Aliya Of Glenwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenwood, Illinois.
- Location
- 19330 South Cottage Grove, Glenwood, Illinois 60425
- CMS Provider Number
- 145758
- Inspections on file
- 58
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Aliya Of Glenwood during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple chronic conditions alleged that a former roommate physically assaulted him at night, repeatedly striking his left chest and causing ongoing rib pain. An LPN reported hearing a loud verbal altercation, removing the resident from the room, and being told by the resident that the roommate had slapped him, after which she assessed the resident and notified the former DON and the physician. The former roommate denied any physical altercation. The incident was not documented in the abuse reportable binder, facility leadership reported being unaware of it, and no investigation or required report to the state health department was initiated, despite facility policy requiring documentation, investigation, and timely reporting of all abuse allegations.
The facility failed to follow its staffing policy and facility assessment-based CNA ratios, resulting in inadequate CNA coverage on a night shift and a resident fall. Due to call-offs, only five CNAs were present for a census of 136 residents, with CNAs assigned between 25 and 33 residents each. A CNA reported that more help was needed to ensure proper nursing care and that some work was not completed. The DON acknowledged that there was not an appropriate number of staff available to meet resident needs at the time of the incident, despite the facility’s assessment tool specifying lower CNA-to-resident ratios for post-acute and LTC units on night shift.
A resident with significant medical conditions and limited use of the left arm reported that she previously used bilateral side rails for bed mobility but, after a bed change, no longer had both rails and had only a left side rail despite repeatedly requesting a right side rail to assist with repositioning. Therapy documentation showed she had effectively used bilateral side rails for bed mobility, and staff confirmed that side rails were later placed per her request but that no restorative assessment was completed and the care plan was not updated as required on admission, quarterly, and with changes. This resulted in a failure to develop and implement a complete, person-centered care plan addressing the resident’s need for assistive bed devices.
A resident with multiple medical conditions, including respiratory failure and end stage renal disease, and with limited use of the left upper extremity, reported that previously available bilateral side rails used for bed mobility were removed after a bed change, leaving her unable to reposition herself without a right side bed rail. She later received only a left side rail and repeatedly requested a right side rail to assist with repositioning. Therapy records documented that she had used bilateral side rails effectively for bed mobility and had specific ROM and bed mobility recommendations. The restorative nurse and DON acknowledged that no restorative assessment was completed upon admission or with the change in condition, despite facility policies requiring restorative and bed rail assessments, including a Restorative Comprehensive Assessment/side rail review, upon admission, quarterly, and with significant changes in function.
A resident with multiple chronic conditions, including respiratory failure, anxiety disorder, end-stage renal disease, and anemia, did not receive a prescribed daily Pregabalin 50 mg pain medication for several days, despite it being ordered for morning administration. The resident reported asking staff about the missing medication in the cart and avoided using a PRN Hydrocodone-Acetaminophen 5-325 mg due to constipation. Review of the MAR and controlled drug records confirmed multiple missed doses, while interviews with the Administrator and DON showed that facility policy requires nurses to obtain unavailable medications from an electronic dispenser or contingency supply, contact the pharmacy as needed, and document reasons for missed doses on the MAR, which was not done.
The facility failed to coordinate and follow through on dental services and recommendations for three residents, including one with dementia and documented oral pain, one cognitively intact resident awaiting upper dentures after extractions, and another resident identified as a poor candidate for dentures who might try a new denture. Care plans and dental consults called for arranging dental care, monitoring oral problems, and pursuing denture fitting, but staff did not ensure timely appointments, did not document or track follow-up visits, and did not communicate dental recommendations to the appropriate departments. Key staff, including the HIM Director and DON, were unaware of specific residents’ dental needs, and the residents were not consistently placed on the facility’s dental list, contrary to the stated process that Social Services, nursing, and the dentist would coordinate and document dental care in the EMR.
The facility failed to maintain functional handicap door push buttons at the main entrance and did not ensure timely reporting or documentation of malfunctions. A family member and front desk staff reported that a main entrance handicap button had not worked for months, and maintenance staff confirmed that all three front entrance buttons were inoperable during a surveyor inspection, despite a resident who uses a motorized wheelchair reporting intermittent function. Surveyors repeatedly found the outside front entrance button nonfunctional even after reported repairs, while maintenance logs documented door checks but did not specifically include the handicap buttons, and routine checks were not completed as stated in the facility’s preventative maintenance policy.
Two residents became involved in a verbal and physical altercation that escalated to one resident punching the other in the face, causing visible redness. One resident reported being hit in the eye during the argument and denied striking back, while the other resident admitted to punching his roommate and described concurrent agitation, verbal aggression, and threats toward staff. A CNA first noticed the red mark on the injured resident’s face and notified a nurse, and subsequent documentation, including a behavioral hospital record, identified the aggressor as a danger to others with psychosis and aggression, despite an existing facility abuse policy prohibiting abuse and mistreatment.
A cognitively intact male resident admitted for skilled therapy, with chronic pain and multiple comorbidities, repeatedly informed staff that he avoids bread, rice, noodles, pasta, corn, breaded foods, and flour because he believes they worsen his joint pain. His diet ticket clearly listed a No Added Salt diet with explicit restrictions against these items, yet during an observed meal a CNA reviewed only the ticket, failed to verify the tray contents, and served Caribbean Jerk chicken that was breaded with bread and flour. The resident became visibly upset, declined a substitute meal, and reported that this problem had occurred repeatedly despite discussions by him and his family. The RD and regional dietary consultant confirmed that the recipe contained bread and flour and that staff are expected to follow tray tickets, while other staff and the DON stated that meal tickets and resident preferences must be checked and honored in accordance with facility dietary policies.
Nursing staff did not consistently complete or document physician-ordered dressing changes for four residents with complex medical needs, as evidenced by missing initials on the Treatment Administration Record and lack of supporting documentation, despite facility policies requiring such care and documentation.
A resident receiving hospice care and identified as high risk for abuse was subjected to repeated verbal abuse, threats, and intimidation by a roommate with a history of criminal behavior and moderate cognitive impairment. Despite ongoing derogatory name-calling, threats of harm, and physical intimidation, staff failed to recognize or respond to the abuse, and background checks for the abusive resident were incomplete or missing. The affected resident experienced ongoing fear and emotional distress, with no effective intervention from facility staff.
A resident with moderate cognitive impairment and a history of criminal behavior was able to keep a BB gun in their possession due to the facility's failure to perform an admission inventory and lack of routine checks of personal belongings. The weapon was only discovered after a staff member searched the resident's items following suspicious behavior, revealing gaps in the facility's supervision and adherence to its own policies.
A resident with bilateral lower extremity burns and a history of chronic pain reported severe pain during the night and requested pain medication, but the night nurse did not provide the prescribed medication, failed to assess the pain level, and did not retrieve medication from the convenience box as required by facility policy, resulting in inadequate pain management.
Two residents did not receive their prescribed medications as ordered due to unavailability, despite facility policy requiring staff to obtain medications from the convenience box if not present. One resident missed doses of a beta blocker for several days, and another did not receive pain medication when requested, resulting in unmanaged pain. Nursing staff acknowledged not following procedures to retrieve the medications.
A resident with multiple comorbidities and moderate risk for skin impairment developed an unstageable sacral wound that was not promptly reported to a physician or NP by staff. The LPN applied a dressing without obtaining treatment orders, and the care plan was not updated until several days later, resulting in a lack of documented wound care and failure to follow facility protocols.
Staff and visitors failed to consistently follow infection control policies, including proper placement of isolation precaution signs and use of PPE, for several residents on contact and enhanced barrier precautions. Observations included missing signage, staff providing high-contact care without gowns or gloves, and a visitor entering an isolation room without PPE, despite facility policies requiring these measures.
A resident with multiple chronic conditions did not receive prescribed PRN antihypertensive medication, timely vital sign assessments, or blood glucose monitoring as ordered. Staff failed to document changes in the resident's condition and did not consistently follow up on abnormal findings, resulting in the resident becoming unresponsive and requiring hospitalization for septic shock and pneumonia.
Nursing staff did not consistently monitor or document required assessments, vital signs, and blood glucose levels for two diabetic residents, despite physician orders and facility policy. Lapses included missing blood glucose records for multiple shifts and lack of documentation following changes in condition, with staff unable to confirm or recall if assessments were performed or recorded.
A resident with multiple serious health conditions received hydromorphone for pain, but nursing staff failed to document the administration of this narcotic on the Medication Administration Record (MAR), recording it only on the Controlled Substance Record. Staff interviews confirmed that both records should have been completed, and the omission was attributed to unreported computer issues. This resulted in incomplete and inaccurate medical records, as confirmed by the DON and hospice nurse.
The facility failed to ensure meals were served at an appetizing temperature, affecting five residents. Residents reported receiving cold dinners, and temperature logs for dinner were not recorded on several dates. A new cook admitted to not documenting temperatures, despite knowing the requirement. The facility's food safety policy mandates logging temperatures for each meal to ensure safety.
A resident with multiple health conditions, including diabetes and peripheral vascular disease, experienced a delay in incontinence care, leading to moisture-associated skin dermatitis. The resident, who is frequently incontinent and requires assistance, reported long wait times for care despite using the call light. The facility's failure to conduct timely skin assessments and report new skin concerns contributed to the development of the skin condition.
A resident with multiple diagnoses, including diabetic neuropathy and opioid dependence, did not receive physician-ordered Oxycodone for over five days due to a change in facility ownership and pharmacy provider. The resident, who frequently experiences severe pain, only received acetaminophen during this period, affecting their sleep and rest. The ADON was unaware of the issue, and the facility could not provide records to show the medication was available during the transition.
A resident with dementia and a high fall risk experienced multiple falls due to inadequate supervision in an LTC facility. Despite being identified as needing close monitoring, the resident was left unsupervised, resulting in significant head injuries from falls. The facility's failure to implement effective fall prevention strategies contributed to these incidents.
A facility failed to follow its skin care prevention policy, leading to a resident developing three facility-acquired non-pressure wounds on the right foot and ankle. The resident, unable to move independently, was dependent on staff for care. Despite efforts by the wound care nurse, the facility did not consistently monitor and document the resident's skin condition, resulting in the resident being hospitalized with osteomyelitis, necrotic right heel ulceration, and sepsis. Hospital records indicated severe sepsis and necrotic right heel ulcer with wet gangrene, with the limb deemed unsalvageable.
A resident with severely contracted lower extremities and high risk for skin breakdown developed a facility-acquired pressure ulcer due to ineffective pressure-relieving interventions. Despite signs of bruising and discoloration, there was no documentation of nurse assessments or monitoring as required by the facility's skin care prevention policy and physician orders. The resident was hospitalized with a serious condition, presenting with a pressure wound with the hamstring tendon exposed.
The facility failed to reconcile controlled medications across all medication carts, with missing entries and signatures on narcotic count forms. Nurses did not perform required counts or report discrepancies, leading to unaccounted discrepancies in medication counts.
The facility failed to securely store medications, with unlocked medication refrigerators and improper storage of non-medical items like food. Additionally, a nurse left a medication cart unlocked and unattended during administration, violating facility policies.
The facility failed to follow infection control protocols during medication administration and equipment use. A nurse did not perform hand hygiene between resident contacts and did not disinfect medical equipment like pulse oximeters and BP machines after each use. Additionally, enhanced barrier precautions were not followed during IV medication administration, and nebulizer masks were improperly stored. These actions indicate systemic issues in infection control practices.
The facility failed to document the administration of the pneumonia vaccine for five residents. The Infectious Preventionist confirmed the absence of documentation, stating that vaccines should be offered upon admission and recorded when given. Facility policy requires offering and documenting immunizations as per CDC and regulatory guidelines.
A resident receiving wound care for a left heel ulcer was not provided privacy, as the wound nurse did not close the door or draw the privacy curtain, leaving the resident visible from the hallway. The nurse acknowledged the oversight, and the DON confirmed that privacy should be maintained during care. The facility could not provide a Privacy Policy related to treatment procedures.
The facility failed to conduct criminal history background checks within 24 hours of admission for three residents. Staff interviews revealed that the checks were delayed due to lack of access to request the necessary information. Additionally, one resident's name was not checked on the Illinois Sex Offender website until days after admission, contrary to the facility's policy.
A resident was found with long, dirty fingernails and expressed a desire for nail care, which staff reportedly did not provide. An LPN noted the resident sometimes refused nail care, but the DON stated that refusals should be documented in a care plan, which was not done. The resident, who is alert and verbal with several medical conditions, had no documented refusal of care plan, contrary to facility policy.
The facility failed to complete a smoking assessment and care plan for a resident who smokes, despite being listed as a smoker and requiring assistance. Additionally, the facility did not conduct fall investigations or update the care plan for another resident who experienced multiple falls. These deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in adherence to facility policies on smoking safety and fall management.
Two residents in an LTC facility experienced significant medication errors. One resident received an IVPB medication at an incorrect flow rate due to an RN following incorrect practices. Another resident, with type 2 diabetes, had insulin doses held without a physician's order, despite high blood glucose levels. These errors highlight failures in adhering to physician orders for medication administration.
A resident on hospice care lacked a physician order for hospice services, and the facility failed to access hospice staff documentation of visits, affecting coordinated care. Despite a visit log indicating hospice nurse and CNA visits, documentation was missing, and the facility's policy requires such documentation for effective communication and care.
A resident with a history of falls and severe dementia sustained a left hip fracture due to the facility's failure to follow the care plan and fall protocol. Despite being identified as a fall risk, the resident was found alone in his room, not dressed appropriately, and not under supervision as required. Staff acknowledged the oversight, and the fracture was confirmed by diagnostic reports.
A resident dependent on staff for activities of daily living was found in bed without clothing, in a soiled brief, and with soiled linen. The resident's roommate noted a lack of assistance with meals and hygiene. The Director of Nursing confirmed the resident's need for full assistance, which was not provided according to the facility's policy.
The facility failed to develop a care plan addressing a resident's drug use history, resulting in the resident being found unresponsive and later pronounced dead due to a drug overdose. Despite the resident's significant medical history, the care plan lacked interventions for drug use, and staff did not observe any signs of active drug use.
Failure to Investigate and Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse policy by not investigating an alleged physical abuse incident involving a cognitively impaired male resident with multiple chronic medical conditions, including chronic respiratory failure, COPD, major depressive disorder, asthma, hypertension, type 2 diabetes, difficulty in walking, and abnormal posture. The resident, who had a BIMS score of 12/15 indicating moderate cognitive impairment, reported that a few weeks prior his former roommate beat him up at night, punching him more than six times in the left lower chest area and causing what he described as a broken rib. He stated he was angry that he was moved to another room instead of the roommate and reported that staff did not assess his left ribs, which he said continued to hurt. Review of the facility’s abuse reportable binder for January through March did not show an incident report for this event. An LPN confirmed that on a late evening in January she heard a loud verbal altercation between the resident and his roommate, entered the room, and immediately removed the resident. The LPN stated the resident told her the roommate had slapped him, and she reported assessing the resident and notifying the former DON and the resident’s physician. The former roommate denied ever fighting with, punching, or slapping anyone. The current Administrator and DON stated they were unaware of the incident, and the Assistant Administrator confirmed that no investigation had been initiated. The Regional Nurse Consultant and Assistant Administrator acknowledged that an investigation should have been started and reported to the state health department immediately, in accordance with the facility’s abuse policy, which requires that all incidents and any allegation involving abuse be documented, investigated, and reported within specified time frames.
Inadequate CNA Night-Shift Staffing Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient CNA staffing on a night shift to meet resident needs in accordance with its own Facility Assessment Tool and Staffing Policy, resulting in a resident fall. On the night in question, the facility’s midnight census was 136 residents, and the facility was scheduled to have eight CNAs but had only five due to call-offs. The DON and Assistant Administrator stated that having five CNAs for a census of 136 should not impede resident care. However, the daily assignment sheet for that night documented that three CNAs on the A and B wings each had 25 residents, the CNA on Unit C had 33 residents, and the CNA on Unit D had 28 residents. The DON acknowledged that there was a resident incident/fall at 1:40 a.m. and that there was not an appropriate number of staff available to meet the needs of the residents. A CNA who worked the 11:00 p.m. to 7:00 a.m. shift reported having 25 residents assigned and stated that CNAs needed more help to ensure proper nursing care was completed, and that some work was not completed. The facility’s Assessment Tool, last updated in August 2025, specified that staffing and resource needs should be based on a holistic approach considering resident acuity, ADLs, personal preferences, and psychosocial needs, and set direct care CNA ratios for post-acute units at 1:12 and LTC units at 1:18 on night shift. The facility’s Staffing Policy, reviewed in May 2025, stated that appropriate numbers of staff must be available to meet resident needs. Despite this, the nursing management team’s handling of call-offs resulted in staffing levels and CNA-to-resident assignments that did not align with the facility’s own assessment-based staffing parameters, contributing to the fall of one resident.
Failure to Care Plan for Assistive Bed Devices for Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, person-centered care plan addressing a resident’s need for assistive bed devices, specifically side rails for bed mobility. A resident with acute and chronic respiratory failure with hypoxia, anxiety disorder, end stage renal disease, and anemia reported that she previously had bilateral side rails and used them for bed mobility, but after a bed change she no longer had both rails. She stated she had received only a left side bed rail over a week prior and had repeatedly asked staff for a right side bed rail to help with repositioning and scooting up in bed. During interview, the resident demonstrated she was unable to use her left arm and could only grasp with her right hand, and that she could not turn or reposition herself without a right side bed rail. Staff interviews and record review showed that the facility did not complete the required restorative assessment or update the care plan to reflect the resident’s need for assistive bed devices. The Restorative Nurse stated that side rails were placed per the resident’s request on a specific date but acknowledged that no restorative assessment was completed, even though such assessments and corresponding care plan updates should occur on admission, quarterly, and as needed. Occupational therapy documentation from an earlier treatment encounter indicated that the resident had bilateral side rails and used them effectively for bed mobility. The DON confirmed that her expectation is that care plans be completed on admission, quarterly, and as needed when changes occur, and the facility’s care plan policy requires development of a baseline, person-centered care plan within 48 hours of admission, including ADL needs. Despite these requirements and the documented and observed need for bilateral side rails, the care plan did not fully address the resident’s assistive bed device needs.
Failure to Complete Restorative and Bed Rail Assessments for Resident With Limited ROM
Penalty
Summary
The deficiency involves the facility’s failure to complete required restorative and bed rail assessments upon admission and with changes in condition for a resident with limited mobility and range of motion (ROM). The resident, who has diagnoses including acute and chronic respiratory failure with hypoxia, anxiety disorder, end stage renal disease, and anemia, reported that she previously had bilateral side rails to assist with bed mobility, but after a bed change they were removed. She stated she received a left side bed rail about a week prior to the survey and had repeatedly asked staff for a right side bed rail to help with repositioning and scooting up in bed. She demonstrated that she was unable to use her left arm, could grasp only with her right hand, and could not turn or reposition herself without a right side bed rail. Interviews and record review showed that the restorative nurse acknowledged that side rails were placed per the resident’s request on 3/3/26 and that no restorative assessment had been completed, despite the facility policy requiring restorative screening upon admission, quarterly, and with any significant change in function. The DON confirmed that a restorative assessment and care plan should be completed upon admission, quarterly, and as needed for changes. Occupational therapy documentation from 2/6/26 indicated the resident had bilateral side rails and used them for bed mobility with partial/moderate assistance, and therapy recommendations dated 2/16/26 included passive ROM to the left upper extremity, active ROM to the right upper and lower extremities, and bed mobility (rolling left and right). Facility policies required assessment for restorative programs and bed rails/side rails upon admission, quarterly, and upon significant change, using a Restorative Comprehensive Assessment/Side rail review, but this process was not completed for this resident as required.
Failure to Provide Ordered Pain Medication and Follow Medication Administration Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Medication Administration policy, resulting in a resident not receiving a prescribed pain medication for multiple days. The resident reported not receiving her ordered Pregabalin 50 mg oral capsule, taken every morning for pain, for more than five days and stated she had asked staff why the medication was not in the medication cart. Review of the Medication Administration Record (MAR) for the month showed that Pregabalin was not given on six specific dates, and the Controlled Drug Record indicated the last dose was administered several days before those missed doses. The resident also stated she avoids using her PRN Hydrocodone-Acetaminophen 5-325 mg due to constipation issues. Interviews with facility leadership confirmed expectations that when a medication is not available in the nurse’s cart, nurses should obtain it from the electronic medication dispenser or contingency supply and contact the pharmacy if needed, as well as document reasons for missed doses on the MAR and notify the provider when required. The Administrator stated that nurses are able to locate medications in the facility’s electronic medication dispenser when they are not in the cart. The DON explained that a “9” on the MAR indicates the medication was not given and that nurses are expected to retrieve medications from the emergency supply and notify the physician if a refill is needed. The facility’s written Medication Administration policy requires that if a medication is ordered but not present, staff must check for misplacement, call the pharmacy, and obtain it from contingency or convenience stock if available, and document reasons for any missed doses on the MAR, which did not occur in this case.
Failure to Coordinate and Follow Through on Dental Services and Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide routine and 24-hour emergency dental care, follow its own dental services policy, implement care plan interventions, and ensure that dental recommendations were followed for three residents, potentially affecting 143 residents. For one resident with dementia and a BIMS score of 8, the care plan identified oral/dental problems related to edentulous tooth infection/pain and directed staff to coordinate dental care and monitor for symptoms. A handwritten note from the resident’s family requested a dental follow-up on a specific date, but there was no corresponding progress note documenting a dental visit or follow-up. Although a later progress note documented that the resident left for a dental appointment, the actual plan of care and follow-up information were not included, and the resident’s name did not appear on the facility’s dental list for several subsequent months. The Health Information Management Director reported not receiving information about the follow-up appointment, not knowing of any upcoming dental appointment for the resident, and having no communication with the resident’s daughter for approximately five months. Another resident, cognitively intact with a BIMS score of 15, had a care plan noting dental/mouth problems and an intervention to consider a dental consult as indicated. Progress notes documented that the resident returned from a dental appointment with a referral for dentures, was scheduled to return for denture fitting, and was awaiting follow-up for upper denture fitting. A later dental consult documented that the upper quadrants had no teeth and did not indicate any denture steps selected. During observation, the resident appeared to be missing all upper teeth and reported that upper teeth had been removed months earlier, that the dentist had indicated three visits would be needed for denture fitting, and that the facility had not set up the necessary appointment. The Administrator stated that the dentist was not accepting the resident’s insurance and that only after obtaining a list of in-network providers were staff in the process of scheduling an appointment, indicating a prolonged delay between the referral and arranging denture services. A third resident, with moderate cognitive impairment and a BIMS score of 9, had a prior dental consult indicating a well-fitting denture. A subsequent dental consult documented that the resident was a poor candidate for dentures due to lack of natural bone but could enroll for dental care at the facility to try a new denture. The Health Information Management Director stated that no one had provided any information about the need for new dentures, and the DON reported being unaware that the resident might require those services. The facility’s Dental Services policy, reviewed in the same time frame, required that documentation by the dentist be recorded in the medical record and that nursing document dental issues in the EMR. Interviews with the Social Service Director and DON described an expectation that residents be screened for dental services, that treatment plans be followed, and that dental orders and consults be communicated and documented, but the records and staff statements showed that these processes were not consistently carried out for the three residents.
Failure to Maintain Functional Handicap Door Push Buttons at Main Entrance
Penalty
Summary
The facility failed to keep essential entrance equipment, specifically the front entrance handicap door push buttons, in safe working condition and failed to ensure staff reported malfunctions. A family member reported that the main entrance handicap door did not open when the button was pressed, and the lead receptionist stated that one of the front entrance push buttons had not been working for a few months, while another unit entrance button was working. When questioned, the maintenance staff initially stated that no one had reported any issues with the handicap push buttons. Upon inspection with surveyors, the maintenance staff confirmed that all three front entrance handicap push buttons were not working, even though they believed the doors had been functioning days earlier. A resident who uses a motorized wheelchair and has intact cognition reported that the buttons had worked during a recent family visit, suggesting intermittent function. Subsequent observations by surveyors showed that, after the maintenance staff stated the buttons were working again, only two of the three front entrance buttons functioned, with the outside front entrance button still failing to open the door. On multiple occasions, surveyors pressed the outside front entrance handicap push button and the door did not open, despite an invoice indicating that repairs had been made and rusty connections found. The maintenance staff later acknowledged that the outside button was again reported as not working and that a replacement pad had been ordered. Review of the facility’s logbook showed that door operations, including locks, gates, and alarms, were tested and documented twice weekly, but the handicap push buttons were not specifically included on the form. The maintenance staff stated that they checked the handicap buttons weekly but did not have them listed on the documentation and also admitted that the usual checks were not performed on the most recent Monday or Tuesday, contrary to the facility’s preventative maintenance policy that requires scheduled and documented maintenance of equipment to ensure a safe, operable environment.
Resident-to-resident physical altercation resulting in facial injury
Penalty
Summary
The facility failed to protect a resident from physical resident-to-resident abuse when one resident punched his roommate in the face, causing a red mark. One resident reported that he and his former roommate were yelling at each other and that the roommate hit him in the eye, resulting in redness; he denied striking the other resident and later stated he felt safer and satisfied after a room change. The other resident admitted he had a verbal and physical altercation with his roommate, acknowledged punching him in the jaw/face, and reported having redness on his own cheek from being hit. Progress notes from the date of the incident document that the aggressor resident was observed in his room agitated, verbally aggressive, combative, yelling, using profanity, and verbally threatening staff, and that he was unable to be redirected despite several attempts to console him. The facility’s initial reportable indicated that the aggressor resident allegedly made unwanted physical contact with his roommate, with redness noted on the right side of the roommate’s face, and that the aggressor was petitioned to the hospital for evaluation. A behavioral hospital record for the aggressor resident documented a treatment plan problem of danger to others with psychosis, noting aggression at the nursing home, including punching and attacking his roommate, and describing his admission as a direct transfer from the nursing home due to psychosis and aggression, with the resident’s own chief complaint being, “I punched someone.” The final reportable summary of investigation stated that, after staff and resident interviews, the roommate reported that the aggressor struck him in the face, and a CNA had initially alerted the nurse to the red mark on the roommate’s face. Despite the facility’s written abuse policy prohibiting abuse and affirming residents’ rights to be free from abuse and mistreatment, this resident-to-resident physical altercation occurred, resulting in documented injury to the affected resident.
Failure to Honor Resident’s Documented Dietary Preferences for Bread and Breaded Foods
Penalty
Summary
The deficiency involves the facility’s failure to consistently honor a resident’s clearly documented dietary preferences, resulting in the resident being served food that he had repeatedly requested to avoid. The resident is an adult male admitted for skilled therapy services with diagnoses including vertebrogenic low back pain, PTSD, atrial fibrillation, chronic low back pain, depression, polyneuropathy, and a cardiac pacemaker. His MDS showed a BIMS score of 12, indicating intact cognition, with no acute change in mental status or disorganized thinking. From admission, the resident and his family repeatedly informed staff that he avoids bread, rice, noodles, pasta, corn, breaded foods, and flour because he believes these foods worsen his chronic joint pain. During an observation, the resident stated that he did not find the food very good and was particularly concerned about being served bread or breaded foods, which he described as “like a poison” to his joints. He reported that despite multiple discussions with staff since admission, he continued to receive these items and that his wife brought food from home several times a week so he would have food he could eat. While the surveyor was interviewing him, a CNA entered to deliver his lunch tray. The CNA was observed reviewing the meal ticket but did not compare the actual food items on the tray to the ticket. When the resident removed the cover, he found a piece of breaded chicken, became visibly sad and frustrated, and declined an offered substitute meal, stating that this problem “always happens.” Review of the meal ticket for that tray showed that the resident’s diet order included No Added Salt (NAS), regular texture, and a specific written restriction of “No Rice, Noodle, Pasta, Rice, Corn, Bread, Breading on food, Flour,” along with a listed menu of Caribbean Jerk Chicken, steamed rice, black beans, pineapple, and beverage. The regional dietary consultant confirmed that the Caribbean Jerk chicken recipe uses bread and flour for coating and acknowledged it should not have been served to this resident given the documented preferences on the ticket. The RD stated that preferences are written on the tray ticket and are expected to be followed, and that the error should have been caught in the kitchen before the tray was sent. Staff interviews, including with CNAs, a dietary aide, and the DON, confirmed that facility practice and expectations are to check meal tickets, verify that trays match residents’ diets and preferences, and send incorrect trays back to the kitchen. One CNA admitted that on the day of the observation she was “moving too fast” and failed to check the food items against the ticket, resulting in the resident receiving breaded chicken contrary to his documented dietary preferences. Facility policies, including the Dietary Standardized Menu Policy and OnTray Dietary Policies and Procedures, state that the facility will make reasonable efforts to provide appetizing food based on individual assessment and plan of care, support residents’ rights to personal dietary choices, and follow each resident’s preferences to the extent nutritionally and medically possible. Despite these policies and the clear documentation of the resident’s preferences on the meal ticket, the resident was served breaded chicken that contained bread and flour. This event, combined with the resident’s and family’s reports of multiple prior communications about his preferences, demonstrates that his dietary preferences were not consistently followed.
Failure to Complete and Document Physician-Ordered Dressing Changes
Penalty
Summary
The facility failed to follow its own policies and procedures, implement care plans, and adhere to physician orders regarding dressing changes for four residents. Documentation review revealed that for each of these residents, there were multiple instances where nursing staff did not sign the Treatment Administration Record (TAR) to indicate that ordered dressing changes were completed. Interviews with facility staff, including the wound care nurse and the Director of Nursing, confirmed that if the TAR is not signed, it is assumed the treatment was not performed, and no alternative documentation was found to show the dressings were changed as ordered. The residents involved had complex medical histories, including diagnoses such as displaced femur fracture, diabetes mellitus, heart failure, end stage renal disease, chronic kidney disease, and wounds requiring specialized care. Physician orders for these residents specified detailed wound care regimens, including daily or scheduled dressing changes, wound assessments, and documentation requirements. Despite these orders, the TARs for each resident showed missing staff initials on multiple dates, and in some cases, there was no supporting documentation in progress notes to indicate the treatments were completed. Facility policies required consistent implementation of wound care protocols, including documentation of each dressing change and regular wound assessments. The failure to document or perform these dressing changes as ordered was acknowledged by both the wound care nurse and the Director of Nursing during interviews. The Infection Preventionist also emphasized the importance of timely dressing changes to prevent infection and further wound complications. The facility's own policies and residents' rights documents underscored the necessity of providing care as ordered and maintaining accurate records, which was not done in these cases.
Failure to Protect Resident from Ongoing Verbal and Psychological Abuse
Penalty
Summary
The facility failed to protect a resident from repeated verbal and psychological abuse by another resident, in violation of its abuse prevention policy. One resident, who was on hospice care and at high risk for abuse, was subjected to ongoing derogatory name-calling, threats of physical harm, and intimidation by his roommate. The abusive resident, who had a history of criminal behavior and moderate cognitive impairment, repeatedly called the other resident disparaging names, threatened to choke and slap him, and physically kicked his bed. These incidents were corroborated by interviews with the affected resident and a third roommate, who confirmed the ongoing verbal abuse and threats. Despite the ongoing conflict and clear distress experienced by the abused resident, facility staff failed to identify or respond appropriately to the situation. Interviews with staff members, including an LPN and a nurse's aide, revealed that they either did not recall or denied witnessing any inappropriate behavior, arguing, or name-calling between the residents, even though the incidents were reported to have occurred in their presence. The administrator and social services consultant also indicated that they were unaware of any abuse or did not have complete background check results for the abusive resident, whose criminal history screening and fingerprint results were missing or incomplete at the time of admission and during the incidents. The facility's policies required immediate reporting and investigation of abuse allegations, as well as interventions to ensure resident safety. However, these procedures were not followed, and the resident continued to experience fear, anxiety, and emotional distress as a result of the ongoing abuse. Documentation showed that the resident felt unsafe, wrote notes expressing fear for his life, and reported his distress to staff, but no effective action was taken to protect him or address the abusive behavior.
Failure to Perform Admission Inventory Allows Resident to Possess Weapon
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision by not performing a required inventory check for a resident upon admission. As a result, the resident was able to possess a BB gun within the facility, which was not detected until a staff member searched the resident's belongings after noticing suspicious behavior and the smell of smoke. The facility's own policy requires an inventory of personal effects upon admission and updates when items are brought in or removed, but there was no documentation of an inventory list for this resident, nor evidence that belongings were checked after the resident returned from hospital visits or potential passes out of the facility. The resident involved had a history of criminal behavior and was assessed as moderately cognitively impaired. The care plan indicated the need for appropriate supervision and observation, but the facility did not routinely check residents' belongings unless there was suspicion. Staff interviews revealed that the BB gun was not listed on the resident's inventory at admission, and there was uncertainty about whether the resident had left the facility and returned with new items. The facility did not have a process in place to check for contraband when residents left and returned, and staff were unable to produce documentation of the resident's inventory or records of out-of-facility passes. The facility's contraband policy prohibits weapons and requires staff to act if there is suspicion of contraband, but does not mandate routine checks. The BB gun was only discovered after a staff member searched the resident's belongings due to suspicious circumstances, not as part of a standard procedure. The lack of an initial and ongoing inventory check allowed the resident to keep a weapon in their possession, which was only addressed after it was found by chance.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident with a history of low back pain, venous thrombosis, embolism, post-traumatic stress syndrome, and bilateral lower extremity burns reported significant pain during the night and requested pain medication. The resident informed a CNA of her pain, which was rated as 8 out of 10, but the night shift nurse was unable to provide the prescribed pain medication, stating it was not available and would be delivered in the morning. The nurse did not retrieve the medication from the convenience box, as was expected by facility policy, and did not assess or document the resident's pain level at that time. Facility records showed that the resident had an active order for oxycodone-acetaminophen to be administered every four hours as needed for pain, and the care plan included interventions to administer pain medication as ordered. The facility's pain management policy required pain to be assessed at least once every shift and documented using appropriate pain scales. Despite these policies and orders, the resident's pain was not effectively monitored or treated during the incident, resulting in a failure to provide safe and appropriate pain management.
Failure to Provide Timely Access to Prescribed Medications
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered for two residents. For one resident with a history of heart failure and hypertension, the beta blocker Toprol XL 50mg was not administered from 8/8 to 8/11 because the medication was not available. The nurse on duty during those days stated that although she contacted the pharmacy for delivery, she did not retrieve the medication from the convenience box as required. The resident's care plan included interventions to administer medications as ordered for altered cardiac function, but the medication was marked as 'not available' in the electronic medication administration record for the missed dates. Another resident, diagnosed with low back pain, venous thrombosis, embolism, and post-traumatic stress syndrome with burn wounds, did not receive prescribed pain medication when requested during the night. The nurse confirmed that the pain medication was not available and, despite checking with the pharmacy and offering an alternative, did not obtain the medication from the convenience box. The resident reported a pain level of 8 out of 10 at the time. Facility policy requires staff to check for misplaced medications, contact the pharmacy, and obtain medications from the contingency or convenience box if available, but this protocol was not followed in these instances.
Failure to Implement Timely Wound Care Orders and Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to implement appropriate measures for the care and management of an unstageable sacral wound in a resident with multiple comorbidities and a rapidly declining condition. The wound was first observed by a Certified Nurse Aide and a Licensed Practical Nurse, but neither notified the Nurse Practitioner or physician to obtain treatment orders at the time of discovery. The LPN cleansed the area and applied a dry border gauze dressing without obtaining proper medical orders or updating the care plan. Documentation shows that there was no treatment administration record or physician orders for wound care for the month in which the wound was identified, and the care plan was not updated until several days later. Interviews with facility staff, including the Wound Care Nurse, Director of Nursing, and Administrator, confirmed that the expected protocol was not followed. The facility's own policies require prompt notification of a health care provider and updating of care plans when a new wound or change in skin condition is identified. The resident was at moderate risk for skin impairment and had diagnoses including encephalopathy, dysphagia, dementia, and atrial fibrillation. The lack of timely notification, absence of treatment orders, and failure to update the care plan directly contributed to the deficiency in pressure ulcer care and prevention.
Failure to Follow Infection Control Policies for Isolation Precautions and PPE Use
Penalty
Summary
The facility failed to adhere to its infection control policies regarding the placement of isolation precaution signs and the use of personal protective equipment (PPE) for residents on contact and enhanced barrier precautions. Multiple instances were observed where required signage was missing or not properly displayed, and staff or visitors entered rooms without donning appropriate PPE as mandated by facility policy. For example, a hospice account executive was seen in a resident's room on contact isolation for E. coli without wearing any PPE, despite clear signage instructing the use of gloves and gowns before entry. In another case, two CNAs provided high-contact care to a resident on enhanced barrier precautions, including dressing and urinary catheter care, without wearing isolation gowns. One CNA admitted uncertainty about the resident's precaution status and the requirements for enhanced barrier precautions. Additionally, a resident with a colostomy, who should have been on enhanced barrier precautions, had no signage at her door for several days, and the infection preventionist acknowledged the oversight, attributing it to the sign being flipped backward. A further deficiency was noted when a resident with a recent room change and an active order for contact isolation due to VRE in the urine had no signage or PPE supplies at the new room entrance. The infection preventionist only brought the necessary sign and PPE bin after being questioned by the surveyor. The facility's own policies require clear signage and the use of PPE for both transmission-based and enhanced barrier precautions, but these protocols were not consistently followed for several residents, as evidenced by direct observation and staff interviews.
Failure to Administer PRN Medication and Monitor Resident Condition
Penalty
Summary
Staff failed to administer prescribed PRN antihypertensive medication, assess and document vital signs, and monitor blood glucose as ordered for a resident with multiple complex medical conditions, including diabetes, hypertension, and heart disease. The resident exhibited a change in condition, including poor appetite, diminished lung sounds, and respiratory symptoms, but there was a lack of timely follow-up, assessment, and documentation by nursing staff. Orders for blood pressure and blood glucose monitoring were not consistently followed, with significant gaps in documentation and administration of medications. Despite the resident showing signs of respiratory distress and confusion, vital signs and blood glucose checks were not performed or recorded as required. When the resident's condition worsened, including unresponsiveness and shallow respirations, staff delayed in administering PRN blood pressure medication and failed to consistently monitor and document the resident's status. Communication with the physician was attempted, but there was confusion among staff regarding the availability of PRN medications and the appropriate steps to take when the physician could not be reached. Ultimately, the resident became unresponsive and required emergency intervention, including intubation and hospitalization for septic shock and healthcare-associated pneumonia. The lack of adherence to physician orders, incomplete documentation, and insufficient assessment contributed to the resident's deterioration and the need for acute medical care.
Failure to Monitor and Document Diabetic Assessments and Vital Signs
Penalty
Summary
Nursing staff failed to meet professional standards of practice by not adequately monitoring and documenting resident assessments, vital signs, and blood glucose levels for diabetic residents. For one resident with multiple diagnoses including type 2 diabetes, chronic kidney disease, and severe dementia, there were significant lapses in documentation. The resident was sent to the hospital for altered mental status and unstable vital signs. Documentation showed a high blood glucose reading upon return to the facility, but there were missing blood glucose records for several shifts prior to the incident, despite physician orders for twice-daily monitoring. Nursing staff could not recall or locate documentation of required assessments or blood glucose checks, and one nurse admitted to not knowing the protocol for documentation when the order was to monitor. Another resident with diagnoses including type 2 diabetes, hypertension, and dysphagia also experienced lapses in monitoring and documentation. Physician orders required blood glucose monitoring twice daily, but the last documented readings and vital signs were several days apart, with no records for multiple shifts. When congestion was noted during a medication pass, the nurse contacted the physician and received new orders but did not document any assessment or vital signs following this observation. The nurse later stated she thought she had documented the assessment but could not confirm it in the record. Facility job descriptions for nursing staff require adherence to physician orders, monitoring and documentation of resident care, and recognition and documentation of significant changes in resident condition. Despite these requirements, the records reviewed showed repeated failures to document required assessments, vital signs, and blood glucose levels, directly contravening both physician orders and facility policy.
Failure to Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to accurately document the administration of a narcotic medication for a resident with multiple complex diagnoses, including type 2 diabetes, stage 4 chronic kidney disease, heart failure, and a neoplasm of the cerebral meninges. The resident, who was only alert to self and unable to answer questions about medication, had an active order for hydromorphone to be administered as needed for pain or shortness of breath. Although the Controlled Substance Record showed that the medication was administered on several occasions, there was no corresponding documentation on the Medication Administration Record (MAR) for those times in January and February. Interviews with nursing staff and the Director of Nursing confirmed that facility policy requires documentation of narcotic administration on both the Controlled Substance Sheet and the MAR, but this was not done for the resident in question. Nursing staff acknowledged the requirement to document in both records and cited ongoing computer system issues as a reason for the lack of MAR documentation, though these issues were not reported to management. The hospice nurse also reported relying on the MAR to verify pain medication administration and noted discrepancies between the MAR and the Controlled Substance Record. Facility policy clearly states that all medications must be documented on the MAR at the time of administration, but this was not followed, resulting in incomplete and inaccurate medical records for the resident.
Failure to Record Food Temperatures Leads to Cold Meals
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing temperature, affecting five residents who were reviewed for dietary services. Residents expressed concerns about receiving cold dinners on several occasions, with some describing their meals as ice cold by the time they were served. The Resident Council President also noted that food was often served cold, and residents were tired of complaining about it. This issue was specific to dinner service and was ongoing, as reported by the residents. Upon review of the temperature logs for meal services, it was discovered that temperatures for dinner were not recorded on several dates. The Dietary Manager, who was absent during these dates, confirmed that a new cook was on duty and had not been documenting the temperatures as required. The cook admitted to forgetting to log the temperatures, despite knowing the importance of doing so. The facility's food safety policy requires that temperatures be logged for each meal to ensure food safety, but this was not adhered to during the specified period.
Failure to Provide Timely Incontinence Care Leads to Skin Dermatitis
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who is dependent on staff for activities of daily living, including incontinence care. This resident, who has a history of Peripheral Vascular Disease, Chronic atrial fibrillation, and Diabetes Mellitus with Diabetic Neuropathy, was assessed as frequently incontinent of bowel and bladder function and required physical assistance from nursing staff for hygiene. Despite being alert and coherent, the resident expressed frustration over the lack of responsiveness from nursing staff when using the call light for assistance. The resident reported waiting over an hour for care after using the call light, which was deactivated by staff without providing the necessary care. This delay in care led to the development of moisture-associated skin dermatitis, characterized by reddened skin with small, scattered openings in the groin area. The resident's electronic health record indicated a moderate risk for developing skin issues, but there was no documentation of skin assessments in the week leading up to the incident. During a skin integrity observation, the Wound Care Coordinator noted the skin condition as a new concern, which had not been reported by the nursing staff. The facility's Skin Care Prevention Policy requires that dependent residents be assessed for changes in skin condition and that any redness or non-blanching erythema be reported to a nurse, who is responsible for alerting the healthcare provider. The policy also mandates cleaning the skin at the time of soiling and using a topical agent as a moisture barrier for incontinent residents. However, these measures were not adequately implemented, leading to the resident's skin condition.
Failure to Provide Ordered Pain Medication Due to Pharmacy Transition
Penalty
Summary
The facility failed to provide physician-ordered pain medication for a resident experiencing pain, which was a deficiency identified during a survey. The resident, who is cognitively intact and frequently experiences pain with a score of eight out of ten on the pain scale, was admitted with diagnoses including peripheral vascular disease, Type II Diabetes Mellitus, Diabetic Neuropathy, Opioid Dependence, and Hypertension. The resident had an active order for Oxycodone 10-325mg to be administered every eight hours as needed for pain. However, due to a change in facility ownership and pharmacy provider, the Oxycodone was unavailable for more than five days, during which the resident only received acetaminophen, affecting their ability to sleep and rest. The Assistant Director of Nursing (ADON) stated that there was no interruption in pharmacy services during the transition, and they were unaware of the resident's concerns about the unavailability of Oxycodone. The facility was unable to provide the drug control sheet for the period before 11/13/24 to show the medication was available, and the Medication Administration Record indicated that Oxycodone was not administered from 11/4/24 to 11/13/24. The facility's pain management policy emphasizes a commitment to resident comfort and effective pain management, but the failure to provide the ordered medication contradicted this policy.
Inadequate Supervision Leads to Multiple Falls and Injuries
Penalty
Summary
The facility failed to adequately supervise a resident diagnosed with dementia and identified as a high fall risk, resulting in multiple falls and injuries. The resident, who had a history of falls and severe cognitive impairment, experienced three falls within a forty-five-day period. The first incident occurred when the resident was found face down on the side of her bed, although no injuries were noted at that time. Subsequent falls resulted in significant injuries, including lacerations to the back of the head requiring sutures and staples. The second fall was unwitnessed and occurred at the nurse's station, where the resident was left unsupervised. The resident attempted to stand from her wheelchair, causing it to tilt backward, leading to a head injury. Despite being identified as a high fall risk and requiring close monitoring, the resident was left without direct supervision, and staff were not present at the nursing station at the time of the fall. The facility's investigation determined that the fall was due to the resident's impulsive behavior, but interventions to prevent such incidents were not effectively implemented. The third fall happened during a change of shift when the resident attempted to stand and sit back down but missed the wheelchair, resulting in another head injury. Although staff were nearby, they were occupied with other tasks and unable to prevent the fall. The resident's care plan included interventions such as placing the resident in a high-visibility area and using anti-tippers on the wheelchair, but these measures were insufficient to prevent the falls. The facility's failure to provide adequate supervision and implement effective fall prevention strategies contributed to the resident's repeated falls and injuries.
Failure to Prevent and Monitor Non-Pressure Wounds
Penalty
Summary
The facility failed to adhere to its skin care prevention policy, resulting in a resident developing three facility-acquired non-pressure wounds on the right foot and ankle. The resident, who was unable to move independently and had contracted legs, was dependent on staff for repositioning and care. Despite the wound care nurse's efforts to manage the resident's skin condition, including obtaining orders for wound cleaning and dressing, the facility did not consistently monitor and document the resident's skin condition. This lack of consistent monitoring and documentation contributed to the deterioration of the resident's wounds. The resident's medical records indicated that there were no weekly skin observations documented between 8/9/24 and 9/1/24, when the resident was hospitalized. The CNAs documented discoloration, redness, and a skin tear on various dates, but there was no corresponding documentation of nurse assessments for these abnormalities. The nurse practitioner noted bruising and discoloration on the resident's right foot and left knee, but could not confirm if these were trauma-related. The resident's treatment administration record showed missed treatments for the right ankle wound and right foot blister on specific dates. The resident was eventually hospitalized with a serious condition, including osteomyelitis, necrotic right heel ulceration, and sepsis. The hospital records noted severe sepsis, necrotic right heel ulcer with wet gangrene, and osteomyelitis, with the limb deemed unsalvageable due to extensive necrosis. The facility's failure to implement effective interventions and monitoring led to the resident's severe condition, as evidenced by the hospital's findings and the facility's documentation lapses.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to implement effective pressure-relieving interventions for a resident with severely contracted lower extremities, who was at very high risk for skin breakdown and dependent on staff for all activities of daily living. This resulted in the resident developing a facility-acquired pressure ulcer on the left posterior distal thigh due to pressure from a posterior mold splint on the left lower leg. The resident was subsequently hospitalized with a serious condition, presenting with a pressure wound to the left posterior distal thigh with the hamstring tendon exposed. The report highlights several instances of inaction and lack of documentation by the facility staff. Despite the presence of bruising and discoloration noted by the nurse practitioner and CNAs, there was no documentation of nurse assessments for these skin abnormalities. Additionally, the facility's skin care prevention policy required dependent residents to be assessed for changes in skin condition, but there was no evidence of monitoring or reporting of the bruising and discoloration to the resident's left knee or skin to the left thigh area. The physician order sheet also required monitoring of the left lower extremity cast and surrounding areas for signs of skin breakdown, but this was not documented in the resident's medical record.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to properly account for the usage, disposition, and reconciliation of controlled medications across all four medication carts reviewed. During the survey, it was observed that the shift change narcotic count forms were incomplete, with missing entries and signatures for several days in June 2024. The registered nurses responsible for the medication carts were unaware of the discrepancies and did not perform the required narcotic counts at the beginning and end of their shifts, as per facility policy. Specific instances of discrepancies were noted, such as tampered medication cards and incorrect remaining tablet counts for residents' medications, including Tramadol, Lorazepam, and Oxycodone. In one case, a small pink tablet was found loose in the narcotic drawer, which was identified as Oxycodone. The nurses involved were unable to explain these discrepancies and did not report them to the Director of Nursing (DON) as required by the facility's policy. The facility's policy mandates that all controlled substances be counted each shift by both the off-going and on-coming licensed nurses, with any discrepancies reported in writing to a supervisor. However, the survey revealed that this procedure was not consistently followed, leading to unaccounted discrepancies in the controlled substance counts. The Director of Nursing confirmed the requirement for shift counts and reporting of discrepancies, but the survey findings indicated a systemic failure to adhere to these protocols.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications in accordance with professional principles and manufacturer recommendations. During an inspection, it was observed that the medication refrigerators in Units A, B, C, and D were unlocked, contrary to the facility's policy that requires them to be locked at all times. Additionally, non-medical items such as thickened dairy and an employee's salad were found stored in the medication refrigerators, which is against the facility's policy that prohibits the storage of food in these refrigerators. The medication refrigerator in Unit C and D was also noted to be overflowing with medications, indicating improper organization and storage. Furthermore, a registered nurse was observed leaving a medication cart unlocked and unattended in the hallway while administering medication to a resident. The nurse left the medications in a plastic cup and water on the resident's bedside table, instructing the resident to take it while she stood by the door. This action violated the facility's policy that mandates medication carts to be locked when out of sight during medication administration. The Director of Nursing confirmed these observations and acknowledged the breaches in protocol.
Infection Control Deficiencies in Medication Administration and Equipment Use
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during medication administration and medical equipment usage. Observations revealed that a registered nurse did not perform hand hygiene between resident contacts and failed to disinfect medical equipment such as pulse oximeters and blood pressure machines after each use. Additionally, the glucometer was not disinfected according to the manufacturer's recommendations, as it was not kept wet with disinfectant wipes for the required duration. These lapses in protocol were observed during interactions with multiple residents, indicating a systemic issue in infection control practices. Further deficiencies were noted in the implementation of enhanced barrier precautions (EBP) during intravenous medication administration. A registered nurse did not don a gown, as required by the facility's policy, when administering medication to a resident with a central line. This oversight was observed despite signage indicating the need for EBP, highlighting a failure to follow established protocols for preventing the transmission of multidrug-resistant organisms (MDROs). The facility also failed to properly store nebulizer masks, as observed with two residents whose masks were left uncovered on dressers without being placed in plastic bags. This practice contradicts the facility's policy, which mandates that nebulizer masks be stored in bags and changed weekly to minimize infection risk. The facility was unable to provide a policy on the disinfection of medical equipment, further underscoring the lack of adherence to infection control standards.
Failure to Document Pneumonia Vaccination for Residents
Penalty
Summary
The facility failed to ensure proper documentation of immunization administration for five residents, identified as R13, R17, R40, R55, and R71. During a record review and interview, it was found that these residents did not have documentation indicating they received the pneumonia vaccine. The Infectious Preventionist, identified as V3, provided the immunization records and confirmed the absence of documentation for the pneumonia vaccine for these residents. V3 stated that vaccines should be offered upon admission and documented in the resident's immunization record when administered. The facility's policy mandates that all residents and staff be offered and encouraged to receive immunizations as recommended by the CDC and relevant regulations, with appropriate documentation including consents, refusals, historical, and administration records.
Failure to Ensure Privacy During Wound Care
Penalty
Summary
The facility failed to ensure privacy during wound care treatment for a resident, identified as R40, who was observed receiving treatment for a left heel wound. The wound nurse, V19, conducted the treatment without closing the door or drawing the privacy curtain, leaving R40 visible from the hallway. This lack of privacy was acknowledged by V19, who admitted that the door should have been closed during the procedure. The Director of Nursing, V2, confirmed that staff are expected to maintain privacy by closing doors and drawing curtains during resident care. Despite requests, the facility was unable to provide a Privacy Policy related to treatment procedures. R40's medical history includes Type 2 Diabetes Mellitus and Peripheral Vascular Disease, and the care plan specifies daily wound care for a pressure ulcer on the left heel.
Failure to Conduct Timely Criminal Background Checks
Penalty
Summary
The facility failed to perform criminal history background checks within 24 hours of admission for three residents, identified as R118, R322, and R323, out of a sample of 26. During a record review, it was noted that the Criminal History Information Response Process for these residents was initiated after the 24-hour window. Interviews with the Admissions Director and the Administrator confirmed that the checks should have been completed within 24 hours, but the staff did not have access to request the necessary information in time. For R322, it was also noted that the resident's name was not checked on the Illinois Sex Offender website until several days after admission. The facility's policy, titled 'Abuse Policy and Prevention Program,' mandates that a criminal history background check be requested within 24 hours after the admission of a new resident and that the resident's name be checked on the Illinois Sex Offender Registration website. The failure to adhere to these procedures was identified during the survey, highlighting a deficiency in the facility's admission process and compliance with its own policies.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care and maintain hygiene for a resident, identified as R98, who was observed with long and dirty fingernails. During an observation, R98 expressed a desire to have his fingernails cut, stating that the staff does not cut them. A Licensed Practical Nurse (LPN), identified as V12, mentioned that R98 sometimes refuses nail care. However, the Director of Nursing (DON), identified as V2, stated that nail care should be provided by Certified Nursing Assistants (CNAs) and that any refusal should be documented in a care plan. A review of R98's medical records showed no indication of a refusal of care or nail care refusal care plan, despite the resident being alert and verbal with several medical conditions, including primary osteoarthritis and hemiplegia following a cerebral infarction. The facility's policy requires nail care to be offered on shower days and as needed, with refusals to be reported to a nurse, but this was not followed in R98's case.
Deficiencies in Smoking Safety and Fall Management
Penalty
Summary
The facility failed to accurately complete a smoking assessment and formulate a care plan for a resident who smokes, identified as R55. Despite being listed as a smoker by the Director of Nursing and confirmed by the Social Service Director and Activity Director, R55's smoking assessment inaccurately indicated that he does not smoke, and no care plan was formulated for smoking safety. R55, who requires assistance when smoking, was admitted with diagnoses including Diabetes Mellitus type 2, a fractured right toe, osteoarthritis, and dependence on renal dialysis. The facility's policy requires a smoking safety assessment to determine the level of assistance needed, but this was not completed for R55. Additionally, the facility failed to initiate fall investigations and update the fall care plan for another resident, R46, who experienced multiple falls. R46 had fall incidents on several occasions, but no documentation of fall investigations or updates to the care plan were noted. The Minimum Data Set/Care Plan Coordinator acknowledged that the care plan should have been updated after the interdisciplinary team investigated the falls. R46 was admitted with a diagnosis of cerebral infarction affecting the right dominant side and had a history of falls prior to admission. The facility's policy mandates that care plans be updated with new interventions based on root cause analysis after each fall, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medication as ordered by the physician, resulting in significant medication errors for two residents. For one resident, the RN prepared and administered an IVPB medication of Meropenem at an incorrect flow rate of 200 instead of the prescribed rate of 100, leading to improper infusion over one hour. This error was due to the RN following incorrect practices observed from other nurses rather than adhering to the physician's order. The resident had been readmitted with a diagnosis of osteomyelitis and required precise medication administration to manage the infection. Another resident experienced issues with insulin administration. The RN held the resident's insulin doses without a physician's order, despite the resident's blood glucose levels indicating the need for insulin. The resident, diagnosed with type 2 diabetes mellitus, had a physician's order for blood glucose monitoring before meals and insulin administration with meals. However, the RN delayed or omitted insulin administration based on the resident's eating habits, which was not in accordance with the physician's orders. This resulted in multiple instances where insulin was not administered as required, potentially affecting the resident's diabetes management.
Failure to Obtain Physician Order and Document Hospice Visits
Penalty
Summary
The facility failed to obtain a physician order for a resident on hospice care and did not access hospice staff documentation of visits to ensure coordinated care and communication. This deficiency was identified during a survey involving a resident who was admitted with diagnoses including dementia without behavioral disturbance and a benign neoplasm of the pituitary gland. Despite being on hospice care, there was no active physician order for hospice evaluation or care in the resident's chart. Additionally, the hospice binder at the nursing station contained a visit log from a hospice nurse and CNA but lacked documentation or notes of these visits. The Director of Nursing (DON) and the Social Service Director (SSD) were informed of the absence of a physician order and the missing hospice documentation. Both acknowledged that there should be a physician order for hospice services and that hospice documentation should be accessible for coordinated care. The SSD indicated that the hospice service provider maintains a binder for each resident, but was unable to locate the necessary documentation of visits from the log. The facility's policy on hospice care emphasizes the importance of communication and documentation between the LTC facility and hospice provider to ensure resident needs are met continuously.
Failure to Follow Fall Protocol Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a plan of care was followed for a resident, identified as R1, who was at risk for falls. The facility did not review information on past falls, attempt to determine the cause of falls, or anticipate and meet the resident's needs. This failure resulted in R1 sustaining a left hip fracture of the femur head. Observations and interviews revealed that R1, who has a history of falls and unspecified severe dementia with behavioral disturbances, was not adequately supervised or dressed appropriately, which contributed to the incident. Despite being identified as a fall risk, R1 was found alone in his room, contrary to the care plan that required him to be at the nurse's station or in activities. The facility's fall prevention and management policy, revised in January 2024, emphasizes the need to evaluate residents at risk for falls and modify care plans as necessary. However, the staff did not adhere to these guidelines. On multiple occasions, staff members acknowledged R1's fall risk but failed to ensure his safety by not following the established protocol. The incident report and diagnostic radiology report confirmed the fracture, and the Director of Nursing and Administrator both acknowledged the oversight in R1's care, noting that the cause of the fracture was unknown but suspected to be due to a fall.
Failure to Provide Adequate ADL Assistance to a Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident identified as dependent on staff for care. On May 9, 2024, a resident was observed in bed without clothing, in a soiled incontinent brief, and with soiled bed linen. The resident's roommate reported that the resident is often left leaning, with dirty clothing, and without assistance during meals. A nurse acknowledged the resident's confusion and dependency on staff, but was unaware of the resident's specific needs. A CNA confirmed that the resident was not soiled during morning rounds but required assistance with dressing. The Director of Nursing confirmed that the resident is alert but confused, requiring full assistance with dressing, meal setup, and incontinence care. The resident's medical history includes type 2 diabetes mellitus with diabetic neuropathy, cerebral infarction, absence of bilateral lower extremities, and vascular dementia with severe psychotic disturbance. The care plan highlights the resident's need for assistance with eating, toileting, hygiene, and ensuring fresh water availability. The facility's policy mandates that all nursing personnel provide a program of activities of daily living to maintain residents at their maximal level of functioning, which was not adhered to in this case.
Failure to Address Resident's Drug Use History in Care Plan
Penalty
Summary
The facility failed to develop a resident-specific care plan with interventions to address a resident's history of drug use. This deficiency resulted in the resident being found unresponsive and non-breathing, and subsequently pronounced dead at the hospital. The resident, who was cognitively intact with a BIMS score of 14, had a history of anoxic brain damage secondary to a drug overdose and was admitted with diagnoses including poisoning by unspecified drugs and functional quadriplegia. Despite these significant medical histories, the resident's care plan did not include any interventions for drug use history. On the day of the incident, the resident was last observed alert and sleeping at approximately 7:50 am. Later, a Certified Nursing Assistant (CNA) found the resident unresponsive with purple fingertips and open eyes. A code blue was called, and CPR was initiated until emergency services arrived and transferred the resident to the hospital. The death certificate later confirmed the cause of death as a drug overdose due to toxic effects of Fentanyl and Cocaine. Interviews with staff and a friend of the resident revealed that there were no visible signs or suspicions of active drug use, and the facility had not found any drugs on the resident. During the investigation, the Director of Nursing (DON) and the Social Service Director acknowledged that the resident's care plan did not document any interventions for the history of drug use. The Social Service Director admitted that in hindsight, the resident should have been care planned for drug use. The facility's policy on comprehensive care plans mandates the development and implementation of a person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs. However, this policy was not followed in the case of the resident, leading to the tragic outcome.
Latest citations in Illinois
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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