Alden Park Strathmoor
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 5668 Strathmoor Drive, Rockford, Illinois 61107
- CMS Provider Number
- 145259
- Inspections on file
- 29
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Alden Park Strathmoor during CMS and state inspections, most recent first.
A resident was admitted from the hospital with discharge paperwork that contained conflicting information about an IV Ceftriaxone order, which was listed as both discontinued in one area and as an active discharge order in another. The IV antibiotic was never started on the resident’s MAR, and the DON later reported that the resident was on hospice, had no IV access, and was not receiving IV antibiotics. Despite the facility policy requiring verification of any order that appears inappropriate for the resident’s condition, the admitting nurse did not contact the physician to clarify the admission orders.
A resident with severe cognitive impairment, malnutrition, and dependence on enteral tube feeding experienced a rapid, significant weight loss of over 20% in about two weeks, dropping from just over 120 lbs to the low 90s. Nursing staff informed the resident’s POA and discussed plans to increase tube feeding volume and rate but did not promptly notify the physician or RD when the significant weight loss was first identified, resulting in several days without documented nutritional interventions. The RD reported learning of the weight loss only after pulling a weekly weight exception report, and the DON stated that staff are expected to immediately notify the RD and physician of significant weight changes, particularly for tube-fed residents, in accordance with the facility’s significant weight loss policy.
A resident with orders for Lantus 40 units at HS and Novolog per sliding scale with meals received Novolog instead of the ordered HS Lantus dose when an LPN removed an insulin pen from a bag labeled as Lantus that actually contained both insulin types. After administering the injection, the LPN noticed the pen color did not match Lantus and realized Novolog had been given. The DON was notified, the resident was reassessed with repeat blood glucose checks, the NP and POA were contacted, and the resident was sent to the ER, where the diagnosis was documented as accidental insulin overdose with hypoglycemia before the resident returned with stable vitals and no new orders.
A resident with paraplegia, stage 4 pressure ulcer, and chronic incontinence was left in a soiled brief overnight after experiencing severe diarrhea. Despite requesting assistance, the resident was not changed until the following morning, when a wound care nurse found stool in the brief and on the sheets. Staff interviews confirmed the resident's dependence on regular incontinence checks, and facility policy required checks at least every two hours.
A resident with paraplegia, stage 4 sacral ulcer, and third-degree burns to both lower legs did not receive daily wound care as ordered by the physician. Observations showed undated and uninitialed dressings, and records indicated missed wound care on two days. The resident, who was alert and oriented, reported that dressings were not being changed as required. Staff confirmed the importance of daily wound care and documentation, and facility policy mandates recording all dressing changes.
A resident with paraplegia, a stage 4 sacral pressure ulcer, and lower leg burns did not receive daily wound care as ordered, with missed treatments and undated dressings observed. Staff interviews confirmed the importance of daily wound care and documentation, and facility policy required both individualized care and proper record-keeping.
Dietary aides did not wash their hands or wear gloves after handling dirty dishware and before touching clean items, resulting in a failure to prevent cross-contamination. This was observed by surveyors and confirmed by the CDM, with the potential to affect all residents in the facility.
The facility did not screen, educate, or offer influenza and pneumococcal vaccines to several residents as required, and failed to administer the pneumococcal vaccine to a resident who had consented. Documentation was missing for all affected residents regarding vaccine screening, education, or administration, as confirmed by the Infection Preventionist.
A resident with a UTI and multiple chronic conditions was placed on contact isolation after a positive culture for Klebsiella pneumonia (MDRO). Although initially told she could leave her room with proper hand hygiene, staff later required her to remain in her room with the door closed for several days, despite her independence and compliance with infection control. Staff interviews confirmed this restriction, even though facility policy allowed for room exit with precautions, resulting in the resident being denied her right to movement.
A resident with a gastrostomy tube consistently received tube feedings at a lower rate and volume than recommended by the dietitian due to conflicting orders in the medical record. Staff administered the feeding at 55 ml/hr and 1100 ml total, instead of the recommended 60 ml/hr and 1200 ml, and did not clarify or update the orders as required by facility policy.
A CNA did not perform hand hygiene or change gloves after assisting a resident with incontinence care, instead proceeding to handle clean clothing and mobility equipment. This action was inconsistent with the facility's hand hygiene policy, which requires hand hygiene when moving from a soiled to a clean body site.
Three residents were not screened, educated, or offered the COVID-19 vaccine or booster upon admission, and there was no documentation in their medical records to indicate that these steps were taken. The Infection Preventionist confirmed the lack of documentation, which was not in accordance with facility policy requiring these actions for all new admissions.
A resident suffered a burn injury after falling against a wall-mounted radiator, and another resident sustained burns from spilling hot tea on her lap. The facility lacked processes to monitor radiator temperatures and ensure hot beverages were served at safe temperatures, posing risks to all residents.
The facility failed to store controlled medications properly, as observed in two medication rooms where morphine and ABHR suppositories were found in unlocked refrigerators. The Director of Nursing confirmed that these substances should be double-locked to prevent misuse. Facility guidelines and federal regulations emphasize the need for secure storage of controlled substances.
A resident with severe COPD and other medical conditions experienced a significant drop in oxygen saturation. The facility failed to complete a full assessment and notify the physician promptly, leading to the resident being transported to the emergency department in respiratory distress and failure.
A resident with Alzheimer's and other conditions experienced a 10.22% weight loss in one month due to the facility's failure to provide necessary meal assistance and interventions. Despite a care plan requiring supervision, staff did not assist or cue the resident during meals, and another resident took food from her plate without intervention.
The facility failed to maintain proper sanitization logs and ensure food was covered during transportation. Observations revealed missing test results for dishwasher sanitizing temperatures and sanitation bucket chemical levels. Additionally, dietary staff were seen transporting uncovered desserts, contrary to facility policy.
The facility failed to ensure proper pressure ulcer interventions for five residents, leading to incorrect air mattress settings and lack of proper repositioning. This resulted in deficiencies in care for residents with documented pressure ulcers or those at high risk for developing them.
The facility failed to properly label and store medications, including undated multi-dose vials of fluphenazine, expired haloperidol, and an unlocked bottle of lorazepam, leading to potential risks for residents.
A resident with hemiplegia, type 2 Diabetes, and depression was not treated with dignity in the dining room. The resident was rushed to finish his meal so other residents could be taken back to their rooms, resulting in the resident not getting enough to eat. The DON confirmed that residents should be allowed sufficient time to eat and that staff should not mention other residents' names as reasons for delays.
A facility failed to keep a urinary catheter drainage bag below the bladder level during a resident's transfer. The resident, with chronic kidney disease and an indwelling catheter, had the drainage bag raised above the bladder by a CNA, which was corrected after an LPN's intervention.
A facility failed to properly store a resident's nebulizer mask and tubing, which were found undated and uncovered in a bedside table drawer. The DON confirmed that such equipment should be dated and stored in plastic bags to prevent cross-contamination.
A resident with multiple diagnoses was observed with a medication cup containing five pills on her bedside table, which she had not taken. The nurse confirmed that the resident refuses to take her medications when staff are in the room, except for a prescribed narcotic. The physician orders did not include any orders for self-administration, and the care plan did not have any interventions for self-administration. The facility's policy requires medications to be administered safely as prescribed and by the same staff at the time of preparation.
Failure to Clarify Conflicting Admission Orders for IV Antibiotic
Penalty
Summary
The facility failed to clarify and implement admission medication orders for one resident when the resident was admitted from the hospital. The hospital discharge packet dated 12/13/25 included a discharge order for Ceftriaxone 2 grams IV every 24 hours through 1/2/26, but the resident’s December 2025 MAR shows that this IV antibiotic order was not initiated on the admission date. The DON stated that the resident returned from the hospital on hospice and, to his knowledge, did not have IV access and was not receiving IV antibiotics. Upon reviewing the hospital discharge packet, the DON noted that in one section the antibiotics were documented as discontinued, but in another section Ceftriaxone was listed under discharge orders, and acknowledged that the admitting nurse should have called to clarify the conflicting orders. The facility’s policy on physician orders for medications or treatments, dated 6/2022, requires that any dose or order that appears inappropriate considering the resident’s age, condition, or diagnosis be verified with the attending physician, which was not done in this case.
Failure to Promptly Notify Clinicians and Intervene for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s physician and Registered Dietician (RD) of a significant weight loss and to initiate timely nutritional interventions. The resident had severe cognitive impairment, was dependent on enteral tube feeding, and had been assessed as malnourished. Weight records showed a drop from 121.4 lbs to 96.9 lbs, then to 94 lbs and 92.8 lbs over a short period, reflecting approximately a 20% weight loss within two weeks. Nursing documentation noted that the nurse informed the resident’s power of attorney about the weight loss and discussed plans to increase tube feeding volume and rate, clarifying that the resident was on a total volume regimen rather than continuous feeding. However, there was no documentation that the physician or RD were notified at the time the significant weight loss was identified. The RD stated that she was not notified of the resident’s weight loss until she independently pulled the weight and vitals exception report prior to a scheduled weight meeting, and that she does not always receive direct notification of significant weight changes. The DON explained that the documentation system triggers for significant weight changes and that such changes should be brought to management the day they are noted so that the nurse practitioner and RD can be notified and recommendations obtained. The DON further stated that staff are supposed to notify the RD and physician immediately when there is a weight change, especially for residents on tube feeding who are at high risk for weight fluctuations, and acknowledged that in this case notification occurred days later. The facility’s policy on significant weight loss defined thresholds for significant loss and required assessment by a licensed dietician, but the resident experienced a 28.6 lb loss within two weeks with no documented nutritional interventions for five days following the identified weight loss.
Wrong Insulin Type Administered Due to Storage and Verification Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received the correct type of insulin as ordered. The resident had physician orders for Lantus 40 units at bedtime and Novolog per sliding scale three times daily with meals. During an evening medication pass, an LPN administered Novolog instead of the ordered bedtime Lantus dose. The LPN reported that the medication bag was labeled as Lantus, but the insulin pen inside was actually Novolog, and both types of insulin had been stored together in the same bag. After administering the dose, the LPN noticed the pen color was incorrect and recognized that the wrong insulin had been given. Following the administration error, the LPN immediately notified the DON, and the resident was assessed and had blood sugar rechecked. The nurse practitioner and the resident’s power of attorney were notified, and the resident was sent to the emergency room. Progress notes document that the resident was transferred for evaluation and treatment related to blood glucose and later returned with stable vital signs and a blood sugar of 137. The hospital after-visit summary lists a diagnosis of accidental or unintentional insulin overdose with hypoglycemia, and notes that the resident’s point-of-care glucose was checked multiple times in the emergency room and that the resident received education on signs and symptoms of hypoglycemia before being discharged back to the facility.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with paraplegia, stage 4 sacral pressure ulcer, third degree burns on both lower legs, clostridium difficile infection, neuropathic bladder, and chronic embolism/thrombosis of the right lower extremity was found to have been left in a soiled brief for an extended period overnight. The resident was totally dependent on staff for toileting hygiene and was always incontinent of bowel, requiring frequent checks and assistance. According to the resident, after experiencing severe diarrhea one night, she requested assistance to be changed around 9:45 PM, but was told by a CNA that the next shift would handle it. No staff attended to her until approximately 6:15 AM the following morning, when the wound care nurse found her still soiled, with stool present in her brief and on her sheets. Staff interviews confirmed that the resident was alert, oriented, and unable to feel if she was wet or soiled, necessitating regular incontinence checks. The wound care nurse corroborated the resident's account, noting the presence of stool and a strong odor in the room, as well as soiled sheets. The facility's policy required resident checks at least every two hours, especially for those who are bedbound and require assistance with turning and incontinence care. The Director of Nurses also stated that such checks are necessary to maintain resident dignity and prevent infection and skin breakdown.
Failure to Perform and Document Ordered Burn Wound Care
Penalty
Summary
A resident with multiple complex medical conditions, including paraplegia, stage 4 sacral pressure ulcer, third-degree burns to both lower legs, and chronic bowel incontinence, was admitted to the facility with physician orders for daily wound care to the right and left lower extremities. Observations revealed that the dressings on the resident's sacral area and both calves were not dated or initialed. Review of the treatment administration record showed that wound care was not performed on either lower extremity on two specific dates, despite daily orders. The resident reported that staff were not changing the dressings as required, and both a Certified Nurse Aide and the Wound Care Nurse confirmed the resident was alert and oriented, emphasizing the importance of adhering to wound care orders to prevent infection and promote healing. The Director of Nurses acknowledged that wound care should be documented immediately after being performed, and lack of documentation indicates either the care was not provided or not recorded. The facility's policy requires documentation of dressing changes on the treatment administration record or electronic health record. The failure to perform and document wound care as ordered for the resident's non-pressure wounds constituted a deficiency in providing appropriate treatment and care according to physician orders and facility policy.
Failure to Perform and Document Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were performed as ordered for a resident with multiple complex medical conditions, including paraplegia, a stage 4 sacral pressure ulcer, and third-degree burns on both lower legs. The resident was assessed as totally dependent on staff for hygiene, dressing, rolling, and transfers, and was always incontinent of bowel. Physician orders required daily wound care to the sacrum, but documentation showed that wound care was not performed on at least two specified days. During observation, the resident's wound dressings were found to be undated and uninitialed, and the resident reported that staff were not changing the dressings daily as required. Interviews with staff confirmed the importance of daily wound care and proper documentation, with the wound care nurse and DON both acknowledging that lack of documentation could mean the care was not provided. The facility's policy required individualized care plans and documentation of dressing changes on the treatment administration record or electronic health record. The failure to perform and document wound care as ordered constituted a deficiency in the facility's pressure ulcer care practices.
Failure to Prevent Cross-Contamination in Dietary Services
Penalty
Summary
Dietary aides failed to follow proper hand hygiene protocols while handling dishware, leading to a risk of cross-contamination. Specifically, one dietary aide loaded dirty cups into the dishwasher and then immediately handled clean pots without washing her hands or wearing gloves. Another dietary aide placed dirty breakfast dishes on a shelf and then handled clean food trays without washing his hands or wearing gloves. The Certified Dietary Manager confirmed that staff should not touch clean dishes after handling dirty items and should practice good hand hygiene. The facility's policy requires food and nutrition services staff to prevent cross-contamination by practicing good hand hygiene, hand washing, and glove use. These actions were observed in a facility with a census of 156 residents, and the failure to follow proper procedures had the potential to affect all residents.
Failure to Screen and Offer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to properly screen, educate, and offer influenza and pneumococcal vaccines to residents as required by policy and CDC/ACIP recommendations. Specifically, five residents were not screened for or offered the influenza vaccine during influenza season, nor were they screened for or offered the pneumococcal vaccine upon admission. In one case, a resident who had provided consent for the pneumococcal vaccine did not receive it. Documentation was lacking for all five residents regarding screening, education, or administration of either vaccine. Interviews with the Infection Preventionist confirmed that there was no documentation to support that these residents had been screened for, educated on, or offered the required vaccines. The facility's own policies state that all residents should be offered the influenza vaccine from October through March and the pneumococcal vaccine upon admission, unless contraindicated or already immunized. These failures were identified through record review and staff interviews, indicating a breakdown in the facility's immunization practices for new admissions and during the influenza season.
Resident Confined to Room During Contact Isolation Despite Independence
Penalty
Summary
A resident with a history of type 2 diabetes, fibromyalgia, generalized anxiety, chronic pain, restless leg syndrome, major depression, and a urinary tract infection (UTI) was placed on contact isolation after a urinalysis revealed Klebsiella pneumonia (MDRO). Physician orders indicated contact precautions for E. coli in the urine. Initially, staff informed the resident that she could leave her room if she practiced hand hygiene, but this guidance was later changed, and she was required to remain in her room with the door closed for the last four to five days of her isolation period. The resident, who was independent in her care and compliant with hand hygiene, was not allowed to leave her room despite her requests and inquiries to multiple staff members, including the Assistant Administrator and previous DON. Staff consistently told her that remaining in her room was facility policy. Interviews with staff, including the Unit Manager, RN, Assistant Administrator, and previous DON, confirmed that the resident was not permitted to leave her room while on contact isolation, even though she was independent and able to follow infection control measures. The Corporate RN stated that residents on contact isolation for a UTI could leave their rooms if they performed hand hygiene and avoided contact with other residents or food. The facility's actions resulted in the resident being confined to her room against her wishes, without clear justification based on her ability to comply with infection control protocols.
Failure to Implement Dietitian-Recommended Tube Feeding Order
Penalty
Summary
A resident with a gastrostomy tube was observed to have their tube feeding pump set at an infusion rate of 55 ml per hour with a total volume of 1100 ml, despite a dietitian's recommendation to increase the rate to 60 ml per hour and a total volume of 1200 ml to address undesirable weight loss. The resident's medical record contained two conflicting tube feeding orders, both starting on the same date, one for 55 ml/hr and one for 60 ml/hr. The medication administration record and progress notes indicated that the resident consistently received the lower rate and volume over several days. During review, a registered nurse identified the discrepancy between the orders and acknowledged the need for clarification from the dietitian, confirming that only one order should be active. The dietitian confirmed her recommendation for the higher rate and volume to maintain the resident's weight. The resident's care plan required tube feeding to be administered as ordered, and facility policy directed staff to verify feeding orders. The failure to update and implement the dietitian's recommended tube feeding order resulted in the resident not receiving the prescribed nutritional support.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to perform proper hand hygiene and did not change gloves after assisting a resident with bladder and bowel incontinence care. The resident, who had diagnoses including Alzheimer's Disease, narcolepsy, anemia, adult failure to thrive, dementia, and a history of falling, was transferred to the toilet, where he urinated and had a large bowel movement. After the resident used toilet paper to wipe himself, the CNA pulled up the resident's clean incontinence brief and pants without performing hand hygiene or washing hands. This action was observed and confirmed to be inconsistent with the facility's hand hygiene policy, which requires hand hygiene when moving from a soiled to a clean body site.
Failure to Screen, Educate, and Offer COVID-19 Vaccine to New Admissions
Penalty
Summary
The facility failed to screen, educate, or offer the COVID-19 vaccine or booster to three residents upon admission, as required by facility policy. For each of these residents, there was no documentation in their medical records indicating that they had been screened for COVID-19 vaccination status, provided with education about the vaccine, or offered the vaccine or booster. Additionally, there was no record of these residents receiving the vaccine while in the facility. During an interview, the Infection Preventionist confirmed that there was no documentation to support that these residents had been screened, educated, or offered the COVID-19 vaccine or booster. Facility policy required that all residents be screened and offered the vaccine upon admission, and that documentation of education, administration, or refusal be maintained in the medical record. This process was not followed for the three residents identified in the report.
Resident Burns Due to Unsafe Radiator and Hot Beverage Handling
Penalty
Summary
The facility failed to ensure the safety of a resident, resulting in a burn injury. A resident, identified as R2, sustained a deep partial-thickness burn to her right foot after falling against a wall-mounted radiator in her room. The incident occurred when R2 fell out of bed and her foot became trapped under the heater, causing a burn that required hospitalization and wound debridement. The facility did not have a process in place to monitor the temperatures of the radiators, and the Maintenance Director confirmed that the facility did not check the temperatures of the radiators or monitor outdoor temperatures. Another incident involved a resident, identified as R3, who sustained full-thickness burns to her thighs and buttocks after spilling hot tea on her lap. The Dietary Manager stated that the facility's policy required hot beverages to be served at a temperature of 120 degrees Fahrenheit or below. However, on the day of the incident, an Activity Aide refilled a carafe with hot water from a pot on the stove without checking the temperature before serving it to R3. This resulted in R3 suffering burns from the scalding hot water. These failures in monitoring and controlling the temperature of radiators and hot beverages posed a risk to all 160 residents in the facility. The lack of adequate supervision and safety measures led to Immediate Jeopardy, as these incidents demonstrated a significant risk of harm to the residents. The facility's inaction in implementing proper safety protocols and monitoring systems contributed to these preventable accidents.
Removal Plan
- All residents' heaters were reviewed for conditions that may make them unsafe. All resident beds were visually inspected to ensure they were not touching or within a close distance of the heaters.
- All staff were educated on room safety checks and notifications to appropriate parties/vendors of equipment malfunction. Ongoing for all incoming staff not on duty.
- The President of Facilities Environmental Services and Life Safety was called in to verify that all resident's heaters are in good repair and functioning properly.
- All staff were educated on updated hot beverage and temperature policy. Ongoing for all incoming staff not on duty.
- Coded door knobs were replaced on both kitchen doors to ensure only kitchen staff are to enter and exit from the kitchen, and have access to kitchen equipment and supplies.
- A crowd control belt was added at the kitchen entrance at the elevator to remind any staff other than Dietary to ask for dietary's assistance.
- Resident Council Meeting held to educate residents on the updated hot beverage policy.
- Resident Council Meeting held to educate residents on room safety and keeping themselves away from thermal surfaces.
- The facility Administrator and IDT reviewed related policies and procedures. The following policies were reviewed: Incident/Accidents; Fall Management; Dietary Food and Beverage temperatures.
- The Administrator initiated a QA audit tool for environmental safety checks to ensure that environmental hazards are resolved. Heaters in residents' rooms and common areas shall be maintained in a manner to prevent residents from prolonged contact with thermal surfaces. Weekly temperature checks of the radiator's thermal surface will be conducted with an Infrared Thermometer and placed on a log. Random room audits will be conducted 1 time per week for the duration of the heating season, and then on an as needed basis to ensure residents are safely placed away from the radiators. The results of the QA Audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Ongoing for QA monitoring.
- The Administrator initiated a QA audit tool for hot beverage serving and temperature taking, to ensure that dietary staff are preparing hot liquids and taking temps of liquids as per the policy and ensure that hot beverages are served at the appropriate temperature. All resident wings will be reviewed 2 times a week for 30 days, then 1 time a week for 30 days, and then on an as needed basis until ongoing compliance is achieved. The results of the QA audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Ongoing for QA monitoring.
- An emergency QA meeting was held by the Administrator with the Interdisciplinary Care Team and Medical Director to review the removal plan. The QA committee shall meet monthly thereafter and review the results of the QA audits. Changes to the policy and procedure shall be made as indicated by the QA results. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator. Ongoing for QA monitoring.
Improper Medication Storage Leading to Potential Diversion
Penalty
Summary
The facility failed to store medications properly to prevent diversion, as observed during a survey of five medication rooms. In the A wing medication room, an unlocked refrigerator contained an unopened bottle of morphine sulfate liquid, labeled for a resident. Similarly, in the C wing medication room, an unlocked refrigerator contained two ABHR suppositories in a clear plastic baggie, labeled for another resident. The Director of Nursing confirmed that morphine and lorazepam, both controlled substances, should be stored under two locks to prevent misuse or abuse. The facility's Medication Pass Guidelines and the Drug Enforcement Administration's classification of morphine as a Schedule II narcotic emphasize the need for double-lock storage of controlled substances. Additionally, the National Institutes of Health highlights the abuse potential of lorazepam, a Schedule IV medication, which should also be securely stored. The facility's Medication Storage Policy requires medications to be returned to the pharmacy if a patient has not returned within 30 days, which was not adhered to in the case of the deceased resident whose medications were still present.
Failure to Notify Physician and Complete Assessment for Change in Condition
Penalty
Summary
The facility failed to ensure a complete assessment was completed with a resident's initial change in condition and did not immediately notify the physician of the change. The resident, who had a history of severe chronic obstructive pulmonary disease (COPD) and other significant medical conditions, experienced a drop in oxygen saturation levels. Despite this, the facility did not obtain physician orders for an increase in oxygen per nasal cannula, which led to the resident being transported to the local emergency department 4.5 hours after the initial change in condition. Upon arrival, the resident was in respiratory distress and failure. The resident's medical history included acute respiratory failure, pneumonia, and dependence on supplemental oxygen, among other conditions. On the day of the incident, the resident's oxygen saturation dropped to 88% and then to 77% when her head was lowered to change her adult brief. The nurse temporarily increased the oxygen to 5 liters, but there was no complete assessment documented or notification to the doctor of the change in condition. The resident's oxygen saturation continued to drop, and she was eventually sent to the hospital in respiratory arrest. Interviews with staff revealed that the resident's baseline oxygen saturation was 93%-96% on 3 liters of oxygen. The staff acknowledged that a drop to 88% would be considered a change in condition that should have been reported to the physician. However, the physician was not notified in a timely manner, and the resident's condition deteriorated. The facility's policies on oxygen titration and change of condition were not followed, contributing to the delay in appropriate medical intervention.
Failure to Assist Resident with Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate assistance and interventions for a resident (R48) with significant weight loss. R48, a female with Alzheimer's Disease, cerebrovascular disease, dementia, osteoarthritis, and chronic kidney disease, experienced a 10.22% weight loss in one month. Despite a diagnosis of failure to thrive and a care plan indicating the need for supervision and assistance during meals, staff did not provide the necessary support. Observations showed that R48 was left unattended during meals, with no staff assisting, cueing, or prompting her to eat. Additionally, another resident took food from R48's plate without staff intervention. The facility's records indicated that R48 had orders for fortified foods and nutritional supplements, but no new interventions were added following her significant weight loss. The dietician confirmed that R48 required supervision during meals and expected staff to assist and intervene as needed. The Director of Nursing attributed the weight loss to a recent illness (shingles), but no additional measures were taken to address the resident's nutritional needs during this period.
Failure to Maintain Sanitization Logs and Cover Food During Transportation
Penalty
Summary
The facility failed to maintain proper sanitization logs and ensure food was covered during transportation, affecting all residents. Observations revealed that the dishwasher sanitizing temperature and sanitation bucket chemical levels were not consistently tested and documented. Specifically, the March dishwasher log was missing eight temperature test results, and the March sanitation bucket log was missing 34 sanitation level test results. The Dietary Manager confirmed the importance of these tests and acknowledged the lapses in documentation, which are crucial for preventing foodborne illnesses among residents. Additionally, food transportation practices were found to be inadequate. Dietary staff were observed transporting uncovered dessert cakes and chocolate puddings from the basement kitchen to the first-floor kitchenette and dining areas. The Dietary Manager admitted that food should be covered to prevent contamination from dust and other particles but was unsure why the desserts were not covered during transportation. The facility's policy mandates that food be transported in covered containers, which was not adhered to in these instances.
Failure to Ensure Proper Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure proper pressure ulcer interventions were in place for five residents, leading to deficiencies in care. For Resident 146, the air mattress was incorrectly set at 270 pounds instead of the resident's actual weight of 176 pounds, which could affect the air distribution and firmness necessary for wound healing. The wound care nurse and unit manager were unaware of who was responsible for ensuring the correct settings on the air mattress, indicating a lack of proper protocol and oversight. Resident 2 was found with an air mattress set at 340 pounds, significantly higher than her actual weight of 161.8 pounds. The unit manager admitted to setting the beds correctly upon delivery but was unsure how the settings could have been changed. The wound care nurse was also unaware of why Resident 2 was on an air bed, highlighting a gap in communication and understanding of the resident's care plan. Other residents, including Resident 11, Resident 36, and Resident 75, also experienced issues with incorrect air mattress settings and lack of proper repositioning. These residents had documented pressure ulcers or were at high risk for developing them, yet the facility failed to implement and monitor appropriate preventative measures. The facility's policy on pressure injury prevention and treatment was not effectively followed, leading to these deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for multiple residents. Specifically, multi-dose vials of fluphenazine decanoate for two residents were found opened and undated, making it impossible to determine their usability. Additionally, eight multi-dose vials of haloperidol labeled with a resident's name were found expired and still stored in the medication room without any current orders for the medication. A registered nurse confirmed that the vials should have been dated and discarded after 30 days, and the expired haloperidol should have been removed to prevent potential misuse. Furthermore, a controlled medication, lorazepam, prescribed to a resident was found improperly stored in an unlocked refrigerator in the memory care wing. The medication, which is a Schedule IV controlled substance with potential for abuse, was not double-locked as required. The Nurse Consultant/Pharmacy verified that lorazepam should be stored under two locks for safety. The facility's policy on controlled drug storage was requested but not provided, indicating a lapse in adherence to proper medication storage protocols.
Failure to Treat Resident with Dignity in Dining Room
Penalty
Summary
The facility failed to treat a resident with dignity while in the dining room. The resident, who has diagnoses including hemiplegia, type 2 Diabetes, and depression, was observed feeding himself lunch. As other residents finished eating, they asked staff to be taken back to their rooms but were told they had to wait until all residents were done eating. A Certified Nursing Assistant (CNA) was heard saying that the residents had to wait until the resident and others were done eating. When asked if he was finished, the resident said yes and was taken back to his room with half of his meal left uneaten. The resident later confirmed he did not get enough to eat and felt like a deterrent to others. The Director of Nursing (DON) stated that residents should be allowed the time they need to finish eating and that there are enough staff available to help residents return to their rooms. The DON also mentioned that staff should not mention another resident's name as a reason for the delay. The facility's care plan, revised in June 2023, indicates that care should be provided in a manner that maintains or enhances each resident's dignity and respect, recognizing their individuality.
Improper Handling of Urinary Catheter Drainage Bag During Transfer
Penalty
Summary
The facility failed to ensure a urinary catheter drainage bag remained below the level of the bladder during a transfer for one resident. The resident, who was admitted with multiple diagnoses including retention of urine and chronic kidney disease, was observed being transferred from a geriatric chair into bed by two CNAs. During the transfer, one CNA raised the urinary drainage bag above the level of the bladder and placed it on the resident's lap in the mechanical lift sling. An LPN supervising the transfer advised the CNA to place the drainage bag below the bladder, which was then done. The incident was noted during a quarterly assessment that documented the resident had an indwelling catheter.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure a resident's breathing treatment equipment was stored in a manner to prevent cross-contamination. A male resident with acute and chronic respiratory failure, among other conditions, had a physician's order for a medicated breathing treatment every six hours. On the morning of 04/02/24, the resident's nebulizer mask and tubing were found inside the top drawer of his bedside table, neither dated nor covered. The Director of Nursing confirmed that nebulizer and oxygen tubing and masks should be dated when first used and stored in a plastic bag when not in use. The facility did not provide a policy on the storage of resident breathing treatment/oxygen equipment when requested.
Failure to Safely Administer Medications
Penalty
Summary
The facility failed to safely administer medications as ordered by the physician for a resident diagnosed with hemiplegia, hypertension, delusional disorders, and anxiety. The resident was observed with a medication cup containing five pills on her bedside table, which she had not taken. The nurse assigned to the unit was not present near the resident's room at the time of observation. The resident mentioned that she forgot to take the medications, and the nurse later confirmed that the resident refuses to take her medications when staff are in the room, except for a prescribed narcotic. The Director of Nursing stated that unless care planned, a resident is to be observed taking the medications, and medications should not be left at the bedside. The physician orders did not include any orders for self-administration of medications, and the resident's care plan did not have any interventions for self-administration. The facility's policy on medication administration requires that medications be administered safely as prescribed and that the same staff prepare and administer the medications at the time of preparation. The medication administration record showed that five medications were administered to the resident during the 8 AM medication administration on the observed date.
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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.
Trusted data from CMS and state health departments
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