Edwardsville Care And Rehab

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 dietary staff appropriately stored, labeled, and dated foods after the original storage container was opened. During an initial kitchen tour, surveyors observed a half-full gallon jug of 2% milk and an opened half-gallon jug of chocolate milk in the stand-alone refrigerator without open dates. In the walk-in refrigerator, five-pound containers of ham salad, pasta salad, and potato salad had been opened but did not have open dates, and a gallon container of creamy Italian dressing had also been opened without an open date. In the dry storage area, an opened two-pound bag of powdered sugar was not sealed and lacked an open date. The observed food items were removed by kitchen staff, and dietary staff later stated that foods should be labeled with an open or use-by date and stored in a sealed container or bag.

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 a water management program for Legionella disease. During observation, record review, and interview, the Maintenance Supervisor confirmed the facility did not have a water management program and stated he tested water temperatures daily in the laundry room and resident rooms but did not document them. He also stated he had Legionella testing materials but had not used them. Maintenance staff reported being unaware of how to establish a water management program and said he would check with the facility's corporation. Administrative staff stated he was unaware the facility was required to develop a water management program and verified that the facility did not have one. The facility's Water Management, Legionella Testing Policy, revised 03/2026, stated the facility would handle and maintain its water supply according to CDC, HICPAC, and FDA guidance, conduct Legionella testing, complete an annual review of the water system, and document infection control committee minutes and findings.

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 care for R4 and R1 in a manner that protected and promoted their dignity. On 08/04/2026 at 07:32 AM, observation in the commons area showed LN G pulling up R4's shirt on his left arm, cleansing the area with an alcohol wipe, and administering a subcutaneous insulin injection in his right upper arm while two surveyors, multiple facility employees, and numerous other residents could view the procedure from the four halls and dining room area. On 08/04/2026 at 07:40 AM, a similar observation in the commons area showed LN G pulling up R1's shirt on his left arm, cleansing with an alcohol wipe, and administering a subcutaneous insulin injection in his right upper arm in full view of two surveyors, multiple facility employees, and numerous other residents. On 08/05/2026 at 08:10 AM, Administrative Nurse D verified that LN G should not administer insulin injections in public areas and that residents should be taken to their rooms or a private area. The facility's Respect and Dignity; Right to Personal Property policy, dated August 2026, stated residents have the right to be treated with respect and dignity.

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 a 14-day stop date or a documented specified duration with rationale for Resident 47’s ongoing PRN lorazepam order. Resident 47 had diagnoses of anxiety, restlessness, and agitation, and her Quarterly MDS documented moderately impaired cognition and dependence on staff for all ADLs. Her psychotropic medication care plan stated staff would administer medications as ordered and monitor side effects and effectiveness, but it did not include directions related to her PRN lorazepam use for anxiety. Resident 47’s physician order dated 06/01/2026 directed lorazepam 0.5 mg every six hours as needed for anxiety, but the order did not include a stop date. The EHR also lacked documentation of a specified duration with a physician-documented rationale for extended use. On 08/05/2026, Administrative Nurse D verified the resident had received PRN lorazepam and confirmed the facility had not obtained the required 14-day stop date or documented rationale for continued use. The facility policy stated PRN psychotropics required a 14-day stop date and, for continued use, documented rationale and indication of duration in the medical record.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an environment free of accident hazards for a resident who smoked and required staff assistance. The resident had diagnoses including nicotine dependence, schizoaffective disorder, diabetes mellitus, and unsteadiness on feet. Her MDS documented a BIMS score of 11, indicating moderately impaired cognition, and she used a walker for mobility. A cognitive loss assessment documented disorganized thinking, wandering, inattention, and refusal of cares. Her smoking care plan directed staff to encourage her to wear a smoking apron and to ensure she was aware of the facility smoking policy and smoking area. The resident's smoking evaluation documented that she smoked flame-lit tobacco, could not light her own cigarettes, and required a smoking apron when smoking, but it did not document that she had been given and acknowledged the facility's Community Smoking Rules. During observations, a nurse aide provided the resident with a cigarette and lit it for her while she sat on a bench outside the patio door, and the resident was not wearing a smoking apron on either observed occasion. Administrative staff verified that the resident had been assessed as needing a smoking apron and that the smoking evaluation lacked documentation that she had been provided the Community Smoking Rules. The facility smoking policy required residents who wished to smoke to be evaluated for safe smoking practices and for smoking-related privileges, restrictions, and concerns to be noted on the care plan.

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 trauma-informed and culturally competent care for a resident with diagnoses of schizophrenia, PTSD, and insomnia. The resident’s admission MDS documented a BIMS score of three, indicating severely impaired cognition, and also noted delusions and PTSD. A CAA documented disorganized thinking with rejection of care, while also stating the resident was able to communicate wants and needs and that the BIMS was not fully accurate because the resident refused to participate in the assessment. The resident’s care plan, revised on 07/31/2026, addressed behavior problems, medication administration, monitoring for side effects, communication approaches, and general behavior management interventions, but it did not identify PTSD-related triggers or include interventions to prevent re-traumatization. The EMR contained a Trauma Informed Care Assessment dated 06/05/2026 that documented PTSD but provided no further information. Social Services stated the assessment was attempted but the resident refused to disclose prior trauma, and stated the care plan should reflect the PTSD diagnosis and provide staff direction on things that could cause re-traumatization. The facility’s Trauma-Informed Care policy required assessment of triggers and individualized interventions to minimize or eliminate re-traumatization.

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 the Consultant Pharmacist identified and reported medication administration issues during the monthly drug regimen review for two residents. One resident had diagnoses of type 2 DM, HTN, and schizophrenia, was cognitively intact on the MDS, and had an order for Novolog insulin 10 units before meals with instructions to hold the dose when blood sugar was below 120 mg/dL and to call the provider for blood sugar below 60 mg/dL or above 400 mg/dL. The resident’s care plan directed staff to administer diabetes medications as ordered and to monitor, document, and report signs and symptoms of hypoglycemia as needed. Review of the Consultant Pharmacist’s monthly regimen reviews from January 2026 through July 2026 showed that the pharmacist reported on one occasion that the resident’s Novolog was not held when blood sugar was below 120 mg/dL, but the reviews did not identify or report additional instances in May and June 2026 when Novolog should have been held. Review of the April, May, and June 2026 MARs showed multiple administrations of Novolog when blood sugar was below the ordered parameter. A licensed nurse and an administrative nurse stated that the physician’s insulin parameters should be followed and that insulin should be held when below the ordered threshold. A second resident had diagnoses of HTN, major depressive disorder, and schizoaffective disorder, with moderately impaired cognition and hospice services. This resident had orders for propranolol 120 mg daily to be held if BP was below 110/60 mm/Hg and amlodipine 10 mg daily to be held if SBP was below 100 mm/Hg or pulse was below 60 mm/Hg. Review of the Consultant Pharmacist’s monthly regimen reviews from January 2026 through July 2026 showed the pharmacist failed to identify and report that BP and/or pulse were not recorded before administration of propranolol and amlodipine. Review of the MARs showed no documented BP or pulse readings with amlodipine administration and no documented BP obtained with propranolol administration. Staff interviews confirmed that physician parameters should be followed and that BP and pulse should be documented when required.

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 a resident’s insulin was held when blood glucose was below the physician’s ordered parameter. The resident had diagnoses including type 2 DM, HTN, and schizophrenia, and his EMR documented intact cognition on the annual MDS. His physician ordered Novolog 10 units subcutaneously before meals with instructions to hold the dose when blood sugar was less than 120 mg/dL and to call the provider for blood sugar less than 60 mg/dL or over 400 mg/dL. Review of the resident’s MAR showed multiple instances in April, May, and June 2026 when Novolog was administered even though blood sugar was below 120 mg/dL. The report states the insulin was not held on three of 90 opportunities in April, three of 93 opportunities in May, and three of 90 opportunities in June. During observation and interview, a licensed nurse and an administrative nurse stated that the physician’s insulin parameters should be followed and that insulin should be held when blood sugar was below the ordered parameter. The facility also failed to ensure physician-ordered parameters were obtained and recorded before administering antihypertensive medications to another resident. That resident had HTN, major depressive disorder, and schizoaffective disorder, with moderately impaired cognition on the annual MDS and hospice services. His orders for propranolol and amlodipine included blood pressure and pulse hold parameters, but review of the MAR from January 2026 through July 2026 showed no documented blood pressure or pulse with amlodipine administration, and propranolol was administered without blood pressure being obtained and documented. A certified medication aide and licensed nurse stated the parameters should be followed, and an administrative nurse stated blood pressure and pulse should be documented when physician parameters are present. The report also identified a third resident with DM whose insulin order lacked blood sugar parameters, and a nurse stated she updated the EMR with blood sugar parameters after noting the issue.

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

Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices. On observation of the medication carts, Resident 13’s Lantus flex pen was not labeled with an opened date or expiration date, and Resident 13’s Novolog flex pen had a date written on it that had smeared and was not legible. On the Hall C medication cart, Resident 86’s Lantus vial and Resident 75’s Basaglar flex pen were both labeled with an opened date that was 44 days old. Licensed Nurse G verified that insulin flex pens and vials should be labeled and dated with the date opened, and Administrative Nurse D verified that outdated insulin should be labeled and discarded. The facility’s policy required drugs and biologicals to be stored safely and not used if discontinued, outdated, or deteriorated, and the insulin administration policy required nurses to check expiration dates and record the expiration date and time when opening a new vial. The medication room refrigerator temperature log was also incomplete. Observation in the medication room showed the log lacked daily temperatures for 12 days in July and 4 days in August. Administrative Nurse E stated the night shift nurse was responsible for the temperature log and confirmed the missing signatures, and Administrative Nurse D stated the nurse responsible for the refrigerator temperatures had been on vacation during the missing entries and that he usually checked the temperatures as well, but he had also been gone during that time. The facility’s medication distribution policy required refrigerated medications to be stored separately, the refrigerator to have a hanging thermometer, and employees to monitor and log the temperature daily.

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 a coordinated plan of care was developed and available for two residents receiving hospice services. For one resident with dementia, arteriosclerotic heart disease, and peripheral vascular disease, the record showed hospice enrollment and a later change to a current hospice provider, but the care plan still referenced the previous hospice and did not identify the current hospice provider, the services hospice would provide, hospice staff visits, supplies, medical equipment, or medications covered by hospice. The resident’s MDS also lacked documentation that hospice services were being received, and the medical record did not show coordination of care between the facility and the current hospice provider. For another resident with HTN, major depressive disorder, and schizoaffective disorder, the record showed hospice services were in place and the resident had moderately impaired cognition with disorganized thinking and inattention. The care plan stated the resident was on hospice and included general comfort and ADL support measures, but it did not include how often hospice staff would visit, what supplies and medications hospice would provide, or what DME hospice would provide. The hospice provider binder also lacked a complete plan of care with required information, including the most recent recertification order and related details. During observations, one resident was seen in a Broda chair being assisted with lunch, and the other was seen in a Broda chair getting ready to receive noon medications. Staff interviews confirmed the missing hospice coordination information. An Administrative Nurse stated the facility should have a hospice care plan to coordinate with hospice services and acknowledged the current hospice information was not in the care plan. A CNA stated staff usually relied on the nurse to explain what hospice provided, and a nurse stated the hospice book should contain the information from the hospice POC and that the resident care plan should reflect the same information.

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 submit complete and accurate direct care staffing information through Payroll Based Journaling (PBJ) based on payroll and other verifiable and auditable data. CMS PBJ reports for FY Quarter 1, Quarter 2, Quarter 3, and Quarter 4 indicated excessively low weekend nurse staffing, but review of the facility’s weekend nursing schedules and working hours for those quarters showed the facility had adequate staffing. During interview on 08/18/25 at 08:26 AM, Administrative Staff A stated the administrator and corporate staff were responsible for submitting the PBJ. The facility’s PBJ policy, revised 10/2025, stated the facility would submit PBJ data in a uniform format to CMS, including staffing community, agency, and contract staff.

Penalty

Inspection fine: $9,113

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 provide adequate supervision and maintain an environment free from accident hazards, resulting in an elopement. A resident with a diagnosis of schizoaffective disorder, hallucinations, delusions, rejection of care, and wandering behaviors was assessed as having intact cognition with a BIMS score of 15 and was care planned as being at moderate to high risk for elopement. The resident’s care plan included interventions such as increased supervision during exit-seeking behaviors, placement in a room away from exits, lodging in a secure unit, medication review, psychiatric services as needed, and use of a WanderGuard with placement and function checks. The WanderGuard was intended to limit the resident’s ability to enter the backyard without staff present. Despite these identified risks and planned interventions, the resident was able to access the smoking patio and leave the facility without staff knowledge or supervision. At approximately 2:45 AM, the resident used a dining room chair placed on the smoking patio to climb over the tall fence surrounding the patio and exit the premises. The door to the patio remained unlocked, and although the WanderGuard alarmed at the door and indicated the need for staff assistance, the resident still gained access to the patio and then climbed the fence. The facility’s cameras later showed the resident using the chair to scale the fence. Staff statements indicated that the last known observations of the resident occurred between approximately 9:00 PM and 2:00 AM, with no indications of unrest reported at those times. After leaving the facility, the resident walked approximately 1.8 miles to a truck stop, remained there for several hours, and then walked back to the facility, returning around 11:45 AM. During this time, outdoor temperatures ranged from 29.9°F to 45.3°F. Staff were unaware of the resident’s absence for about nine hours due to a failure to complete resident safety rounds on both the night and day shifts. Multiple staff members, including CNAs, a CMA, and an LN, reported not completing rounds or not entering the resident’s room, with one nurse noting that the resident’s curtain was pulled and she did not verify his presence. The resident ultimately rang the front doorbell to re-enter the facility, at which point staff assessed him and confirmed he had no injuries. The surveyors determined that the failure to complete rounds and adequately supervise the resident, combined with the environmental setup that allowed use of a movable chair to climb the fence, resulted in an elopement that constituted immediate jeopardy.

Removal Plan

• Update R1's care plan.
• Place a WanderGuard on R1.
• Conduct education on elopement and rounds with staff.
• Give written warnings to staff for failure to complete rounds.
• Complete magnetic lock checks on the doors.
• Complete an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting.
• Complete an elopement drill.

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 staff member. The resident had diagnoses including paranoid schizophrenia, anxiety disorder, shortness of breath, and malignant neoplasm of the breast, with a BIMS score indicating intact cognition. Care plan interventions directed staff to allow the resident to voice needs and concerns, avoid arguing with delusions, redirect the resident to a quiet area if escalating, offer reassurance, and interact in ways that built rapport and monitored for precursors to socially inappropriate behaviors. Despite these interventions, during a snack pass the resident became involved in a yelling and screaming incident with a dietary staff member in the dining room. According to the facility’s investigation and staff interviews, the dietary staff member was seen and heard on camera yelling and screaming at the resident in front of other residents, shouting profanities and using vulgar and offensive references. A CMA reported hearing the dietary staff member call the resident an expletive and described the staff member attempting to get in the resident’s face, prompting the CMA to step between them and remove the resident from the hostile environment. The CMA stated the resident was not getting into anyone’s face or going after staff and that the resident had only asked for more food when the dietary staff member yelled at her. Administrative staff confirmed that camera audio captured the dietary staff member calling the resident an expletive and that staff had to intervene. The resident later stated she remembered the incident, recalled that she was only asking for more food when she was yelled at, and reported that being yelled at by staff was nothing new or out of the ordinary, stating she was yelled at all the time and did not feel safe when this occurred. The facility’s investigation documented that the resident admitted she shouted back at the staff member and that staff intervened and helped calm her down and support her. The investigation noted that the staff member’s behavior, as seen on camera, was not accepted by the facility. The facility’s abuse prevention policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included verbal abuse. The surveyors determined that the facility failed to ensure the resident remained free from verbal abuse, and this failure placed the resident in immediate jeopardy. The investigation and record review also showed gaps in follow-up related to the incident. The facility’s investigation did not include any staff witness statements, despite identification of a direct witness. The resident’s EMR lacked evidence of any follow-up psychosocial assessments or documented staff interviews with the resident related to the incident. One social services staff member stated she was not aware of the details of the incident and had not completed any psychosocial follow-up. Another social services staff member reported speaking with the resident the next day and performing generalized verbal check-ins but did not document these interactions and did not conduct or record a formal psychosocial assessment related to the event. Administrative staff stated there was no additional staff education completed after the incident because the involved staff member was terminated and other staff had prior ANE training.

Removal Plan

• Conduct interviews with each resident to identify if any residents were having adverse outcomes due to staff yelling and shouting profanities and/or any other incidents that may have gone unreported.
• Educate all staff that shouting profanities, calling residents vulgar names, or acting in any other excessive, obtuse, obscene, or nonsensical way would not be permitted at the facility.
• Complete Abuse, Neglect, and Exploitation training with staff, with an emphasis on their duty to report.

Penalty

Inspection fine: $9,113

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

Summary

The facility failed to ensure adequate supervision and appropriate interventions to prevent the elopement of a cognitively impaired resident, identified as at risk for elopement. The resident, who had diagnoses including schizoaffective disorder and diabetes, exited the facility without staff knowledge and remained outside in freezing temperatures for approximately 45 minutes. The resident's care plan had identified them as at risk for elopement and included interventions such as the use of a WanderGuard, which was not functioning properly due to a power interruption at the exit door. The resident's care plan directed staff to assess for elopement risk and ensure the WanderGuard was checked every shift. However, the exit door used by the resident was not equipped with a WanderGuard alert system, and the facility's investigation revealed that loose wiring caused a power interruption, preventing the alarm from sounding. The facility's policy required monitoring of at-risk residents, but the resident was able to leave the facility unimpeded, indicating a failure in supervision and monitoring. The facility's investigation lacked witness statements regarding the elopement, and the nurse's notes did not document a health assessment of the resident upon their return. The facility's policy stated that new wandering behavior or attempted elopement should be documented, and the care plan updated, but there was no documentation of new interventions implemented after the incident. This deficiency placed the resident in immediate jeopardy for potentially life-threatening injury due to exposure to freezing temperatures.

Removal Plan

• Staff conducted a headcount ensuring the safety of all residents in the facility.
• Camera footage was reviewed, identified the malfunction, and effected immediate repairs on the faulty exit door.
• Audited all doors and windows to ensure no similar situations existed. Reported the issue to the stated agency, physician et al.
• Conducted all staff in-service How to check Doors for Lock function.
• Conducted an Ad Hoc QAPI meeting with the Executive Director, Director of Nursing, and Medical Director.

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 full-time certified dietary manager for its 94 residents, which was a requirement according to their Food Service Staffing Policy. The policy stipulated that if the facility dietitian was not full-time, another qualified nutritional professional should be employed as the Dietary Manager. This individual must meet specific qualifications, such as being a certified dietary manager or having a similar certification in food service management and safety. However, the Dietary Manager (DM) BB, who was overseeing meal preparation, did not possess the necessary certification. Although DM BB had completed the required classes, she had not yet scheduled a date to take the certification test. The deficiency was identified through observations and interviews conducted by the surveyors. On one occasion, DM BB was observed overseeing the preparation of a noon meal, which included meatloaf, Capri vegetables, a dinner roll, and strawberry cake. During an interview, DM BB confirmed that she was not a certified dietary manager. This was further verified by Administrative Staff A, who acknowledged that DM BB lacked the necessary certification. The absence of a certified dietary manager placed the residents at risk of not receiving adequate nutrition, as the facility did not comply with its own staffing policy requirements.

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 professional standards for food service safety, as observed in the kitchen. A white upright freezer had a significant ice buildup, and the middle section of a three-door refrigerator contained uncovered, undated, and unlabeled bowls of cantaloupe, which were discarded by dietary staff. The serving window had areas with missing Formica, and the wall under the dishwasher area had blackish streaks and a black substance on the caulking. Additionally, a piece of sheetrock was missing from the ceiling, covered with plastic, and the floor in front of the refrigerators had missing tiles. These conditions were verified by the Dietary Manager and Administrative Staff, who acknowledged the issues and provided explanations for some of the deficiencies. The facility's documentation revealed lapses in temperature monitoring for various refrigeration units, with several dates lacking recorded temperatures. The facility's policies required that food items be covered, labeled, and dated, and that refrigeration temperatures be monitored and documented. However, these procedures were not consistently followed, placing the 94 residents who received meals from the facility's kitchen at risk for foodborne illness. The facility's policies on supervision, maintenance services, and sanitation were not adequately implemented, contributing to the observed deficiencies.

Penalty

No penalty information released

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

Summary

The facility failed to provide written information regarding the bed hold policy to four residents or their representatives when they were transferred to the hospital. This deficiency was identified through observations, record reviews, and interviews. The residents involved were not given the necessary documentation that would inform them of how long their bed would be held during their absence, which is a requirement according to the facility's policy. Resident 35, who had diagnoses including cerebral atherosclerosis, schizoaffective disorder, and dysphagia, was transferred to the hospital without receiving the bed hold policy notice. The resident's electronic health record and care plan did not document the provision of this notice. Similarly, Resident 19, with conditions such as schizoaffective disorder, hypertension, and COPD, was also transferred without receiving the bed hold notice. The facility's administrative staff confirmed the oversight in both cases. Resident 38, diagnosed with COPD, and Resident 72, with acute and chronic respiratory failure and asthma, were also transferred to the hospital without being provided the bed hold policy notice. The facility's policy requires that residents and their representatives be informed of the bed hold policy upon admission and prior to any transfer. However, in these instances, the facility did not adhere to its policy, placing the residents at risk of not being able to return to their original rooms upon discharge from the hospital.

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 label and discard outdated insulin flex pens and expired stock medications, which placed residents at risk for receiving ineffective medications. During an observation of the facility's A hall treatment cart, it was found that the insulin flex pens for three residents were not labeled with open or expired dates. Specifically, one resident's Novolog flex pen was not labeled, another resident's Basaglar flex pen was not labeled, and a third resident's Novolog flex pen was labeled with an expired date. Additionally, a bottle of Vitamin D3 with an expired date was found on the medication cart. Further observations in the A hall Medication Room revealed another resident's Ozempic flex pen was labeled with an expired date. Licensed Nurse I and Administrative Nurse D confirmed that the nurses were responsible for dating the flex pens when opened and discarding outdated insulin and stock medications. The facility's policy on the storage of medication mandates that all drugs and biologicals be stored safely and that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed. The failure to adhere to these procedures resulted in the presence of outdated medications, posing a risk to the residents.

Penalty

No penalty information released

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

Summary

The facility failed to assess and document the eligibility of several residents for pneumococcal vaccinations, specifically the PCV20 vaccine, as per the latest CDC guidelines. The review of the facility's Electronic Medical Records (EMR) revealed that residents, including R85, R16, R57, and R42, had no documented pneumococcal vaccinations or refusals, despite having physician orders directing staff to provide the vaccine according to facility protocol. This oversight indicates a lack of adherence to the facility's policy, which mandates that residents be assessed for vaccination eligibility within five working days of admission and be offered the vaccine unless contraindicated or previously vaccinated. Interviews with facility staff, including Administrative Nurses D and E, highlighted a lack of awareness and implementation of the CDC guidelines for the PCV20 vaccine. Nurse D was unaware of the vaccine requirements and eligibility criteria, while Nurse E confirmed that the facility had not assessed residents for eligibility for further pneumococcal vaccinations, relying instead on the PPSV23 vaccine. This deficiency in following the CDC recommendations and the facility's own policy placed residents at risk of acquiring and spreading pneumococcal disease.

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 written notification of facility-initiated transfers to the residents or their representatives for two residents, R72 and R38. R72, who had a diagnosis of acute and chronic respiratory failure and asthma, was transferred to the hospital without receiving a written notice of the transfer. Despite having intact cognition, as indicated by a BIMS score of 15, R72 was not informed of the transfer, nor was the bed hold policy communicated to her or her representative. Administrative staff confirmed the lack of notification, and Social Services indicated that the Ombudsman was not notified due to a misunderstanding about coverage. Similarly, R38, diagnosed with COPD and receiving oxygen therapy, was transferred to the hospital due to abnormal vital signs without receiving a written notice of the transfer. The resident's clinical record lacked evidence of such notification, and administrative staff verified the omission. Social Services also confirmed the failure to notify the Ombudsman, citing the same misunderstanding about the need for notification. The facility did not provide a policy for notice of transfer/discharge, contributing to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to complete the required Significant Change Minimum Data Set (MDS) for a resident who had been admitted to hospice care. The resident, identified as R81, had a complex medical history including schizoaffective disorder, anxiety disorder, major depressive disorder, and other physical ailments. Despite these conditions and the resident's admission to hospice care, the facility did not conduct a significant change MDS assessment, which is necessary to evaluate and adjust the care plan according to the resident's current needs. This oversight was acknowledged by the Administrative Nurse, who stated that the significant change MDS was overlooked and not completed. The resident's care plan, dated July 2024, did not include interventions for end-of-life or hospice care, despite a physician's order indicating hospice admission in October 2023. Observations and interviews revealed that hospice services were being provided, such as incontinence supplies and CNA visits, but the lack of a comprehensive assessment meant that the resident's care plan was not updated to reflect these changes. The facility's policy requires a comprehensive assessment when there is a significant change in a resident's condition, but this was not adhered to, placing the resident at risk for inappropriate care and unmet needs.

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 the care plan for a resident, identified as R6, who was at risk for smoking-related injuries. R6 had multiple diagnoses, including cerebral infarction, anxiety, paranoid schizophrenia, depression, and abnormal involuntary movements, which necessitated specific precautions while smoking. The care plan required staff to assist R6 to and from the designated smoking area, observe for unsafe smoking behaviors, and provide a smoking apron. However, observations revealed that R6 was smoking without a smoking apron, contrary to the care plan directives. Staff interviews confirmed that R6 should have been provided with a smoking apron, highlighting a lapse in following the established care plan. Another resident, identified as R53, was also not adequately assessed for safe smoking practices. R53 had a diagnosis of nicotine dependence and drug-induced subacute dyskinesia, with a documented need for staff supervision and a smoking apron. Despite this, R53's medical record lacked recent assessments of his smoking abilities or privileges, and he was observed smoking without a smoking apron. Staff interviews revealed that R53 had not been assessed for smoking safety for the past 18 months, contrary to the facility's policy requiring quarterly assessments. This oversight placed R53 at risk for accidents or injury while smoking. The facility's policies on accident prevention and smoking safety were not effectively implemented, as evidenced by the failure to provide necessary smoking aprons and conduct regular safety assessments for residents R6 and R53. The lack of adherence to these policies and care plans resulted in preventable risks for accidents and injuries related to smoking for these residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a coordinated plan of care for two residents, R35 and R81, who were receiving hospice services. For R35, the electronic health record indicated diagnoses of cerebral atherosclerosis, schizoaffective disorder, and dysphagia, with moderately impaired cognition. Despite being admitted to hospice care, R35's care plan lacked documentation of hospice services due to a terminal prognosis. Observations and interviews revealed that the facility did not have specific information on the care plan that coordinated with the hospice care plan for R35, placing her at risk for inappropriate end-of-life care. Similarly, R81's electronic medical record included diagnoses such as schizoaffective disorder, anxiety disorder, major depressive disorder, and drug-induced secondary Parkinsonism. The resident's care plan did not include end-of-life or hospice care interventions, despite a physician order indicating admission to hospice. Observations showed that R81 was receiving hospice services, but the facility's care plan lacked coordination with the hospice provider, as confirmed by staff interviews. This deficiency also placed R81 at risk for inappropriate end-of-life care. The facility's hospice policy and procedure required written identification of hospice services and coordination of the resident's person-centered care plan with the hospice provider. However, the facility failed to adhere to these procedures for both residents, as evidenced by the lack of coordinated care plans and documentation. The absence of a coordinated care plan between the facility and hospice provider for both residents was a significant deficiency, as it compromised the quality of end-of-life care provided to them.