Galena Nursing & Rehab Center

Penalty

Inspection fine: $21,645

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 cognitively impaired resident from abuse and to respond appropriately to injuries of unknown origin, including bruising and vaginal bleeding. The resident had hemiplegia and severe cognitive impairment, required extensive assistance with ADLs, and depended on staff for care. Her care plan noted participation in activities but did not address the involvement of her son, identified as her representative and alleged perpetrator (AP), in her care, and listed another son as DPOA. Prior skin and weekly assessments documented no bruising or vaginal bleeding up to mid-March, and the last weekly skin assessment before the incident showed no bruises or open lesions. On the night in question, a CNA observed significant bruising on the resident’s right leg around late evening and reported it to the charge nurse (LN G). LN G assessed the bruising, determined it was probably from the wheelchair or therapy, and did not report it as an injury of unknown origin to administration. Later that night, around early morning, the same CNA observed bright red blood in the resident’s brief and vaginal area, along with what he thought might be clotted blood or a sore, and again reported this to LN G. LN G, relying on the AP’s report that the resident had been scratching and might have a yeast infection, instructed the CNA to apply antifungal powder or cream without personally assessing the vaginal area and without reporting the bleeding and possible injury to administration or the provider. During this time, the AP remained in the room with the resident, often with the door closed, and staff had previously reported feeling awkward and uncomfortable performing peri care while he was present. On the following day, a day-shift CNA providing peri care observed dried blood on the resident’s labia and vaginal area and notified another nurse (LN I), who noted dried blood and bruising on the right hip and leg and reported this to the charge nurse (LN H). Despite this, an earlier skilled evaluation by LN H that same day inaccurately documented no skin issues. Later that afternoon, a two-nurse assessment by LN H and LN I revealed a large bruise on the right hip and leg resembling the shape of a hand, extensive maroon/purple bruising and petechiae around and into the vagina, small lacerations and shearing injuries to the labia, and bruising on the lower abdomen and thighs. The resident displayed increased anxiety and repeatedly said “Oh God” during the assessment and was unable to explain how the injuries occurred. Multiple staff statements documented that the AP stayed in the room almost continuously with the door closed, remained present during intimate cares, acted nervous and fidgety, sometimes took over incontinent care, and left the building frantically after the injuries were discovered. The facility’s failure to recognize and report the initial bruising and vaginal bleeding as potential abuse, to promptly assess the resident, and to remove or restrict the AP allowed him to remain alone with the resident for many hours while her injuries progressed, resulting in a finding of immediate jeopardy. Additional documentation from the hospital and law enforcement supported concerns of sexual assault. The hospital record noted bleeding in the vaginal area with signs of injury, scattered bruises on the extremities, hips, and thighs, and documented that staff had concern for possible sexual assault. Hospital staff also recorded that the resident became agitated and yelled statements such as “Noooo why would a man do that” when her genitalia were cleaned, and that access to her hospital records was blocked from the patient portal due to reasonable belief that sharing them could result in harm to her life or physical safety. Witness statements from CNAs described the resident asking, “why she let that man do that” and saying “Son, why would you do this to me?” during care, though it was not documented that these statements were reported at the time. Law enforcement officers and the SANE examiner later described the resident’s wounds as among the worst they had seen and indicated that a warrant was required for the SANE exam because the AP, listed as legal representative, had left and could not be contacted. Throughout the period leading up to the discovery of the full extent of the injuries, staff had observed the AP’s constant presence, closed-door behavior, and controlling involvement in care, and some staff had reported discomfort and concerns to charge nurses, but these concerns were not acted upon prior to the incident. The facility’s abuse, neglect, and exploitation policy required prevention of all types of abuse and ensuring resident safety regarding visitors and representatives, but staff did not implement protective measures in response to the AP’s behavior or the resident’s injuries and statements. The failure to promptly recognize, assess, and report bruising and vaginal bleeding of unknown origin, combined with allowing the AP to remain alone with the resident with the door closed and to participate in intimate care despite staff discomfort and the resident’s cognitive impairment, led to the determination that the resident was not kept free from abuse and experienced preventable and intentional physical and sexual abuse and psychosocial trauma. The delay of approximately 16 hours from the initial report of bruising of unknown origin to notification of administrative staff, and the inaccurate documentation of no skin issues by LN H earlier on the day the injuries were identified, were key factors in the deficiency finding.

Removal Plan

• Re-education for abuse, neglect and exploitation (ANE) for all facility staff.
• Implemented a protection plan for Resident 1 (R1) requiring all cares be performed with two staff.
• Implemented a protection plan for R1 requiring the room door to remain open unless private cares were being provided.
• Implemented a protection plan for R1 requiring that if the alleged perpetrator (AP) entered the facility, law enforcement (LE) would be notified immediately.
• Implemented a protection plan for R1 requiring a staff member to go to R1's room and remain with her until law enforcement arrived if the alleged perpetrator entered the facility.
• Implemented a sign-in sheet for all visitors to the facility.
• Implemented a specific visitor log for R1.

Penalty

Inspection fine: $21,645

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 recognize and immediately report signs of possible physical and sexual abuse, including injuries of unknown origin and vaginal bleeding, for one resident. On the night of 03/21, two CNAs observed significant bruising on the resident’s right leg while providing care with the resident’s durable power of attorney (DPOA) and primary caregiver present. They reported the bruising to the charge nurse, who assessed the bruises as small, linear, and appearing old, accepted the DPOA’s explanation that they were from therapy or wheelchair positioning, and did not initiate an investigation, document the findings, or report the injury to administrative staff or external authorities. Later that night, at approximately 04:20 AM, the same CNA observed bright red vaginal bleeding and a possible lesion or clotted blood on the labia, reported this to the same nurse, and was instructed to clean the resident and apply antifungal cream for a presumed yeast infection without the nurse assessing the area or documenting the change in condition. At 06:00 AM, the night nurse verbally passed on that there had been vaginal bleeding, suspected to be from itching or a yeast infection, to the oncoming nurses and recommended contacting the provider, but no one identified these findings as potential abuse or an injury of unknown origin requiring immediate reporting. Around 08:00 AM, another CNA providing peri care with the DPOA present noted dried blood and small cuts or lacerations around the vaginal area and promptly notified a nurse, who confirmed dried blood, bruising on the hip, and a labial laceration but attributed the findings to itching and did not suspect abuse. This nurse reported the findings only to the resident’s charge nurse and did not notify administrative staff, law enforcement, or the state survey agency. During this period, multiple CNAs reported feeling uncomfortable and unsettled by the DPOA’s constant presence during intimate care, his refusal to leave the room, his habit of closing the door, and his jittery and anxious behavior, and at least two CNAs documented that the resident made distressing statements such as asking why they let “that man” do that and “Son, why would you do this to me?”, but these concerns were either not documented as reported or, when reported, were not acted upon. In the early afternoon, around 02:22 PM, two nurses jointly assessed the resident and identified extensive injuries, including a large bruise on the right hip and leg resembling the shape of a hand, dark maroon/purple bruising on the labia and into the vagina, a small laceration at the posterior vaginal opening, a shearing-type injury on the labia, scattered petechiae, bruising on the lower abdomen, and ongoing vaginal bleeding. The resident displayed increased anxiety during this assessment, repeatedly saying “Oh God,” and was unable to state what had happened. Only at this point did the nurses recognize the situation as potential sexual abuse and notify an administrative nurse, who then notified the administrator. Law enforcement was contacted later that afternoon, and the state survey agency was notified by email that evening, nearly 20 hours after the initial identification of an injury of unknown origin and several hours after administrative staff became aware of suspected abuse. Throughout the delay in recognition and reporting, the resident remained in the room with the alleged perpetrator, who had been present during all cares over the previous 23 hours and left the building frantically after the injuries were more fully recognized. The facility’s own abuse policy required immediate reporting, but not later than two hours after an allegation involving abuse or resulting in serious bodily injury, which was not followed in this case.

Penalty

Inspection fine: $21,645

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 implement protective measures and conduct timely assessment and investigation after injuries of unknown origin and signs of potential sexual abuse were identified for a cognitively impaired resident. The resident had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment with a BIMS score of three, dependence on staff for nearly all ADLs, and no documented prior skin conditions. Her care plan did not address the alleged perpetrator’s (AP’s) involvement in care and listed another son as DPOA, while the AP was treated as the primary caregiver and remained in the room with the resident almost continuously, often with the door closed. Staff had previously felt awkward and uncomfortable performing care with the AP present and reported that he frequently remained in the room, watched cares closely, and sometimes took over intimate care, but these concerns were not acted upon. On the evening and night shift, CNAs observed significant bruising on the resident’s right leg and later vaginal bleeding, and reported these findings to the nurse. Around 10:30–11:00 PM, CNA staff reported significant bruising down the resident’s right leg to the nurse, who briefly assessed the bruises in the presence of the AP, accepted the AP’s explanation that the bruising might be from therapy or wheelchair positioning, and did not document the bruising in the EMR at that time. The resident was left alone in the room with the AP. Around 4:20 AM, CNA staff reported bright red blood in the resident’s brief and around the vaginal area to the same nurse, who did not assess the resident but instructed the CNA to apply antifungal cream or powder for a suspected yeast infection, again without further investigation or protective measures. The resident remained alone in the room with the AP with the door closed after care was completed. On the following day shift, multiple staff continued to identify concerning findings without immediate protective action. At approximately 6:00 AM, the night nurse told two oncoming nurses that the resident had vaginal bleeding suspected to be from itching or yeast infection, but no assessment was done at that time. Around 8:00 AM, a CNA providing peri care with the AP present observed dried blood all over the vaginal area and reported it to a nurse, who assessed the resident at about 8:30 AM, noted dried blood, bruising on the labia and vaginal opening, and bruising on the hip, but attributed the injuries to itching and did not suspect abuse; the resident was again left in the room with the AP. Later that afternoon, a two-nurse assessment revealed extensive bruising on the right hip and leg, bruising and lacerations to the labia and vaginal area, bruising on the lower abdomen, and active vaginal bleeding, with the bruising on the hip described as resembling the shape of a hand. During this assessment the AP left the room, which staff noted was unusual. Witness statements documented that throughout this period the AP remained in the room during cares, the door was mostly closed, staff felt unsettled and had previously reported discomfort with the AP’s presence, and the resident made statements such as “why I let that man do that?” and “Son, why would you do this to me?” during or after care. Despite these observations and escalating physical findings, the resident remained alone in the room with the AP for approximately 16 hours after the initial report of bruising and subsequent vaginal bleeding before the situation was reported to administrative staff as potential abuse. The EMR lacked timely documentation of the initial bruising and early vaginal bleeding, and a late entry note regarding the bruising was not entered until several days later, after surveyor interviews had begun. The facility’s abuse, neglect, and exploitation policy stated that the facility would ensure the health and safety of each resident regarding visitors such as family members or resident representatives, but staff did not remove or restrict the AP, did not initiate immediate protective measures when injuries of unknown origin and signs of possible sexual abuse were first identified, and did not promptly report or investigate the concerns. The deficiency was cited at a level of past noncompliance with actual harm, based on the existence of physical sexual abuse injuries that progressed while the resident was left alone with the AP and the likelihood of severe psychosocial trauma related to sexual abuse.

Penalty

No penalty information released

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

Summary

Surveyors identified multiple failures by facility staff to provide necessary assistance with activities of daily living (ADLs) for several residents. One resident with Alzheimer's disease and chorea, who required substantial to maximum assistance for bathing and hygiene, was observed unshaven at breakfast. Staff interviews revealed that shaving was typically performed on shower days, but due to staffing shortages and the bath aide being reassigned to other duties, residents were not consistently receiving showers or being shaven as scheduled. Documentation showed missed or infrequent bathing opportunities, and staff confirmed the resident had not refused care. Another resident with severe cognitive impairment and dependent on staff for dressing was repeatedly observed in soiled clothing throughout the day, including at meals and while resting in bed. Despite multiple staff members interacting with the resident, her soiled clothing was not changed. Staff interviews confirmed the resident was fully dependent for dressing and that her clothing should have been changed if dirty, but this was not done. A third resident with a history of cerebral infarction and cognitive decline required substantial assistance with bathing and personal hygiene. This resident was observed unshaven with greasy, dirty hair, and records indicated missed or unattempted showers. Staff confirmed the resident had not refused care and that personal hygiene was not consistently provided. Additionally, another resident with moderate cognitive impairment and a history of stroke, who required substantial to maximum assistance with eating, was observed at meals without receiving needed feeding assistance until staff intervened later. Staff acknowledged the resident's increased need for help with eating, but assistance was not provided in a timely manner.

Penalty

No penalty information released

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

Summary

The facility failed to address the immediate care needs of a resident with end-stage renal disease who was dependent on dialysis. Upon admission, the resident's baseline care plan did not include any documentation or instructions regarding dialysis care and services, despite the resident's medical record indicating a diagnosis of end-stage renal disease and a regular dialysis schedule. The electronic medical record also lacked orders related to dialysis care, and staff interviews confirmed that no pre- or post-dialysis assessments, vital signs, weights, or site assessments were performed by facility nurses. The resident reported that staff did not obtain vital signs, pre-dialysis weight, or assess the dialysis site prior to his departure for dialysis treatments. Further interviews with facility staff revealed a lack of awareness and education regarding the resident's dialysis care requirements. A certified nurse aide was only aware of a fluid restriction and not of other dialysis-related needs. A licensed nurse acknowledged that the facility missed necessary orders and assessments for dialysis care upon admission, and the administrative nurse confirmed that the baseline care plan should have included dialysis instructions. The facility's policy required baseline care plans to include instructions needed for effective and person-centered care, but this was not followed for the resident in question.

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 a comprehensive care plan for one resident, specifically omitting staff instructions regarding the use of foot pedals when propelling the resident in his wheelchair. The resident had diagnoses of chorea and Alzheimer's disease, with a BIMS score indicating moderately impaired cognition. Documentation showed the resident was generally independent with his wheelchair and walker, but at times required staff assistance for mobility. The care plan noted the resident's jerking movements and independence with a walker but did not address the use of foot pedals during staff-assisted wheelchair propulsion. Observations revealed that staff propelled the resident in his wheelchair without foot pedals, with the resident's feet crossed and tucked under the seat, and the toe of his left foot skimming the floor. Staff interviews confirmed that while the resident usually propelled himself, he sometimes needed staff assistance, at which point foot pedals were expected to be used. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but the care plan lacked specific instructions for staff regarding foot pedal use during assisted wheelchair mobility.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to monitor and report significant weight fluctuations for a resident with a diagnosis of congestive heart failure (CHF). The resident's care plan required daily weights and provider notification for weight gains of three pounds overnight or five pounds in three days, as well as for increased shortness of breath or swelling. Despite this, the electronic medical record showed multiple instances where the resident experienced weight gains meeting or exceeding these thresholds, but there was no documentation that the provider was notified as required by the care plan. Observations confirmed the resident had edema in both legs and was wearing compression socks. Interviews with nursing staff revealed awareness of the notification requirement, and administrative staff stated the expectation that orders be followed. However, no policy was provided to support the process, and the required notifications to the provider were not made on several occasions when the resident's weight increased significantly.

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

Staff failed to ensure a safe environment free from accident hazards for a resident diagnosed with chorea and Alzheimer's disease. The resident, who had moderately impaired cognition and was generally independent with mobility, was observed being propelled in a wheelchair by staff without foot pedals in place. During this incident, the resident's feet were crossed and tucked under the seat, with one foot skimming the floor, increasing the risk of injury. The staff member stated that foot pedals were not used because the resident usually propelled himself, but at times, staff assistance was required for mobility. Further interviews confirmed that staff were expected to use foot pedals when propelling the resident in the wheelchair. The facility did not provide a policy regarding the safe transport of residents in wheelchairs. The lack of foot pedals during staff-assisted wheelchair propulsion constituted a failure to maintain a safe environment and prevent avoidable accidents for the resident.

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 care and services to maintain acceptable nutritional status for two residents. For one resident with a history of stroke, diabetes, and cognitive impairment, the care plan required substantial to maximal assistance with eating, a soft diet with double portions, and nutritional shakes. Despite these interventions, the resident experienced significant weight loss over a two-month period. Observations revealed that staff did not consistently provide the required assistance during meals, and the resident was often left unattended with food and nutritional shakes, resulting in incomplete consumption. Additionally, the kitchen was not informed of the double portion requirement, so the resident did not receive the prescribed diet enhancements. Documentation in the electronic medical record for this resident did not reflect the observed weight loss, and there was a lack of communication and follow-through regarding dietary interventions. Staff interviews confirmed that the resident's need for assistance with eating had increased, but this was not consistently addressed during meal times. The facility also lacked a restorative aide, and nurse aides were expected to provide the necessary support, which was not reliably done. For another resident with end-stage renal disease on dialysis, the facility failed to properly assess and document nutritional needs related to dialysis. The baseline care plan did not include any information about dialysis care, dietary restrictions, or fluid management, despite hospital discharge instructions specifying a diabetic, heart-healthy diet. Orders for daily and weekly weights were not consistently followed, and the registered dietitian's assessment did not address the resident's dialysis status. Staff interviews confirmed that essential dialysis-related care and monitoring were missed, and the care plan was incomplete regarding the resident's specialized 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 provide necessary dialysis assessment, care, and services for a resident diagnosed with end-stage renal disease who was dependent on dialysis. The resident's baseline care plan did not include documentation of dialysis services or instructions for dialysis care. The electronic medical record lacked orders related to dialysis care, and there was no evidence of completed dialysis communication forms before or after treatments. Progress notes inconsistently documented the resident's dialysis schedule and did not consistently record whether the resident attended dialysis, returned from dialysis, or received assessments related to dialysis. On several occasions, there was no documentation of pre- or post-dialysis assessments, vital signs, weights, or fistula assessments. Interviews with staff revealed that the facility missed entering dialysis orders and did not perform required pre- and post-dialysis assessments. The resident reported that nurses did not obtain vital signs, pre-dialysis weight, or assess the dialysis site before he left for dialysis, and sometimes he left before breakfast. Staff confirmed that the resident's representative transported him to dialysis, which contributed to the missed assessments. The facility's hemodialysis policy required coordination and collaboration with the dialysis center to meet the resident's needs, but this was not followed in 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

Staff failed to ensure proper blood pressure monitoring and administration of midodrine for a resident diagnosed with hypotension. The resident's care plan and physician's order required staff to check blood pressure before administering midodrine, only give the medication if the systolic blood pressure (SBP) was less than 100 mm/Hg, and ensure the resident was sitting upright during administration. The care plan also instructed staff not to give the medication while the resident was lying down or within four hours of bedtime. Record review showed that on two occasions, the resident's SBP was below 100 mm/Hg, but midodrine was not administered and the physician was not notified as required. Additionally, staff interviews revealed a lack of awareness of the medication order and the need to notify the provider for out-of-range blood pressures. Observations also indicated that the resident was assisted to lie down after eating, which could conflict with the care plan instructions regarding medication administration.

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

Facility staff failed to implement Enhanced Barrier Precautions (EBP), including the use of gowns and gloves, for residents with conditions requiring such measures. Specifically, one resident with a Foley catheter, another receiving tube feedings and wound care, and a third with an ostomy did not have EBP signage or personal protective equipment (PPE) available or in use. Observations revealed that no EBP signage or PPE was present outside any of the residents' rooms, and staff did not use gowns or gloves when providing care to these residents. Interviews with the affected residents confirmed that staff did not use appropriate protective equipment during care activities. Staff interviews indicated a lack of consistent EBP implementation, with some staff acknowledging that EBP should be used for residents with indwelling devices or wounds, but admitting that these precautions had not been followed. The facility's policy required EBP for residents with wounds or indwelling medical devices, and mandated that gowns and gloves be made available near or outside the resident's room. Despite this, staff reported that EBP had not been practiced, and attributed the lapse to staff oversight and recent changes in nursing leadership.

Penalty

No penalty information released

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

Summary

A deficiency was identified when the facility failed to regularly inspect a resident's bed frame and mattress as part of its maintenance program, specifically to identify areas of possible entrapment. The resident involved had a diagnosis of dementia with severe cognitive impairment, as indicated by low BIMS scores, and was dependent on staff for bed mobility. Observations revealed a persistent gap of approximately six inches between the top of the mattress and the head of the bed. Staff interviews confirmed that the mattress had been shorter than the bed frame for an extended period, and maintenance staff had not checked the bed because it was supplied by hospice and not considered a facility bed. The resident's care plan noted that hospice would provide the bed and mattress, but there was no evidence that the facility ensured the equipment was safe or properly fitted. The facility's policy required reasonable accommodations to individualize the resident's environment, including the bedroom, but this was not followed in this case. The lack of inspection and failure to address the mismatch between the mattress and bed frame placed the resident at risk for injury.