Mayo Clinic Health System - Lake City

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from non-consensual sexual contact by another resident with a known history of sexually inappropriate behavior. One resident (R1) had dementia with severe cognitive impairment, anxiety disorder, and a documented history of childhood sexual abuse/molestation. R1’s care plan, initiated months before the incident, identified her past sexual trauma and directed staff to observe for changes in mood, behavior, sleeping, and eating, and to allow her to talk as she felt appropriate, but did not identify triggers or specific protective interventions. On the morning of the incident, R1 was very confused, disoriented, and already seated in the Country View TV lounge after being gotten up early due to inability to sleep. Staff were monitoring her for confusion and fall risk, but there were no individualized measures in place to protect her from potential sexual abuse by other residents. The other resident (R2) had dementia, an unspecified mood disorder, severe cognitive impairment, and a documented history of sexually inappropriate behavior. In 2023, R2 had inappropriately touched another female resident’s breast under her shirt in the Country View common area, and his care plan and Kardex noted that he occasionally made inappropriate comments to female staff that were usually redirectable. Interventions in the care plan and Kardex instructed staff to ensure awareness of females surrounding R2 when out of his room, ensure adequate space between R2 and the prior victim resident, and to address any concerns for inappropriate behaviors immediately. R2 was able to self-propel in his wheelchair and leave the unit for activities, with staff escort required only for distant locations. After a remodel in 2025, R2 was moved back from an all-male unit to Country View, where female residents were present, without documented comprehensive review or update of his care plan to ensure continued prevention of inappropriate sexual behaviors. Staff interviews showed inconsistent awareness of R2’s sexual behavior history; some NAs and RNs knew of his prior incident, while others stated they were unaware or that the Kardex did not clearly reflect his risk. On the day of the incident, R2 was brought to the TV lounge in his wheelchair around early morning and was able to wheel himself close to where R1 was seated. A nurse (RN-B), positioned at a medication cart with view of the lounge, observed R1 seated in her wheelchair on the left side of R2 and saw R2’s right hand inside the top of R1’s shirt, touching her left breast. RN-B immediately intervened, instructed R2 to remove his hand, and staff separated the residents and returned R2 to his room. R1 did not react during the incident but was later documented as confused, hallucinating, misidentifying a male resident as her father, and making statements such as “my dad just grabbed my boob.” Multiple staff, including NAs and RNs, stated that neither R1 nor R2 had capacity to consent to sexual activity due to dementia. Staff also reported that R2 had recently been “grabby” with staff during toileting and had made sexually suggestive comments, such as asking to kiss or lick a staff member’s belly, but he was generally redirected rather than placed under defined, continuous supervision. The facility’s own policies required individualized care planning, behavioral health assessment, and abuse protection for vulnerable adults, including residents lacking capacity to consent, yet R2’s Kardex and care plan did not establish a clear, individualized supervision system sufficient to prevent his unsupervised access to vulnerable female residents, relying instead on general monitoring and redirection. This lack of clearly defined, consistently implemented supervision and protective interventions led to R2 being able to place his hand under R1’s shirt and touch her breast in the common area. Interviews with the DON, nurse managers, and direct care staff confirmed that supervision expectations for R2 were vague, not consistently documented, and not translated into specific, enforceable directions on the Kardex. Staff at the nurses’ station were generally responsible for monitoring R2 when he was in common areas, but no staff member was specifically assigned to supervise him, and he could independently move throughout the unit in his wheelchair. The DON acknowledged that interdisciplinary reviews and documentation of supervision decisions were not consistently completed after R2’s transfer back to Country View and that the care plan did not clearly define the level of supervision required. As a result of these omissions and the failure to revise and implement individualized interventions despite R2’s known history of sexually inappropriate behavior, R2 was able to access and inappropriately touch R1, who had severe cognitive impairment and a history of childhood sexual abuse, in the Country View TV lounge.

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 report an allegation of resident-to-resident sexual abuse to law enforcement as required by its abuse policy. A nurse observed one resident with dementia and severe cognitive impairment, who used a Wanderguard and had a care plan identifying vulnerability and the need to report any suspicion of maltreatment, sitting in the TV lounge when another resident placed his hand under her shirt and touched her left breast. The second resident also had dementia, severe cognitive impairment, and a care plan identifying vulnerability and the requirement that suspected maltreatment be reported per facility policy. Staff immediately removed the resident’s hand, separated the two residents, and returned the alleged perpetrator to his room. The incident was documented in a facility reported incident (FRI) submitted to the state agency, which noted that both residents did not believe the behavior was inappropriate. Despite the allegation being witnessed by staff and verified in the facility’s 5‑day investigative summary, there was no documentation that the incident was reported to law enforcement. The FRI form section for identifying the name and position of the individual who reported the incident to law enforcement was left blank, and the investigative summary did not indicate any law enforcement notification. Progress notes documented the event and subsequent internal notifications to the administrator, DON, and nurse manager, but did not reference any contact with law enforcement. In an interview, the administrator and DON, who were responsible for managing the investigation, confirmed that the incident was not reported to law enforcement, contrary to the facility’s Vulnerable Adult-Abuse Protection Plan policy, which requires all alleged violations involving abuse, including sexual abuse and potential criminal conduct, to be reported immediately to law enforcement and required state agencies.

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 conduct a thorough investigation of an allegation of resident-to-resident sexual abuse involving two residents with dementia and severe cognitive impairment. One resident, who used a Wanderguard and had care plan interventions for vulnerability and reporting suspected maltreatment, was observed in the TV lounge when another resident placed his hand under her shirt and touched her left breast. Both residents had care plans identifying risk for vulnerability and interventions requiring that any suspicion of maltreatment be reported per facility policy and that a safe environment be maintained. The incident was documented in a facility reported incident and a 5‑day investigative summary submitted to the state agency, which verified the allegation based on staff witnessing the event but did not include detailed findings from a comprehensive investigation. Despite the facility’s written policy requiring immediate and thorough internal investigations of all alleged abuse—including interviews with staff, residents, and witnesses; collection of written statements; care observations; environmental review; and medical record review—the investigation lacked key components. The nurse who witnessed the incident reported it to the charge nurse but was not contacted by administration for a follow‑up interview. The nurse who completed post‑incident assessments was not directed to interview other residents or staff who might have additional information. The assigned nurse for both residents on the date of the incident and the nursing assistant who assisted both residents and placed them in the TV lounge were also not interviewed. During interviews, the DON and Administrator, who were responsible for managing the investigation, were unable to provide documentation showing that comprehensive interviews or a full assessment of the circumstances surrounding the incident had been completed, resulting in a failure to meet the facility’s abuse investigation policy requirements.

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 maintain a complete and accurate medical record for a resident with dementia and an unspecified mood disorder, who had a history of sexually inappropriate behaviors. The resident’s care plan documented prior incidents of sexually inappropriate touching toward another resident and noted that the resident occasionally made inappropriate comments to female staff, which were usually easily redirected. Behavior monitoring records for a specified period showed an entry that the resident was “grabbing others” on one date, but there was no corroborating documentation in the medical record to further describe or support this behavior. Interviews and observations revealed additional sexually inappropriate comments and behaviors by the resident that were not documented in the medical record. A nursing assistant reported that on her first day working with the resident, he asked if he could lick her belly while he was on the toilet, and she redirected him. During an observation, when staff offered to assist the resident to bed, he responded, “With you?” An LPN reported receiving a night-shift report that the resident had been up approximately every hour using the bathroom and had been “real grabby” with staff while being toileted. None of these behaviors were documented in the resident’s medical record, despite the DON stating that staff were expected to document such behaviors in behavior notes for tracking and evaluation, and despite facility policies requiring complete, accessible, and accurate medical records and systematic assessment and documentation of behavioral symptoms.

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 comprehensively assess and document the appropriate sling or harness sizes for residents requiring mechanical lifts for transfers, as required by manufacturer instructions. For two residents who utilized sit-to-stand and full-body mechanical lifts, there was no evidence of a formal assessment that included necessary measurements such as height, weight, distance from tailbone to base of neck, or torso circumference. Instead, staff relied primarily on the resident's weight and a laminated chart in the tub room to estimate sling or harness size, without documenting the specific size in the care plan or Kardex. Interviews with various staff members, including RNs, LPNs, nurse managers, and nursing assistants, revealed a lack of clarity and consistency regarding responsibility for assessing sling/harness size. Staff reported that there was no formal assessment process, and that the size was not routinely updated or included in care plans. Some staff indicated that therapy might be responsible for the assessment, while others believed it was the responsibility of nursing. The process described by staff involved using judgment and trial-and-error to determine if a sling or harness fit properly, rather than following a standardized assessment protocol. Manufacturer instructions for the mechanical lifts and slings used in the facility specify that a full patient assessment must be conducted to determine the appropriate accessory size and type prior to each use. The facility was unable to provide a policy or procedure for mechanical lift equipment, and documentation for the two residents reviewed did not include a Mechanical Lift Sling Assessment. The lack of a comprehensive and documented assessment process for determining sling/harness size led to the deficiency identified by surveyors.

Penalty

Inspection fine: $49,445

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 assess or analyze trends in falls to determine causal factors or root causes and did not implement individualized interventions to prevent or reduce the risk of falls with major injuries for a resident who experienced multiple falls. The resident had a complex medical history, including a recent stroke with left-sided hemianopsia, hemiparesis, cognitive impairment, poor safety awareness, and impulsivity. Despite being identified as at moderate risk for falls and requiring extensive assistance with activities of daily living, the facility did not consistently update or revise the care plan with new interventions after each fall, nor did they conduct comprehensive assessments to determine the appropriate level of supervision needed, particularly during toileting and transfers. The resident experienced several unwitnessed falls, including incidents where he slid out of his wheelchair, attempted to self-transfer from bed to wheelchair, and was left unsupervised on the commode. Documentation revealed that after some falls, interventions were noted in progress notes but not incorporated into the care plan. There was also a lack of assessment regarding whether the resident could be left alone on surfaces other than the wheelchair, such as the commode or other chairs. Staff interviews indicated that therapy and nursing staff were aware of the resident's impulsivity and cognitive deficits, but there was no clear assessment or documentation regarding the level of supervision required during toileting tasks. Incident reports and fall scene investigations were incomplete or missing for several falls, and the facility's post-fall investigation process was not consistently followed. The director of nursing and nurse manager confirmed that fall huddle forms were not completed for all incidents, and root cause analyses were lacking, particularly regarding whether the resident's basic needs were met at the time of the falls. As a result of being left unsupervised on the commode, the resident suffered two thoracic spinal fractures and required hospitalization. The facility's failure to assess, analyze, and implement individualized interventions contributed to actual harm 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 ensure medications were administered to the correct resident, resulting in a significant medication error for one resident. The resident, who had intact cognition and diagnoses of chronic kidney disease stage 3b and hyponatremia, was mistakenly given lisinopril, a medication intended for another resident. This error occurred on the first day a new nurse was independently passing medications. The resident experienced immediate adverse effects, including dizziness, weakness, and hypotension, which required emergency medical treatment. The resident's blood pressure dropped significantly after receiving the incorrect medication, leading to symptoms such as dizziness, nausea, and blurred vision. The resident was sent to the emergency department for further evaluation and treatment, where they received intravenous fluids and albumin to address the hypotension. The resident's condition was closely monitored, and they experienced ongoing symptoms, including weakness and leg pain, following the incident. Interviews with staff revealed that the nurse responsible for the error was new and had not realized the mistake until the resident exhibited symptoms of hypotension. The facility's director of nursing confirmed that the error was significant due to the adverse effects experienced by the resident. The facility's medication administration policy requires that medications be administered as prescribed, with proper resident identification and adherence to the five rights of medication administration, which were not followed in this instance.

Removal Plan

• the facility completed an investigation and causal analysis
• RN-B was immediately re-educated and supervised
• provided education to licensed and unlicensed staff regarding giving medications as ordered and medication administration policy

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 the required written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to three residents whose Medicare A coverage ended. For Resident 2, the NOMNC indicated that the community support manager (CSM) called the family member, who was also the power of attorney, to notify them of the end of skilled services and the beginning of financial liability. However, the NOMNC lacked the signature of the family member acknowledging the notification. The SNFABN also lacked a signature, and the family member stated they did not receive or sign any written notice. Resident 2's payer source changed from Medicare Part A to Private Pay, and they remained in the facility. Similarly, for Resident 162, the NOMNC and SNFABN lacked signatures from the power of attorney acknowledging receipt and understanding of the notices. The family member stated they never received or signed the notices and were unaware of the care level and associated costs. Resident 258's NOMNC also lacked a signature, and the resident was discharged from the facility. The CSM confirmed that she was responsible for providing these notices and acknowledged that she did not remember offering or obtaining written signatures for these residents. The facility's Medicare A Denial policy requires that the NOMNC and SNFABN be signed and dated by the resident or their representative to demonstrate receipt and understanding of the notices.

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 accurately complete the Minimum Data Set (MDS) for a resident reviewed for wandering. The resident, identified as R26, had an admission MDS indicating severe cognitive impairment, physical and verbal behaviors, and wandering with no significant risk, with a Wanderguard in place. However, the quarterly MDS did not document wandering, despite the resident's history of elopement attempts and increased wandering during episodes of delusional thoughts. Progress notes from 3/20/24 to 3/27/24 indicated that on 3/22/24, the resident attempted to leave the facility multiple times, refused medications, and required redirection and 1:1 care. During an interview, the MDS coordinator acknowledged using a reference sheet to confirm assessment dates and stated that she referenced task documentation and progress notes during the assessment period. She admitted to overlooking the progress note dated 3/22/24, which documented the resident's multiple attempts to exit the facility. The director of nursing confirmed the importance of accurate MDS assessments for appropriate resident care and Medicare reimbursement. The facility's policy on the MDS/Careplan Process emphasized the need for comprehensive assessments to identify care needs and develop a plan of care.

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 administer medications according to the physician's orders for a resident with multiple health conditions, including chronic heart failure, atrial fibrillation, hypertension, obstructive sleep apnea, and chronic obstructive pulmonary disease. The resident's physician had ordered Metoprolol Tartrate to be administered daily, with specific instructions to hold the medication if the resident's heart rate was below 50 or systolic blood pressure was below 100. However, the Medication Administration Record and Treatment Administration Record lacked documentation of the required blood pressure and pulse checks prior to administering the medication from May 17, 2024, to the present. Interviews with facility staff, including a trained medication aide, a registered nurse clinical manager, a consultant pharmacist, and the director of nursing, confirmed that the necessary monitoring was not consistently performed as per the physician's orders. The staff acknowledged the importance of these checks to prevent potential adverse effects, such as dizziness or dangerously low blood pressure, which could lead to life-threatening situations. Despite the expectation that these parameters be followed, the facility did not provide a Medication Administration/Monitoring policy and procedure when requested.

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 timely assistance with repositioning for a resident, identified as R4, who had a stage three pressure ulcer. R4's care plan required repositioning every two hours while in bed or a wheelchair to promote healing and prevent further skin breakdown. However, observations revealed that R4 was left seated in a Broda chair for extended periods without repositioning, from 9:42 a.m. to 12:57 p.m., during which time R4 was moved only for lunch and toileting. Interviews with staff, including nursing assistants and a registered nurse, confirmed that R4 was unable to reposition herself and required staff assistance every two to three hours, as per the care plan. Despite this, R4 frequently refused to lay down, preferring to watch television and participate in activities, which contributed to the lack of repositioning. The report highlights that R4 had multiple medical conditions, including moderately impaired cognition, non-traumatic brain dysfunction, atrial fibrillation, heart failure, renal insufficiency, diabetes mellitus, non-Alzheimer's dementia, seizure disorder, depression, and muscle weakness. These conditions, along with the presence of a stage three pressure ulcer, increased R4's risk for further skin breakdown. The facility's failure to adhere to the care plan for repositioning, as confirmed by staff interviews and observations, resulted in a deficiency in providing appropriate pressure ulcer care for R4.

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 adequately investigate, review, and analyze the underlying causes of a resident's anxiety and agitation. The resident, identified as R24, exhibited behaviors such as wandering, exit-seeking, and aggression, which were potentially harmful to himself and others. Despite these behaviors being documented in progress notes, there was a lack of comprehensive assessment and analysis to determine the triggers or underlying causes of these behaviors. R24 had a significant change in their Minimum Data Set (MDS), indicating moderate cognitive impairment and diagnoses including dementia, repeated falls, and malignant neoplasm of the prostate. The care plan identified R24 as at risk for wandering and elopement, with interventions such as verbal reminders and a wanderguard. However, these interventions were often ineffective, as evidenced by multiple incidents of wandering, exit-seeking, and aggression documented between 5/15/24 and 6/11/24. Interviews with staff revealed that while behaviors were discussed in interdisciplinary team (IDT) meetings, there was no documented analysis of the behaviors to identify potential causes. The facility's policy required individualized behavioral care plan interventions and regular reviews by the IDT team, but the medical record lacked evidence of such reviews or analyses. The deficiency highlights a failure to adhere to the facility's policy on mood and behavior management.

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 up on provider orders for a resident diagnosed with dementia, delusional disorders, and anxiety. The resident, identified as R26, had a history of severe cognitive impairment, elopement attempts, and behavioral issues such as verbal aggression and threats. Despite having a care plan in place that included a wanderguard and medication adjustments, the facility did not ensure a psychiatric consult was scheduled as ordered by the provider. Interviews with staff revealed a lack of awareness regarding the psychiatric appointment, and the unit secretary admitted to not documenting or following up on the appointment scheduling process. The resident's progress notes indicated ongoing behavioral episodes, yet there was no documentation of an increase in these behaviors. The unit secretary recalled attempting to make the psychiatric appointment but was unable to do so due to the order being in review. No follow-up actions were taken until prompted by a nurse manager, leading to a delay in securing the necessary psychiatric consultation. The director of nursing acknowledged the importance of following up on provider orders for the proper healthcare of residents, but a policy for provider orders was not provided upon request.

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 proper hand hygiene and use of personal protective equipment (PPE) during therapy sessions for a resident diagnosed with Clostridium difficile (C-Diff). The resident, who required moderate assistance with grooming and hygiene and was frequently incontinent of bowel, was observed in a therapy session where the physical therapist did not change gloves after touching potentially contaminated items. The therapist continued to assist the resident without changing gloves and did not adhere to contact precautions when entering the resident's room, despite clear signage indicating the need for gown and gloves. Additionally, the facility did not properly manage the sorting of soiled and potentially contaminated laundry, increasing the risk of cross-contamination. During a laundry tour, it was observed that laundry staff did not wear gowns while handling soiled laundry, including isolation gowns, which were frequently found loose in storage carts. The facility's policy required the use of gloves and gowns when handling contaminated laundry, but this was not followed, and there were no gowns available in the area for staff to use. Interviews with staff, including the infection preventionist and the director of nursing, confirmed that the observed practices were breaches in infection control. The infection preventionist acknowledged the need for staff to wear isolation gowns during laundry sorting to prevent contamination, and the director of nursing emphasized the importance of following infection control practices to prevent the spread of infection.

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 a resident, identified as R40, was offered and/or provided the pneumococcal vaccine series as recommended by the CDC. R40, who was over the age of 65, had previously received the PPSV23 vaccine in 2012 and the PCV13 vaccine in 2015. However, there was no evidence of shared clinical decision-making with the physician regarding the administration of the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. The immunization record lacked documentation of offering or providing education about the PCV20 vaccine to R40. Interviews with the infection preventionist and the registered nurse clinical manager revealed that the facility's process involved reviewing immunization records upon admission and discussing eligible vaccines with residents. However, in R40's case, the PCV20 vaccine was not addressed, and the resident was not informed about its availability. R40 confirmed that she was unaware of the third pneumonia vaccine and expressed interest in receiving it. The facility's policy indicated that residents should be offered pneumococcal vaccines according to CDC guidelines, but this was not adhered to in R40's case.

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 timely delivery of mail to residents on weekends, which has the potential to affect all residents who receive mail. Interviews with residents revealed uncertainty about mail delivery on Saturdays, with one resident stating that mail was delivered by the activities staff, and another indicating that mail was delivered to family members. The activities director confirmed that her department was responsible for mail delivery, but mail was not delivered on weekends as her staff occasionally worked on weekends and the mail was held until the following Monday. Further interviews revealed that the receptionist stated mail was not delivered on weekends due to the absence of staff at the desk to receive it, and the decision was made to hold mail to safeguard protected health information. The administrator explained that mail was delivered to an attached hospital and sorted by activities staff, but the hospital stopped weekend mail delivery, and the mailroom was locked on Saturdays. No alternative arrangements were made for weekend mail delivery, and a policy regarding resident mail delivery was requested but not provided.