Arlington Heights Health And Rehabilitation 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 RN coverage for at least eight consecutive hours per day, seven days a week, over multiple weekend days within a review period from early June to mid-December 2025. Timecard reports showed that on 16 specific weekend dates, RN hours worked on those calendar days did not total eight consecutive hours, with RN shifts either starting late in the day, ending before eight consecutive hours were reached, or crossing midnight so that only a portion of the shift fell on the calendar day in question. Examples included days when RNs worked only a few hours in the evening, partial coverage split between different RNs, or coverage that began late at night so that only one to two hours of the shift occurred on that date. On some dates, the ADON provided partial RN coverage, but the total RN time on that calendar day still did not meet the eight consecutive hours required. Interviews with facility staff revealed gaps in understanding and oversight of the RN coverage requirement. The Staffing Coordinator, who had been responsible for creating nursing schedules since July 2025, stated she was aware of the need for eight consecutive hours of RN coverage but did not know that the eight hours had to occur within the same calendar day and believed that any eight consecutive hours, even if crossing midnight, were acceptable. The ADON reported that the Staffing Coordinator completed the schedules and that the DON was responsible for reviewing them, while the ADON only assisted when there were call-offs or coverage issues. The DON stated she reviewed schedules mainly when coverage issues arose and acknowledged she was not aware that the eight consecutive hours had to be on the same day. The Administrator stated he knew of the eight-hour requirement but was unaware it was not being scheduled correctly. The RCN reported that the facility did not have a specific RN coverage policy and that they followed the regulation for eight hours daily. The report notes that this failure could place residents at risk of not having their nursing and medical needs met and improper care.

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 accurate PASARR Level 1 (PL1) screening and appropriate referral for a resident with a documented mental disorder. The resident was an adult male admitted with a diagnosis of bipolar disorder, was cognitively intact with a BIMS score of 15, and required substantial assistance with ADLs. His care plan documented an ADL self-care deficit, use of an antipsychotic medication for bipolar disorder, and depression. However, his PASRR Level 1 screening indicated there was no evidence of mental illness and no primary diagnosis of dementia, and the electronic health record contained no evidence that a PASRR Level 2 evaluation had been completed by the local mental health authority. Interviews revealed conflicting and inaccurate information regarding whether and when the resident had been referred to the local mental health authority. One MDS coordinator stated the resident had been referred in September and evaluated in December, while another MDS coordinator stated the resident had not been referred and that she only initiated the referral in December after discovering the omission. She acknowledged that not having the resident assessed could result in him not receiving services he might qualify for and noted there had been confusion about the resident’s insurance coverage that might have contributed to the lack of referral. The facility’s policy required obtaining a PL1 from the referring entity prior to admission and submitting it via the portal within PASRR regulatory timeframes, but the inaccurate PL1 and failure to coordinate a timely PASRR Level 2 evaluation for this resident with bipolar disorder and depression led to the cited deficiency.

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 failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. For one resident, a male with diabetes, seizure disorder, history of TIA, and cerebral infarction, the quarterly MDS showed severely impaired cognition (BIMS score of 5) and a care plan for ADL self-care deficits requiring supervision to limited assistance for personal hygiene. However, the care plan did not address the resident’s pattern of refusing care, including nail care. Observations showed the resident in bed with covers over his head and significantly overgrown fingernails on both hands, despite the resident stating that he had people who cut his nails and indicating he wanted his fingernails cut before again covering his head. Interviews with staff revealed an ongoing pattern of care refusals by this resident that were not reflected in the care plan. An RN reported asking the resident several times for permission to cut his fingernails, with the resident refusing and pulling covers over his head each time. A CNA similarly reported that the resident refused offers for nail care and showers and would always pull the covers over his head. The ADON stated it was normal for this resident to refuse all care, including nail care, and acknowledged that the refusals had not been documented or care planned, despite her belief that refusals should be care planned so staff would understand how to care for the resident. The MDS Coordinator stated she was not aware of the resident’s care refusals, including nail care, and confirmed that nursing staff were responsible for updating care plans or notifying her of issues. For the second resident, an older female with non-Alzheimer’s dementia, reduced mobility, muscle weakness, and a BIMS score of 5 indicating severely impaired cognition, the quarterly MDS and care plan did not reflect the presence of a right-hand contracture. Observation showed the resident’s right hand was contracted, and she was unable to open it, with no device in place for contracture management. Nursing staff and the Director of Rehabilitation confirmed the resident had a right-hand contracture, that therapy had worked with her, and that a splint had been tried but the resident would remove it and complain. The ADON stated the resident had been admitted with the contracture and that there should have been a care plan addressing it, and the MDS Coordinator acknowledged she was unaware of the contracture and that the care plan should have included the contracture, its care, and the resident’s refusals to keep the splint in place. The facility’s policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ identified needs, which was not followed 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 deficiency involves the facility’s failure to ensure a resident who was dependent on staff for ADLs received scheduled bathing/bed baths and that this care was properly documented. The resident was an adult male with COPD, depression, non-Alzheimer’s dementia, and diabetes, with an intact BIMS score of 15. His care plan, revised in late September, identified an ADL self-care performance deficit and specified that he required staff assistance for bathing, including provision of a sponge bath when a full bath or shower could not be tolerated. The November and December POC histories showed that the resident was scheduled for bathing/showers on Mondays, Wednesdays, and Fridays on the 6:00 AM–2:00 PM shift, with instructions to turn in a shower sheet to the charge nurse. However, in the Bathing task section for those days, the POC reflected “Not applicable,” and it was unknown from the records whether the resident received showers/bed baths or refused them. During observation and interview, the resident reported that he did not receive showers, preferred bed baths, and that his scheduled days were Monday, Wednesday, and Friday. He stated the last bed bath he recalled was some day the previous week, either Monday or Wednesday, and that he did not receive bed baths on his scheduled days. He further reported that when he requested a bed bath, staff told him they were short-staffed. The facility’s shower binder on the 200 hall contained no shower sheets for this resident, and requested shower sheets were not provided to the survey team before exit. Multiple staff interviews revealed inconsistent information and documentation practices. One CNA stated the resident’s shower days were on the 2:00 PM–10:00 PM shift and that he mostly refused bed baths, and that care was documented on shower sheets and in the POC, yet no shower sheets were found. Another CNA stated that if the POC showed “Not applicable,” it meant the shower was not provided and did not happen, and acknowledged she had not completed any shower sheets for this resident. A third CNA reported giving bed baths, last sometime the previous month, and stated that “Not applicable” in the POC meant the shower was not provided or offered. The assigned LVN stated the resident was provided bed baths on shower days but sometimes refused, and that staff documented on shower sheets and in the POC, though she could not explain the “Not applicable” entries. The ADON stated the facility was no longer using shower sheets and that staff should document in the POC, and acknowledged that based on POC documentation she could not prove the resident received any showers, adding that if it was not documented, it did not happen. The DON similarly stated she could not confirm from documentation that the resident received showers and that nurses in charge and the ADON were responsible for ensuring showers/bed baths were provided. The facility’s bed bath policy stated that complete bed baths are performed for residents on bedrest needing assistive care and may be done daily or alternated with partial bed baths, but the documentation and interviews did not substantiate that this resident’s scheduled bathing care was consistently provided.

Penalty

No penalty information released

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

Summary

The facility failed to provide ordered pressure ulcer treatments to a resident with multiple pressure injuries over a weekend. The resident was an elderly male with severe cognitive impairment (BIMS score of 2) and a diagnosis of MRSA infection, who was admitted with multiple pressure injuries, including Stage 3 and unstageable ulcers on the left hip, right gluteal fold, sacrum, left buttock, and both ankles. His care plan and wound evaluation documented specific daily treatment orders for each wound, including cleansing with normal saline or wound cleanser, application of Santyl or collagen, use of Hydrofera Blue, and coverage with bordered gauze or foam dressings, to be done daily and as needed for soiling or dislodgement. Record review of the resident’s electronic treatment administration record (eTAR) for December showed no documentation that any wound care was provided on the Saturday and Sunday in question, despite daily treatment orders. The resident reported that he received wound care Monday through Friday but not on the weekend. When the wound care nurse returned the following Monday, she observed that the resident still had the same dressings in place that she had applied on the prior Friday, indicating that the weekend treatments had been missed. Interviews with staff confirmed that weekend wound care was not completed. The ADON who worked that weekend acknowledged she knew the resident had multiple wounds and that she was responsible for performing wound care because the treatment nurse did not work weekends, but stated she missed the treatments, left early both days, and did not inform the relieving nurses that wound care had not been done. The wound care nurse stated that weekend staff were supposed to provide the treatments and that she did not notify management, expecting them to review treatment records. The ADON and DON both stated they were responsible for ensuring MARs/TARs were checked and that they had not reviewed the wound care TAR for this resident. The wound care NP stated that nurses or the wound care nurse were supposed to follow the treatment orders and that missing treatment placed the resident at risk for infection and worsening wounds.

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 safe and appropriate administration and management of IV therapy via a PICC line for a resident receiving intravenous medications. The resident was an adult male admitted with septicemia and intact cognition, with physician orders for a PICC line dressing change every seven days on Mondays and as needed. The resident’s care plan included interventions such as administering IV medications as ordered, checking the IV site dressing daily for signs and symptoms of infection, flushing ports/lines as ordered, and changing the dressing every seven days and PRN. Review of the Treatment Administration Record for December showed no documentation that the PICC line dressing was changed on the scheduled date, and there was no documentation of any refusal by the resident. On observation, the resident was found in bed with a PICC line dressing on his right arm dated 11/29/25. The dressing was peeling and dirty on the surface. The resident reported that the dressing had been applied at the hospital and had not been changed since his admission, and that no staff had requested to change it. A subsequent observation with an LVN confirmed the dressing was transparent, peeling, and appeared dirty, and the LVN acknowledged knowing that the dressing should be changed every seven days and as needed when dirty. The LVN stated she had attempted to change the dressing but said the resident refused and that she notified the ADON; however, she also stated she should have changed it earlier since it was due every seven days and reported she had not received training on PICC line dressings. The PICC insertion site itself was observed to be clean with no signs of infection. A separate deficiency was identified during observation of IV medication administration through the same resident’s PICC line. An LVN donned gloves and a gown before washing her hands, prepared and hung the IV antibiotic, labeled the IV bottle and tubing, then removed her gloves and put on new gloves without performing hand hygiene. She cleansed the PICC line tip with an alcohol swab, connected the IV tubing, allowed the medication to infuse, then removed her gloves and left the room, again without washing her hands, and proceeded down the hall with the medication cart. In interview, the LVN admitted she forgot to perform hand hygiene before and after medication administration and stated she understood that failure to wash hands could lead to cross contamination and infection. The ADON and DON both stated their expectations that PICC line dressings be changed every seven days and as needed, and that staff perform hand hygiene before and after resident contact and procedures. Facility policies on central venous catheter dressing changes and hand washing were in place, but training records requested by surveyors were not provided.

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 parenteral fluids and IV medications were administered in accordance with professional standards, physician orders, and the resident’s care plan. A male resident with septicemia, intact cognition (BIMS score of 14), and an order for daily IV Daptomycin via a PICC line had an IV medication bag in use that was not labeled with the date, time, or initials of the nurse who hung it. An additional empty IV bag in the resident’s room was also unlabeled. The resident’s care plan called for administering IV medications as ordered, monitoring the IV site for infection, flushing ports/lines as ordered, and changing dressings every seven days and as needed. The facility’s IV medication policy required recording the drug name, dose, rate, date, and time on the container label. During observation and interviews, an LVN on duty stated she had not hung the IV bag but confirmed that IV bags and tubing were supposed to be labeled with the resident’s name, date, time, and nurse’s initials, and acknowledged that the unlabeled bag had been hung by the 2:00 PM–10:00 PM nurse. Another LVN later confirmed she was the nurse who administered the Daptomycin during that shift and admitted she knew she was required to label the IV bag and tubing but forgot to do so, despite having completed IV administration training and a skills check the previous month. Both LVNs, as well as the ADON and DON, stated that IV bags and tubing should be dated and initialed to prevent medication errors and infection, and that tubing should be changed every 24 hours. The facility’s failure to ensure labeling of the IV bag and tubing for this resident constituted the cited deficiency in pharmaceutical services and IV administration practices.

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 management of pharmacy consultant recommendations for gradual dose reduction (GDR) of psychotropic medications. The consultant pharmacist completed a monthly drug regimen review on 08/29/25 and documented a GDR request for a resident’s amitriptyline 100 mg daily, noting that per CMS regulations residents on psychotropic drugs must have GDR attempts unless clinically contraindicated. Record review showed the resident, an adult male with a diagnosis of depression and an intact BIMS score of 15, had been admitted earlier in the year and was receiving amitriptyline for major depressive disorder. His MDS and care plan documented ongoing antidepressant therapy and monitoring for depressive symptoms and adverse reactions. Medication administration records for November and December 2025 showed he continued to receive amitriptyline daily as originally ordered. Interviews and record review revealed that the pharmacy consultant’s August 2025 GDR recommendation for this resident’s antidepressant was not communicated to the attending physician and no action was taken. The ADON, who was responsible for reviewing pharmacy recommendations, acknowledged that the August GDR recommendation for the resident’s antidepressant was missed and was not forwarded to the physician. The DON confirmed that the ADON was responsible for reviewing pharmacy recommendations and stated she was unaware that this GDR recommendation had been missed. The facility’s psychotropic drugs policy, dated 10/25/17, stated that the facility implements GDRs and non-pharmacological interventions, unless contraindicated, for psychotropic medications. Despite this policy and the pharmacist’s documented recommendation, the resident’s drug regimen was not adjusted or reviewed with the physician in response to the GDR request.

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 maintain complete and accurate medical records in accordance with its documentation policy for one resident whose clinical record was reviewed. The resident was an elderly female with sequelae of cerebral infarction, dysphasia, gastrostomy status, anxiety disorder, depression, and schizophrenia, and had a BIMS score of 00 indicating severely impaired cognition. Her care plan indicated she wished to remain for long-term care and included an intervention to discuss options at each care plan meeting unless otherwise notified. During observation, she was in bed and did not rouse when spoken to, preventing direct interview. Her family member reported receiving calls about changes in condition but stated he had never attended a care plan meeting in person or by phone, did not recall being told about or invited to any care plan meetings in the last year, and expressed a desire to be invited so he could be updated on her care. The Social Worker stated it was her responsibility to schedule quarterly care plan meetings and that residents and families were invited. She reported that the resident’s family had been invited several times but did not attend, and that she previously sent letters but now called the family, often making 3–4 attempts and leaving voice messages. However, she was unable to locate any documentation of these attempts and acknowledged she had not documented her efforts to invite the family. The DON and Administrator both confirmed that the Social Worker was responsible for scheduling care plan meetings, that families should be notified by phone or letter and invited to attend, and that all attempts should be documented. The facility’s documentation policy required complete and accurate documentation of all relevant communications in the clinical record. Despite this, there was no documentation in the resident’s clinical record showing that the family/legal representative had been invited to participate in quarterly care plan meetings, resulting in an incomplete medical record for the resident.

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 full visual privacy for three residents whose beds lacked properly installed privacy curtains that extended around the entire bed. For one cognitively intact female resident with bone infection, multiple pressure ulcers, cerebral palsy, bowel and bladder incontinence, and total dependence for ADLs, observation showed that when her privacy curtain was pulled closed, the end of her bed remained exposed. She later stated she did not like the end of her bed being exposed, would be upset if someone entered while she was being changed, and would prefer full curtain coverage but did not know that was an option. A cognitively intact male resident with a history of stroke, diabetes, heart disease, and an ADL self-care deficit was also observed in bed with his privacy curtain pulled, yet the end of his bed remained exposed; he reported that while the exposure did not generally bother him, he would not like someone walking in while he was changing and that the curtain had been that way since admission. A third cognitively intact male resident with stroke, muscle weakness, diabetes, and substantial ADL assistance needs was observed in bed with his privacy curtain partially closed; when fully closed, the curtain still did not wrap around to cover the end of his bed. He stated he was not bothered by the uncovered end but would not like someone entering and seeing him exposed, noting that staff close the door when providing care. Multiple staff interviews revealed that maintenance was responsible for hanging privacy curtains once notified, housekeeping was described as responsible for monitoring and replacing curtains, and nurses and CNAs were identified as primarily responsible for notifying housekeeping when curtains needed placement or replacement, though any staff member could do so. The DON confirmed the importance of privacy for resident dignity during care and stated that nurses and CNAs were responsible for alerting housekeeping when curtains needed attention, with maintenance then hanging the curtains. She also stated there was no policy specifically addressing privacy curtains.

Penalty

Fine: $12,740

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

A deficiency occurred when a resident with severe cognitive impairment and a history of cerebral infarction, unspecified dementia, psychotic and mood disturbances, and anxiety was not provided with adequate supervision to prevent elopement. The resident, who had been assessed as a moderate elopement risk, was able to leave the facility unsupervised by following a transport company staff member who used a staff-only passcode to open the exit door. The resident was found half a block away from the facility with her walker and was brought back by staff. There was no prior documentation of exit-seeking or elopement attempts for this resident in the days leading up to the incident. The incident was discovered when a housekeeper, after leaving the building, observed an elderly individual with a walker in the street and reported it to the administrator. The administrator and housekeeper located the resident and returned her to the facility. Review of video footage showed that the resident exited through the main door as a transport company staff member entered, without being questioned or stopped. The door alarm did not sound because the staff member used the entry code, and no staff were aware of the resident's departure until after the fact. Interviews with facility staff revealed that they had not previously observed exit-seeking behaviors from the resident and were unaware of her elopement until notified. The facility's policies required all staff to monitor exit doors and report any attempts or suspicions of elopement, but in this case, the procedures were not effectively implemented, allowing the resident to leave the premises without detection.

Penalty

Fine: $12,740

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

Summary

The facility failed to protect a resident from abuse when two residents with severe cognitive impairment engaged in a physical altercation. One resident, who had a history of physical behaviors directed towards others and was diagnosed with unspecified dementia, entered an empty room with another resident and closed the door. Another resident, also with severe cognitive impairment and a history of physical behaviors, became agitated when the door was closed in her face, pushed the door open, and physically attacked the first resident by grabbing her hair and pulling her out of the room. The altercation escalated, resulting in both residents hitting each other until staff intervened and separated them. The incident resulted in the first resident sustaining scratches to her left cheek and lip, as well as a developing bruise under her left eye. Documentation and witness statements confirmed that staff observed the altercation and responded by running to the scene to separate the residents. Prior to the incident, both residents were known to walk the hallways frequently, and staff were aware of their behavioral triggers and signs of agitation. However, there was no indication that either resident had previously exhibited physically aggressive behaviors towards others, and staff had not anticipated such an incident occurring between them. The deficiency was identified through observation, interviews, and record review, which revealed that the facility did not ensure residents were free from abuse by other residents. The altercation occurred in an unlocked, empty room at the end of the hallway, which both residents attempted to enter. The facility's failure to prevent the altercation and protect the resident from abuse constituted noncompliance with regulatory requirements for resident safety and freedom from abuse.

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 develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, specifically omitting care planning for the resident's Foley catheter. The resident, a male with quadriplegia, neurogenic bladder, and a Stage 2 pressure ulcer, was dependent on staff for toileting hygiene and had a Foley catheter in place throughout the assessment period. Despite these needs, the care plan did not address the Foley catheter, and there were no physician orders related to its care. Nurse Practitioner notes indicated the need for a catheter securement device, but this was not reflected in the care plan or orders. Interviews with nursing staff revealed a lack of clarity regarding the care and documentation of the Foley catheter, with staff relying on general knowledge rather than specific care plans or orders. The Regional Compliance Nurse acknowledged that the interdisciplinary team was responsible for updating care plans and that the omission of the Foley catheter from the care plan and orders was an oversight from admission. The facility's policy required comprehensive care plans to address all medical needs, but this was not followed in this case.

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

A deficiency occurred when a resident who was admitted with a Foley catheter did not have physician orders in place to address the treatment and services required for catheter care. The resident, a male with quadriplegia, neurogenic bladder, and a Stage 2 pressure ulcer, was dependent on staff for toileting hygiene and had a catheter in place throughout the assessment period. Review of the resident's care plan and physician orders revealed that neither addressed the Foley catheter, and the only documentation related to catheter care was a nurse practitioner note instructing to ensure catheter securement to prevent pressure. Interviews with nursing staff and facility leadership confirmed that the admitting nurse did not obtain the necessary orders for the Foley catheter, and subsequent follow-up by the ADON and Regional Compliance Nurse failed to identify and correct the omission. Staff acknowledged that the lack of physician orders could result in missed care and increase the risk of infection. The facility's policy required nurses to review and clarify orders as needed, but this process was not followed, resulting in the deficiency.

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 an alleged incident of verbal abuse was reported immediately, as required by policy, for one resident with severe cognitive impairment and multiple psychiatric diagnoses. An LVN overheard a CNA verbally abusing the resident and wrote a witness statement, which she placed under the Administrator's door while he was out of the building. The Administrator, who was also the facility's abuse coordinator, did not receive the statement and was not made aware of the allegation until later interviews. The LVN did not follow up or attempt to contact the Administrator by phone or other immediate means, as required by the facility's abuse reporting policy. The resident involved was nonverbal and unable to respond to questions due to severe cognitive impairment. The facility's policy required immediate verbal reporting of suspected abuse to the Administrator or designee, including after hours, but this was not followed. The Administrator confirmed that staff were expected to report abuse allegations directly and immediately, typically by phone or text, to ensure resident safety. The failure to report the allegation in a timely manner resulted in a delay in the facility's awareness and response to the alleged abuse.

Penalty

Fine: $23,270

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

Summary

The facility failed to protect residents from abuse, as evidenced by incidents involving a resident with a history of aggressive behavior. This resident, who had profound intellectual disabilities and poor impulse control, was involved in multiple altercations with other residents. The resident used a doll to hit two other residents in the face and head and punched another resident in the stomach. These incidents occurred in common areas such as the dining room, where the resident often interacted with others. The resident's care plan noted the potential for physical behaviors and included interventions to analyze triggers and de-escalate situations. However, these interventions were not effectively implemented, as the resident continued to exhibit aggressive behavior. Staff interviews revealed that the resident's actions were known, and attempts to redirect her were often unsuccessful. The resident's behavior was described as territorial, particularly concerning a male friend, which contributed to the altercations. The facility's failure to prevent these incidents resulted in an Immediate Jeopardy situation, indicating a serious threat to resident safety. The facility's policy on abuse and neglect emphasized the right of residents to be free from abuse, yet the incidents demonstrated a lack of effective measures to protect residents from harm. The facility's response included placing the resident on 1:1 supervision and eventually transferring her to another facility, but these actions were taken after the incidents had already occurred.

Removal Plan

• Resident #1 was immediately placed on 1:1 supervision with facility staff.
• Resident #1 discharged to alternate facility with guardians' approval.
• Resident #1's baby doll with the plastic heads were immediately removed from Resident #1's possession and from resident #1's room by regional compliance nurse.
• Resident's #1's care plan was reviewed by Regional Compliance Nurse for appropriate interventions to prevent resident and staff altercations.
• Resident #1's care plan was updated by the Regional Compliance Nurse to reflect additional interventions of 1:1 supervision and removal of baby dolls with hard plastic pieces.
• IDT team will schedule a care plan meeting with Responsible Party, Physician, and Resident to review and evaluate interventions to prevent repeated altercations with staff and residents.
• The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics: Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented to prevent abuse, Behavior Management Policy- Managing behaviors and intervening appropriately.
• The Medical Director was notified of the immediate jeopardy.
• An ADHOC QAPI was held with the IDT Team to discuss the immediate jeopardy and plan of removal.
• All staff will be in-serviced on the following topics below by the Administrator, Regional Compliance Nurse, DON, and ADON to prevent resident to resident abuse and ensure appropriate response to aggressive behaviors. All staff who are not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to starting their shift: Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented, Behavior Management Policy- Managing behaviors and intervening appropriately.

Penalty

Fine: $23,270

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

Summary

The facility failed to ensure that a resident was treated with respect and dignity, specifically in the context of colostomy care. The resident, a female with a history of stroke, legal blindness, and rectal cancer requiring a colostomy, was moderately cognitively impaired and required assistance with toileting hygiene. On a particular evening, the resident's colostomy bag began leaking, and despite her request for assistance, the staff did not provide timely help. A CNA responded to her call light but informed her that a nurse was needed for the task. The nurse, LVN A, who was monitoring the dining area, placed a new colostomy bag on the resident's table but did not assist her in applying it, citing her responsibilities in the dining area. The resident was left to manage the situation herself, leading to further leakage and embarrassment due to the presence of her roommate and the open door to the hallway. LVN A did not communicate the resident's need for assistance to the other nurse on duty, LVN C, who was unaware of the situation until the surveyor's interview. The Director of Nursing (DON) expressed that the expectation was for nurses to communicate with each other to ensure residents receive timely assistance, which did not occur in this instance. This lack of communication and assistance resulted in the resident feeling embarrassed and not treated with the dignity and respect she deserved.

Penalty

Fine: $23,270

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

Summary

The facility failed to provide adequate colostomy care for Resident #5, a female resident with a history of stroke, legal blindness, and rectal cancer requiring a colostomy. The resident, who was moderately cognitively impaired, required assistance with toileting hygiene and ostomy care. On the evening of February 7, 2025, Resident #5 experienced a colostomy bag leak and requested assistance. CNA B responded to her call light but informed her that a nurse would need to assist. LVN A, who was monitoring the evening meal, placed a new colostomy bag on the resident's table but did not assist her or inform another nurse to provide the necessary care. As a result, Resident #5 attempted to manage the situation herself, leading to further leakage later that evening. Interviews with LVN A and LVN C revealed a lack of communication and coordination between staff members. LVN A did not notify LVN C, who was responsible for resident care during that time, about Resident #5's need for assistance. The Director of Nursing (DON) stated that the expectation was for nurses to communicate with each other to ensure residents receive timely care. The facility's Ostomy Care policy emphasizes the importance of proper stoma care to prevent skin irritation and breakdown, which was not adhered to in this instance.

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 incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and the PASARR evaluation report for eight residents. This failure was identified during interviews and record reviews, where it was found that the facility did not submit the Nursing Facility Specialized Services (NFSS) form requests by the specific deadline for these residents. The lack of timely submission of these forms could potentially place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. The report details the medical conditions and cognitive impairments of the affected residents, who were all PASRR positive and had various diagnoses such as schizophrenia, intellectual disabilities, and anxiety disorders. Each resident's care plan included goals for receiving specialized services as recommended by the local authority per PASRR. However, the facility did not ensure that the necessary NFSS forms were completed and submitted on time, which is crucial for the continuation of these specialized services. Interviews with facility staff, including the Director of Rehabilitation and the Regional Operations Director, revealed a lack of formal training and understanding of the PASRR process. The Director of Rehabilitation, who was new to the position, was responsible for filling out the NFSS forms and ensuring they were signed and uploaded to the portal. However, due to a lack of training, the forms were not uploaded in a timely manner, leading to missed deadlines and errors in the submission process. The Regional Operations Director acknowledged the oversight and was working to correct the errors, but the delay in submission was already noted.

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 develop and implement comprehensive person-centered care plans for two residents, which led to deficiencies in meeting their individual needs. Resident #13, a female with multiple diagnoses including metabolic encephalopathy and Alzheimer's disease, had a physician's order for pleasure feedings that was not included in her care plan. Despite being observed receiving pleasure feedings, the care plan only addressed her tube feeding needs. Interviews with staff revealed a lack of awareness and responsibility for updating the care plan to include pleasure feedings, which could result in staff not knowing the necessary interventions. Resident #63, who has end-stage renal disease and is dependent on dialysis, did not have his dialysis treatment included in his care plan. Although he was observed and interviewed confirming his dialysis schedule, the care plan lacked this critical information. Staff interviews highlighted the importance of an updated care plan for continuity of care and the risk of fluid volume deficit if dialysis was not properly monitored. The MDS Coordinator acknowledged the oversight and the need for care plans to be updated with any changes. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes to meet residents' needs, but this was not adhered to for the two residents. The Director of Nursing emphasized that care planning is a shared responsibility among all staff, yet the care plans for these residents were incomplete, potentially impacting the quality of care provided.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living, specifically incontinence care. The resident, a male with a history of cerebrovascular accident and hemiplegia, required substantial assistance with toileting and was at risk for pressure ulcers. Despite the care plan indicating the need for assistance every two hours, the resident reported not receiving a brief change from 4:00 AM until after 12:00 PM on one occasion, and from 4:00 AM until after 9:00 AM on another occasion. Observations confirmed the resident was left in a soaked state, with wet blankets and sheets, indicating a lack of timely care. Interviews with staff revealed inconsistencies in the care provided. CNA H, responsible for the resident's care, admitted to checking the resident less frequently on busier days and acknowledged that the resident was soaked during brief changes. LVN I and LVN F both expressed expectations for CNAs to check and change residents every two hours, but it was evident that this standard was not consistently met. The DON was not informed of the resident's condition during the incontinent care observation, highlighting a communication gap within the facility. The facility's policy on perineal care was reviewed, which outlined the procedure for cleaning after incontinence episodes. However, the failure to adhere to this policy and the care plan interventions resulted in the resident being at risk for skin breakdown and infection. The lack of timely incontinence care and the failure to maintain the resident's hygiene and dignity were significant deficiencies identified during the survey.

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 safe and appropriate administration of intravenous (IV) fluids for a resident, leading to deficiencies in labeling and timely dressing changes. Specifically, the facility did not label the IV medication bag and tubing with the date, time, and initials, which is necessary to prevent medication errors. Additionally, the resident's peripherally inserted central catheter (PICC) line dressing was not changed for eight days, despite the care plan indicating a change every seven days. This oversight was observed during a survey, where the dressing appeared dirty, and the IV bag and tubing lacked proper labeling. The resident involved was a female with a diagnosis of pneumonia, requiring intravenous access for medication administration. The resident's care plan included monitoring for signs of infection at the insertion site and specified PICC line dressing changes every seven days. However, there were no physician orders for dressing changes and flushes documented, and the treatment administration records lacked any documentation of PICC line dressing changes. Interviews with the licensed vocational nurses (LVNs) revealed that they were aware of the requirements but failed to adhere to them, citing reasons such as being new to the facility and forgetting to input necessary orders. The Director of Nursing (DON) acknowledged the expectation for staff to date and initial IV bags and tubing and to change dressings every seven days. The DON also noted that the admitting nurse should have entered the orders for dressing changes and flushes, but this was not done. The facility had standard orders for these procedures, and training records indicated that staff had received training on IV therapy competency. Despite this, the oversight in labeling and dressing changes was not caught by management, as the Assistant Director of Nursing (ADON) had assured the DON that all orders for new admissions were up to date, which was not the case for this resident.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate pharmaceutical services, specifically in maintaining accurate narcotic logs for two residents. The medication aide responsible for the 100 Hall medication cart did not sign off on the narcotic administration record after administering medications to the residents. This resulted in discrepancies between the narcotic administration records and the actual pill counts in the blister packs. For one resident, the narcotic administration record indicated 13 pills remaining, while the blister pack contained only 11 pills. For another resident, the record showed 102 pills remaining, but the blister pack had 101 pills. The medication aide admitted to administering the medications but forgetting to document the administration on the narcotic log. The Director of Nursing (DON) confirmed that staff are expected to document narcotic administration immediately to prevent discrepancies. Despite previous training on narcotic log documentation, the medication aide failed to comply with the facility's procedures. The DON acknowledged the importance of random checks on medication carts and stated that she had conducted such checks two weeks prior to the incident.

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 an environment free from accident hazards and provide adequate supervision to prevent elopement for a resident with severe cognitive impairment. The resident, who had a history of elopement and was at risk due to cognitive deficits and other medical conditions, managed to leave the facility unnoticed. The resident was found 8 miles away at a restaurant, and the facility was only informed of the elopement by a family member after being contacted by a community member. The deficiency was primarily due to the failure of staff to conduct regular rounds and checks on residents, particularly the resident in question. On the day of the incident, staff did not perform the necessary checks at the end of their shifts or upon starting their shifts. The resident was last seen by a nurse at 4:00 AM, and no further checks were made until the elopement was discovered after 7:15 AM. The resident's care plan had identified him as an elopement risk, yet the necessary precautions and supervision were not adequately implemented. Interviews with staff revealed a lack of adherence to the facility's policies on elopement prevention and response. Staff members admitted to not conducting rounds or checking on residents as required, which contributed to the resident's ability to elope. The facility's policies on elopement risk assessment and response were not effectively followed, leading to the resident's unsupervised departure and subsequent risk of harm.

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 maintain a safe environment free from accident hazards in the south hallway of Zone 3, between the vending machines and the doorway to the smoking courtyard. On July 5, 2024, a large puddle of water was observed in this area, which had entered through gaps in the doorway and a missing threshold during a brief rain shower. Four residents were cautioned about the water on the floor, as they had not noticed it until alerted. Laundry Staff A was asked to get housekeeping or a staff member to clean up the water, and subsequently, they obtained the necessary supplies to address the spill. Interviews with staff revealed that the area was known to have water issues when it rained or when plants were watered outside. Laundry Staff A mentioned that housekeeping typically handled such spills, but they were on break at the time. LVN B and RN E both emphasized the importance of cleaning up spills immediately to prevent slip and fall hazards. The Administrator (ADM) was unaware of the leaking doorway and stated that staff should have put up a caution sign and informed housekeeping. The facility's policy on fall risk and environmental hazards highlighted the need to maintain nonslip surfaces and clean spills immediately, which was not adhered to in this instance.

Penalty

Fine: $8,021

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 maintain an effective Infection Prevention and Control Program, as evidenced by the improper handling of a resident's indwelling urinary Foley catheter. The catheter bag was observed lying flat on the floor, which could lead to cross-contamination and infection. The resident, a male with obstructive and reflux uropathy, had a moderate cognitive impairment and was unaware of the catheter's proper placement. The facility's policy clearly stated that catheter tubing and drainage bags should be kept off the floor, yet this guideline was not followed. Interviews with staff, including an LVN, a CNA, the DON, and the Administrator, confirmed that the catheter bag should not have been on the floor. The LVN acknowledged the oversight and corrected the situation by hanging the catheter bag on the bed railing. The CNA admitted to not noticing the bag's improper placement, and both the DON and Administrator emphasized the importance of keeping the catheter bag off the floor to prevent infection. Despite previous in-service training on catheter care, the staff failed to adhere to the facility's infection control policy.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans for three residents, which could place them at risk of not receiving the individualized care they required. Resident #1, a female with mild cognitive impairment and multiple diagnoses including a leg fracture and heart failure, had a care plan that was not individualized. Similarly, Resident #2, a male with a pacemaker and heart disease, and Resident #3, a male with moderate cognitive impairment and dementia, also had care plans that lacked individualization. The care plans for these residents included generic focuses and interventions that were not tailored to their specific needs. Interviews with the MDS Coordinator and the DON revealed that the facility's care planning process was disorganized, with each department adding their part of the care plan without proper oversight. The MDS Coordinators were responsible for completing the comprehensive care plans but had not individualized them for the residents in question. The DON acknowledged the risk of not having individualized care plans, stating that staff might not know what care the residents needed. The facility's policy required person-centered comprehensive care plans, but this was not being effectively implemented.

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 who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, the facility did not ensure that the resident was not left in a soiled brief for an extended period of time. This failure was observed on multiple occasions, with the resident having to wait for assistance for up to 45 minutes. The resident's family had to be called in to assist with incontinence care due to the lack of prompt response from the facility staff. The resident, a [AGE] year-old female with diagnoses including a fracture of the right lower leg, morbid obesity, heart failure, and asthma, was admitted to the facility and required assistance with most of her ADLs. Her care plan was not individualized, and she was not care planned for bowel and bladder incontinence. On the day of the observation, the resident reported being soiled and having called for help at 8:40 AM, but assistance did not arrive until 9:26 AM. This was the second time that morning she had to wait for an extended period to be changed. Interviews with the resident's family and facility staff revealed that the resident's family often had to assist with incontinence care due to the lack of available staff. The family member reported observing nurses sitting at the nurse station not doing anything while the CNAs struggled to find help. The facility's ADON and DON both stated that call lights should be answered within 5-15 minutes, but this expectation was not met. The facility's current Perineal Care Female policy did not reference time frames for care or define what would be considered prolonged wait times.