Citations in Florida I

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

Facility administration failed to utilize resources effectively to ensure allegations of abuse and neglect were thoroughly investigated and reported in a timely manner for multiple residents. The Nursing Home Administrator’s job description required directing day-to-day functions in accordance with federal, state, and local regulations to assure quality care, including reviewing resident complaints and grievances, maintaining written records of complaints, and reporting all allegations of resident abuse and misappropriation of property. The DON’s job description outlined responsibilities for ensuring quality and safe delivery of nursing services, accurate and timely documentation, continuous observation and monitoring of seriously ill residents, and acting as a patient advocate. Despite these defined roles and responsibilities, the facility did not ensure that an allegation of neglect involving a resident on the smoking patio was properly investigated, documented, or reported. Resident #3 was admitted with serious medical conditions including metabolic encephalopathy, major depressive disorder, antineoplastic chemotherapy, secondary malignant neoplasm of the lung, malignant neoplasm of the brain, severe calorie malnutrition, cachexia, COPD, personal history of pneumonia, and acute respiratory failure with hypoxia. A witness statement dated on a specified date described security camera footage from the smoking patio showing this resident, who was assigned to a specific CNA for care, entering the smoking patio in the afternoon and remaining there without any visits or care from the assigned CNA. The statement indicated that at 5 p.m. the resident was found unresponsive by other staff, assisted indoors, and a code blue was called, with the video showing that the resident received no care of any kind from the assigned CNA for over 4.5 hours. Review of the facility’s abuse log for the relevant period showed that this incident was not listed, indicating it was not entered into the abuse/neglect tracking system. During a complaint survey, interviews with key personnel who were employed at the time of the incident revealed they were not willing or able to participate meaningfully in the survey process regarding the investigation of abuse and neglect. The RN Unit Manager, Director of Rehabilitation, Housekeeping Manager, Assistant DON, two Social Services Directors, and therapy staff denied knowledge of the resident having been left unattended for 4.5 hours, or that the resident coded, required CPR for more than 10 minutes, and subsequently expired. Their responses included statements such as not remembering the incident, not being told anything by administration, not knowing, not feeling comfortable answering, or lacking specifics. At the time of the investigation, it was unclear whether these key staff had not participated in any investigation of this traumatic event or were not forthcoming, which impacted the survey process. Review of the facility’s Compliance and Ethics Reporting policy showed that employees were required to report suspected violations immediately and that all reports were to be investigated and tracked for QAPI, but the handling of this incident and the absence of the event from the abuse log demonstrated that these reporting and investigation processes were not effectively implemented by facility administration. Further, interviews with the RDCS and the facility’s CNO revealed that they only became aware of the witness statement about the resident being left outside for 4.5 hours shortly before the survey interview and that the allegation of neglect had only then been reported. They stated that the LPN who wrote the witness statement had focused on the caregiver rather than the resident and that the LPN had not reviewed the full 4.5 hours of video. The RDCS stated that administration was not forthcoming and that there had been an unsupervised smoking patio at the time of the incident. The CNO reported discovering that the NHA had a culture of hiding information and that the NHA had concealed matters from them. These statements, combined with the lack of timely reporting, incomplete or absent investigation, and failure to document the incident in the abuse log, demonstrate that facility administration did not administer the facility in a manner that ensured effective use of resources to investigate and report allegations of abuse and neglect as required by policy and job responsibilities.

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 consistently implement its infection prevention and control program during an influenza outbreak and in the handling of nebulizer equipment. During an initial tour, surveyors observed that all staff in resident care areas were wearing masks and staff reported this was required due to a flu outbreak that began several days earlier, with 21 residents testing positive. However, in the lobby there was no signage notifying visitors of the outbreak or recommending PPE such as masks, and the receptionist did not provide any information or instructions about the outbreak. Two family members who visited residents on multiple occasions reported they had not been notified of the flu outbreak, had not been offered masks, and only became aware of the situation by seeing staff wearing masks. The Infection Preventionist later confirmed that while resident representatives were notified of the outbreak by telephone, the facility did not encourage mask use for visitors and did not post signage to notify visitors or recommend/encourage mask use, contrary to the facility’s infection control policy requiring visitor education, use of isolation signs, and passive screening via posted signs. Surveyors also observed improper storage of nebulizer masks on two units. On the 300 unit, an uncovered nebulizer mask was seen on a resident’s dresser in front of the television, and on the 100 unit, another uncovered nebulizer mask was observed on a circular table in a resident’s room. Photographic evidence was obtained. The Infection Preventionist, upon reviewing the photos, stated that nebulizer items should be stored in a bag and that all nurses had been instructed on this practice. This practice was inconsistent with the facility’s written policy on oxygen administration, which requires delivery devices to be kept covered when not in use, and with the infection prevention and control policy that all staff follow procedures designed to prevent the development and transmission of communicable diseases and infections.

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 staff with adequate training and effective processes to address language barriers that had been repeatedly reported through grievances and resident council meetings. A cognitively intact resident with a Brief Interview for Mental Status (BIMS) score of 15 reported that language remained a significant barrier and that the resident council had been discussing this issue for months without resolution. This resident stated that staff would push their phones toward residents and attempt to use translator applications for communication, which the resident refused, believing they should be able to communicate with staff directly without a translator. The resident also reported hearing staff speak Spanish while caring for other residents who only spoke English. Review of grievance records showed multiple complaints over several months related to staff not speaking or understanding English and staff speaking Spanish in front of non‑Spanish‑speaking residents, particularly on one unit. One grievance described a CNA who could not answer a resident’s question because she could not speak English and did not understand what the resident was asking, with no resolution documented. Another grievance from a resident and family member reported difficulty communicating with a specific care staff member due to a language barrier and poor response time; the only documented action was that the employee was counseled, with no follow‑up recorded. Resident council grievances repeatedly documented that CNAs on a particular station did not speak or knew very little English, that residents felt uncomfortable with staff using phones to translate, and that staff spoke Spanish to each other during mealtimes in front of English‑speaking residents. These items were repeatedly marked as “Not Resolved – Action Needed,” and residents noted that prior nursing grievances had not been resolved and that they wanted action taken. Surveyor interviews further demonstrated ongoing communication problems and lack of effective staff training. An attempted interview with a CNA could not be completed because the CNA did not understand questions asked in English, evidencing a direct language barrier between staff and surveyors. A unit manager LPN stated that communication with staff on one unit was easier for her because she could use “Spanglish,” and acknowledged that CNAs on that unit had difficulty understanding clinical questions unless speech was slow and clear; she also confirmed that resident council repeatedly raised concerns about staff speaking Spanish in the hallways and that staff used translator applications on their phones to communicate with residents and English‑speaking staff. The Social Services Director acknowledged grievances related to language barriers and stated that staff had only been given verbal reminders not to speak other languages while caring for residents, which had not been effective. The Social Worker reported a potential issue with Spanish‑speaking staff and residents, stated that staff were not allowed to use translators to communicate with residents, and that being able to communicate and read English was a requirement for staff, but also stated that resolutions to grievances were not specifically documented. The Regional Director of Operations stated that the facility needed to go beyond verbal communication to resolve a repeating issue and that more should have been done to provide staff with resources and residents with communication in a language they understand, while facility policies required culturally competent care, effective communication in a language residents can understand, and sufficient guidance and training for staff on communication, which were not 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 deficiency involves the facility’s failure to timely report and investigate multiple allegations and indications of abuse and neglect in accordance with its own Abuse, Neglect and Exploitation policy and federal reporting timeframes. The policy required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but not later than 2 hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. The policy also defined an "alleged violation" as any situation or occurrence observed or reported that, if verified, could indicate noncompliance with federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. Despite this, the facility did not treat several events as reportable allegations and did not report them within the required timeframes. For one resident with multiple serious diagnoses including metabolic encephalopathy, major depressive disorder, metastatic cancer to the lung and brain, severe calorie malnutrition, cachexia, COPD, history of pneumonia, and acute respiratory failure with hypoxia, a written witness statement described security camera footage showing the resident entering the smoking patio in the afternoon and remaining there for the entire afternoon without any visits or care from staff or the assigned CNA. The statement indicated that at 5 p.m. the resident was found unresponsive by another staff member, brought indoors, and a code blue was called, and that the resident did not receive care from the assigned CNA for over 4.5 hours. This statement was signed and dated by an LPN. The incident did not appear on the facility’s abuse logs, and the NHA, DON, and an LPN supervisor each stated they did not investigate or report the event as an allegation of neglect or a reportable event, citing reasons such as viewing it as a "regular code," believing the resident’s terminal diagnoses and poor prognosis made the death unsurprising, and stating there was no supervision of the patio at that time. The LPN who wrote the statement later said the statement about the resident remaining unattended for 4.5 hours was false and that her focus was on the CNA’s performance, but also stated that administration was aware of the statement and did not report or investigate it. For another resident with hemiplegia and hemiparesis, a psychology progress note documented that the resident, who was alert and oriented, reported that a person identified by name came to his room at dusk, patted him on the head, pinched his cheek, and made a familiarizing comment, which the resident described as violating his space and demeaning. The NHA stated that the resident had alleged that a short-haired man slapped him and that he reported this to a nurse two days prior, and that the resident had a similar prior allegation. The NHA reported that the incident was assessed with no injuries and that she did not have a name to go by, and she did not identify the named individual from the psychology note as part of the investigation. She acknowledged that she reported the incident to DCF and AHCA the day after the event and that this did not meet the facility’s policy requirement to report within two hours. For a third resident with hemiplegia and hemiparesis, the abuse log showed an incident in which the resident reported that a female staff member entered her room during the night shift, refused to give her the call light, stated she was not the resident’s assigned CNA and that the resident did not have a CNA, and then left without changing the resident despite the resident’s stated need. The NHA stated that when she reviewed the chart, she saw documentation of the resident being changed only once at 8:17 p.m. and that the assigned CNA reported being with another resident and eventually returning, but there was no exact time. The NHA said the resident had glaucoma and could not clearly identify the staff member, and that the resident later told psych it was probably a misunderstanding and denied being abused. The NHA stated she treated this as a neglect incident, not abuse, because there was no physical injury, and reported the incident to AHCA more than 24 hours after she was notified, despite acknowledging that abuse allegations should be reported within two hours and that the policy defined abuse to include deprivation of goods or services. For a fourth resident with muscle wasting and atrophy, cognitive communication deficit, and unspecified dementia, the abuse log and psychology note documented that the resident reported three people (one male and two females) in her room, with the male asleep in her bed and one female hitting her, then feeding others before all left. The NHA stated that a family member alleged the resident was beaten up by staff and that she was notified when the incident happened. She reported that she notified DCF and AHCA more than two hours after the allegation, explaining that she was with the police and unable to report sooner. The NHA acknowledged that reporting of abuse incidents should occur within two hours. The Regional Director of Clinical Services confirmed that there were no reports filed or investigations conducted for the resident who died on the patio and stated that the NHA should have filed reports within the required timeframes and that another staff member could have submitted reports if the NHA was unavailable.

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 promptly and thoroughly investigate multiple allegations of abuse and neglect, and to treat certain events as reportable alleged violations in accordance with its own abuse, neglect, and exploitation policy. The policy required immediate investigation when suspicion or reports of abuse, neglect, or exploitation occurred, including identifying responsible staff, interviewing all involved persons, and providing complete documentation. Despite this, the facility did not initiate an investigation or log an allegation related to a resident who was observed on security camera footage remaining on the smoking patio for approximately 4.5 hours without care from his assigned CNA and who was later found unresponsive at 5 p.m., after which a code blue was called. The Nursing Home Administrator (NHA), Director of Nursing (DON), and an evening supervisor each stated they did not view this sudden death as an allegation of neglect or a reportable event, and no investigation or abuse log entry was made at the time. The DON acknowledged there was no hydration cart and no supervision of the patio, and the evening supervisor confirmed there was no clear view of the resident while he was outside and that the incident was not witnessed by staff. The deficiency also includes delayed and incomplete responses to other abuse and neglect allegations. One resident with hemiplegia and hemiparesis reported that a male staff member, identified in a psychology note as a person named by the resident, came to his room at dusk, patted his head, pinched his cheek, and asked, "how is my guy today," which the resident described as violating his space and demeaning. The NHA later described a similar allegation as involving a short-haired man who allegedly slapped the resident, but stated the resident could not provide a name and that prior similar incidents were not substantiated. The NHA acknowledged that the abuse allegation was not reported within the two-hour timeframe required by policy, instead being reported the next day to state agencies. Another resident with hemiplegia and hemiparesis reported that during the night shift a female staff member entered her room, refused to give her the call light, stated she was not the assigned CNA and that the resident did not have a CNA, and left without providing requested incontinence care. The NHA stated that chart review showed only one documented change at 8:17 p.m. and that the assigned CNA reported being with another resident and eventually returning, but there was no exact time established. The NHA said she treated this as neglect rather than abuse because there was no physical injury, despite the facility policy defining abuse to include deprivation of goods or services. The NHA also stated she believed she had 24 hours to report if there was no injury, and confirmed that abuse allegations should actually be reported within two hours. A further allegation involved a resident with diabetes mellitus who reported being abused by staff because a nurse would not leave medications at the bedside and the resident refused care from her CNA that night. The NHA stated she did not consider this to be abuse, even though the resident alleged abuse, and that she found it odd but did not question the CNA further after the CNA reported that nothing had happened on her shift. The resident later accepted care and medication from another nurse, and the NHA reported the matter as neglect, not abuse. The NHA also stated that the resident refused to be interviewed by her on two occasions and that she did not know what the resident meant by being abused and never found out. Across these incidents, the Regional Director of Clinical Services confirmed that no reports were filed or investigated for the resident who died after being on the patio, and that the NHA failed to file required reports within policy timeframes, despite the job description requiring the NHA to operate the facility in accordance with federal, state, and local regulations and to review resident complaints and grievances with appropriate written follow-up.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect a resident from neglect related to elopement. A cognitively impaired resident with dementia, severe disorientation, and a history of wandering exited the building from the fourth floor to the outside, unnoticed by staff. The resident was ambulatory, able to walk significant distances independently with a steady gait, and had documented wandering behaviors, including going into other residents’ rooms and requiring frequent redirection for safety. Despite these characteristics and prior identification as an elopement risk on risk evaluations, the resident did not have an active electronic monitoring device in place at the time of the incident. The resident’s records showed that she had previously been identified as an elopement risk and had an elopement-focused care plan that included use of an electronic monitoring device and monitoring of that device for function. Physician orders for checking the electronic monitoring device each shift had been in place earlier in the year but had ended months before the elopement. The care plan, however, still reflected interventions related to an electronic monitoring device. Staff interviews revealed that the resident typically wandered on the fourth floor, was easily redirected, and had not been seen off the unit before. Multiple clinical providers, including the primary care provider, ARNP, PMHNP, and therapy staff, described the resident as ambulatory, oriented only to person, unable to care for herself, and at risk for following others toward exits or elevators. On the day of the incident, staff on the unit saw the resident around change of shift and redirected her to her room, but they were unaware that she had left the floor and the building. An alarm sounded from a stairwell exit door on the lower level, but staff did not initially know why it was sounding or whether a resident had gone out. Another cognitively intact resident, who was outside on a leave of absence, observed the confused resident walking around the west side of the building in a hospital gown and blanket, approached her, and brought her to sit on a bench at the front of the building, where a staff member then saw them and assisted the resident back inside. Facility leadership and staff were unable to determine how the resident traveled from the fourth floor to the first floor or how she accessed a stairwell door that should have been locked with a keypad. The facility’s own abuse/neglect policy defined neglect to include failure to adequately supervise a resident known to wander from the facility without staff knowledge, and the surveyors determined that this failure resulted in a situation that created a likelihood for serious injury or death and constituted Immediate Jeopardy. Interviews with the NHA and DON indicated that the resident had initially been considered an elopement risk earlier in the year, then was viewed as not at risk after a hospital stay when she was non-ambulatory. They acknowledged that an Elopement Risk Assessment completed in May was incorrect because it was based on pre-hospital information, and that the resident was not listed in the elopement binders at the time of the incident. They also confirmed that although the resident’s mobility improved and she began walking well again and wandering, an electronic monitoring device was not reapplied because she was not perceived as exit seeking. Resident representatives reported that the resident had “bounced back” after her decline, was always wandering, tried to get to doors and elevators, and had been described by staff as trying to get out of the building. These documented conditions, combined with the absence of an active monitoring device and the lack of staff awareness of her departure from the unit and building, led to the neglect finding related to elopement.

Removal Plan

• Returned Resident #5 to the facility.
• Completed a skin assessment, pain assessment, and change of condition assessment for Resident #5 with no negative findings.
• Notified Resident #5’s attending physician and obtained new orders for labs; obtained urine culture results showing ESBL and implemented new medication orders.
• Completed psychiatric services via telehealth for Resident #5 with no new orders received.
• Placed Resident #5 on 1:1 supervision and completed an elopement assessment with an electronic monitoring device applied to her lower extremity; maintained 1:1 supervision until discharge.
• Checked electronic monitoring device function and placement for all current residents at risk for elopement with no negative findings.
• Verified all residents’ demographics were in each resident elopement binder at the nurse station, receptionist area, and therapy gym.
• Added Resident #5’s demographics and picture to the elopement binder.
• Completed door checks to ensure all doors worked properly with no negative findings.
• Completed a 100% head count to ensure all residents were in the facility with no negative findings.
• Re-assessed 100% of residents for elopement risk with no new residents identified.
• Completed an elopement drill; reviewed and documented results on the Elopement Drill QAPI worksheet with no negative findings.
• Gathered witness statements from residents and staff.
• Notified DCF and police of an allegation of neglect.
• Arranged for psychiatric services evaluation for Resident #5.
• Discharged Resident #5 to a memory care unit as planned with the IDT, family, and Medical Director.
• Placed a door guard to ensure no one was able to leave the facility until screamers were installed.
• Completed elopement drills every day, three times per day, randomly.
• Completed elopement drills once per week on random days.
• Completed monthly elopement drills on random shifts and days, with results reviewed with the QAPI team.
• Verified screamers were shipped from the manufacturing company.
• Installed cameras and new secure care boxes.
• Completed door checks to ensure doors were functioning properly.
• Met with the IDT and Clinical Consultant to discuss removal of the door guard and removed it.
• Assessed for a possible amber alarm system and installed the system.
• Set up security cameras in the facility with the main station located in the NHA office.
• Held IDT meetings (including the Medical Director) to review the ad hoc/QAPI plan; the Medical Director reviewed and recommended no changes.
• Provided education to 100% of staff (including contract employees) regarding abuse/neglect, missing persons policy, elopement policy (including care plans and Kardex for those at risk), and staff response to door alarms.
• Initiated elopement drills for 100% of staff (including contracted employees).

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one cognitively impaired resident who was known to be at risk for wandering. The resident had diagnoses including unspecified dementia, psychosis, depression, and anxiety, and was consistently described as alert only to self, confused at baseline, and unable to care for herself. Quarterly MDS data showed she could ambulate 150 feet with supervision or touching assistance, and therapy notes documented that she could ambulate 275 feet without an assistive device. Progress notes and staff interviews described ongoing wandering behavior throughout the unit, frequent need for redirection for safety, and episodes of verbal and physical aggression during care. The resident’s psychiatric and primary care providers, as well as her representatives, characterized her as ambulatory, severely cognitively impaired, and unable to care for herself outside the facility. Despite this history, the resident did not have an active electronic monitoring device at the time of the incident, even though prior physician orders and the active care plan documented use of such a device earlier in the year and identified her as an elopement risk. Elopement Risk Evaluations in February and May identified her as at risk, and her care plan included interventions related to elopement risk and monitoring of an electronic monitoring device. The DON later stated that the May Elopement Risk Assessment was incorrect because it was completed based on pre-hospitalization information, and the resident was not listed in the elopement binders as an elopement-risk resident on the date of the event. Facility leadership and nursing staff reported that when the resident returned from the hospital she was initially not an elopement risk due to being unable to get out of bed, and that when she later regained mobility and began walking well again, an electronic monitoring device was not reapplied because she was not considered exit seeking. On the day of the incident, the resident was observed by staff on the fourth floor earlier in the shift, wandering as usual, and was redirected to her room. Approximately 10–15 minutes later, staff became aware that a door alarm was sounding from a stairwell exit on the west side or backside of the building, but they did not initially know why the alarm was going off or whether a resident had gone out. During this time, another cognitively intact resident, who was outside on a leave of absence, saw the confused resident walking around the west side of the building near generators, wearing a hospital gown and blanket, and appearing headed somewhere. He approached her, noted her confusion, and directed her to sit on a bench in front of the building, where a staff member saw them and helped bring her back inside. Staff interviews and the facility’s own investigation confirmed that no staff member observed the resident leaving the fourth floor, using the elevator or stairs, or exiting the building, and that staff did not know she had left the unit until she was brought to the front entrance by the other resident. The facility determined that she had exited through a stairwell door that should have been locked and that the alarm associated with that door could only be heard in or just outside the stairwell, not at the front reception area. This sequence of events, combined with the lack of an active electronic monitoring device and failure to recognize and manage her ongoing elopement risk, led to the resident’s unsupervised exit from the building and the determination of Immediate Jeopardy. Resident representatives reported that the resident had "bounced back" and was up and moving weeks after her May hospitalization, and that she was always wandering, trying to escape, and attempting to get to doors and elevators. They stated that staff had told them multiple times that she tried to get out of the building and that she wandered in and out of other residents’ rooms, taking items. Clinical staff, including the OT, PMHNP, ARNP, and PCP, consistently described her as ambulatory, oriented only to person, confused, easily redirected, and not capable of caring for herself outside the facility, with some specifically stating they considered her an elopement risk. Nonetheless, she was not being monitored with an electronic device at the time of the event, and staff on the unit were unaware she had left the floor until after she had already been outside and was returned by another resident. These actions and inactions regarding risk assessment, care planning, and supervision directly contributed to the elopement event that formed the basis of the cited deficiency and Immediate Jeopardy determination.

Removal Plan

• Returned Resident #5 to the facility.
• Completed a skin assessment, pain assessment, and change of condition assessment for Resident #5 with no negative findings.
• Notified Resident #5’s attending physician and obtained new orders for labs; obtained urine culture results showing ESBL and implemented new medication orders.
• Completed psychiatric services via telehealth for Resident #5 with no new orders received.
• Placed Resident #5 on 1:1 supervision, completed an elopement assessment, and applied a wanderguard to her lower extremity; maintained 1:1 supervision until discharge.
• Completed wanderguard function and placement checks for all current residents at risk for elopement with no negative findings.
• Confirmed all residents’ demographics were included in each resident elopement binder at the nurse station, receptionist area, and therapy gym.
• Added Resident #5’s demographics and picture to the elopement binder.
• Completed door checks to ensure all doors worked properly with no negative findings.
• Completed a 100% head count to ensure all residents were in the facility with no negative findings.
• Re-assessed 100% of residents for elopement risk with no new residents identified.
• Completed an elopement drill and reviewed and documented results on the Elopement Drill QAPI Worksheet with no negative findings.
• Gathered witness statements from residents and staff.
• Notified DCF and police of an allegation of neglect.
• Ensured Resident #5 was evaluated by psychiatric services and confirmed no injuries or complaints related to the event.
• Discharged Resident #5 to a memory care unit as planned with the IDT, family, and Medical Director.
• Placed a door guard at the door to ensure no one was able to leave the facility until additional alarm measures were installed.
• Completed elopement drills multiple times per day on random schedules.
• Completed weekly elopement drills on random days.
• Completed monthly elopement drills on random shifts and days and reviewed results with the QAPI team.
• Verified shipment of screamers from the manufacturing company.
• Installed cameras and new secure care boxes.
• Completed door checks to ensure doors were functioning properly.
• Met with the IDT and Clinical Consultant to discuss removal of the door guard and reached agreement.
• Completed a security company assessment for a possible amber alarm system and installed the system.
• Set up security cameras in the facility with the main station located in the NHA office.
• Held IDT meetings to review the ad hoc/QAPI plan with no negative findings and obtained Medical Director review with no recommended changes.
• Provided education to 100% of staff (including contract employees) related to abuse and neglect, missing persons policy, elopement policy (including care plans and KARDEX for those at risk for wandering/elopement), and staff response to door alarms.
• Initiated elopement drills for 100% of staff (including contracted employees).

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 dinner meals in a timely manner and in accordance with its own meal service timeframes for the majority of dinners reviewed. Fourteen of seventeen dinner meal services in January 2026 were documented as being late, with tray carts leaving the kitchen anywhere from several minutes to over an hour and a half after the scheduled delivery times listed on the Dining Services Cart Delivery Log. The facility’s posted Meal Cart Delivery Schedule in the kitchen showed earlier dinner delivery times than those used in practice, but the Dietary Manager stated staff generally followed the later times on the Dining Services Cart Delivery Log. There was no specific policy and procedure related to honoring meal service times, although the Nursing Home Administrator acknowledged that residents have the right to receive their meals timely and per the meal service schedule. Multiple cognitively intact residents reported that their meals, particularly dinner, were routinely late. One resident who chose to eat breakfast and dinner in his room stated that for the past few months his dinner, expected around 5:00 p.m., was often delivered 30 minutes to two hours late, and that he had reported this to the DON and Nursing Home Administrator without resolution. Another resident, serving as Resident Council President, reported hearing repeated complaints at resident meetings that all three meals were late to rooms, sometimes by almost two hours, and confirmed that his own meals were routinely 45 minutes to two hours late despite his complaints to the Dietary Manager. Additional residents reported similar experiences, including one who said dinner was supposed to arrive around 5:00 p.m. but frequently came 30 to 45 minutes late and sometimes up to two hours late, and another who stated that since admission he often did not receive dinner until 7:00 p.m. or after 8:00 p.m., despite an expected delivery time around 5:00 p.m., and that he had complained to aides, nurses, the social worker, and the Dietary Manager many times. Interviews with dietary leadership and the Nursing Home Administrator revealed ongoing staffing problems in the kitchen that contributed to the late meal service. The Regional Dietary Manager, who stated he usually assists at the facility twice a week, reported that kitchen staff are contracted, that the facility has been unable to retain cooks and dietary aides, and that he has been filling in for various tasks including cooking, prepping, plating trays, delivering carts, cleaning, and paperwork. The Dietary Manager, who works six days a week and attempts to cover all three meal shifts, confirmed he employs a limited number of cooks and dietary aides, has had persistent staffing issues—especially with cooks—and that about half or more of the dinner meals in January 2026 were sent out late, sometimes over an hour to an hour and a half late. He acknowledged that meal delays had been occurring mainly during dinner since around November 2025, that he lacked documentation of supervisory audits of meal service, and that he was unsure whether residents had been informed about the kitchen’s inability to provide meals timely on a consistent basis. The Nursing Home Administrator confirmed awareness of the contracted kitchen’s staffing problems and ongoing efforts to hire staff, but there was no indication in the report that these issues had resolved the pattern of late meal delivery.

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 refund all monies due to a deceased resident’s representative within 30 days of the resident’s death, as required by regulation and the facility’s own refund policy. The resident had resided in the facility for approximately nine years and was Medicaid-eligible, with a gross monthly income of $1,159.22 and a personal needs allowance of $160.00 per month. Billing records showed that the resident’s husband paid a monthly patient responsibility of $314.92 from their joint checking account. Despite the resident’s death, this patient responsibility continued to be drawn from the joint account in the month following death, 13 days after the resident had passed away. Email correspondence showed that the Business Office Manager notified the corporate office accounting department of the resident’s death and requested removal of the resident from Automated Clearing House (ACH) payments. Additional emails documented that the facility was aware the husband was requesting a refund and that the family was due a larger refund than initially believed. At the time of the survey, over four months after the resident’s death, the Corporate Regional Director of Operations and the Administrator confirmed that the resident’s husband was still owed a refund totaling $1,905.35 and that no refund had been issued. The Administrator stated that the Business Office Manager did not have authority to issue refund checks and that they had been waiting for the corporate office to process the refund, contrary to the facility’s written policy requiring final accounting and conveyance of funds within 30 days of death.

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 notify a court-appointed legal guardian of a significant change involving missing dentures for a resident who had been determined totally incapacitated. The resident was admitted with dementia with behavioral disturbances, and a court determination dated 10/26/23 documented the resident’s total incapacity related to dementia and lack of awareness. On 8/8/24, a legal guardian of person and property was appointed, and the guardian’s name, phone number, and email address were documented in the admission record. The resident’s inventory list dated 7/29/24 showed that the resident had upper dentures, and a monthly summary progress note on 1/19/26 indicated the resident wore dentures or partials. On 1/27/25 at 12:24 PM, the resident was observed in the dining room for lunch without dentures in place. During a phone interview on 1/28/26 at 3:40 PM, the legal guardian reported being unaware that the dentures were missing and stated the facility had never notified her of this issue. On 1/29/26 at 10:05 AM, the Executive Director stated that staff believed the dentures had been missing for approximately three weeks and acknowledged that the guardian had not been notified because dentures often go missing for a few weeks before turning up again. Review of the facility’s “Notification of Changes” policy showed that when a resident is deemed incapacitated, the resident’s representative is to be notified so that they can make necessary decisions, which did not occur in this case.