Making CMS Citations Actionable for LTC Providers

Penalty

Fine: $59,580

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 keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.

Removal Plan

• Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
• Ensure Resident #89 has a wander bracelet in place
• Pursue or redirect Resident #89 back into the facility if he exits
• Assess Resident #89 for acute distress or injury after an elopement event
• Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
• Initiate an order for checks of Resident #89’s whereabouts
• Document completion of checks on the Medication Administration Record

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that residents with diabetes received treatment and care in accordance with professional standards of practice and physician orders related to capillary blood glucose (CBG) monitoring and response. Surveyors found that the facility did not have policies for management of diabetes, hypoglycemia, or hyperglycemia available when requested, despite the facility assessment indicating it provides care for residents diagnosed with diabetes. The existing “Episodic and Narrative Documentation” policy only indicated that a narrative entry would be made for physician notification, without specific guidance for hypo- or hyperglycemic events. Manufacturer instructions for the glucometer defined “Low” as less than 20 mg/dl and “High” as greater than 600 mg/dl, and prescribing information for long-acting insulin (Basaglar) described its onset and duration of action, underscoring the need for appropriate monitoring and timely response to abnormal blood glucose values. For multiple residents with diabetes and other comorbidities such as chronic kidney disease, congestive heart failure, coronary artery disease, COPD, dementia, and end-stage renal disease, surveyors identified numerous CBG values that met or exceeded ordered parameters for provider notification or represented clinically significant hypo- or hyperglycemia, without documentation of physician notification, reassessment, or follow-up. Examples included residents with sliding-scale insulin orders specifying to notify the provider if blood glucose was under 70 mg/dl or over 400 mg/dl, yet blood sugars in the 400–500+ mg/dl range and lows in the 50–60 mg/dl range had no corresponding notes, rechecks, or documented provider contact. In some cases, residents had repeated elevated readings over several days, including meter readings of “HI” (over 600 mg/dl), with no documentation of notification or follow-up. Several insulin and blood sugar monitoring orders also lacked any parameters for provider notification, even as residents experienced significantly abnormal CBG values. Specific residents cited included individuals admitted with diagnoses of diabetes and chronic kidney disease, CAD, CHF, dementia, COPD, CKD, ESRD, and heart failure. Their records showed repeated elevated CBG values such as 401–591 mg/dl and lows as low as 55–57 mg/dl without documented assessment for signs and symptoms of hypo- or hyperglycemia, without rechecks, and without documented physician notification as required by orders. In one instance, a resident left the facility for a leave of absence after a CBG of 495 mg/dl without reevaluation. Interviews with LPN staff revealed that they could verbally describe appropriate steps for managing blood sugars under 70 mg/dl or over 400 mg/dl, including rechecking, giving snacks or glucose, monitoring, and notifying the physician and supervisor, and documenting in the MAR and progress notes. However, the clinical records reviewed did not reflect that these actions and notifications were consistently carried out or documented for the abnormal CBG values identified, leading surveyors to determine that the facility failed to notify physicians of elevated or decreased CBG levels and failed to assess residents for hyperglycemia and hypoglycemia, resulting in immediate jeopardy for 12 of 21 residents reviewed.

Plan Of Correction

The physician was notified for Residents R2,R4,R16,R33,R37,R46,R47,R56,R70, R80, R97 and R116 that their Capillary Blood Glucose levels were either greater than 400 or less than 70. The facility NP saw these residents to assess any impact from a Capillary Blood Glucose result not reported to the physician. For residents with current orders for Capillary Blood Sugar testing, results greater than 400 or less than 70 will be recorded, documented, and the MD/designee will be notified to issue further treatment orders as needed. The DON/Designee began educating nursing staff, including contracted staff on the facility's new policy titled "Managing Hypo and Hyperglycemia." The DON/designee will educate new nursing staff to the facility before the start of their first shift. Licensed Nursing Staff will attend Directed In-Service with AAE Consulting Services Inc on May 5th, 2026 Titled F684 Quality of Care 483.25. Licensed staff who do not attend the training in person on this date will have to watch the training provided prior to the start of their next shift. The DON/Designee will review all current diabetic residents in the facility with orders for Capillary Blood Sugar testing results during the daily clinical Morning Meeting M-F to verify that residents' Capillary Blood Sugar results were recorded, documented, and the MD/designee was notified. Saturday and Sunday results will be reviewed by the Nursing Supervisor for the same compliance. The DON /Designee will complete audits for the compliance of the new policy Managing Hypo and Hyperglycemia for 10% of facility resident with orders for Blood Sugar testing for 4 weeks then monthly times 4 The facility NHA will query 5 random nurses 3 times a week for 4 weeks then weekly for 4 weeks and then monthly for 3 months to verify their knowledge of the protocols for Hypo/Hyperglycemic Management. Results of the audits will be reviewed during QAPI and frequency adjusted based on the results of the audits.

Removal Plan

• Report identified residents’ out-of-range finger stick blood sugar results to the Nurse Practitioner and have the NP evaluate the residents and update orders as indicated.
• Review and update Resident R16’s care plan to include a diabetes care plan.
• Conduct NP review/rounds on current residents who may be impacted by a diabetic emergency to verify appropriate orders are in place and update as indicated.
• Have the MDS nurse review current diabetic residents’ care plans to verify a diabetes care plan is in place and update as indicated.
• Create a facility policy titled “Managing Hypo and Hyperglycemia.”
• Provide education by DON/ADON to current nurses (including agency) on the hypo/hyperglycemia protocol; continue for staff not yet trained and all new hires; require completion prior to working a shift.
• Notify the Medical Director of the Immediate Jeopardy and that the NP is seeing all current diabetic residents.
• Hold an ad hoc QAPI meeting with the Medical Director to review and discuss the Immediate Jeopardy and the Immediate Plan of Correction.
• Implement daily review of all current diabetic residents’ FSBS results in weekday morning clinical meeting by DON/ADON and weekend review by nursing supervisor to verify FSBS is recorded/documented and MD/designee is notified; continue per the established audit schedule.
• Implement NHA competency checks by querying random nurses to verify knowledge of hypo/hyperglycemia management protocols per the established audit schedule.
• Review audit results in QAPI and adjust audit frequency based on results.
• Complete a root cause analysis identifying lack of a formalized hypo/hyperglycemia management policy as the cause.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to implement effective procedures to accurately identify residents prior to medication administration. Facility policy required that medications be administered by licensed nurses in accordance with professional standards and that residents be identified by photograph in the electronic health record before medication administration. The admission policy also required that a resident photograph be obtained and uploaded to the electronic health record to ensure accurate identification. Despite these policies, the facility did not consistently maintain resident photographs in the electronic health record and did not have a reliable alternative identification process, particularly for cognitively impaired residents and for staff unfamiliar with the residents. One critical event involved two cognitively impaired residents who shared a room. One resident, admitted with senile degeneration of the brain and a BIMS score of 5 indicating severe cognitive impairment, had physician orders for morphine sulfate concentrate 20 mg/ml, 0.5 ml by mouth once daily, and levothyroxine sodium 25 mcg daily in the morning. The roommate, admitted with dementia and a BIMS score of 3 indicating severe cognitive impairment, did not have these medication orders. An agency RN, on her second shift in the facility and unfamiliar with the residents, entered the shared room to administer medications, called out the name of the resident for whom the morphine and levothyroxine were ordered, and the roommate responded "huh." Without verifying identity using a photograph or another reliable method, the nurse administered the morphine sulfate 0.5 ml and levothyroxine 25 mcg intended for the first resident to the roommate. After administering the medications, the agency RN realized at the computer that the medications had been given to the wrong resident. She immediately obtained the roommate’s vital signs, which showed blood pressure 90/50 mm Hg, heart rate 38 beats per minute, respirations 12, and oxygen saturation 98%, and contacted 911, the physician, and the resident representative. Emergency department documentation later confirmed that the resident arrived with accidental opiate poisoning and profound bradycardia, with reported heart rates as low as 29 beats per minute and low blood pressures, and required two doses of naloxone to stabilize heart rate and blood pressure before being discharged back to the facility the same day. Beyond this event, the facility’s systemic failure to maintain an effective resident identification system contributed to the deficiency. Observations showed that during medication administration, some residents did not have photographs in the electronic health record, even though the system had a designated location for such photos. Staff interviews confirmed that nurses relied primarily on electronic photographs to identify residents, but several residents lacked these photographs. Staff also reported using familiarity with residents, asking residents to state their names when cognitively intact, or relying on room nameplates, and they were unable to describe a consistent method for identifying cognitively impaired residents. Clinical record review identified multiple residents without photographs uploaded until surveyor inquiry, and staffing records showed that agency nurses comprised a portion of licensed staff, increasing the likelihood that unfamiliar staff would depend on incomplete identification tools. The DON confirmed the medication error, the reliance on photographs for identification, and that the admissions position previously responsible for uploading photographs had been eliminated, with no documented competency validation or specific training on resident identification procedures for the agency RN involved.

Plan Of Correction

Facility completed resident identification pictures in the electronic medical records for residents 48, 53, 65, 6, 7, 12, 59, 34, 23 on 4/9/2026. All resident photos uploaded and audited on same date. 2. Audit of all residents completed on 4/9/2026 to ensure photos of all residents were present in their medical chart for identification purposes. 3. Facility procedures for Medication Administration, Resident Admission Procedure and Orientation checklist for LPN/RN were reviewed and updated to reflect the taking of photographs of new residents upon admission and place in the electronic medical record for resident identification, completed on 4/9/2026. Residents received wrist bands on 4/13/2026 with exception of 5 residents who refused to have a wrist band as a secondary method of identification. Agency RN marked as a "do not return" to facility and agency was updated to mediation error on 4/7/2026. Education completed with facility licensed nurses on 4/9/2026 and ongoing on policies and procedures, resident identification, secondary identifications with use of wrist band, and 5 rights of medication administration. 4. New admission audits will be completed by the NHA/designee to ensure photo identification is uploaded to the EMR. QA committee notified of the IJ and abatement plan of correction. New admission audits for picture identification will continue daily X 2 months with results of audits to QA committee for review and alternative actions as required. DON/designee will audit nurses administering medications to ensure the 5 rights of medication pass are followed and all residents have accurate resident identification prior to medications administration is identified in 3 resident med passes, 3 X week for 4 weeks. 5. April 25, 2026

Removal Plan

• Identify residents who do not have photographs in the electronic health record.
• Take resident photographs and upload them to the electronic health record; photograph any residents not available immediately upon their return and upload promptly.
• Audit all residents’ electronic health records to verify photographs are present for identification purposes and review the system process for resident identification.
• Order wristbands for all residents containing the resident’s name and date of birth as a secondary identification method.
• Update resident photographs in the electronic health record as necessary and review them annually during resident care planning meetings by the Social Services Director or designee.
• Ensure resident photographs are taken on the day of admission and uploaded to the electronic health record, and apply a medical wristband with resident name and date of birth per the admission procedure.
• Provide education for LPNs and RNs on the five rights of medication administration and use of electronic health record photographs for resident identification, and make education on obtaining and uploading photographs available.
• Provide the agency staffing company a copy of the education materials to be completed by agency staff prior to accepting shifts and update the agency orientation packet to include the revised admission procedure and updated medication administration policy.
• Audit new admissions to ensure photographs are uploaded appropriately into the electronic health record.
• Conduct daily audits of photograph identification for new admissions for two months, and report results to the Quality Assurance Committee for review and alternative actions as required.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.

Removal Plan

• Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
• Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
• Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
• Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
• Have IT/MIS check and confirm monitoring equipment is functioning properly.
• Implement disciplinary action for staff involved.
• Discuss and initiate a root cause analysis.
• Review and revise the pulse oximetry policy.
• Provide leadership oversight.
• Implement an audit of alert response times.

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 maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.

Removal Plan

• Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
• All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
• All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.