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Skilled Nursing Citation Update – G Level, SSQC and Immediate Jeopardy

Posted Jan 28, 20258 min Read

Regulatory & Clinical
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The Indiana Department of Health conducted 34 recertification surveys and of those five (or 14.71%) were found to be deficiency free. There was a total of five G Level tags, two SSQC citations and two Immediate Jeopardy citations in December 2024.

The Indiana Department of Health conducted Thirty-four recertification surveys and of those five or (14.71%) were found to be deficiency free. There was a total of five G Level tags, two SSQC citations and two Immediate Jeopardy citations in December 2024.

The G Level Citations are as follows:

F686 (1 time) – Treatments/Services to Prevent/Heal Pressure Ulcer

  • Based on observation, record review, and interview, the facility failed to ensure interventions to provide effective pressure relief to the coccyx were implemented for a resident re-admitted with stage two (a partial thickness loss of skin) pressure injury on the coccyx and failed to ensure the physician was notified when the wound deteriorated. This deficient practice resulted in the wound deteriorating to a stage four pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, or cartilage or one in the ulcer) that required two surgical debridement’s. The facility also failed to ensure treatments were signed out as being completed, antibiotics for a wound infection were started promptly, the physician was notified of treatment refusals, and turning and repositioning a resident with a pressure ulcer was completed for 5 of 10 residents reviewed for pressure ulcers.

F689 (3 times) – Free of Accident Hazards/Supervision/Devices

  • Based on interview and record review, the facility failed to ensure services for bed mobility were provided with two staff members present to a dependent resident who required total assistance of two staff for bed mobility for 1 of 3 residents reviewed for falls. This deficient practice resulted in a resident falling from the bed and sustaining a fracture of the left knee.

A nursing note dated 11/29 indicated the CNA reported assisting the resident in her bed without assistance of another staff. He rolled her to the left side of the bed to adjust the bed sheets and incontinence pad when the residents’ right leg went over the side of the bed. The resident stated that she went onto the floor and hit her head. The resident ended up developing a skin tear to her sacrum that was two centimeters (cm) long by 0.2 cm width with no depth. Range in motion was normal per resident’s current physical condition. Neurological checks were initiated within defined limits, and she was alert and oriented times four. Four staff members assisted in getting the resident off the floor and back into her bed.

There was no progress notes documented between 11/29 when fall occurred and 11/30, when the residents had complaints of pain.

A nursing progress note, dated 111/30/24, indicated the CNA notified the nurse that the resident was experiencing 10/10 pain following her fall the previous night. Her left leg and back caused most of the pain. The assessment indicated that the left leg was swollen and painful to touch. The nurse spoke with the resident and family who indicated they wanted the resident to be sent to the Emergency Room for evaluation.

  • Based on observation, record review, and interview, the facility failed to ensure adequate supervision and assistance were provided to a dependent resident who required total assistance of staff for bed mobility. This practice resulted in a fall and the resident sustained a left femur fracture.

A Nurse’s Note dated 12/3, indicated LPN was called to the room by a CNA. The CNA stated that the resident slid to the floor out of the bed while staff was providing care. The resident was observed sitting on the floor on buttocks next to the bed and near the window. There were no visible injuries and no complaints of pain. The resident was not moved, and an ambulance was called. An ambulance arrived and transported resident to the Emergency Department for evaluation and treatment for a fracture.

  • Based on interview and record review, the facility failed to ensure adequate assistance was provided during a mechanical lift transfer and ensure staff used the equipment in accordance with facility policy for a resident who required extensive assistance of two staff and mechanical lift for transfers. The facility failed to ensure adequate supervision was provided in the bathroom for a cognitively impaired resident at risk for falls and failed to ensure a toilet seat was properly attached to the toilet for a resident. The facility failed to ensure new interventions were immediately implemented after a fall.

SSQC and Immediate Jeopardy Citations are as follows:

F600 (SSQC/IJ) – Free from Abuse and Neglect

  • Based on interview and record review, the facility failed to protect the residents’ right to be free from sexual abuse by a staff member for one resident reviewed for abuse. A contracted housekeeping staff member sexually assaulted Resident B.

The Immediate Jeopardy began on 12/21/24, when a housekeeper was observed to be on top of Resident B. Housekeepers’ pants were down, and his private parts were exposed. Resident B’s gown was pulled up, her brief was open, and her private parts exposed. The Executive Director and Director of Nursing was notified of the immediate jeopardy on 12/26. The Immediate Jeopardy was removed, and the deficient practice corrected on 12/22/24, prior to the start of the survey and was therefore Past Noncompliance.

The Past Noncompliance Immediate Jeopardy began on 12/21/24. The Immediate Jeopardy was removed and corrected by 12/22/24 after the facility implemented s systemic plan that included the flowing actions: the facility completed interviews with all cognitively intact residents, skin sweeps on all non-interview able residents, audits of all employee files to ensure background checks and abuse training had been completed, all staff were in-serviced on abuse, the resident was evaluated at the hospital and placed on 15 minute checks, and the employee was terminated and arrested.

F695 (SSQC/IJ) – Respiratory/Tracheostomy Care and Suctioning

  • Based on observation, interview, and record review, the facility failed to ensure adequate and competent staff were on duty to provide respiratory care and services for a resident admitted to the facility with a tracheostomy and was dependent on mechanical ventilation in accordance with physician orders. This resulted in a resident experiencing respiratory distress and subsequent death and a resident experiencing respiratory distress resulting in hospitalization for 2 of 5 residents reviewed for ventilator status. The facility failed to ensure necessary respiratory and ventilator care supplies were available to provide quality of care to the residents on the ventilator unit. This had the potential to affect 11 of 11 residents who resided on the ventilator unit.

The Immediate Jeopardy began on 12/12/24, when a resident with a tracheostomy and ventilator status, was in respiratory distress and the facility failed to ensure respiratory care and services were provided in accordance with physician orders that were listed on the hospital discharge paperwork that included, but not limited to, provide scheduled nebulizer treatments, oxygen therapy, suctioning, tracheostomy care, and ventilator care and maintenance, and have competent nursing staff with knowledge regarding the utilization of a ventilator. This resulted in a resident having respiratory distress and subsequent death. The Immediate Jeopardy was not removed by the exit date of the survey.

F835 (IJ) – Administration

  • Based on observation, interview, and record review, the facility failed to ensure the wellbeing of residents. The facility failed to ensure adequate and competent staff were always on duty to provide respiratory services and failed to have adequate respiratory supplies on hand to effectively provide respiratory care and services for 11 of 11 residents who resided on the ventilator unit. This resulted in a resident experiencing respiratory distress and subsequent death and a resident experiencing respiratory distress and resulting in hospitalization for 2 of 5 residents reviewed for ventilator status. The facility failed to ensure licensed nursing staff were on duty at all times to provide routine and emergency nursing services during two random observations, failed to ensure money was available upon request for 2 of 2 residents reviewed for personal fund accounts, and failed to ensure the facility assessment was completed annually and accurately to identify necessary resources required to provide competent care to 32 of 32 residents who resided in the facility.

The Immediate Jeopardy began on 12/12/24, when the facility had no respiratory therapist available 24 hours a day on the Ventilator unit, supplies were not available to ensure adequate utilization of the ventilator, a nurse was not in the facility 24 hours a day, and residents could not access their personal funds with the potential for psychosocial harm and the potential for serious outcome for all residents. The Administrator was notified of the Immediate Jeopardy on 12/23/24. The Immediate Jeopardy was not removed by the exit date of the survey.

F725 (IJ) – Sufficient Nursing Staff

  • Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to provide competent nursing services during two random observations when no licensed nurse was at the facility. This affected 11/11 residents on the Ventilator Unit and 21 of 21 residents with traumatic brain injuries who resided in the facility.

Based on interviews and reviews, the facility failed to ensure sufficient nurse staffing regarding having a plan for staff call-offs and filling open positions in a timely manner. This had the potential to affect 32/32 residents who reside in the facility.

The Immediate Jeopardy began on 12/22/24, when the facility had no licensed nurse available for 24 hours a day with the potential for significant injury, harm, impairment, or death for all residents. The Immediate Jeopardy was not removed by the exit date of the survey.

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