Edwardsville Care And Rehab

Penalty

Inspection fine: $14,020

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.