Sanford Care Center Vermillion

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for two residents identified as elopement risks, both of whom left the building without staff knowledge. The first resident had severe cognitive impairment with a BIMS score of 0 and diagnoses including unspecified dementia with agitation, depression, anxiety disorder, alcohol abuse in remission, ADHD, and insomnia. He had been assessed as at risk for elopement and wore a roam alert device. On the night of the incident, he was wandering, exit seeking, and exhibiting agitation and threats against staff. Despite these behaviors and his known history of aggression and exit seeking, he was able to push open a south exit door and leave the building at approximately 12:42 a.m. after the door alarm sounded and the RN moved toward the door to reset the alarm. The nurse reported she could not see him outside, immediately called 911, and did not send staff out to search due to concerns for staff safety and the dark conditions. The first resident’s behaviors had been ongoing, including exit seeking and aggressive actions toward staff, and he required significant one-to-one attention. Staff reported that PRN anxiety medication had been administered earlier in the evening but was ineffective, and attempts at distraction, food, and redirection were used. However, the RN stated she had never been trained by the facility to deal with that type of behavior, and both she and a CNA reported they had not participated in any elopement drills during their years of employment. The facility’s elopement policy existed, but education provided after the first elopement focused on assessment rather than on what to do during an actual elopement event. Fifteen-minute visual checks for this resident were not initiated until after the elopement occurred, despite his known elopement risk and severe cognitive impairment. The second resident also had severe cognitive impairment with a BIMS score of 3 and diagnoses including unspecified dementia with behavioral disturbances, anxiety disorder, diabetes, and a history of falls. She was on hospice at admission, identified as an elopement risk, and had a roam alert device applied. On the day of her elopement, she was tearful over her husband’s recent death, pacing the hallways, repeatedly packing her belongings to leave, verbalizing a desire to leave, and was visibly upset. Staff observed that she had removed the inner screens from her room windows and notified a clinical care leader, who instructed staff to keep an eye on her and stated that, without window cranks, she could not do anything further. No 15-minute visual checks were initiated by floor staff, and although she had PRN lorazepam orders, no PRN doses were documented as given that day. Later that evening, staff were notified by police that the second resident had left the building and was found approximately five blocks away. She had removed the screen from her window, pried the window open enough to crawl out, and exited the building without staff knowledge. At the time of her elopement, the outside temperature was about 24 degrees, and she was dressed in layered clothing with sandals and socks and had a blanket with her. The DON later stated that staff should have been concerned when the resident removed her window screens. Interviews revealed that while some nurses had received elopement education after the first resident’s elopement, there had been no further elopement education for staff following the second resident’s elopement, and the DON was unsure when the last elopement drill had been completed. These actions and inactions resulted in two residents at known risk for elopement leaving the facility without staff supervision.

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 protect a resident from verbal abuse by a CNA. A cognitively intact resident with a history of left leg above-knee amputation, depression, and post-traumatic stress disorder reported overhearing a male CNA tell another resident to “shut the [expletive] up” while responding to that resident’s repeated requests. The resident who was the target of the alleged verbal abuse had severe cognitive impairment with a BIMS score of 3, dementia, hearing loss, and chronic kidney disease stage 3, and was known to be impatient, verbally repetitive, and demanding of staff. On the evening in question, the cognitively intact resident was in her room across from the cognitively impaired resident’s room, heard the impaired resident repeatedly calling out and using her call light, and then heard a male voice respond with the profane directive. The cognitively intact resident wheeled herself to her doorway and observed the identified CNA standing by the cognitively impaired resident after hearing the profane statement. She later reported this to facility staff, stating she recognized the CNA’s voice and confirming his presence at the scene. The social worker interviewed both residents the following day; the cognitively impaired resident did not recall the incident and reported feeling fine, while the cognitively intact resident consistently described hearing the CNA tell the other resident to “shut the [expletive] up” and reiterated that the other resident had been calling out and demanding immediate help. Multiple staff, including the DON, LPN, and RN, described the cognitively intact resident as a reliable and truthful reporter. Additional staff interviews and record reviews supported concerns about the CNA’s interactions with residents. A CNA coworker reported that on the evening of the incident the CNA appeared irritated, overwhelmed, and in a bad mood, and that he had been rude to her, though she had not previously heard him swear at residents. An LPN reported having previously observed the same CNA yell at an exit-seeking resident and stated she had used that prior event as a teaching moment, but she had not reported it to management at the time. The facility’s abuse and neglect policy defines verbal abuse as the use of disparaging or derogatory language within a resident’s hearing, regardless of the resident’s ability to comprehend, and states that residents have the right to be free from verbal abuse by anyone. The incident as reported and corroborated by staff interviews demonstrates that the resident was subjected to verbal abuse in violation of this policy and resident rights.

Penalty

No penalty information released

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

Summary

The provider failed to follow industry accepted food safety standards for glove use during meal preparation and service in the dining room kitchenette. During observation, cook E repeatedly handled resident menu slips, clean plates, bread, cheese, burger patties, buns, chips, ketchup packets, and other food items while wearing gloves, and also touched non-food items before touching food with the same gloves. She removed gloves and washed her hands multiple times, but continued to use gloved hands to touch resident menu slips and other items before handling food, including grilled cheese sandwiches and hamburgers being prepared on the hot grill. During interview, cook E stated she thought she made a mistake when handing residents' food items with her gloved hands but was unsure, and said her process was bad because she had to make multiple trips to the sink to wash her hands and put on new gloves. She agreed she should not have touched non-food items with her gloved hands and then touched residents' food. The dietary manager stated she had been worried about staff glove use practices in the kitchen, knew cook E wore gloves and touched other items before touching residents' food, and expected staff to use proper glove use while preparing and serving residents' food.

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 provider failed to ensure a formalized dining assistance program was in place for a resident’s wife who was assisting residents with eating in the dining room. During observation, the visitor used resident 18’s utensils to assist him with eating, then used the same hand to pick up resident 11’s utensils and assist him without washing her hands in between. Resident 18’s wife later stated she had not been trained to assist residents with eating, and the CNA confirmed she had not been trained even though she came to the facility daily to help her husband and would help other residents. Resident 11’s record showed he had impaired swallowing related to a history of TIA and dementia, used his left hand for eating because of a deformity of his right hand, and had a BIMS score of 12 indicating moderately impaired cognition. The MDS coordinator stated there was no list of visitors trained to provide feeding assistance, and the DON stated she was not aware a visitor had assisted resident 11 and did not have a process for training anyone who helped residents eat. The facility’s Dining Assistant policy stated dining assistants must only feed residents without complicated feeding problems and must be selected based on interdisciplinary assessment and the resident’s latest assessment and plan of care.

Penalty

Inspection fine: $44,577

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 provider failed to provide adequate supervision for a resident to prevent actions of self-harm. The resident was observed in his room with multiple open areas on his bilateral lower legs, some of which were actively bleeding, while holding a sharp instrument. Staff interviews revealed that they were aware the resident had various sharp tools in his possession and used these sharps to cut himself to remove bugs he believed were under his skin. The resident's care plan allowed him to have sharps in his possession to remove perceived bugs from his skin. The resident had a history of picking at his skin and cutting himself, believing there were bugs under his skin. He had been seen by a behavioral counselor due to suicidal ideations and hallucinations. Despite this, the resident was allowed to keep sharps in his room, and staff were aware of his behavior but did not adequately supervise or intervene to prevent self-harm. Interviews with staff indicated that the resident was independent, allowed to leave the premises, and would purchase items, including sharps, from a store. The resident's care plan documented his behavioral symptoms, including cutting and picking at his skin, and allowed him to keep sharps in his room. The care plan noted that the resident declined to follow physician-recommended advice and would not allow nurses to care for his open areas. Staff were aware of the resident's behavior and the presence of sharps in his room, but there was no inventory or tracking of the sharps, and the resident's wounds were not regularly documented or treated by nursing staff.

Removal Plan

• All sharps have been removed from Resident 20's room.
• Psychiatry, primary care provider and counselor have been notified for guidance in managing any adverse behavioral changes.
• Resident 20 has been re-educated on hand hygiene, sharps in his room, infection prevention to include covering wounds.
• Updates to the care plan include removing sharps, offering tubi-grips for arms and lower legs for covering of wounds when leaving his room, handwashing education, wound assessment completed, one-hour check while in the facility for behaviors given resident psychiatric history then re-evaluate.
• Center of Excellence for Behavioral Health in Nursing Facilities contacted with expected response.
• Director of nursing spoke to Resident 20 about dressing changes.
• Resident agreed to let nursing staff change dressing twice a day.
• Nursing staff will monitor for any signs of infection during dressing changes and notify the physician if any noticed. These will be documented on Resident 20's treatment.
• Nursing will remove soiled towels and washcloths when in his room providing dressing changes. This has been included in the treatment plan and added to the certified nursing assistant (CNA) flowsheet.
• Resident was informed that he would not need to buy wound/dressing supplies.
• Sharps removed from resident 20's room.
• All other current resident rooms were checked for sharps and any of concern were removed.
• Discussed with Resident 20 that his bags would be checked upon return from shopping.
• Resident signed previous acknowledgment form that he agreed to staff removing sharps that he may bring back.
• Staff will conduct random room checks and will chart in Resident 20's chart as a treatment.
• This has been added to Resident 20's treatment plan and CNA flowsheet.
• Added a treatment order for nursing documentation for behavior/mood of resident 20.
• Resident 20's behavior documentation will be reviewed at interdisciplinary team (IDT) meetings and as needed with adjustments to care/treatment plan as warranted.
• Admission packet updated regarding review of sharps for safety.
• Resident 20's primary contacts have been re-educated on notifying staff prior to bringing/getting sharps items to resident via email.
• Resident 20 has been re-educated on proper hand hygiene for infection prevention and sharps.
• Staff have been re-educated on sharps in rooms and planned review of infection prevention practices related to transmission through OnShift.
• They receive this education annually at minimum.
• A skills fair reviewing infection prevention is scheduled and annually for staff.
• Sharps restriction added to admissions packet.
• Staff re-educated on infection prevention practices and safety of all residents related to sharps in resident rooms.
• Staff were educated through onshift message about the removal of sharps for any resident.
• Additional education provided to nursing staff related to resident 20 returning from shopping, the need to look in resident 20's bags for any sharp objects that staff would need to remove and secure in the medication room, staff will reiterate to resident that he is not able to have those items in his room.
• PRN treatment order added to check bags upon returning from shopping outings.
• Staff will also be educated on the random room checks that will be conducted on Resident 20's room for sharps found, those items will be removed and secured in the medication room.
• Treatment order added to document these random room checks for Resident 20, also added to CNA flowsheet to check room twice a day.

Penalty

Inspection fine: $44,577

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 provider failed to deliver appropriate wound care, assessment, and monitoring for a resident with a history of self-inflicted wounds. The resident was observed with multiple open areas and active bleeding on his lower legs, with bandages on some of them. He was found to be managing his own wound care, using alcohol and Neosporin, without proper education from the facility staff. The resident had a history of a picking disorder and was known to use sharps to cut his skin, which was care planned but not adequately monitored or controlled by the facility. Interviews with nursing staff revealed concerns about the resident's self-harming behavior and the lack of proper wound care documentation. The resident was allowed to keep sharps in his room, and there was no inventory or count of these items. Staff expressed concerns about the potential for infection and the resident's refusal to allow nurses to care for his wounds. Despite being aware of the resident's behavior, the facility did not have a comprehensive plan to address the risks associated with his self-care practices. The resident's care plan acknowledged his behavioral symptoms and the presence of sharps in his room, but it lacked effective interventions to prevent self-harm and ensure proper wound care. The care plan allowed the resident to have sharps due to his refusal to comply with facility policies, and there was no evidence of consistent education or intervention to mitigate the risks. The facility's failure to provide appropriate wound care and monitoring resulted in a deficiency in the care provided to the resident.

Penalty

Inspection fine: $44,577

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 their facility-wide assessment adequately addressed the staffing resources necessary to provide appropriate care and services to residents. The assessment, which was an eleven-page Excel spreadsheet, included various analyses such as a monthly trending analysis of census, physical function and care needs, and medical diseases and conditions of residents. However, it did not specify the number of staff required to care for the residents or how they would be scheduled or assigned. Additionally, the assessment lacked details on how residents' medical and mental health diagnoses would impact their care needs and the level of assistance required from staff. Interviews with the Director of Nursing and the Minimum Data Set nurse confirmed that the facility assessment did not include or address staffing needs. The administrator also acknowledged that there was no connection between the spreadsheet and the staffing needed to ensure appropriate care and services for residents, including the competencies required of staff. Furthermore, there was no specific policy on the process for conducting the facility assessment.

Penalty

Inspection fine: $44,577

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 provider failed to maintain a physician's order consistent with a resident's advance directive. A review of the electronic medical record (EMR) for one resident revealed a discrepancy between the displayed do not resuscitate (DNR) status and a full code order, which permits life-sustaining measures, including resuscitation. The director of nursing (DON) and the Minimum Data Set (MDS) nurse were interviewed, and it was found that the DON did not have a current DNR order for the resident. The MDS nurse had faxed the physician to request an order but had not received one. The provider's advance directive policy requires that advance directive orders be reviewed with the resident or healthcare decision-maker at each care plan meeting and that any changes be documented and communicated to the physician for updated orders. The policy also specifies that physician's orders must be specific regarding life-sustaining measures.

Penalty

Inspection fine: $44,577

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 provider failed to maintain the temperature of the memory care unit's pantry refrigerator below 41 degrees Fahrenheit, as required by professional standards. On multiple occasions, the refrigerator's temperature was observed to be above the acceptable range, with readings of 46 degrees F and 50 degrees F on consecutive days. The temperature logs for the refrigerator were incomplete, with no documented temperatures for several months, including December 2023 and June 2024. Interviews with staff revealed a lack of clarity regarding the responsibility for monitoring and recording the refrigerator's temperature, contributing to the oversight. The director of nursing acknowledged that the night nurses were responsible for checking the refrigerator temperatures, but the task had not been consistently performed. The absence of completed temperature logs for several months indicated a systemic failure in monitoring the refrigerator's temperature. The facility's policy required daily monitoring and logging of refrigerator temperatures, with specific actions to be taken if temperatures exceeded the acceptable range. However, these procedures were not followed, leading to the deficiency in maintaining proper food storage conditions.

Penalty

Inspection fine: $44,577

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 provider failed to properly clean and disinfect a community-shared blood glucose meter, which was used for two residents, leading to a potential increased risk for bloodborne pathogen infections. During an observation, a registered nurse (RN) used a gray top Sani-cloth wipe to clean the glucose meter after checking the blood glucose levels of one resident and then used the same meter for another resident without following the correct cleaning procedure. The RN was unaware of the specific policy for cleaning the glucose meter and did not allow the meter to remain wet for the required contact time as per the manufacturer's instructions. Interviews with the clinical learning and development specialist and the director of nursing revealed that the staff did not adhere to the proper cleaning process, which involved using a wipe to clean visible blood or fluids and then another wipe to ensure the meter remained wet for the appropriate contact time. The facility's policy and the glucose meter's user manual specified the need for cleaning and disinfecting the meter after each use, with a contact time of three minutes for the gray top Sani-cloth. The failure to follow these procedures was confirmed through interviews and a review of the facility's policy and the manufacturer's instructions.

Penalty

Inspection fine: $44,577

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 report identifies deficiencies in the storage and administration of medications for two residents in the facility. Resident 16 was found with two boxes of eye drop medication on his bedside table, which were left by a nurse and not retrieved. The resident, who was cognitively intact, did not have an order for self-administration of these medications. Similarly, Resident 2 had a container with various lotions and ointments on a stand next to his recliner, without an order for these items to be at the bedside. Interviews with the LPN and the Director of Nursing confirmed that there were no orders for medications to be left at the bedside, except for cough drops, and that Resident 16 did not have such an order. The report also details an incident involving Resident 37, who fell from a mechanical lift due to improper use. The resident, who had severe cognitive impairment and a history of falls, was being transferred using an EZ sit-to-stand lift without the leg belt secured. This was contrary to his care plan, which specified the use of a total mechanical lift for all transfers. The incident occurred while two CNAs were assisting the resident, and it was noted that the staff had not read the care plan to verify the correct transfer method. The resident had previously experienced fainting-like spells when using the sit-to-stand lift, and a note was posted in his room to use the total mechanical lift instead. Interviews with staff revealed a lack of consistent communication and adherence to care plans. CNA I admitted to not reading the care plan and following the previous shift's method, while CNA H, a PRN staff member, was unaware of the updated transfer instructions. The Director of Nursing acknowledged the absence of lift assessments and a policy for determining the appropriate lift device. The MDS nurse admitted to possibly forgetting to update the care plan date and was unaware of any fainting-like episodes before the incident. The facility's policy and the manufacturer's manual for the lift devices were reviewed, highlighting the need for proper assessment and adherence to care plans for safe resident handling.