North Lake Care Center And Rehab

Penalty

Inspection fine: $15,445

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

Summary

The facility failed to provide appropriate supervision to a resident assessed as at risk for elopement, resulting in the resident exiting the facility through an unsecured door on the second floor. The resident, who had severe cognitive impairment with a BIMS score of 00, was able to leave the facility on a Saturday evening when there were no staff present in the area. The resident was found approximately 0.3 miles away in an industrial area, having crossed a busy road and active railroad tracks. The resident's care plan, initiated a few days before the incident, identified the resident as having a potential for elopement due to cognitive impairment and wandering behavior. Despite this, the facility's elopement risk evaluation and care plan interventions were not effectively implemented. The resident was able to navigate through the facility and exit through a door that was not secured with a magnetic lock, as it was not considered a resident area. The alarm on the door was not audible to staff, and there were no staff present to respond to the alarm. Interviews with facility staff revealed that the resident had been seen in the upstairs area the previous evening and redirected, but this information was not communicated effectively. The facility's investigation determined that the second floor was not identified as a risk area, and the door was not secured in a manner consistent with other doors in the facility. The lack of supervision and inadequate security measures contributed to the resident's ability to elope from the facility.

Removal Plan

• An Ad hoc QAPI with Root Cause Analysis was performed with the IDT team, including: the Administrator, the Regional Director of Operations, the Regional Clinical Director, the Regional Maintenance Director. QAPI meetings were scheduled for the last Thursday of each month.
• All current residents' Elopement Assessment were reviewed and updated by nursing. There were no newly identified residents at high risk of elopement.
• Staff education was initiated to include Abuse and Neglect policy and procedure, Elopement policy and procedure, and new processes of closing the dining room door when the room is not in use.
• Elopement drills were conducted daily up to every shift daily to continue on for 14 days, then weekly for 4 weeks, then monthly thereafter.
• The Senior Safety and Technology company installed Maglock (mag) on the second-floor exit door next to HR department office and the door between the unit and the Activities/Dining room for added security.
• Education on the Identifying residents with behavioral symptoms that put the residents at risk for elopement was initiated.
• Daily audits of the doors and alarms were initiated and the results reported to QAPI/QA Committee of the findings.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate housekeeping and maintenance services, resulting in a failure to maintain a clean, comfortable, sanitary, and homelike environment in 9 of 30 rooms and the Community Shower Room. Specific deficiencies observed included clogged sinks and toilets, unsecured faucets, missing drain plugs, dirty basins and faucets, worn and exposed particle board on overbed tables, lack of overbed tables, duct tape covering screens on air conditioning units, loose toilet seat rails, and accumulation of debris under beds. Additionally, the Community Shower Room had an odor similar to sewage emanating from the shower and sinks. These observations were made during an environmental tour conducted with the Director of Maintenance, who acknowledged understanding of the findings. The deficiencies indicate a lack of proper maintenance and housekeeping services, compromising the residents' right to a safe, clean, comfortable, and homelike environment. The issues identified could potentially impact the residents' daily living and overall well-being.

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 follow its own policies and procedures for Enhanced Barrier Precautions (EBP) for 17 of 18 residents, as evidenced by the absence of gowns at or outside the residents' doors. The Director of Nursing (DON) confirmed that the facility follows CDC guidelines, which require PPE (gowns and gloves) to be located at the residents' doors. However, observations revealed that multiple rooms with EBP signs did not have the required gowns available, and the existing PPE was inadequately distributed across divisions, with some divisions lacking the necessary PPE entirely. This failure was observed despite the DON's assertion that PPE was available on blue linen carts and in central supply rooms, indicating a significant lapse in adherence to infection control protocols. Additionally, the facility's laundry rooms were found to be inadequately maintained, posing a risk of cross-contamination. The dirty laundry room had peeling paint with loose edges, which could contaminate the laundry. Sorting bins in the dirty laundry area had accumulated dirt and refuse beneath their false bottoms, and similar issues were found in bins used for clean laundry. The clean laundry folding area also had debris under the false bottoms of bins, and workers were observed mishandling potentially contaminated items. Furthermore, the industrial dryers had foreign matter adhering to the drum surfaces, and the floors in both the dirty and clean laundry areas had large areas of peeling paint, further risking contamination of clean laundry. These deficiencies highlight significant lapses in the facility's infection prevention and control program, particularly in the areas of PPE availability and laundry room maintenance. The observations and interviews conducted during the survey indicate a failure to adhere to established policies and CDC guidelines, thereby compromising the facility's ability to prevent the spread of multi-resistant organisms (MDROs) and maintain a clean environment for residents and staff.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Resident #19 received showers according to her preferences and the facility's schedule. Resident #19, who was cognitively intact with a BIMS score of 15, expressed that she was rarely offered showers and would like to have them at least weekly. The facility's documentation indicated that her bathing schedule was set for Mondays and Thursdays during the 3 PM to 11 PM shifts, but it did not specify whether she received a bath or a shower. Interviews with staff revealed that there was a shower book and that refusals were to be documented in the EMR after consulting with a nurse. However, the documentation did not differentiate between a bath and a shower, and there was no clear record of whether Resident #19's preferences were being honored. During interviews, staff confirmed the process for documenting showers but acknowledged that the records did not specify whether a bath or a shower was provided. This lack of specificity in the documentation and the failure to offer showers as per the resident's preference led to the deficiency. The facility did not ensure that Resident #19's right to choose between a bath and a shower was respected, as required by her comprehensive Admission MDS.

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 the fingernails of two residents, Resident #45 and Resident #48, as observed and reported during a survey. Resident #45 was noted to have fingernails extending about 1/2 inch past his fingertips on both hands. Despite expressing a desire to have his nails trimmed, the resident's fingernails remained untrimmed for several days until they were finally addressed. Similarly, Resident #48 had fingernails extending at least 1/2 inch beyond his fingertips and expressed dissatisfaction with their length. The resident mentioned having to pay for nail trimming services in the past and indicated that the facility staff had not trimmed his nails despite his requests. His nails were eventually trimmed after several days of waiting and asking the staff for assistance. Interviews with staff revealed a lack of clarity regarding the responsibility for nail care. A Certified Nursing Assistant (CNA) indicated that while the Activities staff typically performed nail trimming, the responsibility for ensuring it was done fell to the nurses and CNAs. The CNA also mentioned a belief that they were not allowed to trim the fingernails of diabetic residents, although this restriction was not clearly stated in the facility's policy. This confusion and lack of timely action led to the deficiency in maintaining proper nail care for the residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the safe transfer of a resident, resulting in skin damage. Resident #18, who has multiple diagnoses including quadriplegia and contractures, was being transferred via a Hoyer lift by a CNA with the assistance of the resident's mother. During the transfer, the resident sustained a 4-inch cut on the left elbow. The Director of Nursing (DON) confirmed that the CNA performed the transfer alone, despite the facility's expectation that two staff members should be involved in such transfers. The facility does not have a formal policy requiring two staff members for Hoyer lift transfers, which contributed to the incident. Additionally, the facility failed to provide necessary safety devices for residents while smoking. Resident #80, who has a history of nicotine dependence and other medical conditions, was observed smoking without a required smoking apron on multiple occasions. The facility's smoking policy mandates the use of smoking aprons to ensure safety, but the aprons were not provided to the residents. Interviews with staff revealed that the aprons were kept in the Activities closet and were not consistently made available to residents, leading to lapses in safety measures. These deficiencies highlight lapses in the facility's adherence to safety protocols, both in the context of resident transfers and smoking safety. The lack of proper supervision and equipment contributed to the incidents involving Resident #18 and Resident #80, respectively. The facility's failure to follow established safety practices resulted in harm and potential risk to the residents involved.

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 assess a resident for the risks associated with the use of bed rails, obtain physician's orders for the use of bed rails, and initiate a care plan for the use of bed rails for one resident. The facility's policy on bed safety and bed rails, revised in August 2022, outlines the necessary steps for evaluating and implementing bed rails, including an interdisciplinary evaluation, risk assessment, and obtaining input from the resident and/or responsible party. However, these steps were not followed for Resident #134, who was observed using half side rails on the bed without a documented assessment, care plan, or physician's orders. Resident #134, who was admitted with multiple diagnoses including anemia, hypertension, chronic lung disease, and dependence on renal dialysis, had a BIMS score indicating cognitive intactness. The resident was dependent on staff for transfer and bed mobility and was frequently incontinent of urine and always incontinent of bowel. Despite the resident's request for bed rails to prevent falling out of bed, the facility did not conduct the required risk assessment or obtain the necessary physician's orders and care plan documentation for the use of bed rails.

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 follow physician's orders related to the timing for administration of medication for three residents. Resident #19 was receiving two medications, mirtazapine and alprazolam, which had a potential drug interaction and were ordered to be administered at different times. However, both medications were administered at 9:00 PM, contrary to the physician's order. This error was identified during a side-by-side record review and interview with the LPN/Unit Manager, who acknowledged the mistake in scheduling the alprazolam order upon the resident's admission. Resident #63, who was cognitively intact, reported not receiving his night medications at the prescribed bedtime of 9:00 PM. Instead, the medications were administered at varying times, ranging from 6:30 PM to after midnight. The review of the Medication Administration Record (MAR) confirmed that the medications were often given late, with timestamps showing administration times well past the scheduled 9:00 PM slot. The Consultant Nurse agreed with these findings upon review. Resident #68, who had diagnoses including Generalized Anxiety Disorder and ADHD, also experienced issues with medication timing. The resident's ADHD medication, Dextroamphetamine Sulfate, was ordered to be administered three times a day at specific times. However, the medication was given more than one hour late on nine occasions out of 45 opportunities, with one instance being over two hours late. The resident reported that the late administration interfered with her sleep. The Director of Nursing and the Regional Clinical Consultant acknowledged the discrepancies in medication administration times during an 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 pharmacist failed to identify a timing issue with a possible drug-to-drug interaction for Resident #19. The resident was admitted with diagnoses including major depression and anxiety disorders and was receiving both an antidepressant (mirtazapine) and an antianxiety medication (alprazolam). The order for alprazolam specifically stated it should not be administered with mirtazapine. However, the Medication Administration Record (MAR) showed that both medications were being administered at 9:00 PM, contrary to the order which scheduled alprazolam for 6:00 PM. This error was identified during a side-by-side record review and interview with a Licensed Practical Nurse (LPN)/Unit Manager, who confirmed the mistake was made upon the resident's admission. Pharmacy reviews from January 2024 through April 2024 did not include any recommendations for Resident #19, indicating that the Consultant Pharmacist overlooked the issue. During a phone interview, the Consultant Pharmacist acknowledged the oversight and explained that administering both medications together could cause added sedative effects, CNS depression, and respiratory depression. This deficiency highlights a failure in the monthly drug regimen review process, as the pharmacist did not identify the critical timing issue and potential drug interaction for the resident.

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 monitor behaviors as ordered by the physician related to psychotropic medications for five of six sampled residents. Resident #19 was admitted with orders to monitor behaviors twice daily and document interventions and outcomes, but there were multiple instances in May and April 2024 where this monitoring was not performed. Specifically, there were 6 out of 29 shifts in May and 20 out of 60 shifts in April where behavior monitoring was not documented for Resident #19. Resident #35, who was admitted with diagnoses including Lymphedema, Major Depressive Disorder, and Anxiety Disorder, also had lapses in behavior monitoring. The Behavior Monitoring Flow Sheet for May 2024 showed that interventions, medication management, and side effects were not documented for 8 out of 30 opportunities. Similarly, Resident #68, with diagnoses including Generalized Anxiety Disorder and Major Depressive Disorder, had 15 out of 30 opportunities in May 2024 where behavior monitoring was not documented. Resident #64, admitted with Anxiety Disorder and Unspecified Psychosis, had severe cognitive impairment and also experienced lapses in behavior monitoring. The Behavior Monitoring Flow Sheet for May 2024 revealed that interventions, medication management, and side effects were not documented for 20 out of 45 opportunities. Lastly, Resident #236, with diagnoses including Dementia and Major Depressive Disorder, had 2 out of 3 opportunities in May 2024 where behavior monitoring was not documented. The Director of Nursing and Regional Clinical Consultant acknowledged these deficiencies during an interview on May 16, 2024.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the accuracy of records for a resident, leading to a deficiency in maintaining accurate documentation of the resident's discharge. The resident, who had diagnoses including Anxiety Disorder, Alcohol Abuse, and Nicotine Dependence, left the facility after signing out and did not return as anticipated. Despite the resident's clear communication that he would not return until a later date, the facility did not document this information accurately in the resident's medical record until much later. Interviews with staff revealed that the resident had a history of signing out and returning the same day, but on this occasion, he informed the staff that he would not return until the following Monday. The staff attempted to contact the resident and his family, and even involved the police for a wellness check, but there was no immediate documentation of these actions in the resident's chart. The lack of timely documentation led to confusion about the resident's discharge status. The MDS Director initially coded the discharge as 'return anticipated' and only changed it to 'return not anticipated' after receiving supporting documentation much later. The Administrator and other staff acknowledged the absence of proper documentation in the resident's chart regarding the resident leaving against medical advice (AMA) and the subsequent actions taken by the facility. This failure to document accurately and promptly resulted in a deficiency in maintaining the resident's medical records according to accepted professional standards.

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 offer, educate, and obtain consent for the pneumonia vaccine for five residents. Specifically, Residents #53 and #18 did not have Pneumococcal consents or refusals documented, and none of the five residents had evidence of being offered the vaccines or provided with education. The facility's policy requires that residents or their legal representatives receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine, and that this education is documented in the resident's medical record. However, this was not adhered to in the cases reviewed. During the review, it was found that Resident #53 had documentation of refusal for the Influenza vaccine but no consent or refusal for the Pneumonia and COVID-19 vaccines. Similarly, Resident #18 had consent for the Influenza vaccine but no other consents. The Director of Nursing (DON) acknowledged the lack of documentation and education, mistakenly believing that the CDC guidelines only required the Pneumonia vaccine for individuals of a certain age. This misunderstanding contributed to the failure to offer and document the necessary vaccinations and education for the residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure bed rails were maintained in working condition and inspected for fitness and function for one of the two sampled residents reviewed for bed rails. The facility's policy required maintenance staff to routinely inspect all beds and related equipment to identify risks and problems, including potential entrapment risks. However, the Director of Maintenance was unaware of the concerns with the bed rails not staying in a raised position for the resident. The resident, who was cognitively intact and dependent on staff for transfer and bed mobility, reported that the bed rails had not stayed in a raised position since being admitted. The Director of Maintenance later fixed the bed rails by readjusting and tightening the holding mechanism and pin, but there was no documentation of regular inspections performed as required by the facility's policy. The resident's care plan included the use of bed rails as an enabler for bed mobility, and the resident had multiple diagnoses, including anemia, hypertension, chronic lung disease, and dependence on renal dialysis. Despite the facility's policy stating that maintenance staff should provide a copy of inspections to the administrator and report results to the QAPI committee, the Director of Maintenance was unable to generate documentation of audits or maintenance of the side rails and bed from the electronic system. This lack of documentation and awareness of the bed rail issues led to the deficiency identified by the surveyors.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the accessibility and functionality of call bells for two residents. For Resident #9, observations revealed that the call device was on the floor next to the bed and later not in sight when the resident was in a wheelchair. Interviews with the resident confirmed that she was unaware of the call device's location, indicating a lack of accessibility to the call system. The resident's care plan emphasized the need for assistance with personal care tasks and mobility, but the call system's inaccessibility hindered this support. For Resident #53, the call bell system was not functioning, and the resident had to rely on his roommate to call for assistance. The resident had been waiting for a new bed for two months due to the malfunctioning call bell. The Maintenance Director was unaware of the issue until the surveyor's interview, and there was no documentation in the electronic work record system. The Maintenance Director attempted to fix the device but was unsuccessful, and a new device was arranged for delivery. Interviews with staff confirmed awareness of the problem but indicated a lack of timely resolution and proper documentation.