Madeira Healthcare Center

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 its activities program was directed by a qualified professional, as required. Review of the personnel record for the Activities Director showed a hire date of 04/02/26 and further revealed that this individual did not meet the qualifications required to serve as an activity director in the facility. An interview with the Regional Director of Clinical Operations confirmed that the Activities Director had been hired on that date and did not meet the requirements to be employed as a qualified activity director. This deficiency had the potential to affect all residents in the facility except for 14 facility-identified residents (#3, #8, #12, #36, #45, #50, #51, #62, #67, #73, #78, #81, #82, and #89) who did not participate in facility activities. The facility census at the time was 91 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 conduct quarterly care conferences for eight residents, as required by their policy. The residents affected had various medical conditions, including Alzheimer's Disease, depression, anxiety disorder, end-stage renal disease, heart and kidney transplants, multiple sclerosis, cerebral infarction, type two diabetes, schizophrenia, and Down syndrome. These residents required varying levels of assistance with activities of daily living (ADLs), and some had cognitive impairments, while others were cognitively intact. For Resident #39, the last documented care conference was held on 06/19/24, with no further documentation found in the progress notes from 08/01/24 to 03/26/25. Similarly, Resident #2's records showed no documentation of care conferences, and Resident #7 had no care conferences documented for 2024 or 2025. Resident #33 had only one documented care conference on 07/30/24, and Resident #63 had care conferences documented on 08/24/22 and 04/17/24, but none thereafter. Residents #9, #22, and #60 had no documentation of care conferences for the entire year of 2024. Interviews with the Regional Director of Clinical Operations and the Social Services Director confirmed the lack of documentation for these care conferences. The facility's policy requires that care plans be reviewed quarterly and that residents and their representatives be informed and involved in the care planning process, which was not adhered to in these cases.

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 prevent food contamination during a lunch meal service, affecting a resident with multiple sclerosis, dysphagia, morbid obesity, and major depressive disorder. The resident, who was admitted with moderate cognitive impairment and was dependent on staff for eating and other personal care, was observed being fed by a CNA. The CNA used his bare fingers to tear a piece of a cheese quesadilla before placing it in the resident's mouth with a fork, which was confirmed by the CNA during an interview. The Regional Director of Clinical Operations verified that staff should not handle residents' food with bare fingers. The facility's policy on meal distribution, revised in February 2023, mandates the use of proper food handling techniques to prevent contamination.

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's right to dignity and respect was upheld during incontinence care. Resident #19, who was cognitively intact and required maximal assistance for personal care, was observed receiving incontinence care in a private room without a privacy curtain. During this care, the resident's body was partially exposed when an LPN entered the room without knocking or asking for permission, thereby breaching the resident's privacy. The door to the resident's room was the only privacy barrier available. The incident was confirmed through staff interviews and a review of the facility's policy on resident rights, which mandates that staff knock and announce themselves before entering a resident's room if the door is closed. The policy aims to ensure that care is provided in a respectful and private manner. This deficiency was identified during a complaint investigation and affected one of the three residents reviewed for dignity, with the facility having a census of 87.

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 timely implement pressure ulcer prevention interventions as ordered for Resident #002, who was admitted with multiple complex medical conditions including traumatic brain injury, multiple sclerosis, and chronic kidney disease. Upon admission, the resident was identified with stage I and stage II pressure ulcers and was at high risk for developing further pressure ulcers. Hospital discharge orders included the use of a low air loss mattress and heel lift boots, but the facility did not document the implementation of these interventions from the resident's admission on December 13, 2024, until discharge on December 24, 2024. Heel protectors were not documented as being implemented until December 17, 2024. The Wound Care Nurse Practitioner (WCNP) was unaware of the resident's right heel pressure wound until December 17, 2024, and identified it as a facility-acquired stage II pressure ulcer. The WCNP did not recall seeing any skin recommendations from the hospital and was not aware of the discharge orders. The Regional Director of Clinical Operations confirmed the lack of documentation for the low air loss mattress and delayed implementation of heel protectors. The facility's policy on skin care and wound management emphasizes the prevention of skin impairment and promotion of wound healing, which was not adhered to in this case.

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 adequate infection control practices during incontinence care for a resident. The resident, who was admitted with diagnoses including intracerebral hemorrhage, hemiplegia, hemiparesis, morbid obesity, encephalopathy, and depression, was observed to be cognitively intact and always incontinent of bowel and bladder. During an observation, a Certified Nurse Aide (CNA) provided incontinence care to the resident while a Licensed Practical Nurse (LPN) Unit Manager provided stand-by assistance. After cleaning, rinsing, and drying the resident, the CNA did not change her soiled gloves before touching the resident's clean incontinence brief, clean linens, clean gown, head pillow, call light cord, and bed control cord. Interviews conducted with the CNA and the LPN Unit Manager confirmed that the CNA did not change her gloves after completing incontinence care, which was against the expected infection control practices. The LPN Unit Manager verified that the CNA should have changed her gloves before handling the resident's clean items. This deficiency was investigated under a specific complaint number, indicating non-compliance with infection control protocols.

Penalty

Inspection fine: $16,801

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 timely interventions for a cognitively impaired resident with a history of wandering and exit-seeking behavior. This resident, who resided in a secured unit, managed to elope from the facility without staff knowledge. The resident left the secured unit, found a car with keys inside in the parking lot, and drove approximately 8.2 miles away from the facility. The resident was missing for about two hours before being located by the police and returned to the facility. The resident had been admitted with diagnoses including dementia, insomnia, hypertension, and a history of traumatic brain injury, among others. The resident's quarterly Minimum Data Set assessment indicated severe cognitive impairment and independent mobility without an assistive device. The resident's care plan noted a history of wandering, agitation, restlessness, and exit-seeking behavior, with interventions in place to manage these risks. However, the facility was unable to determine how the resident exited the facility, although it was suspected that the resident might have used a stairwell door. Interviews with staff revealed that the resident had not appeared agitated or actively exit-seeking prior to the elopement but was displaying usual wandering behavior. The facility's elopement prevention policy required identifying residents at risk and developing individualized interventions, but the failure to prevent the resident's elopement indicated a lapse in the implementation of these measures. The facility's inability to determine the exact method of exit and the unchanged door codes contributed to the deficiency.

Removal Plan

• Resident #37 was placed immediately on one-on-one supervision.
• The DON provided verbal education on elopement to all staff working in the facility.
• The DON began reassessing residents for wandering/elopement risk.
• Maintenance Director #106 completed an audit/evaluation of all egress doors in the building.
• The code to the stairwell exiting to the front parking lot from the secured memory care unit was changed.
• The DON and the Administrator began educating all staff regarding elopement policies, procedures and prevention.
• Director of Social Services (DSS) #114 completed a new Brief Interview of Mental Status (BIMS) evaluation for Resident #37.
• The Interdisciplinary Team (IDT) met and conducted a Quality Assurance and Performance Improvement (QAPI) review.
• Clinical Manager (CM) #125 completed a Wanderguard audit.
• The Administrator audited the elopement binder with preliminary findings from the wandering/elopement risk assessments.
• The DON and Unit Manager (UM) #190 completed wandering and elopement risk assessments.
• They held a meeting with Minimum Data Set Nurse (MDS Nurse) #107 regarding care planning.
• The IDT reviewed care plans for all like residents and agreed upon interventions.
• The Administrator posted signs on the entry doors indicating visitors should not leave cars running unattended in parking lot.
• MDS Nurse #107 completed a review and updated all of the care plans for residents identified to be at risk for elopement.
• The Administrator reviewed the elopement binders again to verify all resident information was updated and current.
• The facility conducted an elopement drill during mealtime.
• The Administrator and the DON completed all staff re-education on elopement policies, procedures and prevention for all staff in facility with signatures obtained.
• To monitor for ongoing compliance, the DON or ED will conduct elopement drills on random shifts.
• The Administrator, the DON and department leaders will complete random audits of at least five staff per day to determine comprehension of elopement policies, procedures and prevention techniques.
• Maintenance Director #106 and/or designee will complete daily audits of the secured doors in the facility to ensure proper functioning and security.
• Daily audits will continue and then be referred to the facility QAPI team to review for further monitoring recommendations.
• The IDT met to review Resident #37's need for ongoing one-on-one observation.
• The IDT agreed to continue one-on-one observation for the resident.
• Interviews confirmed staff were educated and verbalized knowledge of the facility's elopement policies and procedures and guidelines for monitoring residents who have been placed on one-on-one supervision.
• Maintenance Director #106 changed the remaining two door codes to the stairwells and the elevator code for the secured unit.
• The facility will change the door codes monthly moving forward.
• Resident #37 was placed on immediate one-on-one observation and will be reviewed by the facility IDT/QAPI team to determine appropriate interventions.