff working short. The absence of a staffing policy further exacerbated the issue, contributing to the deficiencies observed in resident care and safety.

Penalty

Fine: $245,505

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 the services of a Director of Nursing (DON) on a full-time basis, which has the potential to affect all residents residing in the facility. On April 28, 2024, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN) confirmed that there was no DON, as the previous DON had quit on April 22, 2024. The facility administrator also confirmed the absence of a DON and stated that there was no staffing policy in place. Observations on April 28, April 30, and May 1, 2024, confirmed the absence of a DON in the facility. Additionally, the staffing schedule from April 22, 2023, to May 1, 2024, did not document a DON.

Penalty

Fine: $245,505

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

Summary

The facility failed to implement and maintain an effective Quality Assurance program, which has the potential to affect all 71 residents residing in the facility. The last documented Quality Assurance meeting was held on September 26, 2023. During an interview on May 21, 2024, the Administrator confirmed that no Quality Assurance meetings had been conducted since September 2023. Additionally, the Maintenance Director, who started in October 2023, stated on May 22, 2024, that he had not attended any monthly or quarterly Quality Assurance meetings. The facility's policy, dated November 2017, requires the Quality Assurance team to meet monthly, which was not adhered to as per the findings.

Penalty

Fine: $245,505

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 answer call lights in a timely manner, impacting the care of three residents. Resident 1, admitted with acute respiratory failure with hypoxia, reported being left on a bedpan for 45 minutes due to insufficient staffing during the night shift. This resident noted that call light response times were acceptable when staffing levels were adequate but were significantly delayed when staffing was low, particularly during the night shift. Resident 2, with multiple diagnoses including colostomy status and mild intermittent asthma, expressed difficulty in receiving assistance to be laid down due to a lack of available CNAs. This resident reported waiting up to three hours for call light responses, especially during weekends on the second and night shifts. Resident 3, with a history of gastrointestinal hemorrhage and respiratory failure, also experienced delays in call light responses, sometimes waiting up to three hours to be changed. Observations revealed that this resident was found in a saturated incontinent brief and wet bed linens, with the CNA unaware of the last time the resident had been changed. The facility's staffing challenges were acknowledged by a staff member, who stated that there were not enough CNAs and nurses to cover all shifts, leading to staff working short. The resident council minutes further documented concerns about insufficient help during evening shifts.

Penalty

Fine: $245,505

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

Summary

The facility failed to provide complete incontinence care for a resident, identified as R3, who was reviewed for bladder incontinence. R3, who is cognitively intact and dependent on staff for activities of daily living, reported that call lights take about two hours to be answered and that she has had to wait up to three hours to be changed. On one occasion, R3 was found in bed with a saturated incontinent brief, wet bed pad, and wet bottom sheet. The Certified Nursing Assistant (CNA), identified as V7, was unaware of the last time R3 had been changed and did not provide proper perineal care. V7 used a soapy washcloth without rinsing or drying R3, used the same washcloth for multiple areas, and did not change gloves after handling soiled items. The facility's Resident Council Minutes indicated that residents have expressed concerns about insufficient staffing during evenings. The facility's perineal care policy, dated July 2017, requires washing the perineal area from front to back, rinsing, and drying with a different washcloth, which was not followed in this instance. The CNA admitted to not following proper procedures, including not changing gloves and not knowing when R3 was last changed. This incident highlights a deficiency in providing adequate incontinence care and adhering to established care protocols.