Making CMS Citations Actionable for LTC Providers

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 ongoing training, competency, and supervision of staff in the safe use of manual and mechanical lifts, resulting in an avoidable accident involving a resident with obesity, a history of multiple strokes, and significant functional limitations. The resident, who was care planned for manual or mechanical lift transfers, sustained a left heel bone fracture after her foot became trapped between the lift and the wheelchair during a transfer. The resident reported that staff did not place her feet correctly on the lift, and despite her attempts to alert them, her foot was not repositioned, leading to the injury. Documentation revealed that the staff member involved had not received recent or adequate training or competency evaluation for lift use, and the facility could not provide evidence of such training for other staff members assigned to similar duties. Observations and interviews indicated that staff continued to use the manual lift for the resident after the incident, and that other residents were also transferred using improper techniques, such as not ensuring feet were fully supported on the lift's footrest. Staff interviews revealed a lack of recent training, with some staff unable to demonstrate or explain proper lift use. Personnel files for multiple CNAs lacked documentation of training, in-service, or competency evaluations related to lift use. Additionally, a worn and damaged sling was observed in use during a transfer, contrary to manufacturer instructions and facility policy, which require slings to be discarded if damaged. The facility's investigation into the incident was incomplete, with missing or insufficient documentation and a lack of comprehensive staff interviews. The Director of Nursing and Administrator were unaware of the incident until days later, and the incident was not properly reported or investigated according to facility policy. Manufacturer instructions for the lift and sling emphasized the need for trained caregivers and proper equipment inspection, which were not followed. These failures created an imminent danger and substantial probability of serious harm for all residents requiring lift transfers.

Plan Of Correction

On 06/20/2025, Resident #48 was assessed by the DON/Designee; no additional issues were identified. On 6/19/2025, the Administrator reported the incident to AHCA, DCF, and law enforcement as required, with a thorough investigation initiated. On 6/30/2025, the Administrator reported the incident involving the lift to the FDA in accordance with the Safe Medical Device Act of 1990. Resident #33's lift pad was immediately taken out of service and replaced upon discovery on 6/21/2025. All current residents requiring the use of mechanical lifts have the potential to be affected. The DON/Designee audited all residents in the facility; 45 residents were identified that require the use of facility lifts. All 45 residents were assessed on 06/20/2025, with no injuries noted. The DON/Designee assessed all mechanical lift slings on 06/21/2025, to ensure all lift slings were in proper working condition, with any findings addressed as identified. The DON/ADON have reviewed, revised, and implemented new competency evaluation forms for all facility lifts to provide more specific instructions on 06/19/2025. The DON/Designee will educate Licensed Nursing Staff, Certified Nursing Assistants, Physical and Occupational Therapists regarding the proper use of all facility lifts by 07/25/2025. All new employees will receive the training as part of their new hire orientation. The DON/Designee will audit ten residents requiring mechanical lifts weekly for four weeks, then five residents requiring mechanical lifts weekly for eight weeks, to ensure the safe use of facility lifts and prevent avoidable accidents. The Administrator/Designee will submit the audit findings to the QAPI Committee monthly for review and further recommendations. Date of completion is 07/25/2025.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with a diagnosis of nontraumatic intracerebral hemorrhage in the brain stem, severe cognitive impairment, and at risk for elopement was not adequately supervised, resulting in the resident leaving the facility unsupervised. The resident had previously been assessed as low risk for elopement, but on the day of the incident, was observed by a CNA packing belongings and expressing a desire to leave. Despite this, the resident was not immediately reassessed for elopement risk, and no detailed monitoring plan or interventions were implemented in accordance with the facility's elopement policy. Staff, including the DON and Social Services Assistant, were made aware of the resident's intent to leave and were instructed to monitor the resident and ensure the facility doors were supervised. However, the doors were not continuously monitored, as the receptionist responsible for this task was not present and no other staff were specifically assigned to this duty. As a result, the resident was able to exit the facility undetected, travel to a previous residence, and remain away from the facility for over six hours before being returned by an unidentified individual. Interviews and record reviews confirmed that staff failed to follow the facility's policy and procedure for elopement prevention, including reassessment of risk and implementation of appropriate interventions when a resident demonstrates behaviors such as packing belongings and verbalizing a desire to leave. The lack of immediate supervision and failure to monitor facility exits directly led to the resident's elopement.

Removal Plan

• Resident agreed to be transferred to the acute care hospital for further evaluation. The attending physician issued the order for transfer.
• Resident will remain on 1 to 1 (1:1) supervision for safety until transportation arrives for pickup. An order was obtained by the physician, and a log was used by the staff to document.
• The facility will implement 24-hour monitoring of the doors to strive and prevent harm to all our patients.
• Resident refused to be transferred to the General Acute Care Hospital (GACH) when transport arrived.
• Received orders from physician to apply a wander guard to Resident.
• Obtained informed consent from Resident's Responsible Party (RP).
• Resident continued to refuse the wander guard despite several attempts and education on safety. Physician and Resident's RP made aware.
• Resident will remain on 1:1 monitoring with a log for staff to document to ensure safety and continuous 24-hour monitoring of doors to prevent another incident reoccurring.
• Resident's elopement assessment was updated to reflect Resident being at high risk for elopement.
• Situation, Background, Assessment Recommendation (SBAR) documentation initiated for Resident and 72-hour SBAR documentation initiated.
• Resident's care plan was updated with interventions implemented to prevent a repeat event.
• Resident spoke with a psychiatrist via resident's telephone for evaluation for psychological support and emotional distress. The psychiatrist ordered a follow-up with social services for discharge. Resident was placed on psychological monitoring.
• Resident will be seen by a psychologist for evaluation for psychosocial distress related to the recent event of elopement.
• All residents have had an elopement risk evaluation assessment. All residents will be assessed upon admission, quarterly and in the event of a significant change with care plans updated.
• Residents who are at high risk for elopement will be added to the quarterly Quality Assurance and Performance Improvement (QAPI) committee to identify other residents who have the potential to be affected.
• Care plans will be updated for all residents who are at low, moderate or high risk for elopement and will include strategies and interventions to maintain the residents' safety.
• The facility has identified only one resident at high risk for elopement which is Resident.
• The facility will put a system in place for residents who are identified as low to moderate elopement risk for frequent visual monitoring.
• The facility has put into place 24-hour door monitoring to ensure the deficient practice does not reoccur.
• The Director of Nursing (DON) and Director of Staff Development (DSD) in-serviced staff members concerning the facility's policy to preserve and maintain resident safety by instituting measures to monitor and prevent resident from opportunities of wandering and eloping away from facility. DSD will in-service all licensed staff and before working assigned shift, staff will be in-serviced. As new hires come in, they will be educated and in-serviced on the elopement policy as well.
• The facility will place an elopement binder at each nursing station identifying which residents are at low, moderate, and high risk for elopement. Included in the binder will be policy and procedures related to elopement, face sheets with clear picture identifiers of residents at risk and protocols for the event of an elopement.
• The facility will implement a system that when an employee observes a resident leaving the premises he/she should attempt to prevent the resident from leaving in a courteous manner, get help from staff immediately in the vicinity, instruct the charge nurse and or DON that the resident is attempting to leave or has left the premises.
• The facility will implement a system that when a resident is missing, the facility will initiate the elopement/missing resident emergency procedure, initiate a search of the building and premises and notify the Administrator (ADM), the DON, the resident's responsible party, physician, law enforcement, ombudsman, and CDPH.
• The facility will implement a system for when the resident who eloped is found, the DON and or charge nurse will examine the resident for injuries, contact the physician, report findings and conditions of the resident, notify the resident's responsible party, notify local law enforcement that the resident has been located, and initiate 72-hour SBAR documentation.

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 and comfortable air temperature range for residents when the central air conditioning units in multiple halls broke down. Specifically, the central air conditioning unit for the 500 hall failed on 4/28/25, and although window air conditioning units were installed in residents' rooms, the facility did not monitor the room temperatures to ensure they remained within a safe and comfortable range. Subsequently, on 5/19/25, the central air conditioning unit for the 400 hall also broke, and the facility did not implement immediate or appropriate actions to maintain safe temperatures in residents' rooms and common areas. On 5/20/25, temperatures in various resident rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended range and creating a likelihood of serious harm or death from prolonged heat exposure. Temperature monitoring logs from January through May 2025 showed that temperatures were only documented twice a month in common areas and hallways, not in individual resident rooms. The logs indicated temperature ranges up to 80°F, but did not capture the elevated temperatures that occurred in resident rooms during the air conditioning failures. Resident interviews revealed ongoing discomfort due to excessive heat, with multiple residents reporting difficulty sleeping, sweating, and feeling unwell over several days. Resident Council minutes from January through April 2025 documented repeated concerns about temperature regulation, with residents consistently reporting that temperatures were either too hot or too cold and that the issue was not being resolved. Staff interviews confirmed that the facility attempted to repair the air conditioning units and installed window units as a temporary measure, but did not implement a comprehensive safety plan or monitor room temperatures until after the elevated temperatures were identified by surveyors. The DON acknowledged that interventions to address the heat were not implemented until 5/20/25 at 3:30 p.m., after the high temperatures had already been present. The failure to monitor and control room temperatures, despite ongoing resident complaints and known equipment failures, resulted in the determination of Immediate Jeopardy due to the risk of heat-related complications for residents.

Removal Plan

• Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
• Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
• Temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
• Maintenance staff were educated on maintaining the facility temperatures between 71 degrees and 81 degrees.
• Air conditioners will be maintained in working condition.
• If an air conditioner unit fails, maintenance staff along with administration will activate the emergency plan to maintain facility temperatures between 71 and 81 degrees.
• Clinical staff education on abuse/neglect related to assessment and care of residents when the temperatures are above 81 degrees, verified by posttest results and interview.

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 protect residents from neglect by not taking immediate and appropriate actions to maintain safe and comfortable temperature levels when multiple central air conditioning units broke down in several halls and common areas. Despite the breakdown of the central air conditioning units in the 400, 500, and 700 halls, the facility did not implement its Emergency Preparedness Plan in a timely manner to ensure residents' comfort and minimize the risk of hyperthermia. Window air conditioning units were installed in some resident rooms, but there was no consistent monitoring of room temperatures to ensure they remained within a safe range. Residents repeatedly reported discomfort due to excessive heat, with room temperatures documented between 81.3°F and 84.3°F. Multiple residents complained of being excessively hot and uncomfortable for several days, with some describing difficulty sleeping and feeling as if they were overheating. Resident Council meeting minutes over several months also documented ongoing concerns about temperature regulation, indicating that the issue was persistent and not adequately addressed by facility leadership. Temperature monitoring logs provided by the facility only included common areas and did not document temperatures in individual resident rooms. The logs showed that temperatures were only checked twice a month, rather than more frequently, and did not reflect the elevated temperatures experienced by residents. The facility's own policies defined neglect as the failure to provide necessary goods and services to avoid physical harm or distress, yet there was no evidence that the facility consistently monitored or responded to unsafe room temperatures until after the deficiency was identified by surveyors.

Removal Plan

• Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
• Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
• Took temperatures throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
• Will continue to maintain hourly temperature logs until all air conditioner units are repaired.
• Provided facility-wide staff abuse/neglect education, verified through staff interview and record review of post-test results.
• Ensured no staff will be permitted to work until they are reeducated on Abuse and Neglect policies.
• Education included a written competency test to include who and when to notify when a resident room is at or above 81 degrees.
• Education included information on where the cool zones are located, and that failure to report is considered neglect.

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 its resources effectively and efficiently to maintain a safe and comfortable temperature for residents when multiple central air conditioning units broke down in several halls and common areas. Despite being aware of ongoing issues with the air conditioning units, as documented in resident council meeting minutes from January through April, administration did not implement immediate and effective measures to address the excessive heat. Residents repeatedly raised concerns about uncomfortable temperatures, and the administration acknowledged the problems but only noted that the concerns were being addressed, without evidence of timely or sufficient action. On multiple occasions, temperatures in residents' rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended comfort range. Several residents reported ongoing discomfort, difficulty sleeping, and feeling overheated for weeks, with some stating that the issue had persisted for months. The facility's temperature monitoring logs did not include resident rooms and were only conducted twice a month in common areas, failing to capture the actual conditions experienced by residents. The Director of Nursing confirmed that interventions to mitigate heat exposure, such as providing ice, water, and monitoring vital signs, were not implemented until after temperatures had already reached excessive levels. Interviews with residents and staff further revealed that the excessive heat was a persistent problem, with residents expressing that their complaints were not adequately addressed. The administration's approach relied on hallway temperature checks to trigger room checks, which proved insufficient. The lack of timely and comprehensive action to ensure a safe and comfortable environment for all residents created a likelihood of serious harm or death due to prolonged exposure to excessive heat, resulting in the determination of Immediate Jeopardy.

Removal Plan

• Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
• Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
• Took temperatures throughout the facility at multiple times and verified they were within the range of 71 to 81 degrees.
• Facility will continue to maintain hourly temperature logs until all air conditioner units are repaired.
• Completed education with the Administrator and Director of Nursing (DON) by the President of Clinical Operations regarding their responsibility to implement the facility excessive heat emergency plan related to broken air conditioning units.
• Education included the monitoring process and notification procedure to the Chief Executive Officer/Chief Nursing Officer and to ensure residents are provided with a clean, comfortable environment.
• Chief Nursing Officer educated the Administrator and DON on their job descriptions, emphasizing responsibility to ensure proper temperatures and a safe, comfortable environment.
• Reviewed the agenda and staff sign-in page for the Quality Assurance and Performance Improvement (QAPI) meeting, which included a review of the affected regulations and implementation of the facility's Excessive Heat Emergency Plan.