Allure Of Pinecrest
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Morris, Illinois.
- Location
- 414 South Wesley Avenue, Mount Morris, Illinois 61054
- CMS Provider Number
- 145024
- Inspections on file
- 29
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Allure Of Pinecrest during CMS and state inspections, most recent first.
A cognitively impaired resident with vascular dementia, severe cognitive impairment, and documented wandering and exit-seeking behaviors was able to leave the building unsupervised. The resident, who wore a wanderguard and was known to wander persistently to multiple doors and resist redirection, exited through a unit door whose alarm was later found disengaged and not sounding. Staff working nearby reported hearing no alarm, despite describing the alarms as typically loud, and the resident was only discovered outside when an activity aide arriving early for her shift heard tapping on a window and brought the resident back inside. This occurred despite facility policies requiring functional door locks/alarms, vigilant response to alarms, and adequate supervision for residents at risk of elopement.
A resident with a PEG tube for dysphagia had the tube dislodged and was sent to the ED, but the facility failed to document the incident, the resident’s departure, or related clinical details in the medical record. A CNA reported finding the tube on the floor, obtaining normal VS, and preparing the resident for transport after notifying an RN. The RN reported managing multiple emergencies and acknowledged that documentation may not have been completed. Staff interviews indicated that an order for transfer, progress notes, and documentation of physician and family notification should have been present, in contrast to facility policy requiring complete, accurate, and timely documentation of resident care and events.
A resident with a history of atrial fibrillation and a stage four pressure ulcer had a critically high INR while on warfarin therapy. The facility did not notify the wound care provider of this abnormal lab result before wound debridement was performed, resulting in significant bleeding that required cauterization. Staff interviews confirmed that the wound care team was unaware of the lab value prior to the procedure, contrary to facility policy requiring notification of changes affecting treatment.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
Staff failed to prepare pureed pork to a pudding-like consistency for several residents on pureed diets, resulting in a product that was lumpy, stringy, and required chewing. Both the cook and Food Service Director acknowledged the texture was not appropriate and did not meet the facility's policy for pureed foods.
Staff did not wear gowns, as required, while providing incontinence care to a resident on enhanced barrier precautions due to a feeding tube. Although gloves were used, both CNAs also touched the resident's tube feeding equipment without full PPE, contrary to facility policy and posted instructions.
The facility did not provide required Advance Beneficiary Notice (ABN) forms to three residents whose Medicare Part A coverage ended, even though they were given Notice of Medicare Non-Coverage (NOMNC) forms and transitioned to private pay or personal insurance. Staff interviews revealed a lack of awareness and implementation of the ABN process, despite facility policy requiring its use.
A dependent resident with multiple diagnoses was found with a saturated incontinence brief and pad, and staff could not confirm when incontinence care was last provided. The resident, who relies on staff for toileting and hygiene, did not refuse care. Facility policy and staff interviews indicated that incontinence care should be performed at least every two hours and that pads should not be used with briefs, but these standards were not followed.
The facility did not follow physician orders for two residents: one did not have a prescribed anticoagulant held prior to scheduled surgery despite pre-op instructions being faxed and received, resulting in surgery rescheduling; another with spinal fractures was observed multiple times out of bed without the ordered back brace, despite staff awareness of the order.
Two residents at risk for falls were not safely transferred according to facility policy. One was moved without a gait belt by a CNA, while another, unable to bear weight, was lifted by two CNAs using improper techniques and without required alarms in place. Both cases involved residents with documented fall risks and prior incidents, and staff interviews confirmed that proper procedures were not followed.
Two residents with dementia did not consistently receive individualized, non-pharmacological interventions as outlined in their care plans and the facility's dementia care policy. Staff were observed physically guiding residents who were resistive to care, rather than using recommended approaches such as providing choices, involving them in activities, or allowing time for response.
A resident with multiple cognitive and psychiatric diagnoses was prescribed quetiapine and furosemide, and the pharmacist recommended a CMP lab be completed and repeated every six months. Although the provider signed off on the recommendation, the lab order was not entered or completed as required, and the omission was not addressed until the following month, contrary to facility policy.
A deficiency was found when a blue pill bottle in the memory care unit medication cart had a legible resident name but an illegible medication name and dispensed date. An LPN could not identify the medication, and the ADON confirmed that labels must be legible and replaced if not. Facility policy requires all medication labels to be clear and replaced by the pharmacy if they become illegible.
A wound care nurse failed to wear a gown while providing care to two residents on enhanced barrier precautions, despite the facility's policy requiring both gloves and gowns for wound care. One resident had skin cancer on the left ear, and the other had a wound on the right great toe. The infection control preventionist confirmed the requirement for gowns during such care.
The facility failed to monitor weights and complete lab work for two residents with CHF, leading to one resident's readmission to the hospital due to fluid overload. Despite physician orders, weights and labs were not conducted as required, impeding effective management of the residents' conditions.
The facility failed to maintain resident dignity, as evidenced by a CNA's rude behavior towards two residents, leading one to avoid seeking assistance. Additionally, staff were observed using cell phones during work hours, contrary to facility policy. The ADON acknowledged multiple complaints about the CNA's attitude, and the administrator confirmed the prohibition of cell phone use by staff.
A resident with moderate cognitive impairment reported feeling scared and disrespected when a CNA forcibly removed a blanket from her lap and insisted she go to the dining room despite being in her pajamas. Staff interviews corroborated the resident's account, revealing the CNA's history of rude behavior. The CNA was suspended and later terminated her own employment.
A resident with multiple health conditions, including Parkinson's Disease, recurrent pneumonia, and dementia, was admitted with a comfort-focused treatment plan. Despite signs of distress such as clamminess, increased respirations, and elevated vital signs, the night shift nurse and nurse practitioner chose to keep the resident comfortable on-site per the power of attorney's wishes. Throughout the day, the resident exhibited symptoms like coughing, low oxygen levels, and difficulty obtaining vital signs. The nurse practitioner did not provide clear orders for oxygen or manual blood pressure monitoring. The resident's condition deteriorated, leading to a critical incident where the resident was found unresponsive and subsequently passed away. The lack of timely and appropriate interventions and inadequate monitoring contributed to the outcome.
A resident experienced an 11.41% weight loss over six months due to the facility's failure to provide prescribed nutritional supplements. Despite orders for a health shake and pudding, the resident did not receive these items during a meal observation. The dietary staff admitted to not providing the supplements, contributing to the resident's significant weight loss.
The facility failed to ensure that PRN psychotropic medications had a specified duration for five residents. Physician orders for these residents did not contain a stop date or duration for the medications prescribed. The Director of Nursing confirmed that PRN psychotropic medications should have a duration or stop date, as per the facility's policy.
The facility failed to ensure staff wore isolation gowns when providing high contact care to a resident on enhanced barrier precautions. Despite a sign indicating the need for gloves and gowns, two CNAs did not wear isolation gowns while providing incontinence care to a resident with a gastrostomy. The DON confirmed that high contact care activities require the use of gloves and gowns, as per the facility's Enhanced Barrier Precautions policy.
A facility failed to ensure a resident's head remained elevated above 30 degrees while a tube feeding was infusing. The resident, who had dysphagia and a gastrostomy, was observed with their head of bed lowered below 30 degrees during incontinence care, contrary to their care plan and facility policy. The tube feeding was not paused, increasing the risk of complications.
The facility failed to assess and implement interventions for a resident's known contracture in her left hand. Despite the resident's history of stroke and functional limitations, there was no documentation or updated care plan addressing her condition. Staff interviews revealed a lack of awareness and documentation, and the facility's policy on preventing decline in range of motion was not followed.
A resident experienced multiple unsafe transfers with a sit-to-stand lift, resulting in being lowered to the floor. Staff failed to use two-person assistance and did not apply necessary safety straps, despite the resident's known difficulties with standing during transfers.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident from leaving the building unsupervised despite known elopement risk and wandering behaviors. The resident had vascular dementia with behavioral disturbance, severe cognitive impairment, and a documented history of restlessness, pacing, intrusive behavior in peers’ rooms, calling out for parents, and repeated attempts to exit the facility. An elopement/wandering assessment identified behaviors such as attempting to leave without a responsible escort, pacing and roaming, and becoming agitated while looking for family, with a plan to use a wanderguard device. Nursing notes prior to the incident documented that the resident had been combative, agitated, exit seeking, going into other rooms, and difficult to redirect, with frequent checks maintained. On the day of the elopement, the resident, who was identified as an elopement risk, exited the facility through door #4 without staff knowledge. The door alarm did activate, but staff did not hear it due to environmental noise at the nurses’ station. The resident was later found outside by the door, tapping on the window to be let back in, and was brought back into the building by an activity aide who arrived early for her shift and heard the tapping. Staff interviews indicated that the resident frequently wandered, persistently went to multiple doors, twisted knobs, pushed on doors, and tried to get out, and that she did not take redirection well. Following the incident, staff interviews revealed that door #4 on the memory care unit was found disengaged and unlocked, and no one reported hearing an alarm at the time the resident exited. A CNA reported that when she checked the doors after the resident was returned, door #4 was disengaged and could be opened without the alarm sounding. Housekeepers working in nearby hallways also stated they did not hear any alarm, even though they described the alarms as typically very loud and easily heard from their work areas. Maintenance staff explained that the door system required the alarm to be engaged for it to sound when pushed, and that if it was disengaged, the door could be opened without triggering an alarm. The facility’s elopement and wandering policy stated that the facility is equipped with door locks/alarms to help avoid elopements, that alarms are not a replacement for necessary supervision, that staff must be vigilant in responding to alarms, and that adequate supervision will be provided to help prevent accidents or elopements, which did not occur in this case.
Failure to Document PEG Tube Dislodgement and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident who was dependent on a percutaneous endoscopic gastrostomy (PEG) tube for nutrition due to dysphagia and cognitive communication deficit. The resident’s face sheet and care plan documented gastrostomy status and the need for tube feeding. Emergency department records show that the resident arrived with a dislodged feeding tube and had a temporary tube placed, with an outpatient procedure planned to replace the PEG. However, the facility’s medical record contained no documentation of the PEG tube being pulled out, no description of the incident, and no indication that the resident left the facility for emergency care. Staff interviews confirmed that the event occurred and that required documentation was omitted. A CNA reported finding the resident in bed with the feeding tube on the floor, minimal blood at the site, and the resident in no apparent distress; she took vital signs, which were normal, and prepared the resident for transport to the emergency room, reporting the incident to an RN. The RN stated she was notified that the PEG tube had been removed, directed the CNA to obtain vital signs, and notified the on-call manager and physician before sending the resident to the emergency room, but acknowledged that due to multiple simultaneous emergencies it would not be surprising if nothing was documented. An LPN stated there should have been an order for hospital transfer, progress notes detailing the event, and documentation of family and physician notification. The DON stated nurses should document why and when a resident leaves, with whom, and in what condition. This lack of documentation was inconsistent with the facility’s policy requiring complete, accurate, and timely documentation of each resident’s experiences and care, to be completed no later than the end of the shift in which the care occurred.
Failure to Notify Wound Care Provider of Critical Lab Value Prior to Procedure
Penalty
Summary
The facility failed to notify the wound care provider of a resident's critically elevated INR lab value prior to performing wound care. The resident, who had a history of a stage four pressure ulcer to the left heel, atrial fibrillation, and a left hip fracture, was receiving warfarin therapy. On the day in question, the resident's INR was reported as 7.8, a value significantly above the therapeutic range, and this result was flagged in the laboratory report. Despite this, there was no documentation in the progress notes that the provider or the resident's family had been notified of the abnormal result. Subsequently, the wound care physician assessed and debrided the resident's left heel wound without knowledge of the elevated INR. During the procedure, the wound bled heavily and required cauterization and pressure bandaging. Interviews with facility staff confirmed that the wound care nurse and physician were not informed of the critical lab value prior to the procedure. The facility's policy required prompt notification of changes that may necessitate an alteration in treatment, but this was not followed in this instance.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prepare Pureed Pork to Required Consistency for Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed pork served to residents on pureed diets was prepared to the required pudding-like consistency. During meal preparation, the cook measured, weighed, and blended pork with broth for residents requiring pureed diets. Despite multiple attempts to blend the pork, the resulting product was observed to be lumpy and stringy, rather than smooth and pudding-like as required by the facility's policy. The cook acknowledged the difficulty in achieving the correct texture, particularly noting that pork tends to be more difficult to puree. Further observations confirmed that the pureed pork was not fully blended and required chewing, which is inconsistent with the dietary needs of residents on pureed diets. The Food Service Director also agreed that the texture was inappropriate. The facility's policy specifies that pureed foods must be ground, pressed, or strained to a soft, smooth, thick paste similar to thick pudding, which was not achieved in this instance for all residents on pureed diets reviewed.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow required infection prevention protocols for a resident on enhanced barrier precautions. The resident, who had a feeding tube, was identified as needing enhanced barrier precautions, which included the use of gloves and gowns during high-contact care activities such as changing incontinence briefs. On the observed date, two certified nursing assistants entered the resident's room to provide incontinence care. Although they wore gloves, they did not wear gowns as required by the posted signage and facility policy. During the care, both staff members also touched the resident's tube feeding equipment. Interviews with the staff and the infection control nurse confirmed that gloves and gowns should be worn when providing incontinence care to residents on enhanced barrier precautions, especially those with implanted medical devices like feeding tubes. The resident's care plan and the facility's policy both specified the need for appropriate PPE during high-contact care activities to reduce the risk of transmission of multidrug-resistant organisms. The failure to wear gowns during the care activity constituted a breach of the facility's infection control program.
Failure to Issue Advance Beneficiary Notices for Non-Covered Services
Penalty
Summary
The facility failed to provide required Advance Beneficiary Notice (ABN) forms to residents whose Medicare Part A coverage was ending, as observed in three cases reviewed. In each instance, the residents were given a Notice of Medicare Non-Coverage (NOMNC) form indicating the last covered day of Medicare services, but there was no documentation that the ABN form was provided. Facility records confirmed that while the NOMNC was issued, the ABN was not, even when residents transitioned to private pay or personal insurance after Medicare coverage ended. Interviews with facility staff revealed a lack of understanding and implementation regarding the ABN process. The Social Services Director and Memory Care Coordinator/Social Services were responsible for providing NOMNC forms but did not provide ABN forms, with one staff member unfamiliar with the ABN entirely. The Business Office Manager, who handled financial discussions with residents, also did not provide or document the ABN form. The facility's own policy required the use of the CMS-approved ABN form for Part A items and services, but this was not followed in the reviewed cases.
Failure to Provide Timely and Appropriate ADL Assistance for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including major depressive disorder, osteoarthritis, and Alzheimer's disease was not provided with adequate assistance for activities of daily living (ADLs) as required by her care plan. On observation, certified nursing assistants (CNAs) found the resident in bed with both an incontinence pad and an incontinence brief, both saturated with dark urine, and the resident reported being wet. The CNAs were unable to determine when the resident's incontinence brief was last changed, and one CNA stated that the resident should have been gotten up by the night shift earlier in the morning. Facility policy requires that residents unable to perform ADLs receive necessary services to maintain hygiene, and staff interviews confirmed that incontinence care should be provided at least every two hours and that an incontinence pad should not be used together with an incontinence brief. The resident's records indicated she is dependent on staff for toileting and personal hygiene and does not refuse care.
Failure to Implement Physician Orders for Pre-Surgical Medication Hold and Back Brace Use
Penalty
Summary
The facility failed to implement and follow physician orders for two residents, resulting in deficiencies in care. For one resident with dementia, Alzheimer's disease, and atrial fibrillation on anticoagulation therapy, the facility did not hold the prescribed blood-thinning medication as instructed in pre-surgical orders faxed by the resident's surgeon. The pre-op instructions, which required holding the medication for three days prior to scheduled abdominal hernia surgery, were faxed to the facility but not acted upon. The resident continued to receive the medication, leading to the surgery being rescheduled. Documentation and interviews confirmed that the facility received the faxed orders but failed to implement them in a timely manner. Another resident admitted with compression fractures of the spine had a physician order to wear a back brace when out of bed. Despite this order being present in the resident's records, observations on multiple occasions showed the resident seated in a recliner without the back brace. Staff interviews confirmed awareness of the order, but the brace was not applied as required. The facility's procedures for handling consulting physician orders were not followed, resulting in the resident not receiving the prescribed treatment.
Failure to Ensure Safe Transfer Practices and Accident Prevention
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents identified as being at risk for falls and requiring assistance. One resident, with a history of falls, decreased muscular coordination, and the use of assistive devices, was transferred by a CNA without the use of a gait belt, contrary to facility policy. The CNA lifted the resident by the waistband of her pants during transfers from a recliner to a wheelchair and from the wheelchair to the toilet. Another CNA confirmed that a gait belt should be used for all transfers involving this resident. A second resident, admitted with multiple diagnoses including osteoarthritis, osteoporosis, and Alzheimer's disease, had a history of falls and was care planned for sensor alarms and assistance with transfers. During observed transfers, two CNAs used a gait belt but lifted the resident, who was unable to bear weight, by the gait belt and then by holding under her arms and legs. The resident's bed alarm did not sound, and no wheelchair alarm was applied. Documentation showed the resident had experienced skin tears and falls during previous transfers. Staff interviews indicated that the resident was not bearing weight and should have been re-evaluated by nursing and therapy. Facility policy required safe handling and regular review of mobility needs, which was not followed in these instances.
Failure to Provide Individualized Dementia Care and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents diagnosed with dementia, as evidenced by the care of two residents. One resident with diagnoses including neurocognitive disorder with Lewy bodies, Alzheimer's disease, anxiety, major depressive disorder, and a history of falls, was observed to be resistive to care. Despite a care plan instructing staff to use a warm, safe, and inviting approach, emphasizing dignity and patience, staff were observed physically pushing the resident towards the bathroom when he was unwilling to walk, rather than allowing time or using alternative non-pharmacological interventions as outlined in the care plan. Interviews with staff indicated inconsistent application of the care plan, with some staff offering snacks or dancing to encourage movement, while others resorted to physical guidance. Another resident with dementia, anxiety, and restlessness was also observed to be resistive to care, repeatedly attempting to stand and walk. The care plan directed staff to provide choices and use individualized, non-pharmacological approaches, but staff were seen physically guiding the resident back into a chair and telling her to sit down, rather than involving her in activities or walking with her as recommended. The facility's own dementia care policy requires individualized, non-pharmacological interventions to enhance well-being, but observations and interviews revealed that staff did not consistently follow these approaches for residents displaying dementia-related behaviors.
Failure to Address Pharmacist-Identified Medication Review Irregularity
Penalty
Summary
A deficiency occurred when the facility failed to address an irregularity identified by the pharmacist during the monthly medication review for one resident. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, Alzheimer's disease with early onset, anxiety disorder, major depressive disorder, dementia, and a history of falling, was receiving quetiapine and furosemide. The pharmacist recommended a Comprehensive Metabolic Panel (CMP) be completed immediately and every six months thereafter, as documented in the Medication Regimen Review (MRR) dated March 11, 2025. Although the physician signed off on this recommendation and a nurse indicated the order was faxed to the lab, there was no evidence that the lab order was actually entered or completed in March. A subsequent MRR in April noted that the CMP lab results were still missing and the order had not been entered. The advanced practice nurse signed off to schedule the lab for the next available day, and staff documented that the order was placed for April 23, 2025. However, review of the order summary confirmed that no CMP lab draw was ordered in March, and the order was not entered until April. The facility's policy requires staff to act upon all pharmacist recommendations according to established procedures, but this was not followed in this instance.
Illegible Medication Label Found in Memory Care Unit
Penalty
Summary
A deficiency was identified when a blue bottle containing white round pills was found in the locked memory care unit medication cart, with the resident's name legible on the label but the medication name and full dispensed date illegible. The LPN present was unable to identify the medication, only stating it was believed to be a hospice medication. The Assistant Director of Nursing confirmed that medication labels should be legible and replaced if not. The facility's policy requires all medication labels to be legible at all times and replaced by the issuing pharmacy if they become illegible, soiled, incomplete, or worn. The failure to maintain a legible medication label was observed for a resident with multiple diagnoses, including heart disease, unsteadiness, convulsions, dementia, Alzheimer's disease, and anxiety disorder.
Failure to Use Required PPE During Wound Care
Penalty
Summary
The facility failed to ensure that staff wore the required personal protective equipment (PPE) for residents on enhanced barrier precautions. Specifically, a wound care nurse provided care to two residents without wearing a gown, which is required under the facility's infection control policy. The first resident had a diagnosis of skin cancer on the left ear, and the nurse provided wound care using gloves but no gown. The second resident had a wound on the right great toe, and again, the nurse used gloves but did not wear a gown. The facility's infection control preventionist confirmed that staff should wear both gloves and gowns when providing wound care to residents with wounds, as per the enhanced barrier precautions policy.
Failure to Monitor Weights and Labs for CHF Residents
Penalty
Summary
The facility failed to obtain necessary weights and complete lab work for residents with congestive heart failure (CHF), specifically affecting two residents, R1 and R5. R1 was discharged from the hospital with instructions to have weekly lab work and weights monitored due to CHF and chronic kidney disease. However, the facility did not document R1's weight upon admission and failed to conduct the required lab work on the specified dates. This oversight contributed to R1's readmission to the hospital with fluid overload and exacerbation of CHF. R1's condition deteriorated over several days, with increasing edema and decreased oxygen saturation levels, which were not adequately monitored due to the lack of timely lab work and weight measurements. Despite physician orders for daily weights and lab tests, these were not performed as required, impeding the physician's ability to manage R1's condition effectively. The facility's failure to adhere to physician orders and monitor R1's condition closely led to a significant decline in R1's health, resulting in emergency hospitalization. Similarly, R5, another resident with CHF, was not weighed daily as ordered by the physician. The facility's records showed multiple instances where R5's weight was not documented, indicating a pattern of non-compliance with physician orders. This lack of monitoring could potentially lead to undetected weight changes, which are critical for managing CHF. The facility's inaction in both cases highlights a deficiency in providing necessary care and services as per physician orders.
Failure to Maintain Resident Dignity and Staff Conduct Issues
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by the behavior of a Certified Nursing Assistant (CNA), identified as V12, towards two residents. One resident, R12, expressed that V12 was short with residents, leading her to avoid asking V12 for assistance, opting instead to manage on her own or wait for another staff member. Another resident, R14, reported that V12 entered her room without knocking and, when questioned about it, refused to discuss the matter and subsequently refused to assist her. Interviews with other staff members, including V16 CNA and V3 CNA, corroborated these claims, describing V12 as rude and having an attitude problem. The Assistant Director of Nursing (ADON), V2, acknowledged receiving multiple complaints about V12's attitude, highlighting that R12's reluctance to seek help from staff was a significant issue. Additionally, the facility was found to be non-compliant with its policy on maintaining resident dignity due to staff using cell phones during work hours. A CNA, V7, was observed using a cell phone at the nursing station, and a resident, R14, noted that staff frequently used their phones, which she found inappropriate. The facility's administrator, V1, confirmed that staff were not permitted to use cell phones while on duty. The facility's policy, dated December 1, 2023, emphasizes the importance of treating residents with respect and dignity, including speaking respectfully and respecting residents' living spaces and personal possessions.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner, as evidenced by an incident involving a CNA and a resident with moderate cognitive impairment. The resident, who had multiple diagnoses including Alzheimer's Disease and chronic kidney disease, reported that a CNA forcibly removed a blanket from her lap and insisted she go to the dining room despite her being in her pajamas and not feeling well. The resident felt scared and disrespected by the CNA's loud and abrasive behavior, which included a comment that the resident 'hadn't seen anything yet' in response to a request for an apology. Interviews with staff corroborated the resident's account, revealing that the CNA had a history of using an abrasive tone and being rude to both staff and residents. Another CNA who entered the room confirmed that the resident was in her nightgown and should not have been taken to the dining room. The RN on duty also reported hearing the CNA make a 'not too smart' comment in the hallway, which could have been overheard by other residents. The facility's investigation led to the immediate suspension of the CNA involved, who subsequently terminated her own employment. The facility's policy on promoting and maintaining resident dignity emphasizes treating each resident with respect and acting upon their preferences, which was not adhered to in this incident.
Failure to Monitor and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to assess and monitor a resident (R93) who experienced a change in condition, ultimately resulting in the resident's death. R93, a resident with mild intellectual disabilities, Parkinson's Disease, recurrent pneumonia history, major depressive disorder, dementia, and dysphagia, was admitted to the facility with a comfort-focused treatment plan, including instructions to transfer to the hospital only if comfort could not be achieved on-site. Despite signs of distress, including clamminess, increased respirations, and elevated vital signs, the night shift nurse and nurse practitioner opted to keep R93 comfortable at the facility rather than transfer to the hospital as per the resident's power of attorney's wishes. The failure to adequately assess and respond to R93's deteriorating condition continued throughout the day, with reports of coughing, low oxygen levels, and difficulty obtaining vital signs. Despite these concerning symptoms, the nurse practitioner did not provide clear orders for oxygen or manual blood pressure monitoring. The resident's condition worsened, leading to a critical incident where R93 was found unresponsive, with visible signs of distress, ultimately passing away in the facility. The lack of timely and appropriate interventions, including failure to follow through on physician orders and inadequate monitoring, contributed to the tragic outcome for R93.
Failure to Provide Nutritional Supplements
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for a resident (R64), which contributed to an 11.41% weight loss over six months. R64 was admitted with multiple diagnoses, including Alzheimer's disease, dementia, and generalized anxiety disorder. The resident had orders for a health shake three times per day and pudding with lunch. However, during an observation on May 7, 2024, R64 did not receive the prescribed health shake or pudding cup at lunchtime. The dietary staff admitted to not providing the supplements because R64 was not seated, and another resident nearby tends to grab things. R64's weight records show a significant decline from 147.2 pounds in November 2023 to 130.4 pounds in May 2024. The dietitian confirmed that the health shake and ice cream were ordered to increase R64's caloric intake due to weight loss. The facility's Weight Monitoring Policy emphasizes the importance of implementing and monitoring nutritional interventions to maintain residents' nutritional status. The failure to provide the ordered supplements directly contradicts this policy and contributed to R64's continued weight loss.
Failure to Ensure PRN Psychotropic Medications Had a Specified Duration
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications had a specified duration for five residents reviewed for psychotropic medications. Specifically, the physician orders for these residents did not contain a stop date or duration for the medications prescribed. For instance, one resident had orders for Haloperidol Lactate Concentrate and Lorazepam Oral Concentrate without a stop date or duration. Another resident had an order for Lorazepam Concentrate for anxiety, also lacking a stop date or duration. Similar deficiencies were found in the orders for three other residents, all of which were missing the required duration or stop date for their PRN psychotropic medications. The Director of Nursing confirmed that PRN psychotropic medications should have a duration or stop date. The facility's policy on the use of psychotropic medications, implemented in December 2022, states that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration, typically 14 days. If an extension beyond 14 days is needed, the attending physician or prescribing practitioner must document their rationale and indicate the duration for the PRN order. However, this policy was not followed in the cases reviewed, leading to the identified deficiencies.
Failure to Use Isolation Gowns During High Contact Care
Penalty
Summary
The facility failed to ensure staff wore isolation gowns when providing high contact care to a resident on enhanced barrier precautions. A resident with a gastrostomy was observed to be incontinent of stool and had their adult incontinence brief changed by two CNAs. Despite a sign on the resident's door indicating the need for gloves and gowns during high contact care, the CNAs did not wear isolation gowns while providing incontinence care. The Director of Nursing confirmed that residents with catheters or implanted medical devices should be on enhanced barrier precautions and that high contact care activities, such as providing incontinence care, require the use of gloves and gowns. The facility's Enhanced Barrier Precautions policy also indicated that gowns and gloves should be used during high contact resident care activities, including providing hygiene and changing briefs.
Failure to Maintain Proper Head Elevation During Tube Feeding
Penalty
Summary
The facility failed to ensure a resident's head remained elevated above 30 degrees while a tube feeding was infusing. The resident, who had dysphagia, a gastrostomy, and gastro-esophageal reflux disease, was observed with their head of bed lowered below 30 degrees while the tube feeding continued to infuse. This occurred during incontinence care provided by two CNAs, who did not pause the tube feeding during the process. The resident's head of bed was nearly flat, and the tube feeding pump was infusing at 50 milliliters per hour. The resident's care plan and order summary report both indicated that the head of bed should be elevated 30 to 45 degrees at all times while the tube feeding is infusing. Additionally, the facility's policy on the care and treatment of feeding tubes required adherence to current clinical standards of practice to prevent complications. Despite these guidelines, the CNAs did not follow the proper protocol, and the RN confirmed that the tube feeding should be paused when the head of bed is lowered below 30 degrees to prevent the risk of aspiration.
Failure to Assess and Implement Interventions for Contracture
Penalty
Summary
The facility failed to assess and implement interventions for a known contracture in a resident's left hand. The resident, who had a stroke affecting her left side, was observed with her left hand fingers curled into her palm. Despite the resident mentioning the use of a brace and other devices in the past, her most recent Care Plan contained no documentation of her contracture or range of motion/restorative needs. The Minimum Data Set indicated functional limitations, but there was no follow-up or updated care plan addressing these issues. Interviews with the facility staff, including the Director of Nursing, Assistant Director of Nursing, and Physical Therapy Director, revealed a lack of awareness and documentation regarding the resident's contracture. The Physical Therapy Director confirmed that the resident had not been seen by therapy since 2023, and there were no recent assessments or interventions documented. The facility's policy on the prevention of decline in range of motion was not followed, as there was no systematic approach for assessment, care planning, and preventative care for the resident's contracture.
Failure to Ensure Safe Transfer of Resident
Penalty
Summary
The facility failed to ensure a resident was safely transferred with a sit-to-stand lift, resulting in multiple incidents where the resident was lowered to the floor. The first incident occurred when a CNA was transferring the resident to the toilet, and the resident began letting go of the grab bars. The CNA, who was alone and unable to reach the call light for assistance, slowly lowered the resident to the floor. The resident's nurse's notes indicated that the resident frequently bent her knees and needed constant cueing to stay standing during transfers. Despite this, the resident continued to be transferred using the sit-to-stand lift until a physical therapist recommended downgrading to a mechanical sling lift for safety reasons. A second incident occurred when another CNA was transferring the resident in the morning. The resident, who did not want to get up, let go and slid through the sling, landing on the floor because the leg strap was not applied. A Licensed Practical Nurse (LPN) who heard the CNA instructing the resident to put her feet back found the resident with one foot off the base of the lift. Despite attempts to reposition the resident, she was eventually lowered to the ground. Interviews with staff, including the Therapy Director and the Director of Nursing, confirmed that two staff members should always assist with sit-to-stand transfers for safety, and the resident should have been changed to a mechanical sling lift if having trouble with the sit-to-stand lift.
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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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