Lyndon Crossing

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 store medications and biologicals in a secure manner as required by facility policy and professional standards. During an observation, a medication cart was found unattended and locked, but medications labeled with a resident's name, a capped syringe, and a glucometer with a test strip were left on top of the cart. No staff were present in the area at the time. The facility's policy, reviewed and acknowledged by staff, clearly states that all drugs and biologicals must be stored in locked compartments and not left unattended. Interviews with the LPN involved, the unit manager, a registered nurse, and the Director of Nursing confirmed that leaving medications and syringes unattended on top of the cart was against facility policy and unsafe. The LPN admitted to being aware of the policy but stated he was trying to administer medications on time. Other staff members reiterated that medications and syringes should not be left unattended and that the LPN should have sought assistance if needed.

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 implement a comprehensive, person-centered care plan for a resident assessed as being at risk for elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and was placed on a secured memory care unit for safety. An Elopement/Wandering Risk Evaluation identified the resident as a moderate elopement risk, and the comprehensive care plan required that the resident reside on the secured unit with supervision while on the unit. The care plan also included diversion and structured activity interventions such as toileting, walking inside and outside, reorientation strategies with signs and pictures, and use of memory boxes. In the days leading up to the incident, progress notes documented that the resident repeatedly expressed a desire to go home. On the night of the elopement, an alarm sounded on the women’s memory care unit exit door. Staff interviews revealed that CNAs and the LPN on duty were occupied providing showers and care to other residents when the alarm went off. One CNA reported seeing the resident at the exit door and moving her to the dining room but did not know the code to stop the alarm and sought assistance from the LPN. The LPN reported checking the courtyard, stepping outside, and checking resident rooms after the alarm, but staff did not identify that the resident was missing at that time. Another CNA stated that after the alarm was silenced, she returned to showering residents and later noticed the unit was unusually quiet, as the resident was typically loud, but no one was actively looking for the resident. The resident ultimately left the facility unsupervised and without staff knowledge, later being found by citizens in a local park who contacted law enforcement. The sheriff’s officer reported that when he first arrived at the facility and asked staff if the resident was missing, staff stated she was in her room; only after checking the room did they realize she was gone. The resident told the officer and bystanders that she had been held captive and had run away, and she told surveyors she had prayed for an intervention, that both exit doors opened, and that she escaped through a faulty fence slat and ran to the park. She also stated she was very unhappy, did not feel she belonged at the facility, and would leave again if able. Staff interviews confirmed that the care plan interventions requiring supervision on the secured unit and provision of diversional, person-centered activities were not implemented at the time of the elopement because staff were engaged in care of other residents and some staff were unfamiliar with the unit and its procedures.

Removal Plan

• Updated Resident 1 care plan to include increased supervision by staff, implemented q15-minute checks immediately, and completed psychosocial visit/assessment once daily for 3 days
• Completed pain evaluation for Resident 1 (no negative findings)
• Conducted medication and laboratory reviews for Resident 1
• Conducted elopement drills by Maintenance Director to ensure staff comprehension; staff verbally validated understanding
• Completed 100% elopement evaluations on all facility residents by licensed nursing staff
• Reviewed 100% of elopement care plans by MOS Coordinator and Director of Nursing Services
• Completed 100% staff education (including contract staff) on the Elopement policy and procedure by Executive Director, Director of Nursing Services, and department heads; staff verbally validated understanding
• Completed education for Social Services staff and MDS Coordinator on updating resident care plans and implementing interventions; staff verbally validated understanding
• Reviewed all residents’ care plans to ensure elopement risk is reflected on the comprehensive care plan and Kardex
• Implemented requirement that all residents who trigger for 'at-risk' and 'high-risk' will have an elopement care plan
• Revised resident care plans to include residents at risk for elopement
• Reviewed the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement
• Implemented weekly audits of new admissions for 3 months to ensure elopement risk and interventions are in place and care plan/Kardex updated
• Provided education to nursing staff on updating care plans, elopement evaluation, and Kardex as needed
• Continued staff education plan until complete; no staff (including new hires/contract) may work until educated; staff verbally validated understanding
• Completed elopement risk assessments on all residents by Director of Nursing Services/MOS Coordinator/Therapy Director
• Educated MOS/Social Services on elopement evaluation and implementing individualized interventions (supervision/observation), completing evaluations, following care plan/Kardex, and responding to alarms; staff verbally validated understanding
• Educated 100% of staff on revising care plans after identifying at-risk residents, individualized supervision/observation interventions, completing evaluations, following care plan/Kardex
• MOS Coordinator reviewed all baseline and comprehensive care plans to ensure revisions after identification of at-risk residents per elopement evaluations
• MOS Coordinator reviewed all comprehensive care plans to ensure revisions after identification of at-risk residents per elopement evaluations
• Held an ad-hoc QAPI meeting with leadership/IDT to review the plan and findings
• Forwarded Care Plan and Elopement Assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance
• Held QAPI meetings monthly
• Audited and reviewed all monitoring by Executive Director and/or Director of Nursing Services until ongoing compliance is achieved; corrected deficient practices immediately and referred to QAPI Committee for further review and interventions

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 provide adequate supervision and maintain a safe, secure environment for a cognitively impaired resident on a memory care unit, resulting in an elopement. The resident was admitted with dementia with behavioral disturbance, cognitive communication deficit, anxiety, and major depressive disorder, and hospital records indicated the need for a secured, locked unit due to impaired safety decisions and poor safety awareness. On admission, the facility’s elopement/wandering risk evaluation scored the resident as a moderate elopement risk, and the admission MDS showed a BIMS score of five, indicating severe cognitive impairment. The resident’s care plan, initiated shortly after admission and later revised, included goals and interventions to maintain safety on the secure unit, including supervision while on the unit and provision of activities of interest with redirection as needed. In the days leading up to the incident, progress notes documented escalating behaviors and clear exit-seeking. Notes from several days before the elopement described the resident as having behavioral issues, constantly stating a desire to go home, yelling out for God to get her out, and repeatedly expressing a desire to leave. Staff interviews further confirmed that the resident frequently packed a suitcase, made statements about wanting to go home, pushed on exit doors, and watched the doors to see if someone would go out. On the day of the elopement, staff reported the resident was antsy, wanted to get out, and was not redirectable, with social services noting that the resident insisted she needed to get to her dying mother. Despite these known behaviors and documented risks, the resident was placed in a room directly catty-corner to an exit door on the secure unit, and there is no indication in the report that enhanced supervision such as 1:1 monitoring was consistently implemented at the time of the incident. On the evening of the elopement, staff on the women’s memory care unit consisted of one LPN and two CNAs for 16 residents, and all three staff members reported being occupied with other resident care tasks when the alarm sounded. One CNA reported hearing the alarm, going to the exit door, seeing another resident in a wheelchair, moving that resident, and, along with the LPN and another CNA, checking the courtyard and not seeing anyone before the LPN turned off the alarm. Another CNA stated she saw the eloping resident at the exit door when the alarm went off, moved her to the dining room, and then returned to provide a shower to another resident, noting that the door did not lock right away and that no one was actively looking for the resident later. The LPN reported responding from the men’s secure unit when the alarm sounded, checking the courtyard and resident rooms per policy, and stated he did not realize the resident was missing until a law enforcement officer arrived and asked about her. The resident was able to exit the building through the alarmed exit door and then leave the courtyard through a deteriorated wooden gate connected to the privacy fence. The maintenance director later acknowledged that the gate’s wood boards were beginning to deteriorate before the incident and that the resident was able to push through the boards and then place them back, securing the gate with empty plant pots on the opposite side, which led staff to believe the gate was secure when checked. The resident reported that on the night she left, both exit doors near her room opened, that the wood gate was faulty and allowed her to get through, and that she ran to a nearby park where she sat on a bench and told a couple about her escape. Concerned citizens at the park called 911, and a sheriff’s officer responded, found the resident, and then went to the facility, where staff initially stated the resident was in her room and were unaware she had left until they checked and found her missing. The officer reported that no staff member told him they were looking for or missing a resident, and the resident herself stated she was unhappy in the facility, did not feel she belonged there, and would leave again if able. The facility’s own elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision to prevent accidents, that alarms were not a replacement for necessary supervision, and that staff were to respond to alarms in a timely manner. The policy also required a systematic approach to monitoring and managing residents at risk for elopement, including identification and assessment of risk, implementation of interventions to reduce hazards and risks, and monitoring and modifying interventions as needed, with interventions added to the care plan and communicated to appropriate staff. Despite this, staff interviews revealed that at the time of the elopement, all assigned staff were engaged in other resident care tasks, could not provide supervision or diversional activities as outlined in the care plan, and did not recognize or report the resident as missing until notified by law enforcement. The combination of the resident’s known exit-seeking behavior, placement in a room adjacent to an exit door, a defective courtyard gate, and staff being occupied with other tasks when the alarm sounded led to the resident leaving the secure unit and the facility without staff awareness, resulting in the identified deficiency under F689 for failure to ensure adequate supervision and a hazard-free environment.

Removal Plan

• Conduct elopement drills once per shift to ensure staff comprehension of the elopement drill process.
• Complete a 100% audit of door and lock evaluations with no negative findings.
• Complete 100% elopement evaluations.
• Provide 100% staff education (including contract staff) on the Elopement policy/procedure and appropriate resident supervision.
• Initiate an investigation of the incident, including staff interviews and a root cause analysis.
• Repair the defective courtyard gate by facility staff and a licensed contractor.
• Inspect all doors, locks, and gates throughout the facility to ensure proper functioning.
• Add additional interventions to the resident’s care plan: increased supervision, q15-minute checks for 72 hours, and review of medications and labs.
• Adjust the exit door on the Memory Care Unit to prevent delayed egress.
• Review the Elopement Policy by the IDT to include individualized interventions for residents at risk for elopement.
• Audit new admissions weekly for 3 months to ensure elopement risk and interventions are in place.
• Complete elopement risk assessments on all residents.
• Educate MDS/Social Services on completing elopement evaluations, implementing interventions based on findings (including supervision/observation), and the necessity of staff availability and timely alarm response.
• Hold an Ad-Hoc QAPI meeting with leadership/IDT members to review the plan and findings.
• Forward elopement assessment audits to the Executive Director for QAPI Committee review monthly for at least 3 months to ensure ongoing compliance.
• Hold QAPI meetings monthly.
• Correct any deficient practices identified through monitoring immediately and report/review them through the QAPI Committee until ongoing compliance is achieved.
• Complete elopement drills each shift for 1 day and monthly ongoing.

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 observed that staff failed to follow proper procedures for checking food temperatures during meal service. Specifically, staff were seen inserting food thermometers through the plastic wrap covering food items such as creamed corn, pureed enchilada casserole, and kernel corn on the steam table, rather than removing the plastic wrap before taking temperatures. According to the USDA guidelines and the facility's own policies, thermometers should be inserted directly into the food, avoiding any barriers like plastic wrap, to prevent cross contamination and ensure accurate temperature readings. Interviews with the Interim Dietary Manager, a staff member, the DON, and the Administrator confirmed that the correct procedure is to remove any plastic or foil covering before inserting the thermometer. The DON and Administrator both acknowledged that piercing plastic wrap could introduce a choking or aspiration hazard and that staff are expected to use clean, dry thermometers and inspect them prior to use. The failure to follow these procedures was identified as a deficiency affecting all residents who received food from the kitchen.

Penalty

Inspection fine: $20,563

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 develop a baseline care plan for a resident identified as at risk for elopement upon admission. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, epilepsy, aphasia, and chronic congestive heart failure, was admitted to the facility and assessed as at risk for elopement. Despite this assessment, the facility did not create a baseline care plan with necessary interventions to address the resident's risk for elopement, leading to the resident leaving the facility without staff's knowledge. The resident's clinical records indicated severe cognitive impairment, with deficits in short-term memory, delayed recall, orientation, problem-solving, and safety awareness. The facility's policy required that residents at risk for elopement receive adequate supervision and have a person-centered care plan developed within 48 hours of admission. However, the care plan for this resident did not include interventions for wandering or elopement risk, even after the resident had eloped and was found by emergency services with stroke-like symptoms. Interviews with facility staff revealed a lack of communication and understanding regarding the resident's elopement risk. Several staff members, including LPNs and CNAs, were unaware of the resident's risk for elopement and did not receive guidance from management on monitoring the resident. The facility's interdisciplinary care plan team failed to implement a systematic approach to managing the resident's elopement risk, resulting in the resident's unsupervised departure from the facility.

Removal Plan

• The facility provided an acceptable IJ Removal Plan, alleging removal of the IJ.

Penalty

Inspection fine: $20,563

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 safety measures for two residents, leading to significant deficiencies. One resident, admitted with a history of cognitive impairments and assessed as at risk for elopement, was not provided with a care plan addressing this risk. Consequently, the resident left the facility without staff knowledge and was found the next day at a local hospital. The facility's policy required a systematic approach to monitor and manage residents at risk for elopement, which was not effectively implemented in this case. Another resident was admitted without a smoking safety assessment or fall risk assessment, despite having a history of cerebral infarction and requiring assistance with transfers. This resident experienced multiple falls, one resulting in an ankle injury, and was allowed to smoke unsupervised initially. The facility's failure to conduct timely assessments and implement appropriate interventions contributed to the resident's falls and potential safety hazards. Interviews with staff revealed a lack of communication and understanding regarding the residents' risks and the necessary precautions. Staff were unaware of the residents' elopement and fall risks, and there was confusion about the facility's policies and procedures. The facility's inadequate response to these risks and the absence of documented interventions in the care plans highlight the deficiencies in ensuring resident safety and supervision.

Removal Plan

• Implemented a systematic approach for monitoring and managing residents at risk for elopement.
• Conducted a thorough search for R401 and ensured all exit doors, door alarms, and windows were functioning properly.
• Changed door codes to prevent unauthorized exits.
• Placed R401 on one-to-one supervision upon return to the facility.
• Reviewed and revised the facility's policy on elopements and wandering residents.
• Ensured all staff were aware of residents at risk for elopement and the necessary interventions.
• Conducted staff training on the importance of monitoring residents at risk for elopement and the procedures to follow if a resident is missing.
• Implemented a baseline care plan for each resident, including interventions to address safety concerns such as elopement.

Penalty

Inspection fine: $20,563

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 residents and/or their guardians with quarterly statements of their personal funds accounts, as required by their policy. This deficiency was identified for five residents who were sampled for personal funds accounts. The facility's policy mandates that individual financial records should be available to residents through quarterly statements and upon request. However, interviews with residents and their representatives revealed that they did not receive these statements unless specifically requested, and in some cases, they had to visit the facility to obtain them. This lack of communication led to confusion about account balances and payments. The Business Office Manager (BOM) acknowledged the issue, noting that the facility was acquired by another company, which delayed the transfer of resident funds accounts. The Director of Nursing (DON) was unaware of the issue and confirmed that not providing quarterly statements violated residents' rights. The Administrator admitted that there were issues with residents receiving their statements, although she claimed that the problem had been resolved since her hire date. Despite these claims, the deficiency persisted, affecting the residents' ability to manage their personal funds effectively.

Penalty

Inspection fine: $20,563

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 safe, clean, comfortable, and homelike environment for its residents, as evidenced by the lack of hot water in 14 out of 19 resident rooms. Observations revealed that the water in these rooms remained cold even after running for several minutes, with temperatures recorded as low as 44 degrees Fahrenheit. This issue persisted despite the facility's policy requiring a safe and comfortable environment, and residents reported having no hot water for over a month, impacting their daily living activities such as washing hair. Interviews with residents and staff highlighted the ongoing nature of the problem. Several residents expressed frustration over the lack of hot water, with some stating they had informed the facility's new owner and the Ombudsman about the issue. Staff interviews revealed a lack of awareness and communication regarding the problem, with maintenance personnel unaware of the cold water issue in specific rooms and shower areas. The Maintenance Director admitted to only checking water temperatures in one room per hallway weekly, which may have contributed to the oversight. The facility's infrastructure issues were exacerbated by recent extreme cold temperatures, which caused pipes to burst and ceilings to cave in. This led to a high demand for the limited functional shower facilities, with 72 residents relying on a single shower room at times. The Director of Nursing acknowledged the intermittent hot water supply and the strain on available shower facilities, while the Administrator was unaware of the extent of the cold water issue until recently. Renovations were ongoing, affecting multiple shower rooms, which further complicated the situation.

Penalty

Inspection fine: $20,563

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

Summary

The facility failed to conduct performance reviews for all Certified Nursing Assistants (CNAs) at least once every 12 months, as required. This deficiency was identified for five CNAs whose personnel records were reviewed. Specifically, CNAs #2, #18, #20, #31, and #32 did not have documented performance evaluations within the previous 12 months. Additionally, the facility did not provide evidence of regular in-service education based on the outcomes of these reviews for CNAs #18, #31, and #32. The facility's policy required CNAs to attend a minimum of 12 hours of continuing education annually, but this requirement was not consistently met, as evidenced by the varying hours of training documented in the personnel files. The facility's Executive Director admitted that there was no staffing policy in place, and staffing was based on the facility's assessment. The President of Regional Clinical Operations acknowledged that the facility had undergone a change in ownership, which affected the availability of training and performance evaluation documentation. The new Administrator, who was still acclimating to her role, recognized the importance of performance evaluations in providing feedback and assessing competencies, skills, and knowledge. However, the lack of completed evaluations meant that staff could not benefit from this feedback, potentially impacting their performance and the quality of care provided.

Penalty

Inspection fine: $20,563

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 electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of 2024. This failure resulted in no registered nurse (RN) hours being reported and a lack of licensed nursing coverage for 24 hours a day on four or more days within the quarter, specifically in August and September 2024. The facility's Payroll Based Journal (PBJ) report indicated excessively low weekend staffing and no RN hours during this period. Despite requests, the facility could not provide verification that the staffing data for the third quarter had been successfully submitted to CMS. Interviews revealed that the President of Finance (VPF) was responsible for submitting the payroll data and acknowledged an error in the submission process due to a change in ownership and software transition. The VPF attempted to submit the data on October 14, 2024, but received an error message the following day, indicating the data was not submitted. The Administrator, new to her position during the ownership change, was aware of the software error and understood the importance of timely data submission, as the failure affected the facility's survey outcome and star rating.

Penalty

Inspection fine: $20,563

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 establish and maintain an effective infection prevention and control program, as evidenced by the improper wound care practices observed for two residents, R20 and R67. During wound care for R20, an LPN did not perform hand hygiene when transitioning from dirty to clean tasks, such as after removing a dressing and before opening sterile items. The LPN also failed to place a barrier on the table before placing supplies, and her gown came into contact with open dressings, potentially contaminating the wound. These actions were contrary to the facility's policies on hand hygiene and enhanced barrier precautions. For R67, the LPN similarly neglected to perform hand hygiene and change gloves between dirty and clean tasks during wound care. The LPN placed supplies on an unclean table without a barrier and retrieved a dropped dressing from the floor without discarding it. Additionally, the LPN did not change gloves or wash hands after touching non-sterile items, such as the bed controls and tube feed pump, before handling wound care supplies. These practices were inconsistent with the facility's infection control policies and could lead to contamination and infection. Interviews with the Director of Nursing, Wound Care Nurse/Staff Development Coordinator, and the Wound Doctor confirmed that the observed practices did not meet the expected standards for infection control. They emphasized the importance of hand hygiene, glove changes, and the use of barriers to prevent contamination during wound care. The failure to adhere to these protocols for both residents highlights a significant deficiency in the facility's infection prevention and control program.

Penalty

Inspection fine: $20,563

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 its abuse prohibition policy by not verifying and maintaining documentation of screening and training for new employees. Specifically, the facility did not complete the required criminal background checks, nurse aide abuse registry checks, and Kentucky Adult Caregiver Misconduct Registry (KACMR) checks for 9 out of 12 personnel files reviewed. These checks were either completed after the employees' hire dates or not documented at all. Additionally, there was no evidence that newly hired staff received the mandatory abuse training at the beginning of their employment. The personnel files reviewed revealed several instances where the required checks and training were not completed. For example, Registered Nurses (RNs) and Certified Nursing Assistants (CNAs) had their background checks and registry checks completed after their hire dates, and there was no documentation of abuse training. In some cases, such as with CNA24 and CNA19, there was no evidence of any checks or training being completed. The former administrator's file also lacked documentation of a nurse aide abuse registry check and abuse training. Interviews with the Administrator and the Regional President of Talent and Acquisition highlighted that the Human Resources staff were responsible for completing these pre-employment checks. The Administrator expected these checks to be completed before new employees entered the facility to prevent potential harm to residents. However, the checks were not consistently completed, and the facility's current owners, who took over on September 1, 2024, were not aware of the background checks for employees hired before that date.

Penalty

Inspection fine: $20,563

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 report an allegation of abuse within the required timeframe, as outlined in their policy. Certified Nursing Assistant (CNA) 14 witnessed CNA 13 allegedly choking Resident 79 during a care incident. This event occurred at approximately 5:20 AM, but the report was not made to the administration until 8:37 PM, resulting in a delay of about 15 hours. This delay hindered the facility's ability to promptly investigate the alleged abuse. Resident 79, who has severe cognitive impairment due to dementia, was reportedly combative during care, which led to the alleged incident. The resident was later assessed and showed no physical signs of abuse, such as bruising or changes in voice. The facility's policy mandates immediate reporting of abuse allegations, but this was not adhered to, as the report was significantly delayed. Interviews with staff revealed that CNA 14 delayed reporting the incident, and there was no corroborating evidence from other staff or physical signs on the resident to substantiate the abuse claim. The Interim Administrator and Director of Nursing confirmed the expectation for immediate reporting of such incidents, which was not met in this case, leading to a deficiency in the facility's handling of the situation.

Penalty

Inspection fine: $20,563

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 develop and implement a comprehensive person-centered care plan for a resident, identified as R22, who was wearing a SoftPro Ambulating ankle foot orthoses (AFO) boot. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, cerebral infarction, and dementia, was assessed as cognitively intact. Despite this, the care plan did not address the use of the AFO boot, which was necessary for the resident's mobility and safety. Observations revealed that the resident could not self-ambulate in his wheelchair due to a broken AFO boot, and his foot was dragging on the floor because the wheelchair footrest was not elevated. Interviews with the Director of Nursing (DON) and the Minimum Data Set Coordinator (MDSC) revealed a lack of awareness and assumption that the care plan for the AFO boot was in place. The DON acknowledged the boot was broken and had ordered a replacement but was unaware that the care plan was not updated. The MDSC stated that care plans should be completed promptly, and the Administrator emphasized the importance of updating care plans within 24 hours of admission. Despite these protocols, the care plan for the AFO boot was not developed, indicating a lapse in the facility's adherence to its own guidelines and federal requirements.

Penalty

Inspection fine: $20,563

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

Summary

The facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards, as evidenced by observations of undated, opened, unlabeled, and expired medications in one of five medication carts and one of two treatment carts. Specifically, a tube of Silvasorb gel with an expiration date of July 2024 was found without a label or identifier, and a tube of Diclofenac 1% topical medication was found without an open date or storage bag for a resident. Additionally, a pill of Cyclobenzaprine 5 mg was found separated from its pack and unlabeled in the medication cart for the B hall. Interviews with nursing staff revealed that the pharmacy inspects the carts monthly, but the facility's policy did not adequately address the documentation of open/expiration dates or the labeling of medications. Interviews with the Unit Manager, Staff Development, and the Director of Nursing (DON) highlighted the expectation that expired medications should not be present in the carts and that medications should be labeled with open dates and resident identifiers. The Unit Manager stated that nursing staff were responsible for weekly and monthly checks of the medication and treatment carts, while the DON emphasized the importance of checking expiration dates daily. The Administrator reiterated the expectation that medications should not be in the carts without personal containers and identifiers, and that loose medications must be destroyed. The lack of proper labeling and storage of medications poses a risk of medication errors, as noted by the staff development personnel.