Elderwood At Waverly

Penalty

Inspection fine: $110,520

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 multiple residents from sexual abuse by another resident with Alzheimer’s disease, resulting in Immediate Jeopardy and actual harm. Facility policy required staff training on abuse prevention, recognition of abuse, and ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or sexually aggressive conduct. Despite this, the resident with Alzheimer’s disease (Resident #2), who had moderate cognitive impairment and ambulated independently, was repeatedly involved in sexually inappropriate situations with six other residents, most of whom had severe cognitive impairment and were dependent on staff for mobility and care. The facility did not consistently assess, care plan, or monitor at-risk residents or the aggressor in a way that prevented repeated incidents. In the first incident, a nurse documented that Resident #2 was found in another cognitively impaired resident’s bed with a hand moving inside that resident’s brief. Resident #2 was removed and moved to another unit, but the incident report lacked staff statements and did not document Resident #2’s activities prior to discovery or when either resident was last observed. There was no documented social work follow-up or updated interventions for the victim resident, despite a care plan noting trauma and anxiety related to prior traumatic events. The only documented care plan change for Resident #2 was a temporary unit move, medication review, and behavioral monitoring, and there was no documentation of care plan updates when Resident #2 was later moved back to the original floor or of specific interventions addressing sexually inappropriate behavior. Subsequent incidents showed a pattern of inadequate protection and follow-up. In one event, a severely cognitively impaired resident was found in Resident #2’s bed, naked from the waist down, while Resident #2 was completely unclothed; staff noted apparent fluid on the sheet, but there was no care plan update or new interventions for the victim, and Resident #2’s care plan was only revised to note that another resident had been found in the bed, with no new protective measures. In another incident, Resident #2 was observed in a dining room kissing a severely cognitively impaired resident and removing a hand from the resident’s thigh area; although staff separated them and documented the event, there was no care plan revision for the victim. In a further incident, a cognitively intact resident reported that it was not acceptable for Resident #2 to touch their breast when Resident #2 attempted to kiss and rub the resident’s breast; the only documented intervention was to keep the residents apart in the activity room, and there was no care plan revision or psychosocial follow-up for the victim. Additional incidents continued despite knowledge of Resident #2’s history. In one case, staff found Resident #2 at the bedside of a severely cognitively impaired resident with both hands under the sheet; the victim’s brief was almost completely unsecured, and the resident stated, “it hurts,” though no open skin areas were found. In another case, Resident #2 was found lying in the bed of a severely cognitively impaired resident who was yelling for help, and later sitting on the same resident’s bed holding their hand; staff noted that Resident #2 wandered frequently at night and that there were no safety measures in place to protect female residents aside from general monitoring. Interviews with social services staff and the DON confirmed prior knowledge of Resident #2’s sexually inappropriate behaviors with multiple female residents, acknowledged that there were no safety measures in place for several of the victim residents, and revealed that no psychosocial follow-ups or psychological evaluations were completed for the victims. The Medical Director reported being notified only recently about the pattern of inappropriate sexual behaviors, despite expecting to be informed of such incidents. These actions and omissions demonstrate that the facility failed to implement effective assessments, care plan revisions, monitoring, and protective interventions to prevent ongoing sexual abuse of residents.

Removal Plan

• Resident #2's care plan was revised to show 1:1 supervision at all times.
• All residents who resided on the first floor South Unit had their care plans revised to be at risk for a victim of abuse.
• All nursing staff working on South Unit were educated on Resident #2's revised care plan (confirmed by signature records).
• The Medical Director and Nurse Practitioner #29 assessed Resident #2's medications and made changes.
• A referral for a psychiatric evaluation of Resident #2 was made.
• All staff were re-educated on recognizing and reporting abuse.
• Education was verified through staff interviews across departments and review/verification of education signature sheets against a full staffing list.
• All residents on the South Unit were interviewed by members of the Interdisciplinary Team to rule out any further instances of unreported abuse; progress notes from the last 30 days were also reviewed for those residents (no concerns identified).
• Social Worker #14 followed up with Residents #3, #4, #5, #6, #7, and #8 to ensure no psychosocial/emotional harm was noted.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse by staff. A support aide struck a resident on the left shoulder after the resident, who was known to be combative with care, hit the aide during a transfer. The facility’s abuse prevention policy required staff training on prevention of all forms of abuse, recognition of abuse, and supervision of staff on all shifts to identify inappropriate behaviors such as rough handling and physical punishment. Despite this policy, the aide reacted to being hit by the resident and struck back, constituting physical abuse. The resident involved had Alzheimer’s disease with severely impaired cognition, used a wheelchair, and was dependent on staff for all ADLs. The comprehensive care plan documented alteration in mood and behavior due to Alzheimer’s disease, communication deficits, and dementia with psychotic disturbance. It also noted that the resident could be combative and resistive to care, verbally aggressive, and at times refused all care. Interventions in the care plan included providing verbal cues prior to care routines, administering medications as ordered, reporting changes in mood and behavior to the physician, redirecting and providing distractions during agitation, and reapproaching as appropriate. During the incident, the resident was combative with care, hit the support aide during transfer, and the aide responded by hitting the resident on the shoulder. The incident was witnessed and reported by another CNA who was assisting with the transfer. This CNA stated that the resident struck the support aide, and the aide then hit the resident’s left shoulder with their right hand while saying, "don’t hit me," and that the slap was not hard but could be heard. The resident, due to cognitive impairment, could not describe what had happened when assessed afterward. The facility’s investigation, including staff interviews and review of statements, concluded that abuse had occurred when the support aide struck the resident in response to the resident’s combative behavior during care.

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 #142, who had diagnoses including Parkinson's disease, dysphagia, and dementia, received the necessary assistance with activities of daily living, specifically with eating. The resident's care plan required supervision or touching assistance for eating, with maximum encouragement, and specified that meals should be taken in the dining room. However, observations revealed that the resident was often left without the required supervision and cueing during meals, leading to inadequate food intake. From March 20 to March 27, 2025, the resident's meal consumption was consistently low, with many meals left untouched. Observations on multiple occasions showed the resident staring straight ahead without eating, holding food without consuming it, and being distracted by the television. Staff failed to provide the necessary encouragement or assistance, as required by the resident's care plan. Interviews with staff confirmed that the resident required supervision with maximum cueing, but this was not consistently provided. The lack of supervision and cueing was acknowledged by various staff members, including a Certified Nurse Aide, a Licensed Practical Nurse, and a Registered Nurse Unit Manager, who all stated that the resident needed constant encouragement to eat. The Assistant Director of Therapy also noted that the resident's functional maintenance program required consistent cueing to ensure proper nutrition. Despite these requirements, the resident was often left unattended or inadequately assisted during meals, resulting in poor nutritional intake.

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 supervision and adhere to care instructions for two residents, leading to potential safety risks. Resident #171, who had dysphagia and was on aspiration precautions, was observed consuming ice chips without a physician's order or proper supervision. Despite care instructions specifying that the resident should only have 60 milliliters of ice chips while sitting upright in a chair, staff provided a 20-ounce cup of ice chips and allowed the resident to consume them while lying in bed. This action was contrary to the aspiration precautions in place and increased the risk of aspiration. Resident #164, diagnosed with early onset Alzheimer's disease and a history of falling, was at high risk for elopement. The resident frequently wandered into non-residential areas, including the lobby, kitchen, and employee cafeteria, without a documented plan to address these behaviors. Although the resident was equipped with a wander alert device, there were multiple instances where the functionality of the device was not checked due to the unavailability of a meter. This lack of monitoring and intervention increased the risk of the resident accessing potentially unsafe areas. The facility's policies on aspiration precautions and the electronic wandering security system were not adequately followed, leading to these deficiencies. Staff interviews revealed a lack of awareness and adherence to care instructions and policies, contributing to the unsafe conditions for both residents. The failure to ensure proper supervision and adherence to care plans resulted in significant safety concerns for the residents involved.

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 diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not implement telepsychiatry recommendations for non-pharmacological interventions to manage the resident's behavioral symptoms. The resident, who had severe cognitive impairment and a history of aggressive behaviors, was not provided with the recommended interventions to address their agitation and combativeness. The resident's comprehensive care plan documented various behavioral issues, including resistance to care, verbal threats, and self-abusive acts. Despite these documented behaviors, the facility did not incorporate the telepsychiatry recommendations into the resident's care plan. These recommendations included identifying behavioral triggers, providing trauma-informed care, and encouraging proper sleep patterns. Observations revealed that the resident continued to exhibit distressing behaviors, such as wandering and yelling, without appropriate interventions being implemented. Interviews with facility staff indicated a lack of awareness and implementation of the recommended non-pharmacological interventions. Staff members were unsure of the specific interventions for the resident's behaviors and did not consistently provide the necessary support to address the resident's distress. The failure to implement these recommendations resulted in the resident experiencing ongoing distress and agitation, highlighting a deficiency in the facility's care planning and intervention processes.

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 food and drink were palatable, attractive, and served at safe and appetizing temperatures during two lunch meals tested on 3/24/2025 and 3/28/2025. On 3/24/2025, multiple residents reported that the cube steak was difficult to cut and chew, with some residents requiring meal replacements. Observations revealed that the cube steak was tough, and residents with specific dietary needs, such as those requiring easy-to-chew food, were not adequately accommodated. The facility's policy required the Director of Dining Services or a designee to maintain proper food temperatures and holding times, but this was not effectively implemented. On 3/27/2025, a lunch meal was tested for taste, temperature, and palatability, revealing that several food items were not served at appropriate temperatures. The applesauce, turkey bake, Brussels sprouts, coffee, and milk were all outside the recommended temperature ranges. Interviews with staff indicated a lack of awareness regarding proper food temperatures, and the Food Service Director acknowledged the issue, citing budget constraints as a factor in the quality of the cube steak. Despite being aware of the meal replacement requests, the Food Service Director had not received complaints about food temperature or quality prior to the survey.

Penalty

Inspection fine: $10,364

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 document and communicate a resident's updated Advance Directives, leading to a discrepancy between the paper medical record and the electronic medical record. The resident had changed their Medical Orders for Life-Sustaining Treatment from a full code status to a Do Not Resuscitate (DNR) order. However, the paper record and electronic record did not match, resulting in confusion when the resident was found unresponsive. Nursing staff initially followed the outdated paper record, which indicated a full code status, and began cardiopulmonary resuscitation. The resident, who had diagnoses including acute posthemorrhagic anemia, pancytopenia, and chronic kidney disease, had returned from the hospital and expressed a desire to change their code status to DNR. The updated Medical Orders for Life-Sustaining Treatment form was completed and signed by the resident's healthcare proxy, but it was not properly filed. Instead, it was placed on a provider clipboard for review, leading to the outdated form remaining in the file. This oversight resulted in the staff initiating life-saving measures contrary to the resident's wishes. Interviews with facility staff revealed a breakdown in the system for updating and filing Medical Orders for Life-Sustaining Treatment forms. The Registered Nurse Unit Manager was unsure of the correct procedure for filing the new form, and the staff were not aware that the updated form should have replaced the old one in the file. This miscommunication and procedural error led to the initiation of unwanted life-saving measures, highlighting a critical failure in the facility's process for handling advance directives.

Removal Plan

• The system for filing the forms was revised. The Medical Orders for Life Sustaining Treatment forms were to be completed upon admission and readmission to ensure accurate code status. Once the new Medical Orders for Life Sustaining Treatment form was completed, it was to be placed in the file and the old form would be marked on the last page. form changed, new form completed. The reviewer would enter the date and time, then sign. Once completed, the voided form would be filed in medical record. The new Medical Orders for Life Sustaining Treatment form was to remain in the file on the unit (not the medical provider clipboard).
• All licensed nursing staff were educated on the process for completing a new Medical Orders for Life Sustaining Treatment form, and identification and verification of advance directives. The electronic record would be verified initially and then the paper medical record would be used to confirm the status; this record would be brought to the room where basic life support was being considered.
• A full house audit was completed to verify all Medical Orders for Life Sustaining Treatment forms were signed and executed, and that orders were entered correctly into the electronic medical record.
• The facility initiated five audits per week for three months to ensure staff could verbalize the appropriate measures and how to verify code status when they found an unresponsive resident.
• All staff responsible for performing cardiopulmonary resuscitation or verifying Medical Orders for Life Sustaining Treatment forms were re-educated by the Director of Nursing and Educator on the facility policy for Basic Life Support and the new process for filing the Medical Orders for Life Sustaining Treatment forms.
• The facility will complete audits for six months for any resident who expired at the facility to ensure that the policy for Basic Life Support and Medical Orders for Life Sustaining Treatment orders were honored. Any deficiency will be reported to the Director of Nursing immediately.
• The facility planned to conduct one code drill per shift for one month, and then quarterly thereafter, to monitor compliance.
• Medical Orders for Life Sustaining Treatment audits would be completed by the social workers weekly, for eight weeks and then monthly for three months. All results of the audits were to be reported to the Quality Assurance Team.

Penalty

Inspection fine: $10,364

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 with Alzheimer's disease and self-feeding difficulties received the necessary assistance during meals as outlined in their care plan. The resident, who had severely impaired cognition and required partial to moderate assistance with eating, was observed during breakfast and lunch without receiving the planned assistance. Despite the care plan specifying that the resident needed one-person physical assistance and adaptive equipment, staff did not provide the required support or encouragement during meals. During breakfast, the resident was observed eating independently without staff assistance, consuming only a portion of their meal. Similarly, during lunch, the resident was left to eat on their own, resulting in incomplete consumption of their meal. Staff members, including Certified Nurse Aides, were aware of the care plan requirements but failed to provide the necessary assistance, which could potentially impact the resident's nutritional status. Interviews with staff revealed a lack of awareness regarding the specific level of assistance required for the resident, despite the information being available on care plans and meal tickets. The Director of Therapy and the Registered Nurse Unit Manager confirmed that the resident required partial to moderate assistance, which included physical and verbal cues to encourage intake. The failure to adhere to the care plan and provide the necessary assistance during meals was identified as a deficiency in the facility's care practices.