Rocky River Gardens Rehab And Nursing Ctr

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 #90’s family concerns about bruising and swelling on the resident’s face were addressed in a timely manner with resolution. Resident #90 was admitted on 09/22/25 and discharged on 04/07/26. Diagnoses included demyelinating disease of the central nervous system, cognitive communication deficit, unspecified dementia, alcohol abuse, unspecified psychosis, visual hallucinations, mood affective disorder, and need for help with personal care. The quarterly MDS assessment indicated intact cognition. After CNA #225 reported discoloration under the resident’s right eye and swelling on the right side of the face, LPN #261 assessed the resident, who denied pain and had vital signs within normal limits. The resident stated the hairbrush in her bag had hit her in the face while she was trying to retrieve it, and the physician and DON were notified. The resident’s family later expressed concerns to the DON about the bruising on Resident #90’s face, but the family reported there was no follow-up and they never heard back regarding the concern. The DON confirmed receiving a call from the family about the incident and stated she told them the resident had hit herself with her hairbrush, but she could not recall details of the call, the family’s response, or any documented follow-up or resolution. The RDCS confirmed that resident or family concerns should be investigated immediately and followed up with a call regarding the outcome, and confirmed this family concern was not addressed timely. Facility grievance policies stated grievances and complaints would be investigated, resolved, and the resident or representative informed of findings and corrective actions within 5 working days.

Penalty

No penalty information released

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

Summary

Surveyors identified a failure to implement the facility’s Enhanced Barrier Precautions (EBP) policy during high-contact care for two residents with wounds and an indwelling device. One resident, admitted with post-polio syndrome, hemiplegia, lymphedema, muscle weakness, and dependence for personal care, had two stage 3 pressure injuries present on admission and a physician order for daily wound care to the right hip. During observed wound care, the wound care LPN repositioned the resident, removed the soiled dressing, cleansed, assessed, and redressed the right hip wound without donning an isolation gown, despite an EBP sign on the door specifying gown and gloves for wound care. The LPN acknowledged she did not wear a gown and confirmed she should have. The EBP supply cart located next to the resident’s door was observed with a thick layer of dust and grime and dried liquid spill marks. The resident later reported that staff never wore an isolation gown when providing care. Another resident, admitted with neuromuscular bladder dysfunction, muscle weakness, and need for assistance with personal care, had an indwelling Foley catheter, frequent bowel incontinence, and dependence for personal hygiene. The care plan documented EBP related to the indwelling Foley, with interventions including gown and gloves for high-contact care, and physician orders required Foley output measurement every shift. During observation of catheter care, a CNA emptied 300 milliliters of urine from the resident’s catheter drainage bag without donning an isolation gown and stated he did not need to wear one. The DON stated that staff providing catheter care, including emptying the drainage bag, or wound care should wear PPE including gloves and an isolation gown, and confirmed that the involved CNA and LPN worked throughout the facility and could expose all residents requiring care. The facility’s EBP policy specified that residents with wounds or indwelling medical devices require gown and glove use during high-contact care activities to reduce transmission of multidrug-resistant organisms.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide timely incontinence care and scheduled bathing/showering for multiple residents who required assistance with activities of daily living. For one resident with spinal stenosis, muscle weakness, repeated falls, and schizoaffective disorder, the admission MDS documented total dependence or extensive assistance needs for toileting and hygiene, and the care plan required prompt response to needs and one‑to‑two staff assistance for toileting. Staff interviews revealed that when this resident requested to be changed during a meal service, CNAs and an LPN told him they could not provide incontinence care during tray pass due to a facility policy of “no patient care during meal passes.” The resident’s call light was turned off, he turned it back on, and ultimately removed his soiled brief and threw it into the hallway. Staff confirmed they delayed his incontinence care until after meal service. Other residents reported they were told they had to wait until after meals to be changed, and that they were not changed in the morning before breakfast despite being incontinent. Another resident with COPD, muscle weakness, and frequent bowel and bladder incontinence, who used a motorized wheelchair and was dependent for toileting hygiene, was care planned to be checked and changed every two hours and as needed. On the morning of observation, this resident was found in an electric wheelchair with pants saturated with urine and reported not having been changed since the start of the CNA’s shift at 7:00 a.m. because staff were doing breakfast and were “not allowed” to change residents during meals. Later that afternoon, observation of incontinence care showed the resident’s pants and chair pad were heavily soiled with urine and stool, and stool was present on the resident’s side and peri area. The primary CNA confirmed the last check/change had been around 9:00 a.m. and stated she usually waited for the resident to request changes, while the resident reported being unable to sense incontinence and that some CNAs did not routinely check her. Physical findings included deep red inner buttocks and creasing of the buttocks and thighs from prolonged sitting without movement. The facility also failed to provide scheduled showers or baths to several residents and had documentation irregularities. One cognitively intact resident, frequently incontinent and dependent for bathing, was scheduled for showers twice weekly but had multiple dates over several months with no shower record and no indication of being offered or receiving a bath or shower; the DON confirmed that on those dates the resident would not have received or been offered bathing as scheduled. Another cognitively intact resident requiring substantial assistance with bathing reported not receiving scheduled showers consistently, stating staff said there was not enough staff; shower records showed multiple missed or not‑offered showers on scheduled days, which the DON verified as accurate. A third resident, dependent for bathing and recently hospitalized, reported begging for a bath for several days, stated she only received about one shower a month, and complained of being offered showers in the middle of the night. Review of shower sheets showed a shower documented on a date when she was hospitalized, and a later bed bath entry bearing a CNA’s forged signature; the DON and the CNA confirmed the resident was not in the facility on the documented date and that the CNA had not signed the later record. A further resident with systemic lupus erythematosus, cerebral palsy, and muscle weakness, who required substantial assistance for bathing and was scheduled for twice‑weekly showers, reported not having a shower in three weeks and attributed this to hot water issues. Observation noted very oily hair. Shower sheets showed two recent entries indicating the resident refused showers, both signed with a CNA’s name and an illegible nurse signature. During review, the CNA whose name appeared on the forms stated the resident had never refused on those dates, denied the signatures were hers, and pointed out that the signatures did not match her known signature from a prior date. The DON confirmed that residents should receive at least two showers or baths per week, that lack of hot water would not constitute a refusal, and that no staff member should sign for a CNA who did not provide the care. These findings collectively demonstrate failures to provide timely incontinence care and scheduled bathing, as well as inaccurate and falsified documentation of ADL 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 deficiency involves the facility’s failure to store medications in a safe and secure manner as required by its own policy and professional standards. Surveyor observation on 01/08/26 at 8:15 A.M. showed that a medication cart on the third floor North hall was left unlocked with no staff present. A resident was seated nearby and additional residents were present in the hallway. At 8:20 A.M., an LPN returned to the cart and acknowledged that she had left it unlocked while she went down the hall to perform blood sugar checks. A second observation on 01/12/26 at 9:33 A.M. showed another medication cart on the second floor near the nurse station left unlocked and unattended, with residents present in the halls and near the nurse station. At 9:37 A.M., the same LPN confirmed that the cart had been left unattended while she stepped away. The facility’s written policy, revised April 2007, states that all drugs and biologicals must be stored in a safe, secure, and orderly manner, and that all compartments containing drugs and biologicals must be locked when not in use, and that carts used to transport such items must not be left unattended if open or otherwise available to others. The facility identified that this failure had the potential to affect most residents on the second and third floors, excluding those specifically noted as requiring assistance with mobility.

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 maintain required hot water temperatures and to keep resident rooms and common areas clean and in good repair. On an environmental tour of the third floor, the Maintenance Director measured water temperatures in several occupied rooms using the facility thermometer. In one resident’s bathroom, the sink water reached only 100°F after running for five minutes and then quickly dropped to 62°F. In another room, the bathroom water did not rise above 54°F after running for over three minutes, and in a third room the bathroom water reached only 99°F after six minutes. The Maintenance Director stated that water temperatures should be between 105°F and 120°F and acknowledged ongoing concerns with the mixing valve. He reported that he ordered a rebuild kit on 12/23/25 after being made aware of hot water concerns, then went on vacation, and that the company he used was also on vacation when he returned. He confirmed that the facility did not contact an alternate company to obtain the part or service sooner. Residents and staff reported persistent problems with inadequate hot water on the third floor. One resident stated that staff had to run the water for a long time to get it slightly warm and that sometimes the water used for cleaning felt slightly warm and sometimes cold, adding that the problem had been going on a long time and that she had informed the Administrator. Another resident reported receiving bed baths with cold water. CNAs reported that residents had expressed concerns about water not getting hot enough and that staff had to let the water run for a while before it would get warm, but sometimes it could run for hours and still not get warm on the third floor. The Maintenance Director confirmed that the first and second floors had sufficient hot water if it ran long enough, but the third floor was not always reaching the appropriate temperature. The Administrator stated that the hot water issue was due to a broken mixing valve first identified on 12/23/25 and confirmed that no interventions were put in place so third-floor residents could wash or be washed with warm water. The deficiency also includes failures to maintain resident rooms and facility areas in a clean and orderly condition and in good repair. One resident, who was cognitively intact with end stage renal disease, muscle weakness, gait and mobility abnormalities, and total dependence for personal hygiene, bed mobility, and transfers, reported that his toilet had not flushed for a week, that a light above his bed had not worked correctly for several weeks, and that a socket by his bed had no cover since his admission. Observation confirmed the toilet would not flush, one of two bed lights had no bulb, and the phone jack socket was broken. The Maintenance Director stated he had removed the bulb two or three weeks earlier and had not replaced it because he was ordering new lights, and he was unaware of the broken socket. Additional observations showed significant uncleanliness and disrepair in other resident rooms and hallways. In one room, five visible floor tiles under the bed were broken with missing pieces, the floor and floor mat next to the bed were very dirty with ground-in dirt, dried spills, and apparent food particles, and there were large areas of thick black/brown substance resembling removed floor strips and remnants of a mat stuck to the floor. The dresser drawer had a broken handle, and the dresser surface had dust and dried spills. The resident stated that the facility needed to clean better and that he would like that. In another room, the floor was very dirty with ground-in dirt and mud throughout, and there were multiple trash items under and protruding from under the bed into the walkway, including used tissues, dirty clothing, crumpled papers, and wrappers, with embedded dirt and grime under and beside the trash. The resident was resting on a mattress without sheets, reported preferring to lie on sheets, and stated that the sheets provided did not fit and would not stay in place. He confirmed his room was very dirty and stated that staff only wiped the middle of the floor and did not perform deep cleaning, saying it had been that way forever. Staff interviews corroborated the poor environmental conditions. A CNA who viewed the two residents’ rooms described them as disgusting and stated that housekeeping did not do a good job. The CNA also confirmed that the third-floor halls, including around the entire nurses’ station, were scuffed with multiple large scrapes that were discolored gray, with the edges showing the tiles were originally light tan. The Administrator, observing the same rooms and hallways, confirmed the dirty floors, trash under the bed, lack of sheets on the mattress, and heavily scuffed, discolored hallway floors. The Housekeeping Manager stated that the conditions were not right and confirmed that none of the facility floors had received a deep cleaning in over a year, explaining that there was no equipment or person to perform it despite repeated requests. An LPN stated that the building was filthy and that everybody knew it. These conditions were inconsistent with the facility’s written policy on providing a safe, clean, comfortable, and homelike environment with clean, sanitary, and orderly surroundings and clean bed and bath linens in good condition.

Penalty

No penalty information released

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

Summary

Surveyors identified a failure to implement care-planned fall-prevention interventions for two residents assessed as being at risk for falls. For one resident with dementia, gait abnormalities, muscle weakness, and a history of falls with injury, the care plan dated 05/20/22 included interventions such as "call don't fall" signage in the room, keeping the bed in the lowest position, and placing nonskid strips in front of the bed. During observation on 01/08/26, the resident was found lying in bed with the bed not in the low position, no "call don't fall" signage present, and the bed positioned over the nonskid strips. The CNA present confirmed the resident was at risk for falls, verified the bed was not low, stated she did not remember ever seeing the signage, and confirmed the bed was over the nonskid strips. For another resident with systemic lupus erythematosus, cerebral palsy, muscle weakness, impaired balance, use of psychotropic medications, history of TIA, impulsive behaviors, and two or more prior falls, the care plan initiated 11/11/20 included an intervention to apply dycem to the wheelchair, with this intervention dated 01/26/21. A fall risk assessment showed the resident was at moderate risk for falling. On observation with an LPN on 01/08/26, the resident was sitting in a chair and then transferred to bed; the LPN confirmed there was no dycem in the chair or in the room, and the resident did not recall ever having dycem in the wheelchair. Record review with the LPN confirmed the care plan required dycem to be applied to the chair. A progress note dated 01/09/26 documented that another nurse found the resident on the floor in another resident’s room and stated dycem was in place in the chair, but in a later interview the LPN clarified that dycem was not in the chair at the time the resident was found on the floor and that dycem was applied only afterward. The facility’s fall policy required review of the care plan and documentation of appropriate interventions to prevent future falls.

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 maintain accurate and complete documentation of bathing and hygiene care for two cognitively intact residents, contrary to its charting and documentation policy. One resident, admitted with chronic respiratory failure with hypoxia, muscle weakness, and needing assistance with personal care, used a wheelchair and was dependent on staff for bathing and showers per the care plan. The census showed this resident was hospitalized on a date in October and did not return until several days later, yet the shower record indicated a shower was provided during the hospitalization, which the DON confirmed could not have occurred. Shower records from mid-October through early January showed scheduled showers documented as completed, while the resident reported having begged for a bath for three days, stated there was no hot water, and that she only received one shower a month. A shower sheet dated early January showed a bed bath with a CNA’s signature that did not match the CNA’s prior signature; the CNA later confirmed by phone that she did not have that resident assigned that day and did not sign the sheet. The scheduler confirmed a different CNA had the resident that day, and that CNA confirmed she did not provide or document the scheduled bath or shower and did not know why it was not offered. The second resident, admitted with systemic lupus erythematosus, cerebral palsy, muscle weakness, and a need for assistance with personal care, used a wheelchair and required substantial to maximal assistance for bathing and showering. The care plan included providing a sponge bath when a full bath or shower could not be tolerated. This resident reported not having a shower in three weeks and attributed the lack of bathing to hot water issues on the unit; observation showed the resident’s hair was very oily, and the resident expressed feeling “disgusting.” Shower records indicated that showers were refused on two dates in January, with both sheets signed by the same CNA and an illegible nurse signature. During an interview and review of the shower sheets, the CNA stated the resident never refused showers on those dates, became upset, and asserted that the signatures on those sheets were not hers, pointing to an earlier shower sheet where her authentic signature appeared and looked different. An LPN confirmed the questioned signatures did not resemble the earlier signature, and the DON confirmed that no staff member should sign for a CNA other than the CNA providing the care. The facility’s policy required documentation in the medical record to be objective, complete, and accurate, which was not followed in these instances.

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 comprehensive individualized interventions to prevent an unauthorized leave of absence (LOA) for a resident who was under adult protection services (APS) with a guardian directive prohibiting the resident's husband from taking her off facility premises or into his vehicle. This resulted in Immediate Jeopardy and actual harm when the resident's husband took her outside the facility and left the grounds with her in his vehicle without staff knowledge. The resident was later found deceased by local police with a gunshot wound to the head, along with her husband, who also had a self-inflicted gunshot wound. The resident had a history of unspecified psychosis, Crohn's disease, generalized anxiety disorder, depression, and delusional disorder. She had been hospitalized for acute psychosis and had a protective order in place due to accusations of abuse from her husband. Despite these circumstances, the facility did not implement a care plan for visitation or the resident's protection order, nor were there interventions to ensure adequate supervision or monitoring of her whereabouts during visits with her husband. The facility's LOA logbook showed that the resident's husband signed in for a visit, but there were no nursing progress notes from the time he arrived until the resident was discovered missing. Interviews with staff revealed that they were aware the resident was not supposed to leave the premises with her husband, but there was no clear plan or assigned person to supervise the resident during her husband's visits. The facility's policy on abuse, neglect, and exploitation emphasized the importance of providing necessary goods and services to avoid harm, which was not adhered to in this case.

Removal Plan

• LPN #300 notified the DON that Resident #200 was not in the facility.
• LPN #300 notified Physician #302 and left a voicemail to return call to facility.
• The DON attempted to contact Resident #200's husband and left a voicemail asking him to return the call.
• LPN #300 notified APS Guardian #320 that Resident #200 was not in facility.
• The DON notified the local police department of an unauthorized LOA for Resident #200.
• The DON arrived at facility and spoke with Police Officer #322 regarding the situation and supplied him with Resident #200's face sheet and diagnosis list.
• A root cause analysis was conducted by VPO #303, VPC #304, RDO #305, RDCS #306, Administrator, and DON related to the incident.
• VPCS #304 and VPO #303 educated the DON and Administrator on the facility adequate supervision of residents, LOA procedure, and facility abuse/neglect policy.
• The DON and Administrator educated all department heads on adequate supervision of residents, abuse/neglect policy and LOA procedure.
• RDCS #306 reviewed all residents' medical records for guardian status, to ensure appropriate LOA orders and any protective orders were in place and care planned.
• The DON, ADON #308, LPN #309, HR #310, DM #311, DOR #312, Housekeeping Supervisor #313, AD #314 educated their departments so that all staff were in-serviced on the facility adequate supervision of residents, LOA procedure, and facility abuse/neglect policy.
• Admissions Director #315 reviewed and updated the facility bed board per LOA orders.
• The DON updated the LOA sign-out books with a new form to include anticipated return time at all nurse's stations and the front desk.
• LPN #309 updated and implemented the nurse report sheets at all nurse's stations.
• A QAPI meeting was held with the IDT to review root cause analysis, facility interventions, facility policies, and facility response.
• LPN #319 reviewed LOA orders, protective orders and LOA care plans for accuracy and updated as necessary.
• Audits were initiated for bed board completion and accuracy.
• Audits were initiated for completion and accuracy of LOA books.
• Audits were initiated for accuracy and completion of nursing report sheets.
• Audits were initiated for new admission or existing residents for new or revised protective orders, guardian status, and updated LOA orders to reflect in the residents' care plans.
• Audits were initiated for new admission or existing residents with a mental health diagnosis to ensure they were offered psychological services.
• Observational audits were initiated of ten residents who required supervision of care to ensure monitoring was effective.

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 appropriately monitor a resident's ability to urinate and signs of urinary discomfort following the removal of an indwelling urinary catheter. The resident, who had been admitted with diagnoses including acute kidney failure and benign prostatic hyperplasia, had an order to discontinue the Foley catheter and start a bowel and bladder program. However, documentation was incomplete, and there was no evidence of monitoring the resident's urination or any discomfort after the catheter removal. The resident's medical records showed that the catheter was removed early in the morning, and the resident was educated on voiding and when to alert staff if he did not urinate. Despite this, there was no documentation of any assessment or monitoring of the resident's urination, discomfort, or bladder/abdominal condition from the time of catheter removal until the resident was sent to the hospital the following morning. The resident was found to have urinary retention and a urinary tract infection with hematuria at the hospital. Interviews with facility staff and the resident confirmed the lack of monitoring and documentation. The facility's policy on urinary incontinence did not include guidelines for monitoring after catheter removal, contributing to the oversight. The resident expressed dissatisfaction with the care received, stating that no staff checked on him, leading him to contact emergency services independently.

Penalty

Inspection fine: $34,48225 days payment denial

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 ensure the proper functioning of a WanderGuard device for a resident with a history of exit-seeking behavior, leading to the resident's elopement. The resident, who had multiple medical conditions including schizophrenia, bipolar disorder, and end-stage renal disease, was able to leave the facility undetected through a smoking patio exit door. The WanderGuard system, which was supposed to prevent such incidents, did not function as intended, allowing the resident to travel from Ohio to Wisconsin without staff knowledge. The resident was not seen by facility staff for nearly three hours before being discovered missing. During this time, the resident missed essential medical treatments, including hemodialysis and several prescription medications for high blood pressure, angina, and mental illness. The resident was eventually found by a university police department in Wisconsin, approximately 425 miles away from the facility, and was transported to a local hospital for evaluation and treatment. Interviews and reviews of the facility's records revealed that the staff did not check the functionality of the WanderGuard device, only its placement. The facility's protocol for WanderGuard use was not clearly defined, leading to a lack of proper checks and balances. The resident's care plan and elopement risk assessments were not adequately updated to reflect the resident's high risk for elopement, contributing to the failure to prevent the incident.

Removal Plan

• RN #811 instructed STNA #823 and STNA #824 to search the unit for Resident #69.
• RN #811 called a code and LPN #825 and LPN #826 searched all facility floors and outside areas.
• RN #827 notified the Director of Nursing (DON) that Resident #69 was missing.
• The DON instructed RN #811 to complete a resident head count of the entire facility and obtain witness statements from all staff present.
• Police Officer (PO) #834 arrived from the local police department and took a report from RN #811. RN #811 provided the officer with Resident #69's demographic information, the last time he was seen and a brief description of what he was wearing prior to the elopement.
• A root cause analysis was conducted by RDO #800, RDCS #801, the Administrator and the DON. The root cause of Resident #69's elopement was determined to be a system failure to ensure the resident's WanderGuard was in place and/or functional and adequate supervision.
• RDO #800 re-educated the DON and the Administrator on the facility's elopement policy and best practice, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents.
• The DON initiated in-person education with all facility staff on the elopement policy and best practice, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents. Dietary Manager (DM) #828, Housekeeping Director (HD)#806, Activities Director (AD) #808 and Assistant Director of Nursing (ADON) #838 assisted with the education, after receiving the education from the DON and/or Administrator. Education will be provided for all new employees during orientation.
• ADON #838, Unit Manager (UM) #829 and Wound Nurse (WN) #830 re-assessed all residents for elopement and verified care plans were up to date.
• Director of Maintenance (DOM) #804 checked all doors equipped with WanderGuard sensors to ensure functionality.
• An Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the root cause analysis, facility interventions, facility policies on wandering and elopement and facility response. The Administrator re-educated attendees on the elopement policy, WanderGuard protocol, door alarm response and supervision of residents.
• RDCS #801 reviewed residents with WanderGuard orders to ensure placement and functionality of the WanderGuards and the residents' care plans were accurate. All reviewed residents had functioning WanderGuards in place and care plans were updated.
• Minimum Data Set Nurse (MDSN) #833 conducted a second review of all resident care plans and updated, as needed, to ensure all care plans accurately reflected elopement risk and WanderGuard use/interventions.
• DOM #804, or designee, would conduct checks of doors equipped with WanderGuard sensors five times per week for two weeks then weekly.
• The DON, or designee, would audit nine WanderGuard placement and function three times weekly for four weeks then one time weekly for four weeks.
• LPN #812 was notified by university police in Milwaukee, WI that Resident #69 was found on their campus. LPN #812 immediately notified ADON #838, who then immediately notified the DON and Administrator.
• University police transported Resident #69 to an area hospital for further evaluation due to missed medications and hemodialysis treatments.
• AD #839 and STNA #840 picked-up Resident #69 from the hospital in Milwaukee, WI and transported the resident back to the facility.
• Resident #69 returned to the facility. LPN #814 assessed Resident #69 and the resident was placed on one-on-one supervision for safety. The resident's WanderGuard was replaced and tested to ensure it properly functioned.
• RDCS #801 reviewed Resident #69's care plan for accuracy.
• LPN #837 reassessed Resident #69 for elopement risk. Resident #69 was assessed to be at high risk for elopement.
• DOM #804 conducted an elopement drill with no concerns identified with staff response.
• MDSN #833 updated Resident #69's care plan to include updated elopement risk and interventions. Resident #69's physician orders were updated to check WanderGuard placement and function each shift.
• DOM #804 placed an order for an additional WanderGuard testing device and WanderGuard bracelets to provide additional supplies.
• DOM #804, or designee, would conduct elopement drills/resident supervision on each shift weekly for four weeks and then monthly indefinitely.
• The DON or designee, would audit elopement assessments and interventions for accuracy and completeness weekly for four weeks.

Penalty

Inspection fine: $33,586

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 a resident from neglect, resulting in a fall with injury and subsequent death. The resident, who had a right leg amputation, diabetes, chronic kidney disease, and congestive heart failure, required two-person assistance for all care. However, on the evening of the incident, a single State Tested Nursing Assistant (STNA) was providing care alone. The STNA was changing the resident's bed linens when the resident fell from the bed, landing face down on the floor. The STNA did not immediately seek help or provide assistance, leaving the resident on the floor crying for help. After the fall, the resident was transported to the hospital and diagnosed with a rib fracture. Upon returning to the facility, the resident was not monitored according to protocol, which required neurological checks for 72 hours post-fall. The facility staff failed to identify an acute change in the resident's condition, including altered mental status and low blood pressure, which ultimately led to the resident's death. The lack of timely medical intervention and failure to follow established care protocols contributed to the severity of the incident. The facility's investigation revealed that the STNA did not adhere to the care plan requiring two-person assistance, and the resident was not adequately monitored after the fall. The facility's policies and procedures for preventing neglect and responding to changes in a resident's condition were not followed, leading to the resident's deterioration and eventual death. The incident highlighted significant lapses in staff adherence to care protocols and monitoring procedures.

Removal Plan

• RDCS #401 met with the Interdisciplinary Team to complete a root cause analysis and identified a system failure.
• RDCS #401 educated the Administrator, DON, ADON, and UM #171 on post fall monitoring including skilled charting, vital signs, neuro checks for all unwitnessed falls or witnessed falls with head injury per neuro check form, and two-person assist for care.
• A Quality Assurance Performance Improvement meeting was held to review the root cause analysis and all agreed on the system failure.
• RDCS #401 provided education to the team on post fall monitoring and checking binder at nurse's station for number of persons required to assist with resident care at the start of nursing shift.
• The Administrator, DON, ADON, UM #171, DM #180, HS #199, and BOM #110 educated all facility staff on post fall monitoring and checking the binder at nurse's station for two person assist for resident care at the start of nursing shift.
• UM #171 reviewed fall investigations to ensure interventions were in place and appropriate care plans were in place for all residents.
• The DON and MDS Nurse #251 audited care plans, Kardex, and physician orders for all residents to ensure all assistance orders were in place and care planned appropriately.
• The ADON and UM #171 created a binder for each nurse's station that contained the number of persons required to provide resident care.
• The RDO met with the IDT to complete an additional root cause analysis and identified a system failure as LPN #150 failed to identify Resident #101's change in condition and provide timely intervention.
• A QAPI meeting was held to review the root cause analysis and all agreed on the system failure.
• The RDO provided education to the team on abuse and neglect policy and acute change in condition policy.
• The Administrator, DON, ADON, UM #171, DM #180, HS #199, and BOM #110 educated all facility staff on the facility abuse and neglect policy and acute change in condition policy.
• UM #171 assessed residents with a BIMS score of 12 or lower to ensure further instances of neglect or change in condition without identification/intervention.
• The DON reviewed the report to ensure there were no residents with identified change in condition without appropriate follow-up.
• The DON reviewed change of condition assessments to ensure appropriate interventions.
• LPN #150 was suspended pending an investigation for resident neglect.
• The RDO submitted a Self-Reported Incident for neglect related to Resident #101.
• The facility implemented a plan for audits to be completed by the DON/designee for every fall occurrence to ensure appropriate post fall monitoring.
• The facility implemented a plan for audits to ensure the appropriate number of staff were providing care per identified needs.
• The facility implemented a plan for audits to ensure the person assist binders were accurate and up to date.
• The DON/designee would complete random staff interviews on all shifts to ensure binders were reviewed at start of shift.
• All new physician orders related to transfer status would be audited by DON/designee.
• The DON/designee would observe random residents to ensure no change in condition without assessment and intervention and no signs of abuse or neglect.
• The DON/designee would interview random residents to ensure no allegations of abuse or neglect.
• The DON/designee would randomly review charting to ensure no change in condition without assessment and intervention.
• All audits would be reviewed during QAPI meetings, and any identified concerns addressed immediately by QAPI committee.
• In-service sign-in sheets confirmed most facility staff received the training/education.

Penalty

Inspection fine: $33,586

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 were treated with respect and dignity, as evidenced by an incident involving a resident with a right leg amputation, diabetes, chronic kidney disease, and congestive heart failure. The resident required substantial assistance with daily activities and was ordered to have two-person assistance for all care. However, video footage revealed that a single STNA was attempting to change the resident's bed sheets while the resident was lying naked on her side at the edge of the bed. The resident expressed concern about falling, and despite her pleas, she fell face down onto the floor. The STNA then moved the bed, causing the resident's leg to drop to the floor, and left the room without addressing the resident's distress. When the STNA returned with additional staff, the resident expressed that she had been let fall, and the STNA blamed the resident for not holding onto the bed. The STNA and the resident argued, with the STNA dismissing the resident's claims. The facility's policy on resident rights, which emphasizes respect, kindness, and dignity, was not upheld in this situation. This incident was part of a complaint investigation, highlighting a deficiency in the facility's adherence to resident rights.

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 keep medication in a secured environment and did not discard expired tuberculin solution, potentially affecting all 110 residents. Observations revealed that the second-floor medication room door was ajar and not latched completely, allowing it to be pushed open without using the door handle. The door handle was part of a code locking system with the number 7 button stuck, enabling the door to be unlocked. Similarly, the third-floor medication room door was closed but not locked, and staff could enter without using a code. An STNA was observed entering the third-floor medication room without a nurse escort to retrieve supplies. Interviews with staff confirmed that the medication room doors had not been locked for several days due to the malfunctioning code boxes, and the facility policy stated that only authorized persons should have access to the medication room. Additionally, the facility failed to discard expired tuberculin solution. Observations in the first-floor medication refrigerator revealed two partially used vials of Apisol Tuberculin solution without opened dates. An LPN confirmed that these vials should have had opened dates. Similarly, the third-floor medication room refrigerator contained a partially used vial of Aplisol TB solution without an opened date. The ADON confirmed that the vials should have opened dates and should not be used past 30 days from the opened date. The manufacturer guidelines for Aplisol TB solution indicated that vials in use for more than 30 days should be discarded due to possible oxidation and degradation affecting potency.

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 foods were labeled, dated, and not retained when expired, which had the potential to affect 106 residents receiving food from the facility's kitchen. During an observation of the facility's nourishment refrigerators, it was found that the first-floor resident refrigerator contained expired yogurts and milk, the second-floor resident refrigerator had an unidentified pink substance and frozen popsicle material, and the third-floor resident refrigerator had containers labeled with a resident's room number but no date. These findings were verified by the Food Service Director (FSD), who indicated that refrigerators were checked weekly for expired food, but there was no documentation to support this process. The facility's policy, revised in February 2014, stated that perishable foods must be stored in re-sealable containers with tightly fitting lids, labeled with the resident's name, the item, and the use-by date. The nursing staff was responsible for discarding perishable foods on or before the use-by date. However, the FSD confirmed that there was no documentation regarding staff going through these refrigerators for expired food, and the housekeeping staff helped with this process. This lack of adherence to the policy and absence of proper documentation led to the deficiency observed 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

The facility failed to ensure resident funds were disbursed as required and in a timely manner after the death of Resident #120. Resident #120, who had diagnoses including paranoid schizophrenia, unspecified psychosis, major depressive disorder, schizophrenia unspecified, unspecified severe protein-calorie malnutrition, psychotic disorder with hallucinations due to known physiological condition, and a history of COVID-19, expired in the facility. A review of the resident's fund statement revealed an ending balance of $1069.28, with no evidence of final disbursal. The Business Office Manager contacted the resident's guardian a week after the resident's death but did not receive any follow-up, resulting in the funds not being disbursed within the required 30-day period.

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 a significant change Minimum Data Set (MDS) 3.0 assessment was completed for Resident #14. Resident #14 was admitted to the facility with diagnoses including dementia with behavioral disturbance, diabetes, high blood pressure, anxiety, and depression. The resident was admitted to hospice services for dementia with behavioral disturbance. However, the comprehensive annual MDS 3.0 assessment indicated the resident did not have a life expectancy of less than six months, despite receiving hospice services. An interview with the MDS Registered Nurse confirmed that a significant change assessment was not completed after the resident was admitted to hospice, and this was missed during an MDS audit.

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 accurately complete Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #5, who was admitted with multiple diagnoses including high blood pressure and a history of falls, had two documented falls with injuries that were not accurately reflected in the MDS assessment. Additionally, the MDS inaccurately indicated the use of a trunk restraint, which was not observed or reported by staff. These inaccuracies were confirmed by the MDS Registered Nurse (RN) during an interview. Resident #90, diagnosed with Alzheimer's disease and dementia, had an MDS assessment that incorrectly indicated the use of physical restraints. Observations and staff interviews confirmed that no restraints were used for this resident. The MDS RN admitted to accidentally marking the use of restraints in the assessment. Similarly, Resident #14, who was admitted with dementia and other conditions, had an MDS assessment that failed to accurately reflect their hospice status and the presence of a pressure ulcer. The MDS RN confirmed these inaccuracies during an interview. These deficiencies highlight the facility's failure to ensure accurate and complete MDS assessments, which are crucial for proper care planning and resident safety. The inaccuracies in the MDS assessments for Residents #5, #14, and #90 were identified through a combination of record reviews, observations, and staff interviews, revealing a pattern of documentation errors that could impact the quality of care provided to the 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 ensure a timely skin assessment upon admission for Resident #11, who was admitted with diagnoses including chronic kidney disease, heart failure, peripheral vascular disease, and Alzheimer's disease. Despite the resident's initial refusal to undergo a head-to-toe skin assessment, the staff did not make further attempts to complete the assessment within the required eight hours or thereafter. This lack of follow-up resulted in an incomplete initial assessment of the resident's skin condition. The resident's baseline care plan included interventions such as the use of a pressure-reducing mattress and cushion, and regular skin assessments. However, progress notes and weekly skin assessments revealed that no further attempts were made to complete the initial skin assessment after the resident's refusal. The facility's wound nurse confirmed that the staff should have made additional attempts to complete the assessment, as per the facility's policy on the prevention of pressure ulcers, which mandates an assessment within eight hours of admission.

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 timely responses to pharmacy recommendations for two residents, leading to deficiencies in medication management. For Resident #90, who had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and PTSD, a pharmacy recommendation dated 10/31/23 suggested a gradual dose reduction of Divalproex. However, the recommendation was not addressed by the nurse practitioner until 12/06/23, exceeding the facility's expected 30-day response time. Additionally, the response form was incomplete, as the nurse practitioner did not select a response option, only indicating disagreement with the recommendation without further explanation. For Resident #109, who had diagnoses including dementia with behavioral disturbance, prostate cancer, shared psychotic disorder, anxiety, and depression, a pharmacy recommendation dated 12/21/23 requested an appropriate diagnosis for the use of the antipsychotic medication Zyprexa. The psychiatric nurse practitioner signed the recommendation on 01/12/24 but failed to provide an appropriate diagnosis from the list provided by the pharmacist. The facility's policy on Medication Regimen Reviews, revised in April 2007, did not specify a time frame for responses to pharmacy recommendations, contributing to the delay and incomplete responses observed 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 assess and monitor the use of an antipsychotic medication, Zyprexa, for a resident diagnosed with Alzheimer's Disease, COPD, heart failure, and high blood pressure. The resident, who was dependent on staff for all personal hygiene, transfers, and dressing, had been prescribed Zyprexa for behaviors since 12/25/23. However, from 02/01/24 to 04/11/24, there were no documented behaviors that would justify the continued use of the medication. The Director of Nursing confirmed that the diagnosis of behaviors was not appropriate for the use of Zyprexa, as the resident had not exhibited any behaviors in the last 90 days. The facility's failure to document or address the continued use of Zyprexa was evident in the progress notes from 09/10/24 to 10/01/24, which lacked any entries reflecting the physician's assessment or changes to the diagnosis. Additionally, a pharmacy recommendation dated 09/10/23 had suggested that the physician address the diagnosis for the use of Zyprexa, but this was not followed up. The facility's policy on medication regimen reviews, dated 04/01/07, emphasizes the importance of appropriate medication use to maintain each resident's highest practicable level of functioning and to prevent adverse consequences, 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 a medication administration error rate of less than 5%, resulting in a medication error rate of 5.41%. This deficiency was identified during an observation of medication administration for a resident. The Licensed Practical Nurse (LPN) prepared morning medications for the resident, which included crushing soft gel capsules of Omega 3 Fish Oil and B Vitamin Complex. The manufacturing guidelines for these medications explicitly state that they should not be crushed or split, as this can lead to incorrect dosages. Despite this, the LPN proceeded to crush the soft gel capsules and attempted to administer the liquid contents, which was not successful for the B Vitamin Complex, leading to a medication error. The resident's physician-signed medication orders required medications to be crushed for ease in swallowing, but the specific forms of Omega 3 Fish Oil and B Vitamin Complex used were not suitable for this method of administration. The LPN confirmed during an interview that the soft gel capsules should not have been crushed and that an alternative form of the medication should have been used. The facility's policy on administering medications, revised in December 2012, mandates that medications be administered in a safe and timely manner as prescribed. The failure to adhere to these guidelines and the manufacturer's instructions resulted in a medication error rate exceeding the acceptable threshold, affecting the resident's medication administration 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 ensure accurate documentation of a resident's weight in the medical record, affecting one resident out of three reviewed for nutrition. Resident #107, who had diagnoses including chronic kidney disease, diabetes mellitus with diabetic nephropathy, protein-calorie malnutrition, and dementia with behavioral disturbance, had inconsistent weight recordings. The weights documented from August 2023 to March 2024 included weights taken while the resident was in a wheelchair, which weighed 40.8 lbs. Additionally, the methods of weighing the resident standing or using a mechanical lift were also noted to be inaccurate. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) revealed that the resident's weight of 170 lbs. was likely inaccurate, and the resident's son, a physician, had no concerns about the resident's weight. Further interviews with the DON and Registered Dietitian (RD) confirmed that the resident was always weighed in his wheelchair, and the documented weights were not accurate. The resident did not require the use of a mechanical lift, and the weights recorded using this method were also incorrect. The RD mentioned that the resident had a recent hospitalization and experienced some weight loss but had since gained weight. The resident was reweighed and found to be 131 lbs. The facility's policy on charting and documentation, revised in July 2017, stated that documentation in the medical record should be objective, complete, and accurate, which was not adhered to in this case.