Peak Resources-wilmington, Inc

Penalty

Inspection fine: $23,230

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 adequate supervision and a hazard‑free environment for a resident with severe cognitive impairment and known exit‑seeking behavior, resulting in an unsupervised elopement at night in freezing temperatures. The resident had dementia with agitation, severe cognitive impairment on MDS, and documented wandering 4–6 days per week. Her care plan and physician orders required use of an electronic wandering alarm device, daily function checks of the device, and every‑shift checks of placement and battery, along with frequent safety checks due to high fall and elopement risk. The resident had a prior unsupervised exit from the facility, during which she fell outside the front entrance and sustained a head laceration, and she was identified by the facility as high risk for elopement and placed on 15‑minute observational checks. Despite these identified risks and interventions, the facility’s alarm device system for the 200‑hall exit door had not been functioning properly since early January, and the annunciator for that door produced no audible alarm when a resident with an electronic device approached or exited. The Administrator, DON, and Maintenance Director all acknowledged awareness that the 200‑hall door alarm was not working, that the annunciator had been tampered with to reduce loudness, and that repair would not occur for several weeks. Although other exit doors and their alarms were reported as functional, the 200‑hall door—leading to a back parking lot, wooded area, ditch, and nearby road—remained in use and would open after being pushed for 15 seconds without generating an audible alarm in the building. Security camera coverage of this door was also partially obstructed by a tree and dumpster area, preventing direct visual confirmation of exits through that door. On the evening of the incident, the resident was last clearly observed around 10:45 p.m. when a nurse retrieved her from another hall and returned her to the 200 hall, positioning her near the nurses’ station. The nurse responsible for the resident’s 15‑minute checks then focused on end‑of‑shift computer documentation and did not perform the required checks. At the 11:00 p.m. shift change, there was no clear handoff of responsibility for the 15‑minute monitoring between the off‑going nurse and the oncoming medication aide and NA; staff reported ambiguity about who was responsible for the checks at that time. The NA assigned to the resident began her shift by stocking supplies and answering call lights, assuming the nurse was performing the 15‑minute checks, and did not verify the resident’s whereabouts. Staff on the unit were unaware that the resident had left the building until two unknown individuals, who had found her outside sitting in a ditch, returned her in her wheelchair to a rear door shortly before midnight, at which time she complained of being cold. No staff member could account for the resident’s location between approximately 10:45 p.m. and her return, and the facility later determined by process of elimination and limited camera footage that she had exited through the non‑alarming 200‑hall fire door while wearing her electronic monitoring device.

Removal Plan

• Conducted an immediate full census bed count after Resident #1 was returned; all residents were accounted for.
• Assisted Resident #1 to her room and applied blankets due to complaint of cold.
• Director of Nursing performed a comprehensive assessment of Resident #1 (vital signs, temperature, skin check, injury assessment).
• Continued Resident #1 on 15-minute monitoring checks.
• Implemented 1:1 monitoring for Resident #1 to continue until an electronic monitoring device can be applied when the door alarm annunciator is repaired or until transfer to a secure/locked unit is possible.
• Completed an investigation into the incident (including review of security footage/process of elimination) to determine Resident #1 exited via the 200-hall door and that 15-minute checks were not completed during shift change due to unclear assignment.
• Completed an elopement risk assessment for Resident #1 and determined continued risk for elopement.
• Maintained Resident #1’s picture and name in the facility elopement book (kept at nursing station and front desk).
• Revised Resident #1’s wandering care plan to include 1:1 monitoring and additional interventions (remove from unsafe situations/other residents’ rooms; address basic needs/comfort measures; provide care/activities/daily schedule resembling prior lifestyle).
• Completed an audit of all residents at risk for elopement to ensure appropriate interventions are in place; identified high-risk residents and continued 15-minute checks for all high-risk residents until annunciators are replaced.
• Added a wanderer custom banner flag to the face sheet of all residents identified as high risk for elopement.
• Maintained a list of all residents with the banner flag (DON/designee) and placed it in front of the elopement books at each nursing station and the receptionist desk.
• Conducted an elopement drill (CODE FIND) to heighten staff awareness, observe staff actions per policy, and debrief successes/failures afterward.
• Revised the 15-minute Resident Monitoring Tool to include instructions for initiation/completion of 15-minute checks, formal assignment of staff, how to complete the form, who to submit it to, and shift-time changes so off-going shift completes checks on the hour to allow oncoming shift time for report/assignments.
• Revised the assignment process so the DON/designee completes assignment sheets for 15-minute checks; the NA assigned to the resident is responsible for completing the 15-minute checks; the charge nurse delegates coverage as needed.
• Provided facility-wide in-service education (with teach-back) on the Elopement Policy, location/use of the elopement book, 15-minute monitoring checks (purpose/procedure/documentation), supervision expectations, and ensuring coverage during shift change/breaks/mealtimes.
• Educated staff who are on leave/PRN prior to returning to duty; tracked staff who have not received education (SDC responsible).
• Educated newly hired staff on elopement policy/procedures during orientation (SDC/designee).
• Assigned Administrator and DON ultimate responsibility to ensure implementation of the credible allegation to remove immediate jeopardy.

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 treat residents with dignity and respect, as evidenced by multiple incidents involving staff interactions with residents. Resident #26, who was cognitively intact and required assistance with mobility and toileting, experienced an incident where Nursing Assistant (NA) #5 argued with her and her family member, using curse words in the process. This incident was witnessed by the Director of Nursing (DON), who noted that NA #5's behavior was disrespectful and inappropriate. Another incident involved NA #1, who was reported to have been rude and argumentative with Resident #26 during the night shift. The resident's family member witnessed NA #1 slamming doors and refusing to assist the resident, which upset the resident. This behavior was consistent with previous reports of NA #1's interactions with other residents, indicating a pattern of disrespectful conduct. Further incidents were reported involving NA #1 with Residents #54 and #85. NA #1 was accused of being loud, cursing, and slamming objects in the residents' room, which made the residents feel disrespected and upset. These actions were reported to the DON, who noted that NA #1's behavior was part of a recurring pattern of poor customer service and lack of respect for residents' dignity.

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 adhere to the care plan for a resident who required assistance with activities of daily living (ADL) due to partial paralysis of all four limbs, chronic pain, anxiety, and neuromuscular dysfunction. The care plan, initiated on December 12, 2023, specified that the resident needed two or more staff members for care at all times. However, on November 3, 2024, a nurse aide (NA #6) provided ADL care and repositioning alone, contrary to the care plan requirements. This was confirmed through interviews with the resident, who reported being treated roughly, and with staff members who acknowledged the deviation from the care plan. The Director of Nursing (DON) and other staff members, including a nurse and a physician assistant, confirmed that the care plan required two staff members to assist the resident at all times. Despite this, NA #6 admitted to providing care alone on the specified date. The incident was documented in a grievance interview with the DON, who reiterated the necessity of following the care plan. The failure to provide the required level of assistance as outlined in the care plan constitutes a deficiency in the facility's adherence to established care protocols.

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 nutritional supplements to a resident diagnosed with protein calorie malnutrition, Alzheimer's, and dysphagia. The resident experienced significant weight loss over several months, as documented in their electronic health record. Despite a physician's order for a frozen nutritional cup with meals, observations on multiple occasions revealed that the resident did not receive the prescribed supplement. Instead, the resident's meal trays lacked the frozen nutritional treat, and on one occasion, pudding was provided as a substitute. Interviews with facility staff, including the Registered Dietitian and the Dietary Manager, confirmed the oversight. The Registered Dietitian was unaware of the resident not receiving the nutritional supplement as ordered, and the Dietary Manager admitted to being out of the frozen nutritional treat due to a delay in the food vendor shipment. The Dietary Manager, new to the position, acknowledged the failure to maintain necessary stock of the prescribed supplements, which contributed to the resident's nutritional decline.

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 honor the food preferences of Resident #76, who was admitted with diagnoses including dysphagia and gastroesophageal reflux. Despite being cognitively intact, the resident's care plan and dietary preferences were not updated appropriately, leading to repeated instances where the resident received meals that did not align with her preferences or dietary restrictions. Specifically, the resident was served rice, which she was not supposed to receive, and frequently received peanut butter sandwiches and fish, which she did not like or could not eat. Additionally, the resident requested salads but was told they were unavailable due to a lack of dressing, despite the facility's policy that salads were always available. Interviews with the Dietary Consultant and Registered Dietitian revealed that the Dietary Manager was new and had not updated the resident's preferences as required. The Registered Dietitian admitted to not being aware of the resident's specific dislikes, such as fish and peanut butter sandwiches, and acknowledged that the resident's profile had not been updated since the previous year. The facility's failure to provide meals according to the resident's preferences resulted in the resident relying on snacks provided by her family or not eating at all.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's right to be free from physical abuse when a Nurse Aide (NA) continued to provide care despite the resident's complaints of pain. The incident involved a resident with partial paralysis of all four limbs, chronic pain, anxiety, and neuromuscular dysfunction. The resident's care plan included interventions for effective pain management and gentle handling during activities of daily living (ADL). However, during a care session, the resident reported pain and discomfort, which the NA ignored, continuing the care despite the resident's requests to stop. The resident, who had intact cognition and no history of rejecting care, reported that the NA was rough during a bath and incontinence care, causing increased pain in her back. Despite the resident's repeated requests for the NA to stop due to the pain, the NA continued the care without providing any justification for her actions. The resident did not sustain any physical or emotional injuries but was concerned about the NA's disregard for her pain complaints. Interviews with the facility's Physician Assistant, Administrator, and Director of Nursing confirmed that the NA should have ceased care immediately upon the resident's complaint of pain. The NA acknowledged hearing the resident's complaints but chose to continue the care. The facility's investigation revealed that the NA was placed on leave and subsequently terminated. However, the facility's corrective action plan was deemed unacceptable by the State Agency, as it did not adequately address the potential for other residents to be affected by similar practices.

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 supervision to a severely cognitively impaired resident, who was inadvertently let out of the facility by visiting children. The resident, who was equipped with a wander guard, managed to exit the building when the children held the front door open, preventing the wander guard system from locking the door. As a result, the resident was outside without staff knowledge for approximately five minutes, during which she self-propelled her wheelchair to the curb cut for wheelchairs leading to the parking lot and overturned, hitting her head. The resident, identified as having a cognitive communication deficit and unspecified dementia with agitation, was dependent on staff for transfers to her wheelchair. Despite having a care plan that included interventions for wandering behavior, such as equipping the resident with a device that alarms when she wanders close to exit doors, the system failed when the door was held open. The wander guard was documented as functioning properly earlier in the shift, but the incident occurred when the door was unable to lock due to being held open by the children. Staff interviews revealed that the resident had been attempting to exit the facility multiple times that evening, setting off the wander guard alarms. However, the absence of a receptionist to monitor the door from 4:30 P.M. to 8:00 P.M. contributed to the lack of supervision. The incident was further compounded by the fact that the door alarm system was not triggered once the resident was outside, as the door had been held open. The resident was found outside with a laceration to her scalp and was transported to the emergency department for evaluation and treatment.

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 clean and homelike environment for residents in several rooms across two halls. Observations revealed cluttered and dirty nightstands, floors littered with debris such as cough drop wrappers and food, and stained privacy curtains. Additionally, furniture in the rooms was scratched, and drawers did not close properly. These conditions were consistent across multiple days, indicating a persistent issue with cleanliness and maintenance. Interviews with residents and staff highlighted systemic issues contributing to the deficiency. Residents expressed concerns about the infrequency of room cleaning, with one resident noting that her room was cleaned only every three days. Housekeepers reported being unable to clean all rooms daily due to staffing shortages and high workloads, with each housekeeper responsible for cleaning approximately 20 rooms plus common areas. The Housekeeping Account Manager acknowledged these challenges and noted that rooms were not always cleaned to standard, partly due to new staff and call-outs. The Unit Manager and Administrator were also interviewed, revealing a lack of clarity regarding responsibilities for maintaining room cleanliness and addressing clutter. The Unit Manager assumed rooms were cleaned daily but was unsure who was responsible for cleaning spills or removing unused medical equipment when housekeeping was unavailable. The Administrator expected rooms to be clean and clutter-free, acknowledging the need to address scratched furniture. Despite some improvements noted by residents, the facility continued to struggle with maintaining a clean and homelike environment.

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 properly assess a resident before transferring her back to bed after she was found on the floor. The resident, who had severe cognitive impairment and a history of falls, was receiving hospice care and had a prognosis of less than six months to live. On the morning of the incident, a nurse aide found the resident on the floor on her fall mat and, without seeking assistance from a nurse, placed her back in bed. The nurse aide later admitted to being exhausted and acknowledged that she should have requested a nurse's assessment before moving the resident. Subsequent assessments by nursing staff revealed a hematoma above the resident's eye, which was not initially reported. The nurse on duty was informed of the injury only after the resident had been moved back to bed. The Director of Nursing and other staff confirmed that protocol requires a nurse to assess any resident who has fallen before they are moved. The failure to follow this protocol led to the deficiency noted in the report.