Alden Debes Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 550 South Mulford Avenue, Rockford, Illinois 61108
- CMS Provider Number
- 145142
- Inspections on file
- 43
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Alden Debes Rehab & Hcc during CMS and state inspections, most recent first.
A resident with multiple comorbidities, functional limitations, and dependence on staff for ADLs was given numerous morning medications by an RN, who placed the pills and liquids on the bedside table and left without observing ingestion, then documented them as administered. The resident reported that nurses commonly leave medications at the bedside without supervision and that she has dropped or spilled pills, including when they were left while she was sleeping. Review of the medical record showed there was no MD order authorizing self-administration, and staff confirmed that self-administration requires a physician’s order per facility policy.
A resident’s scheduled morning medications, including insulin and multiple oral agents, were not administered within the facility’s required 1-hour window, resulting in an 80% medication error rate during an observed med pass. An RN checked the resident’s blood sugar and gave long-acting insulin, then brought 19 additional pre-poured medications into the room, administered only Flonase, left the rest on the bedside table, and documented them as given despite the eMAR showing them as overdue. Review of the MAR confirmed numerous 8:00 AM orders for once- and twice-daily medications, and staff acknowledged that medications highlighted red are overdue and that late twice-daily doses disrupt ordered spacing, contrary to the facility’s medication administration policy.
A nurse prepared 19 medications for a resident and left them in cups on top of an unlocked medication cart in the hallway while entering the resident’s room with only insulin to check blood sugar and administer the injection. The cart, positioned past the doorway and out of the nurse’s line of sight, left the prepared medications unattended and accessible. Another nurse confirmed this practice was not acceptable and that prepared medications should have been secured in the locked cart, contrary to facility policy requiring medications to be stored in locked compartments accessible only to authorized staff.
A resident with multiple chronic conditions, open surgical wounds, an indwelling catheter, and a colostomy was on contact isolation for an MRSA wound infection, with posted signage and facility policy requiring hand hygiene and use of gown and gloves upon room entry. An RN twice entered the resident’s room wearing only gloves to check blood sugar and administer insulin and other medications, and the RN’s sweater contacted the resident’s bedding on both occasions. A CNA later entered the same room without any PPE and touched the bedside table and bed rail while interacting with the resident. The resident reported that staff do not always wear a gown and gloves when entering the room, and the IP nurse confirmed that appropriate PPE should have been used to comply with contact precautions.
A resident on contact isolation for a blood infection reported being told by staff that she could not leave her room to shower and went about 11 days without a shower, during which she felt she smelled bad. CNAs stated that residents are to receive showers twice weekly and that residents on contact isolation can leave their rooms to shower, but one CNA acknowledged not assisting this resident with showering. An RN confirmed the resident’s isolation was later discontinued and she then received a shower, and that the resident had not been showered before that time. The resident’s care plan documented an ADL performance deficit with interventions for assistance with bathing and hygiene, and the facility’s bath/shower report showed she did not receive showers twice weekly as required by facility policy.
A resident with multiple comorbidities and mild cognitive impairment, care-planned as a fall risk and on a restorative bed mobility program requiring side rails for support, fell from bed during incontinence care when side rails and floor mats were not in place and the resident was instead holding onto the bedside table. While a CNA was turning the resident and reaching for supplies, the resident reported feeling weak, let go of the bedside table, and rolled off the bed, sustaining bruising and abrasions to the head, face, elbow, finger, and knee. Post-fall observation and staff interviews confirmed that required safety interventions, including side rails for bed mobility and floor mats, were not in use at the time of the incident, despite facility policy to assess hazards and implement appropriate fall-prevention measures.
A resident’s x-ray results were reported to the facility but were not promptly communicated to the nurse practitioner. An LPN checked the EMR once during the night and saw the results as pending, did not recheck later in the shift, and did not notify the NP. An RN later documented that results were relayed and the NP ordered hospital transfer, but the NP reported they were not notified by staff and only became aware of the results upon independently reviewing the EMR. The DON stated nurses are expected to check for x-ray results at shift start and end and immediately notify the NP when results are available.
Two residents with severe dementia were involved in an incident where one was observed placing his hand inside the other's diaper area in the activity room. The event was witnessed by another resident and an activity aide, who intervened and alerted staff. Both residents were unable to recall the incident due to cognitive impairment, and a body assessment found no injuries. The facility's failure to prevent this contact resulted in a deficiency related to abuse prevention.
A resident reported to family that a CNA had hit him, and the family informed facility management. Despite the facility's policy requiring immediate removal of staff accused of mistreatment, the CNA continued to work with the resident the next day. The DON did not return a call from the family seeking assurance that the CNA would not care for the resident, and the Operations Manager did not clarify the allegation or ensure proper action was taken.
A resident's family reported to the Operations Manager that a CNA was rough and allegedly hit the resident, but this allegation was not immediately communicated to the Abuse Coordinator or reported to the State Agency as required. The initial report was sent approximately 48 hours after the allegation, contrary to the facility's policy for immediate reporting.
The facility failed to ensure that call lights were within reach for three residents at risk for falls. One resident had the call light clipped to the opposite side of the bed, another had it clipped behind the bed, and a third had it coiled and clipped to the wall. All residents had care plans indicating a risk for falls due to weakness, with interventions to keep call lights accessible.
A resident with Parkinson's Disease suffered a third-degree burn after being handed a cup of hot coffee from an unregulated single-serving coffee maker. The coffee spilled onto her leg, causing a severe burn due to the high temperature. The facility failed to monitor the coffee temperature, leading to the incident.
Two residents in a facility experienced an incident of resident-to-resident abuse. One resident, with a history of schizoaffective disorder and aggressive behavior, physically assaulted another resident, who has schizophrenia and cognitive deficits. Despite the known risks and previous aggressive incidents involving the aggressor, the facility failed to prevent the assault, highlighting a deficiency in protecting residents from abuse.
A facility failed to document the notification of a Physician or NP when a resident's blood glucose levels were outside ordered parameters. The resident, with a history of diabetes and other complex conditions, had frequent instances of hypoglycemia and hyperglycemia. Despite the facility's policy, there was no documentation of notifications on several occasions, as confirmed by the DON and NP.
A resident with a right hand contracture and multiple medical conditions, including diabetes, was found with a long, thick nail causing pain. The resident reported inadequate hand cleaning, and a CNA noted the difficulty in cutting the nail, stating that nurses were responsible. The DON acknowledged the resident's frequent refusal of care and the lack of recent attention to the nail issue. The facility's policy for nail care, especially for diabetic residents, was not followed, as documented in the Treatment Administration Record.
A resident with venous stasis ulcers did not receive consistent application of dressings as ordered, leading to a deficiency in care. Despite physician orders for daily application of a support bandage, observations showed the resident's dressings were not applied, and staff interviews confirmed noncompliance and lack of documentation. The facility's policy on skin alterations was not followed, resulting in inadequate wound care management.
A resident with hemiparesis and hemiplegia did not receive necessary ROM therapy, leading to a decline in mobility. The resident's care plan required ROM exercises, but these were discontinued without explanation. The DON incorrectly assumed dressing the resident sufficed for ROM therapy. Incomplete assessments and task sheets further highlighted the facility's failure to provide adequate care.
A resident, dependent on staff for transfers, was injured during a mechanical lift transfer when only one CNA was present, contrary to the facility's policy requiring two staff members. The resident sustained a bruise to the eye when the lift's arm hit her. The incident was reported by the resident and confirmed by a nurse, highlighting a failure to adhere to safety protocols.
A facility failed to have physician orders for a suprapubic catheter and its care for a resident with a neurogenic bladder. The resident returned from the hospital without rewritten catheter orders until months later. The Director of Nursing admitted the orders should have been on the TAR to remind staff of the care needed. The resident's POS lacked catheter orders, and the MARs for April and May did not include catheter treatments. The facility's catheter care policy did not specify when to change the catheter, except when dislodged.
A resident with significant weight loss was not adequately assisted or encouraged with meals, leading to continued nutritional decline. Observations showed the resident often ate alone without necessary supervision, and meal documentation inaccurately reported food intake. Despite care plans and physician orders for fortified foods and supplements, these were not effectively administered, contributing to the resident's weight loss.
Two residents received incontinence care that did not adhere to infection control practices. A CNA placed soiled linens on a chair and did not change gloves before assisting a resident with other tasks. Another CNA placed soiled items on the floor before bagging them. These actions were against the facility's policies, which require soiled linens to be transported in closed bags and not placed on the floor to prevent cross-contamination.
A resident with multiple medical conditions was left in urine for hours after a staff member refused to assist her to the bathroom, causing emotional distress and embarrassment. The incident was reported by a CNA and corroborated by the resident's daughter, leading to the staff member's termination.
Failure to Supervise Medication Administration and Lack of Order for Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to supervise a resident during medication administration and to ensure that self-administration occurred only with a physician’s order. The resident was assessed as cognitively intact but with range of motion limitations in both upper and lower extremities and was dependent on staff for all other activities of daily living. Her admission record listed multiple diagnoses, including MRSA infection, local skin and subcutaneous tissue infection, disruption of an external surgical wound, chronic kidney disease stage 3A, chronic pain syndrome, major depressive disorder, generalized anxiety disorder, extracorporeal dialysis catheter, colostomy, anemia, bilateral hip osteoarthritis, lower abdominal pain, type II diabetes mellitus, and a healing right femur fracture. During a morning medication pass, an RN administered the resident’s insulin injection and nasal spray, then placed the remainder of her morning medications in cups on the bedside table and left the room without observing her take them. The unsupervised medications included 18 different drugs, such as clonidine, buspirone, amlodipine, ferrous gluconate, liquid protein supplement, glipizide, gabapentin, losartan, lorazepam, metformin, metoprolol, oxybutynin ER, terazosin, sertraline, senna-docusate, pantoprazole, Miralax in water, and milk of magnesia. The RN documented these medications as administered and moved the medication cart down the hall. Later, the resident reported that most nurses leave her pills on the bedside table without watching her take them, that she does not like this practice because she has dropped pills before, and that pills have spilled when left on the table while she was sleeping and bumped it. She also stated she is clumsy and sometimes drops a pill. Review of the resident’s orders confirmed there was no physician order permitting her to self-administer medications. Facility staff stated that residents allowed to self-administer must have a physician’s order, and the facility’s self-administration policy specified that residents may self-administer only according to a physician’s order and under specified conditions.
High Medication Error Rate Due to Late and Improperly Documented Administration
Penalty
Summary
The deficiency involves the facility’s failure to administer medications at the ordered time, resulting in an 80% medication error rate during a medication pass observation. On 3/3/26 between 8:44 AM and 9:18 AM, an RN was observed checking a resident’s blood sugar and administering long-acting insulin at 9:10 AM, then retrieving 19 additional medications that had been pre-poured for the same resident. At 9:12 AM, the RN administered only Flonase nasal spray and left the remaining medications on the bedside table before exiting the room. The electronic MAR showed the resident’s medications highlighted in pink/red, indicating they were overdue, yet the RN documented them as administered and moved the medication cart further down the hall. Record review of the March 2026 MAR showed multiple medications ordered for administration at 8:00 AM, including Lantus insulin, Flonase, clonidine, buspirone, amlodipine, ferrous gluconate, Pro T Gold, glipizide, gabapentin, losartan, lorazepam, metformin, metoprolol, oxybutynin ER, terazosin, sertraline, senna-docusate, pantoprazole, polyethylene glycol, and milk of magnesia, many of which were scheduled once or twice daily. Facility staff stated that medications should be administered within one hour before or after the ordered time, and that medications turning red in the system indicate they are overdue. Staff also stated that late administration of twice-daily medications affects spacing between doses and could affect therapeutic levels. The facility’s medication administration policy requires drugs to be administered in accordance with written physician orders and established procedures, which was not followed in this instance.
Unsecured Prepared Medications Left Unattended on Medication Cart
Penalty
Summary
The deficiency involves unsecured medications left unattended on a medication cart after being prepared for administration to a resident. On 3/3/26 at 9:10 AM, an RN (V5) prepared 19 different morning medications for a resident (R1) and placed them in several cups on top of the medication cart. The RN then entered the resident’s room carrying only the resident’s insulin to check blood sugar levels and administer the insulin. The medication cart, with the remaining 19 prepared medications on top, was pushed against the wall past the resident’s doorway and was not within the RN’s line of vision. During this time, another nurse, an LPN/Infection Preventionist (V4), was observed coming up the hall and was asked whether it was acceptable to leave medications on top of the cart when the nurse goes into a room. V4 stated it was not acceptable to leave medications on top of the medication cart unattended and later confirmed that, since the medications had already been prepared, they should have been placed back into the locked medication cart so other residents could not access or grab them. The facility’s policy dated 05/2025 requires resident-specific medications to be stored in a locked cabinet or cart accessible only to authorized staff, with Schedule II controlled medications stored under a double-lock system.
Failure to Use Required PPE for Resident on Contact Isolation
Penalty
Summary
The deficiency involves staff failing to follow the facility’s contact isolation and PPE requirements for a resident on contact precautions for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. The resident had multiple complex medical conditions, including chronic kidney disease, type II diabetes mellitus, chronic wounds, an indwelling urinary catheter, a colostomy, and multiple open surgical wounds to the abdomen and right lower extremity, placing her at increased risk for infection. Her care plan and physician orders specified single-room isolation with contact precautions for MRSA, and the facility’s posted signage outside her room directed all individuals to perform hand hygiene and don gloves and a gown before room entry, discarding them before exit. The facility’s written policy on contact precautions required hand hygiene prior to entering and exiting the room and mandated that all individuals entering the room use PPE appropriately, including gloves and a gown. Despite these requirements, surveyors observed multiple instances of noncompliance. An RN entered the resident’s room wearing only gloves to check blood sugar and administer insulin, during which the RN’s sweater touched the resident’s bedding. After being told by the IP nurse to wear proper PPE when entering the room, the RN re-entered the room again wearing only gloves to administer additional medications, and her sweater again contacted the resident’s bedding. Later, a CNA entered the same resident’s room without any PPE, touched the bedside table and bed rail, and interacted with the resident. The resident reported that staff do not always wear a gown and gloves when entering her room and stated she had an abdominal wound infection for which she was receiving antibiotics. The IP nurse confirmed that the resident was on contact isolation for MRSA of the abdominal wound and that the RN should have performed hand hygiene and donned both gown and gloves before entering the room.
Failure to Provide Required Showers and ADL Assistance During Contact Isolation
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with activities of daily living, specifically bathing, to a resident who was unable to independently meet this need. Surveyors observed the resident in her room without an isolation sign posted and noted she had no shower stall in her bathroom. The resident reported that upon admission she was placed on contact isolation for a blood infection and was repeatedly told by staff she could not leave her room to shower, resulting in her not receiving a shower for approximately 11 days and feeling that she smelled bad. Certified nursing assistants stated that residents are supposed to receive showers twice a week and that residents on contact isolation can leave their rooms to shower, and one CNA acknowledged not assisting this resident with showering while she was in isolation. A registered nurse confirmed that the resident’s contact isolation was discontinued on a specific date and that she received a shower then, and that the resident had reported not receiving a shower prior to that time. The resident’s care plan documented an ADL performance deficit with interventions to assist with bathing and personal hygiene, and also noted contact isolation precautions, while the facility’s bath/shower report showed the resident did not receive showers twice weekly as required by facility policy, which states bathing is to provide cleanliness, comfort, and prevent body odors.
Failure to Implement Care-Planned Fall Prevention Interventions During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to ensure that safety interventions were in place for a resident identified as being at risk for falls. The resident had multiple diagnoses including osteomyelitis, palliative care status, type 2 diabetes, heart disease, chronic kidney disease stage 3, hypertension, mild cognitive impairment, and lymphedema. Her care plan identified her as at risk for falls, with self-care deficits and a need for staff assistance with bed mobility, and included interventions such as using side rails for support and cueing her to grasp the side rail for positioning. A Restorative Nursing assessment documented that she was on a bed mobility program and would roll side to side during care and repositioning using side rails as needed, and that side rails were indicated as an enabler to promote independence. Despite this, staff interviews and observations confirmed that side rails were not in place prior to the fall, and the resident instead held onto the bedside table during care. On the date of the fall, a CNA reported providing incontinence care and rolling the resident to her side while the resident held onto the bedside table because side rails were not in place. The CNA stated that while reaching for a towel with one hand and maintaining one hand on the resident’s body, the resident let go of the bedside table, said she got weak, and rolled off the bed onto the floor on the right side, where the bedside table was located. The nurse on duty reported that when she entered the room after the fall, the floor mats were not on the floor and that she believed the resident hit her head on the bedside table. The fall incident report documented multiple injuries including a lump with swelling on the right forehead, right eye bruising, a chin abrasion, a small cut on the right elbow, a bruise and small cut on the right ring finger, and bruising to the left knee. Subsequent observation showed the resident in a large bariatric bed with a large dark purple/greenish bruise to the right eye/forehead area and a small laceration to the chin, with the bedside table on the right side of the bed and thick bilateral floor mats on the floor. The Restorative Nurse confirmed the resident should have had side rails for bed mobility, acknowledged that her strength varied day to day and that she should have something to hold onto when weak, and was unsure who was responsible for ensuring side rails were in place, despite the facility’s Management of Falls Policy requiring assessment of hazards and implementation of appropriate interventions to minimize fall risks.
Failure to Promptly Notify Practitioner of Radiology Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of radiology results for one resident. The resident’s x-ray was performed on 1/5/26 at 6:37 PM, and the radiology report indicates the results were reported to the facility on 1/6/26 at 1:43 AM. The nurse practitioner ultimately reviewed the results on 1/6/26 at 4:59 PM. The facility’s nursing schedule shows that an RN and an LPN were assigned to the resident’s hall when the x-rays were ordered and when the results were received. The LPN reported checking the resident’s electronic medical record for updated x-ray results around 3:30 AM on 1/6/26 and stated that at that time the results still appeared as pending. The LPN did not check again for updated x-ray results for the remainder of the shift, despite being instructed that nurses should check for results at the end of each shift and notify the nurse practitioner immediately when results are received. The RN later documented in a nurse’s note on 1/6/26 at 5:30 PM that the x-ray results were relayed to the nurse practitioner, who then ordered the resident sent to the local hospital for further evaluation and treatment. However, the nurse practitioner stated that no facility staff notified them that the x-ray results had been uploaded prior to their own review at 4:59 PM on 1/6/26, and that earlier notification would have resulted in the resident being sent to the hospital earlier in the day. The Director of Nursing confirmed that the facility’s expectation is that nurses check for x-ray results at the beginning and end of their shifts and notify the nurse practitioner by call, text, or in person when results are available, to ensure the practitioner receives and reviews them.
Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents with severe dementia from sexual abuse. One resident with Alzheimer's disease and a severely impaired BIMS score was observed by another resident and an activity aide making physical contact and placing his hand inside the diaper area of another resident, who was also severely cognitively impaired and on hospice care. The incident occurred in the activity room, where the resident was seen with his hand inside the other resident's pants, and staff were alerted by a witness. The staff intervened and separated the residents after the inappropriate contact was observed. Both residents involved were unable to provide details about the incident due to their cognitive impairments. The event was reported to facility management and a body assessment was conducted on the resident who was touched, with no injuries found. The care plan for the resident at risk for abuse noted interventions to keep her safe, but the incident still occurred. The facility's policy affirms residents' rights to be free from abuse, including sexual abuse, but the failure to prevent this incident resulted in a deficiency.
Failure to Remove Accused CNA from Resident Contact Following Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy by not immediately removing a Certified Nurse Assistant (CNA) accused of mistreatment from resident contact. According to the facility's policy, any employee accused of mistreatment must be removed from resident contact immediately until the investigation is reviewed by the administrator or designee. In this case, a resident reported to family members that the CNA had hit him. The family relayed this allegation to the Operations Manager, who did not clarify the nature of the complaint with the resident and only reported that the CNA was 'rough' to the Assistant Administrator. The Assistant Administrator stated she was not informed of the specific allegation of being hit. Despite the report, the accused CNA continued to work as the resident's CNA the following day, as confirmed by timecard records and staff interviews. The Director of Nursing received a message from the resident's family member requesting a call back to ensure the CNA was not assigned to the resident, but did not return the call. As a result, the accused CNA maintained direct contact with the resident after the allegation was made, contrary to the facility's stated policy.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse in a timely manner to the State Agency, as required by its own policy. On a Sunday, a resident's stepdaughter and ex-wife informed the Operations Manager that the resident reported being hit by a CNA. The Operations Manager acknowledged receiving this information after 3 PM but did not report the allegation to the Abuse Coordinator. Instead, she only mentioned to the Assistant Administrator that there was an issue involving the resident's family, without specifying the abuse allegation. The Assistant Administrator confirmed that she was not informed of any abuse allegation that day. The Abuse Coordinator, who is also the facility Administrator, stated that he was not notified of the abuse allegation on the day it was reported by the family. The initial incident report was sent to the State Agency approximately 48 hours after the allegation was made, documenting that a family member reported a CNA had hit the resident and that the CNA was suspended pending investigation. The facility's abuse policy requires immediate reporting of such allegations to the Department of Public Health, but this was not followed in this instance.
Failure to Ensure Call Lights Within Reach for Residents at Risk of Falls
Penalty
Summary
The facility failed to ensure that residents at risk for falls had their call lights within reach, as observed in three out of six residents reviewed for safety. On the specified date, one resident was found sitting in a chair with the call light clipped to the opposite side of the bed, making it inaccessible. This resident's care plan indicated a risk for falls due to weakness and included an intervention to keep the call light within reach. Another resident was observed in a wheelchair with the call light clipped behind the bed, out of reach. This resident's care plan also noted a risk for falls due to generalized weakness, with a similar intervention to ensure the call light was accessible. A third resident was found with the call light coiled and clipped to the wall behind the bed, which a CNA later adjusted to be within reach. The facility's policy on fall management emphasizes assessing hazards and ensuring interventions are in place to minimize fall risks, which was not adhered to in these cases.
Resident Suffers Severe Burn from Unregulated Coffee Temperature
Penalty
Summary
The facility failed to ensure the safe serving of hot beverages, resulting in a resident, R1, suffering a severe burn. R1, who was cognitively intact and used a wheelchair for mobility, was involved in an incident where she was handed a cup of hot coffee by another resident, R2. The coffee, dispensed from a single-serving pod-type coffee maker in the counselor's office, was at a temperature that caused a third-degree burn when it spilled onto R1's left thigh. The incident occurred as R1 was being assisted by R2 to move her wheelchair, and the coffee was dropped during the exchange. R1's medical history included Parkinson's Disease, which contributed to her hand tremors and potentially affected her ability to handle the hot beverage safely. The wound resulting from the spill was extensive, measuring 12 to 14 inches in length and 5 to 6 inches in width, with nearly 100 percent of the wound covered in slough tissue. The wound care assessments confirmed the severity of the burn as third-degree, involving all layers of the skin and requiring significant medical attention. The facility's failure to monitor and regulate the temperature of the coffee from the single-serving coffee maker contributed to the incident. The coffee was found to be dispensed at temperatures significantly higher than the facility's regulated kitchen coffee machines, which were set to avoid burns. The lack of a process to measure and control the temperature of coffee from the single-serving machines on the unit was a critical oversight, leading to the severe injury sustained by R1.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving two residents. One resident, identified as R58, who has a history of schizoaffective disorder and aggressive behaviors, was observed to have physically assaulted another resident, R30, who has schizophrenia and cognitive communication deficits. The incident occurred when R58, who was known to have verbal and physical aggression issues, shoved and punched R30, causing him to fall to the ground. Despite the presence of staff and surveillance cameras, the facility did not prevent this incident from occurring. R58's behavioral history included multiple instances of verbal aggression, inappropriate behavior, and difficulty with redirection, as documented in his progress notes. These behaviors were known to the facility, as R58 had a care plan indicating his potential for verbal and physical aggression. Despite this, R58 was not adequately monitored or managed to prevent the assault on R30. The facility's failure to implement effective interventions and supervision for R58, given his documented history, contributed to the occurrence of the abuse. The facility's abuse policy emphasizes the protection of residents from abuse by anyone, including other residents. However, the policy's implementation was insufficient in this case, as the staff did not identify or mitigate the risk posed by R58's behaviors. The incident highlights a lapse in the facility's responsibility to ensure a safe environment for all residents, particularly those with known behavioral issues that could lead to conflict or harm.
Failure to Document Notification of Out-of-Range Blood Glucose Levels
Penalty
Summary
The facility failed to ensure that nursing staff documented the notification of a resident's Physician or Nurse Practitioner when the resident's blood glucose levels were outside the parameters ordered by the physician. This deficiency was identified for one resident, who was being treated for type II diabetes mellitus and was on insulin medication. The resident's blood glucose levels were frequently outside the ordered parameters, with instances of both hypoglycemia and hyperglycemia recorded over several months. However, there was no documentation in the nurse progress notes indicating that the Physician or Nurse Practitioner was notified of these out-of-range blood glucose levels on multiple occasions. The resident in question had a complex medical history, including diagnoses of schizoaffective disorder, encephalopathy, generalized anxiety disorder, and adult failure to thrive, and was assessed to have moderate cognitive impairment. Despite the facility's policy requiring notification of the Physician if blood glucose results were outside the given parameters, the Director of Nursing acknowledged that while nurses reported the levels to the Nurse Practitioner, they failed to document these notifications. The Nurse Practitioner confirmed the resident's condition as a brittle diabetic, indicating that the resident's blood glucose levels were difficult to manage, with significant fluctuations occurring with changes in insulin dosage.
Failure to Provide Adequate Nail Care for Resident with Contracture
Penalty
Summary
The facility failed to provide adequate care for a resident's right hand contracture and nails, as observed during a survey. The resident, who has a history of type 2 diabetes mellitus, Parkinson's disease, schizoaffective disorder, cellulitis of the right lower limb, spastic hemiplegia, adult failure to thrive, and a history of falling, was found with a contracted right hand and a long, thick nail on the right thumb. The resident reported that staff do not clean her right hand, and the nails were causing pain by cutting into her hand. A CNA acknowledged the difficulty in cutting the thick nail and mentioned that nurses were responsible for cutting the resident's nails, but the resident often refused care. The Director of Nursing (DON) confirmed that the resident frequently refuses care and that staff should re-approach later when care is refused. However, the DON was unaware of any recent discussions about the resident's nails and noted that the order for nurses to cut the resident's nails weekly was discontinued, as it should not have been in place. The Treatment Administration Record indicated that the nails were to be cut weekly by the night shift nurse, but this was not completed as documented. The facility's policy requires all residents to have clean, well-trimmed nails, with diabetic residents' nails to be cut by a nurse, which was not adhered to in this case.
Failure to Consistently Apply Dressings for Resident with Venous Stasis Ulcers
Penalty
Summary
The facility failed to ensure that a resident's dressings were consistently applied as ordered, leading to a deficiency in care. The resident, identified as R20, has multiple medical conditions including venous insufficiency and peripheral vascular disease, which require specific wound care management. Despite physician orders to apply a multipurpose support bandage to both lower extremities every morning and remove it at bedtime, observations and interviews revealed that these dressings were not consistently applied. On one occasion, R20 was observed with multiple open sores on her lower left leg, with drainage present, and reported that the dressings were not applied as scheduled. The facility's records showed that the treatment administration record for June 2024 did not document the completion of R20's leg wound dressing and support bandage on a specific date. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that R20 was noncompliant with her dressings, often removing them herself. However, there was a lack of documentation regarding these incidents and the reapplication of dressings. The facility's policy on skin alterations emphasizes the need for individualized care plans and appropriate treatment, which was not adhered to in this case.
Failure to Provide Range of Motion Therapy
Penalty
Summary
The facility failed to provide necessary services to prevent the decline in a resident's Range of Motion (ROM). The resident, who has hemiparesis and hemiplegia affecting her left side following a cerebral infarction, was supposed to receive ROM therapy as part of her care plan. However, the resident reported that the facility was not providing the ROM therapy, leading to a loss of mobility in her left arm. Observations confirmed that the resident's left arm was bent and close to her body, with a rolled-up washcloth in her hand, indicating a lack of proper ROM exercises. The Restorative Nurse acknowledged that the resident was on a restorative ROM program, which was discontinued in February 2024, without a clear reason. The Director of Nursing mistakenly believed that dressing the resident counted as ROM therapy. Additionally, the Restorative Nursing Assessments from February to June 2024 were incomplete, lacking documentation of goals, progress, or changes needed in the restorative plan. The resident's task sheet also did not list ROM under the restorative category, further indicating a lapse in the provision of necessary care to maintain or improve the resident's ROM.
Failure to Safely Transfer Resident with Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in an injury. The resident, who was cognitively intact and dependent on staff for transfers due to conditions such as morbid obesity, osteoarthritis, and congestive heart failure, was supposed to be transferred with the assistance of two staff members as per her care plan. However, during a transfer from her bed to a recliner, only one CNA was present, and the resident was injured when the arm of the lift hit her in the eye, causing a bruise. The incident was reported by the resident and confirmed by a Registered Nurse who observed the injury. The facility's policy mandates that two caregivers are required to operate the mechanical lift to ensure resident safety. Despite this policy, the CNA attempted the transfer alone, which led to the resident's injury. The Director of Nursing and other staff confirmed that the policy was not followed, and attempts to contact the CNA involved were unsuccessful.
Lack of Physician Orders for Suprapubic Catheter Care
Penalty
Summary
The facility failed to ensure there were physician's orders for a suprapubic catheter and its care for a resident with a neurogenic bladder, anxiety, agitation, and paranoia. The resident returned from the hospital in March 2023, but the catheter orders were not rewritten until June 26, 2024. The Director of Nursing acknowledged that the orders should have been documented on the Treatment Administration Record (TAR) to remind staff of the necessary care and to document its completion. The resident's Physician Order Sheet (POS) lacked orders for the suprapubic catheter prior to June 26, 2024, and the Medication Administration Records (MAR) for April and May 2024 did not include treatments for the catheter. The facility's Suprapubic Catheter Care Policy and Procedure from February 2011 did not specify when to change the catheter, except when it becomes dislodged, and indicated it should be replaced by a physician or nurse practitioner.
Failure to Assist and Document Nutritional Intake for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss, identified as R93, was adequately assisted and encouraged with meals. Observations revealed that R93 was often left to eat alone without assistance or verbal cueing, despite needing supervision or touching assistance for eating as indicated in the Minimum Data Set (MDS). On multiple occasions, R93's meal trays were not set up, and the resident did not consume significant portions of the meals, including fortified foods intended to supplement her diet. The documentation inaccurately reflected that R93 consumed 75-100% of her fortified potatoes, which was not the case. R93's weight log showed a significant weight loss of 7.5% from March 2024 to June 2024, with a history of gradual weight loss over six months. The resident's care plan and physician orders included fortified foods and supplements to address her nutritional needs, but these were not effectively administered or documented. The Registered Dietician (RD) and Director of Nursing (DON) acknowledged the need for accurate documentation and the importance of offering alternatives and assistance to residents with significant weight loss. The facility's Nutrition Care Significant Weight Loss policy outlines the procedure for addressing significant weight loss, including assessment by a Licensed Dietician and discussion with the interdisciplinary team. However, the facility did not adhere to these procedures, as evidenced by the lack of proper meal assistance and inaccurate documentation of R93's food intake. The failure to provide necessary support and accurate documentation contributed to the resident's continued weight loss and nutritional decline.
Infection Control Deficiencies in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during incontinence care for two residents. In the first instance, a Certified Nursing Assistant (CNA) was observed providing care to a resident with severe cognitive impairment and multiple diagnoses, including hemiplegia and congestive heart failure. The CNA placed soiled linens on a chair instead of in a plastic bag and did not change gloves after handling the soiled items before assisting the resident with other tasks. This was contrary to the facility's policy, which requires soiled linens to be transported in closed impermeable bags and hand hygiene to be performed after contact with contaminated items. In the second instance, another resident with a history of type 2 diabetes, Parkinson's disease, and cellulitis, among other conditions, was observed during personal hygiene care. The CNA placed soiled items on the floor before eventually placing them in a clear plastic bag. The facility's policy mandates that soiled linen should not be placed on the floor to prevent cross-contamination. The Infection Preventionist confirmed that placing linen on the floor is against infection control practices, as it can lead to germs being spread throughout the facility.
Neglect Resulting in Resident Left in Urine for Hours
Penalty
Summary
The facility failed to ensure a resident's right to be free from neglect, resulting in a resident lying in urine for hours, causing embarrassment and emotional distress. The resident, an elderly female with multiple diagnoses including acute cystitis, acute kidney failure, and obstructive sleep apnea, reported that on the night of the incident, she used her call light to request assistance to go to the bathroom. However, a staff member responded with a nasty remark and did not assist her, leaving her to wet herself. The resident felt afraid to ask for further help and was embarrassed by the situation. The next morning, a CNA found the resident and her bed saturated with urine and reported the incident to the administrator, describing it as neglectful care. Interviews with staff and the resident's daughter corroborated the resident's account. The daughter reported that the call light was moved out of the resident's reach, and the resident was told to urinate in her undergarment. The facility's investigation confirmed that the staff member involved was not always pleasant and had been let go due to poor performance. The facility's abuse policy defines neglect as the failure to provide necessary goods and services to avoid physical harm or mental anguish, which aligns with the events described in this incident.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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