Veterans Victory House

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 deficiency involves the facility’s failure to ensure adequate supervision and prevent a successful elopement for one resident identified as at risk for wandering and elopement. The resident was admitted with diagnoses including traumatic subdural hemorrhage, muscle weakness, difficulty in walking, and need for assistance with personal care. An admission MDS showed a BIMS score of 9/15, indicating moderate cognitive impairment, and documented that the resident used a wheelchair and required substantial assistance for most ADLs. The facility’s own policy defined wandering and elopement, required staff training on elopement prevention, and called for interventions and care plan documentation for residents at risk of elopement. Physician orders were in place directing staff to check the resident’s wander guard for effectiveness and function every shift beginning shortly after admission. However, review of the MAR/TAR for the period from admission through the date of elopement showed that this order was not consistently documented as completed. For the period 01/30/26–02/19/26, there was an order to check the wander guard every shift, but it was only signed once on the date of the elopement for the first shift. There was no documentation on the MAR/TAR for January related to checking the wander guard, despite the order being in effect. The resident’s care plan, initiated on admission and revised on 02/19/26, identified behavioral symptoms of wandering and elopement related to impaired cognition and impulsivity, and included an intervention to equip the resident with a wander guard upon admission for 48 hours and to check the device’s proper functioning every shift, but the documented implementation of these checks was lacking. In the days leading up to the elopement, progress notes documented that the resident needed frequent redirection due to wandering in and out of other residents’ rooms, and that staff discussed with the resident’s representative the possibility of obtaining a sitter because of these behaviors. Another note described the resident being found seated on a fall mat after getting out of bed to remove pictures from the wall and pack his bag, indicating ongoing impulsive and wandering behavior. On the night of the elopement, a CNA reported that the resident had been described as hard to redirect and constantly pacing the unit in his wheelchair. Later that night, the resident was found wandering in the parking lot and brought back inside by a CNA; the nurse documented that the door alarm was not going off at the time the resident was found outside. The resident’s representative later stated that he had been informed that the front door was not working properly and that the resident had a wander guard device that should have locked the door when he left, but the door did not function correctly, allowing the resident to exit the building. Based on these findings, surveyors determined that the facility failed to provide adequate supervision and accident prevention, resulting in a successful elopement and an Immediate Jeopardy determination at F689. The State Agency determined that the facility’s non-compliance with federal health and safety regulations caused or was likely to cause serious injury, harm, impairment, or death, and identified the Immediate Jeopardy as related to 42 CFR 483.25, Quality of Care. The Immediate Jeopardy was determined to have existed as of the date of the elopement. The survey findings emphasized the lack of documented adherence to physician orders and care plan interventions for checking the wander guard device, the presence of documented wandering and impulsive behaviors, and the fact that the resident was able to leave the building without triggering a door alarm. These combined actions and inactions led to the conclusion that the facility did not ensure the environment was free from accident hazards and did not provide adequate supervision to prevent the resident’s elopement.

Removal Plan

• Resident was immediately located and safely returned to the facility.
• Full nursing assessment completed by licensed nurse; no injuries noted.
• Physician/Medical Director and responsible party notified by administrator.
• Resident placed on increased monitoring immediately.
• Wandering/elopement risk reassessed.
• Care plan updated to include enhanced interventions.
• Wander guard applied and verified functioning.
• Staff education initiated by administrator.
• Incident reported per facility policy and state requirements.
• Facility conducted a 100% audit of all residents for elopement risk.
• Verified wander guard placement and function for all residents.
• Verified accuracy of assessments and care plans for all residents.
• Updated care plans to include individualized interventions such as secured unit placement/discharge plan and structured activities to reduce wandering.
• Conducted environmental safety checks.
• All exit doors secured and alarmed and verified by maintenance department weekly.
• Wander guard system tested by maintenance department weekly with a log.
• All staff education completed by DON/Administrator on policy/protocol for wandering and elopement and immediate response procedures if a resident is missing.
• Results reviewed in QWAPI meetings monthly for 3 months, with corrective actions implemented as needed.

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 a failure to protect a resident from physical abuse by a CNA. The facility’s abuse policy defines physical abuse as including hitting, slapping, and controlling behavior through corporal punishment. The resident involved was admitted with major depressive disorder and dementia with agitation, and a recent MDS showed a BIMS score of 7/15, indicating severe cognitive impairment. The resident was generally independent with toileting and transfers. On the day of the incident, the resident was on a locked dementia unit and had experienced bowel incontinence, leaving the bathroom soiled. A CNA entered the resident’s room to assist with cleaning the bathroom. During this interaction, the resident became agitated and combative, reportedly spitting on the CNA and striking the CNA in the face with a wet washcloth containing bowel movement. The CNA later reported that she responded by holding the resident’s hands above her head and then making contact with the resident’s face with an open hand, described as a slap or “smudging” the resident’s face. The CNA admitted to multiple staff, including the charge nurse, DON, Administrator, and Social Services, that she had put her hands on the resident and struck the resident in the face with an open hand in retaliation for the resident’s actions. A police report documented that the CNA admitted to assaulting the resident with an open-hand slap during a physical altercation. Staff who assessed the resident after the incident noted that the resident appeared visibly upset but had no visible injuries, and the resident was unable to recall the specific events due to severe cognitive impairment. The State Agency determined that the facility’s non-compliance with abuse regulations caused or was likely to cause serious harm and cited the facility under 42 CFR 483.12 for failure to ensure the resident was free from physical abuse.

Removal Plan

• Removed CNA3 from the resident care area after the incident.
• Interviewed CNA3 regarding the incident.
• Terminated CNA3 by the Administrator and DON.
• Notified law enforcement of the incident.
• Submitted a report to the Regional Ombudsman.
• Completed a nursing assessment and body audit of R1; no injuries found.
• Notified R1's family/responsible party of the incident.
• Monitored residents for psychosocial distress or changes by nursing staff and Social Services.
• Provided 1:1 re-education for staff working in skilled nursing on abuse and appropriate response/intervention and workplace fatigue.
• Conducted an investigation and determined there was no physical evidence of abuse.
• Social worker interviewed all residents on Unit 3 regarding abuse, whether any abuse had been witnessed/experienced, and whether residents felt safe.
• Social worker interviewed residents on other skilled units regarding abuse and whether residents felt safe.
• Arranged for MD and PA to evaluate R1; MD issued new medication orders and PA checked on the resident.
• Obtained family consent for a psychiatric evaluation.
• Social worker contacted the family and obtained updates; family visited and reported no changes in mood/behavior/psychosocial status.
• Social worker checked in on R1 and monitored for changes.
• Initiated in-house education for all staff working in Skilled Nursing on types/definitions of abuse, dementia with abuse prevention, de-escalation of behaviors, and how to appropriately avoid these situations.
• Re-educated staff on who the Abuse Coordinator is and how to notify the Abuse Coordinator of concerns.
• Reviewed the abuse policy with staff.
• Obtained statements from all staff who work in Skilled Nursing.
• Continued education ongoing.
• Nursing management (DON, ADON, Unit Managers) to conduct rounding and audits for signs of abuse.
• Held QAPI and updated it regarding this issue.

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 was free from accident hazards and received adequate supervision during ambulation, resulting in a fall and left hip fracture. The facility’s Fall Management Program policy included staff education and interventions to prevent unsafe transfers and ambulation. The resident had severe cognitive impairment, as evidenced by a BIMS score of 3/15, and used a walker and wheelchair. A Safe Resident Handling Data Collection form documented that a gait belt and walker were required for transfers with staff and that the resident continued to require use of a gait belt. The resident’s care plan included assistance with transfers and ambulation and provision of adaptive equipment, but there was no physician order for a gait belt, and gait belt use was not listed on the care plan. Instead, the Administrator stated that transfer methods, including gait belt use, were communicated via name tags on residents’ doors and that the resident had a history of tripping over her own feet and falling. On the day of the incident, the resident was being assisted by a CNA from the bathroom when the resident’s feet became twisted and she fell to the floor. The CNA reported she was holding the resident’s pants while walking her from the bathroom and acknowledged that the fall was her fault. Documentation indicated the resident fell in her room while being transferred/ambulated from the bathroom with the CNA present, wearing shoes at the time. The Administrator confirmed that the resident had been assessed for gait belt use and that the resident did not have a gait belt on when she fell. The Administrator stated that, in situations where a resident is already in motion without proper equipment, staff should hold the resident and call for help rather than continue ambulation. The resident sustained a subcapital femoral neck fracture of the left hip, required surgical repair at a hospital, and was later readmitted to the facility for rehabilitation and strengthening, with documentation noting she had been confined to a wheelchair prior to the fall and was unlikely to progress beyond her previous level of activity.

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 notify a resident’s physician of significantly elevated blood pressures as required by facility policy. The facility’s policy on Change in a Resident’s Condition or Status, revised February 2021, states that the nurse will promptly notify the attending or on-call physician when there is a significant change in the resident’s physical condition, defined as a major decline or improvement that will not normally resolve without intervention. The resident was admitted with diagnoses including Alzheimer’s disease, essential hypertension, and hypothyroidism, and had an active order for Benazepril 5 mg daily for hypertension with instructions to hold the medication if systolic blood pressure (SBP) was less than 110. The admission MDS showed the resident was unable to complete the BIMS interview and had an active diagnosis of hypertension. Blood pressure records showed multiple elevated readings, including 172/102 and 172/101 on one day and 171/119 on the following day. Review of the nurse’s notes revealed no documentation that the physician or PACE program was notified of these elevated blood pressures. The care plan indicated the resident was a PACE participant and directed staff to contact PACE for any medical needs. During interviews, the UM stated all medication orders came from PACE, and the DON acknowledged that 171/119 was an elevated blood pressure and that a call should have been made to the on-call PACE medical director, with family also to be notified of the change in condition. The patient liaison and weekend supervisor both reported not being informed of the elevated blood pressures, and CNA staff reported notifying an RN of the elevated readings but was unsure what occurred afterward. The RN stated she did not recall the patient but indicated that if there was no progress note, the notification would not have been documented anywhere else.

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 obtain and administer Lacosamide, an ordered seizure medication, for one resident, resulting in 11 missed doses over the period from 1/7 to 1/13. The resident was admitted with diagnoses including epilepsy, paranoid schizophrenia, and dementia. Review of the care plan showed no care plan addressing epilepsy, seizure risk, or seizure medications. Review of the MAR for 1/7/26 through 1/14/26 showed that the resident did not receive Lacosamide 100 mg, ordered as 1.5 tablets by mouth twice daily for seizures, for a total of 11 missed doses. The facility’s policy on Adverse Consequences and Medication Errors defined a medication error to include omissions when a drug is ordered but not administered. During interviews, an LPN stated that if a progress note about Lacosamide not being given was scratched out, it meant the medication was administered, and that when waiting for a medication, the nurse keeps a running list and calls the pharmacy for status updates. The Staff Development Coordinator reported that the protocol for missing medications requires nurses to call the pharmacy and document the call, notify the MD for alternatives, and check the Omnicell if the medication is not a narcotic. The DON stated that on admission, floor nurses should send all prescriptions to the pharmacy and, if a prescription is missing, contact onsite/on-call providers to obtain one so the pharmacy can send the medication stat, and reported being unaware that there was no prescription for Lacosamide. The resident’s PCP stated she had no memory of being notified about any missed Lacosamide doses and explained that the NP should be notified first and work with the pharmacy, and if issues persist, the PCP should be contacted; she also stated that missing medication should be communicated immediately by direct means, not by a note left in a book.

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 deficiency in the facility’s infection prevention and control program related to the maintenance of laundry equipment. Review of the Alliance Laundry Systems washer manufacturer guidelines showed that, as part of end-of-day maintenance, the AC invert drive filter was to be cleaned by removing the external plastic cover, taking out the foam filter, and washing it with warm water and allowing it to air dry, or by vacuuming the filter. During an observation of the laundry area, the filter located on the front of the washing machine was found to be heavily soiled with lint and debris, despite a metal manufacturer label directly beneath the filter stating, "Clean Daily." Three of three washing machines observed had this issue. In an interview conducted at the time of the observation, the Laundry Supervisor acknowledged the condition of the filter and stated that laundry personnel did not maintain the filter, indicating that maintenance staff were responsible for cleaning it. In a subsequent interview, the Maintenance Supervisor reported that maintenance staff usually cleaned the filter about three times a week on Monday, Wednesday, and Friday, rather than daily as directed by the manufacturer. The Maintenance Supervisor also stated there was no log or record maintained to verify that the filter was cleaned as required.

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 the resident environment remained free of accident hazards when medications were left at the bedside for one resident. The facility’s “Oral Medication Administration Procedure” policy states that staff must administer oral medications in an organized and safe manner, remain with the resident while the medication is swallowed, and never leave medication in a resident’s room without an order for self-administration. Review of the resident’s orders showed there was no order for self-administration of medication. The resident involved had diagnoses including post hemorrhagic anemia, gastrointestinal hemorrhage, irritable bowel syndrome, and osteoarthritis, and had a BIMS score of 15/15, indicating no cognitive impairment. The baseline care plan documented decreased ability to perform ADLs/self-care related to debility/generalized weakness. During observation, two white tablets were found in a medication cup on the resident’s bedside table. An LPN confirmed the medications should not have been left in the room and that the resident did not have an order to self-administer. The resident stated that a nurse had brought the medications the previous night and that she was saving them to use when needed, identifying them as Imodium. The DON stated that nurses are not to leave medications at the bedside and should remain with the resident to ensure medications are swallowed safely, and that anyone could take medications left at the bedside.

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 a failure to ensure that a resident was free from significant medication errors when an LPN administered another resident's medications. Facility policy required that medications be administered safely and as prescribed, including verifying the resident's identity before administration using methods such as checking an identification band, reviewing a photograph on the medical record, and, if necessary, confirming identity with other staff. The policy also required the person administering medications to check the label three times to verify the right resident, medication, dosage, time, and route, and prohibited administering medications ordered for one resident to another. Despite these requirements, the LPN pre-poured medications for more than one resident at a time and did not correctly verify the resident's identity before administration. The resident who received the wrong medications, identified as R2, had been admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. Another resident, identified as R3, had diagnoses including heart failure, high blood pressure, chronic pain syndrome, and lumbar spondylosis, and had active orders for multiple medications: oxycodone 30 mg three times daily, amlodipine 5 mg (two tablets once daily), losartan 50 mg twice daily, dofetilide 250 mcg twice daily, gabapentin 600 mg four times daily, and metoprolol 50 mg once daily. R2 did not have physician orders for these medications. On the morning of the incident, the LPN labeled a medication cup with a resident's name, poured medications into the cup, mixed whole pills in pudding, and administered them to R2 in her room. The LPN later discovered that R2's medication cup was still on the cart and realized that the medications given to R2 were actually those prescribed for R3. Following the administration error, staff documented that R2 had received oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide 250 mcg (also documented once as 520 mcg), gabapentin 600 mg, and metoprolol 50 mg, none of which were ordered for her. Progress notes and vital sign records showed that R2 subsequently experienced low blood pressure and slow heart rate, with multiple blood pressure readings in the 70s and 80s systolic and 40s diastolic, and heart rates in the 40s and 50s. A nurse practitioner assessed R2 shortly after the error and initially noted no acute distress, but within an hour R2 became symptomatic. Later documentation indicated that R2 was transferred to the hospital, where she was evaluated for somnolence, hypotension, bradycardia, and hypoxia after receiving the incorrect medications. Hospital records described that she required interventions including IV fluids, naloxone, atropine, and vasoactive medications due to persistent hypotension over several days, and she was diagnosed with hypotension due to drugs, drug overdose (accidental or unintentional), confusion caused by a drug, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. The state survey agency determined that the facility's non-compliance with pharmacy services requirements caused or was likely to cause serious injury, harm, impairment, or death, and cited the facility at F760.

Removal Plan

• The Administrator notified the Medical Director of the Immediate Jeopardy.
• R2 was assessed by the Nurse Practitioner, and new orders were written for vital signs every 30 minutes and Midodrine stat.
• R2 was sent to the emergency department for a higher level of care.
• The Assistant Director of Nursing began the investigation into the medication error.
• The Assistant Director of Nursing counseled LPN1 related to the medication error and failure to follow the five rights of medication pass, including prepulling medication that resulted in the medication error; the licensed nurse was placed on a process improvement plan.
• The Assistant Director of Nursing provided 1:1 education with LPN1 related to types of medication errors, causes, and prevention.
• The Assistant Director of Nursing began a medication pass in-service related to the 5 rights of medication administration.
• The Assistant Director of Nursing or designee began education with the licensed nurses on the 5 rights of medication pass and medication administration.
• The Assistant Director of Nursing or designee began education on the medication administration policy to include how to verify the medications are correct for all licensed nurses on or before their next scheduled shift.
• The Assistant Director of Nursing or designee began competency checks on medication pass on all licensed nurses.
• The Administrator, the Director of Nursing, and the Assistant Director were re-educated on Medication Pass, including medication errors, by the Regional Assistant Director of Clinical Services.
• The Director of Nursing completed a review of hospitalizations to determine if any were related to medication error.
• The Director of Nursing completed a medication error review to ensure proper documentation, appropriate corrective action, and reporting compliance.
• Nurse management will randomly select each nurse daily to observe medication passes for 7 days, then weekly for 4 weeks, then monthly for 2 months.
• The nurse involved in the deficiency will complete medication pass competency daily for 7 days, weekly for 4 weeks, monthly for 2 months, and quarterly for 2.

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 timely report a significant medication error that resulted in serious bodily injury to the Administrator and the State Agency within two hours, as required by its own abuse, neglect, exploitation, and misappropriation reporting policy. The policy, last revised in September 2022, states that suspicions of abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the Administrator and appropriate authorities, defining "immediately" as within two hours for allegations involving abuse or resulting in serious bodily injury. Despite this, the medication error involving Resident 2, which led to hospitalization, was not entered on the facility’s reportable incident log and was not reported to the State Agency or Administrator as required. Resident 2 was admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. On the morning of 12/04/25, LPN1 pre-pulled medications for more than one resident at a time and prepared medications for Resident 2 and Resident 3. When Resident 3 requested pain medication, LPN1 retrieved oxycodone for Resident 3 but then became distracted and administered Resident 3’s medications to Resident 2 instead. Witness statements from the Unit Manager and ADON documented that Resident 2 received multiple medications not prescribed for them, including oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide, gabapentin 600 mg, and metoprolol 50 mg. Progress notes show that Resident 2’s blood pressure remained low despite ordered midodrine and fluids, with documented hypotension, bradycardia, and decreased respirations, and the resident was ultimately transferred to the hospital for further evaluation. Following the error, LPN1 reported the incident to her supervisor, and the ADON and NP were notified; however, the Administrator and State Agency were not notified as required by policy. The DON, who was on maternity leave at the time, later stated that the incident should have been reported to the State Agency but confirmed that no report was submitted and that the ADON was unaware the incident needed to be reported. The ADON stated she was unsure if the Administrator had been notified and acknowledged she did not know she was required to report the incident to the State Agency. The Facility Administrator reported that he only became aware of the medication error recently, after speaking with another resident, and confirmed that no report had been sent to the State Agency and that he had not been informed of the incident when it occurred.