Alpine Fireside Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 3650 North Alpine Road, Rockford, Illinois 61114
- CMS Provider Number
- 146066
- Inspections on file
- 28
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Alpine Fireside Health Center during CMS and state inspections, most recent first.
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.
A cognitively intact resident reported that cash she kept in her purse, stored in a dresser drawer, went missing after her son brought her money for a hair appointment. The son confirmed he placed the cash in her purse in the resident’s room, where additional smaller bills were already present, and later learned from the resident that all the money was gone. An incident report documented the missing funds and a room search that did not locate the money, demonstrating the facility’s failure to protect the resident from misappropriation of her belongings.
A resident reported that $90 was missing from her room after her son had given her the money, and the facility’s incident report noted that staff interviews and video review were conducted, with no concerns identified. However, hallway surveillance showed four CNAs entering the resident’s room when the resident was not present, and the CNA supervisor who reviewed the footage did not assess or report whether the resident was in the room at those times. The social service designee interviewed staff using only broad, general questions and did not specifically ask the CNAs why they entered the room in the resident’s absence, and one CNA had no written statement on file. As a result, the allegation of misappropriation was not promptly and thoroughly investigated as required by facility policy.
A resident with severe dementia, multiple comorbidities, and a history of combative behavior during care was found with a black eye, swollen lip, and additional bruising of unknown origin after staff provided incontinence and clothing care while short-staffed and without assistance. Despite a recent care plan meeting noting increased agitation, identified behavioral interventions, and a PRN haloperidol order, staff did not administer the PRN medication, did not consistently follow the care plan to stop and re-approach when the resident became agitated, and did not ensure two-person assistance during care as practiced by other CNAs. The resident’s injuries were discovered after the shift in which a CNA reported significant combativeness but no observed bruising, and the facility was unable to determine how the injuries occurred, demonstrating a failure to provide appropriate dementia-focused care and supervision to prevent injury.
A resident with dementia, cognitive impairment, high fall risk, and documented behaviors of restlessness, anxiety, and sleep disturbance was care planned for 1:1 supervision when anxious and attempting to stand, and had a history of removing alarms and not staying seated. On a night when the resident was awake all shift, restless, and kept at the nurse’s station due to behaviors and attempts to get out of bed, an LPN left the resident alone at the nurse’s station to go on break, while a CNA was seated around the corner and could not see the resident. Within minutes, staff heard the alarm and screaming and found the resident on the floor by the nurse’s station, resulting in a right hip fracture and right knee fracture, despite facility policy requiring fall risk assessment and implementation of interventions for residents at risk for falls.
Surveyors found that the facility failed to provide required bed-hold notices to two residents who were transferred to the hospital and did not return, and failed to notify the ombudsman of transfers or discharges for three residents, including one with a planned discharge and another who later died in the hospital. Record review showed no bed-hold documentation in the EMR at the time of transfer or during hospitalization, and no evidence of ombudsman notification for any of the affected residents. The DON, social services staff, and admissions liaison each reported they were not providing ombudsman notifications, and bed-hold information was only given at admission. The facility’s bed-hold policy did not specify when notices must be provided, and there was no policy for ombudsman notification.
A resident with multiple medical conditions, including bowel and bladder incontinence and difficulty walking, was observed with a large wet area on her pants and a strong urine odor after being up in a wheelchair for several hours. When a CNA transferred the resident to the toilet, the resident was found wearing both a thick disposable incontinence pad and an incontinence brief, both saturated with urine. Staff later stated that incontinence care should occur at least every two hours and as needed, that only one brief should be used at a time, and that heavy wetters should be checked more frequently. This situation did not follow the resident’s care plan, which required keeping her clean, dry, and changed as needed, nor the facility’s ADL policy requiring necessary services to maintain personal hygiene.
A resident with dementia, sepsis, UTI, and two stage 4 sacral pressure injuries, assessed as high risk for skin breakdown, did not receive ordered pressure-relieving interventions. Surveyors observed that the resident was placed in bed on a low air loss mattress with the pump turned off and left off while the resident remained in bed, despite staff recognizing air mattresses as a key pressure injury prevention measure. Waffle boots ordered for use while the resident was in bed were found on the floor next to a recliner instead of on the resident’s feet, indicating the facility did not follow the care plan, physician orders, or its own wound care policy.
A resident with dementia, depression, dysphagia, UTI, a prior ankle fracture, and a documented history of multiple falls was assessed as high fall risk and care planned for chair/bed alarms and staff oversight with transfers. Despite this, a CNA observed the resident self-transferring from a wheelchair to the toilet while the chair alarm sounded, told the resident not to get up alone, then turned off the alarm, closed the door, and left the resident alone in the bathroom. Another CNA later confirmed the resident should not be left alone in the bathroom and does not always remember to use the call light, indicating staff did not follow the fall-prevention care plan and facility policy.
Surveyors observed that an LPN did not follow physician orders and facility policy for medication administration, resulting in a 10.71% medication error rate during a medication pass. One resident with multiple chronic conditions received an incorrect dose of calcium/vitamin D and a delayed dose of a phosphorus/potassium/sodium supplement, while another resident with neurological and cardiac diagnoses received a scheduled acetaminophen dose outside the facility’s 60-minute administration window. The facility’s policy requires medications to be given as prescribed and within 60 minutes of the scheduled time, which was not met in these cases.
Two residents developed multiple facility-acquired pressure ulcers, including wounds that progressed from stage 2 to unstageable, due to failures in early identification, timely intervention, and consistent use of pressure reduction devices. Staff did not consistently follow infection control protocols during dressing changes, and pressure-relieving interventions were not always implemented as required.
A nurse failed to wear a gown while performing a wound vac dressing change for a resident on contact isolation for MRSA, despite facility policies and physician orders requiring both gown and gloves for such care. The resident confirmed the omission, and the DON stated that both gown and gloves are necessary for close contact care to prevent infection.
A resident with a history of falls and medical conditions, including a right hip fracture, fell during a transfer due to the CNA's failure to use a gait belt. The resident sustained a hematoma and bruising. The facility's policy requires a Fall Risk Assessment and interventions, which were not followed in this instance.
A resident with cognitive impairment sustained second-degree burns after spilling hot coffee served at unsafe temperatures. The CNA, unfamiliar with the resident's condition, provided coffee without supervision. The facility lacked clear policies on safe coffee temperatures and monitoring procedures.
The facility failed to maintain sanitary food preparation practices, as the Dietary Manager had an uncovered open wound while preparing food and used an improper method to sanitize the food thermometer. The thermometer was dipped into a sanitation bucket without verifying the correct chemical concentration, potentially compromising food safety.
A facility failed to notify a resident's physician when blood glucose levels exceeded the set parameters. The resident, with type II diabetes and dependent on staff for most activities, had orders for blood glucose checks twice daily, with instructions to call the doctor if levels were above 250. Despite multiple high readings, there was no documentation of physician notification. The facility's policy required notifying the physician of condition changes, but the administrator confirmed no such documentation was found.
The facility failed to conduct weekly assessments of pressure wounds for two residents, leading to irregular intervals between assessments. One resident with a Stage 3 pressure injury on the hip had assessments ranging from 9 to 24 days apart, while another resident with multiple stage II pressure injuries had assessments 9 to 16 days apart. The Wound Care Nurse acknowledged the lapses, and the facility's policy requiring regular monitoring was not consistently followed.
The facility failed to prevent cross-contamination during incontinence care for a resident with dementia, did not implement enhanced barrier precautions for a resident with a catheter and wound, and allowed an LPN to touch medications with bare hands, violating infection control and medication administration policies.
The facility failed to ensure fall interventions were in place for two residents with a history of falls. One resident was found with a disconnected pad alarm and no floor mats, while another was found without a pad or clip alarm. The facility's policies on fall prevention were not consistently implemented.
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 Protect Resident From Misappropriation of Money
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from misappropriation of her money. The resident reported that her son brought her $90 in cash, which she placed in her purse along with additional money she believed totaled about $20, and stored the purse in the bottom drawer of her dresser. When she went to retrieve the money on the morning of 1/08/2026 to pay for a scheduled hair appointment, she discovered that all of the money was missing. The resident stated she had kept the money in her purse in the dresser drawer in her room. The resident’s son confirmed that he brought $90 in cash at his mother’s request so she could get a haircut and perm, and that he placed the money in her purse in the bottom dresser drawer in her room, where there was already a $10 bill and a couple of $5 bills. He estimated the total loss to be about $120. The facility’s incident report documented that the resident reported approximately $110 missing and that a room search was conducted but the money was not located. The facility’s policy defines misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent, and the investigation and interviews established that the resident’s money went missing while under the facility’s care and was not recovered or replaced.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of misappropriation of a resident’s money. One resident reported that money was missing from her room after her son had provided her with $90. The facility’s incident report documented that staff from various departments and shifts were interviewed and that surveillance cameras were reviewed between the time the money was reportedly provided and the time the loss was reported. The report stated that all staff entering the room were assigned to the resident, their entry times were considered appropriate for their responsibilities, and no questionable behavior or concerns were identified during staff interviews. Further review of surveillance video from the resident’s hallway over a multi-day period showed four CNAs entering the resident’s room when the resident was not present. The CNA supervisor, who initially reviewed the video, stated she had focused only on who went in and out of rooms and did not consider whether the resident was in the room at the time. She did not relay to the social service designee that these CNAs entered the room while the resident was absent. The social service designee, who conducted staff interviews, reported she only asked general questions and did not ask the CNAs why they were in the room when the resident was not there. Typewritten interview forms for three of the CNAs showed only broad questions about inappropriate interactions, resident mood changes, and coworker stress, all answered negatively, and there was no documentation of specific questioning about their presence in the room during the time the money went missing. No written statement was provided for the fourth CNA. This investigation process did not align with the facility’s policy requiring all reports of theft or misappropriation of resident property to be promptly and thoroughly investigated.
Failure to Protect Combative Dementia Resident From Injury During Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dementia and known aggressive behaviors was cared for in a manner that prevented injury. The resident had multiple diagnoses including vascular dementia, major depressive disorder, cerebrovascular disease, chronic kidney disease, COPD, and benign prostatic hypertrophy, and was described as severely cognitively impaired, unable to communicate effectively, and often nonsensical in speech. On observation, the resident was noted to have a yellow, green, and purple bruise under the right eye, a small red spot with faint bruising on the chin, and a recently healed area on the upper lip. The resident’s wife reported that she had visited him two days before the facility notified her that he had facial bruising and a swollen lip, and the facility’s incident report categorized the injuries as a bruise of unknown origin. In the days leading up to the discovery of the injuries, staff and hospice documentation indicated that the resident had increasing agitation and combative behaviors during care, associated with his progressing dementia. A care plan meeting with the family and hospice nurse occurred shortly before the incident, during which staff discussed the resident’s overall decline, increased agitation, and strategies for staff approaches, including non-pharmacological interventions and medication changes. The care plan identified a problem of physical behaviors toward others, with interventions such as administering medications, attempting to refocus behaviors, and stopping care and re-approaching when the resident became agitated. The resident had a PRN haloperidol order entered shortly before the incident, but the medication administration record showed it had not been used. On the night shift prior to the discovery of the bruising, a CNA reported that the resident was very combative during incontinence and clothing changes, and that she completed care alone because the unit was short-staffed, despite the resident’s known behaviors. She described difficulty removing a soiled shirt while the resident’s arms were moving all over and stated she informed the nurse only that the resident was combative, without reporting any injury or bruising. Another CNA, who had put the resident to bed earlier without bruising present and later found him with a black eye and cut lip, stated she always used a second staff member when providing care to him and had advised the night CNA not to change him alone due to his behaviors. The night RN acknowledged being told the resident was combative but did not administer any medication to address behaviors. The facility’s dementia training policy emphasized the need for specialized, person-centered care and ongoing staff training, but staff interviews and the sequence of events showed that the resident’s known aggression and dementia-related behaviors were not consistently managed in a way that prevented injury, resulting in unexplained facial bruising and other bruises of unknown origin.
Failure to Provide Required 1:1 Supervision for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure fall prevention interventions were in place for a resident with a known history of falls and behavioral symptoms. The resident had Alzheimer’s disease and dementia, was cognitively impaired, alert only to self, had poor safety awareness and impaired decision-making, and required frequent redirection. The care plan dated 12/12/25 identified that the resident did not stay in a chair, removed alarms, and needed 1:1 staff supervision throughout the day when experiencing increased anxiety, restlessness, and yelling. A fall risk assessment and Minimum Data Set documented that the resident was at high risk for falls due to abnormal gait or balance, medications that could impair balance, conditions affecting ambulation, and cognitive impairment with poor decision-making. In the hours leading up to the fall, progress notes documented significant behavioral issues and sleep disturbance. On 12/22/25 at 11:01 PM, the resident was noted as disruptive, crying, yelling/screaming, having sleeping problems, feeling angry/anxious, and feeling restless/anxious. A subsequent progress note on 12/23/25 at 4:44 AM recorded that the resident was awake all shift. Staff interviews confirmed that on the night of the fall, the resident had been “up and busy all night,” not sleeping, and was kept at the nurse’s station due to these behaviors and attempts to get out of bed. The DON and the nurse practitioner both stated that, per the care plan, the resident should have 1:1 care when exhibiting such anxious, restless, and standing behaviors. Despite these identified risks and care plan directives, the resident was left unsupervised at the nurse’s station. The LPN reported that she had the resident sitting with her at the nurse’s station because of the resident’s behaviors, then left the nurse’s station to go on break, leaving the resident there alone and only informing a CNA who was seated around the corner at the beginning of another hall and could not see the resident. Within minutes, staff heard the resident’s alarm and screaming and found the resident on the floor on her right side by the nurse’s station, with no nurse present. The progress note and emergency department documentation show that the resident sustained a right intertrochanteric hip fracture and a right patellar fracture, requiring hospital admission and surgical repair. The facility’s fall policy states that on admission and readmission, a fall risk assessment will be completed and interventions implemented for residents at risk for falls, but the required 1:1 supervision intervention was not in place at the time of the fall.
Failure to Provide Bed-Hold Notices and Notify Ombudsman of Transfers and Discharges
Penalty
Summary
Surveyors identified that the facility failed to provide required bed-hold notices to two residents and failed to notify the ombudsman of transfers and discharges for three residents. One resident was transferred from the facility to the hospital and did not return, instead being discharged to another placement with family; another resident was transferred to the hospital and later expired there; and a third resident had a planned discharge from the facility. For the two residents who were transferred to the hospital, there was no documentation in the electronic medical record that a bed-hold notice was provided to them or their representatives at the time of transfer or during hospitalization. Staff interviews confirmed that nursing did not send out bed-hold notices on transfer and that no additional bed-hold notices were sent after admission because residents received a copy in their admission contract. The facility’s bed-hold policy described the bed-hold policy itself but did not specify when a copy of the notice should be provided to residents or their representatives. The survey also found that the facility did not notify the ombudsman of resident transfers and discharges for three reviewed residents. Record review showed no documentation that the ombudsman was notified of the transfer or discharge for the resident who went to the hospital and then to another placement, the resident who had a planned discharge, or the resident who was transferred to the hospital and later died there. The ombudsman stated that facilities should be notifying the ombudsman program of resident discharges and that this facility had not been doing so. The social services staff member reported she had not been notifying the ombudsman of transfers or discharges because she was unaware this was required, and the DON stated that nursing did not notify the ombudsman and she was unsure if anyone else did. The admissions liaison confirmed she did not send anything to the ombudsman. The administrator acknowledged that bed-hold notices were given on admission only and that there was no facility policy for ombudsman notification, and the facility was unable to provide a policy addressing ombudsman notifications.
Failure to Provide Timely Incontinence Care and ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely ADL care, specifically incontinence care, to a resident who required assistance. The resident was admitted with diagnoses including anorexia, polyarthritis, excoriation disorder, difficulty walking, and paranoid schizophrenia, and had a care plan effective September 20, 2025, indicating she was at risk for skin breakdown related to bowel and bladder incontinence and directing staff to ensure she was kept clean and dry and changed as needed. On December 8, 2025, at 11:20 AM, a CNA (V9) used a mechanical stand lift to transfer the resident, revealing a large wet circle on the back of the resident’s pants and a strong urine odor. When the CNA placed the resident on the toilet and removed her incontinence brief, the resident was found to be wearing both a thick disposable incontinence pad and an incontinence brief, both saturated with urine; the CNA stated the resident had been up in her wheelchair since about 8:00 AM and that the extra pad and brief were used because the resident was a heavy wetter. Another CNA (V12) later stated that incontinence care should be provided at least every two hours and as needed, that residents should only wear one incontinence brief at a time, and that heavy wetters should be checked and changed more frequently. The facility’s ADL policy states that residents unable to carry out ADLs will receive necessary services to maintain good grooming and personal hygiene, but the observed condition of the resident’s saturated incontinence products and clothing demonstrated that timely incontinence care was not provided in accordance with the care plan and policy.
Failure to Implement Ordered Pressure-Relieving Interventions for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered pressure-relieving interventions were in place for a resident with existing pressure injuries and a high risk for further skin breakdown. The resident was admitted with diagnoses including sepsis, UTI, dementia, and a sacral pressure injury, and an assessment identified her as high risk for pressure injuries. Physician orders directed the use of waffle boots while in bed, and the care plan included encouraging the resident to float her heels and use an air mattress. Weekly wound assessments documented two stage 4 pressure injuries to the sacrum and indicated the use of a low air loss mattress. On the observed day, CNAs transferred the resident to bed with a sacral dressing in place and a pump attached to the bed, but the pump was not turned on and the resident’s feet were placed directly on the mattress. Over 30 minutes later, the air mattress pump remained off until a CNA attempted to turn it on, then shut it off again after hearing a loud noise, stating she did not know what was wrong and would notify maintenance. An hour later, the air mattress was still off while the resident was asleep in bed. Additionally, waffle boots ordered for use while in bed were observed on the floor beside the resident’s recliner rather than on the resident. Staff interviews described pressure injury prevention interventions such as repositioning, air mattresses, and elevating feet, and the facility’s wound care policy stated that evidence-based treatments would be provided in accordance with current standards of practice and physician orders.
Failure to Supervise High Fall-Risk Resident During Bathroom Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of fall-prevention interventions for a resident with a high risk of falls and a history of multiple falls. The resident, admitted in June 2024, had diagnoses including depression, dysphagia, major depressive disorder, UTI, dementia, and a nondisplaced fracture of the lateral malleolus, and had fallen five times in the prior four months. A fall risk assessment identified the resident as at risk for falls, and the care plan effective October 30, 2025, documented that the resident was at risk for falls, sometimes self-transferred, and required chair and bed alarms to alert staff of unplanned movement, as well as oversight and assistance with transfers. On December 8, 2025, a surveyor observed the resident transferring independently from a wheelchair to the toilet while the chair alarm was sounding; a CNA entered, told the resident she was not supposed to get up alone, then turned off the alarm, closed the bedroom door, and left the resident alone in the bathroom. The next day, another CNA stated that this resident should not be left alone in the bathroom and that the resident does not always remember to use the call light. The facility’s fall prevention policy required interventions for residents assessed at risk for falls to be implemented and documented in the plan of care. These observations, interviews, and record reviews show that staff did not follow the resident’s care plan and the facility’s fall prevention policy by leaving a high fall-risk resident unattended in the bathroom after silencing the chair alarm, despite the resident’s documented history of falls, cognitive impairment, and need for supervised transfers.
Medication Administration Errors Exceed Acceptable Error Rate
Penalty
Summary
Surveyors identified a medication administration deficiency in which the facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 10.71% (3 errors out of 28 opportunities) during a medication pass observation. For one resident (R30), who had multiple diagnoses including dementia, alcohol-induced persisting dementia, hypertensive heart and chronic kidney disease with heart failure, moderate protein malnutrition, Alzheimer's disease, major depressive disorder, delusional disorder, hypokalemia, and anorexia, the Medication Record for December 1–31, 2025 showed an order for phosphorus/potassium/sodium one packet by mouth four times daily at 8:00 AM, 12:00 PM, 5:00 PM, and 8:00 PM, and calcium 600 mg with vitamin D3 20 mcg daily. On December 8, 2025 at 10:34 AM, an LPN (V11) administered calcium 600 mg with vitamin D3 10 mcg instead of the ordered 20 mcg dose and also administered the resident’s 8:00 AM dose of phosphorus/potassium/sodium at 10:34 AM, outside the facility’s stated 60-minute window from the scheduled time. For another resident (R24), who had diagnoses including traumatic subdural hemorrhage, atrial fibrillation, Alzheimer's disease, anorexia, dementia, anxiety disorder, major depressive disorder, osteoarthritis, delusional disorders, and poly-osteoarthritis, the Medication Record for December 1–31, 2025 showed an order for acetaminophen 325 mg, give 650 mg by mouth three times per day at 8:00 AM, 12:00 PM, and 5:00 PM. On December 8, 2025 at 10:20 AM, the same LPN (V11) administered the resident’s 8:00 AM scheduled dose of acetaminophen, which was not given within 60 minutes of the scheduled administration time. The facility’s undated Medication Administration Policy states that medications are to be administered as prescribed, in accordance with written physician orders and good nursing principles, and within 60 minutes of the scheduled time, which was not followed in these instances.
Failure to Prevent and Identify Pressure Ulcers and Maintain Infection Control
Penalty
Summary
The facility failed to identify and intervene in the early stages of pressure injuries for two residents, resulting in the development and worsening of multiple facility-acquired pressure ulcers. One resident was admitted without a pressure injury to the coccyx, as documented on the admission skin check. However, a wound was later discovered on the coccyx that had already progressed to an unstageable pressure injury by the time it was identified. The wound measured 6.5 cm x 4.5 cm and contained both granulation and slough tissue. Staff interviews confirmed that skin checks were performed during showers and care, but the wound was not detected until it had reached an advanced stage. The resident was noted to have severe cognitive impairment and was dependent on staff for most activities of daily living, including mobility and hygiene, which increased the risk for pressure injuries. Another resident developed several facility-acquired pressure ulcers, including a stage 2 pressure ulcer on the right buttock, an unstageable pressure ulcer on the right great toe (later staged as a 2), a right heel ulcer that progressed from stage 2 to unstageable, and a stage 2 ulcer on the right groin. The right heel ulcer began as a blister, which ruptured and evolved into a wound with necrotic tissue, eventually being classified as unstageable. The resident had diabetes and edema, which contributed to the development of the blister. Documentation and staff interviews indicated that the resident was supposed to have both heels offloaded and be repositioned every two hours, but the resident reported that repositioning was not consistently performed. The care plan included interventions such as pressure relief mattresses, floating heels, and wound care, but these measures were not always implemented in a timely or consistent manner. During wound care observations, staff failed to follow proper infection control protocols. For example, a nurse did not change gloves between removing soiled dressings and applying clean ones, and used her finger to apply ointment directly to the wound. Supplies used during the dressing change were not handled in a manner that would prevent cross-contamination, as items were carried out of the resident's room and placed on common surfaces before being cleaned. Additionally, pressure reduction devices, such as offloading boots, were not reapplied after dressing changes, and soiled items were left in the resident's room. These lapses in infection control and pressure injury prevention contributed to the development and worsening of pressure ulcers in the affected residents.
Failure to Use Required PPE During Wound Care for Resident on Contact Isolation
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to wear a gown while performing a wound vac dressing change for a resident who was on contact isolation due to methicillin-resistant Staphylococcus aureus (MRSA) in the nares and a right knee surgical wound. The resident's care plan and physician orders specified the need for contact isolation precautions, including the use of personal protective equipment (PPE) such as gloves and gowns during care. During the observed dressing change, the RN wore gloves but did not don a gown, despite the resident being on isolation for MRSA. Another RN, who entered the room to troubleshoot the wound vac, was observed wearing both a gown and gloves. The resident confirmed that the RN did not wear a gown during the dressing change. The Director of Nursing stated that both gown and gloves are required for close contact care to prevent contamination and infection. Facility policies on infection control, contact precautions, and enhanced barrier precautions all require the use of appropriate PPE, including gowns and gloves, during high-contact resident care activities such as wound care. Documentation showed the resident had a surgical wound with significant tunneling and a wound vac in place, requiring regular dressing changes.
Failure to Use Gait Belt Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safe transfer of a resident with a history of falls, leading to an accident. The resident, a female with a right hip fracture, hypertension, chronic kidney disease, and congestive heart failure, was observed with a dark purple hematoma on her forehead and bruising around her right eye and side of her face. She reported falling while transferring from her bed to her wheelchair because the Certified Nursing Assistant (CNA) did not use a gait belt during the transfer. The CNA confirmed that she did not use a gait belt, believing the resident was not a fall risk and did not require it. The resident's Minimum Data Set assessment indicated she was cognitively intact but required moderate assistance with transfers due to limited range of motion in one lower extremity. A Fall Risk assessment showed she had a previous fall at home, resulting in a right femur fracture. The facility's Fall Policy requires a Fall Risk Assessment and implementation of interventions for residents at risk, which were not adequately followed in this case, as evidenced by the lack of a gait belt during the transfer.
Resident Sustains Burns Due to Unsafe Coffee Temperature
Penalty
Summary
The facility failed to ensure that a resident's coffee was served at a safe temperature, resulting in the resident sustaining second-degree burns. The incident involved a resident with severe cognitive impairment who required staff supervision or assistance for eating. On the day of the incident, a CNA, who was unfamiliar with the resident's condition, provided her with a cup of coffee in bed without realizing her cognitive limitations. The resident spilled the coffee on herself, leading to significant burns on her thigh and calf. The CNA discovered the burns when he returned to the resident's room and noticed coffee stains on her sheets. Upon further inspection, he found blisters on the resident's thigh and alerted the Director of Nurses (DON), who assessed the burns and provided initial treatment. The resident's condition was further evaluated by a wound care nurse and a nurse practitioner, who confirmed the severity of the burns and recommended further medical evaluation. The facility's dietary manager was responsible for monitoring coffee temperatures, which were found to be between 175-190°F, a range that could cause burns. However, the facility lacked a clear policy on safe coffee temperature limits and monitoring procedures. The dietary manager admitted to not recording coffee temperatures unless an incident occurred, and the facility's policies did not adequately address the safe serving of hot liquids, particularly to residents with cognitive impairments.
Unsanitary Food Preparation Practices
Penalty
Summary
The facility failed to ensure that food was prepared and served in a sanitary manner, as evidenced by the actions of the Dietary Manager, who had an open wound on his right inner forearm that was not covered while preparing and serving food. This was observed during the preparation of the lunch meal, where the Dietary Manager was involved in taking food temperatures without covering the wound, which had a small smear that appeared to be blood. The facility's policy requires that open wounds be covered to prevent contamination, but this was not adhered to, potentially compromising the sanitary conditions of food preparation. Additionally, the Dietary Manager used an improper method to sanitize the food thermometer between temperature checks of different food items. Instead of using alcohol wipes, the thermometer was dipped into a sanitation bucket containing quaternary ammonium compound sanitizer, which was not tested for the correct chemical sanitation level before use. The test strip used to check the sanitation level showed a yellow color, indicating an incorrect concentration, contrary to the Dietary Manager's assertion that it was between 150 ppm and 200 ppm. This improper sanitization process further contributed to the unsanitary conditions in food preparation.
Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician when blood glucose levels were outside the parameters set by the physician's orders. The resident, who had type II diabetes mellitus and was dependent on staff for all activities of daily living except eating, had physician's orders for blood glucose checks twice daily, with instructions to call the doctor if levels were greater than 250 or less than 70. Despite this, there were multiple instances between July and October where the resident's blood glucose levels exceeded 250, yet there was no documentation that the physician or nurse practitioner was notified. The facility's policy required staff to notify the physician of any condition changes and document the condition, interventions, and response in the resident's record. However, the review of the resident's nurse progress notes and communication portal notes showed no evidence of such notifications on several occasions when the blood glucose levels were high. The administrator confirmed that no further documentation was found to show that the physician or nurse practitioner had been updated, and the expectation was for the nurse on duty to call the doctor, not use the communication portal.
Failure to Conduct Weekly Pressure Wound Assessments
Penalty
Summary
The facility failed to conduct weekly assessments of pressure wounds for two residents, R23 and R15, as required by their wound management policy. R23, who had a Stage 3 pressure injury on the right hip, had irregular intervals between wound assessments, ranging from 9 to 24 days, instead of the weekly assessments that were supposed to be conducted. The Wound Care Nurse, V4, acknowledged that assessments were typically done weekly, but there were gaps in the documentation, especially when she was off duty. R15, who had multiple diagnoses including chronic kidney disease and Alzheimer's disease, developed six stage II pressure injuries on her buttocks and coccyx. The assessments for these wounds were not conducted weekly, with intervals ranging from 9 to 16 days between assessments. R15 had been sent to the hospital and returned more deconditioned, which may have contributed to the skin breakdown. The Wound Care Nurse, V4, admitted that the assessments were not done weekly and emphasized the importance of regular monitoring to track wound progress and inform the physician for potential new orders. The facility's policy required regular monitoring and documentation of pressure sores, but the documentation provided showed inconsistencies in following this policy. The Director of Nursing and the Administrator were aware of the situation, and the Administrator confirmed that all available assessments had been provided, indicating a lack of adherence to the facility's wound management policy.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to perform incontinence care properly for a resident with multiple diagnoses, including Alzheimer's disease and dementia, who was dependent on staff for toileting and bathing. During an observation, two CNAs provided incontinence care to the resident but did not follow proper procedures to prevent cross-contamination. They used the same wet wipe for multiple areas and wiped from back to front, contrary to the facility's policy, which requires using a clean wipe for each area and wiping from front to back to prevent infection. Another deficiency was noted with a resident who had an indwelling catheter and a wound on her heel. The facility did not implement enhanced barrier precautions for this resident, as required by their policy for residents with wounds or indwelling medical devices. The CNA responsible for the resident's care was unaware of any isolation requirements, and there were no signs indicating the need for enhanced barrier precautions in the resident's room. Additionally, a medication administration error was observed when an LPN was seen touching medications with her bare hands before placing them into a medication cup. This practice was against the facility's policy, which states that medications should be handled without direct contact to prevent contamination. The DON confirmed that nurses should not touch medications with their hands, highlighting a lapse in adherence to proper medication administration protocols.
Failure to Implement Fall Interventions for High-Risk Residents
Penalty
Summary
The facility failed to ensure fall interventions were in place for residents with a history of falls. Resident R2, who had a history of eight falls and was at high risk due to an unsteady gait and dementia, was found in bed with her legs off the bed and no floor mats in place. The pad alarm intended to alert staff of unplanned movement was disconnected and turned off. R2's family member confirmed that the alarm was often found turned off, and R2 had recently fallen out of bed again. The Licensed Practical Nurse confirmed that R2 should have had a pad alarm or clip alarm in place and mats on the floor next to her bed. Resident R3, who had a history of three falls and was at risk due to an unsteady gait and amputation of toes, was found seated in a recliner without a pad or clip alarm. The clip alarm was found turned off and hanging off the handle of a wheelchair in R3's room. The Director of Nursing stated that floor mats and position alarms are used as fall interventions for high-risk residents and that CNAs should check to ensure alarms are in place and working. The facility's Fall Policy and Fall Prevention Program policy indicated that interventions should be documented in the Plan of Care, but these were not consistently implemented for R2 and R3.
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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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