Allure Of Moline
Inspection history, citations, penalties and survey trends for this long-term care facility in East Moline, Illinois.
- Location
- 430 South 30th Avenue, East Moline, Illinois 61244
- CMS Provider Number
- 146041
- Inspections on file
- 35
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Allure Of Moline during CMS and state inspections, most recent first.
The facility failed to honor several residents' expressed preferences not to be served meals on Styrofoam, instead providing lunch on Styrofoam plates with Styrofoam cups and plastic utensils despite residents stating they preferred ceramic or regular dishes and reporting this had occurred multiple times. Staff, including CNAs, confirmed that Styrofoam products were routinely used for room trays and sometimes in the dining rooms. The Administrator questioned the use of Styrofoam during an observed meal, and the DON acknowledged that using Styrofoam at mealtimes was a dignity issue inconsistent with the facility’s policy to promote and maintain residents’ dignity during meals.
A resident with left-sided hemiplegia following a CVA did not have her call light within reach while in bed, after a CNA reportedly removed it due to frequent use. Staff confirmed the resident could not access the call light on her own, and facility policy required it to be accessible for residents needing assistance.
A resident with dysphagia and moderate cognitive impairment, who required a pureed diet and close supervision, was left unsupervised in the dining room. The resident, known for taking food from others' trays, accessed and consumed solid foods, resulting in a fatal choking incident. Staff interviews revealed there was no formal supervision protocol in place to prevent such occurrences.
A resident who was alert, oriented, and dependent on staff for bathing was left exposed during a shower when a CNA failed to fully close the shower room door. The resident expressed discomfort with the lack of privacy, and staff interviews confirmed that facility policy requires doors to be closed during personal care to maintain dignity.
The facility did not ensure an RN was on duty for eight consecutive hours each day, as required, over multiple days. Staffing records and schedules showed repeated gaps in RN coverage, and leadership acknowledged ongoing recruitment challenges and selective hiring practices. This deficiency had the potential to impact all residents in the facility.
The facility did not provide required written notice of its bed hold policy to residents or their representatives when residents were transferred to the hospital. Medical records for several residents lacked documentation of this notification, and the Administrator confirmed that bed hold notices were not issued as required.
A resident receiving Lithium Carbonate had a physician's order for lithium levels to be checked every three months, but the facility did not document any lithium level checks after the initial test. The DON confirmed that no further monitoring was completed as required by the physician's order and facility policy.
The facility did not follow its abuse policy after a verbal altercation between two residents, as the incident was only noted in a care plan without a nursing progress note, investigation, or report to the state agency. The Administrator in Training was not informed, and required procedures for investigation and reporting were not followed.
The facility did not report an allegation of resident-to-resident verbal abuse, including threats of physical harm, to the Abuse Coordinator or the State Agency as required by policy. The incident was documented in a care plan after being discussed in a morning meeting, but no formal abuse report was made due to lack of communication among staff.
The facility did not investigate an alleged incident of resident-to-resident verbal abuse, despite its policy requiring immediate action and documentation. The event was only noted in a care plan after being discussed in a morning meeting, with no formal investigation or notification to the Abuse Coordinator.
A resident dependent on staff for hygiene did not receive scheduled showers as required by facility policy, with documentation showing missed showers and no record of refusals or care provided. The DON confirmed that the expected frequency of showers and documentation was not met, and the resident's family noted ongoing concerns about the resident's hair hygiene.
A CNA did not follow facility policy for catheter care by cleansing only the perineal area and omitting care to the meatus and catheter tube for a resident with an indwelling urinary catheter. Both the CNA and DON confirmed that full catheter care should include cleaning the meatus, perineal area, and catheter tube each time.
A resident with end stage renal disease did not consistently receive physician-ordered daily weights or scheduled doses of Lokelma to manage high potassium levels. Documentation showed missed weights and medication administrations over several weeks, despite facility policy and care plan requirements for daily monitoring and timely medication for dialysis care. The DON confirmed the missed care and cited issues with insurance and pharmacy supply for the medication.
A LPN administered insulin to a resident with Type 2 Diabetes Mellitus without wearing gloves, contrary to the facility's infection control policy requiring standard precautions for procedures involving potential exposure to blood or body fluids.
For approximately a month, 22 residents on one hall did not have access to hot or warm water in their rooms, requiring CNAs to obtain hot water from the nurses station for resident care. Both staff and residents reported the issue, and maintenance logs confirmed consistently low water temperatures well below policy standards. The problem began after new water pipes were installed, and despite internal checks and notifications, no external help was sought to resolve the deficiency.
A resident with a history of aggressive behavior and communication barriers physically struck another resident with severe cognitive impairment in the dining room. Staff intervened after the assault, and no injuries were found. The aggressive resident's care plan did not address his language needs, despite repeated incidents of escalating behavior and prior staff interventions.
A resident with multiple diagnoses was found with her morning medications left unattended at her bedside, as an LPN did not remain to observe her taking them. The resident was unaware the medications were there, and facility policy requires staff to observe medication consumption. The DON confirmed that medications should not be left on the table and that staff are to stay with residents until all pills are taken.
A resident reported being hit by a CNA with a chair, expressing feelings of being unsafe and frequently abused. Another CNA heard the resident's distress and reported it to an LPN. Despite these reports, the facility did not investigate the allegations or remove the CNA from duty, leading to a deficiency in handling abuse allegations.
The facility failed to maintain proper infection control, with fecal matter found on toilets and improper storage of soiled washcloths. Residents reported unsanitary conditions, confirmed by staff, indicating a lapse in adherence to infection prevention policies.
The facility failed to provide the required RN coverage for several days, affecting all 91 residents. The nursing schedule showed no RN coverage on multiple days, and limited hours on others. The DON confirmed the issue, citing difficulty in attracting RN applicants.
The facility failed to follow its Enhanced Barrier Protection and Contact Isolation Precautions policy, leading to infection control deficiencies. Staff did not consistently use required PPE, such as gowns and masks, during high-contact care activities for residents under isolation precautions. Observations showed staff performing care with only gloves, despite the need for additional protective equipment, as confirmed by the DON and other staff.
A resident with severe cognitive impairment tested positive for Covid-19, and the facility initiated isolation precautions. However, the resident's family was not informed of the positive test until two days later, contrary to the facility's policy requiring immediate notification of significant changes in condition. This delay was confirmed by the DON.
A CNA in the facility was found to have verbally abused and neglected residents, including making them wait unnecessarily and using derogatory language. Two residents reported the CNA's refusal to assist those not assigned to her and her inappropriate behavior towards confused residents. The facility's investigation confirmed these allegations, resulting in the CNA's termination.
The facility failed to provide written notice of transfer to three residents and their representatives, as required by their policy. The medical records showed that these residents were transferred to a local hospital, but there was no evidence of the required written notice. The Corporate Compliance Nurse confirmed the lack of documentation and notification.
A resident reported feeling intimidated and humiliated by a CNA who turned off the call light without addressing needs, changed the resident without communication, and got the resident up without consent. The resident expressed feelings of dread and belittlement, leading to the CNA's termination after an investigation confirmed mental and verbal abuse.
A resident with bipolar disorder and autistic disorder experienced theft and exploitation when the former BOM opened an account in the resident's name and withdrew $11,900 without consent. The resident was cognitively intact, and the facility's policy on misappropriation of resident property was violated. The former BOM's employment was terminated, and a police report was filed.
The facility failed to prevent verbal abuse by a Certified Nurse Aide (V5) who took away a resident's (R2) urinal, causing distress and leaving the resident in a wet bed. R2 and another resident (R7) reported that V5 often refused to help and made disparaging comments about their ability to care for themselves. The allegations were confirmed, and V5 was terminated.
A facility failed to ensure timely response to a resident's call light. A CNA was observed using her cell phone instead of responding to a resident with a leaking colostomy bag. The resident's care plan required prompt assistance due to visual/hearing impairments and a history of falls. The administrator acknowledged challenges in preventing staff from using cell phones during shifts.
Failure to Honor Resident Preferences Regarding Use of Styrofoam During Meals
Penalty
Summary
The facility failed to honor multiple residents' stated preferences not to be served meals using Styrofoam products, affecting 8 of 12 residents reviewed for dignity. During a lunch observation, several residents were served their meals on Styrofoam plates with Styrofoam cups and plastic utensils. One resident stated they had previously informed staff they did not like Styrofoam and preferred ceramic or regular dishes. Other residents commented that it would be nice to be served meals in regular dishes and reported that this was not the first time they had been served using Styrofoam products. Additional residents reported they had been served meals on Styrofoam in the past and expressed a preference for regular dishes. Staff interviews confirmed that Styrofoam products were used for residents who ate in their rooms and were also used at times in the dining rooms during meals and for room trays. The Administrator, who was present in the dining room during the observed lunch, questioned why Styrofoam products were being used and stated they should not be used, indicating awareness that regular dishes were expected. The DON acknowledged that using Styrofoam during meals was a dignity issue and emphasized that the facility was the residents' home and that regular dishes should be used at mealtimes. The facility’s policy on promoting and maintaining residents’ dignity during mealtimes states that residents are to be treated with respect and dignity in a manner that maintains or enhances quality of life and recognizes residents’ individuality and rights, which was not followed when residents’ expressed preferences regarding dishware were not honored.
Call Light Not Accessible for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident, who was unable to move her left side due to a cerebrovascular accident (CVA) and required substantial assistance for bed mobility, did not have her call light within reach while in bed. The resident reported that a CNA entered her room at night, took her call light away, and told her she was using it too much. Observations confirmed that the call light was placed on the nightstand, out of the resident's reach, and staff interviews corroborated that the resident could not have moved the call light herself due to her physical limitations. Staff interviews further revealed that the resident frequently used her call light for assistance, particularly at night, and facility policy required that the call light be accessible and secured for residents. The care plan for the resident specifically indicated the need to encourage her to use the call bell for assistance, given her self-care deficits. Despite these requirements, the call light was not accessible, resulting in a failure to accommodate the resident's needs and preferences as required.
Failure to Supervise Resident with Dysphagia During Meals Resulting in Fatal Choking Incident
Penalty
Summary
A deficiency occurred when a resident with dysphagia, who was on a pureed diet and required close supervision during meals, was left unsupervised in the dining room. The resident had a history of cerebral infarction, hemiplegia, aphasia, and moderate cognitive impairment, and was known to be at risk for choking and aspiration. Care plans and physician orders specifically indicated the need for supervision during meals and noted the resident's tendency to take food from other residents' trays, as well as attempts to eat nonfood items. On the day of the incident, the resident finished his pureed meal and was able to self-propel his wheelchair across the dining area. Staff interviews revealed that the resident was known for quickly grabbing and consuming food not on his prescribed diet, particularly when unsupervised or while leaving the dining room. Multiple staff members acknowledged that there was no formal process or procedure in place to ensure the resident did not access inappropriate foods when exiting the dining area. Supervision was described as informal, relying on staff awareness and reminders to other residents not to leave food unattended. During the incident, staff were occupied with other duties and did not notice the resident's movements. The resident was later found in distress, choking on solid food items such as bread and hot dogs, which were not part of his prescribed diet. Despite immediate intervention by CNAs, an LPN, and EMTs, the resident was unable to be resuscitated and expired. Staff interviews confirmed that the lack of a structured supervision protocol contributed to the resident's ability to access and consume hazardous foods, leading to the fatal choking event.
Failure to Ensure Privacy During Resident Shower
Penalty
Summary
A deficiency occurred when a resident was not provided privacy during a shower. On the observed date and time, the shower room door in the C hall was left halfway open while a resident, who was naked and covered in soap, was being assisted by a CNA. Both the resident and the CNA confirmed that the door should have been closed, and the resident expressed discomfort with the door being open. Interviews with facility staff, including the Administrator, another CNA, and the Assistant Director of Nursing, confirmed that facility policy requires the door to be closed during showers to maintain resident privacy and dignity. The resident involved had multiple medical diagnoses, including Parkinson's disease, osteomyelitis, COPD, diabetes, and other chronic conditions. She was alert, oriented, and dependent on staff for bathing and toileting. The facility's policy on promoting and maintaining resident dignity specifically states that staff must ensure privacy during care, including showers. The failure to close the shower room door resulted in a lack of privacy for the resident during personal care.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Professional Nurse (RN) for eight consecutive hours a day, seven days a week, as required. Review of the facility's daily staff posting sheets and monthly nursing schedule over a specified period revealed multiple days where there was no documented eight-hour RN assignment. The facility's own assessment tool indicated the necessity of appropriate staffing, including RNs, to meet resident care needs. During an interview, the Corporate Nursing Officer acknowledged ongoing difficulties in recruiting and retaining RNs, despite increased pay and incentives, and noted reluctance to hire certain available RNs due to concerns about their work history or reputation. This deficiency had the potential to affect all 99 residents residing in the facility, as documented in the facility's application for Medicare and Medicaid.
Failure to Provide Bed Hold Policy Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives at the time of transfer to the hospital, as required by facility policy. Record review showed that four residents who were discharged or hospitalized on multiple occasions did not have documentation in their medical records indicating that they or their representatives received the bed hold policy notice. Specifically, the records for these residents lacked evidence of written notification at the time of each transfer for hospitalization or therapeutic leave. During an interview, the Administrator confirmed that bed hold notices were not given at the time of transfer and acknowledged that the facility was aware of this ongoing issue.
Failure to Monitor Lithium Levels as Ordered
Penalty
Summary
The facility failed to monitor blood levels of a psychotropic medication, Lithium Carbonate, as ordered by the physician for one resident. The resident had a physician's order for Lithium Carbonate 450 mg twice daily and for lithium levels to be checked every three months, starting from 2/5/2024. The last documented lithium level in the resident's medical record was from 11/5/2024, and as of 5/20/2025, there was no documentation of any subsequent lithium level checks. The Director of Nursing confirmed that the resident had not had their lithium level checked since the last recorded date, despite the standing order and facility policy requiring timely laboratory monitoring.
Failure to Implement Abuse Policy Following Resident Verbal Altercation
Penalty
Summary
The facility failed to implement and follow its Abuse, Neglect, and Exploitation policy for two of three residents reviewed for abuse. The policy requires immediate investigation and reporting of all alleged violations, including verbal altercations, to the Administrator and appropriate agencies within specified timeframes. However, a verbal altercation involving two residents was documented in a care plan, but there was no corresponding nursing progress note, abuse investigation, or report to the state agency. The Social Service Director noted the incident in the care plan after it was discussed in a morning meeting, but could not recall which nurse reported the incident, and there was no documentation of the event over the weekend when it occurred. The Administrator in Training, who serves as the facility's Abuse Coordinator, confirmed that she was not made aware of the incident and that no investigation or report was initiated. The lack of communication and documentation by nursing staff and the Social Service Director resulted in the failure to follow the facility's abuse policy, which mandates prompt investigation and reporting of all abuse allegations, including those involving verbal altercations between residents.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to both the facility's Abuse Coordinator and the State Agency for two of three residents reviewed for abuse. According to the facility's Abuse, Neglect and Exploitation policy, all alleged violations must be reported to the Administrator, state agency, and other required agencies within specified timeframes. In this case, a verbal altercation, including threats of physical harm, occurred between two residents. The incident was documented in one resident's care plan after being discussed in a morning meeting, but no abuse report was made to the Abuse Coordinator or the State Agency. The Social Service Director confirmed she documented the incident in the care plan based on information from a morning meeting but was not present during the weekend when the incident occurred and could not identify the reporting nurse. The Administrator in Training, who also serves as the facility's Abuse Coordinator, confirmed she was not informed of the incident and that no abuse report was submitted to the state agency. The lack of communication and failure to follow reporting procedures resulted in the deficiency.
Failure to Investigate Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The facility failed to investigate an alleged incident of resident-to-resident verbal abuse involving two residents. According to the facility's Abuse, Neglect and Exploitation policy, any suspicion or report of abuse, including verbal altercations, requires an immediate investigation, including identifying and interviewing all involved parties and thorough documentation. However, for an incident involving a verbal altercation and threats of physical harm between two residents, there was no documentation of an abuse investigation, no nursing progress note detailing the event, and no evidence that the required investigative steps were taken. The care plan for one resident was updated to reflect the altercation, but this was based on information shared during a morning meeting and not on a formal investigation. The Social Service Director confirmed that the incident was reported after the weekend, but she did not know which nurse initially reported it, and there was no follow-up with the Abuse Coordinator. The Abuse Coordinator stated she was not made aware of the incident and would have expected to be notified to initiate an investigation. As a result, the facility did not respond appropriately to the alleged violation as required by its own policy.
Failure to Provide Scheduled Showers and Document Hygiene Care
Penalty
Summary
A resident who was dependent on staff for hygiene did not receive the required weekly showers as outlined in the facility's policy. The policy states that residents should be assisted with bathing to maintain proper hygiene, with showers provided according to a set schedule or upon request. Observation revealed the resident was in a high-back wheelchair, appeared pleasantly confused, and had oily, unwashed hair. The resident's family member reported that although the resident was scheduled for showers twice a week, the hair often appeared greasy and unwashed unless specifically requested or washed by the family member. Review of the resident's shower documentation for May showed showers were only recorded on three dates, with no documentation of any showers from May 10th to May 20th. The Director of Nursing confirmed that the resident should have received two to three showers during this period and that there was no documentation of refusals or showers provided. The expectation was that CNAs complete a shower sheet for each shower, and refusals should be documented in the notes, but neither was present for this resident during the specified timeframe.
Failure to Perform Complete Catheter Care per Facility Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform indwelling urinary catheter care according to facility policy for a resident with a urinary catheter. The facility's policy requires that catheter care be performed every shift and as needed, including cleansing the resident's meatus, perineal area, and the catheter tube itself. During an observed catheter care procedure, the CNA assisted the resident to stand and cleansed only the perineal area, omitting care to the meatus and the catheter tube. The CNA later confirmed that the meatus and catheter tube should have been cleansed during the procedure. The Director of Nursing (DON) also verified that proper catheter care for a male resident includes cleaning the meatus, perineal area, and catheter tube each time care is provided. This failure to follow established catheter care procedures was identified for one resident reviewed for urinary catheters out of a sample of 35.
Failure to Provide Prescribed Dialysis Medication and Daily Weights
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who required hemodialysis. The resident had physician orders and a care plan specifying the need for daily weights and administration of Lokelma (sodium zirconium cyclosilicate) on specific days to manage high potassium levels. Documentation showed that the resident was not weighed on several ordered days in April and May, and multiple scheduled doses of Lokelma were not administered during this period. The medication was prescribed in response to a significantly high potassium level, and the care plan required close monitoring and collaboration with the dialysis center. The Director of Nursing confirmed that there were multiple missed daily weights and missed doses of Lokelma, citing issues with insurance coverage and pharmacy supply for the medication. The facility's own policy required timely medication administration and daily weights for residents receiving hemodialysis, as well as communication with the dialysis center regarding treatment orders and resident status. Despite these requirements, the resident did not consistently receive the prescribed medication or daily weights as ordered by the physician.
Failure to Use Gloves During Insulin Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to apply gloves during the administration of insulin to a resident with Type 2 Diabetes Mellitus. The facility's infection control policy requires staff to use standard precautions, including wearing personal protective equipment such as gloves, when there is potential exposure to blood or body fluids. During observation, the LPN prepared and administered five units of Humalog Insulin subcutaneously to the resident's left arm without donning gloves, then disposed of the used syringe. The LPN confirmed that gloves were not used during the procedure, which was not in accordance with the facility's infection control guidelines.
Failure to Maintain Safe Hot Water Temperatures in Resident Care Area
Penalty
Summary
The facility failed to provide hot water at comfortable temperatures for 22 residents residing on D-Hall. Certified Nurse Assistants (CNAs) and residents reported that there had been no hot or even warm water in any of the rooms on D-Hall for about a month. CNAs had to obtain hot water from the nurses station to clean residents in the mornings, and residents described the water from their bathroom sinks as cold and uncomfortable. Maintenance staff confirmed the issue, noting that water temperatures in resident rooms reached only 76 degrees Fahrenheit after several minutes, which is below the facility's policy for safe water temperatures. Maintenance logs showed a pattern of low water temperatures in D-Hall rooms over several weeks, with readings as low as 49 to 76 degrees Fahrenheit. The Maintenance Director acknowledged being informed of the problem by nursing staff one to two weeks prior and stated that the issue began after new water pipes were installed about a month ago. Despite checking equipment and notifying the Corporate Maintenance Director, no outside assistance had been called to address the ongoing lack of hot water. Facility policy requires maintaining appropriate water temperatures in resident care areas, but this standard was not met for the affected residents on D-Hall.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault involving a resident with Alzheimer's dementia and severe cognitive impairment and another resident with Paranoid Schizophrenia and moderate cognitive impairment. The incident occurred when one resident, who has a history of aggressive behavior and communication difficulties due to language barriers, became agitated and struck another resident in the dining room. Staff were present and intervened to separate the residents, but the assault had already occurred. The resident who was struck did not exhibit a reaction and was assessed with no injuries found. Prior to the incident, there were multiple documented episodes of the aggressive resident displaying escalating behaviors, including yelling, cursing, and attempts to strike other residents. Staff had to intervene on several occasions to prevent altercations. The care plan for the aggressive resident identified risks for verbal and physical aggression but did not address his communication or language needs, despite staff observations that language barriers contributed to his frustration. Both residents involved were assessed as being at moderate risk for mistreatment.
Failure to Observe Medication Administration
Penalty
Summary
A resident who was cognitively intact and had multiple diagnoses, including hypertension, anxiety, depression, and respiratory failure, was observed lying in bed with a cup containing five pills and three large chewable tablets on the bedside table. The resident was unaware that her morning medications were present and could not recall how long they had been there. The May 2025 Medication Administration Record indicated that her morning medications included duloxetine, loratadine, calcium, dronedarone, pregabalin, and calcium carbonate. An LPN reported that she had completed the medication pass, provided the resident with her medication cups, and instructed her to take them but did not remain to observe the resident consume the medications. The LPN acknowledged that she should have stayed to ensure the medications were taken. The DON confirmed that facility policy requires nurses to observe residents taking their medications and not to leave medications unattended. The facility's policy also specifies that staff must observe resident consumption of medication.
Failure to Investigate Alleged Abuse and Protect Resident
Penalty
Summary
The facility failed to investigate an allegation of potential physical abuse and ensure the alleged victim was protected from further abuse. A resident, identified as R4, reported that a CNA, referred to as V5, hit them with a chair while they were in the bathroom. R4 expressed feeling unsafe and stated that they were abused frequently without any intervention. Another CNA, V4, heard R4 yelling about being pushed down by V5 and reported this to an LPN, V3. Despite these reports, the facility did not conduct a thorough investigation into the allegations. The Administrator, V1, confirmed that no investigation was completed regarding the potential abuse reported by R4. Additionally, V1 did not remove V5 from their duties, although V3 was instructed to move V5 to a different hall. The lack of documentation and investigation into the abuse allegations, as well as the failure to protect the resident from further potential abuse, highlights a significant deficiency in the facility's handling of abuse allegations.
Inadequate Infection Control Measures
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as evidenced by the presence of fecal matter on toilets and improper storage of soiled washcloths. Observations revealed that three residents experienced unsanitary conditions in their shared bathrooms. One resident reported finding dirty washcloths with feces in the sink and fecal matter on the toilet, which was confirmed by a CNA. Another resident also reported similar issues, including dirty adult incontinent briefs on the floor and fecal matter on the bathroom walls. A housekeeper corroborated these findings, noting the frequent presence of soiled washcloths and briefs in resident rooms. The Director of Nursing acknowledged awareness of the issue, indicating that CNAs were not adequately cleaning up after themselves. The facility's Standard Precautions Infection Control Policy mandates that all staff assume residents may be infected or colonized with transmissible organisms, requiring adherence to standard precautions to prevent infection spread. However, the observed conditions and staff admissions suggest a failure to implement these policies effectively, leading to potential cross-contamination and compromised infection control.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required nursing coverage of a Registered Nurse (RN) for the period of July 8-17, 2024. This deficiency has the potential to affect all 91 residents residing in the facility. According to the facility's nursing schedule, there was no RN coverage on July 8, 9, 10, 15, 16, and 17, 2024. Additionally, on July 12, 2024, an RN was present for only 8 hours, and on July 13-14, 2024, an RN was present for only 4 hours each day. The Director of Nursing confirmed the lack of RN coverage during this period and acknowledged the facility's difficulty in attracting RN applicants, which has resulted in being cited for this deficiency.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Protection and Contact Isolation Precautions policy and procedures for five residents, leading to deficiencies in infection control practices. The Enhanced Barrier Precautions policy requires the use of personal protective equipment (PPE) such as gloves, gowns, and masks during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that staff did not consistently use the required PPE when entering rooms of residents under contact isolation or enhanced barrier precautions. For instance, a resident colonized with ESBL and under contact isolation had a sign on their door instructing staff to wear gloves, gowns, and masks, yet the PPE bin outside the room lacked isolation gowns. A CNA was observed inside the room without PPE and did not perform hand hygiene upon exiting. Similarly, another resident with a wound and an indwelling urinary catheter was under enhanced barrier precautions, but staff performed care activities wearing only gloves, neglecting to use gowns and masks as required. Additional instances included staff performing wound care and gastric tube management for residents under enhanced barrier precautions while only wearing gloves, despite the need for gowns and masks to prevent potential fluid splashes. These observations indicate a systemic failure to implement the facility's infection prevention and control policies, as confirmed by the Director of Nursing and other staff members.
Failure to Timely Notify Family of Resident's Covid-19 Diagnosis
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition in a timely manner. The facility's policy requires informing the resident, consulting the resident's physician, and notifying the resident's family member or legal representative when there is a significant change in the resident's physical condition or when new treatment is required. In this case, a resident with severe cognitive impairment tested positive for Covid-19 on March 26, 2023, and isolation precautions were initiated. However, the resident's family was not informed of the positive Covid-19 test until March 28, 2024, as verified by the Director of Nursing. This delay in notification constitutes a failure to adhere to the facility's policy on notification of change.
Verbal Abuse and Neglect by CNA
Penalty
Summary
The facility failed to prevent verbal abuse and neglect of a resident, identified as R70, among a sample of 29 residents. The facility's policy, dated February 2023, mandates the protection of residents from abuse and neglect. However, during a group meeting, R70 reported that a Certified Nurse Aide (CNA), identified as V8, was hateful and refused to help residents, including making them wait unnecessarily. R70 also observed V8 telling confused residents to leave her alone. Another resident, R18, corroborated these claims, stating that V8 was rude, refused to assist residents not assigned to her, and used derogatory language towards confused residents. R70 provided a written statement on July 17, 2024, further detailing V8's inappropriate behavior, including refusing to help those in need and turning off call lights without returning to assist. The facility's incident log from July 16, 2024, confirmed the allegations, documenting that V8 was verbally inappropriate and abusive, creating an environment where residents might be afraid to ask for assistance. The investigation concluded that V8's actions were abusive, leading to her termination from the facility.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide written notice of transfer to three residents and their representatives, as required by their Notification of Change policy. The policy mandates that the facility must inform the resident, consult the resident's physician, and notify the resident's family member or legal representative when there is a change requiring such notification, including a transfer or discharge. Specifically, the medical records for three residents, identified as R41, R74, and R94, showed that they were transferred to a local hospital on different dates, but there was no evidence that the facility provided the required written notice of transfer to the residents or their representatives. On July 18, 2024, at 2:00 PM, the Corporate Compliance Nurse (V7) confirmed that the facility did not provide the necessary written notices of transfer for these residents. This lack of documentation and notification represents a failure to comply with the facility's policy and regulatory requirements for resident transfers.
Failure to Prevent Mental Abuse
Penalty
Summary
The facility failed to prevent mental abuse for one resident (R3) as evidenced by the actions of a Certified Nursing Assistant (CNA), identified as V5. According to the report, R3 reported an incident where V5 turned off the call light without addressing R3's needs, later returned to change R3 without any communication, and then proceeded to get R3 up without consent. R3 expressed feelings of intimidation, humiliation, and dread towards V5, describing the CNA as unprofessional and unapproachable. The incident was reported to the Administrator in Training, who confirmed that R3 felt belittled and humiliated by V5's behavior. R3's care plan was updated to reflect the risk for abuse and to encourage finding a trusted staff member to talk to without feeling humiliated. Further investigation revealed that V6, an LPN, also observed R3's distress and confirmed R3's negative feelings towards V5. V6 stated that R3 described V5 as cold, rude, and deflating, and mentioned that V5's behavior made R3 feel terrible. V6 did not report the issue earlier because V5 was not present at the time. The facility's policy on abuse, neglect, and exploitation was reviewed, which defines mental abuse as including humiliation, harassment, and threats of punishment or deprivation. The investigation concluded with the termination of V5, confirming the allegation of mental and verbal abuse.
Misappropriation of Resident Funds by Former BOM
Penalty
Summary
The facility failed to protect a resident with diagnoses of bipolar disorder and autistic disorder from theft and exploitation. The former Business Office Manager (BOM) opened an account in the resident's name and withdrew $11,900 without the resident's consent. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 15/15, experienced unauthorized transactions from their ABLE account to the BOM's personal electronic money account. The facility's policy on abuse, neglect, and exploitation clearly defines misappropriation of resident property, which was violated in this case. The facility's final report to the State Agency indicated that the investigation was ongoing and that the family was not cooperating with the staff. However, a police report was filed. The former BOM's employment was terminated after the incident was discovered. The resident's father reported the issue to the facility and subsequently filed a police report when he noticed the discrepancy in the account balance. The Regional Nurse confirmed that the former BOM should not have taken the resident's funds.
Failure to Prevent Verbal Abuse by Certified Nurse Aide
Penalty
Summary
The facility failed to prevent the verbal abuse of a resident (R2) by a Certified Nurse Aide (V5). According to the report, V5 instructed another Certified Nurse Aide (V6) to take away R2's urinal, which V6 refused to do. V5 then took the urinal herself, causing distress to R2. R2 reported that this was not the first time V5 had taken his urinal, and that V5 would often take it away if he asked for too much help during the night, leaving him in a wet bed. R2 also mentioned that V5 had previously refused to button his shirt and made disparaging comments about his ability to care for himself. Another resident (R7) corroborated R2's claims, stating that V5 often refused to help and made similar comments about their ability to perform self-care tasks. The facility's Abuse Investigation confirmed the allegations of verbal abuse, leading to the termination of V5. The investigation included interviews with other residents, which supported the claims against V5. Despite attempts to obtain a statement from V5, she did not provide any information or feedback, and all communication was handled through her union. The facility's policy on Abuse, Neglect, and Exploitation clearly defines verbal abuse and mandates protections for residents, which were not upheld in this instance.
Failure to Respond to Call Light in a Timely Manner
Penalty
Summary
The facility failed to ensure staff responded to a resident's request for assistance in a timely manner. The incident involved a resident with diagnoses including colostomy, cataracts, and glaucoma. On the specified date, two call lights were activated at the nurse's station, one of which was from the resident's room. A Certified Nurse Assistant (CNA) was observed sitting in the hallway near the resident's room, looking at her personal cell phone and not responding to the call light. When questioned, the CNA admitted she had not noticed the call light and promptly attended to the resident. The resident needed help with putting on socks and addressing a leaking colostomy bag, which had caused stool to leak through his pants. The resident expressed concern about missing his smoke break due to the delay in assistance. The CNA acknowledged that the call light had been on for at least five minutes and recognized that even this duration was too long when the resident had feces on his skin. The resident's care plan indicated a need for prompt response to all requests for assistance due to a history of falls and visual/hearing impairments. The facility's policy on call lights emphasized that all staff members are responsible for responding to activated call lights. The administrator acknowledged difficulties in ensuring staff refrain from using their cell phones while on duty and confirmed that the CNA in question had just started her shift and should have been attending to call lights instead of using her phone.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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