Vancrest Of Urbana, Inc

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

Staff failed to safely transfer a resident with severe cognitive impairment and bilateral lower extremity functional limitations using a mechanical Hoyer lift. During a transfer to a recliner, staff used a Hoyer lift that was not wide enough to accommodate the recliner, but proceeded with the transfer regardless. As the resident was being lowered, the lift's bar swung back and struck the resident in the forehead, causing a laceration and bruising that required emergency room treatment and sutures. The incident involved both a hospice aide and a facility aide, and it was confirmed that the staff continued the transfer despite recognizing the equipment was not appropriate for the task. In a separate incident, another resident with bilateral below-knee amputations and chronic respiratory failure experienced a fall from bed during routine care. The resident, who was cognitively intact and required substantial assistance with bed mobility, was rolled onto his right side by a CNA working alone, after being unable to find another staff member to assist. The resident rolled out of bed and onto the floor. The fall report was found to be inaccurate, and the resident was not interviewed about the incident. The nurse on duty did not assess or interview the resident following the fall, and the fall investigation report was incomplete. Both incidents demonstrate failures in providing adequate supervision and assistance devices to prevent accidents, as well as failures in thoroughly investigating and accurately documenting resident falls. The facility's policies required staff to ensure resident safety during activities of daily living and to identify interventions related to specific fall risks, but these were not followed in the cases described.

Plan Of Correction

What corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #19 has been assessed and evaluated for appropriate transferring techniques, per facility policy, on multiple dates (note attached audit of completion). Through ongoing assessment, resident has been transferred, with no difficulty, and without injury obtained. Patient denies any concerns/discomfort with transferring techniques concluded. The oversized recliner was removed prior to survey initiation, per family request. Hospice provider has been advised to provide ample amount of time/notification for DME changes/removal to allow for appropriate transition of resident. Resident #25 has been interviewed for bed mobility preferences. Resident states he prefers to be a two person assist despite his ability to complete tasks with one individual. Resident's plan of care has been updated to identify specifics of patient preference (note attached). Facility staff educated on change of care, same date (included for reference). How will you identify other residents having the potential to be affected by the deficient practice and what corrective action will be taken: Managerial personnel will conduct random audits of bed mobility tasks and transfer completion guided per each individual's plan of care. Audits will be assessed daily, on each unit, at random time intervals x 1 week, twice weekly x 2 weeks, and once per week x 4 weeks. If concerns are identified, those individuals will be re-educated of the facility's transfer policy and procedures with hands-on guidance to be done. Initiation of a Performance Improvement Plan will be conducted, as needed. What measures will be put into place or what systemic changes will you make to ensure the deficient practice does not recur: Upon admission, each resident shall be assessed for safe transfers/bed mobility tasks guided per the functional status and personal preference expressed. Activities of daily living will be re-assessed quarterly, as needed, and with any significant medical changes following the initial admit, per facility designee, and will be reflected on the individualized plan of care. How the corrective actions will be monitored to ensure the deficient practice will not recur, ie., what quality assurance program will be put into place; and dates when corrective action will be completed: This plan of correction will be implemented, and the corrective action will be evaluated for its efficiency. The plan of correction is integrated into the facility's Quality Assurance Program. All auditing tools will be completed, as dictated, with thorough review. Any adverse findings/trends noted will be corrected immediately and brought to the Quality Assurance and Performance Improvement Committee for review. Please consider this plan of correction to be an allegation of compliance as if 07-18-2025. Resident #19's most recent assessment was done on 07/18/2025, which was completed by nurse on the unit. Hospice nurse was notified the date of the incident, which was 06/06/2025. The Director of Nursing, unit managers, and maintenance director reviewed wheelchairs and personal chair sizes to ensure mechanical lifts meet manufacturer guidelines when in use. No concerns were identified, and audit was completed the week of survey. Mechanical lift inspections are done monthly by the maintenance director. Maintenance Director reports any adverse findings to the Director of Nursing. A thorough investigation was completed per interdisciplinary team on 04/14/2025, which included Director of Nursing, Unit Manager, and MDS nurse. Initial interview incident was conducted per agency nurse at time of fall. Subsequent communication completed on 04/14/2025 per Unit Manager. In clinical care meeting on 04/14/25, resident #25 incident reviewed including preference stated by resident and during that time resident did not express any concerns with changes in the plan of care. During plan of correction review, resident was reinterviewed and expressed the desire to have two staff assist during bed mobility this time forward, which was 07/22/25. Plan of care updated with the following information. Yes, each fall investigation is led by the Director of Nursing and reviewed with the clinical team. The new processes were put into place and the implementation of the IPRO fall tracking tool alongside current facility policy and procedures for incident investigations. The licensed nurses and STNA are educated on transferring techniques including Hoyer lift policy and procedure at time of hire, annually, and with any manufacturer changes or new equipment. Upon hire would be our HR representative, annually or any changes would be completed by managerial nursing staff. Maintenance Director supplies any information regarding new lifts introduced into the facility. All nurses are oriented upon hire regarding risk management completion, interviewing staff/obtaining witness statements, and interviewing residents when applicable regarding cognition. In specific to this incident, agency staff was reeducated on thorough investigation; however, per risk management completion, it appears incident review was conducted accordingly. Director of Nursing reviews and signs each risk management. If concerns are identified, the Director of Nursing does a one-on-one reeducation with the staff member. Yes, all audits observed will include Hoyer transfers guided per resident’s individual plan of care. Yes, all falls are investigated to ensure thoroughness, including resident/staff interviews as applicable. Director of Nursing reviews with clinical staff. Every fall is reviewed and will continue to be reviewed indefinitely. Yes, it is the facility's utmost opinion that a thorough investigation was concluded on 04/14/2025 following the fall of resident #25. The initial interview of the incident was concluded immediately per agency nurse at the time of fall. Subsequent communication was completed, post ED return, per unit manager 04/14/2025. The new IPRO fall tracking tool was initiated 07/08/2025. The IPRO tracking tool has been utilized for all falls in July 2025. This new process will continue indefinitely. Yes, all staff (nurses and CNA's) have been educated on the proper transferring techniques, via Hoyer lift, post survey initiation and the AOC date, conducted per managerial nursing staff beginning 07/02/2025 through survey completion. Yes, all nurses have been re-educated on thorough fall investigation completion to include interviewing residents and staff (as applicable) after the survey start and prior to the AOC date. This guidance was transcribed per Director of Nursing and expressed to staff per nurse managers. The agency nurse was provided appropriate policy and procedure guidelines for incident/progress note completion on 04/14/2025 directly via the agency portal.

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 date dry products upon delivery, discard expired foods, and ensure proper glove use during food preparation. Observations revealed undated and expired food items in the dry storage area, including spiral noodles, vanilla wafers, yellow cake mix, powdered sugar, brown sugar, and three bean salad. Interviews with dietary staff confirmed these findings and indicated a lack of adherence to the facility's food receiving and storage policy, which mandates labeling and dating of dry foods and using a first-in, first-out system for rotation. Additionally, a dietary aide was observed preparing a cheeseburger without changing gloves after touching various surfaces, including the fryer basket handle, prep table, and tongs, before handling the food again. The dietary aide acknowledged the failure to change gloves or wash hands during the process, which is a violation of proper food handling procedures. These deficiencies had the potential to affect all 67 residents receiving food from the kitchen.

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 serve palatable meals to the residents, affecting five out of 17 residents reviewed for dietary services. Resident #19 reported that the food was often cold when received. Resident #66 stated that the chicken and dumplings served for lunch were dry and that the quality of food varied significantly from day to day. Resident #22, who had moderately impaired cognition, found the chipped beef gravy tasteless and unappetizing. Resident #21 complained that her meals were cold, tasteless, and consisted mainly of carbohydrates, which she did not eat. She refused both lunch and dinner on one occasion due to the poor quality of the food. Resident #25, the Resident Council President, also reported that the food was usually served cold and tasteless, and despite addressing these concerns multiple times with the administration, no improvements had been made. A test tray observation revealed that the mashed potatoes were acceptable, but the chicken and dumplings were unrecognizable, dry, and flavorless, and the carrots were soggy and watered down. The Dietary Manager confirmed that the chicken and dumplings were prepared from frozen ingredients and combined with cream of chicken soup. Resident Council notes from February, March, and April 2024 indicated ongoing concerns about the food and menus, which had not been addressed by the facility administration.

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 residents were given the Notice of Medicare Non-coverage (NOMNC) in a timely manner. This deficiency affected one resident, who had chronic hepatitis and hypertension and was moderately cognitively impaired. The resident was admitted on an unspecified date and discharged on another unspecified date. The NOMNC indicated that the resident's last covered day of Part A services was 10/17/23, and the notice was signed by the resident on the same day. An interview with the Business Office Manager confirmed that the resident did not receive the NOMNC until the last covered day, contrary to the facility's policy, which requires the notice to be issued at least two calendar days before benefits end.

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 plans were person-centered to include all areas of concern for three residents. Resident #14, who had Alzheimer's disease, dementia, and age-related physical debility, was severely cognitively impaired and dependent on staff for toileting. Despite being incontinent of bowel and bladder, Resident #14's care plan did not address incontinence care. This was confirmed by the Quality Assurance Nurse (QAN) #122, who acknowledged that the care plan should have included incontinence care from the beginning of the resident's stay at the facility. Resident #50, diagnosed with Alzheimer's disease, dementia, anxiety, and insomnia, also had severe cognitive impairment and was receiving an antidepressant. However, the care plan did not include any information regarding the use of psychotropic medications. This omission was confirmed by the Director of Nursing. Similarly, Resident #72, who had metabolic encephalopathy, chronic kidney disease stage three, major depressive disorder, and adjustment disorder with anxiety, was dependent on staff for toileting and was incontinent of bowel and bladder. Despite this, there was no active care plan for incontinence care, as verified by both STNA #69 and QAN #122. The facility's policy on care planning, which emphasizes comprehensive, person-centered care plans based on resident assessments, was not adhered to in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident had the proper diagnosis for the administration of an antipsychotic medication. Resident #3 was admitted with diagnoses of delirium due to a known physiological condition, Alzheimer's disease, and anxiety. The Minimum Data Set (MDS) assessment indicated severe cognitive impairment. Despite this, the resident was prescribed Zyprexa, an antipsychotic medication, for delirium without a diagnosis of schizophrenia or bipolar disorder, which are the conditions Zyprexa is commonly used to treat. The Director of Nursing confirmed that the resident did not have a diagnosis of schizophrenia or bipolar disorder. The facility's policy on antipsychotic medication use, dated 07/2022, states that a resident will only receive antipsychotic medication when necessary to treat a specific condition for which they are indicated and effective. However, the review of the guidance from Medscape revealed that Zyprexa is not approved for dementia-related psychosis in the geriatric population due to increased risks. This discrepancy indicates a failure to adhere to the facility's policy and proper medical guidelines, leading to the unnecessary use of antipsychotic medication for Resident #3.

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 residents were offered the pneumococcal vaccine, affecting three of five residents reviewed for pneumococcal immunization. Resident #19, admitted on an unspecified date, received the influenza vaccination but was not offered the pneumococcal immunization. The Director of Nursing (DON) confirmed this oversight. Similarly, Resident #20, also admitted on an unspecified date, had no evidence of being offered or receiving the pneumococcal vaccine prior to admission, as confirmed by the DON. Resident #50, admitted on an unspecified date, was also not offered the pneumococcal immunization, which the DON confirmed. The facility's undated policy stated that all residents should be offered the pneumococcal vaccine within five working days of admission, which was not adhered to in these cases.