Ralls Nursing Home

Penalty

Inspection fine: $21,021

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 deficiency involves the facility’s failure to protect a resident from physical and verbal abuse and to ensure a safe environment free from abuse. The resident was an elderly female with Alzheimer’s disease, schizoaffective disorder (bipolar type), paranoid schizophrenia, generalized anxiety, intermittent explosive disorder, insomnia, conversion disorder with seizures/convulsions, muscle weakness, and difficulty walking. Her MDS showed a BIMS score of 6, indicating severe cognitive impairment, daily rejection of care, and psychosis with hallucinations and delusions. She used a wheelchair and had care plan focuses addressing aggressive behaviors, delirium risk, and mood problems, with interventions including simple communication, monitoring for agitation, and medication management. On the evening of the incident, video footage showed the resident sitting alone in the dining room in her wheelchair, reading a book or Bible and watching TV. LVN A and CNA B engaged in a verbal exchange with the resident after she told them to stop talking about someone; staff told her to “mind your business” and made repeated comments about finding another place for her to live and questioning why she had not been made to move. LVN A stated she was going to find a new place for the resident and that the resident could not stay there, and made a gesture with her hand across her neck while making a sound with her mouth. CNA B then repeatedly told the resident she needed to go to bed, turned off the dining room and TV room lights while the resident was reading and watching TV, and stood on a chair to turn off ceiling fan lights, despite the resident stating she did not want to go to bed and telling staff not to tell her what to do. The video further showed CNA B pushing the resident in her wheelchair toward the hall while the resident resisted by pushing her feet toward the ground and telling staff to stop. As the wheelchair was pushed, the resident reached for an overbed table and went forward out of the wheelchair onto the floor. Staff then left her on the floor at LVN A’s direction before discussing using a blanket to move her. The resident was observed on the floor, verbally telling staff to stop, and striking out at staff while they continued to interact with her. CNA B obtained a blanket, and together CNA B, LVN A, and CNA C placed the blanket over the resident; CNA B grabbed the resident’s forearm and began dragging her down the hall on the blanket while the resident attempted to hit and kick. CNA C grabbed the blanket at the resident’s feet and assisted CNA B in dragging the resident down the hall and into her room, while LVN A walked alongside and made comments including that the resident should be sent out. The resident later reported to the ADON that she had been dragged down the hall on a blanket when she refused to go to bed early, and a skin assessment documented bruising to her lower forearm. None of the three staff on duty reported the incident at the time, and they continued to work subsequent shifts with the resident before the incident was discovered via video review. Interviews with administrative staff corroborated that LVN A, CNA B, and CNA C verbally abused the resident, forced her toward her room in the wheelchair, pushed the wheelchair so hard that she came out of the chair onto the floor, and then wrapped her in a sheet or blanket and dragged her down the hall to her room while she was telling them to stop. The ADM and DON both described that the resident had been quietly reading her Bible and was not bothering anyone before staff decided she needed to go to bed, turned off the lights, and escalated the situation. The BOM’s review of the video confirmed that staff told the resident to mind her own business, threatened to get her out of the facility, turned off lights that were not normally turned off, pushed her in the wheelchair until she fell out, and then dragged her down the hall on a sheet or blanket. Staff interviews showed that LVN A believed using a blanket to move the resident was the safest option and did not consider it abuse, despite prior in-service training that dragging a resident down the hall on a blanket and turning off lights to force a resident to bed are forms of abuse. Other staff interviewed stated that residents should not be forced to go to bed, forcefully pushed in wheelchairs when refusing, or dragged on the floor to their rooms.

Penalty

Inspection fine: $21,021

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 deficiency involves the facility’s failure to implement its written policies and procedures requiring that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported immediately, and no later than two hours when abuse or neglect with bodily injury is alleged. A cognitively impaired female resident with Alzheimer’s disease, paranoid schizophrenia, schizoaffective disorder (bipolar type), generalized anxiety, intermittent explosive disorder, conversion disorder with seizures, insomnia, and a history of aggressive behaviors alleged that staff verbally and physically abused her. Her MDS showed a severely impaired BIMS score of 6, daily rejection of care, and psychosis with hallucinations and delusions, and she used a wheelchair. On 12/19, during the evening/night shift, the resident reported that staff turned off the TV while she was watching a show in the dining area, told her she had to go to bed, put a blanket over her head, grabbed her feet, and dragged her down the hall to her room on the blanket. She stated she stayed in her room that night and did not report the incident the following day. Progress notes documented by the ADON on 12/22 indicated that the resident voiced she had been dragged down the hall on a blanket when she refused to go to bed early, that staff turned off the TV and forced her, dumped her out of her wheelchair, and then dragged her down the hall. A skin assessment on 12/22 by the ADON documented bruising to the resident’s lower forearm, and the resident was not on blood thinners at the time. Interviews and timecard reviews established that LVN A, CNA B, and CNA C were the only staff on duty on the night of 12/19 when the incident occurred, and they continued to work subsequent shifts on 12/20 and 12/21 without reporting the incident to administrative staff. The DON stated the incident occurred around 7:00 PM on 12/19 and was not reported until 12/21, when it was discovered on facility video footage shortly after the same three staff started their shift. The ADM stated he had video of the incident, that LVN A, CNA B, and CNA C abused the resident, and that all three were implicated and failed to report the event. Interviews with the ADON and BOM showed that the resident’s allegation of abuse was not immediately reported to the Administrator prior to investigation. The BOM reported that on Sunday, as she was leaving work around 6:00 PM, the ADON called and relayed that the resident had reported an allegation of abuse but that the ADON did not know if it had occurred or which staff were involved. The BOM then reviewed the video, identified the incident and the involved staff, and notified the ADM, ADON, and corporate nurse. The ADON later acknowledged that, based on policy, she expected staff to report any abuse immediately and that staff did not follow the abuse, neglect, and exploitation policy when they failed to report the abuse the night it happened. Statements typed by administration for LVN A, CNA B, and CNA C documented that they admitted to dragging the resident down the hall on a blanket and did not believe they had done anything wrong, citing the resident’s behaviors and medication noncompliance. Despite existing policies and prior in-service training on abuse, neglect, resident rights, and the requirement to report abuse, the incident was not reported within the required timeframe, and the facility failed to ensure that its abuse/neglect reporting policies were implemented for this resident. The facility’s written Abuse, Neglect, Exploitation, Misappropriation Prevention Program policy, revised April 2021, stated that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that the program includes identifying and investigating all possible incidents of abuse, neglect, mistreatment, or misappropriation and reporting any allegations within required federal timeframes. Interviews with multiple staff (including CNAs, LVNs, and the ADON) confirmed they had received training on abuse and neglect, reporting abuse, and resident rights, including explicit instruction that dragging a resident down the hall on a blanket and turning off lights or TV to force a resident to go to bed are forms of abuse and violations of resident rights. Nonetheless, on the night of the incident, LVN A, CNA B, and CNA C did not report the event, and the ADON and BOM did not immediately report the resident’s allegation to the Administrator before initiating review of the video. This sequence of actions and inactions led to the identified deficiency that the facility failed to implement its abuse/neglect reporting policies and procedures for this resident.

Removal Plan

• Conduct safe surveys.
• Provide in-service training on abuse and neglect, resident rights, and misappropriation.
• Review in QAPI and discuss with staff.
• Monitor camera footage across shifts to monitor staff.

Penalty

Inspection fine: $21,021

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 deficiency involves the facility’s failure to ensure that an allegation of abuse was reported immediately, as required by policy and federal regulations, and that involved staff were removed from contact with the resident pending investigation. A cognitively impaired female resident with Alzheimer’s disease, schizoaffective disorder, paranoid schizophrenia, intermittent explosive disorder, and other psychiatric and neurologic diagnoses alleged that staff verbally and physically abused her. She reported that while she was watching television in the dining room, night-shift staff turned off the television and told her she had to go to bed, then dumped her out of her wheelchair, placed a blanket over her head, grabbed her feet, and dragged her down the hall to her room. A subsequent skin assessment documented bruising to her lower forearm, and she was not on blood thinners at the time of the incident. The incident occurred during a night shift when an LVN and two CNAs were the only staff on duty. According to the DON and ADM, these three staff members were captured on video dragging the resident down the hall on a blanket and were determined to have verbally and physically abused her and violated her resident rights by forcing her to go to bed and turning off the lights. Despite this, none of the three staff reported the incident to the Administrator or other facility leadership at the time it occurred or at any point during the following shifts. They continued to work their full night shift immediately after the incident and returned for subsequent night shifts, continuing to provide care to the same resident without reporting the event. The resident did not report the abuse on the day following the incident and remained in her room, later stating that she told staff to leave her alone. Two days after the incident, she reported to the ADON and other CNAs that staff had dragged her to her room and turned off the television. The ADON, who had been trained on abuse, neglect, and resident rights, stated that based on facility policy she expected staff to report any abuse immediately and acknowledged that staff did not follow the abuse, neglect, and exploitation policy requiring immediate reporting to the Administrator or designee. Interviews with the LVN involved revealed that she believed she had not done anything wrong, did not recognize dragging the resident on a sheet as abuse, and did not report the incident. The facility’s written policies clearly defined abuse, required immediate reporting of suspected abuse by any staff member, and prohibited actions such as unreasonable confinement and willful infliction of injury or mental anguish, but these requirements were not followed by the involved staff, resulting in the failure to immediately report the alleged abuse and to protect the resident from further contact with the alleged perpetrators. The noncompliance was identified as Past Noncompliance (PNC) with Immediate Jeopardy that began on 12/19/25 and ended on 01/07/26. The Immediate Jeopardy related to the failure to report the alleged abuse immediately and to remove the involved staff from resident care while the incident remained unreported and uninvestigated.

Penalty

Inspection fine: $21,021

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 deficiency involves the facility’s failure to protect multiple residents from misappropriation of personal property by a staff member, RN D. Several residents had intact or impaired cognition and varying levels of dependence for activities of daily living, including residents with paraplegia, Alzheimer’s disease, depression, anxiety, and other psychiatric and visual conditions. One cognitively intact resident reported that personal items such as a decorative wine bottle with flowers, signs, containers with flowers and markers, and unopened face cream were missing from her room. Another resident reported a missing wallet and ID, and staff assisted in searching for these items before they were later found among property returned in trash bags. Video footage and staff interviews revealed that RN D used a code to unlock and enter a side gate, placed bags in a wheelchair, moved around the building with bags in hand, and exited and re-entered through the gate while carrying bags. The Administrator and Business Office Manager described that large trash bags were later found outside the facility near gates and around the exterior, and that these bags contained clothing, jewelry, electronics, shoes, perfume, cologne, and other items. An inventory list documented that items in the bags were identified as belonging to five residents, including perfume, skin care products, a cash app card, ID card, Social Security card, iPad, phone, wallet, clothing, shoes, and a razor with guards and bag. Interviews with the DON, Administrator, Business Office Manager, and other staff established that residents, other than the one who reported a missing wallet and personal items, generally did not know their belongings were missing and had not reported losses. Staff stated they had received training on resident rights and understood that residents should not be forced to do anything against their will and that staff should not borrow, use, or take residents’ personal items. Despite this, RN D, who had documented training on resident rights and abuse, neglect, exploitation, and misappropriation, wrongfully took residents’ belongings over a period of time while working night shifts and transporting items out of the building, resulting in misappropriation of property for at least five residents. Law enforcement involvement confirmed that RN D was found in possession of stolen property and identification belonging to an elderly resident, and he was to be charged with multiple counts of theft and a felony related to possession of an elderly person’s identification. The facility’s own policies defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent and stated that residents have the right to be free from misappropriation and exploitation. The events described show that, despite these policies and staff training, the facility did not prevent RN D from taking and wrongfully using residents’ personal property, resulting in the cited deficiency for failure to protect residents from misappropriation of their belongings. Safe surveys conducted with residents after the incident documented that residents reported feeling safe and did not identify concerns or fear of staff, and multiple staff interviews reiterated their understanding that taking residents’ belongings was prohibited. However, these measures and understandings did not prevent the misappropriation that had already occurred. The deficiency centers on the fact that residents’ personal property, including identification and personal effects, was taken without their knowledge or consent by a nurse employed at the facility, and the facility only became aware of the scope of missing items when they were returned in trash bags and identified as belonging to specific residents.

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 medication aide (MA) administered multiple medications, including Tegretol, Lipitor, Baclofen, Metoprolol, Neurontin, and Quetiapine Fumarate, to a resident who did not have physician orders for any of these medications. These medications were prescribed for another resident, not the one who received them. The error occurred while the MA was passing medications and became distracted due to the presence of residents near the medication cart, which he had previously expressed caused him difficulty concentrating. The MA immediately recognized the error and reported it to the Assistant Director of Nursing (ADON) and Director of Nursing (DON). The resident who received the incorrect medications had a complex medical history, including Alzheimer's disease with early onset, essential hypertension, cognitive communication deficit, intermittent explosive disorder, psychotic disorder with hallucinations, dry eye syndrome, acute atopic conjunctivitis, and muscle weakness. At the time of the incident, the resident was observed to be active and alert, both before and after the medication error. Following the administration of the wrong medications, the resident was monitored, and her vital signs remained stable. However, the physician later ordered her transfer to the hospital for close observation. Facility records and interviews confirmed that the resident did not have any physician orders for the medications administered in error. The facility's policies required staff to verify resident identity and medication details before administration, but these procedures were not followed in this instance. The error was documented in the medication error report, and the incident was confirmed through interviews with the MA, ADON, DON, and other staff members. The resident was subsequently discharged from the hospital with no new orders and returned to her baseline condition.

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 a private meeting space for resident council meetings for 14 of 35 confidential residents reviewed for resident council. Observation of the dining room on 9/15/25 showed multiple staff and residents coming in and out while the Resident Council meeting was in session. In a confidential group interview on 9/15/25, 14 alert and oriented residents who attended resident council stated the meetings were always held in the dining room, staff came in and out with no privacy, and they filtered what they said because staff were present. They also stated there was no sign posted requesting privacy during Resident Council and that they were not comfortable with the meeting being held in the dining room because it was right outside the ADM's office. Interview on 9/16/25 with the Activities Director revealed Resident Council had been held in the dining room for the entirety of her 10-year employment at the facility. She stated the dining room was not a private space, there were no doors to close, and no sign had been posted during Resident Council to request privacy. She also stated there was a partition on the east side of the dining room that could be used to create a more private area, but she had not used it because she was not used to utilizing the partition. The Administrator stated the dining room was not a private setting for Resident Council and said she expected the AD to host the meetings behind the partition, but the AD had not done so due to lack of training. Record review showed Resident Council minutes for June, July, and August 2025 documented meetings held in the dining room with 8, 10, and 12 residents present, respectively.

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 14 of 35 confidential residents reviewed with information about their rights related to filing grievances or concerns. During Resident Council interviews and record review on 09/15/2025, 14 confidential residents stated they did not have access to a grievance form, did not know they could file a grievance anonymously, and had not seen a posting of the grievance procedure on the resident bulletin board. Observation of the facility at 3:45 PM on 09/15/2025 showed that facility postings did not include instructions regarding the grievance procedure. The ADM stated on 09/16/2025 that she was the grievance officer and was responsible for reviewing grievances and assigning them to department heads. She stated grievance forms were available upon request at the nurses' station and that staff completed a grievance form if a resident had a complaint. She also stated there was no procedure for residents to submit grievances anonymously. Record review of the grievance policy updated April 2017 stated residents and their representatives have the right to file grievances orally or in writing, that grievance/complaint procedures should be posted on the resident bulletin board, that grievances may be submitted anonymously, and that contact information for the grievance recipient is provided upon admission.

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 use of a registered nurse for at least 8 consecutive hours a day, seven days a week for 3 of 30 days reviewed for RN coverage. Record review of the facility’s punch details showed that on 8/30/2025 the facility had RN coverage for 3.5 hours, on 9/4/2025 the facility had RN coverage for 7.02 hours, and on 9/13/2025 there was no documented RN coverage. During an interview on 9/16/2025, the DON stated she was responsible for ensuring RN coverage and explained that one day the RN was delayed at the airport and could not provide coverage for the rest of the day. She also stated that on 9/13/2025 she had been sick, was unable to provide coverage, and could not find anyone to come in. The DON stated she expected RN staff to provide coverage for the entire 8 hours they were scheduled and not to clock out early. The ADM stated the DON was responsible for ensuring RN coverage and that RN coverage was required to ensure quality care for residents. Record review of the facility policy titled Departmental Supervision dated 8/2006 stated that an RN nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities for 8 consecutive hours per 24-hour period beginning at midnight.

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 store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation, two packages of uncooked pork loin were found stored above ready-to-eat and prepared foods in the freezer, including a chocolate pie and sweet potato casserole. A plastic scoop was also observed stored inside a bucket of ice used to prepare residents’ drinks for lunch. In addition, plastic containers of individual condiments such as mayonnaise, mustard, picante sauce, tabasco sauce, tartar sauce, ranch dressing, and ketchup did not have expiration or use-by dates on the packets or storage containers. The kitchen was also observed to have multiple sanitation issues. A window seal above the kitchen sink had a thick yellow and brown buildup of dirt and grime, the wall above the kitchen stove had a yellow layer of grease, dirt, and grime, the cart used for storing silverware and meal trays had a buildup of food and grease, and the floor and wall beside the refrigerator were soiled with dirt, grease, and grime. These conditions were observed during the initial kitchen tour and again on a later observation, showing the same issues remained present. During interview, the dietary manager stated she had been in the role for about one week and said uncooked meats should be stored below ready-to-eat foods. She stated she was responsible for putting away food items in the freezer and refrigerator, was unaware the pork loins were stored above ready-to-eat items, and was unaware the ice scoop was left in the ice container. She also stated she was unaware the condiments did not contain expiration or use-by dates and acknowledged there was not a way to ensure rotation without dates. The administrator stated the kitchen was expected to be clean and sanitary, the dietary manager was responsible for ensuring proper food storage and labeling, and uncooked pork should not be stored above ready-to-eat foods because it could result in cross contamination.

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 violation involving a resident’s unexplained medical emergency and death was reported immediately to the State Agency. Resident #37, a [AGE]-year-old female with a history of bilateral below-the-knee amputations, GERD, bipolar disorder, schizoaffective disorder, muscle wasting, lack of coordination, insomnia, obesity, muscle weakness, anxiety, and type 2 diabetes, had a BIMS score of 7 indicating severe cognitive impairment. Her MDS and dietary records did not identify swallowing problems, and her care plan did not include swallowing difficulty or direct supervision during meals. She was ordered a reduced concentrated sweets diet with regular texture/consistency and double portions, and she was documented as requiring setup or clean-up assistance with eating. On 8/3/2025, Resident #37 was found lying on a mat in her room unresponsive and without a pulse or respirations. CPR was started, 911 was called, and EMS arrived and continued resuscitation efforts. The EMS report documented that a large piece of possible meat-like foreign body was found in the upper airway during intubation and removed, after which the tube could pass. EMS also documented that Resident #37 had no pulse and no respirations on arrival, later regained a pulse, and was transported to the hospital. The facility’s progress note later stated that EMS found food in her airway and that the cause of death would be choking, but the facility did not report the incident to the State Agency. During interviews, the VPOO stated the facility did not report the event because it was unable to determine whether the resident choked at the facility or at the hospital. The DON stated she was notified of the incident, that the resident had been found unresponsive while food trays were being passed, and that she did not believe there was neglect, abuse, or a suspicious death requiring reporting. The MDI stated EMS reported food in the airway during intubation, but she did not suspect trauma, abuse, or foul play and did not instruct the facility not to notify the State Agency. The facility policy required all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property to be immediately reported to the administrator and to the State survey and certification agency.

Penalty

Inspection fine: $16,543

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 was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

Inspection fine: $16,543

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 effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through review of facility documentation and staff interviews, which revealed that the required policies and procedures were either not in place or not consistently followed. The lack of clear guidance and enforcement contributed to an environment where incidents of abuse, neglect, or theft could occur without adequate prevention or timely intervention. Surveyors found that staff were not adequately trained or informed about the necessary steps to identify, report, and prevent such incidents, and there was insufficient oversight to ensure compliance with regulatory requirements.

Penalty

Inspection fine: $16,543

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 suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.

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 an effective infection control program, as evidenced by the improper hand hygiene practices of a CNA during incontinence care for a resident. The resident, a cognitively intact male with a history of malignant neoplasm of the prostate, epilepsy, and atrial fibrillation, was observed receiving care that did not adhere to proper infection control protocols. Specifically, the CNA did not change gloves or perform hand hygiene after handling soiled materials and before touching clean items, such as a clean brief, during the care process. Interviews with the CNA, DON, and ADM revealed that while handwashing training is conducted regularly, the CNA did not follow the established procedures during the observed care. The CNA acknowledged the mistake and attributed it to nervousness. The DON and ADM confirmed the importance of hand hygiene and glove changes between tasks to prevent infection and cross-contamination, as outlined in the facility's hand hygiene 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 maintain a safe, functional, sanitary, and comfortable environment on its grounds, specifically in the front entrance parking lot. Observations made on multiple occasions throughout the day revealed a trashcan near the front entrance that was overflowing with trash, including Styrofoam food containers, cups, fast food bags, and other miscellaneous items. The trashcan's lid could not close due to the volume of trash, and this situation persisted for at least five hours. Interviews with the Maintenance and Housekeeping Supervisor and the Regional Director/Interim Administrator revealed a lack of a systematic approach to ensure regular checks and timely disposal of trash in outdoor areas. The Maintenance and Housekeeping Supervisor acknowledged awareness of the overflowing trashcan but was preoccupied with other tasks and did not address it immediately. He also noted that most housekeeping staff were new and still undergoing training. The Regional Director/Interim Administrator confirmed the absence of a system to regularly check outdoor trashcans and mentioned plans to create a check-off list for housekeeping staff. The facility's policy, revised in May 2008, stated that grounds should be maintained in a safe and attractive manner, with maintenance responsible for keeping the grounds free of litter.

Penalty

Inspection fine: $203,17711 days payment denial

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 sexual abuse, as evidenced by multiple incidents involving inappropriate sexual behavior by residents with known histories of such behavior. Resident #2, a male with severe cognitive impairment and a history of wandering and aggressive behavior, was involved in two separate incidents of sexual misconduct. On one occasion, he was found with his penis in Resident #3's hand, and on another, he was discovered in bed with Resident #4, with his hand in her pants. Despite these incidents, the facility did not implement adequate protective measures or consistent monitoring to prevent further occurrences. Resident #5, another male resident with severe cognitive impairment and a history of inappropriate sexual behavior, was involved in incidents of kissing and touching other residents without consent. Despite these behaviors, the facility failed to provide adequate supervision or intervention to prevent further inappropriate conduct. The lack of timely and effective response to these incidents highlights a significant deficiency in the facility's ability to protect residents from abuse. Interviews with staff revealed a lack of communication and training regarding the supervision and management of residents with known behavioral issues. The facility's administration and nursing staff did not consistently implement or monitor protective measures, such as 1:1 supervision, even after incidents of sexual misconduct were reported. This failure to act appropriately and promptly placed residents at risk of further abuse and demonstrated a pattern of non-compliance with regulations designed to ensure resident safety.

Penalty

Inspection fine: $203,17711 days payment denial

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 implement its policies and procedures to prevent abuse and neglect, as evidenced by several incidents involving multiple residents. One significant incident involved a resident who fell in the shower while being assisted by a CNA. The CNA did not report the fall to the nursing staff, resulting in a delay in medical assessment and treatment. The resident sustained a hip fracture, which was only discovered later when the resident complained of pain. Interviews revealed that the CNA believed the incident was not reportable and did not follow the care plan, which required two staff members for transfers. Additionally, the facility failed to report and investigate multiple sexual incidents involving residents. In one case, a male resident was found with his pants unzipped and his penis in the hand of a female resident, who appeared to be asleep. The incident was not reported to the state agency, and the facility did not conduct a thorough investigation. The facility's administration did not consider the incident reportable due to the residents' dementia, and no immediate protective measures were taken. The facility's inaction placed residents at risk for continued abuse and neglect, as well as potential harm and mental anguish. The lack of proper reporting and investigation procedures, along with the failure to follow care plans, contributed to the deficiencies identified by the surveyors. These failures highlight significant gaps in the facility's ability to protect its residents and ensure their safety and well-being.

Penalty

Inspection fine: $203,17711 days payment denial

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 report multiple incidents of inappropriate sexual contact between residents, which were not reported to the proper authorities as required by state law. The incidents involved residents with severe cognitive impairments, including dementia and Alzheimer's disease. The facility did not report these incidents within the mandated two-hour timeframe, which is required when the events involve abuse or result in serious bodily injury. This failure to report was observed in five out of nine residents reviewed for abuse and neglect. The first incident involved a male resident with severe cognitive impairment and a history of wandering and aggressive behavior, who was found with his pants unzipped and his penis in the hand of a female resident who was asleep. Despite the severity of the incident, the facility's administration did not report it, citing the dementia of both residents as a reason for not considering it abuse. The Director of Nursing (DON) and the Administrator were aware of the incident but did not take the necessary steps to report it to the state agency. Subsequent incidents involved the same male resident and other female residents, as well as another male resident with a history of sexual dysfunction and aggressive behavior. These incidents were also not reported, with the facility's administration again citing the cognitive impairments of the residents involved. Interviews with staff revealed a lack of clear communication and understanding of the reporting requirements, with some staff expressing concerns about the incidents but being overruled by higher management. The Regional Director, who was consulted, also failed to ensure that the incidents were reported, despite acknowledging the expectation that they should have been.

Penalty

Inspection fine: $203,17711 days payment denial

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 investigate several incidents involving residents, leading to deficiencies in addressing potential abuse and neglect. One incident involved a fall that occurred with a resident while in the care of a CNA. The resident, who had a history of cerebral infarction, major depressive disorder, and cognitive communication deficit, fell in the shower and sustained a hip fracture. Despite the resident's care plan indicating the need for assistance from two staff members during transfers, the CNA attempted the transfer alone. The incident was not reported to the nursing staff immediately, resulting in a delay in treatment and assessment. Another series of incidents involved inappropriate sexual contact between residents. A resident with dementia and a history of behavioral issues was found in a compromising situation with another resident. Despite the severity of the incident, the facility did not conduct a thorough investigation or report the incident to the appropriate authorities. The administration's decision not to report was based on the belief that the behavior was not willful due to the residents' cognitive impairments. The facility's administration and nursing staff failed to follow established protocols for investigating and reporting incidents of potential abuse and neglect. Interviews with staff revealed a lack of communication and understanding of the importance of reporting such incidents. The administration relied on guidance from a regional director, which led to the decision not to report the incidents, despite the potential risks to resident safety.

Penalty

Inspection fine: $203,17711 days payment denial

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 immediately inform the representative of a resident involved in an incident of inappropriate sexual behavior. The incident involved a male resident who was found in a female resident's room, engaging in inappropriate sexual conduct. The staff intervened and placed the male resident under 1:1 monitoring, but the family of the female resident was not notified of the incident as required by facility policy. The female resident, who was involved in the incident, had a history of Alzheimer's disease, cognitive communication deficit, and major depressive disorder, which left her severely cognitively impaired and dependent on staff for her needs. The incident was documented by an LVN, who reported it to the Director of Nursing (DON) but failed to notify the resident's family. Interviews with staff revealed that the charge nurse was responsible for notifying the family, but this did not occur. The facility's policy on abuse investigation and reporting requires that the resident's representative be informed of any incidents involving abuse or mistreatment. Despite this policy, the family member of the female resident was not informed until several days after the incident, leading to distress and dissatisfaction. The facility's administration acknowledged the oversight but did not provide a clear explanation for the failure to notify the family promptly.

Penalty

Inspection fine: $62,438

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 the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility staff, including the Administrator and DON, did not adequately address the ongoing behavior of one resident entering another resident's room, leading to physical altercations. This failure involved a resident with severe cognitive impairment and another resident with a history of physical and verbal aggression, resulting in multiple incidents where the aggressive resident entered the other resident's room and caused harm, including pulling the resident out of bed and causing scratches and abrasions. The aggressive resident had a documented history of combativeness, wandering, and aggression, yet was not placed on special supervision until after a significant incident occurred. Despite multiple reports from staff and family members about the aggressive resident's behavior, including attempts to pull the other resident out of bed and physical aggression towards staff, the facility did not implement effective interventions to prevent these incidents. The care plans and progress notes indicated that the aggressive resident's behavior was known, but the facility's response was inadequate, leading to repeated incidents. Interviews with staff, family members, and the residents involved revealed that the facility's actions were insufficient to prevent the aggressive resident from entering the other resident's room. Staff reported the incidents to their supervisors, but no effective measures were put in place to address the behavior. The facility's failure to implement appropriate supervision and interventions resulted in ongoing risk and harm to the residents involved.

Penalty

Inspection fine: $62,438

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 address, resolve, and promptly resolve grievances in accordance with its policy for a resident, a family member, and a staff member. The facility did not document, resolve, or follow up on grievances related to the behavior of another resident, which included physical aggression and wandering into other residents' rooms. This failure involved multiple incidents where the aggressive resident pulled another resident out of bed, causing fear and potential harm. The aggressive resident had a history of combativeness, wandering, verbal aggression, and physical aggression, which was documented in his care plan and progress notes. Despite these documented behaviors, the facility did not implement effective interventions to prevent further incidents. The facility's staff, including CNAs and the DON, were aware of the aggressive resident's behavior but did not take adequate steps to address the grievances raised by the affected resident, his family member, and the staff. Interviews with the affected resident, his family member, and staff revealed that the facility's administration and nursing staff were aware of the ongoing issues but failed to take appropriate actions. The facility's grievance log did not contain any records related to the concerns raised about the aggressive resident's behavior. The facility's policies on grievances and resident rights were not followed, leading to unresolved issues and potential risks to residents' safety and well-being.

Penalty

Inspection fine: $62,438

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 implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility staff, including the Administrator, failed to report incidents between two residents to the governing state agency. The incidents involved Resident #1, who had severe cognitive impairment and required maximum assistance, and Resident #2, who had advanced dementia and a history of aggressive behavior. On multiple occasions, Resident #2 entered Resident #1's room, resulting in physical altercations where Resident #1 was pulled out of bed and scratched. These incidents were not reported in a timely manner to the state agency as required by the facility's policies. The report details that on one occasion, Resident #2 pulled Resident #1 out of bed, causing scratches and abrasions. Despite the severity of the incident, the facility staff, including CNAs and LVNs, failed to report the abuse immediately to the abuse coordinator. The Administrator was also found to have not reported the incident to the state agency. Interviews with staff revealed that there was confusion and a lack of immediate action in reporting the abuse, even though the staff had been trained to do so. The DON and ADM were aware of the incidents but did not take appropriate steps to ensure timely reporting and intervention. Further interviews and record reviews indicated that Resident #2 had a history of wandering and aggressive behavior, which was known to the facility staff. Despite this, adequate measures were not taken to prevent further incidents. The facility's failure to implement effective monitoring and reporting systems placed residents at risk of harm. The ADM admitted to not being fully aware of the ongoing issues between Resident #1 and Resident #2 and did not implement additional interventions outside of medication adjustments and monitoring from psychiatric services. This lack of action and oversight contributed to the deficiency in preventing and reporting abuse and neglect in the facility.

Penalty

Inspection fine: $62,438

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 comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for a resident with a history of dementia, depressive disorder, mood disorder, and blindness in one eye. Despite the resident's ongoing incidents of physical and verbal aggressive behaviors, the care plan was not updated to reflect these changes, potentially placing the resident and others at risk of harm. The resident's records revealed multiple incidents of physical and verbal aggression, including pulling another resident out of bed, hitting staff with a walking stick, and wandering into other residents' rooms. These behaviors were documented in progress notes and provider investigation reports, yet the care plan remained unchanged since January 2024. The MDS Coordinator and other staff members were aware of these incidents but did not update the care plan accordingly. Interviews with the MDS Coordinator, ADM, and DON indicated a lack of communication and monitoring regarding the resident's care plan. The MDS Coordinator stated that she would revise the care plan if informed of changes in the resident's behavior, but she was unaware of the extent of the resident's aggression. The ADM and DON acknowledged the importance of updating care plans but were also unaware that the resident's care plan had not been revised. The facility's policy requires care plans to be updated with significant changes in the resident's condition, but this was not followed in this case.