Calhoun Convalescent Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with known cognitive impairment and wandering behaviors. The resident had dementia with severe cognitive impairment, a BIMS score of 7/15, generalized muscle weakness, unsteadiness on feet, and abnormal gait and mobility. The admission MDS and care plan identified the resident as at risk for falls and elopement, with documented wandering throughout the facility and a recent elopement. An elopement risk observation completed shortly before the incident documented that the resident did not have safe decision-making capabilities. Nursing staff reported that the resident remained ambulatory with good strength and endurance, had impaired judgment and poor safety awareness, and required close supervision due to ongoing exit-seeking behaviors. On the day of the incident, staff last observed the resident in a safe environment ambulating in the facility between approximately 5:30 PM and 5:40 PM, which was described as baseline behavior. Around this same time frame, the alarm on a dining room/fire exit door near the dietary department sounded. Dietary staff responded, visually checked the area, reported not seeing anyone, re-engaged or disarmed the alarm, and returned to the kitchen. Multiple staff later acknowledged that it was difficult to hear the alarm in the kitchen and that they were unable to determine how long the alarm had been sounding before it was noticed. The facility’s elopement policy required immediate notification of all employees and a prompt, thorough search process when a resident was considered missing, but there is no indication that a facility-wide code or missing resident procedure was initiated at the time the door alarm sounded. Subsequently, between approximately 5:50 PM and 6:05 PM, the resident’s CNA noticed the resident was not in the room to receive a dinner tray and began looking for the resident, prompting a census head count. Staff were unable to locate the resident in the building, and a search was initiated. Around 6:08 PM to 6:39 PM, an employee leaving work by car believed they saw the resident near a nearby Dollar General store and called the facility. A nurse drove to the store but did not find the resident. During this period, the local police were notified by Dollar General about a suspicious person with a hospital bracelet. Police located the resident at a nearby intersection; the police report described the resident as delirious, disoriented, and unable to provide coherent responses. EMS was requested, and the resident was transported to a hospital emergency department. The facility later confirmed that the resident had eloped from the building and was found with a wander guard still in place, and staff, including the administrator and DON, were unable to state exactly how the resident exited the building, though they believed it may have been through the dining room door whose alarm had sounded earlier. Interviews with staff revealed additional gaps related to supervision and elopement procedures. One CNA assigned to 1:1 care for the resident stated it was her first day in that role and could not confirm how long the resident had been on 1:1 care. Another CNA, who had recently completed orientation, reported not receiving any in-service training related to elopements and stated that the survey interview was the first time she heard about the resident’s exit from the building. The LPN on duty reported that the resident had been on 30-minute checks due to wandering, last saw the resident around 5:25 PM–5:30 PM, and assumed the resident was doing usual laps in the facility. The DON and administrator both acknowledged that staff could not determine how long the door alarm had been sounding before it was heard and that staff responded by looking outside, not seeing anything, and shutting off the alarm. These actions and inactions, in the context of a known high-risk, cognitively impaired, exit-seeking resident, led to a successful elopement and formed the basis of the cited deficiency under 42 CFR 483.25 for failure to keep the environment free of accident hazards and provide adequate supervision.

Removal Plan

• Evaluate resident at emergency room; confirm no injuries.
• Initiate and continue 1:1 supervision for the resident.
• Assess each exit door to validate doors are working properly.
• Update the resident’s elopement risk assessment to reflect current status.
• Update the resident’s care plan and resident profile.
• Complete an elopement drill.
• Administrator will notify the charge nurse, Director of Nursing, and Social Service designee that a resident is missing as part of drill procedure.
• Director of Nursing/designee will announce Code [NAME] to signal the elopement drill procedure.
• Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds; complete the entire search process within 30 minutes.
• If search fails to locate resident within allotted time, Administrator/designee will place a mock telephone call to appropriate community agencies, resident's legal representative, and attending physician; staff will provide mock police with physical identifying information.
• Continue the search if resident not located, including having staff search surrounding streets by car for a 2 mile radius.
• When the volunteer resident is located, the charge nurse will complete a head-to-toe assessment.
• Social Services designee will assess the resident for emotional distress.
• Director of Nursing will notify appropriate community agencies, attending physician, and resident's legal representative.
• Facility Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences.
• When missing resident is found, make an announcement: Code [NAME] all clear.
• Update elopement risk assessments for all residents.
• Place residents identified as elopement risk in the elopement binder and update their care plans and profiles.
• Reeducate facility staff on the elopement policy and Abuse, Neglect & Misappropriation policy.
• Provide education to any staff not receiving this education prior to their next scheduled shift.
• Review new admission elopement risk assessments in Clinical Morning Meeting to validate accuracy and interventions if indicated.
• Review quarterly elopement risk assessments to validate accuracy and interventions if indicated.
• Maintenance Director/designee will inspect facility exit doors to validate doors are functioning properly.
• Administrator will round with the Maintenance Director validating doors are functioning properly.
• Hold an Ad Hoc QACPI.
• Notify the Medical Director of the incident and plan.
• Present results of audits in the QAPI Committee meeting for review and recommendations.

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 residents received their mail in a timely manner and unopened. The undated facility Mail Distribution policy stated that incoming personal mail is to be distributed unopened and within the same day it is delivered to the Activity Department, and that mail should be delivered to the resident's room within 24 hours of receipt. The Resident Rights policy also stated that residents have the right to privacy in written communications and to promptly receive mail unopened. During the Resident Council meeting, residents stated that their mail is opened and sometimes delivered late, not on the date it is delivered to the facility. An Activity Assistant stated she had been instructed by management to open all resident mail and inspect the contents before delivery because residents sometimes order and receive things they should not have access to. The Activity Director stated she had been instructed to open all mail belonging to residents, no matter how big or small, before delivering it, and that letters were also opened before being given to residents. The Business Office Manager stated she would open resident mail if she thought it was something she needed to fill out and send back for the resident, or if it was an incoming check for facility payment, and would then give the opened mail to the resident if it was not related to payment or a document she needed to complete.

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 stored in accordance with accepted professional principles because unlabeled, outdated, and expired medications were found on 4 of 4 medication carts. The facility policy stated that medications and biologicals are to be stored safely and securely, that medications with a manufacturer’s expiration date expressed in month and year expire on the last day of the month, and that outdated, contaminated, or deteriorated medications are to be immediately removed from stock. During observation, Medication Cart A on the North Hall contained a house stock bottle of Zinc 50 mg with approximately 100 tablets that had expired in 01/2026 and remained on the cart. Additional observations showed multiple insulin pens in use without open dates or expiration dates documented on the pens. Medication Cart A contained a Soliqua Insulin 100/33 pen with no open date and no expiration date, despite a label stating to discard the insulin after 10 days if no open and expiration date were present. Medication Cart C contained a Humulin 70/30 KwikPen with no open date and no expiration date, Medication Cart D contained two Novolog insulin pens with no open date and no expiration date, and Medication Cart F contained a bottle of B Complex tablets that had expired in 01/2026. The medications were confirmed by RN1, LPN1, LPN3, and LPN4 during the observations.

Penalty

No penalty information released

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

Summary

The facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments at the intervals ordered by the provider for 3 of 3 residents reviewed who were receiving psychotropic medications. Facility policy titled Medication Management stated that AIMS testing should be completed as a baseline on admission or re-admission with an enduring antipsychotic medication, on initiation of an anti-psychotic medication, and at least every six months and with dosage changes. The record review showed that the ordered AIMS schedule was not followed for the residents reviewed. R41 was admitted with diagnoses including severe bipolar disorder with psychotic features, major depressive disorder, generalized anxiety disorder, and dementia. He had a BIMS score of 15 out of 15 and was receiving aripiprazole 30 mg at bedtime. His order required AIMS assessments every three months on the 22nd of March, June, September, and December. The observation history showed AIMS assessments on 03/31/25, 12/12/25, and 01/26/26, but none were found for 06/2025 or 09/2025 as ordered. R92 was admitted with diagnoses including borderline personality disorder, anxiety disorder, and schizoaffective disorder. She had a BIMS score of 15 out of 15 and was prescribed Saphris 10 mg twice daily. Her order required AIMS assessments every three months on the 20th of March, June, September, and December. The observation history showed only one AIMS assessment on 10/19/25, with no other AIMS assessments found. R97 was admitted with diagnoses including schizoaffective disorder, pseudobulbar affect, depressive episodes, generalized anxiety disorder, and vascular dementia. He had a BIMS score of 06 out of 15 and was prescribed haloperidol 5 mg every evening and haloperidol decanoate 100 mg/mL every 28 days. His order required AIMS assessments every three months on the 2nd day in January, April, June, and October. The observation history showed AIMS assessments on 04/02/25, 07/02/25, 12/12/25, and 01/02/26, but none were found for June or October as ordered.

Penalty

No penalty information released

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

Summary

The facility failed to complete a Significant Change MDS for R92 after she began receiving Hospice care. Facility policy stated that residents referred to Hospice need a Significant Change MDS, and the MDS policy identified enrollment in a hospice program as a situation requiring a significant change assessment. R92’s record showed diagnoses including chronic kidney disease, Type 2 diabetes mellitus, heart disease, CHF, chronic pain syndrome, COPD, anxiety disorder, and schizoaffective disorder. Her orders showed she was admitted to Gentiva Hospice on 01/09/26, but no Significant Change MDS was listed as completed in response to that change. R92’s MDS record showed a Quarterly MDS completed on 11/17/26 and an Annual MDS completed on 02/17/26, with the Annual MDS indicating she was receiving Hospice care at that time. During interview, the Regional MDS Coordinator stated a Significant Change MDS should have been done when R92 was placed on Hospice and said, “There’s no doubt about that. It should have been done.” The DON and Administrator both stated the facility had a gap in NAC coverage during January, and the Administrator reported the NAC nurse was out from 01/09/26 through 01/26/26 and resigned on 01/27/26.

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 update the care plan for a resident whose code status changed from Full Code to Do Not Resuscitate (DNR). The resident, who had diagnoses including chronic kidney disease, Type 2 diabetes mellitus, heart disease, congestive heart failure, chronic pain syndrome, chronic obstructive pulmonary disease, anxiety disorder, and schizoaffective disorder, had an order for DNR status entered on 11/24/25. However, the care plan reviewed on 02/22/26 still identified the resident as Full Code and included goals and approaches reflecting full resuscitation status. The facility policy stated that the person-centered care plan is interdisciplinary and is used to guide staff in providing treatment, care, and services. During interview, the Social Services Director stated that when a resident changes advanced directives, either she or the Nurse Assessment Coordinator changes the care plan, and she had already changed it that day to show DNR status. The Director of Nursing stated there had been a gap in the Nurse Assessment Coordinator position after the prior nurse left in December, and the Administrator stated the care plan was probably not changed because the Nurse Assessment Coordinator was out from 01/09/26 through 01/26/26 and resigned on 01/27/26.

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 hand hygiene was offered and/or assisted before meal service for two residents observed during dining. The facility policy titled Infection Prevention and Control Policies and Procedures, Subject: Hand Hygiene/Handwashing, stated that hand hygiene/handwashing is to be performed before eating and before preparing, distributing, handling, or serving food. During meal observations, one resident with vascular dementia, muscle weakness, schizophrenia, bipolar disorder, and dysphagia who required setup or clean-up assistance with eating was not offered hand hygiene before breakfast or lunch, and another resident with polyarthritis, hypertensive heart disease with heart failure, and muscle weakness was not offered hand hygiene before breakfast or lunch. The second resident was cognitively intact, and both residents were observed receiving meals without hand hygiene being offered first. Interviews confirmed the observations. The first resident indicated by gesture that hand hygiene had been offered before breakfast, but the second resident stated that hand hygiene was not offered before lunch and her son reported that staff never offer hand hygiene before meals. CNA1 stated it was policy to clean resident hands before meals but admitted forgetting to offer it that day. CNA2 stated the second resident usually cleans her hands herself with hand sanitizer, but confirmed she did not do so that day. CNA3 stated she was unsure of the procedure and confirmed she did not offer hand hygiene to any residents she served. The Administrator stated it was her expectation that staff offer hand hygiene to each resident before meals, including a warm clean cloth or at least hand sanitizer.

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 follow its abuse, neglect, exploitation, or mistreatment policy requiring that all alleged violations concerning abuse be reported immediately and verbally to the Facility Abuse Coordinator, the Administrator, and the State Survey and Certification Agency. The policy also states that employees have the right to report allegations directly to the state agency. Despite this, allegations of sexual abuse involving three residents were not reported to the State Agency within the required 2-hour timeframe. The abuse allegations were discussed in a morning staff meeting on 02/06/2026, and some staff reported learning of the allegations as early as 02/04/2026 and 02/05/2026, but there was no timely notification to the State Agency as required. The residents involved all had significant cognitive impairments. One resident had diagnoses including cognitive communication deficit and dementia, with an admission BIMS score of 2/15 indicating severe cognitive deficits. Another resident had diagnoses including alcohol dependence with alcohol-induced persisting dementia, PTSD, anxiety disorder, major depressive disorder, and schizophrenia, and a Quarterly MDS documented that a BIMS was not conducted because the resident could not understand and was not understood. The third resident had diagnoses including dementia, TIA, cerebral infarction, convulsions, adult failure to thrive, and cocaine use, with a Quarterly MDS BIMS score of 6/15 indicating severe cognitive deficits. Allegations included one resident being observed by a CNA with her hands in the brief of another resident, and a separate allegation that two residents had sexual intercourse when one was found in the bed of the other. Progress notes for all three residents contained no documentation of alleged abuse, and although multiple staff members, including department heads and LPNs, were aware of the allegations and the allegations were reported to a nurse when they occurred, staff did not report them to the Abuse Coordinator, and the Abuse Coordinator did not report them to the State Agency.

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 implement care plan interventions related to fall prevention for one resident identified as being at risk for falls. Facility policy on Fall Management, revised 05/05/23, requires that residents at risk for falls be identified, that care be planned, and that interventions be implemented and reflected on the care plan, with individualized interventions reassessed and revised as needed. The resident had diagnoses including dementia, history of falling, diabetes mellitus, hypokalemia, chronic kidney disease, and urinary tract infection, and a Quarterly MDS showed a BIMS score of 3/15, indicating severe cognitive impairment. The same MDS documented that the resident required maximum assistance for bed mobility, was dependent for toilet transfers, and had no falls since admission or prior assessment. The resident’s care plan, initiated 05/29/2024, identified impaired cognitive function and risk for falls related to dementia, decreased mobility, history of falls, impaired vision, and impaired cognition, and included interventions such as maintaining a safe environment with even, clutter-free floors, nursing monitoring during ambulation in the hall, encouraging the resident to wait for assistance before ambulating, use of a fall mat at bedside, reminders to call for assistance with the call bell prior to transfers and ambulation, and staff education. A Fall Incident Report dated 10/19/2025 documented that the resident had a history of falling, was bed bound, required a Hoyer lift and two-person assist for transfers, and had a last fall on 10/24/2024. On two separate observations on 02/11/2026, the resident was seen in bed asleep with the bed in the lowest position, periodically pulling herself up using top bedrails, and no fall mats were in place despite the care plan intervention. In an interview, the DON stated that the care plan and MDS were not updated, that there had been only one MDS nurse who was behind, that there was currently no MDS nurse on staff, and that unit managers were trying to update MDS and care plans daily; the DON also acknowledged that the fall was not documented in the care plan and that interventions should have been put in place based on submitted statements.

Penalty

Inspection fine: $14,056

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

Summary

The facility failed to provide appropriate supervision to prevent a resident's elopement, which resulted in Immediate Jeopardy. The resident, who was severely cognitively impaired with a BIMS score of 1 out of 15, had a history of wandering and was at risk of elopement. Despite having a Wander guard in place, the resident managed to leave the facility unsupervised. On the evening of the incident, the door alarm system was triggered, but the response was delayed due to confusion about which door was alarming. The resident was found outside in the parking lot, having fallen and hit her head. Interviews with staff revealed that the alarm system was functioning, but the response was not immediate, leading to the resident's successful elopement. The resident's medical history included vascular dementia, neurocognitive disorder with Lewy bodies, and other conditions requiring supervision. The facility's policy on elopement was not effectively implemented, as evidenced by the resident's ability to leave the premises and sustain an injury.

Removal Plan

• Resident R1 had fall, possibly hitting head. Sent to ED for evaluation as precaution.
• Elopement risk evaluation repeated.
• Resident had Wandergard in place and properly functioning at time of incident.
• MD/RP notified.
• Administrator and CSD notified of incident.
• Residents at risk of elopement have the potential to be affected.
• Elopement risk evaluations done on current residents in facility reviewed by nursing managers for accuracy.
• Residents identified at risk will be reviewed for appropriate interventions.
• All doors check for auditory alarm; found to be in working order.
• Educate facility staff the expectation that if a door is noticed to be alarming, immediately report to door to verify no resident has eloped then do a facility wide head count of residents.
• If door is found to be malfunctioning, administrator to be notified immediately and an employee posted at the door until otherwise indicated and redirected by a member of management.
• Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified.
• Staff will be reeducated on appropriate response to alarms.
• Any member of target audience not receiving this will receive prior to next scheduled shift.
• New admissions will be reviewed in morning meeting daily as part of the clinical morning meeting process.
• Elopement risks assessments will be reviewed for accuracy and interventions validated if indicated.
• Quarterly assessments will be reviewed as part of the MDS/Care planning process.
• The Director of Nursing or designee will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy.
• The maintenance director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months.
• The Administrator or designee will make rounds weekly for 4 weeks then monthly for 2 additional months to validate that doors are functioning properly.
• The maintenance director or designee will activate a door alarm once a month on each shift to validate appropriate response for 3 months or until compliance.
• Ad hoc QAPI held.
• Medical Director was notified of the incident and plan for improvement.
• This process will be reviewed in QAPI for a minimum of 3 months.