University Nursing 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 ensure a nurse obtained a physician’s order prior to inserting and anchoring a urinary (Foley) catheter for a resident who was being evaluated for possible UTI and sepsis. The resident had diagnoses including hypertension, iron deficiency anemia, sequelae of cerebral infarction with hemiplegia, chronic pain syndrome, hypokalemia, prior UTI, and bandemia, and was always incontinent of bowel and bladder. On the day of the incident, staff noted blood in the resident’s urine, burning with urination, altered mental status, low blood pressure, and a low‑grade temperature. The on‑call NP was notified and gave orders for IV fluids, labs, and a urinalysis with culture and sensitivity, but there was no order documented for insertion or anchoring of a Foley catheter. Earlier in the day, the DON started an IV due to the resident’s low blood pressure and change in condition, and staff were instructed to obtain a urine specimen. Multiple nurses, including the DON, RN 21, and LPN 3, later stated that for an incontinent resident they would normally obtain a clean‑catch specimen if possible or perform a straight (in‑and‑out) catheterization for a urinalysis, and that they would not anchor a Foley catheter for this purpose. They also indicated that a physician’s order and an appropriate diagnosis were required before inserting and anchoring a Foley catheter. The Administrator and DON confirmed that nurses needed a physician’s order to anchor a Foley catheter, and the Senior Regional Director of Clinical Services reported there was no policy related to physicians’ orders. Despite this, LPN 13 reported that when she worked with the resident that day, aides told her the resident, who was normally incontinent, had been dry and she believed he was probably dehydrated. She inserted the smallest catheter available but did not obtain urine return, then decided to inflate the 10 cc balloon and leave the catheter in place rather than attempting catheterization again, even though there was no physician’s order for a Foley catheter. The resident, who did not normally have a catheter, was in pain. Later, RN 19 came on duty, found the catheter anchored, and when lab staff arrived he deflated the balloon and removed the catheter to obtain the urine sample. Following removal, the resident began bleeding profusely from the urethra, and the on‑call NP was notified and the resident was sent to the hospital, where he was admitted with septic shock, UTI, and urosepsis and had a 16 French catheter inserted.

Penalty

Inspection fine: $51,660

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 reassess and monitor a resident after a change in condition related to possible aspiration. The resident had diagnoses including pneumonia, other lung disorders, and dysphagia, and was on a mechanically altered, soft bite-sized diet with ground meat and thin liquids per Speech Therapy recommendations. Care plans identified chewing difficulties and risk for impaired gas exchange, with interventions to monitor chewing/eating difficulties and assess vital signs and lung sounds as needed, including oxygen saturation. On the day of the first aspiration event, staff in the dining room observed the resident coughing, gurgling, spitting out mucus and food, and having a wet-like cough. The resident’s oxygen saturation was reported in the 80s on 2 L O2, with low blood pressure, and the NP was notified via secure messaging. The NP ordered a stat chest x-ray and Q4H nebulizer breathing treatments. A mobile chest x-ray was completed and showed patchy bilateral airspace disease, with pneumonia to be considered and follow-up recommended. A late-entry progress note documented that the NP was notified of the x-ray results. However, the clinical record lacked documentation that the resident was reassessed or that vital signs were obtained between the initial notification to the NP and the NP’s progress note the following day. The NP later documented that the resident had an episode of hypoxemia following a choking incident, that lung sounds were clear at the time of her assessment, and that she planned Q4H breathing treatments, close monitoring of oxygen saturation, periodic reassessment of respiratory status, and initiation of doxycycline for suspected pneumonia. The MAR showed that doxycycline doses were missed because the medication was not yet available, and there was no documentation that the antibiotic was administered once it arrived. Nursing staff interviews confirmed that on the day after the first aspiration, one LPN only listened to the resident’s lungs, did not obtain a full set of vitals or oxygen saturation, and did not document a full assessment, despite the resident having had recent respiratory issues. Between the NP’s note and the resident’s subsequent decline, the record contained no documented nursing assessments or vital signs, despite the resident having experienced a significant change in condition and being started on an antibiotic for suspected pneumonia. On the day of the second aspiration event, staff again observed the resident coughing, drooling, having trouble chewing and swallowing, spitting out mucus and food, and sounding congested. The resident’s oxygen saturation was again in the 80s on 2 L O2, and an SBAR event report documented decreased oxygen saturation and increased congestion, leading to the decision to send the resident to the hospital, where he was diagnosed with aspiration pneumonia and acute hypoxic respiratory failure. Multiple LPNs and the DON acknowledged that there were no progress notes, vital signs, or event documentation in the EMR between the two aspiration episodes, despite facility policy requiring documentation of nursing actions, physician contacts, and assessments for acute or life-threatening changes in condition, and job descriptions requiring daily documentation, hot charting, and daily event follow-up. Facility leadership and corporate staff further indicated that a hot charting or infection control event should have been initiated and followed with ongoing documentation of assessments after the resident was started on an antibiotic. Interviews with nursing staff involved in the initial aspiration episode revealed that they did not document vital signs or progress notes related to the event, even though they recognized the resident had possible aspiration and respiratory changes. The DON confirmed that there should have been at least a progress note, SBAR, or documented event following the possible aspiration, and that the next shift’s nurse should have taken vital signs and documented an assessment. The absence of documented reassessments, vital signs, and follow-up monitoring after the resident’s change in condition and initiation of treatment formed the basis of the cited 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 deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA in the dementia unit dining room. During a random observation, surveyors heard the CNA loudly say to one resident, "If you give me four seconds I will come and get you!" Shortly afterward, in the presence of an LPN and the assistant to the nurse practitioner, the same CNA loudly told another resident who was repeatedly requesting to lie down and asking for help, "If you are going to lay down, then stay down. I can't help you every four seconds. I am not going to give you ice cream, and I am not going to give you cookies. You are going to eat your food!" These statements were made in a raised voice in the dining room setting. In interviews, the CNA stated she did not consider her behavior to be abusive and indicated she had to "talk over" the resident because the resident did not hear her. She reported that the resident would eat many cookies and primarily wanted cookies and ice cream, and she described her own behavior as needing to get loud and that ignoring the resident would be abuse. The LPN present indicated he did not know if what the CNA said was abuse and reported he did not hear exactly what was said, but he acknowledged that yelling at residents was not effective and that he taught staff to use a different vocal approach with residents with dementia. Another CNA reported witnessing the same CNA using raised tones with residents and telling a resident, "That's enough," and stated that she had not reported this because other staff handled the resident in a similar way. The resident subjected to the verbal statements had diagnoses including severe vascular dementia with mood disturbance, psychotic disorder with delusions due to a physiological condition, depression, anxiety, delusional disorders, and hallucinations, with a recent MDS indicating severe cognitive impairment. Her care plan documented increased repetitive behaviors, including repeatedly exiting and re-entering her room, frequently requesting cookies, food, water, and to go to bed, and making repetitive verbal requests such as "I want a drink of water" and "I want to lay down." Interventions in the care plan included reminiscing, one-on-one interactions, offering movies/TV, and calming music to help her self-soothe. Despite this, staff interviews and observations showed that the CNA used raised tones and limiting language toward the resident in the dining room, contrary to the facility’s abuse prohibition policy, which defines verbal abuse as the use of oral or gestured language that includes disparaging or derogatory terms within a resident’s hearing, regardless of their ability to comprehend.

Penalty

Inspection fine: $22,925

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

Summary

The facility failed to protect a resident's right to be free from sexual abuse by another resident. A cognitively impaired female resident, diagnosed with Alzheimer's disease and severe cognitive impairment, was observed wandering into a male resident's room on multiple occasions. The male resident, who had a documented history of inappropriate sexual behaviors and a diagnosis of sexual disorder and dementia, was found on two separate occasions in physical contact with the female resident. On the first occasion, the male resident was observed rubbing the female resident's buttocks over her clothing. On the second occasion, the female resident was found lying on the male resident's bed with her pants and brief pulled down, and the male resident's hand was inside her genital area. Both residents were separated and redirected by staff, but no immediate interventions were implemented to prevent recurrence between the two incidents. Staff failed to notify the physician and the female resident's representative immediately after the incidents. The nurse on duty did not complete head-to-toe assessments of either resident following the events, nor were other notifications made in a timely manner. The staff member who witnessed the incidents did not report the inappropriate sexual touching to anyone immediately, instead making a note to chart the behavior and pass it on in shift report. There was a delay in implementing increased supervision and moving the female resident to a different room, as these actions were not taken until several hours after the second incident. Additionally, the facility's abuse investigation and reporting procedures were not followed as required by policy, including immediate assessment, notification, and protection of the residents involved. The male resident had a well-documented pattern of sexually inappropriate behaviors toward female staff prior to the incident, including touching, making sexual comments, and requesting inappropriate actions. Despite these known risks, interventions in place were limited to redirection and assigning male caregivers when available. The female resident was known to wander and had interventions such as stop signs on doors, but these were only somewhat effective. The lack of immediate and effective interventions, failure to follow abuse reporting protocols, and insufficient supervision directly led to the recurrence of resident-to-resident sexual abuse and the resulting severe psychosocial harm to the female resident.

Removal Plan

• Completed abuse training for all staff
• Increased monitoring and surveillance for Resident B and Resident C
• Updated care plans
• Resident C was sent to be evaluated at a psychiatric facility
• Completed physical assessments of residents on the secured dementia care unit
• Developed quality assurance actions for ongoing monitoring

Penalty

Inspection fine: $22,925

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 report an alleged incident of sexual abuse between two cognitively impaired residents. The incident involved a female resident who wandered into a male resident's room in the memory care unit, where staff observed the male resident's hand near the female resident's private area while she was seated on his bed. There was uncertainty among staff regarding whether the residents were clothed, and the initial staff member who witnessed the event did not immediately report it to management, believing it did not require further attention. The incident occurred in the evening, but the report to the Indiana Department of Health (IDOH) was not made until the following day, exceeding the facility's policy requirement to report within two hours. Multiple staff members, including the Social Services Director (SSD), Director of Nursing (DON), and Administrator, were involved in the communication and investigation process. The SSD was notified by the DON via secure message and subsequently contacted the nurse who witnessed the incident. The SSD advised the nurse to contact the Administrator but did not provide further instructions or come to the facility that night. The Administrator and DON discussed the situation, but the information exchanged was vague, and the DON did not directly contact the nurse who witnessed the event. The SSD and Administrator handled the investigation and notifications, but there were delays in notifying the residents' representatives and law enforcement. Facility policy required immediate reporting of abuse allegations to the Executive Director and the IDOH within two hours, as well as notification to law enforcement and Adult Protective Services. Despite these requirements, the incident was not reported to the appropriate authorities in a timely manner. The delay in reporting and lack of immediate action by staff and management contributed to the deficiency cited in the report.

Penalty

Inspection fine: $22,925

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 conduct a timely and thorough investigation into an alleged incident of resident-to-resident sexual abuse involving two residents in the memory care unit. The incident occurred when a female resident wandered into a male resident's room, resulting in potential inappropriate contact. Although the residents were separated and full body assessments were eventually completed, these assessments were not performed immediately after the incident. Additionally, 15-minute safety checks for both residents did not begin until over two hours after the event. The facility's investigation was incomplete, as it did not include statements from all staff present during the incident, such as a CNA and an RN, nor did it incorporate a late entry note detailing the event. Furthermore, the investigation did not collect additional information from key staff or include all relevant documentation. The facility's policy required immediate initiation of the investigation, direct supervision of the resident alleged to have initiated the abuse, and prompt reporting to the state health department. However, the staff member responsible for coordinating the investigation did not provide further instructions or come to the facility on the night of the incident, and did not ensure that all necessary statements were collected. There was also a delay in notifying the nurse practitioner about the incident. Additional information provided by a CNA regarding the nature of the contact was not included in the investigation submitted to the state, and the facility did not ensure that the state was made aware of this information in a timely manner.

Penalty

3 days payment denial

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

Summary

A deficiency was identified when staff failed to treat a physically dependent, visually impaired resident with respect and dignity during an interaction regarding the resident's request for a hat to cover a bald spot. The resident, who had diagnoses including epilepsy, muscle weakness, and significant visual impairment, expressed dissatisfaction with a headband not adequately covering her bald spot and requested a hat. During the incident, a CNA responded by telling the resident she was already wearing a headband and did not need a hat, and then abruptly removed the headband from the resident's head without prior verbalization, despite the resident's visual impairment. The CNA was observed on video removing the headband in an abrupt manner, causing the resident's arm to jerk away as she attempted to fix her hair, and then quickly placing a hat on the resident's head before propelling her to the dining room. Interviews with staff and the resident confirmed that the CNA acted in a rushed and irritated manner, did not communicate her actions to the resident, and handled the resident's request without the expected level of respect and sensitivity, particularly given the resident's visual impairment. The incident was reported by another staff member, and it was noted that the CNA had previously displayed attitude issues toward the resident. The facility's policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, which was relevant to the observed actions.

Penalty

3 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 reasonable accommodations for a resident with significant physical and cognitive limitations by not keeping the resident's call light within reach. Resident 2 had diagnoses including hypertensive heart disease with heart failure, anemia, asthma, age-related osteoporosis, macular degeneration, overactive bladder, cognitive communication deficit, and unsteadiness on feet. Current physician orders directed that the resident be up with a mechanical lift and two-person assist, use a wheelchair for mobility on the unit, wear bunny boots in bed, have heels floated every shift, receive fluid monitoring and additional fluids every shift, and have the head of bed elevated while in bed due to shortness of breath related to asthma. A significant change MDS assessment indicated the resident was severely cognitively impaired, dependent for all transfers, and incontinent of bowel and bladder. During multiple observations, the resident was found seated in a wheelchair or asleep in bed with the call light lying on the floor behind the bed or head of the bed. On one occasion, the resident's breakfast tray was on the bedside table with the silverware still wrapped and the breakfast and juice untouched, while the call light remained on the floor. A CNA stated he did not know whether the resident required assistance to eat or drink, then picked up the call light and attached it to the resident's blanket, stating it should be within reach. An LPN also stated she did not know if the resident was able to use the call light. The care plan identified the resident as at risk for falls and required keeping personal items and the call light in reach, but the DON stated she would locate a policy for call light access and no further information was provided before survey exit.

Penalty

3 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 a resident prescribed quetiapine received appropriate gradual dose reductions or had an individualized documented indication for continued antipsychotic use. The resident had diagnoses including Alzheimer’s disease, neurocognitive disorder with Lewy body dementia, anxiety disorder, major depressive disorder, and senile degeneration of the brain. Current orders included quetiapine 75 mg three times daily, along with venlafaxine, hydrocodone-acetaminophen, trazodone, and alprazolam. Multiple quarterly and significant change MDS assessments documented no delusions, hallucinations, or behaviors, while the care plan and behavior notes described intermittent anxiety, restlessness, yelling, confusion, nausea, and occasional agitation. The clinical record contained several behavior communication notes and progress notes describing episodes in which the resident was anxious, tearful, restless, confused, or upset, including calling out for help without being able to state what he needed, refusing meals, becoming nauseated or vomiting, and becoming agitated at the front door or during care. Some notes described interventions such as reassurance, repositioning, quiet environments, distraction, and anti-nausea medication, with varying effectiveness. A psychiatric nurse practitioner note stated the resident’s cognitive status was consistent with dementia, that he denied hallucinations, and that no new or worsening behaviors were reported at that time. Another psychiatric note documented that medication review for possible GDR was considered, but reduction was not recommended because it was believed to risk decompensation. Pharmacy recommendations repeatedly identified quetiapine 75 mg three times daily as due for review and referenced targeted behaviors such as hallucinations, delusional thinking, anxiety, and restlessness. Several recommendations stated there were no recent behaviors or that the last attempted GDR had been declined or contraindicated by the provider. The record also included provider rationales that reduction could increase psychiatric instability, be detrimental to mental health, or was contraindicated because the resident was seeing his deceased wife or because the family declined GDRs. However, the clinical record lacked documentation supporting some of those stated behaviors, including documentation that the resident was seeing his deceased wife or that he exhibited delusions and/or hallucinations in the record reviewed.

Penalty

3 days payment denial

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

Summary

The facility failed to ensure a dependent resident had access to drinking water or other fluids for 1 of 1 residents reviewed for hydration. Resident 2 had diagnoses including hypertensive heart disease with heart failure, anemia, asthma, age-related osteoporosis, macular degeneration, overactive bladder, cognitive communication deficit, and unsteadiness on feet. The resident was severely cognitively impaired, dependent for all transfers, incontinent of bowel and bladder, and had a significant weight loss that triggered a significant change MDS assessment. Current orders included documenting all fluids taken with medications every shift, offering an additional 240 mL of fluids every shift, and keeping the head of bed elevated while in bed. Observations showed the resident without accessible fluids at multiple times: on 9/3/25, a cup of water was on a bedside table across the room near the other bed while the resident was seated in a wheelchair; on 9/4/25, an empty cup of water was on a bedside table three to four feet from the bed, and a clear plastic cup was lying upside down on the floor beside the bed. On 9/8/25, the resident was asleep in bed and there were no drinks on the bedside table. Staff interviews indicated the resident could drink without assistance, and one RN stated the resident might need coaxing at first. The facility policy stated fresh water or other preferred beverages would be passed to all residents on each shift and additional fluids would be offered throughout each shift.

Penalty

3 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 follow physician orders for oxygen supplies and oxygen administration for two residents receiving respiratory services. For one resident with COPD, CHF, and dementia, staff observed portable and concentrator oxygen tubing bags dated 8/18/25, while the tubing itself was not dated or labeled. The oxygen concentrator also did not have a humidifier bottle present, even though the resident’s order required oxygen at 2 liters per minute via nasal cannula and that the oxygen tubing and humidity be changed weekly on Sundays during night shift. For a second resident with acute respiratory failure, acute pulmonary edema, obstructive sleep apnea, and hypertensive heart disease with heart failure, staff observed an oxygen concentrator in the room with an oxygen tubing bag that was dated 8/18/25 and contained undated, unlabeled tubing. The resident stated she wore oxygen at night because her oxygen levels dropped and sometimes used it during the day when short of breath. The electronic record did not contain an order for oxygen use, although the care plan included administering oxygen as ordered and noted impaired gas exchange related to her respiratory history and shortness of breath when lying flat. Staff interviews showed confusion about whether the second resident still required oxygen and whether oxygen had been implemented as a nursing measure after a prior change in condition. The DON stated oxygen administration required an order and care plan, while an RN and CNA reported the resident wore oxygen at night and sometimes during the day. The resident later stated the concentrator had been removed from her room and that she had been on oxygen for years for sleep apnea and heart issues.

Penalty

3 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

Drugs and biologicals were not stored and labeled in accordance with accepted professional principles when unlabeled and unused medications were found in two medication carts. During an observation of the Memory Care Unit medication cart with an LPN, a loose blue pill marked G and a small white oblong pill marked K 31 were found on the bottom of drawers in the cart. The LPN stated the loose pills needed to be destroyed in the drug destruction solution. During an observation of the 100 Hall medication cart with the ADON, an insulin pen for Resident 42 was found without an open date. Four loose pills were found in the second drawer, three loose pills were found in the third drawer, and 10 loose pills were found in the fourth drawer, including tablets and capsules with various markings and some with no visible markings. The ADON stated the pills needed to be destroyed in the drug destruction solution and that insulin pens needed an open date written on them. The DON later stated insulin pens needed to be dated as soon as the pen was opened and that any loose medications need to be destroyed in the drug destruction solution. Five residents received insulin from the 100 Hall medication cart.

Penalty

3 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 approaches to maintain a QAPI program to prevent repeat deficiencies identified during a post-survey revisit. Review of the prior annual recertification and licensure survey completed on 9/9/25 showed deficiencies related to oxygen therapy and medication storage. During interview, the Administrator stated the QAA committee met on October 23, 2025 and reviewed the annual survey results and the plan of corrections, and that regular meetings were held with the belief that the facility’s QAPI tracking and trending processes were effective. During a later interview, the Administrator stated the POC binder contained everything related to the annual survey deficiencies and that audits were performed as scheduled. She also stated that weekly audits were fine, but problems occurred when the process moved to monthly audits. Because of the repeated problems, the audit sheets were going to be revamped to include a certain number of residents or medication carts to be audited, and that audits needed to be more detailed rather than just a spot check. The repeat concerns cited during the 9/9/25 survey included failure to dispose of unlabeled and unused medications in 2 of 3 medication carts reviewed and failure to follow physician orders to change, label, and date oxygen supplies for 6 of 7 residents reviewed for respiratory services.

Penalty

3 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 infection prevention and control practices were followed during dining services for 4 of 5 residents observed in the memory care dining room. During a continuous dining observation on 9/3/25 from 11:57 a.m. to 12:45 p.m., CNA 10 served Resident 32, Resident 1, Resident 21, and Resident 22 their meal trays and handled the tops of their chicken patty sandwich buns with bare fingertips while preparing the sandwiches. CNA 10 used her left bare hand to hold or apply pressure to the buns, used a knife in her right hand to cut the sandwiches in half, and in some instances placed the bun in the palm of her hand while adding ketchup or mayonnaise packets to the sandwich. For Resident 1, CNA 10 removed the top bun with her right bare hand, opened a ketchup packet with both hands, held the bun in her left bare hand, spread ketchup on it with a knife, and then pressed the bun with her fingertips before cutting the sandwich. For Resident 21, CNA 10 handled the bun with her left bare hand, opened a mayonnaise packet with both hands, placed the bun in her left palm, added mayonnaise, pressed the bun with her fingertips, and cut the sandwich in half. For Resident 22, CNA 10 handled the bun with her left bare hand, opened a ketchup packet with both hands, pressed the bun with her fingertips, and cut the sandwich in half. During the observation, CNA 10 stated she was not sure of the proper technique to assist residents with their sandwiches. She later stated she was not to touch the bread when serving sandwiches, performed hand hygiene between residents, and thought it was okay to touch food items. The DON stated staff were not to handle food items with bare hands and were expected to use a barrier or utensils when food items were handled. The facility policy titled General Food Preparation and Handling, revised in May 2025, stated bare hands should never touch raw or ready-to-eat food directly and that food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid bare hand contact.

Penalty

No penalty information released

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

Summary

The facility failed to implement adequate skin assessments and obtain necessary medical orders for a resident, leading to the development of a severe pressure injury. Resident B, who was admitted following surgical repair of a right femur fracture, was at risk for skin breakdown due to factors such as weakness, incontinence, and the use of a right leg immobilizer. Despite these risks, the facility did not conduct skin assessments under the immobilizer or obtain orders for its use, which contributed to the development of a necrotic wound on the resident's right knee. The resident's care plan, dated shortly after admission, identified the risk for skin breakdown but lacked specific interventions to manage the immobilizer and prevent pressure injuries. The facility's records showed that skin assessments were not documented, and there was no clarification or documentation of orders for the immobilizer. This oversight was compounded by the lack of communication with the orthopedic surgeon regarding the immobilizer and the absence of timely wound care orders for the knee injury. The deficiency was further highlighted by the progression of the knee wound, which became unstageable and required hospitalization. The wound was initially identified during an orthopedic follow-up, but treatment orders were delayed, and the wound worsened, leading to an above-the-knee amputation. Interviews with facility staff revealed a lack of awareness and documentation regarding the immobilizer and skin assessments, contributing to the deficient practice.

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 identify and implement appropriate interventions for the care of a surgical wound for a resident who was reviewed for wound care. The resident, who had a history of a right femur fracture, acute posthemorrhagic anemia, and dementia, was admitted to the facility following surgical repair of the right femur. Despite the presence of a dressing on the surgical site and a right leg immobilizer, the facility did not complete an assessment of the skin under the immobilizer upon admission. The resident's care plan indicated a risk for skin breakdown and required weekly skin assessments, which were not documented in the clinical record. Additionally, there were no physician orders for the care of the surgical site or the immobilizer at the time of admission. The facility's staff, including an LPN and the DON, failed to obtain clarification for the missing orders, and the dressing on the surgical wound was not removed or changed as per the surgeon's instructions. Interviews with facility staff and the orthopedic surgeon's nurse revealed that the dressing should have been changed five days post-surgery, but this was not done. The facility's policies required a thorough head-to-toe assessment at admission and verification of physician orders, which were not followed in this case. The lack of weekly skin assessments and failure to address the missing orders contributed to the deficiency in the resident's wound care management.

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 staff failed to report an allegation of abuse involving Resident C and Resident D to the Administrator as per the facility's policy. Resident C reported that Resident D entered her room multiple times, argued, yelled, and kicked her in the left shin. Although Resident C experienced soreness, there was no open wound. The incident was not documented in Resident C's clinical record, and the Director of Nursing (DON) and Administrator were not informed of the incident in November 2024. Interviews with staff revealed that RN 6 was informed by Resident C about the incident but did not document it in the clinical record. LPN 4 and CNA 3 were aware of the incident but did not report it to the Administrator. Resident C's clinical record, reviewed on January 29, 2025, showed no entry of the incident or any assessment following it. Resident C was cognitively intact with diagnoses including lymphedema, venous insufficiency, peripheral vascular disease, major depressive disorder, and cellulitis. Resident D, who had moderate cognitive impairment and diagnoses of vascular dementia with mood disturbance and major depressive disorder, also had no record of the incident in her clinical notes. The facility's policy, revised in June 2023, required all abuse allegations to be reported immediately to the Executive Director, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper reconciliation of controlled medications for two of the three medication carts reviewed, specifically the 200 Unit and 300 Unit medication carts. The 200 Unit Shift Change Verification of Controlled Substances log from October 1 to October 4 lacked necessary information, including signatures and count completion for several shifts. On October 1, the night shift nurse did not sign the log, and an LPN later placed the night shift nurse's initials on the sheet for both blank spots. The Director of Nursing (DON) indicated that the log was not signed for the night shift on October 1 because they believed the signatures were placed on the wrong log. The log lacked documentation of count completion for each shift during shift changes in October 2024. Similarly, the 300 Unit Shift Change Verification of Controlled Substances log from October 1 to October 7 was missing on-coming and off-going shift signatures and reconciliation of controlled medication counts for multiple shifts. The facility's policy, dated February 1, 2018, required that incoming and outgoing nurses count all controlled substances at the change of each shift and document this on the Shift Change Verification of Controlled Substances form. However, this policy was not adhered to, leading to incomplete documentation and reconciliation of controlled medications.

Penalty

No penalty information released

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

Summary

The facility failed to administer medications according to physician orders for two residents. Resident 19, who has multiple diagnoses including flaccid hemiplegia and dysphagia, did not receive her prescribed dose of hydrocodone-acetaminophen on two occasions. The narcotic count sheet indicated the medication was not removed for her dose on one of these occasions. Similarly, Resident 51, diagnosed with Parkinson's disease and dementia, missed doses of hydrocodone-acetaminophen and warfarin. The narcotic count sheet showed discrepancies, suggesting possible drug diversion, as the medication was signed out but not documented as administered in the electronic medical record (eMAR). The facility also failed to obtain daily weights for Resident 65, who has acute respiratory failure and congestive heart failure, as per physician orders. The clinical record lacked documentation of daily weights on several specified dates, and there was no indication of resident non-compliance. Interviews with nursing staff revealed that daily weights were supposed to be obtained by CNAs and reported to nurses, but this process was not consistently followed. The Director of Nursing (DON) acknowledged the failure to monitor daily weights effectively, noting that the position responsible for this task was vacant until recently. The facility's policies for medication administration and resident weight monitoring were not effectively implemented. The medication administration policy was not provided, and the weight monitoring policy required weights to be taken no less than monthly or as per physician orders. The DON and nursing staff interviews highlighted gaps in the documentation and monitoring processes, contributing to the deficiencies in medication administration and weight monitoring.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision and implement immediate, resident-centered interventions to prevent falls for a cognitively impaired resident. The resident, who had severe cognitive impairment due to vascular dementia and Alzheimer's disease, was observed with injuries consistent with a recent fall. Despite having a physician's order to use a walker for mobility, the resident was frequently seen ambulating without it, leading to multiple falls. The resident's care plan included interventions such as keeping personal items within reach and encouraging the use of a walker, but these were not effectively implemented. The resident experienced several falls, both witnessed and unwitnessed, with varying degrees of injury. On multiple occasions, the resident was observed wandering without her walker, and staff failed to redirect her or ensure she used her walker. Video surveillance footage showed the resident wandering without assistance, and staff did not intervene to prevent her from entering other residents' rooms, which was a known risk factor for her falls. The facility's policy on fall management was not adequately followed, as evidenced by the lack of immediate new interventions after falls and the absence of a stop sign across doorways, which was a known effective method of redirection for the resident. Interviews with staff revealed that the resident was known to wander frequently and required constant reminders to use her walker. However, on the day of the fall resulting in significant injuries, staff did not provide the necessary supervision or redirection. The resident's fall management plan was not effectively implemented, as evidenced by the continued falls and lack of immediate interventions. The facility's failure to provide adequate supervision and implement resident-centered interventions contributed to the resident's repeated falls and injuries.

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 by a staff member towards a resident. The incident involved Nurse Aide (NA) 6 and Resident C. NA 6 was overheard by CNA 8 using inappropriate language towards Resident C, specifically whispering 'Shut the f--k up' while providing care. This incident was reported immediately by CNA 8 to the Assistant Director of Nursing (ADON), and NA 6 was subsequently suspended and later terminated after admitting to the inappropriate language during an interview with the Administrator and the Director of Nursing (DON). Resident C, who was on hospice and not alert and oriented, did not hear the inappropriate language and showed no signs of distress according to Social Services follow-up. However, the use of such language was considered verbal abuse as per the facility's policy on abuse prohibition, reporting, and investigation. The incident occurred when NA 6 was called in on his day off and arrived at the facility frustrated and not in uniform. He was supposed to assist CNA 8 in the Memory Care Unit. During the shift, NA 6 displayed a poor attitude and was not actively assisting with resident care. When asked to help change Resident C, who was in pain and moaning, NA 6 stood by the bedside looking at his phone and then whispered the inappropriate language. CNA 8 immediately reported the incident to the ADON, who then escorted NA 6 out of the building. The facility's investigation included interviews with the involved staff members and a review of the incident. NA 6 admitted to using inappropriate language out of frustration. The facility's policy defines verbal abuse as the use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, regardless of their ability to comprehend. The incident was documented, and NA 6 was disciplined according to the facility's policy on abuse prohibition.

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 controlled medications were accounted for at the time of administration in the Memory Care Unit. During a narcotic count observation, an LPN indicated she needed to sign off the controlled drugs given that morning before completing the narcotic count. She had been sidetracked by a resident who was screaming. The medications for multiple residents, including lorazepam, tramadol, and hydrocodone-acetaminophen, were signed out during the observation for various times earlier that morning. During an interview with the DON, it was revealed that the facility did not have a specific policy for signing off controlled medications, although the expectation was that nurses would sign off medications as they administered them. The DON provided a skills check-off titled Medication Administration Observation, which indicated that controlled medications should be signed out at the time of removal. This deficiency was related to Complaint IN00433743.