Redbud Village

Penalty

Inspection fine: $14,015

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

Summary

The deficiency involves the facility’s failure to prevent misappropriation and diversion of resident medications, including controlled substances, for 15 cognitively impaired residents, resulting in missed doses. A certified medication aide (CMA) was observed on camera removing a black trash bag from the medication cart, carrying it to the soiled utility room, and leaving it there. Review of the footage showed the CMA popping medications out of residents’ bubble packs, placing some pills into a medication cup and then into a black trash bag, and placing other popped medications into a medication cup stored in the top left-hand drawer of the medication cart. The controlled substance drawer was unlocked while pills were being placed into cups in that drawer, and subsequent review determined that nine controlled substances or muscle relaxers popped from residents’ medication cards were not accounted for. The incident came to light when laundry staff discovered a black trash bag containing numerous pills at the bottom of a soiled laundry barrel in the utility room and reported it to nursing staff. Administrative staff later identified 43 pills in the bag belonging to 15 different cognitively impaired residents. The facility’s records showed that these residents did not receive multiple ordered medications during the night in question, including psychotropics, anticonvulsants, opioids, anticoagulants, antibiotics, muscle relaxants, sleep aids, and other medications such as stool softeners, cholesterol medications, and pain medications. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent, and the actions of the CMA were determined to be targeted toward residents with cognitive impairment who would not remember whether they had received their medications. Specific resident records documented clinical outcomes associated with the missed medications. One resident with Alzheimer’s disease, dementia, pain, mood disturbance, and anxiety, who was ordered antipsychotics, anticonvulsants, opioids, and other medications, did not receive several of these medications that night and later reported feeling disrespected, wanting to leave the facility, feeling ugly, and having back pain that limited mobility. Another resident with Alzheimer’s disease, dementia, and anxiety, ordered antianxiety and opioid medications, did not receive tramadol, lorazepam, melatonin, and gabapentin, and was documented as very restless and up to the bathroom multiple times through the night. A third resident with major depressive disorder, psychosis, anxiety, impaired cognition, and psychotropic use did not receive an antibiotic, antidepressant, antipsychotic, and gabapentin, and was documented as expressing delusional beliefs about being held captive and needing to leave at midnight. Other affected residents missed various medications, and all 15 residents involved were cognitively impaired and therefore unable to reliably report the missed doses or their effects.

Penalty

Inspection fine: $10,764

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 care-planned supervision to prevent a fall with major injury for a cognitively impaired resident with a known history of falls, dizziness, and weakness. The resident’s EMR documented diagnoses including paroxysmal atrial fibrillation, orthostatic hypotension, dizziness, and tobacco use. A Significant Change MDS dated 12/03/25 showed a BIMS score of 4, indicating severely impaired cognition, and documented that the resident required moderate assistance for sit-to-stand and transfers, maximum assistance for toileting, dressing, and personal hygiene, and was dependent for bathing. The MDS and CAAs documented that the resident had experienced two or more falls with injury (not major) since 10/08/25 and was identified as a fall risk. A Morse Fall Scale dated 12/08/25 showed a score of 70, indicating high fall risk. The resident’s care plan, initiated 08/09/22, documented a history of syncopal episodes and risk for falls, with directions for staff to encourage the resident to call for assistance if feeling weak, dizzy, or unsteady before transferring or ambulating. The care plan also directed staff to observe and monitor the resident for changes in gait or balance when or after smoking, as the resident had been noted to become dizzy after smoking, and to provide a safe environment. A smoking safety evaluation dated 11/17/25 documented that the resident had problems with balance while sitting or standing, had previously burned skin, clothing, furniture, or other items, and dropped ashes on self. The evaluation and care plan required staff to light the resident’s cigarette and monitor the resident while smoking. The facility’s smoking policy stated that any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer at all times while smoking. In the weeks prior to the incident, multiple notes documented the resident’s increasing weakness, dizziness, and decline in functional status. On 11/20/25, staff found the resident on the floor after feeling weak and dizzy while going to get coffee, with reported head and neck pain. On 11/23/25, a CNA found the resident on the floor again, with the resident reporting dizziness, head impact, weakness, and confusion, leading to an ER transfer. Subsequent notes on 11/25/25, 11/26/25, 12/28/25, and 01/02/26 documented that the resident was weaker, had difficulty getting out of bed and into a wheelchair, had decreased appetite and fluid intake, was more fatigued, and had declined from being more independent to requiring one to two staff for ADLs. A note dated 12/23/25 documented the resident was found on the ground outside after attempting to transfer from a wheelchair to lawn furniture and slipping from the chair cushion to the ground. On 01/08/26 at approximately 8:57 PM, a licensed nurse assisted the resident to the north patio smoking area, placed a smoking apron, and lit the resident’s cigarette. The nurse then went back inside the facility, leaving the resident outside on the patio without direct physical presence. The facility’s incident report later stated the nurse monitored the resident through the windows while at the nurse’s cart until the resident finished smoking, but the nurse then stepped away from the window when another staff member asked about another resident’s pain medication. At approximately 9:05 PM, the nurse heard the resident yell for help, went outside, and found the resident on the ground lying on the left side, with one slipper off. The resident reported losing balance when standing up and that the slipper came off, causing the fall. The resident was transported to the hospital, where imaging showed a non-displaced subcapital hip fracture and a mid-left femoral neck fracture, and surgery was performed to repair the hip. During interview, an administrative nurse stated she considered watching the resident from the window to be direct supervision and acknowledged that the resident’s slippers were at least two sizes too big, and that staff should have had the resident wear tennis shoes to go out to smoke.

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 all door alarms were in functional working order to alert staff to residents exiting the facility unattended. On the night of the incident, a cognitively impaired resident with a history of Alzheimer's disease, major depressive disorder, and hypertension, exited the facility without triggering any alarms. The resident, who was at risk for elopement and falls, walked past a Certified Nurse Aide and exited through a dining room door that did not alarm. The resident then proceeded to unhook a chain on a locked gate, exited the courtyard, and crossed a busy highway before being found by a neighbor who called the police. The resident's medical records indicated severe cognitive impairment and a history of falls, with a recent assessment showing a decreased risk for elopement, leading to the discontinuation of a WanderGuard bracelet. However, the resident's care plan had documented previous attempts to leave the facility unattended. On the night of the incident, the resident's exit was not detected until the police notified the facility. The resident was found with minor scratches but no major injuries. Observations and interviews revealed that the dining room door alarm was not functioning, and there was no policy in place for regular door alarm checks. The facility's maintenance personnel were supposed to check the door alarms, but no documentation was found to confirm this. The failure to ensure the door alarms were functional placed the resident in immediate jeopardy, as staff were unaware of the resident's exit until notified by the police.

Removal Plan

• An elopement assessment completed for R1.
• Staff placed a WanderGuard bracelet on R1.
• Staff were posted to ensure constant visualization of the door until the alarm was fixed.
• The Dining Room door was fixed and alarming correctly.
• Daily door alarm checks for all doors were implemented.