Alpine Care Of St. Charles Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Charles, Illinois.
- Location
- 611 Allen Lane, Saint Charles, Illinois 60174
- CMS Provider Number
- 145433
- Inspections on file
- 28
- Latest survey
- March 21, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Alpine Care Of St. Charles Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment experienced an unwitnessed fall from bed that was observed by a CNA and reported to an RN, who assisted in lifting the resident back to bed, did not document the incident, and did not notify the MD. Subsequent shifts, including agency CNAs, an agency RN, a dialysis RN, and an OT, noted new acute right leg/hip pain, inability to bear weight, and a marked increase in assistance needed for transfers, but none were aware of any recent fall. The day-shift RN, also unaware of the fall, reported the hip pain to the MD and obtained a routine rather than STAT x-ray, which later revealed a right femoral neck fracture. The facility’s policy required immediate MD notification of accidents and significant changes in condition, but this did not occur, leading to delayed medical evaluation of the fracture.
A resident with severe cognitive impairment experienced an unwitnessed fall from bed that was observed by a CNA and assessed by an RN, but the RN did not document the event in the EMR, notify the MD, or inform subsequent nursing staff. A separate fall incident report was completed as a QA-only document and not integrated into the clinical record, so oncoming RNs and CNAs were unaware of the fall and did not initiate post-fall or neuro assessments. The resident was repeatedly transferred, including for toileting, dialysis, and therapy, while vocalizing acute right leg/hip pain and showing decreased ability to bear weight, but staff and therapy providers were not told of any recent incident. The day-shift RN, still unaware of the fall, reported hip pain to the MD and obtained a routine rather than STAT x-ray, and the fall coordinator later confirmed there was no EMR documentation or required 72-hour post-fall monitoring despite facility policy.
A resident with a history of AV fistula complications was admitted with orders to use a new permcath for dialysis, but the facility failed to communicate this change to the dialysis team. As a result, the AV fistula was used for treatment, leading to severe arm swelling and pain, and the resident required hospitalization for an acute cephalic vein thrombosis. Documentation and care planning did not reflect the updated orders, and the dialysis nurse lacked access to critical hospital discharge information.
Kitchen staff did not follow sanitary food handling and storage practices, including improper cleaning and use of thermometer probes, inadequate hair restraint use, leaving food uncovered, and storing expired or spoiled food items. These actions were inconsistent with facility policies and affected all residents receiving food from the kitchen.
Four residents with cognitive and physical impairments did not receive needed assistance with personal hygiene tasks such as nail care and shaving, despite requesting help from CNAs. Observations showed untrimmed fingernails and unshaven facial hair, and interviews confirmed that requests for care were not met. Facility policy requires meeting residents' ADL needs, but these were not fulfilled as observed.
The facility did not ensure proper coordination and documentation of hospice care activities for four residents, as hospice staff recorded care notes in their own system and did not provide written documentation to the facility. Facility staff relied on verbal updates, and hospice visit notes were missing from the residents' records, resulting in incomplete documentation of hospice services and care plans.
Two residents were allowed to keep and self-administer medications at their bedside without proper assessment, updated physician orders, or care planning. One resident had multiple medications at bedside with missing or outdated self-administration assessments and no care plan, while another with mild cognitive impairment had an inhaler and nasal sprays without required assessments or orders for all medications. Facility policy requiring regular evaluation and demonstration of self-administration ability was not followed.
A resident who was thin and frail did not receive their ordered nutritional supplement drink at lunch because the supplement was not included on their meal ticket. The dietician had not completed the required nutritional assessment or care plan, and the supplement order was not communicated to dietary staff as required by facility policy, resulting in the supplement not being provided.
Medications, including tablets, eye drops, and powder, were found unsecured on the bedside tables of three residents. One resident reported that a nurse left her refused medications in her room, while the other two had their medications left out as well. The DON confirmed that all medications should be kept secured in the med cart according to facility policy.
Two residents with significant dental needs were not assessed or assisted in obtaining routine dental services. Despite documented oral health issues and assessment forms indicating the need for dental evaluations, staff failed to refer these individuals for dental care due to unclear processes and lack of communication between nursing and social services.
Multiple residents' personal refrigerators were found with excessive ice buildup, expired and unlabeled food, missing temperature logs, and lack of thermometers. Staff interviews revealed confusion over responsibilities for cleaning, temperature monitoring, and food disposal, resulting in inconsistent adherence to facility policies regarding food safety and refrigerator maintenance.
Staff failed to follow infection control protocols by not changing gloves or performing proper hand hygiene between care activities, and by placing urinary catheter drainage bags directly on the floor for multiple residents. Gloves were improperly stored in uniform pockets and hand sanitizer was not used according to policy, leading to lapses in standard precautions during resident care.
A resident with cognitive impairment alleged sexual abuse by a male CNA, but the facility failed to investigate or report the incident promptly. The administrator delayed action due to an unrelated allegation, and the police were notified days later, contrary to the facility's abuse policy.
A resident with severe cognitive impairment and multiple medical conditions experienced a delay in receiving an x-ray for a suspected fracture, resulting in a delay in diagnosis and treatment. Despite an x-ray being ordered on 8/13/2024, it was not performed until 8/16/2024, leading to a delay in the resident being sent to the hospital for appropriate care. The facility's staff failed to follow up on the x-ray order promptly, and the Director of Nursing could not explain the delay.
The facility failed to label and date medications after opening, affecting six residents. Medications such as inhalers, insulin pens, and ophthalmic solutions were not dated, contrary to pharmacy recommendations for expiration. Additionally, a narcotic medication with a broken seal was improperly taped over instead of being discarded, as confirmed by a Nurse Consultant.
The facility did not follow the prescribed menu portion sizes for pureed beef top round roast beef, using a #8 scoop instead of the required #6 scoop for five residents on pureed diets. This resulted in a deficiency as the dietary staff did not adhere to the menu spreadsheet, leading to inadequate nutrition portions being served.
A facility failed to request a timely re-evaluation for a PASARR II screening for a resident with a serious mental illness. The resident, admitted with bipolar disorder, anxiety, and PTSD, did not receive a follow-up assessment after the initial PASARR II evaluation expired. Despite tracking assessments in the Maximus system, the facility did not conduct the required re-evaluation, resulting in a deficiency.
The facility failed to assist three residents with activities of daily living (ADLs), resulting in neglect of personal hygiene and incontinence care. One resident with severe cognitive impairment was found with dried stool on his hand and body, while another dependent resident was not provided with requested grooming and showering. A third resident expressed discomfort due to unkempt facial hair and long fingernails, highlighting a lack of adherence to the facility's policy on meeting residents' physical needs.
A facility failed to provide appropriate splint and therapy services for a resident with quadriplegia and other conditions, leading to a deficiency in maintaining range of motion. The resident's care plan required a left resting hand splint to be applied daily, but observations showed it was not consistently used. Staff acknowledged the requirement, but there was no documentation to confirm adherence to the prescribed schedule.
A resident with chronic respiratory failure was found with an almost empty portable oxygen tank during a group meeting, leading to coughing and reduced participation. A nurse replaced the tank, improving the resident's condition. The facility's policy requires continuous oxygen administration as per physician's orders.
A facility was found to have a 12% medication error rate due to improper administration of medications. An RN initially drew an incorrect dose of Heparin for a resident but corrected it before administration. Another RN administered Bisacodyl instead of Docusate Sodium without consulting a physician and failed to prime a new insulin pen before use. The DON emphasized adherence to physician's orders and proper medication administration protocols.
A facility failed to follow infection control practices during incontinence care for a resident. A CNA did not perform hand hygiene between glove changes while cleaning a heavily soiled resident and applied barrier cream with soiled gloves. The DON confirmed that hand hygiene is required between tasks, aligning with the facility's policy and CDC guidelines.
Failure to Notify Physician After Unwitnessed Fall and New Acute Hip Pain
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of an unwitnessed fall and subsequent acute right hip pain for a cognitively impaired resident, resulting in delayed medical care for a right hip fracture. The resident had a severely impaired cognitive status per a recent MDS and was unable to provide information about the fall. On the evening shift, a CNA found the resident on the floor next to her bed in a sitting position and notified the assigned RN. The RN assessed the resident, assisted in lifting her back to bed by carrying her under the arms with the CNA, determined she had not sustained an injury, and did not document the fall in the EMR or notify the physician of the incident. On the following overnight and day shifts, multiple staff members observed new, acute right leg/hip pain and functional decline without being aware of the prior unwitnessed fall. The overnight agency RN administered acetaminophen for pain but had not been informed of any incident. The agency CNA on that shift was also unaware of any fall and assisted the resident with pivot transfers based on prior instructions that she required only minimal assistance. The next morning, a CNA noted that the resident, who previously required minimal to partial assistance, now required extensive assistance, guarded her right lower extremity, and was unable to bear weight. This CNA reported her concerns to the agency RN and then to the oncoming RN, but was instructed to continue routine care, and subsequently observed the resident vocalizing pain during transfers to dialysis and therapy. Throughout that day, the dialysis RN and the occupational therapist were informed of the resident’s acute right leg pain and observed her vocalizing pain, screaming, and holding her right lower extremity when it was moved, yet neither had been notified of any recent fall. The OT documented that the resident verbalized pain, was unable to grade it, and screamed while holding her right lower extremity during movement. The day-shift RN, who had not been told of the fall, reported the resident’s right hip pain to the physician and obtained an order for a routine, not STAT, hip x-ray, which was completed later that evening. The radiology report, reviewed remotely that night, showed a subcapital fracture of the right femoral neck. The physician later stated she had not been notified of the fall or the acute pain at the time of the incident and that, had she been informed, she would have further assessed the resident and ordered STAT testing or hospital transfer sooner. The facility’s policy required immediate physician notification of accidents with potential for requiring physician intervention and significant changes in condition, but the RN on the evening of the fall did not follow this policy.
Failure to Document and Communicate Unwitnessed Fall Resulting in Delayed Assessment of Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to document, report, and monitor an unwitnessed fall for a severely cognitively impaired resident, which led to delayed medical care for a right hip fracture. On the evening of 3/01/2026, a CNA found the resident on the floor next to her bed in a sitting position and notified the assigned RN. The RN assessed the resident, determined she had no apparent injury, and assisted the CNA in manually lifting the resident back to bed by carrying her under the arms. The RN did not document the fall in the electronic medical record (EMR), did not notify the physician, and did not inform the oncoming nursing staff of the incident. A fall incident report was completed separately, indicating an unwitnessed fall and transfer back to bed, but it was marked as privileged and not part of the clinical record, and it was not integrated into the EMR. Because the fall was not documented in the EMR or communicated in shift report, the night-shift agency RN and CNA were unaware of the incident and did not perform any post-fall assessments or enhanced monitoring. The night CNA was instructed that the resident required only minimal assistance with transfers and proceeded to pivot-transfer her for toileting, without knowledge of a recent fall. Staff who routinely cared for the resident reported that prior to 3/02/2026 she required minimal to partial assistance with transfers. Early on 3/02/2026, a CNA assisting with dressing noted the resident vocalizing acute right leg pain, stopped care, and consulted the agency RN, who had just administered an analgesic. When the CNA asked if there had been a recent incident such as a fall, the agency RN reported there was no such event documented or reported in the EMR, and the CNA proceeded with transfers using a gait belt, observing that the resident now required extensive assistance, guarded her right lower leg, and was unable to bear weight. Throughout 3/02/2026, multiple staff members encountered the resident’s acute right leg and hip pain without knowledge of the prior unwitnessed fall. The CNA transporting the resident to dialysis reported the pain to the dialysis RN, who in turn notified the day-shift RN but was not informed of any recent incident. The dialysis communication form requested information on any change in condition, including recent falls, but no fall was reported. During therapy, the OT was not notified of any recent incident and documented that the resident screamed and held her right lower extremity when it was moved and was unable to safely stand. The day-shift RN, who had not been told of the fall and saw no EMR documentation of it, did not perform post-fall assessments and later reported the resident’s right hip pain to the physician, obtaining an order for a routine, rather than STAT, x-ray. The facility’s fall coordinator confirmed that there was no EMR documentation or 72-hour post-fall assessments for the unwitnessed fall, despite facility policy requiring incident reports to be documented in the medical record and accessible to staff, and requiring post-fall assessments and neurological checks for unwitnessed falls.
Failure to Communicate Updated Dialysis Orders and Assess Post-Dialysis Complications
Penalty
Summary
A deficiency occurred when the facility failed to communicate a resident's updated dialysis access order to the dialysis team and did not adequately assess for post-dialysis complications. The resident, who had a history of severe bleeding complications from his right arm AV fistula, was discharged from the hospital with instructions to use a newly placed permcath for dialysis instead of the AV fistula. Upon admission, the facility did not update the dialysis team with these new orders, and the dialysis Communication Report sheet did not reflect the change or the recent complications. As a result, the dialysis nurse used the resident's AV fistula for treatment, unaware of the updated order to use the permcath. After the treatment, the resident developed severe right arm swelling and pain. The family member notified the nurse on duty, who observed the swelling and contacted the nephrologist. The resident was subsequently transferred to the hospital, where he was diagnosed with an acute cephalic vein thrombosis in the right arm. Record review revealed that the facility's admission and care planning documentation did not include the new permcath access site or the updated dialysis orders. The dialysis nurse did not have access to the hospital discharge documents uploaded into the facility's EMR, and the baseline care plan and order summary did not reflect the required use of the permcath. The facility's policies and service contract required timely and accurate communication of changes in dialysis orders, which was not followed in this case.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
Facility kitchen staff failed to follow sanitary practices and safe food storage procedures, affecting all residents who receive oral nutrition from the kitchen. Observations included improper handling of thermometer probes, such as dropping a probe cover on the floor and placing it on a prep table without cleaning, using an uncleaned probe to check food temperatures, and using an alcohol wipe to push food off a probe back into a tray. Staff also failed to wear hair restraints properly, leaving hair exposed during food preparation, and left pureed food items uncovered on the steam table before service. Additional deficiencies were noted in food storage and labeling. In the walk-in cooler, a bag of pulled turkey lacked an expiration, use-by, or thaw date, and was fully thawed. Moldy and spoiled produce, including a zucchini with white fuzzy spots and green peppers with black, mushy areas, were found stored with other food. In dry storage, a scoop for thickener was left uncovered and exposed to environmental contaminants, and prune juice bottles past their best-by date were still present. Staff interviews confirmed that these practices did not align with facility policies for food labeling, storage, and sanitation. Facility policies require proper thawing, labeling, and storage of food items, as well as the use of clean, sanitized equipment and utensils. Staff acknowledged that food items past expiration or best-by dates should be removed, vegetables with visible spoilage should not be stored, and hair restraints must cover all hair. The observed failures to follow these procedures resulted in unsanitary conditions and improper food handling in the kitchen.
Failure to Provide Timely ADL Assistance for Residents Needing Personal Hygiene Support
Penalty
Summary
Surveyors observed that the facility failed to provide necessary assistance with activities of daily living (ADLs) for four residents who required help with personal hygiene tasks such as nail care and shaving. Direct observations revealed that one resident had long fingernails with a black substance underneath, despite requesting assistance from CNAs, while another had long yellow fingernails and also expressed a desire for nail care. Two additional residents were noted to have facial hair and stated they wanted to be shaved, but reported that CNAs had been too busy to assist them. These residents had documented diagnoses including major depressive disorder, dementia, anxiety disorders, schizophrenia, and impaired mobility, and their care plans indicated a need for substantial or maximal assistance with personal hygiene. Interviews with the residents confirmed that their requests for assistance with ADLs had not been fulfilled. The Director of Nursing stated that ADL care, including shaving and nail care, is typically provided on shower days or as needed, according to resident preference, and that CNAs are responsible for these tasks. Facility policy requires evaluation and provision of care to meet each resident's physical and psychosocial needs, including ADLs. Despite these policies, the observed lack of assistance resulted in unmet hygiene needs for the affected residents.
Failure to Maintain and Coordinate Hospice Documentation
Penalty
Summary
The facility failed to coordinate and maintain documentation of hospice care activities and the hospice care plan for four residents receiving hospice services. Hospice staff documented care and progress notes in their own electronic system and did not provide copies of this documentation to the facility. Facility staff received verbal updates from hospice staff, but written documentation, such as after-visit notes, was not consistently included in the residents' hospice binders or the facility's medical records. The only documentation provided by hospice to the facility included admission packets, DNR forms, POA forms, admission assessments, history and physicals, and occasionally physician orders. Interviews with facility RNs and the DON confirmed that hospice staff were expected to document in the hospice binder and provide verbal updates, but facility nurses only documented hospice notes when they initiated contact with hospice. Review of the hospice binders for the four residents revealed that essential hospice visit notes and after-visit documentation were missing. The binders typically contained only initial admission documents, consents, and sporadic physician orders, with little to no ongoing documentation of hospice visits or care provided. The facility care plans for each resident receiving hospice services were limited, listing only general goals and interventions related to comfort and pain management, with instructions to contact hospice as needed. The facility's agreement with the hospice provider stated that hospice would coordinate with the facility to ensure documentation of services was completed and that hospice care plans and documentation would be included in the facility medical record. However, this coordination and documentation did not occur as required, resulting in incomplete records of hospice care activities for the affected residents.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure ongoing assessment and care planning for residents who desired to self-administer medications. In one case, a cognitively intact resident had multiple medications, including eye drops, an inhaler, and a topical cream, stored at his bedside. While there were physician orders for self-administration of some medications, there were no orders for others, and the required self-administration assessments were either outdated or missing. The resident reported not being taught how to take the medications, and there was no documentation of a care plan addressing self-administration. The facility's policy required regular assessment and demonstration of self-administration ability, but these procedures were not followed, and the policy did not specify how bedside medications should be secured. Another resident with mildly impaired cognition also kept an inhaler and nasal sprays at his bedside. Although there was a physician order for unsupervised self-administration of the inhaler, there were no such orders for the nasal sprays. The resident stated he was not assessed by nursing staff for his ability to self-administer these medications, and there was no documentation of such assessments or related care planning in his record. These findings indicate a lack of compliance with facility policy and federal regulations regarding the assessment, authorization, and care planning for self-administration of medications.
Failure to Assess and Provide Ordered Nutritional Supplement
Penalty
Summary
A resident who appeared thin and frail was not provided with their ordered nutritional supplement drink during lunch on multiple occasions. Observations showed that the resident's meal tray included juice and Lactaid milk, but not the prescribed supplement. Staff interviews revealed that the resident's meal ticket did not list the supplement, and the dietary staff prepared meals based on these tickets. The dietician confirmed that she was responsible for assessing residents' nutritional needs and that dietary communication slips were used to inform the kitchen of required supplements. However, the resident's dietary evaluation was not completed following both their initial admission and subsequent readmission, resulting in the supplement order not being entered into the dietary system or reflected on the meal ticket. Record review indicated that the resident's dietary evaluation form and nutritional care plan remained incomplete, and there was no documentation of an assessment of the resident's nutritional needs. The order for the supplement drink was present in the medical record, but it was not communicated to the dietary staff via the required forms or the electronic system. Facility policy required a nutritional assessment within 24-72 hours of admission and communication of supplement orders to the kitchen, but these procedures were not followed, leading to the resident not receiving the ordered nutritional supplement.
Failure to Secure Resident Medications
Penalty
Summary
Surveyors observed that medications were not properly secured for three residents. One resident had a medication cup containing six tablets of various shapes and colors left on her bedside table, with a handwritten label and another cup covering it; the resident stated she had refused the medication and that it was left by a nurse from a previous shift. Another resident had a vial of eye drops lubricant on her bedside table, and a third resident had Nystatin powder also left on her bedside table. The Director of Nursing confirmed that all medications should be secured in the medication cart and not left in resident rooms, as per facility policy, which requires medications to be stored safely and in locked storage areas.
Failure to Assess and Assist Residents in Obtaining Dental Services
Penalty
Summary
The facility failed to assess and assist two residents in obtaining routine dental services. Both residents had been living at the facility for an extended period and reported not having seen a dentist, despite visible dental issues such as missing and broken teeth, visible decay, and loose or missing dentures. Documentation showed that oral health assessments indicated the need for dental evaluations for both individuals, but no abnormalities were recorded on the assessment forms. The forms did note that a dental check-up was required as soon as possible. Interviews with staff revealed that the process for identifying and referring residents for dental care was unclear and inconsistently followed. The Social Services Director was unaware of the residents' dental needs and was not familiar with the assessment forms used to identify such needs. Additionally, the residents were not included on the facility's list of those enrolled in the dental program, and there was confusion among staff regarding responsibility for completing assessments and communicating dental care needs.
Failure to Maintain and Monitor Resident Refrigerators and Food Safety
Penalty
Summary
The facility failed to maintain and monitor residents' personal refrigerators, as evidenced by multiple observations and record reviews. One resident's freezer section was completely filled with accumulated ice, rendering the freezer door frozen shut and inaccessible. Temperature logs for this refrigerator were incomplete, with several days missing entries. Another resident's refrigerator contained expired food, significant ice buildup, a melted cup of ice cream, and unidentifiable crumbs at the bottom. The temperature log for this refrigerator was also incomplete for several days. Additionally, a third resident's refrigerator lacked a thermometer and contained undated and unlabeled food items, including a piece of chicken breast wrapped in saran wrap. Interviews with staff revealed confusion and inconsistency regarding responsibilities for cleaning, defrosting, temperature monitoring, and food disposal in resident refrigerators. CNAs, housekeeping, and maintenance staff each described different roles, with some overlap and lack of clarity. Facility policies required proper labeling, dating, and timely disposal of food brought in from outside, as well as regular checks and maintenance of resident refrigerators. However, these policies were not consistently followed, leading to the deficiencies observed.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices among staff caring for three residents with urinary catheters and incontinence needs. In one instance, a CNA donned gloves and PPE to assist a resident with morning care, including changing an incontinence brief and dressing the resident, but did not change gloves between different care activities. The CNA also placed the resident's full urinary catheter drainage bag directly on the floor, both before and after care. In another case, two CNAs changed a resident's soiled incontinence brief, with one CNA repeatedly obtaining gloves from his uniform pocket and not consistently performing proper hand hygiene between glove changes. The gloves stored in the uniform pocket were not considered clean, and hand sanitizer was not used according to facility policy, as it was wiped off with a washcloth instead of being rubbed until dry. A third resident was observed with a full urinary catheter drainage bag left on the floor for several hours. When two CNAs later assisted with care, one obtained gloves from his uniform pocket and did not change gloves or perform hand hygiene between different care activities, including cleaning the catheter tubing, peri-area, and dressing the resident. Both CNAs failed to change gloves and perform hand hygiene as required. Facility policies reviewed by surveyors specified that gloves should be single-use and not stored in uniforms, hand hygiene should follow CDC guidelines, and catheter drainage bags should always be kept off the floor. The Assistant Director of Nursing confirmed staff expectations for proper glove use, hand hygiene, and catheter care, which were not followed in these instances.
Failure to Investigate and Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to investigate allegations of sexual abuse in a timely manner and did not implement their abuse policy and procedure. A resident with moderate cognitive impairment and multiple medical conditions, including dementia and depression, alleged that a male CNA from a staffing agency sexually abused her. The resident reported the incident to a counselor and hospital staff, but the facility did not initiate an investigation or report the allegation to the police until several days later. The facility's administrator received a call from hospital staff about the allegation but did not act immediately due to an unrelated open allegation of physical abuse. The police were only notified four days after the initial report by the hospital. The facility's policy requires immediate reporting of such allegations, but this was not followed. The resident was not interviewed by facility staff until prompted by a surveyor, and the alleged perpetrator was identified through a review of the staffing schedule.
Delay in Radiological Services for Resident with Fracture
Penalty
Summary
The facility failed to provide timely radiological services for a resident with a change in medical condition, resulting in a delay in diagnosis and treatment. The resident, who had severe cognitive impairment and multiple medical conditions including ESRD, was admitted to the facility and later sent to the hospital with an acute comminuted fracture of the right proximal tibia and fibula. On 8/13/2024, a nurse practitioner ordered an x-ray for the resident's right leg due to reported pain, but the x-ray was not performed until 8/16/2024, more than 48 hours later. This delay in obtaining the x-ray led to a delay in the resident being sent to the hospital for appropriate treatment. The resident's medical records and staff interviews revealed that the x-ray order was not followed up on promptly, despite the resident's continued complaints of pain and the nurse practitioner's follow-up visit on 8/15/2024. The Director of Nursing could not provide an explanation for the delay in obtaining the x-ray. The resident was eventually diagnosed with a fracture and returned to the facility with a leg brace. The delay in radiological services and subsequent treatment was a significant deficiency in the facility's care for the resident.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label and date medications after opening, which is necessary to determine their expiration dates. This deficiency was observed during a survey where multiple residents' medications were found to be improperly managed. For instance, two Wixela inhalers for one resident were opened but not dated, despite the pharmacy's recommendation to discard them 30 days after opening. Similarly, another resident's Humalog Kwik Pen and a third resident's Basaglar Kwik Pen were opened without being dated, even though they should be discarded 28 days after opening. Additionally, Tobramycin and Dexamethasone Ophthalmic Solution for another resident was also opened and not dated, with the pharmacy recommending disposal 28 days post-opening. Furthermore, the facility failed to discard a narcotic medication with a broken seal. During the inspection, it was noted that a resident's Diazepam tablets were opened and taped over to reseal, which is against the proper protocol. The Nurse Consultant confirmed that once the seal of the blister is torn, the medication should be discarded and not taped over. These findings indicate a lack of adherence to proper medication labeling, storage, and expiration protocols, affecting six residents in the sample reviewed.
Failure to Follow Menu Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu spreadsheet for serving pureed beef top round roast beef, resulting in a deficiency. During a lunch meal service, the dietary staff, including a cook and a dietary aide, used a #8 scoop instead of the required #6 scoop to serve the pureed beef to five residents on pureed diets. This discrepancy was observed despite the meal tickets indicating the correct serving size of a #6 scoop. The Registered Dietitian confirmed that the dietary staff should have followed the menu spreadsheet to ensure the adequacy of nutrition. The facility's portion control chart indicated that a #8 scoop equates to 4 ounces, while a #6 scoop equates to 5 1/3 ounces, highlighting the shortfall in the portion size provided to the residents.
Failure to Conduct Timely PASARR II Re-evaluation
Penalty
Summary
The facility failed to request a re-evaluation for a PASARR II screening for a resident with a serious mental illness (SMI) diagnosis within the required timeframe. The resident, identified as R59, was admitted with diagnoses including bipolar disorder, specified anxiety disorder, and PTSD. The resident's care plan indicated a need for appropriate assessments to understand her past and encourage verbalization of thoughts and feelings. However, the PASARR II evaluation, which was effective from February 12, 2023, to April 13, 2023, was not followed up with a re-evaluation as required. The Vice President of Operations (V21) stated that the facility tracks assessments in the Maximus system, which should notify them when an assessment is due. Despite this, no re-evaluation was conducted for R59, and the facility was unable to explain why. The facility's policy mandates PASARR screenings within the allowed timeframe, but this was not adhered to in R59's case. The oversight was identified during a survey, highlighting a deficiency in the facility's compliance with PASARR requirements.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in their care. One resident, who had severe cognitive impairment and required substantial assistance, was observed with dried stool on his hand and body, indicating a lack of timely incontinence care. Despite being in the dining room for over two hours, the resident was not assisted with toileting needs until the issue was brought to the attention of the Director of Nursing (DON). The resident's care plan specifically required staff to check for incontinence episodes and anticipate toileting needs, which was not adhered to. Another resident, who was dependent on staff for all ADLs, expressed a desire for a shower and grooming, which was not provided over several days. Observations noted greasy hair, facial hair, and a musty odor, indicating neglect in personal hygiene care. A third resident, who required extensive assistance with ADLs, was found with unkempt facial hair and long, discolored fingernails, despite expressing discomfort and a desire for grooming. The facility's policy required evaluation and assistance with physical needs, including ADLs, which was not adequately followed for these residents.
Failure to Provide Appropriate Splint and Therapy Services
Penalty
Summary
The facility failed to assess and provide appropriate splints and therapy services to maintain or prevent further progression of deformities or reduction in range of motion for a resident identified as R76. R76, who was diagnosed with quadriplegia, major depressive disorder, morbid obesity, and critical illness myopathy, was dependent on staff for all activities of daily living. The resident's care plan required the application of a left resting hand splint during the day to maintain functional positioning and prevent contractures. However, observations over several days revealed that the splint was consistently not applied, despite being prescribed to be worn daily for four to eight hours. Interviews and record reviews indicated a lack of documentation and adherence to the prescribed splint application schedule. The restorative nurse and other staff members acknowledged that the splint should be applied daily, but there was no evidence in the facility's records to confirm that this was being done. The facility's policy on restorative nursing programs, which includes contracture prevention and management, was not followed, as there was no documentation in the resident's electronic restorative log to reflect the provision of services and frequency of splint application.
Oxygen Tank Deficiency for Resident
Penalty
Summary
The facility failed to ensure that a resident's portable oxygen tank contained enough oxygen to deliver the prescribed therapy. The resident, who had multiple diagnoses including chronic respiratory failure with hypoxia and was dependent on supplemental oxygen, was observed in a group meeting with an oxygen nasal cannula attached to a portable oxygen tank. The gauge on the tank indicated it needed a refill, as it was in the red area. A nurse was called to replace the tank, and after the replacement, the resident's coughing decreased, and participation in the group discussion improved. The resident's active order summary indicated that oxygen was to be administered continuously as needed. However, during the incident, the oxygen was set at 2 liters per minute, and the tank was nearly empty. The Director of Nursing later clarified that the resident's oxygen should be administered continuously. The facility's policy on oxygen therapy stated that it should be administered as indicated and upon a physician's order, to ensure adequate oxygenation for patients.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician's orders, resulting in a 12% medication error rate. This deficiency was identified through the observation of medication administration for two residents. For one resident, a registered nurse (RN) prepared to administer Heparin Sodium but initially drew an incorrect dose of 0.9 ml instead of the prescribed 1 ml. The error was corrected before administration, but it highlighted a lapse in following the exact dosage as per the physician's order. For another resident, the RN was unsure about how to administer Docusate Sodium, which cannot be crushed, and instead administered Bisacodyl without consulting the physician. Additionally, the RN failed to prime a new insulin pen before administering the insulin, which is a necessary step to ensure accurate dosing. The Director of Nursing (DON) confirmed that staff must adhere to the physician's orders and the five rights of medication administration, emphasizing the importance of priming insulin pens before use.
Infection Control Breach During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident identified as R13. On July 24, 2024, two CNAs, V17 and V18, provided care to R13, who was heavily soiled with urine and feces. During the care, V17 initially performed hand hygiene after cleaning the front perineum but failed to do so after changing gloves twice while cleaning the back perineum. Furthermore, V17 applied barrier cream and an incontinence brief while still wearing the same soiled gloves, which is against the facility's hand hygiene policy. The Director of Nursing (DON), identified as V2, confirmed that staff are required to perform hand hygiene between glove changes, between tasks, and before and after completing care to prevent infection spread. The facility's hand hygiene policy, revised on June 6, 2024, aligns with CDC guidelines and specifies that hand hygiene should be performed before moving from a soiled to a clean body site, after contact with body fluids, and after removing gloves. The failure to follow these procedures during the care of R13 represents a breach in infection control practices.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
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