Strongsville Healthcare And Rehabilitation

Penalty

No penalty information released

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

Summary

The facility failed to consistently implement Enhanced Barrier Precautions for a resident with an indwelling Foley catheter and other hands-on care needs. Resident #24 was admitted with diagnoses including hemiplegia and hemiparesis following intracerebral hemorrhage, neuromuscular dysfunction of the bladder, and need for assistance with personal care. The physician order required EBP with gloves and gown for dressing, bathing/showering, transferring, hygiene care, changing linens, changing briefs, and assisting with toileting. During observation, a CNA provided incontinence care, turning and repositioning, and later assisted with transfers and toileting without wearing an isolation gown. The resident stated staff never put a gown on during catheter care or other care, and staff interviews confirmed they had not been using gowns for the resident’s hands-on care. The facility also failed to properly use PPE for a resident on droplet isolation for COVID-19. Resident #53 was readmitted with a diagnosis of COVID-19 and had an order for droplet isolation precautions. During observation, an LPN entered the resident’s room wearing a gown, N-95 mask, and gloves but did not wear goggles. Another CNA entered the room with the lower strap of the N-95 dangling under the chin, no goggles, and gloves in hand while providing Foley catheter care, brief care, barrier cream, and repositioning. A different CNA was observed removing goggles after leaving the room and placing them directly into the isolation cart with clean PPE without sanitizing them. The RN infection preventionist confirmed staff should wear gown, gloves, mask, and goggles, and that both N-95 straps should be secured. Laundry handling and Legionella water management procedures were also not maintained as described in facility policy. Housekeeping/laundry staff stated they did not know which laundry belonged to which residents’ rooms, that isolation room laundry was not separated from other residents’ laundry, and that they never wore an isolation gown or apron when sorting or washing residents’ laundry. In addition, the maintenance and property management staff confirmed there was no diagram or description identifying areas in the water system that needed routine flushing to prevent Legionella growth. The maintenance supervisor stated he only flushed four eye wash stations monthly and was unaware of other areas in the building that required flushing, including empty resident rooms, ice machines, and hoses.

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 educate and offer the COVID-19 vaccine to all eligible staff. During an interview, a CNA stated the last time the facility educated or offered staff the COVID-19 vaccine was in the fall of 2024. The Infection Preventionist RN confirmed that facility staff were not educated or offered the COVID-19 vaccine in 2025 or 2026 and stated she did not know she was supposed to do so. Review of staff education related to COVID-19 also confirmed staff were not educated on the vaccine’s benefits, risks, and potential side effects for 2025/2026. The Regional Director of Clinical Operations confirmed staff were to be offered COVID-19 vaccines annually. Review of the CMS Regulatory Update dated 05/31/23 showed the federal staff vaccine mandate was rescinded, but the educate-and-offer requirement remained in place. Review of the facility policy, Employee Infection and Vaccination Status, dated January 2024, stated employees are offered or provided vaccinations per state or local agency policies/regulations and are given educational materials for non-mandated vaccines, with declinations documented in the employee health record.

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 comprehensive assessments were completed for residents who were transferred from a sister facility after a fire. Resident #111 was admitted with diagnoses including paraplegia, essential hypertension, and legal blindness, but the medical record showed an admission MDS 3.0 comprehensive assessment marked with an inactivation of entry and no evidence that the facility completed a comprehensive, accurate, standardized assessment of functional capacity. A Medicaid representative confirmed the office did not instruct the facility to omit required MDS assessments, while the RRN stated the resident’s MDS assessments were not completed because the resident was a transfer from the sister facility and he had been told by corporate office that MDSs did not have to be completed for that resident. Resident #107 was admitted with diagnoses including dementia, schizophrenia, and atrial fibrillation. The MDS assessment list showed no MDS assessments completed by the facility since admission, with an entry MDS initiated and then inactivated, and an admission assessment also inactivated. Staff stated the resident had been transferred from a sister facility after a fire and had been at the facility for three months, and they verified no MDSs were completed per directive from management. The RRN stated the assessments were not being completed by either the receiving facility or the originating facility because management had directed that they did not have to be completed until the residents returned to the originating facility. Resident #109 was admitted with diagnoses including quadriplegia, depression, and anxiety. The MDS assessment list showed no MDSs completed by the facility since admission, with an entry MDS initiated and then inactivated. Staff gave the same explanation that the resident had been transferred from a sister facility after a fire and that no MDSs were completed based on management direction. The RRN also reviewed CMS guidance stating that if a resident would not return within 30 days, the evacuating facility should discharge the resident and the receiving facility would admit the resident if that was the resident’s choice, and he verified the facility did not follow that guidance. The Administrator confirmed that six residents were transferred to the facility following the fire at the sister facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure comprehensive assessments were completed timely for residents transferred from a sister facility after a fire. Review of the records for Residents #107, #109, and #111 showed that each was admitted to the facility on 03/13/26 with diagnoses including conditions such as paraplegia, quadriplegia, dementia, schizophrenia, atrial fibrillation, depression, anxiety, essential hypertension, and legal blindness. For each of these residents, the admission MDS 3.0 assessment was initiated but then inactivated, and the record did not contain a completed MDS that reflected the resident’s medical, functional, and psychosocial conditions. The record review showed that Resident #111 had an admission MDS with a description of inactivation of entry, and the assessment did not reflect the resident’s overall status using the appropriate RAI process. Resident #107 had no MDS assessments completed by the facility since admission; an entry MDS and an admission assessment were both initiated and then inactivated. Resident #109 likewise had no MDS assessments completed by the facility since admission, with an entry MDS initiated and then inactivated. The report stated that the facility did not ensure the accuracy and integrity of these residents’ assessments, including proper documentation, qualified professional involvement, and adherence to observation periods. Interviews showed that facility staff believed the assessments did not have to be completed because the residents were transfers from a sister facility that had evacuated after a fire. A Medicaid representative confirmed she had not instructed the facility not to complete the MDS assessments and stated they should have been completed according to the guidance previously sent. The RRN also acknowledged that the facility did not follow the CMS FAQ guidance he presented, which addressed how MDS cycles should be handled when residents return to the evacuating facility or are discharged and admitted to the receiving facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure care planning conferences were completed at least quarterly for two residents reviewed for care planning. Resident #10 was admitted with diagnoses including dementia, bipolar disorder, and essential hypertension. The record showed care conferences on 09/30/25 and 02/20/26, and the Annual MDS 3.0 assessment described severe cognitive impairment. A family member stated she missed the care conference and tried to reschedule, but the facility never returned her phone calls. A prior SSD confirmed the resident’s care conferences were not completed at least quarterly. Resident #111 was admitted on 03/13/26 as a transfer from a sister facility with diagnoses including paraplegia, essential hypertension, and legal blindness. The record included a social service progress note from 05/14/26 stating the clinical and administrative team gathered for a care conference at the daughter’s request, waited up to 15 minutes, and the daughter did not arrive; staff attempted to call her but did not reach her. The family member stated a care conference had not been completed since the transfer and that staff did not contact her to conduct one. The prior SSD confirmed the resident was transferred from a sister facility and the medical record did not show evidence that a care conference had been completed since 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 accurate care plans were initiated and updated for two residents reviewed for care planning. Resident #24 was admitted with diagnoses including hemiplegia and hemiparesis following intracerebral hemorrhage affecting the left dominant side, neuromuscular dysfunction of the bladder, and need for assistance with personal care. The medical record showed a physician order for an indwelling Foley urinary catheter due to obstructive uropathy and an order for Enhanced Barrier Precautions requiring gloves and gown for specified care activities. The Annual MDS indicated the resident was cognitively intact and required assistance with toileting hygiene, bed mobility, and transfers, but the record contained no care plan for the indwelling urinary catheter or for EBP when reviewed by surveyors. Resident #20 was admitted with diagnoses including type II diabetes mellitus, chronic kidney disease, and lack of coordination. The Annual MDS showed the resident was moderately cognitively impaired and had adequate vision with corrective lenses, but the medical record contained no care plan for vision or corrective lenses. During interview, the resident was observed wearing glasses and stated he could not see well even with them and could only see movement, not letters to read. The resident's daughter stated he had seen the eye doctor, received new glasses, and his vision had continued to worsen, and an RN UM confirmed the resident had expressed concerns about poor vision even with glasses.

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 appropriate immediate care was provided to a resident after a fall. Resident #84 had diagnoses including metabolic encephalopathy, dementia, and muscle weakness, used a wheelchair for mobility, and required extensive assistance with transfers and other activities of daily living. The resident was identified as being at risk for falls, and the care plan included fall-prevention interventions such as non-slip socks, a call light, and a floor mat beside the bed. On the morning of the incident, staff found the resident on the floor beside the bed. The resident was lying on her back with her head near the foot of the bed and her legs toward the head of the bed. Staff documented that there was no visible injury, but the resident stated that her legs hurt. The LPN checked vital signs and completed neurological checks while the resident was still on the floor, then turned the resident, placed a sheet underneath her, and, with the CNA, lifted her back into bed using the sheet. Staff moved the resident despite her complaints of pain and before notifying the physician or CNP for direction. After the resident was returned to bed, the CNP was notified and a STAT x-ray of the pelvis and bilateral femurs was ordered. X-ray results later showed a left femur fracture, and the resident was sent to the ED for evaluation and treatment. Hospital records showed the resident was admitted for trauma and multiple injuries, including closed displaced supracondylar fractures of both femurs, a questionable right radial neck fracture, and subacute T5/T12 compression fractures. Staff interviews confirmed that the resident complained of pain at the time of the fall and that staff should not move a resident who falls and reports pain until the physician or CNP has been notified and provides direction.

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

Drugs and biologicals were not labeled and stored in accordance with accepted professional principles when expired medications were found in medication carts and an insulin pen was left without an open date or expiration date. Resident #4 had diagnoses including Parkinson’s disease with dyskinesia, essential hypertension, and type II diabetes mellitus without complications. Review of the resident’s physician orders showed multiple orders for Lantus/glargine insulin, and during observation of the East Hall Long Term Medication Cart B, the resident’s Lantus KwikPen was found opened and in use with no open date and no expiration date. The DON confirmed the insulin was not dated and could not determine whether it was expired. Resident #19 had diagnoses including rheumatoid arthritis, essential hypertension, and muscle weakness, and the resident’s physician orders included COQ10 100 mg by mouth in the morning. During observation of the South Hall Medication Cart, an over-the-counter bottle of COQ10 100 mg was found expired in 04/2026. The DON confirmed Resident #19 was the only resident receiving COQ10 from that cart. The facility policy stated medications and biologicals were to be stored safely, securely, and properly, following manufacturer’s recommendations or those of the supplier.

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 honor a resident's preferences for getting out of bed, as evidenced by medical record review, resident interview, and staff interview. The resident, who was cognitively intact and had multiple complex diagnoses including heart failure, COPD, respiratory failure, and major depressive disorder, required substantial assistance for bed mobility and was dependent on staff for transfers. Her care plan documented her right to make decisions regarding her daily lifestyle and directed staff to make every reasonable effort to meet her stated preferences. However, there was no documentation in her progress notes or behavior logs to support that she refused to get out of bed, nor was there evidence that staff consistently offered her the opportunity to get out of bed as per her preferences. During interviews, the resident confirmed she was never offered assistance to get out of bed and often had to request it herself, leading to frustration and at times choosing not to ask. A CNA acknowledged that staff likely did not offer to assist the resident out of bed as often as they should, citing her history of refusals, and also confirmed that refusals were not documented. This lack of consistent offering and documentation resulted in the facility's failure to reasonably accommodate the resident's needs and preferences regarding getting out of bed.

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 honor Resident #37’s preferences for getting out of bed and to promote and facilitate resident self-determination through support of resident choice. Resident #37 was admitted with multiple diagnoses including heart failure, COPD, malnutrition, respiratory failure, kidney failure, pulmonary hypertension, encephalopathy, anemia, atrial fibrillation, cardiomegaly, major depressive disorder, muscle weakness, dysphagia, pneumonitis, and diverticulitis. Her MDS assessment indicated she was cognitively intact and required substantial to maximum physical assistance for rolling in bed and was dependent on staff for chair/bed-to-chair transfers. The resident’s care plan documented that she had the right to make decisions regarding her everyday lifestyle and that the facility should make every reasonable effort to meet her stated preferences. However, review of progress notes and behavior logs found no documentation supporting refusals to get out of bed. During interview, the resident stated she was never offered to get out of bed, that she sometimes asked but no one would assist her, and that she became frustrated by having to ask. A CNA confirmed staff probably did not offer to get her out of bed as often as they should because of her history of refusing, and also confirmed refusals were not captured in documentation.

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 sufficient staffing to meet the needs of its residents, as evidenced by multiple instances of delayed response to call lights and inconsistent provision of showers. The report highlights that several residents experienced significant delays in having their call lights answered, with some waiting as long as 49 minutes. This delay in response was confirmed by staff interviews, where it was acknowledged that call lights should be answered in less than 15 minutes. The lack of timely response was attributed to insufficient staffing, which also impacted the ability to complete daily tasks such as showers. Residents with varying degrees of cognitive impairment and physical needs were affected by the staffing deficiencies. For instance, a resident with severe cognitive impairment and incontinence issues did not receive showers consistently, receiving only bed baths instead. Another resident, who was moderately cognitively impaired and at risk for falls, experienced a 21-minute delay in call light response during mealtime, a time identified as particularly challenging due to staffing shortages. These instances were corroborated by staff interviews, which revealed that the workload was often too much for the available staff, leading to incomplete tasks. The facility's payroll-based journal data indicated a one-star staffing rating, which was attributed to the use of agency staff at the time. Staff interviews revealed that employees often worked past their scheduled hours and through breaks to manage their workload, yet still struggled to meet the residents' needs. The facility's administration claimed to adjust staffing based on census and acuity, but there was a disconnect between administrative perceptions and the experiences reported by staff and residents. The deficiency was investigated under specific complaint numbers, indicating ongoing concerns about staffing levels.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident, identified as Resident #76, had access to a call light within their functional abilities. Resident #76, who was admitted with diagnoses including Multiple Sclerosis, paralysis of the left side, tremors, and depression, was cognitively intact but required varying levels of assistance for daily activities. The care plan for Resident #76 included interventions to consider the need for assistive devices and encourage the use of the call light for staff assistance. However, during an interview and observation, it was revealed that Resident #76 had a call light pad lying on her chest but was unable to push it or activate the call light to call for assistance. A Certified Nursing Assistant confirmed that Resident #76 could not use the call light, and there was no documented evidence of her ability to use it in the past. The facility's policy on the Resident Call System, dated March 2023, stated that the facility would provide an environment to meet residents' needs, including responding to call lights. Despite this policy, the Administrator was unaware of Resident #76's inability to use the call light pad until the issue was brought to her attention. This deficiency was investigated under Complaint Number OH00161454 and affected one resident directly, with the potential to affect six others identified by the facility as using a modified call light.

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 three residents consistently received showers as required by their care plans and facility policy. Resident #6, who was severely cognitively impaired, had not received a shower since admission and only received bed baths, despite his and his son's preference for showers. Resident #74, who was moderately cognitively impaired, had inconsistencies in the records regarding whether he received showers or refused them, with discrepancies noted between the shower sheets and CNA tasks. Resident #76, who was cognitively intact, reported receiving showers less than once per week, contrary to her preference for showers over bed baths. Interviews with staff, including a CNA and the Director of Nursing, confirmed that showers were not consistently provided as per the facility's policy, which stated that residents should be offered a shower or bath twice a week and as needed. The Director of Nursing acknowledged the inconsistencies in the documentation and was unable to verify the accuracy of the records. This deficiency was investigated under a specific complaint number, indicating noncompliance with the facility's bathing and personal care policy.

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 call lights were answered in a timely manner, affecting five residents out of six reviewed for this issue. The residents involved had various medical conditions, including cellulitis, amputations, obesity, heart failure, dementia, and arthritis, among others. Observations and interviews revealed that call lights for these residents remained unanswered for periods ranging from 19 to 49 minutes, despite the facility's policy and staff expectations that call lights should be answered within 10 to 15 minutes. For instance, Resident #1's call light was unanswered for 19 minutes, while Resident #8's call light was unanswered for 49 minutes. The deficiency was confirmed through interviews with staff members, including a Registered Nurse and a Certified Nursing Assistant, who acknowledged the delays in responding to call lights. The facility's policy, dated March 2023, stated that call lights should be responded to in a timely manner, yet the observations indicated otherwise. The Administrator also confirmed that the expectation was for call lights to be answered in approximately 10 minutes, highlighting a discrepancy between policy and practice. This deficiency was investigated under Complaint Number OH00161454.

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 to prevent a resident with dementia, PTSD, and severe cognitive impairment from leaving the facility without staff knowledge. The incident occurred when the resident was seen on camera standing inside the facility in front of the main door. A visiting family member entered from outside, punched in the door code, and let the resident out without notifying staff. The resident's whereabouts remained unknown for approximately one hour and 45 minutes until a concerned citizen found him sitting on the curb of a heavily traveled street. The resident was found confused and with an abrasion on his left hand due to a fall. He was transported to the emergency room for further evaluation. The facility's staff was unaware of the resident's absence until notified by the local police department. The door alarm had sounded, but a staff member did not respond, assuming it was activated by another staff member retrieving food. The facility had identified 20 residents at risk for elopement, but the most recent elopement assessment did not identify this resident as being at risk. The care plan for the resident included interventions for wandering, but these were not sufficient to prevent the elopement. The facility's failure to supervise adequately and respond to the door alarm contributed to the resident's unsupervised exit.

Removal Plan

• The facility was alerted by the local police department Resident #37 was missing from the facility
• The door alarms were checked by LPN #500.
• RDCS #300 reviewed the facility elopement policy with no changes being made to the policy.
• The Administrator and DON were re-educated on the facility elopement policy by RDCS #300.
• Upon return from the local ER, Resident #37 was placed on 1:1 supervision with Certified Nursing Assistant (CNA) #581.
• Resident #37 was assessed by the DON upon his return from the local ER.
• Resident #37's care plan was updated by Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350. The update included the addition of 1:1 supervision.
• Resident #37's 1:1 supervision was discontinued, and the resident was transferred to the facility secured memory care unit.
• Elopement risk assessments were completed on all 89 residents who resided in the facility. The assessments noted 20 residents were identified at high risk for elopement. All residents at high risk of elopement resided on the secured memory care unit. Subsequent elopement assessments would be completed on a quarterly and as-needed basis by the nursing leadership team.
• The Administrator re-educated all staff on the facility's elopement policy and procedure.
• Residents at high risk of elopement were listed in an elopement binder kept at the front desk. The binder was updated. The binder included the resident's demographics, including a photograph. The elopement binder would be reviewed 5 times weekly and updated as needed by the Administrator or designee.
• The front door entrance code was changed by Maintenance Director #499. The facility implemented a plan for the door code to be changed weekly for six months, then as needed to address family members having the access codes.
• Resident #37's daughter and Visiting Family Member #375 were re-educated on the facility's elopement policy, visitation, and door access by the Administrator.
• An elopement drill was completed. This was coordinated by Director #499.
• The facility implemented a plan for ongoing elopement drills to be completed to verify staffs understanding and implementation of the facility elopement policy on alternate shifts monthly for six months, then quarterly thereafter. This would be completed by Maintenance Director #499 and overseen by the Administrator.
• Signage was placed at the front entrance for families, visitors, and residents stating, Visiting Hours are 8am-8pm. Doors are locked in off-hours to ensure the safety of our residents. Call [PHONE NUMBER] for after-hour assistance. Questions may be directed to the Administrator. This was completed by the Administrator.
• An ad hoc Quality Assessment and Performance Improvement (QAPI) meeting was held. The Administrator presented the QAPI Team with investigation and all findings for discussion and review. Discussion included an action plan from the (elopement) incident involving Resident #37. Staff in attendance included the Administrator, DON, RN Unit Manager #524, RN MDS Coordinator #350, Social Service Designee (SSD) #710, Therapy Director #715, Activity Director #720, Maintenance Director #499, Housekeeping/Laundry Director #730, Food Service Director #735, Medical Director #765, Human Resources Director #755, Business Office Manager (BOM) #740, Admissions Coordinator #745, Pharmacy Consultant #760, and Scheduler #750.
• The facility implemented a plan for ongoing audits to monitor elopement risk to be completed on each unit and include a random sample of 3-5 residents weekly for four weeks, then randomly thereafter. The audits would include monitoring for residents who were exhibiting signs or symptoms which could be indicative of an increased elopement risk such as residents wandering aimlessly, with cognitive impairments, behavior patterns, packed belongings, statements of wanting to leave the facility, and/or staying near an exit door as well as auditing door codes and staff response time for door alarms. The audits would be completed by the Administrator, DON, or designee. The results of the audits would be reviewed in QAPI.
• The facility implemented a plan for all new employees to receive education on the facility's elopement policy upon hire during orientation by HR Director #755 or designee, then annually and as needed thereafter.

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 report an incident of potential neglect involving a resident with severe cognitive impairment and multiple diagnoses, including dementia and PTSD. The resident, identified as an elopement risk, was found outside the facility by a concerned citizen and was subsequently taken to the emergency room for evaluation. The incident occurred when a visiting female opened the lobby door, allowing the resident to exit the building. Despite the resident's elopement and subsequent injury, the facility did not report the incident to the State Survey Agency as required by their policy. The facility's policy mandates that all alleged violations involving neglect must be reported immediately or within 24 hours if no serious bodily injury occurs. However, the Administrator, following corporate guidance, did not complete a Self-Reported Incident (SRI) report, believing that elopements were not reportable. This oversight was discovered during an investigation of a separate complaint, revealing a deficiency in the facility's adherence to reporting requirements for potential neglect incidents.

Penalty

Inspection fine: $27,254

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 cognitively impaired resident from abuse by a Certified Nursing Assistant (CNA). The incident occurred when the CNA physically abused the resident while providing care, as captured on video surveillance. The video showed the CNA hitting the resident in the bathroom, resulting in the resident crying out in distress. The abuse continued when the CNA hit the resident in the face after returning to the bed, causing further emotional distress. The resident involved had a history of Alzheimer's disease with late onset and unspecified dementia without behavioral disturbance. The resident's care plan noted behavior problems such as resistance to care and rummaging through things, but there were no documented incidents of aggressive behavior towards staff or others on the day of the incident. The resident required assistance with toilet hygiene and was occasionally incontinent of urine. The abuse was discovered when the resident's family viewed the surveillance footage and reported it to the police. The police arrested the CNA, who was later terminated by the facility. Interviews with staff revealed that the CNA was not a full-time staff member on the secured memory care unit and had not received the facility's dementia training. The facility's abuse policy emphasized the right of residents to be free from abuse, neglect, and corporal punishment.

Removal Plan

• CNA #813 was taken into police custody by the police department. CNA #813's employment was terminated.
• Resident #1 was assessed by RN Unit Manager (UM) #808.
• Resident #1's care plans were reviewed and updated by RN Minimum Data Set (MDS) #914 to include new behavioral focus interventions.
• RN UM #808 assessed all residents on the SMCU for evidence of abuse which included skin checks and pain assessments.
• All residents, including the 23 residents on the SMCU, were reviewed by RN MDS #914 to ensure they were accurate to meet the residents' needs.
• The facility abuse policy was reviewed by RN CDCS #920 with no updates or changes being made.
• RN CDCS #920 re-educated the Administrator and the DON on the facility abuse policy and procedure.
• A new procedure was developed by the DON: Residents on the SMCU Become a Two-Person Assist During an Episode of Combative Behavior.
• The Administrator re-educated all staff on the Abuse Policy and the new procedure for Residents on the SMCU Become a Two-Person Assist During an Episode of Combative Behavior.
• All current staff were educated on facility's dementia-focus program, Compass Training, by the Administrator.
• The Administrator presented the QAPI team with the abuse investigation and all findings were discussed and reviewed.
• An audit was completed by the Administrator and DON to monitor compliance of the abuse education.
• The facility implemented a plan for the Administrator, DON and/or designee to conduct an audit on three to five residents per week for four weeks, and randomly thereafter.

Penalty

Inspection fine: $27,254

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

Summary

The facility failed to ensure that a resident's care plan interventions were implemented to prevent elopement. The resident, who was admitted with Alzheimer's disease and dementia, was identified as an elopement risk due to cognitive status and disorientation. Despite having interventions in place to manage wandering behavior, the resident was able to leave the secured memory care unit unsupervised. On the day of the incident, the resident was observed on surveillance video leaving the unit through a 15-second egress door. A registered nurse noticed the door open but did not follow the resident outside, assuming other staff were attending to the resident. The resident was outside the building for approximately thirteen minutes before being found by a laundry aide who was leaving for the day. The facility did not document the elopement in the resident's medical record or the incident/accident log, and no investigation was conducted. The facility's elopement policy, which outlines steps to be taken in such situations, was not followed. The Director of Nursing confirmed the lack of documentation and investigation, acknowledging that the staff failed to ensure the resident's safety as per the policy.

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 had an adequate supply of oxygen to attend an outside doctor's appointment. Resident #88, who had chronic respiratory failure and chronic obstructive pulmonary disease, was admitted to the facility and required oxygen at two liters via nasal cannula to maintain oxygen saturation above 92%. On the day of the appointment, the resident's daughter called the facility to report that the resident's oxygen tank was empty. The facility staff, including an LPN, confirmed that the resident's oxygen was ordered as needed and that the daughter would often adjust the oxygen flow despite the resident's needs. The LPN immediately delivered an oxygen tank to the doctor's office, which was approximately 15 minutes away, and found the resident not in distress upon arrival. The doctor's office also had oxygen available, as confirmed by the resident's daughter. The resident experienced no further complications related to oxygen through discharge to another facility at the request of the daughter. The facility's policy required that appropriate equipment be sent with residents during appointments, which was not adhered to in this instance.