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 maintain a safe environment free from accident hazards by allowing emergency exit doors on two units to be secured shut with zip ties and rolled gauze, preventing egress. The facility's policy required that exit doors remain unlocked and unobstructed at all times to allow for rapid evacuation, and maintenance logs indicated that door operations were checked daily, with no mention of obstructions. However, on the day of the survey, observations revealed that the emergency exit doors on the short halls of two units were physically secured, blocking access to the outside. Multiple staff members, including nurses and aides, were unaware that the emergency exit doors were secured shut. Interviews revealed that the doors would frequently alarm due to high winds, which may have led to the use of zip ties and gauze to prevent the alarms from sounding. Despite this, there was no documentation or communication among staff or management regarding the application of these obstructions, and maintenance staff were also unaware of the situation. The Nursing Home Administrator and DON confirmed they were not aware that the emergency exit doors had been secured in this manner. The deficiency was identified during the survey, and it was determined that the facility's failure to ensure unobstructed emergency exits placed residents in immediate jeopardy of serious harm, as it would have prevented safe egress during an emergency.

Removal Plan

• Removed the zip ties and rolled gauze that secured the emergency exit doors shut
• Inspected all doors to ensure proper functioning
• Educated all staff on emergency doors and route of egress and the facility's policy that all emergency exit doors should be unobstructed
• Maintenance checks all exit doors for proper functioning

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 cognitive impairment, alcohol-induced dementia, and a court-appointed guardian was not provided with effective supervision, resulting in a serious incident. The resident, who had a history of confusion, agitation, and impaired judgment, was allowed unsupervised access to an enclosed courtyard where he was considered a safe smoker. On the day of the incident, the resident became upset after being told by staff that he would be moved to a secured unit. Subsequently, he stacked patio furniture, climbed onto an awning, and then accessed the facility's roof. Staff observed the resident running and sitting on the edge of the roof, prompting the fire department to be called for his safe removal. Prior to this event, the resident had not exhibited wandering or exit-seeking behaviors, but staff had noted increased agitation and unsafe behaviors, including attempts to take his non-smoking roommate outside to smoke. Despite these observations and discussions with the guardian about escalating behaviors and the potential need for a higher level of care, the resident remained in the unsecured unit. The resident's care plan had not been updated to reflect the increased risk, and he was not placed under enhanced supervision or restricted from unsupervised courtyard access until after the incident occurred. Additionally, the facility failed to complete a smoking assessment on admission and quarterly for another resident to determine if independent smoking was safe or if supervision was required. The lack of timely reassessment and supervision for residents with cognitive impairment and behavioral changes contributed to the occurrence of the incident and the identified deficiency.

Removal Plan

• Resident #120 was placed on enhanced supervision and restricted from unsupervised courtyard access after the incident.
• Resident #120 was reassessed and changed from a safe smoker to a supervised smoker.
• Resident #120 was relocated to a room closer to the nurses' station for increased observation.
• All residents with cognitive deficits and physical capabilities were assessed for wandering, change in behavior, increased agitation, and problematic behaviors.
• Wander guard transmitters were placed on all residents identified as having the ability to wander.
• The Interdisciplinary Team reviewed all residents to identify those with wandering or exit-seeking behavior.
• Staff members were assigned as wandering resident monitors on duty to monitor wandering residents and points of egress.
• All staff received in-service training on supervision of wandering residents, continuous observation, escalation of concerns, and environmental risk identification.
• Staff were instructed to relocate residents displaying exit-seeking or wandering behavior to the secure unit and notify the DON for evaluation.
• All employees were re-hired by new ownership and required to complete dementia and behavior management training to be eligible for rehire.
• All new hires receive training on dementia and care of wandering/behavioral residents during orientation and thereafter.
• Unsupervised courtyard access was restricted for residents with wandering or unsafe behaviors.
• Designated staff monitor the courtyard during resident use.
• Routine environmental rounds are conducted to identify elevated surfaces and climbing risks.
• Behavioral escalation triggers are incorporated into care planning.
• Nurse managers are to be notified immediately for new agitation, pacing, wandering, or exit-seeking behavior; a wandering assessment is completed, wander guard placed, provider and responsible party notified, and care plan updated.
• Residents with new wandering or exit-seeking behaviors are discussed in clinical meetings.
• The DON is responsible for ensuring wandering assessments, notifications, wander guard initiation, and care plan updates are completed.
• A list of exit-seeking/wandering residents is updated and reviewed by the DON and Social Worker.
• Resident wandering assessments and nursing documentation are audited by the DON/ADON to identify residents with increased agitation, exit-seeking, or wandering behavior.
• Audits ensure residents with these behaviors have wander guards and appropriate care plan interventions.
• Audit results are discussed at the clinical At-Risk IDT Meeting and presented to the QAPI Committee for review and revision as needed.
• All residents are assessed for wandering and exit-seeking and with any significant change in condition.
• Education on facility processes for residents with increased agitation, pacing, exit-seeking, or wandering behavior is provided to all staff and reviewed.

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 staff failed to provide proper and effective Basic Life Support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code when found unresponsive, pulseless, and not breathing. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately call a code blue or initiate CPR upon discovering the resident's condition. Instead, staff delayed action while attempting to verify the resident's code status, and there was confusion and lack of clarity among staff regarding the resident's code status and the location of this information in the medical record. Chest compressions were not started until approximately 12 minutes after the resident was found unresponsive. When CPR was eventually initiated, it was performed on the resident's bed without first placing the resident on a firm, flat surface or using a backboard, which was available in the facility. Staff did not consistently perform continuous and uninterrupted CPR, and there were inconsistencies in the rate and quality of chest compressions. Additionally, staff failed to use the Ambu-bag for rescue breathing, instead placing a non-rebreather mask on the resident, which is not appropriate during CPR. EMS personnel arriving at the scene observed these deficiencies and had to move the resident to the floor to continue CPR. Interviews and record reviews revealed that some staff members lacked current BLS/CPR certification, and there were discrepancies in staff knowledge regarding proper CPR procedures, including compression rates and the use of equipment. Documentation and staff statements indicated that the emergency cart was not properly checked or restocked, resulting in missing essential equipment such as the Ambu-bag. These failures resulted in the resident not receiving timely and effective life-saving measures as required by their full code status.

Removal Plan

• Quality Assurance Nurse (QA) and the RN on duty review the current residents' care profile in the facility's electronic health record (EHR) system, Code Status.
• QA and the RN verify the residents' Code Status via POLST forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status.
• A copy of the list of Full Code residents is made readily available to staff at the nurse's station for reference and is updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed.
• DON/Designee provides in-service education to nursing staff regarding the availability of the list of residents who are Full Code.
• DON checks the Emergency Cart (EC) and ensures that CPR backboard is available.
• RN and/or Designated Licensed Nurse conduct inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This is validated by the DON and/or Designee.
• RN and/or Designated Licensed Nurse conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard.
• DON initiates in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly.
• DON initiates in-service to RNs, LVNs, and CNAs regarding providing rescue breathing, not placement of a non-rebreather mask.
• DON provides continued in-services for all of the facility's RNs, LVNs, and CNAs.
• DON initiates in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly.
• Director of Staff Development (DSD) reviews employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date.
• Identified CNA attends the CPR certification training and is put on temporary suspension until CPR certification is received as part of Direct Care Staff competency.
• Identified LVN that does not have a current CPR/BLS certification is placed on suspension and is not permitted to return to work without an active certification for CPR/BLS.
• Clinical Nurse Consultant provides 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards.
• DON/Designee provides in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
• DON/Designee provides in-service to LVN 2 upon returning to work. LVN 2 is not on the schedule until education/reeducation is provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation.
• DON/Designee provides in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
• A Certified CPR instructor provides mandatory re-education and training for all Licensed Nurses and CNAs which is also attended by the DON and DSD with return demonstration conducted.
• A series of ongoing CPR Certification Training sessions is provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training.
• A Code Blue drill is initiated and continues weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR.
• An RN is designated as the team leader for Code Blue emergencies.
• Additional CPR training is provided by a Certified CPR Instructor to provide mandatory re-education and training for all Licensed Nurses and CNAs with return demonstration.
• Any Licensed Nurses or CNAs are not permitted to work directly with patients if they do not complete the Certified CPR refresher course.
• Director of Staff Development (DSD)/Designee maintains a log for all Direct Care Staff of their active Certification for BLS/CPR.
• DSD/Designee notifies staff with BLS/CPR certification expiring within a month.
• DSD/Designee presents to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification.
• No Direct Care Staff are permitted to work directly with patients without an active BLS/CPR certification.
• QAA Committee reviews audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions.

Penalty

Fine: $14,020

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 the facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for a resident with Alzheimer's disease and moderately impaired cognition. The resident, who had a history of forgetfulness and required assistance with activities of daily living, was able to leave the facility multiple times without staff awareness or proper sign-out procedures. On several occasions, the resident left the premises in a personal vehicle, including one incident where he traveled to another city and another where he was found lost and returned by police. Despite these incidents, the resident's care plan did not initially include interventions addressing his access to a vehicle or his ability to drive. The facility's records showed that the resident's cognitive impairment and diagnosis of Alzheimer's were known, and staff were aware that he required supervision and cues for safety. However, after the resident left the facility and drove significant distances without staff knowledge, there were no immediate updates to his care plan to address the risk associated with his access to a vehicle. Interviews with staff and family confirmed that the resident was able to leave the facility unsupervised, and staff were not consistently verifying sign-out and return procedures. The resident's responsible party and staff expressed concerns about his ability to drive safely due to his cognitive deficits. The facility's policy required assessment and care planning for residents at risk of elopement or unsafe wandering, but these measures were not effectively implemented for this resident. Staff interviews revealed gaps in communication and understanding of protocols related to resident supervision and sign-out procedures. The lack of timely interventions and supervision allowed the resident to repeatedly leave the facility and operate a vehicle, despite clear risks associated with his medical condition and cognitive status.

Penalty

No penalty information released

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

Summary

The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria. The deficiency was identified after a resident, who was bedbound, ventilator-dependent, and had not left the facility for over two weeks, became unresponsive and was hospitalized with septic shock and pneumonia. The resident subsequently tested positive for legionella pneumophila antigen and died in the hospital. Review of the facility's water management documentation revealed significant gaps, including the absence of updated control measures for areas affected by flooding and closure, lack of detailed plumbing schematics, and insufficient documentation of water system maintenance, flushing, and monitoring. There was no evidence that the water management plan had been revised to address changes in the physical plant, such as the closure of the Somerset unit after flooding, nor was there a written description of how water was supplied, heated, stored, or circulated throughout the building. Observations and interviews further revealed that water stagnation and potential sources of contamination were not adequately addressed. For example, the Somerset unit, which had been closed after flooding, still had water running to certain areas, and there were no logs or documentation to confirm that water lines were being flushed to prevent stagnation. In addition, the attic area above the affected resident's room showed signs of mold, water damage, a decomposed animal carcass, and leaking pipes, all of which were verified by maintenance staff. These environmental conditions, combined with the lack of clear signage and communication to staff regarding water restrictions and infection control measures, contributed to the risk of legionella exposure. The facility's infection control practices were also found lacking in other areas. For instance, a respiratory therapist was observed providing suctioning and tracheostomy care to a resident in contact isolation for Clostridium difficile infection without wearing appropriate personal protective equipment. This failure to adhere to standard infection control protocols had the potential to affect multiple residents on the same unit. Overall, the facility's inaction and insufficient oversight in both water management and general infection control practices led to the identified deficiencies.

Removal Plan

• Registered Nurse (RN) #431 notified the Medical Director, Administrator, Director of Nursing (DON) and Infection Control Physician of the Legionella case.
• Administrator, DON, Assistant Director of Nursing (ADON) and Human Resources instructed staff to avoid unflushed/restricted water and to use alternative (bottled or approved) water and ice.
• Administrator, Maintenance Director #368 and Dietary Director #317 implemented bottled water for all drinking and cooking.
• Use of ice machines, showers, whirlpool tub, hoppers were restricted on the Aspen unit and on the Birch, Dogwood, Crabapple units only bed baths with provided wipes were permitted as use of showers was restricted.
• Administrator, DON, ADON and Human Resources provided staff education to RNs, Licensed Practical Nurses (LPN), certified nursing assistants (CNA), Housekeepers, Activity staff, Respiratory Therapists (RT), and agency staff. The education included the Centers for Disease Control Legionella signs and symptoms, transmission, surveillance/detection, and the facility's water management program. For any staff not on the schedule due to leave or other reasons, education would be provided prior to start of next shift.
• DON and Registered Nurse (RN) #350 assessed all current residents for signs/symptoms of legionella infection (cough with phlegm, chest pain, fever, chills, and shortness of breath).
• Water was delivered to the facility by commercial provider.
• Bags of ice were delivered by commercial provider.
• Use of ice machine, sinks, showers, whirlpool tub, and hoppers were restricted on the remaining units of Birch, Crabapple, Dogwood and Somerset.
• A phone call was held with the local health department and Ohio Department of Health Bureau of Environmental and Radiation Protection for guidance on legionella mitigation and testing.
• Portable handwashing sinks were delivered and stationed on Aspen unit.
• Signage was posted by VPCS #806, RDCS #803, the DON, ADON and Respiratory Therapy Director instructing staff to avoid unflushed/restricted water and to use alternative (bottled/approved) water.
• ServPro performed professional attic cleaning on the Aspen unit including debris removal, HEPA vacuuming, antimicrobial treatment, stain/odor blocking sealant application, air/surface testing, removal of wet insulation, ceiling repair below the attic and vent pipe repair within the Aspen unit Hallway/Attic area between rooms 503, 508, 502, 509, 510 and 501.
• A phone call meeting was held with a legionella consultant to review the facility water management plan.
• Portable handwashing stations were delivered and stationed throughout the facility.
• Maintenance Supervisor (MS) #368 installed legionella prevention filters on the Aspen unit (in the shower room, medication room and rooms 501, 502, 503, 504, 505, 506, 507, 509, 510, 515, 516, 517, 518 and 519).
• Regional Director of Operation completed Somerset unit water flush which included full flushing of all pipes, bathrooms, sinks, hoppers and dialysis den. Documentation was submitted to the Administrator.
• An Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the Medical Director, VPCS, RDO, RDCS, Administrator, DON, MDS, Housekeeping, MS #368, Human Resources, RN #431 and the ADON for QAPI tracking including weekly flushing compliance, audit outcomes, symptom surveillance, environmental concerns, legionella water management program review and risk assessment analysis review.
• MS #368 installed additional legionella prevention filters to two hand sinks in dialysis, one hand sink in the therapy gym, one hand sink in the first floor public rest room, one hand sink in laundry and six sinks in the kitchen, one sink in the Birch, Dogwood, Crabapple medication rooms, one sink in the first floor dining room, one sink in the Dogwood shower room and the Crabapple room sinks in rooms 710, 716 and 718.
• RDO re-educated MS #368 on weekly flushing, documentation rules, proper procedures (15 minutes run time, full toilet flush/hopper flush) and reporting/escalation steps.
• RDO contacted an additional Legionella Consultant #901 for mitigation support.
• Legionella Consultant #901 performed water testing of samples collected across Aspen, Birch, Crabapple, Dogwood and Somerset units.
• The facility implemented a plan for clinical monitoring by the DON/ADON or designee to review resident documentation weekly for four weeks for symptoms such as temperature, pulse, respirations, blood pressure, oxygen level, lung sounds, cough and phlegm, chest pain, fever/chills, shortness of breath.
• The facility implemented a plan for environmental monitoring by the Administrator or designee to review flushing logs weekly for four weeks and monthly thereafter.
• The facility implemented a plan for enhanced surveillance by the DON/ADON to include enhanced respiratory illness monitoring and immediate reporting of suspected cases.
• The facility implemented a plan for the water management program to be on-going and include daily monitoring of temperature, disinfectant levels, flushing logs, legionella filters for placement and function twice a day and monthly Water Management Plan meetings until investigation closed.