Northwestern Healthcare Center

Penalty

Inspection fine: $68,250

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 protect residents from all forms of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. This deficiency indicates that at least one resident was not safeguarded from abuse or neglect, as required by regulations. The report identifies a lapse in the facility's responsibility to ensure a safe environment free from abuse and neglect for its residents.

Penalty

Inspection fine: $68,250

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

A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.

Penalty

Inspection fine: $68,250

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 expired foods were disposed of timely. During an 08/11/25 kitchen observation with the Dietary Manager, expired food items were found in multiple storage areas, including a case of sour cream packets dated 07/14/25 and a jar of Dijon mustard dated 03/27/25 in the walk-in cooler, another expired jar of Dijon mustard dated 03/27/25 and a container of bread crumbs dated 06/06/25 in the dry stock room, and an expired jug of prune juice dated 07/03/25 in the resident refrigerator. The Dietary Manager verified that the sour cream packets, Dijon mustard, bread crumbs, and prune juice were expired and stated that he or his staff were to go through food storage weekly and dispose of out-of-date foods at that time. The facility identified that 79 residents received meals from the kitchen, and Residents #6 and #45 were ordered nothing-by-mouth.

Penalty

Inspection fine: $68,250

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 and maintain a comprehensive QAPI program and plan to address care issues and concerns in the facility. Review of QA committee attendance records showed QA meetings were held on four dates over the previous 12 months, but the facility was unable to provide evidence of ongoing QAPI program implementation related to the neglect of Resident #87 and Resident #90's fall. During interview, the Administrator confirmed there was no evidence, including documentation, of QAPI program implementation for these events. The annual survey and multiple complaint allegations identified noncompliance in abuse resulting in Immediate Jeopardy, actual harm, and death involving Resident #87. At 11:30 P.M., Resident #87 complained of chest pain to a CNA, who reported the change to an RN; the RN then failed to timely identify and obtain treatment following the acute change in condition. CPR was also not initiated timely when Resident #87 was found unresponsive without vital signs, and the resident expired at 2:50 A.M. with cause of death listed as cardiopulmonary and pulseless electrical activity with onset 15 minutes prior to death. The survey also identified noncompliance in quality of care resulting in actual harm to Resident #90, who required substantial to maximal assistance to roll left and right and was dependent on staff for toileting, but was improperly rolled from an elevated bed and fell to the floor, sustaining multiple fractures including fractures of both femurs, the fibula, and tibia, and required hospitalization.

Penalty

Inspection fine: $68,250

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 Quality Assurance (QA) meetings were held at least quarterly with the Medical Director present to address care issues and concerns in the facility. Review of the QA committee attendance records for the previous 12 months showed four QA meetings held in four consecutive months on 04/25/25, 05/05/25, 06/02/25, and 07/07/25, but there were no other records of QA meetings from 09/01/25 to 03/31/25. During interview on 08/20/25 at 11:52 A.M., the Administrator confirmed there were no other QA meetings documented and had no evidence that the meetings had taken place or that the Medical Director was present. The facility's undated QAPI Plan stated that the facility would have a QAPI meeting every month with required members present.

Penalty

Inspection fine: $68,250

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 and implement an infection prevention and control program when staff did not perform hand hygiene between residents and after glove use during medication administration and a blood glucose check. During observation on 08/12/25 at 7:43 A.M., LPN #814 opened the locked medication cart, prepared medications for Resident #76, signed off the medications in the electronic medical record, and then proceeded directly to administer them without performing hand hygiene before giving the medications or after contact with the resident and the environment. The same LPN was then observed administering medications to Residents #111 and #110 without performing hand hygiene between each resident's medication administration. During an observation on 08/12/25 at 8:06 A.M., LPN #814 wore gloves to obtain Resident #63's blood glucose and did not perform hand hygiene before donning gloves or after removing them. In interview, LPN #814 verified she had not performed hand hygiene as required during medication administration to Residents #76, #110, and #111 or during the blood glucose check for Resident #63. Later, LPN #914 was observed at 8:20 A.M. administering medications to Resident #51 without performing hand hygiene before or after resident contact, and she verified she had forgotten to perform hand hygiene before and after contact with residents and the environment as required. The DON and Regional Director confirmed staff were to follow the facility's medication administration policy, which required hand hygiene before beginning medication administration and before and after each resident's medication administration.

Penalty

Inspection fine: $68,250

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 quarterly statements to residents with personal trust fund accounts, as required by both facility policy and the signed Resident Fund Management Service Authorization Agreement. Record review showed that a resident who had authorized the facility to manage their funds did not receive any quarterly statements for their account, despite the agreement specifying that statements would be provided at least quarterly. The resident's account had a balance, but the resident reported not receiving statements and being unaware of the account balance, even after making multiple requests for this information. An interview with the Business Office Manager confirmed that no quarterly statements had been distributed to residents or their guardians. The facility's policy requires accurate and timely information to be provided to residents regarding their personal funds, but this was not followed. The deficiency was identified through record review, resident and staff interviews, and policy review, affecting at least one resident directly, with the potential to impact others with similar accounts.

Penalty

Inspection fine: $68,250

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 notify Medicaid residents when their resident funds reached $200 less than the SSI resource limit. For Resident #28, the record showed an admission date of 06/07/23, Medicaid as a payor source, and that the resident was the primary financial contact and cognitively intact. The resident fund account quarterly statement showed a balance of $2,372.91, and the facility had no documentation that a spend down notification had been provided. During interview, Resident #28 stated he was not aware of how much money was in the account, and the BOM confirmed there was no documented proof that spend down letters had been sent. For Resident #45, the record showed an admission date of 07/20/18, Medicaid as the payor source, and that the resident was not interviewable. The resident fund account quarterly statement showed a balance of $4,186.56, with no documented evidence of a spend down notification. The BOM again confirmed there was no documented proof that spend down letters had been sent and stated she had only been at the facility for six weeks and was still catching up from the previous manager. The facility policy stated the business office was to notify all Medicaid residents when the asset limit was approaching.

Penalty

Inspection fine: $68,250

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 care plans were timely updated and care conferences were held quarterly with the resident and/or family for two residents reviewed. For Resident #49, who was admitted with diagnoses including type II diabetes mellitus with ketoacidosis without coma and chronic obstructive pulmonary disease, the MDS showed some cognitive impairment. Her care plan dated 07/09/25 stated she was independent with showers and/or bathing with assistance only as needed based on time of day, mood, pain, or fatigue. However, a progress note dated 07/16/25 documented that she was confused to the point she would urinate on the floor and was unable to care for herself. During interviews on 08/11/25 and 08/14/25, the resident and CNAs stated she needed assistance with bathing and ADLs, and on 08/18/25 an LPN confirmed the resident required assistance with ADLs including showers and that the care plan should have been updated to reflect the change in care need. For Resident #58, who was admitted on 09/18/24 with diagnoses including front temporal neurocognitive disorder, depression, anxiety, and altered mental status, the record showed a care conference on 11/11/24 with the resident, guardian by telephone, social worker, and DON. The resident stated on 08/11/25 that she had not been asked to attend a care conference this year. On 08/14/25, the SWD stated care conferences were completed yearly, quarterly, and within 72 hours of admission, but could not find documentation of any care conference for Resident #58 after 11/11/24 and confirmed there should have been two care conferences completed that year, with none completed.

Penalty

Inspection fine: $68,250

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 Resident #49 received proper treatment and assistive devices to maintain hearing abilities. Resident #49 was admitted with diagnoses including type II diabetes mellitus with ketoacidosis without coma and COPD, and the medical record showed a physician order for audiology consultations as needed. A progress note documented that the resident’s brother requested audiology, optometry, and dental appointments, and the resident was placed on a list to be seen for those services. The MDS reflected some cognitive impairment and minimal difficulty related to hearing, and the care plan identified impaired cognition, weakness, poor safety awareness, and risk for communication problems related to dementia. Subsequent progress notes documented the resident stating her mood had not been great because of hearing and vision issues, that she was angry her hearing and vision were not fixed, and that she was depressed about limited hearing. Later notes documented the resident stating her hearing was bad, having vertigo, and self-isolating in her room and sleeping most of the day because she was unable to hear well. The audiology patient list from the last visit showed the resident was not seen, and during interview the resident stated staff were not doing anything about her hearing and sometimes ignored her. A CNA confirmed the resident had hearing difficulty and needed staff to speak louder. The SSD stated she handled audiology appointments, but later confirmed the resident had no history of being seen by the audiologist, was not on the upcoming list, and had no prior or upcoming audiology appointments scheduled.

Penalty

Inspection fine: $68,250

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

Provide appropriate foot care failed for one resident with diabetes mellitus type II and chronic obstructive pulmonary disease. The resident was admitted to the facility with a physician order for podiatry consultations as needed, but review of the podiatry patient list showed the resident was not seen at the last podiatry visit. During observation, the resident was lying in bed in a gown and both feet had toenails that were long, brittle, and brown in color. The resident stated she was overdue for a shower, needed assistance because her feet were swollen, and said staff sometimes ignored her and focused on other residents. A CNA confirmed the resident had long toenails and stated CNAs were responsible for cutting residents’ nails unless they were diabetic, and that the podiatrist cut toenails for residents who required or requested it. The SSD stated she handled podiatry appointments and that staff would notify her if a resident needed ancillary services, but follow-up interview confirmed the resident had no history of being seen by the podiatrist and was not on the upcoming list. The facility’s Resident Rights document stated residents would receive personal care including nail care and/or clipping, but the resident did not receive that care as documented.

Penalty

Inspection fine: $68,250

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 pureed foods according to the recipes and standards of practice for two residents who were identified to receive pureed meals. During observation, a dietary staff member placed four chicken thighs and two two-ounce ladles of chicken gravy into a food processor, blended the mixture, then added four to eight ounces of hot water from a pan on the stove and blended again. The staff member stated there was no broth available that day and that gravy was sometimes used to thin the pureed product. The Dietary Manager verified staff were not to add hot water to purees and confirmed the recipe was not followed as written because it directed staff to add broth or gravy if thinning was needed. A second observation showed the same staff member placing eight cups of corn with milk and butter, along with eight cups of water, into the food processor and blending the mixture, then adding two four-ounce scoops of thickener and blending again. The Dietary Manager again verified staff were not to add hot water to purees. Review of the diet list dated 08/11/25 identified two residents as receiving pureed food, and the recipes reviewed for chicken and cream-style corn directed staff to blend the food until smooth and use broth, gravy, liquid, or commercial thickener as needed.

Penalty

Inspection fine: $68,250

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 administer its operations in a manner that enabled it to use resources effectively and efficiently because it did not employ enough laundry staff to meet resident needs. During observation of the soiled linen room on the Back-South hall, two yellow bins were uncovered and overflowing with yellow and brown-stained towels, sheets, gowns, and clothing, and five open, unsealed bags of soiled linens were on the floor in various areas. A laundry aide confirmed the bins were uncovered and overflowing with dirty linens. Later observation of the soiled linen room on the Front-South hall showed multiple bags of soiled linen that were open and unsealed. The laundry aide stated the soiled linen had not been taken care of in a couple of days, that she had been called in to assist even though she was not scheduled to work, and that no one was scheduled to work laundry until 2:00 P.M. or 3:00 P.M. She also stated the CNAs were having a hard time finding clean linens because of the piled high soiled linens. Review of the facility's Laundry Handling & Processing Policy showed the facility had a policy to reduce the risk of disease transmission based on hygiene, common sense, and CDC guidance.

Penalty

Inspection fine: $68,250

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 it had a transfer agreement with one or more hospitals certified by Medicare or Medicaid to allow residents to be moved quickly to the hospital when medical care was needed. During an entrance conference for an annual and complaint survey on 08/11/25 at 8:45 A.M., the surveyor requested the facility transfer agreement from the Administrator. Review of facility documents and continued requests for the transfer agreement during the annual and complaint survey produced no results. On 08/21/25 at 12:30 P.M., the Administrator confirmed the facility did not have a transfer agreement with one or more hospitals. This deficiency had the potential to affect all 81 residents residing in 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 complete personal laundry and return it to residents in a timely manner, affecting three residents and potentially impacting all 81 residents who relied on the facility for laundry services. Interviews with staff, including LPNs and CNAs, revealed complaints from residents and families about missing clothes or delayed returns from the laundry. Residents reported waiting up to two weeks for their clothing, with some items never returned. The issue was also raised in a resident council meeting, where multiple residents complained about the poor laundry service. The facility's laundry process involved CNAs collecting laundry and placing it in bins in the soiled room, from where laundry aides would pick it up. However, observations showed a large backlog of dirty personal clothing, with a pile over five feet tall. The facility had limited laundry equipment, with only two medium washers and two dryers, which contributed to the delay. The Administrator acknowledged the problem, stating that a two-week turnaround was unacceptable. The facility's grievance log recorded 16 complaints about missing clothing over a period of several months.

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 arrange for an escort for Resident #80 to an outside appointment on 11/05/24, despite previous appointments always having an escort. Resident #80, who has diagnoses including Parkinson's disease, legal blindness, glaucoma, and schizophrenia, was admitted on an unspecified date and has intact cognition but highly-impaired vision, using a wheelchair for mobility. The medical record and nurse's notes indicated that an escort was needed for appointments on 09/24/24, 09/27/24, and 10/01/24, but the order for 11/05/24 did not mention the need for an escort. Interviews with LPNs and the Director of Nursing confirmed that nurses are responsible for arranging escorts when needed, and it was acknowledged that an escort was not sent with Resident #80 on 11/05/24. This deficiency was investigated under Complaint Number OH00159778.

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 was free from significant medication errors due to a delay in transcribing and administering the resident's medication orders upon admission. The resident, who had multiple medical diagnoses including paraplegia, fractures, seizures, diabetes, gout, depression, and hypertension, was admitted to the facility but did not receive several of his prescribed medications in a timely manner. The delay in transcription and administration of medications ranged from two to nine days after admission. Upon review, it was found that the hospital discharge orders for the resident included a comprehensive list of medications for various conditions, but these were not transcribed into the facility's electronic medical record on the day of admission. The only medication order transcribed on the admission date was for oxycodone, while other critical medications for conditions such as hypertension, diabetes, and seizures were not administered until several days later. Interviews with facility staff revealed a lack of clarity and documentation regarding the failure to transcribe these orders, and the former Assistant Director of Nursing, who was responsible for transcribing the orders, was no longer available for comment. The facility's policies on medication administration and physician orders did not provide specific guidance on the transcription of admission orders, contributing to the oversight. The Director of Nursing, who was new to the facility, confirmed the deficiency and noted the absence of documentation explaining the delay. The deficiency was investigated under a complaint, highlighting a significant lapse in the facility's medication management process.

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 infection control practices during medication administration, specifically affecting Resident #39. The resident, who had a history of schizoaffective disorder, bipolar type, type 2 diabetes mellitus, chronic obstructive pulmonary disease, vascular dementia, and repeated falls, was observed during a medication administration session. The LPN responsible for administering medications placed a glucometer directly on the resident's bed without using a barrier, which is against the facility's policy for blood glucose point of care testing. The incident was confirmed through interviews with the LPN and the Director of Nursing (DON). The LPN admitted to forgetting to place a barrier under the glucometer, and the DON confirmed that a barrier should have been used. This oversight in infection control practices had the potential to affect other residents residing on the Back North Hall, as the facility census was 87. The deficiency was identified during an investigation of a separate complaint.

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 a medication error rate of less than five percent, resulting in a calculated error rate of 10.34 percent. This deficiency was identified during an observation of medication pass, staff interviews, and review of medical records, manufacturer's instructions, and facility policy. The errors affected two residents out of four observed during the medication pass. Resident #58, who has a history of cerebral infarction, dementia, and other conditions, was administered crushed potassium chloride ER by an LPN, despite the manufacturer's instructions indicating that the medication should not be crushed, chewed, or sucked. The LPN incorrectly believed the medication could be crushed based on previous advice from a pharmacy. Resident #75, with diagnoses including chronic kidney disease and heart failure, received levothyroxine and simethicone along with other medications after having breakfast, contrary to the manufacturer's instructions that levothyroxine should be administered on an empty stomach and not with simethicone. The medication technician was unaware of these specific administration requirements and administered the medications based on the resident's preference. The facility's policy on medication administration was found to be lacking in adherence to manufacturer's recommendations, contributing to the medication errors.

Penalty

Inspection fine: $26,813

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 appropriate pressure ulcer care and prevent new ulcers from developing for Resident #46, who was at risk due to conditions such as hemiparesis, type two diabetes mellitus, and morbid obesity. Despite being dependent on staff for bed mobility and incontinence care, the resident developed two new Stage III pressure ulcers on the right posterior thigh, which were not timely identified or properly treated. The resident reported increased pain and expressed concerns about the lack of timely incontinence care and assistance with turning and repositioning. The care plan for Resident #46 included interventions such as weekly skin checks and assistance with turning and repositioning, but these were not consistently implemented. The resident's medical record did not show evidence of being turned and repositioned, nor were there any weekly skin checks completed from 08/01/24 through 08/22/24. Observations confirmed that the resident was not repositioned during specific times, and interviews with staff revealed a lack of timely care and reluctance to assist the resident due to her size and dependency. The facility's policy required evaluation of each resident's skin condition upon admission and weekly thereafter, along with the implementation of prevention strategies for pressure ulcers. However, the facility did not adhere to these guidelines, as evidenced by the absence of weekly skin checks and the delayed response to the resident's skin condition. The deficiency was further highlighted by the lack of documentation and communication regarding the resident's risk factors and necessary interventions.

Penalty

Inspection fine: $26,813

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 proper infection control practices during incontinence care and high-risk care activities, affecting two residents and potentially impacting others requiring enhanced barrier precautions. Resident #31, who had severe cognitive impairment and was frequently incontinent, was observed receiving incontinence care from a State Tested Nursing Assistant (STNA) who did not wear a gown as required by the Enhanced Barrier Precautions. The STNA also failed to change gloves after handling soiled items and improperly used washcloths to soak up urine in the resident's heel protectors, which should have been replaced. Resident #12, who required enhanced barrier precautions due to an indwelling catheter, was transferred by two STNAs and an LPN without wearing gowns, despite the presence of a sign indicating the need for such precautions. The LPN admitted to not understanding the sign's meaning, and the STNAs acknowledged their failure to wear gowns during the transfer. This oversight occurred despite the facility's policy requiring PPE during high-contact care activities. The facility's policies on standard and enhanced barrier precautions were not adhered to, as evidenced by the staff's failure to use appropriate PPE during high-contact activities. The Director of Nursing and other staff members recognized the need for further education on enhanced barrier precautions, indicating a gap in staff training and awareness regarding infection control protocols.

Penalty

Inspection fine: $26,813

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 timely incontinence care for Resident #46, who was affected by hemiplegia, hemiparesis, type two diabetes mellitus, and morbid obesity. The resident's care plan indicated a need for assistance with activities of daily living due to these conditions, including the use of a mechanical lift with two-person support and regular checks for incontinence to prevent skin breakdown. Despite these requirements, the resident was found to have been left in a soaked incontinence brief with urine and feces for an extended period, as observed on the morning of 08/20/24. The resident reported that she often did not receive timely changes, and her call light was left unanswered for several hours during the night. Interviews with staff revealed that the resident's call light was activated, and she was calling for assistance, but her aide did not respond promptly. Another STNA eventually attended to her, finding her bed, gown, and incontinence brief saturated. The STNA reported that many aides were reluctant to care for the resident due to her size and dependency. The facility's policy on routine resident care emphasized the importance of providing care for incontinence with dignity and maintaining skin integrity, which was not adhered to in this instance. This deficiency was investigated under Complaint Numbers OH00156946 and OH00156175.

Penalty

Inspection fine: $26,813

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 timely evaluation, monitoring, and treatment of a resident's left knee contusion with fracture blisters, hematoma, and effusion. The resident was admitted to the facility with a history of a fall resulting in a left knee injury, and the hospital discharge instructions included specific care for the knee, such as no weight bearing, use of a knee immobilizer, and regular skin checks. However, the facility did not develop a care plan for the resident's knee condition, and there was no evidence of skin assessments or documentation regarding the knee's condition during the resident's stay. The resident's medical records revealed a lack of documented skin assessments and treatment orders for the knee condition from the time of admission until a week later. The facility's policy required weekly skin assessments and evaluations upon admission, but these were not conducted. Interviews with facility staff indicated that the resident's dressing was not changed or assessed until a week after admission, and there was no documentation to support claims that the resident refused care or that verbal orders were received to leave the dressing in place. The resident expressed dissatisfaction with the care received and was eventually transferred to the hospital, where it was noted that the knee wound had worsened. The hospital staff expressed concern that the wound was open upon the resident's return, whereas it had not been open previously. The facility's failure to adhere to its own policies and the lack of proper documentation and care planning contributed to the deficiency identified in the report.

Penalty

Inspection fine: $26,813

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 the safe transfer and transportation of a resident to a medical appointment, resulting in a fall incident. The resident, who had multiple medical conditions including hemiplegia, hemiparesis, and morbid obesity, required a mechanical lift with two-person support for transfers. On the day of the appointment, the resident was transported in an inappropriate wheelchair due to her custom wheelchair being broken. During the return trip, the resident slid out of the wheelchair, and upon arrival at the facility, staff had to lower her to the ground to reposition her, causing distress and embarrassment to the resident. Another resident, who had a history of falls and was at risk for further falls, experienced a fall resulting in a head injury. The resident was found on his knees with a laceration on his head and a pool of blood next to him. The resident was not wearing any footwear at the time of the fall, despite care plan interventions that included ensuring the resident wore non-skid footwear. The fall report lacked documentation of events leading up to the fall, and the resident was transferred to the emergency department for further evaluation. The facility's policies on resident transportation and fall prevention were not adequately followed, contributing to the incidents. The transportation policy required collaboration between social services and nursing for transportation needs, which was not evident in the decision to use an inappropriate wheelchair. Additionally, the fall prevention policy required a thorough investigation and documentation of falls, which was not fully completed in the case of the second resident.

Penalty

Inspection fine: $57,132

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 with physician orders for mechanically altered diets were provided the correct texture food items to prevent choking and meet their individual needs. This deficiency resulted in Immediate Jeopardy and actual harm/death when Resident #91, who was ordered a Dysphagia Advanced diet and was edentulous, was served a broccoli salad. The resident was subsequently found unconscious, required cardiopulmonary resuscitation (CPR), and when Emergency Medical Services (EMS) arrived, intubation was initially unsuccessful due to a piece of broccoli being found in the resident's airway. Resident #91 was pronounced deceased as a result of the incident. This affected one resident and had the potential to affect 15 additional residents who were identified as being on a Dysphagia Advanced diet ordered by their physician or other delegated provider. The facility census was 90. Review of the closed medical record for Resident #91 revealed that the resident had diagnoses including memory deficit following cerebral infarction, diabetes, peripheral vascular disease, hypertensive heart disease, hepatitis C, and hyperlipidemia. The resident was severely cognitively impaired and was independent with eating. The resident's care plan included providing a mechanically altered diet due to being edentulous and not wearing dentures. The resident was referred to Speech Therapy (ST) due to exacerbation of decreased safety awareness during oral intake, increased signs and symptoms of dysphagia, and risk for aspiration. The recommended discharge diet order was mechanical soft textures (Dysphagia Advanced). On the day of the incident, Resident #91 was served a meal tray with a broccoli salad cut into bite-size pieces while sitting on the edge of his bed. The broccoli salad was not properly chopped to meet the Dysphagia Advanced diet requirements. The resident was found unconscious and not breathing, slumped over with his face on his dinner tray. CPR was started by facility staff, and EMS was notified. EMS arrived and initially, intubation was unsuccessful until a piece of broccoli was removed from the resident's airway. The resident expired at the facility. The facility's investigation concluded that Resident #91 had choked on the improperly prepared broccoli salad.

Removal Plan

• Physician #17 was notified of Resident #91's death by Registered Nurse (RN) #9.
• Resident #91's daughter was notified of Resident #91's death by Licensed Practical Nurse (LPN) #10.
• LPN/Unit Manager #2 interviewed all residents with Dysphagia Advanced diet orders about their meal consistency for the dinner meal with no additional concerns identified.
• The DON and LPN/Unit Manager #2 initiated a house audit to identify any residents on Dysphagia Advanced diet. In addition, Regional Director of Operations Registered Dietitian (RDORD) #13 and RN #1 audited validation diet orders in the electronic medical record to ensure the meal tickets matched.
• The DON began conducting interviews and obtained witness statements from nursing staff working the time of the event involving Resident #91. All the interviews/witness statements were completed.
• The DON initiated education with facility staff on Dysphagia Advanced diet, the difference between diets/food textures/thickened liquids/obstructed airway care and meal service policy. Education included dietary staff to serve food consistencies as ordered and nursing staff to validate meal being served to resident matches meal ticket prior to serving to residents. The education was completed.
• The DON audited the breakfast meal to ensure Dysphagia Advanced diets were prepared appropriately with no concerns identified.
• The Administrator and DON reviewed all notes from Speech Language Pathologist (SLP) #15 and interviewed SLP #15 with no concerns identified.
• RDORD #13 reviewed Resident #91's meal ticket and dietary profile.
• RDORD #13 audited all diets in the electronic medical record and from the dietary meal tracker master list. Three (Residents #31, #20 and #12) residents' diet orders were fixed due to duplicate orders in the electronic medical record.
• The Administrator gave a verbal warning and suspended Cook #5 pending investigation in an effort to investigate the event prior to Cook #5 returning to work.
• The DON requested the EMS run report from the City Fire Department.
• RN #18 educated all residents/responsible parties with Dysphagia Advanced diets that refused to eat in dining room for potential risks of unsupervised dining. Education record assessment completed, and care plans were updated.
• Dietary Manager (DM) #4 educated Cook #5 on preparing a Dysphagia Advanced diet with a return demonstration completed successfully.
• The DON conducted an audit of all residents in house to identify residents ordered Dysphagia Advanced diet. The DON assessed all residents ordered a Dysphagia Advanced diet with no concerns identified.
• RDORD #19 in collaboration with Regional Speech Therapy Director #20 updated the Dysphagia Advanced diet policy/manual to define the appropriate size of chopped vegetables to be approximately 0.5 inches. There were no food exclusions outside what was listed on the Dysphagia Advanced policy as long as the food items met the size requirement.
• The DON conducted education with facility staff related to the updated Dysphagia Advanced policy/manual with the adjusted size of chopped vegetables to be approximately 0.5 inches via electronic communication. Any staff not able to be educated by that time would be educated prior to the start of their next scheduled shift.
• DM #4 initiated education with all Cooks related to preparing Dysphagia Advanced diet, including a return demonstration. All additional Cooks would be trained prior to the start of their next scheduled shift.
• The Administrator/DON/Designee with support of interdisciplinary team began audits which will be scheduled to be conducted on meal trays at different mealtimes to ensure correct meal consistencies were being served as ordered. Auditing would occur five times a week for two weeks, then three times a week for two weeks. Results of the audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) committee with additional recommendations as warranted.
• Director of Therapy #21 conducted an audit of residents ordered a Dysphagia Advanced diet to identify date of last therapy screen. For any resident not screened in the last 90 days or that have not received speech therapy in the last 90 days, a screen would be completed.