Lincoln Park Care 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 maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.

Removal Plan

• The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
• Upon the resident’s safe return, the resident was reassessed.
• A new Wander Guard with a secure band was placed on the resident’s ankle.
• The resident’s room was moved adjacent to the nurses’ station for monitoring.
• The resident was placed on 1:1 monitoring for all shifts.
• The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
• The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
• The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
• Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
• The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
• A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
• All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.

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 prepare meals in the proper consistency for 3 of 6 residents reviewed on a modified diet during dining observation. During lunch observation, Resident #53, Resident #224, and Resident #326 each received whole French fries, and Resident #224 also received macaroni salad that had not been chopped before being served. The surveyor observed CNA#1 provide the trays, and the CNA then cut the items to chopped consistency only after the residents had already received them. Resident #53 had diagnoses including dementia, protein-calorie malnutrition, and hypertension, and the annual MDS indicated the resident was unable to complete a BIMS interview due to cognition. The resident had a physician order for a lactose free diet with chopped texture and thin liquids, and the care plan identified the resident required a mechanically altered diet due to poor dentition. Resident #224 had diagnoses including dementia, protein-calorie malnutrition, and type 2 diabetes mellitus, with a quarterly MDS showing a BIMS score of 7 of 15, indicating severely impaired cognition. The resident had a physician order for a regular diet with chopped texture and thin liquids, and the care plan directed staff to provide and serve the diet as ordered. Resident #326 had diagnoses including type 2 diabetes mellitus, vitamin D deficiency, and hyperlipidemia, and the quarterly MDS showed a BIMS score of 5 of 15, indicating severely impaired cognition. The resident had a physician order for a regular diet with chopped texture and thin liquids, and the care plan directed staff to provide diet per MD orders. The SLP confirmed that the residents were on chopped consistency diets and that the French fries and macaroni salad should have been served chopped. The FSD stated that residents on chopped diets should have all items served at the appropriate consistency and said meal trays are checked before being sent to residents, but could not explain why the items had not been chopped before service.

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 that resident dietary preferences and ordered meal items were consistently provided for 5 of 5 residents reviewed during lunch meal observations. During the meal on the second-floor dining room, the surveyor observed that multiple tray-ticket items were missing from resident trays, including an egg salad sandwich, fortified mashed potatoes, and sherbet for one resident; a sliced tomato and hot coffee for another; fortified mashed potatoes for a third; whole wheat bread, an orange, and orange juice for a fourth; and yogurt, fortified mashed potatoes, and grapes for a fifth. The surveyor documented these omissions while observing the meal service and comparing the trays to the tray tickets. Record review showed that the affected residents had diagnoses including dementia, protein-calorie malnutrition, diabetes mellitus, schizophrenia, hypertension, hyperlipidemia, congestive heart failure, and vitamin D deficiency. Several residents had impaired cognition, with BIMS scores ranging from unable to complete to 14 of 15, and care plans identified nutritional risks such as malnutrition, weight loss, variable intake, and need for therapeutic or mechanically altered diets. Physician orders included lactose-free, chopped, regular, and thin-liquid diets, and care plans directed staff to provide and serve diets per MD orders, including fortified mashed potatoes for some residents. The Food Service Director stated that resident meal trays should be checked for accuracy before being sent to the nursing units. The facility policy titled Tray Identification stated that the Food Service Director or supervisor would check trays for correct diets before carts were transported to their designated areas. Despite this, the observed trays were missing ordered items at the time of service, and the DON stated the kitchen concerns would be corrected immediately.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper kitchen sanitation practices in accordance with professional standards. During a kitchen tour with the Food Service Director present, the surveyor observed a dietary aide and the Chef both wearing hooped earrings in preparation area #1. The dietary aide stated that hooped earrings were acceptable as long as they did not hang down to the shoulders. The facility’s employee dress code policy stated that jewelry that could cause a safety hazard is not permitted. In the walk-in freezer, the surveyor observed multiple items stored higher than 18 inches from the ceiling and a full tray of meatloaf labeled with a use-by date of 12/2/25. The Food Service Director stated the meatloaf was mislabeled and that the date reflected when it was placed into the freezer, not the use-by date, and said it would be discarded because of the mislabeling. In the walk-in refrigerators, the surveyor observed two containers of egg salad and tuna salad with use-by labels dated 12/3/25, and the Food Service Director stated those items should have been disposed of the day before. The facility’s food safety policy stated food must be clearly marked with the date or day by which it is to be consumed or discarded, and that the Head [NAME] or designee is responsible for checking the refrigerator daily for expiring food items and discarding them accordingly.

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 a sanitary environment for residents, staff, and the public by not keeping the dumpster and surrounding area free of garbage and debris. During a tour of the kitchen and garbage area with the Food Service Director, the surveyor observed garbage debris around the dumpster and surrounding areas, including cardboard, food wrappers, food containers, cups, gloves, paper products, plastic bottles, and medication cups. The FSD stated that the maintenance department should have cleaned the area. The facility policy titled Refuse Receptacle/Dumpster Use stated that outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

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 that residents' call devices were readily accessible for multiple residents who were observed in bed with call bells placed out of reach. Surveyors observed Resident #135 with the call bell wrapped around the wall light above the bed, Resident #365 with the call bell on the floor behind the head of the bed, and Resident #209 with the call bell on the floor behind the head of the bed. These residents had diagnoses that included dementia and other chronic conditions, and their records showed cognitive impairment and dependence on staff for ADL care. Their care plans included interventions directing staff to keep the call light within reach. Additional observations showed Resident #6 with the call bell clipped to the wall behind the oxygen concentrator and Resident #9 with the call bell draped over the wall light above the bed, both out of reach. Their records reflected diagnoses including dementia, schizophrenia, diabetes mellitus, hypertension, and COPD, along with cognitive impairment and need for staff assistance with ADLs. When the surveyor later showed the call bell placement to the charge nurse, the charge nurse acknowledged that the call bells were not within the residents' reach and confirmed that staff should position them within reach. Surveyors also observed Resident #3 with the call light hanging on top of the wall light and later on the floor under the bedside table, and Resident #13 with the call light lying on the floor, with the resident stating they did not know where it was and would keep screaming if they could not find it. Resident #481 was observed with the call light under the bed and later on the floor. Their records reflected dementia or vascular dementia, severe or moderate cognitive impairment, and care plans that included keeping the call light within reach. The CNA and LPN interviewed by the surveyor stated that the call light should be within the resident's reach, and the DON stated that staff would make sure the call bell was in bed and within reach of 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 provide a homelike environment for residents on multiple units, as surveyors observed numerous environmental and housekeeping concerns during room and unit tours. In one bathroom, a white trim molding, a urinal, and a bucket were found inside the bathtub, which also had staining near the faucet. On Unit 3, surveyors observed a bathroom floor, toilet seat, and toilet bowl heavily soiled with a yellow substance; a broken end table; a wall and molding heavily soiled; a bathroom door heavily soiled; broken tiles on the bathroom floor; a bedside table in disrepair; and a broken heater vent cover. Additional observations on the third floor included dried dark brown and light brown splattered substances on a wall and oxygen concentrator in room E-307, a loose bathroom sink pulling away from the wall, a damaged and hanging radiator cover, and large areas of scraped, peeling, and damaged paint with exposed sheetrock and black scuff marks. On Unit 1 South, surveyors observed a length of vinyl cove base molding lying on the floor and exposing plywood underneath, jagged and torn cove base molding, peeling paint exposing wall board, a hole in the wall behind a door knob, and missing room number signage for two rooms. The LNHA and other leadership staff confirmed the environmental findings and stated that the issues detracted from the facility's homelike environment. The Director of Maintenance stated that issues should be reported and addressed through the electronic reporting system, but a review of the TELS reports for November and December 2025 did not reflect the issues identified during the survey.

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

Medication administration was not carried out according to physician orders and accepted standards of practice for multiple residents. One resident with Parkinson’s disease, anxiety disorder, and hypertension had an order for Midodrine 5 mg three times daily with a hold parameter for systolic blood pressure greater than 130, but the e-MAR did not include plotting of blood pressure values. During observation, an LPN took the resident’s blood pressure, documented it on paper, and administered Midodrine when the systolic pressure was 116. The same nurse also administered Clonazepam but did not sign the e-MAR after giving it, and the controlled drug record showed the medication had been signed out earlier that morning. The facility policy required the nurse to initial the MAR after administration and to document controlled substances after the medication was given. Another resident with urethral stricture, paroxysmal atrial fibrillation, and hypertension had an order for Olmesartan 40 mg daily to be held for systolic blood pressure less than 130. Review of the e-MAR showed multiple administrations when the documented blood pressure was below the ordered parameter, including readings such as 128/80, 112/66, 120/59, 128/67, 106/64, 120/79, 122/60, 123/68, 129/73, and 127/66. The facility policy stated medications must be administered in accordance with the orders, including any required time frame. A third resident had an order for Lidoderm Patch 5% to the right hip for pain, 12 hours on and 12 hours off, but the order did not include a quantity. During medication pass observation, the resident reported pain in the hip and groin area, and the nurse applied one patch to the back side of the hip. The nurse later acknowledged the order did not specify the number of patches and that the patch placement did not cover the groin pain area. In addition, narcotic reconciliation was inaccurate and incomplete: during controlled substance counts, multiple residents’ bingo cards did not match the IPCDR counts, one resident’s bingo card could not be located, one nurse did not sign the narcotic count sheet for the shift, another nurse reported wasting a tablet without a witness or documentation, and several IPCDR entries were blank or missing information about when and who removed doses.

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 a communication device for Resident #468, who had a language barrier and severely impaired cognition. During medication administration, an LPN prepared and administered Breo Ellipta 100-25 mg, ordered for COPD, and told the resident to rinse and spit after inhalation. The resident inhaled the medication and drank the water provided by the LPN. No communication board or device was found in the room to help instruct the resident, and the LPN acknowledged that the resident did not understand English and that she had not used another staff member to translate. The resident’s record showed a primary language other than English, a BIMS score of 3 out of 15, and a care plan intervention calling for the resident’s preferred language and the use of a communication board with basic words and pictures. During interviews, the LPN/ADON stated that communication sheets, picture boards, and another nurse who spoke the resident’s language were available on the floor, but these resources were not used during the medication pass. The facility policy for communication stated that staff would use different modes of communication, including language boards, interpreters, and family members.

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 that incontinence care was provided in a timely manner for three dependent residents on the 3rd-floor North Nursing Unit. During an incontinence tour, a CNA and the surveyor observed Resident #302 in bed with a brief saturated with urine, Resident #320 in bed with a pull-on and an incontinence brief inside it, both saturated with urine, and Resident #275 in bed with an adult brief saturated with urine. The CNA confirmed the conditions for each resident, and for Resident #320 stated that the use of both a pull-on and an incontinence brief was against facility policy. Resident #302 had diagnoses including Alzheimer's disease and diabetes mellitus, a BIMS score of 3 indicating severe cognitive impairment, and was documented as requiring staff assistance for toileting and being always incontinent of bowel and bladder. Resident #320 had diagnoses including dementia and epilepsy, severely impaired cognitive skills for daily decision making, and was dependent on staff for toileting and always incontinent of bowel and bladder. Resident #275 had diagnoses including diabetes mellitus and dementia, a BIMS score of 2 indicating severe cognitive impairment, and was documented as requiring staff assistance for toileting and being incontinent of bowel and bladder. Each resident's care plan included interventions related to incontinence care, including providing incontinent care as needed or checking for incontinence and assisting with care as needed. During interview, the CNA stated incontinence care should be provided every 2 hours and that the three residents had not been changed per facility policy. The LPN/charge nurse, the ADON, and the DON each confirmed that incontinence care should be provided every 2 hours, and the facility's ADL and urinary incontinence policies reflected that residents should receive necessary ADL assistance and that incontinent briefs should be checked every 2 to 2.5 hours or more often 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 facility failed to clarify medication routes identified in the Consultant Pharmacist’s monthly medication review for one resident. Resident #425 was admitted with diagnoses including dysphagia, gastrostomy, and unspecified severe protein-calorie malnutrition, and the Medicare 5-day MDS documented that the resident could not complete a BIMS due to current cognition and was receiving tube feeding. The resident was observed in bed with an enteral feeding machine and tube feeding products at bedside. Review of the resident’s orders showed Senna Oral Liquid ordered to be given by mouth at bedtime and Acetaminophen 325 mg tablets ordered to be given by mouth every 4 hours as needed for fever. The CP monthly medication reviews for October and November 2025 both directed staff to clarify the route of administration for Tylenol and senna. Staff interviews confirmed the medications were not being clarified: an LPN stated the medications were not given during her shift and would contact the MD for clarification, the UM stated the oral orders were an error and that the Charge Nurse was assigned to review CP medication reports and clarify orders, and the Charge Nurse stated they were responsible for clarifying CP orders but had missed the two medications that needed clarification. The RN stated the resident received all medications via feeding tube and acknowledged not fully reading the order because the oral route was not noticed.

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 that medications were administered without error at a rate of 5% or greater. During a morning medication administration observation, surveyors observed five nurses administer medications to six residents. There were 28 opportunities and two medication administration errors, resulting in a 7.14% error rate. The deficient practice involved two residents and two nurses observed during the medication pass. For one resident, an RN prepared medications for two residents in the same room and initially prepared only one tablet of memantine instead of the ordered two tablets for a resident with diagnoses including bipolar disorder, major depressive disorder, and dementia. The resident’s record showed mildly impaired cognition. The RN acknowledged the order required two tablets and added the missing tablet only after the surveyor reviewed the e-MAR. For another resident with diagnoses including hypertension, benign prostatic hyperplasia, and GERD, an LPN prepared medications to be crushed in applesauce and opened a tamsulosin capsule, despite the pharmacy label indicating the medication must be taken whole and the consultant pharmacist noting it should not be crushed, chewed, or opened unless a physician’s order allowed it. The LPN acknowledged there was no physician’s order permitting the capsule to be opened. The facility policy required checking the right medication, dosage, time, and method three times before 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

The facility failed to properly label, store, and dispose of medications and biologicals in multiple medication carts and medication room refrigerators. During inspection of the 2nd floor east wing high-side medication cart, an opened multi-dose vial of Fluphenazine Decanoate 25 mg/ml was found with an opened date of 10/31/25 and was expired. The LPN present acknowledged that the vial had a 28-day expiration after opening and should have been removed from active medication. On the 3rd floor east wing high-side medication cart, the surveyor found an opened Humalog insulin pen that was not dated. The LPN acknowledged that once an insulin pen is opened it should be dated. On the 3rd floor south wing high-sided medication cart, an unopened vial of Retacrit with a pharmacy label date of 12/10/25 was found stored in the cart, and the LPN acknowledged that it should have been stored in the refrigerator. The facility policy stated that outdated drugs or biologicals shall not be used and that medications requiring refrigeration must be stored in a secured refrigerator in the drug room or other secured location. In the first-floor west-wing medication room, the refrigerator temperature log showed a temperature of 48 degrees on 12/5/25 with no action documented, and no temperatures were recorded on 12/6/25 or 12/8/25. The refrigerator was observed with frost inside and a thermometer reading of 48 degrees, while refrigerated medications and biologicals inside included Mounjaro, Novolin 70/30, Lantus, Novolog, insulin glargine, Dupixent, and other residents' injectable medications. In another medication cart, an opened vial of Tuberculin PPD was found left out at room temperature even though the product required refrigeration. In the first-floor south unit medication room refrigerator, an opened vial of Acetylcysteine 20% solution dated 11/22/25 was found in active inventory, and the RN/CN stated that nurses on all shifts were responsible for removing expired biologicals and medications.

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 follow infection control procedures on all three nursing units during a COVID-19 outbreak. Specifically, five out of thirteen staff members were observed not wearing required personal protective equipment (PPE), such as surgical masks, in designated areas where mask use was mandated. During the initial tour, a laundry employee was seen without a surgical mask and stated they were unaware of the requirement. The Licensed Nursing Home Administrator (LNHA) and an Information Technology (IT) employee also entered a unit without masks, later stating they forgot to put them on. Additionally, a psychiatrist and a student intern were observed at the nursing station with their surgical masks worn improperly under their chins and acknowledged this during an interview. The facility's outbreak response plan required all personnel to wear PPE, including respiratory protection, in common areas and when entering rooms under droplet precautions. At the time of the survey, two residents were COVID positive, and several rooms were under droplet precautions with appropriate signage and PPE supplies available. Despite these protocols, multiple staff members failed to comply with mask requirements in common areas, as confirmed by both observation and staff interviews. The Director of Nursing (DON) acknowledged that the observed staff should have been wearing surgical masks in the affected building.

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 proper infection control practices and hand hygiene during meal service and tracheostomy care, as observed by surveyors. On the first-floor JDT unit, a Certified Nursing Assistant (CNA) did not perform hand hygiene between residents while serving meals, despite acknowledging the facility's policy requiring such practices. Similarly, on the 2 East unit, another CNA failed to perform hand hygiene between residents and did not follow Enhanced Barrier Precautions (EBP) protocols, which require hand hygiene before entering and after leaving rooms of residents on EBP. Additionally, a Licensed Practical Nurse (LPN) on the 2 East unit did not perform proper hand hygiene during tracheostomy care for a resident on EBP. The LPN washed her hands without lathering outside the stream of water and used the same paper towel to turn off the faucet, contrary to the facility's hand hygiene policy. The LPN acknowledged the mistake, attributing it to nervousness. The facility's policies, including the Hand Hygiene policy and Enhanced Barrier Precaution Policy, emphasize the importance of hand hygiene in preventing the spread of infections. However, staff members failed to comply with these guidelines, as confirmed by interviews with the Infection Preventionist and the Director of Nursing. These deficiencies were observed and documented by the surveyor, highlighting lapses in infection control practices within the facility.

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 that an antipsychotic medication was administered in accordance with professional standards of clinical practice to a resident experiencing episodes of auditory hallucinations. During a medication pass observation, a Registered Nurse (RN) was responsible for administering Risperidone Solution to the resident. The RN diluted the medication in water, as the resident preferred it this way, but did not ensure the full dose was consumed. After administering the medication, the RN noticed that some of the diluted solution remained in the cup, indicating that the resident did not receive the full prescribed dose. The resident involved had a history of paranoid schizophrenia and anxiety disorder, with documented episodes of auditory hallucinations. The RN's medication pass observation competencies showed a history of errors, although none were recorded in the most recent assessment. The incident was observed by a surveyor, who confirmed with the RN that the full dose was not administered. The RN acknowledged the mistake and stated that the resident likely did not receive the entire 4 mg dose as ordered by the physician.

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 consistently provide pharmaceutical services in accordance with professional standards, as observed during a survey. One of the deficiencies involved a medication refrigerator on the 3-West unit that was not lockable, containing prescription medications such as insulin. The Licensed Practical Nurse (LPN) on duty was unaware of the lock's functionality, and attempts by multiple staff members, including the Assistant Director of Nursing (ADON), to lock the refrigerator were unsuccessful. This issue was acknowledged by the Director of Nursing (DON) during a discussion with the surveyor. Another deficiency was identified in the handling of controlled substances. A discrepancy was found in the narcotic count for a resident who had been discharged from the facility. The resident's Lorazepam medication was not removed from the active inventory, and a tablet was unaccounted for. The LPN involved admitted to an error in the shift-to-shift count and acknowledged that the medication should have been removed or returned to the pharmacy upon the resident's discharge. The ADON confirmed that the medication should have been pulled to prevent errors and misplacement. Additionally, the facility was found to have borrowed medications from one resident to administer to another, which is against policy. A newly admitted resident experienced a seizure, and due to the unavailability of their medications, the LPN borrowed Lorazepam and Keppra from other residents. This action was confirmed by the DON after reviewing camera footage. Furthermore, a discontinued medication for another resident was not removed from the active inventory, and an undated bottle of blood glucose test strips was found in a narcotic box, which should have been dated according to the manufacturer's specifications.

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 that a resident, identified as Resident #114, was offered the pneumococcal vaccination according to the current CDC and ACIP recommendations. The resident, who had a history of chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension, was observed by a surveyor and had a BIMS score indicating intact cognition. Despite the resident's medical record indicating that their pneumococcal vaccine was up to date, documentation showed that they had received Prevnar 13, and there was no record of prior pneumococcal immunization or an offer of PCV15 or PCV20 as recommended by the CDC. The facility's policy on pneumococcal vaccination, dated September 10, 2023, stated that vaccinations should be administered in accordance with CDC recommendations. However, the policy did not reflect the current recommendations, and the resident's immunization record lacked essential details such as the type of vaccine administered, site, date, lot number, expiration date, and the name of the person administering the vaccine. The RN/IP and DON were unable to provide a rationale for the administration of Prevnar 13 instead of the recommended vaccines, and there was no documentation of communication with the physician regarding the CDC's current recommendations. During interviews, the RN/IP and DON acknowledged the oversight, and the DON stated that the policy was updated following the surveyor's inquiry. The physician involved indicated that Prevnar 13 was still relevant and that PCV20 could be administered as a subsequent dose. However, the facility's documentation practices did not align with their policy, as there was no record of the physician's rationale for choosing Prevnar 13 or any communication about the CDC's recommendations.