Allure Of Zion
Inspection history, citations, penalties and survey trends for this long-term care facility in Zion, Illinois.
- Location
- 3615 16th Street, Zion, Illinois 60099
- CMS Provider Number
- 145443
- Inspections on file
- 33
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Allure Of Zion during CMS and state inspections, most recent first.
A resident with a diagnosis of anxiety had a PRN order for lorazepam, a psychotropic medication, to be given every four hours as needed for anxiety without any documented duration or stop date. The facility pharmacist stated that PRN psychotropic medications require a stop date, and the facility’s psychotropic medication policy limits PRN psychotropics to 14 days unless the physician documents a rationale and specific extended duration. The absence of a stop date or defined duration on this PRN lorazepam order resulted in a deficiency.
Two residents with dementia and known wandering behaviors were not adequately supervised, resulting in one resident entering another's room and lying in her bed for over 30 minutes without staff intervention. Staff failed to immediately redirect or remove the resident, despite both having care plans requiring such actions, and facility policies mandating supervision and prompt intervention for wandering behaviors.
A resident with severe cognitive impairment and bladder incontinence was left in soiled clothing for several hours without timely incontinence care, despite being dependent on staff. Observations revealed the resident was wearing two heavily soiled incontinence briefs, and staff interviews confirmed that care had not been provided as required by the care plan and facility policy.
A resident with severe cognitive impairment and a history of falls and skin tears did not have required fall and skin tear prevention interventions in place, including a properly attached chair alarm and protective sleeves on both arms, despite care plans and physician orders. Staff were unclear about the correct use of these interventions, resulting in inadequate supervision and protection.
A CNA did not change gloves between dirty and clean tasks while providing incontinence care to a resident with a history of ESBL in the urine, despite Enhanced Barrier Precautions being in place. The CNA handled personal care, clothing, shared equipment, and grooming without changing gloves, and was unaware of the reason for the resident's precautions. The DON confirmed that glove changes are required to prevent infection spread.
A resident with advanced dementia and multiple medical conditions was not properly supervised or assessed upon admission, resulting in an unwitnessed fall and rib fracture. Staff were aware of the resident's high fall risk but did not provide adequate supervision or evaluate mobility needs before the incident occurred.
A resident with multiple serious diagnoses did not receive physician-ordered Augmentin as scheduled due to a delay in pharmacy delivery and staff not realizing the medication was available in the facility's convenience box. The antibiotic was not administered until nearly two days after the order was written, despite documentation and staff interviews confirming the medication's availability on site.
Multiple residents reported missing money from their personal belongings, including cash kept in nightstands, purses, and pouches. In one case, a resident observed a staff member going through her drawer before discovering her money was gone. Other residents and their families noticed funds missing when attempting to use them for personal needs. All affected residents were alert and oriented, and the facility's policy prohibits misappropriation of resident property.
A resident's reported missing money was not promptly reported or investigated according to facility policy. The Social Service Director notified the administrator, but there was a delay in informing the DON and state authorities, resulting in a failure to follow required procedures for reporting and investigating alleged misappropriation of property.
A resident's missing cash was reported by her daughter on two occasions, but the allegations were not immediately reported to the state agency as required. The Social Service Director notified the administrator, but the DON was not informed until days later, resulting in a delay that did not comply with facility policy for reporting suspected misappropriation of property.
A resident's reports of missing money were not immediately investigated after being reported to the Social Service Director and administrator. The DON was not informed until days later during a leadership meeting, resulting in a delay that did not follow facility policy requiring immediate investigation of alleged misappropriation.
Two residents with Stage 4 sacral pressure ulcers were not provided with low air loss mattresses as ordered by their wound care physician and outlined in their care plans. Both residents were observed without the required pressure-redistributing support surfaces, and staff confirmed that these interventions should have been in place according to facility policy.
Staff did not wear required gowns while providing direct care and wound dressing changes to a resident with a Stage 4 pressure wound who was on Enhanced Barrier Precautions (EBP), despite facility policy and CDC guidelines mandating gown and glove use during high-contact care activities.
A nurse failed to properly account for a resident's controlled medication when, after administering a dose of Lorazepam, she accidentally discarded a bottle containing 10 remaining tablets into the garbage. The error was discovered during a narcotic count, and the missing medication was not recovered. The nurse left the area before the discrepancy was resolved, contrary to facility policy, resulting in a failure to protect the resident's belongings and medication.
A resident's Lorazepam administration was not accurately documented, with a missing time and signature for one dose and inconsistencies between the medication count and records. LPNs involved could not clarify who administered the dose, and the facility's policy requiring complete documentation for controlled substances was not followed.
A resident with recurrent UTIs and a positive ESBL test did not receive a timely Infectious Disease consultation due to a failure by a nurse to execute a physician's order. The Nurse Practitioner had instructed the RN to initiate the referral process, but the order was not entered, and no appointment was made. This oversight was discovered during a survey, highlighting a lapse in following the facility's policy for carrying out physician orders.
A resident was moved to a different room without receiving written notice or being shown the new room and introduced to the new roommate. The move followed an incident with another resident, but the facility did not adhere to its policy of providing written notice and involving the resident in the decision-making process.
A resident with a history of traumatic brain injury and dementia, known for wandering and aggressive behavior, was inadequately supervised, leading to the resident entering other residents' rooms. Video footage and staff interviews confirmed the resident's frequent wandering and aggressive incidents, highlighting a failure to implement effective care plan interventions and provide necessary supervision.
A resident was sent to the hospital with another resident's transfer paperwork, leading to a mix-up in documentation. The error was identified when an ER nurse contacted the facility to clarify the resident's identity. The Director of Nursing admitted to printing the wrong paperwork, resulting in a billing error for a procedure the resident did not undergo.
Two residents developed severe pressure ulcers due to the facility's failure to identify and address areas of pressure. One resident developed stage 4 pressure injuries on both heels, requiring surgical debridement, while another developed an unstageable pressure ulcer on the left hip, which progressed to stage 4. The facility did not conduct timely skin assessments or follow its own policies for pressure injury prevention, leading to delayed interventions and inadequate care.
A resident with severe cognitive impairment and multiple health issues experienced significant weight loss due to the facility's failure to perform weekly weights as ordered by a physician. The resident's care plan did not address the weight loss, and the dietician was unaware of the need for weekly monitoring, leading to a delay in intervention.
The facility failed to store medications according to policy, with refrigerated medications found in non-refrigerated narcotic boxes and an unlocked medication cart accessible to unauthorized individuals. Additionally, the facility lacked temperature logs for medication room refrigerators, risking improper storage conditions.
The facility failed to ensure monthly Medication Regimen Reviews (MRRs) by a licensed pharmacist for five residents, each with various medical conditions. The deficiency was due to missing documentation after the previous DON left, and a recent pharmacy switch. The new pharmacy is now responsible for MRRs, but the old DON did not print the MRRs from the previous system.
A facility failed to obtain and display a physician's order for a resident's code status, despite the resident having a POLST form indicating a DNR status. The resident's electronic medical record and physician's orders did not reflect this, contrary to the facility's policy. Staff acknowledged the oversight and the potential for delays in emergencies.
The facility failed to conduct PASRR Level 2 assessments for two residents with serious mental illness. One resident was admitted with psychosis and anxiety, receiving antipsychotic medications, yet no Level 2 review was conducted. Another resident with bipolar and major depressive disorders also lacked a Level 2 assessment. The Admissions Director was unaware of the requirement, and the facility's policy on coordinating assessments was not followed.
A resident with severe cognitive impairment and incontinence issues did not receive thorough incontinence care. A CNA failed to cleanse the resident's perineal and groin area after removing two wet incontinence briefs, one of which contained feces. The DON acknowledged the oversight and noted the CNA's need for further education.
Two residents at risk for falls were not properly monitored due to ineffective use of clip alarms. One resident's alarm was not attached, and another's alarm was missing a clip, leaving both residents vulnerable to falls. Staff confirmed the alarms were not functioning as intended.
A resident with heart disease and pneumonia was administered oxygen at an incorrect rate and with contaminated tubing. The oxygen was set at 4 liters per minute instead of the prescribed 2 liters, and the tubing was reused after falling on soiled linens and the floor. CNAs did not follow infection control procedures, and the facility's policy on changing contaminated tubing was not followed.
The facility failed to implement proper infection control measures for two residents. One resident with a stage 4 pressure ulcer and a PICC line was not placed on enhanced barrier precautions, and staff did not use PPE as required. Another resident with an indwelling urinary catheter was not provided with appropriate infection control, as a CNA did not perform hand hygiene or wear a gown while providing care. These actions were contrary to the facility's infection prevention policies.
A resident was injured after a CNA used a mechanical stand lift instead of following the care plan, which specified a two-person assist with a gait belt. The incident resulted in a fall and a head injury requiring an ER visit. The facility's policy mandates adherence to the resident's care plan and the use of two staff members for mechanical lifts.
A facility failed to complete skin assessments for a resident for four weeks, resulting in an unstageable pressure ulcer that progressed to Stage 4 and required surgical debridement. The resident, who had moderate cognitive impairment and was at risk for pressure ulcers, was often left lying on her back for long periods. The facility's DON confirmed the lapse in skin assessments, and the wound physician noted the wound's deterioration despite weekly treatments.
PRN Psychotropic Medication Order Lacked Required Stop Date
Penalty
Summary
The deficiency involves the facility’s failure to ensure an as-needed (PRN) psychotropic medication order included a required duration or stop date. One resident, identified as having a diagnosis of anxiety on a face sheet printed on 2/17/26, had an order on the same date’s Order Summary Report for lorazepam, a psychotropic medication, to be administered every four hours as needed for anxiety, with no duration or stop date specified. During an interview on 2/27/26 at 10:23 AM, the facility pharmacist stated that a PRN psychotropic medication such as lorazepam requires a stop date. The facility’s undated “Use of Psychotropic Medication(s)” policy states that PRN psychotropic medications shall be limited to no more than 14 days unless the attending physician documents in the medical record a rationale for extending the order and indicates a specific duration. This lack of a documented stop date or specified duration for the resident’s PRN lorazepam order, despite the facility policy and pharmacist’s statement that such orders must be time-limited, constitutes the identified deficiency.
Failure to Monitor and Intervene for Dementia Residents with Wandering Behaviors
Penalty
Summary
The facility failed to adequately monitor and intervene for two residents with dementia who exhibited wandering behaviors. On the morning of 12/8/25, one resident with severe cognitive impairment was observed entering another cognitively impaired resident's room and lying in her bed, both fully clothed. Video surveillance reviewed by the administrator showed the resident wandering unsupervised throughout the facility for about an hour before entering the other resident's room. Staff did not remove the resident from the room until over 30 minutes after entry, and there was no staff presence observed during this period. Both residents had documented histories of wandering and confusion, with care plans indicating the need for staff to distract and intervene as appropriate. Interviews with staff revealed that when the incident was discovered, immediate intervention did not occur. A CNA who found the resident in the bed reported the situation to an RN, who was occupied with medication administration and did not act immediately, instead waiting for the day shift to assist. The RN stated uncertainty about the nature of the relationship between the residents and did not know how long the resident had been in the room. Facility policies required immediate redirection and supervision of wandering residents, but these were not followed, resulting in a lack of timely intervention for both residents involved.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident with severe cognitive impairment, Parkinson's Disease, congestive heart failure, and bladder incontinence was observed to have not received timely incontinence care despite being dependent on staff for assistance. The resident was noted sitting in a reclining wheelchair with wet pants and a strong urine odor. Staff interviews and record reviews revealed that the resident had not been changed since approximately 8:00AM, and by late morning, the resident's clothing remained soiled. The resident's care plan required perineal cleaning with each incontinence episode, but this was not followed. Further observations showed that the resident was wearing two incontinence briefs, both heavily soiled, which staff stated was a common practice for this resident. The assigned CNA confirmed that no incontinence care had been provided since the start of her shift. The interim DON acknowledged that wearing two briefs was not appropriate and that the resident had gone too long without being changed or repositioned. The facility's policy required appropriate treatment and services for incontinent residents to prevent infections, but this was not adhered to in the resident's care.
Failure to Implement Fall and Skin Tear Prevention Measures
Penalty
Summary
The facility failed to implement and maintain fall and skin tear prevention measures for a resident with significant risk factors, including severe cognitive impairment, Parkinson's Disease, congestive heart failure, and a history of falls and skin tears. Despite care plans and physician orders specifying the use of a chair alarm at all times and protective sleeves on both arms, observations revealed that the resident had two alarms attached to her chair but neither was clipped to her, and only one protective sleeve was in use while the other was left in the chair. Staff interviews confirmed a lack of understanding regarding the proper use of the alarms and the necessity of protective sleeves for the resident's fragile skin. Record review indicated multiple prior incidents of skin tears and falls, with care plans and orders updated to address these risks. However, during the survey, the required interventions were not consistently in place, as evidenced by the resident's exposed right arm and improperly applied alarms. The facility's policy mandates that interventions to reduce environmental hazards and provide adequate supervision must be implemented, but these measures were not effectively carried out for this resident.
Failure to Change Gloves During Incontinence Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to change gloves during incontinence care for a resident with a history of ESBL (Extended-spectrum beta-lactamase) in the urine, despite physician orders and care plan instructions for Enhanced Barrier Precautions. During observed care, a CNA removed a soiled incontinence brief, cleansed the resident's perineal area, applied a clean brief, assisted with clean clothing, handled a mechanical lift remote, and combed the resident's hair without changing gloves between tasks. The CNA admitted to not changing gloves as required and was unaware of the specific reason for the resident's precautions. The Director of Nursing confirmed that gloves should be changed when moving from dirty to clean tasks, especially for residents with a history of ESBL, to prevent the spread of infection.
Failure to Supervise High Fall Risk Resident on Admission
Penalty
Summary
A deficiency occurred when a resident with a high risk for falls was not adequately supervised upon admission to the facility. The resident, who had diagnoses including vascular dementia, wet gangrene, and osteomyelitis, arrived at the facility before the start of the incoming nurse's shift and had not yet been officially admitted or assessed by nursing staff. Both the registered nurse and the CNA on duty were aware that the resident was a high fall risk, but the resident had not been evaluated for mobility or supervision needs prior to the incident. The CNA reported that she found the resident attempting to get up from bed and, unsure of the resident's mobility status, suggested the use of a urinal and unfolded a walker without confirming if it belonged to the resident. The CNA then left the room to dispose of trash, during which time the resident attempted to get up independently and fell. The fall was unwitnessed, but the resident was found on the floor, reported head and back pain, and was subsequently sent to the hospital for evaluation. Following the fall, the resident's daughter reported ongoing pain, which led to further assessment and the discovery of a minimally displaced rib fracture. The facility's policy required that the environment be free of accident hazards and that residents receive adequate supervision to prevent accidents. In this case, the lack of timely assessment and supervision for a high-risk resident directly led to the fall and injury.
Delay in Administration of Ordered Antibiotic
Penalty
Summary
A deficiency occurred when a resident with diagnoses including wet gangrene, osteomyelitis, and dementia was not administered Amoxicillin-clavulanate (Augmentin) as ordered by the discharging physician. The hospital discharge instructions specified that the resident was to receive Augmentin every eight hours, with the next dose due on the evening of admission. Although the physician order was entered with the correct start date, the medication was not administered until nearly two days later. Facility records and staff interviews revealed that the delay was due to the medication not being delivered promptly and a lack of awareness that Augmentin was available in the facility's convenience box. Nursing staff documented that the medication was unavailable, and the DON confirmed that the nurse did not know the convenience box contained the required medication. The delay in administration was further compounded by communication with the pharmacy regarding medication availability.
Failure to Protect Residents from Misappropriation of Money
Penalty
Summary
The facility failed to protect residents from the misappropriation of their money, as evidenced by multiple incidents involving four residents. One resident reported waking up to find a staff member going through her nightstand, after which she discovered $210 missing from her drawer. The resident was alert and oriented, and her account of the incident remained consistent when discussed with staff and police. The staff member identified as being assigned to her care that night matched the resident's description and was seen entering the room on video footage. Another resident's daughter reported that money kept in envelopes for personal use was missing from the resident's purse on two separate occasions. The daughter had placed the money in the resident's room, and the loss was only discovered when the resident attempted to use the funds. The incidents were reported to the Social Service Director after the second occurrence. In a separate case, a resident reported $35 missing from her bedside dresser, which had been left there by her Power of Attorney for snacks and beverages. The loss was discovered during interviews related to another theft investigation, and the POA confirmed the funds had been provided. A fourth resident reported $40 missing from a pouch he kept with him at all times, only noticing the loss when he attempted to use the money at a vending machine. Staff confirmed the resident had money in his pouch the previous day, but a search of his room did not recover the missing funds. All four residents involved were alert and oriented at the time of the incidents, and the facility's policy prohibits misappropriation of resident property.
Failure to Timely Report and Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its Abuse Policy regarding the timely reporting and investigation of an alleged misappropriation of money for one resident. The resident's daughter reported missing envelopes of money on two separate occasions to the Social Service Director, who notified the administrator. However, there was a delay in reporting the allegations to the Director of Nursing and the Illinois Department of Public Health (IDPH). The Director of Nursing stated she was not informed of the missing money until six days after the initial allegation, during a morning meeting, and confirmed that no investigation or report to IDPH had occurred prior to her being notified. Facility policy requires that all allegations of abuse, neglect, exploitation, or misappropriation of resident property be reported immediately to the administrator and state agencies, and that an immediate investigation be initiated. In this case, the policy was not followed, as the allegations were not promptly reported or investigated. The documentation shows that the required notifications and investigation were delayed, contrary to the facility's written procedures.
Failure to Timely Report Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to ensure that an alleged misappropriation of a resident's money was reported immediately to the State Survey Agency as required. The incident involved a resident whose daughter reported missing envelopes of cash on two separate occasions. The first report involved two envelopes containing $23 each, noticed missing several days after being left in the resident's room. The second report involved four envelopes totaling $86 missing from a zipper pocket in the resident's purse. In both cases, the Social Service Director notified the facility administrator, but there was a delay in reporting the allegations to the Illinois Department of Public Health (IDPH). According to interviews and record review, the Director of Nursing was not informed of the missing money until several days after the initial report, during a leadership meeting. The facility's policy requires that all alleged violations involving misappropriation of property be reported to the administrator and state agency immediately, or within specified timeframes depending on the severity. The delay in reporting the allegations to IDPH did not meet these requirements, resulting in a deficiency.
Failure to Promptly Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to promptly initiate an investigation into an alleged misappropriation of money for one resident. The resident's daughter reported missing envelopes containing cash on two separate occasions to the Social Service Director, who notified the administrator but did not immediately begin an investigation. Documentation shows that the missing money was first reported as two envelopes totaling $46, and later as four envelopes totaling $86, all of which were kept in the resident's room or personal belongings. Despite these reports, a full investigation was not initiated until several days later, after the issue was brought up during a leadership meeting. Interviews and record reviews revealed that the Director of Nursing was not informed of the missing money until the leadership meeting, and acknowledged that the incident should have been reported and investigated immediately according to facility policy. The facility's policy requires immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation, but this protocol was not followed in this case, resulting in a delay in addressing the alleged misappropriation.
Failure to Provide Low Air Loss Mattresses for Residents with Stage 4 Pressure Ulcers
Penalty
Summary
The facility failed to provide low air loss mattresses for two residents with Stage 4 sacral pressure ulcers, despite physician orders and care plans specifying this intervention. One resident was admitted with a Stage 4 sacral pressure ulcer and deep tissue damage to the right heel, with both the wound physician's plan of care and the resident's care plan indicating the need for a low air loss mattress. However, during observation, the resident was found in bed without the required mattress and confirmed not having a special mattress. The wound care nurse also verified that the resident did not have a low air loss mattress and stated that all residents with pressure wounds should have one. A second resident, also admitted with a Stage 4 sacral pressure ulcer, was observed in her room without a low air loss mattress. During the survey, maintenance staff entered to replace her standard mattress with a low air loss mattress, and the resident confirmed she was receiving the new mattress as recommended by the wound care doctor. The facility's policy requires evidence-based interventions, including appropriate pressure-redistributing support surfaces, for all residents with pressure injuries. Despite this policy and physician recommendations, the required mattresses were not provided to these residents.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a Stage 4 pressure wound who had a current order for EBP. During a dressing change, three staff members, including a wound care nurse, a CNA, and a life enrichment staff member, provided direct care and assisted with wound care activities without wearing gowns, as required by the facility's EBP policy. The infection prevention nurse confirmed that staff are expected to wear gowns, gloves, and masks when providing close contact care to residents on EBP, especially those with Stage 4 or greater wounds. The facility's policy and CDC guidelines specify that gowns and gloves are necessary during high-contact care activities for residents on EBP.
Failure to Safeguard and Account for Controlled Medication
Penalty
Summary
A deficiency occurred when a nurse (LPN) failed to properly account for a resident's controlled medication, specifically Lorazepam tablets. The nurse reported that after administering a dose, she accidentally discarded the entire bottle containing 10 remaining tablets into the garbage. This was discovered during the routine narcotic count, which revealed the bottle was missing. The nurse admitted to possibly giving another dose in the morning and stated she realized the error only during the count. Video footage confirmed the nurse was seen preparing medications and discarding the bottle, but did not show her administering the medication. The resident involved was unable to communicate whether the medication was received, and the medication was supplied in bottles by hospice. The facility's policy requires staff to remain in the area until all discrepancies are resolved or reported as unresolved, but the nurse left the building before the issue was fully addressed. Other staff members noted the nurse's unusual behavior and that she had access to multiple medication carts. The missing medication was not recovered, as the garbage had already been removed. Documentation showed the medication was last signed out for administration, but the remaining tablets were unaccounted for, resulting in a failure to safeguard the resident's controlled substances as required.
Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of a controlled substance for one resident. The Controlled Substance Proof of Use form for a bottle of Lorazepam showed that one tablet was removed, but there was no time recorded or signature from the person who administered it. The next documented administration was later that same day, with the appropriate signature and time. The resident's Medication Administration Record (MAR) did not show a corresponding administration for the undocumented dose, and staff interviews revealed confusion about who administered the medication and when. One LPN stated that she might have given another dose in the morning, but the count in the bottle did not match the documentation. Another LPN stated she did not administer the medication during her shift and described how the count and documentation were reconciled after the discrepancy was discovered. The facility's policy requires that all controlled substances removed from the medication cart or cabinet be recorded on the designated usage form with clear and complete documentation. In this instance, the required documentation was incomplete, with missing time and signature for the administration of Lorazepam. Staff interviews confirmed that the documentation was not completed at the time of administration, and the process for reconciling the medication count was not followed as per policy.
Failure to Execute Physician Order for Infectious Disease Consultation
Penalty
Summary
The facility failed to carry out a physician's order for an Infectious Disease consultation for a resident, identified as R2, who was reviewed for Quality of Care. R2 had a history of recurrent urinary tract infections (UTIs), with the most recent one testing positive for extended-spectrum beta-lactamases (ESBL) on 12/19/24. Despite the Nurse Practitioner (V4) giving an order on 12/26/24 to the Registered Nurse (V5) to start the referral process for an Infectious Disease consultation, the order was not entered, and no appointment was made. This oversight was discovered on 1/8/25 when V4 noticed the missing order in R2's medical records. Interviews revealed that V5 recalled receiving the order but failed to act on it, and the Director of Nursing (V2) was unaware of the lapse until the surveyor's inquiry. The Assistant Director of Nursing (V3) noted that telehealth appointments with Infectious Disease doctors could be arranged quickly, suggesting that timely action could have facilitated a prompt consultation. The facility's policy requires nurses to note and carry out physician orders, which was not adhered to in this instance, leading to the deficiency.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to notify a resident in writing about a room change initiated by the facility. The resident, identified as R1, was moved to a different room after an incident where a male resident entered her room and kissed her on the cheek. The facility decided to move R1 to prevent further incidents with the male resident, R2. However, R1 expressed dissatisfaction with the move, stating she was not at fault and preferred her previous room due to its view. She also reported difficulties with her new roommate, who kept the TV volume high, affecting R1's ability to hear her visitors and her own TV. R1 was not shown her new room or introduced to her new roommate before the transfer, and she did not receive any written notice about the room change. The Social Service Director, identified as V4, confirmed that the facility's practice was to move the resident who complained about an incident. V4 also stated that while a form is filled out for room changes, it is not provided to the resident. The facility's policy requires written notice of room changes, including reasons for the move, and assistance from social services to help the resident adjust. However, there was no documentation in R1's electronic medical record regarding the room change, and the facility did not adhere to its policy of providing written notice and involving the resident in the decision-making process.
Inadequate Supervision of Wandering Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with wandering and aggressive behaviors, leading to the resident entering other residents' rooms. On December 4, 2024, video footage from November 24, 2024, showed the resident independently walking down the hallway and entering two different resident rooms. A Certified Nursing Assistant (CNA) was seen redirecting the resident out of the rooms, but the resident continued to wander. Interviews with staff revealed that the resident frequently wanders and has a history of aggressive behavior, including grabbing a CNA's arm and causing pain. The resident's psychiatric evaluations and behavior notes indicate a history of traumatic brain injury, dementia, and aggressive outbursts, requiring medication to manage behavior. The resident's care plan, printed on December 4, 2024, identified the resident as an elopement risk and wanderer due to disorientation and impaired safety awareness. However, the care plan interventions, such as distracting the resident with activities and identifying wandering patterns, were not effectively implemented. Staff interviews confirmed that the resident requires constant supervision to prevent entering other residents' rooms, but this level of supervision was not consistently provided, leading to the deficiency in ensuring a safe environment for all residents.
Incorrect Transfer Paperwork Sent with Resident
Penalty
Summary
The facility failed to ensure that the correct transfer paperwork was sent with a resident to the hospital, resulting in a mix-up of documentation. On March 6, 2024, a resident identified as R2 was sent to the hospital after pulling out his gastrostomy tube (g-tube) and required emergency room care to have it replaced. However, the transfer paperwork sent with R2 mistakenly contained the information of another resident, R1. This error was discovered when an emergency room nurse contacted the facility to clarify the identity of the resident in the emergency room. The Director of Nursing, identified as V2, admitted to printing the incorrect face sheet and code status for R1, which was then sent with R2 to the hospital. This mistake led to a billing error, as R1's wife discovered a charge for a tube feeding procedure that R1 did not undergo, since R1 remained at the facility on the day in question. The facility's policy on transfer and discharge requires specific information to be provided to the receiving provider, which was not adhered to in this instance.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to identify and address areas of pressure for two residents, leading to the development of severe pressure ulcers. Resident R45 developed two stage 4 pressure injuries on both heels, which required surgical debridement. The resident had a history of severe cognitive impairment and required substantial assistance for daily activities. Despite being at high risk for pressure ulcers, as indicated by the Braden Scale, the facility did not adequately monitor or report changes in skin condition. The Wound Nurse, V11, was not notified of the wounds until they had progressed significantly, and the initial assessment was delayed. The facility's policy required nursing assistants to report skin concerns immediately, but this protocol was not followed, resulting in the advanced stage of the wounds. Resident R56 also developed an unstageable pressure ulcer on the left hip, which progressed to a stage 4 ulcer requiring debridement. The resident's care plan indicated a risk for pressure ulcers, but weekly skin assessments were not conducted as required by the facility's policy. The wound was initially identified as a blister, but it was not properly monitored, leading to its progression. The Wound Nurse, V11, acknowledged that weekly assessments should have been performed due to the resident's high risk for skin breakdown, but these assessments were not documented or conducted. The facility's failure to adhere to its own policies and procedures for pressure injury prevention and management contributed to the development and progression of severe pressure ulcers in both residents. The lack of timely skin assessments and communication among staff members resulted in delayed interventions and inadequate care. The Director of Nursing and other staff members recognized the oversight and expressed concern over the failure to identify and address the skin issues before they became severe.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to perform weekly weights as ordered by a physician for a resident, resulting in a significant weight loss of 7.96% over a three-month period before it was identified by the facility staff. The resident, who has severe cognitive impairment and multiple diagnoses including traumatic subdural hemorrhage, type 2 diabetes, and anemia, experienced a weight loss of 5.47% within less than one month, dropping from 120.6 lbs to 114 lbs. The resident's care plan did not address the weight loss, and the physician's orders for weekly weights were not followed, leading to a further weight reduction to 111 lbs by July. The Director of Nursing acknowledged the issue, noting that the dietician was not aware of the resident's need for weekly weights, and the lead certified nursing assistant was not notifying staff to weigh the resident weekly. The dietician stated that the resident was not on the list for review due to the lack of recorded weights, which prevented timely intervention. The facility's policy on weight monitoring emphasizes the importance of maintaining acceptable nutritional status and requires weekly weight monitoring for residents with weight loss, which was not adhered to in this case.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store medications according to their policy, as observed during a survey. On the 400-hall and 200-hall medication carts, liquid Norco and Lorazepam, which require refrigeration, were found stored in the narcotic box instead of a refrigerator. Additionally, the 200-hall medication cart was found unlocked, allowing unrestricted access to medications, except for those in the double-locked narcotic box. This cart was left unattended near a common use bathroom, posing a risk of unauthorized access by visitors, staff, and residents. Furthermore, the facility did not maintain temperature logs for the medication room refrigerators, as confirmed by the LPN and the DON. Without these logs, there is no assurance that medications requiring refrigeration were stored at the correct temperatures, potentially compromising their effectiveness. The facility's Medication Storage policy mandates that all drugs and biologicals be stored in locked compartments and that refrigerated products be kept at temperatures between 36-46 degrees Fahrenheit, with daily temperature recordings.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a Medication Regimen Review (MRR) was completed by a licensed pharmacist on a monthly basis for five residents. These residents, identified as R8, R26, R41, R56, and R61, were part of a sample of 24 residents reviewed for MRR compliance. Each of these residents had only one MRR completed in 2024, with R8, R41, R56, and R61 having their reviews in June, and R26 in July. The residents had various medical conditions, including type 2 diabetes mellitus, major depressive disorder, hypertension, anxiety, depression, atrial fibrillation, bipolar disorder, COPD, osteoarthritis, and Parkinson's disease. The deficiency was attributed to a lack of documentation and oversight following the departure of the facility's previous Director of Nursing (DON). The facility's administrator, identified as V1, stated that many documents, including MRRs, went missing after the old DON left. The facility had recently switched pharmacies, and the new pharmacy was responsible for conducting MRRs and documenting them in the Electronic Medical Records (EMR). However, the old DON had access to the previous pharmacy's system and was supposed to print out the MRRs, which was not done. The facility's pharmacy services policy and procedure outlined the responsibilities of providing pharmaceutical services, including the accurate management of medications and collaboration with facility leadership to address pharmaceutical concerns affecting resident care.
Failure to Obtain and Display Resident's Code Status
Penalty
Summary
The facility failed to obtain and display a physician's order for a resident's code status, which is a critical component of the resident's advance directives. The resident, who has multiple diagnoses including Parkinson's disease, unsteadiness, repeated falls, lack of coordination, and syncope, had a POLST form dated December 2021 indicating a Do Not Resuscitate (DNR) status. However, the resident's electronic medical record and physician's orders for July 2024 did not reflect this code status, which is a violation of the facility's policy on residents' rights regarding treatment and advance directives. During interviews, a registered nurse and the Director of Nursing acknowledged the absence of the code status in the electronic medical record and the lack of a physician's order. They expressed concern that this oversight could lead to delays in emergency situations, as staff would need to search through the resident's chart to locate the POLST form. The facility's policy emphasizes the importance of supporting and facilitating a resident's right to formulate an advance directive, which was not adhered to in this case.
Failure to Conduct PASRR Level 2 Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a PASRR Level 2 assessment was completed for residents with serious mental illness, affecting two residents in the sample. Resident R66 was admitted with diagnoses including unspecified psychosis and anxiety, and was prescribed antipsychotic medications such as Quetiapine, Risperidone, and Haloperidol. Despite these indicators of serious mental illness, R66's PASRR Level 1 assessment indicated no need for a Level 2 review. The Admissions Director, V5, admitted to not being aware of the requirement for a PASRR Level 2 for residents with serious mental illness and stated she had not been trained on the process. Similarly, Resident R41, who had diagnoses of bipolar disorder and major depressive disorder, was also not subjected to a PASRR Level 2 assessment upon admission. The Administrator, V1, acknowledged that the admissions process failed to identify the need for a Level 2 review for R41. The facility's policy mandates coordination with the PASRR program to ensure appropriate care for individuals with mental disorders, but this was not adhered to in these cases.
Inadequate Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide thorough incontinence care for a dependent resident, identified as R37, who has severe cognitive impairment and is always incontinent of bladder. R37's medical history includes hemiplegia, hemiparesis, cerebral infarction, and dementia with behaviors. During an observation, a Certified Nursing Assistant (CNA), identified as V14, was seen providing toileting assistance to R37. V14 removed two incontinence briefs from R37, both of which were wet with urine, and the inner brief had feces on it. Despite the strong urine odor and the presence of feces, V14 only cleansed R37's buttocks and applied a clean brief without cleansing the perineal and groin area. The Director of Nursing (DON), identified as V2, stated that perineal care should be performed after each incontinent episode to prevent infection and provide dignity to each resident. The facility's policy on incontinence care, dated February 2023, requires that residents who are incontinent receive appropriate treatment to prevent infection. V14 admitted to not realizing the need to clean R37's groin area, attributing the oversight to being newer and needing more education. This incident highlights a deficiency in the facility's adherence to its incontinence care policy.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure fall prevention measures were effectively implemented for two residents, both of whom were identified as being at risk for falls. The first resident, R3, had a history of severe cognitive impairment and was at risk for falls due to incontinence. Despite having a physician's order for a clip alarm to be in place, the alarm was found unattached to the resident, rendering it ineffective. This was confirmed by a Licensed Practical Nurse who acknowledged that the alarm should have been clipped to the resident to alert staff if the resident attempted to get up. Similarly, the second resident, R30, also had severe cognitive impairment and a history of falls. Observations revealed that the clip alarm intended to prevent falls was not properly attached to the resident, as the clip was missing from the cord. This was noted on two separate occasions, and a Certified Nursing Assistant confirmed the alarm's ineffectiveness due to the missing clip. The alarm was later replaced, but subsequent observation showed it was still not clipped to the resident, leaving the resident at risk of falling.
Failure to Administer Oxygen Correctly and Maintain Infection Control
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician-prescribed rate and did not handle oxygen tubing in a manner to prevent cross-contamination for a resident. The resident, who had diagnoses including heart disease, pleural effusion, and pneumonia, was observed with oxygen set at 4 liters per minute instead of the prescribed 2 liters per minute. The resident was heavily incontinent of bowel, and the oxygen tubing was found lying on soiled linens and the floor. Despite this, the tubing was picked up and placed directly back into the resident's nose by the CNAs, without being replaced or cleaned. The CNAs involved in the incident did not follow proper infection control procedures, as they reused the contaminated nasal cannula. The Director of Nurses confirmed that oxygen is a medication and must be administered as ordered by the physician, and that contaminated tubing poses a serious infection control issue. The facility's policy states that oxygen tubing should be changed if it becomes soiled or contaminated, which was not adhered to in this case.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for two residents, leading to deficiencies in care. One resident, identified as having a stage 4 pressure ulcer and a PICC line, was not placed on enhanced barrier precautions despite having conditions that warranted such measures. Observations revealed that staff did not wear gowns or eye protection when caring for this resident, and there were no isolation signs or personal protective equipment (PPE) available outside the resident's room. The facility's policy required enhanced barrier precautions for residents with wounds or indwelling medical devices, but these were not followed in this case. Another resident, who required enhanced barrier precautions due to an indwelling urinary catheter, was also not provided with appropriate infection control measures. A Certified Nursing Assistant (CNA) failed to perform hand hygiene or wear a gown while emptying the resident's urinary drainage bag, despite the resident being on isolation. The CNA then proceeded to assist another resident without performing hand hygiene, further compromising infection control. The Director of Nursing confirmed that staff should wear PPE and perform hand hygiene before and after providing care to residents on enhanced barrier precautions, but these protocols were not adhered to in this instance.
Failure to Follow Resident's Care Plan During Transfer
Penalty
Summary
The facility failed to transfer a resident according to the resident's care plan, resulting in a fall and injury. On 04/24/24, a resident (R1) was observed with two staples in the top posterior area of her head. The resident's family expressed concerns about the use of a mechanical stand lift, which was not part of R1's care plan. The Assistant Director of Nursing (ADON) confirmed that the Certified Nursing Assistant (CNA) used the mechanical stand lift inappropriately and did not report the resident's weakened condition to the nurse before attempting the transfer. The resident's care plan specified a two-person extensive assist with a gait belt, not a mechanical stand lift. The incident occurred on 04/11/24, when the resident was being transferred using a mechanical stand lift, resulting in a fall in the resident's room. The fall was witnessed by the CNA, and the resident sustained a small scrape to the back of her head, which required an ER visit. The facility's Safe Resident Handling/Transfers Policy mandates that two staff members must be utilized when transferring residents with a mechanical lift, and all transfers should be performed according to the resident's individual plan of care. The CNA's failure to adhere to these guidelines led to the resident's fall and subsequent injury.
Failure to Perform Timely Skin Assessments Leads to Severe Pressure Ulcer
Penalty
Summary
The facility failed to complete skin assessments for a resident for four weeks prior to identifying a pressure injury that had become unstageable. This resident, who had moderate cognitive impairment and was at risk for developing pressure ulcers, was found to have an unstageable pressure ulcer on the coccyx, which later progressed to a Stage 4 wound requiring surgical debridement. The resident's granddaughter, who held power of attorney, reported that the resident was often left lying on her back for long periods, and the wound had become infected by the time the resident was hospitalized and placed on hospice care. The facility's Director of Nursing confirmed that no skin assessments were performed for approximately four weeks before the discovery of the resident's sacral wound. The facility's wound physician noted that the wound had worsened over time despite weekly assessments and adjustments to the wound treatment. The facility's policy on pressure injury prevention and management was not followed, leading to the resident's wound deteriorating from unstageable to Stage 4, necessitating surgical intervention.
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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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