Arcadia Care Aledo
Inspection history, citations, penalties and survey trends for this long-term care facility in Aledo, Illinois.
- Location
- 304 S.w. 12th Street, Aledo, Illinois 61231
- CMS Provider Number
- 145886
- Inspections on file
- 52
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Arcadia Care Aledo during CMS and state inspections, most recent first.
A resident with dementia, known wandering behavior, and a history of falls was allowed to remain near unit doors despite prior incidents of being struck by those doors. While a dietary cook was bringing in a lunch cart, the resident was standing behind the double doors and was hit when the doors were opened, resulting in a fall and subsequent right femur fracture with hip dislocation. After the fall, the cook and a CNA manually lifted the resident from the floor into a wheelchair without a gait belt or mechanical lift and before an RN/LPN assessment, contrary to the facility’s transfer policy requiring mechanical lifts for residents needing a two-person assist or who cannot be safely transferred by normal technique.
A resident with dementia fell when a dietary staff member opened double doors into the hallway where the resident was standing, causing a change of plane and resulting in the resident landing on the floor with right-sided discomfort. The dietary staff and a CNA then lifted the resident from the floor, stood her up, and placed her in a wheelchair without using a gait belt and before any nurse could perform a post-fall assessment. The LPN later found the resident already in the wheelchair and stated the resident had been moved before she could assess for possible injuries. The DON reported that facility practice requires a nurse to assess a resident after a fall, including ROM, pain, and vital signs, and that residents should not be moved prior to this assessment, consistent with the facility’s fall prevention policy.
A resident with multiple chronic conditions was not assessed for fall risk as required by facility policy, with no documented fall risk assessments completed for several consecutive quarters. This lapse was confirmed by both the DON and a regional RN after the resident sustained a hip fracture from a fall.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Multiple residents with cognitive impairment and behavioral issues were not adequately protected from physical abuse by peers, resulting in altercations and injuries. In one case, a resident was left suspended in a mechanical lift by a staff member, who was observed yelling and using the lift to control the resident's movements. Staff interviews and facility documentation confirmed that supervision and intervention were insufficient, and that the actions taken did not meet expected standards of care.
The facility failed to maintain cleanliness on the tops of stationary kitchen equipment next to food preparation areas. During a kitchen tour, it was observed that the tops of the upright refrigerator and freezer were covered with dirt and debris. The Dietary Manager confirmed that these surfaces should have been cleaned, acknowledging the role of ventilation and air movement in the accumulation of dirt. This deficiency could potentially affect all 38 residents in the facility.
The facility failed to keep the lids of outdoor trash dumpsters closed and secure, allowing potential access by pests and animals. This was observed during a kitchen tour with the Dietary Manager, who confirmed the lids should be closed. The deficiency could affect all 38 residents in the facility.
The facility failed to use standardized diagnosing tools for infections, as required by their Antibiotic/Antimicrobial Stewardship Program. Infection control logs lacked set standards for diagnosing infections, affecting all 38 residents. An LPN/Infection Preventionist acknowledged the absence of tools like McGeer's or Loeb's and planned to implement them. The Medical Director and DON were responsible for setting standards, but this was not adhered to, leading to the deficiency.
The facility failed to justify the use of psychotropic medications for several residents and did not attempt a Gradual Dose Reduction (GDR) for a resident, despite policy requirements. One resident was on Quetiapine without documented behaviors necessitating its use, while another resident's care plan lacked specific behaviors justifying antipsychotic medication. Additionally, a resident on Venlafaxine and Aripiprazole had no documented harmful behaviors, yet no GDR was attempted. The facility's Director of Nursing confirmed the lack of documentation for GDR attempts.
A resident requiring a mechanical lift for transfers was incorrectly transferred using a stand pivot method, leading to a near fall and a broken toe. The facility failed to assess the resident's transfer needs properly, resulting in an injury due to inadequate supervision and accident prevention.
A facility failed to assess and identify triggers for a resident with PTSD, as required by their Behavioral Health Services Program policy. The resident, who also has dementia and psychotic disorder, was not provided with a care plan identifying specific environmental factors triggering their behaviors. Despite the need to gain the resident's trust for background stories, no comprehensive PTSD assessment was completed, and the care plan lacked individualized interventions.
The facility failed to prevent physical abuse between two residents in the Memory Care Unit. On two occasions, one resident approached and struck another, leading to altercations. Staff intervened promptly, and no injuries were noted. Both residents had severe cognitive impairments.
The facility failed to prevent resident-to-resident abuse between two residents in the Memory Care Unit. Despite multiple altercations, effective interventions were not implemented. R2's room was moved, but this did not prevent further interactions with R1. R1 was placed on 15-minute checks instead of 1:1 monitoring, and R1's transfer to a non-secure unit was unsuccessful. No interventions were in place after R1's return to the Memory Care Unit, leaving R2 vulnerable.
A facility failed to notify a physician and obtain treatment orders for a resident with burns and did not investigate or implement fall interventions for two high-risk residents. One resident had untreated burns from spilled hot tea, and both residents experienced multiple falls without proper follow-up or new interventions. The facility lacked a system to track and monitor falls, contributing to inadequate care.
A nurse aide was employed full-time and provided direct care without completing a state-approved training and competency evaluation program. Initially hired as a housekeeper, the aide transitioned to a CNA role but did not pass the required skills competency portion. This oversight affected all residents in the facility.
Two residents at a facility, both identified as high risk for falls, experienced multiple falls due to inadequate supervision and failure to implement necessary interventions. One resident, with severe dementia, suffered a head laceration and hematoma after being left unattended without non-skid footwear. Another resident, with a history of weakness and recent fractures, sustained serious injuries including a fractured hip and pelvis after falling in an unsupervised dining room. Staff shortages and failure to adhere to care plans contributed to these incidents.
A resident with a history of fractures was readmitted to the facility and had an open area on the left buttock noted during the initial skin assessment. The facility failed to document the pressure wound, notify the physician, or obtain treatment orders as required by policy. The wound was later discovered by an LPN, who found a heavily soiled bandage and confirmed no prior assessment or treatment orders were completed.
A resident with severe dementia and anxiety did not receive prescribed Alprazolam due to unavailability, leading to increased agitation. The facility's policy requires documentation of omitted doses, but none was provided. The DON confirmed the medication was not ordered or delivered, and alternative sources were not utilized.
A resident with MRSA in her leg wound was not administered a prescribed antibiotic, Linezolid, in a timely manner after returning from the hospital. The medication was delivered late, and the first dose was given 35 hours after the last hospital-administered dose, contrary to the facility's Medication Administration Policy.
A resident's physician-ordered lab tests were not collected on time, leading to a rescheduled appointment with an infectious disease physician. The DON confirmed the tests were delayed due to a lack of awareness and repeated failures by the lab to process the orders, despite multiple follow-up calls by a nurse.
The facility failed to label residents' clothing in a dignified manner, using black markers that bled through and smeared on the fabric, affecting the quality and readability of the labels.
The facility failed to address and resolve multiple resident grievances, including issues with missing laundry, call light response times, maintenance requests, and transportation. The Resident Council President reported that residents do not receive feedback on their complaints, leading to repeated unresolved issues.
The facility failed to post the daily direct care staff hours and resident census, potentially affecting all 44 residents. The DON was unaware of the requirement and had not posted the data since starting in March 2024. Subsequent checks also found no posted data, and no policy on staff posting was provided by the time of the Exit Conference.
The facility failed to maintain clean kitchen equipment, properly date cooked food items, and monitor and record required temperatures and sanitation levels. These deficiencies were observed during a survey, with missing logs and undated food items noted. The kitchen staff confirmed these lapses, potentially affecting all 44 residents.
The facility failed to place appropriate signage for transmission-based precautions for a resident with MRSA and lacked interventions and documentation for Legionella management. The Infection Control Plan and QAPI Agenda did not include a Legionella prevention policy, potentially affecting all residents.
The facility failed to implement an antibiotic stewardship program, including assessing and monitoring residents for infections, ensuring appropriate antibiotic usage, and using recognized surveillance criteria. The DON/ICP did not formally track or document infection control practices or conduct reports, affecting all 44 residents.
The facility failed to designate a qualified infection preventionist responsible for the Infection Prevention and Control Plan. The designated Infection Preventionist, who was also the DON, had not completed the required specialty training. This deficiency has the potential to affect all 44 residents in the facility.
The facility failed to offer and document required immunizations for five residents, as per their policy. The records for these residents lacked documentation for influenza and/or pneumococcal vaccinations, and refusals were not properly recorded.
The facility failed to ensure the memory care unit had warm water and was clean and free of odors for 19 residents. Observations revealed pungent urine odors, sticky floors, and debris in several rooms. Staff confirmed the lack of hot water for about a year, and maintenance issues were not addressed due to high repair costs. The facility's policies on water temperature monitoring and housekeeping were not followed.
An LPN was observed pre-popping medications and storing them in medication cups labeled only with residents' first names, contrary to facility policy. The DON confirmed that medications should be administered immediately after verification.
The facility failed to notify the Ombudsman monthly of a resident transfer to the hospital and did not provide the resident and their representative with a written notice of transfer. The Social Services Director confirmed these omissions.
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative upon the resident's transfer to a hospital. The Social Services Director confirmed that neither the resident nor the resident's representative received the required bed hold policy or written notice of transfer.
The facility failed to monitor a physician's order for self-catheterization and did not update a resident's care plan to reflect self-catheterization needs. The resident, diagnosed with Hereditary Spastic Paraplegia and Neurogenic Bladder, had a physician's order for self-catheterization that was not included in the current Physician Order Sheet, and the care plan lacked documentation addressing these needs. A lab test showed the resident had a UTI with Escherichia Coli. The DON confirmed the missing documentation.
The facility failed to obtain a physician's order for dialysis treatments, did not update the care plan for a resident receiving dialysis services, and did not assess the resident's dialysis fistula for hemorrhage post-dialysis. The resident, who has End Stage Renal Disease, reported that the nurse never monitors the fistula after dialysis. The Director of Nurses confirmed these deficiencies.
A resident with a PICC line for Vancomycin to treat MRSA had several doses missed, as documented in the MAR. Despite the facility's policy to notify the physician of missed doses, this was not done. Interviews with nursing staff revealed a lack of communication and accountability, with the DON unaware of the issue.
The facility failed to prevent resident-to-resident sexual abuse when a resident with severe cognitive impairment was inappropriately touched by another resident in the dining room. The incident was observed by an Activities Aide and reported to the DON, who separated the residents and involved Social Services. The offending resident was moved to a different hallway.
The facility failed to update the care plans of two residents following an incident of resident-to-resident sexual abuse. Despite immediate actions taken to separate the residents and involve social services, the care plans were not revised to include the incident or necessary interventions, as confirmed by the Director of Nursing.
A resident with dementia fell and sustained a head injury, but the facility failed to notify the family as required. The resident's Health Care Power of Attorney and second emergency contact were not informed by the facility, leading to frustration and disbelief when they learned of the incident from a hospice nurse. The facility's registered nurse did not follow the established protocol for notifying family members.
The facility failed to monitor and implement new interventions for two residents after falls, and did not assess a resident's suicidal statement. One resident's neurological assessments were incomplete, and no new fall prevention measures were documented. Another resident expressed a desire to die after a fall, but no psychological assessment or increased monitoring was conducted. The DON confirmed these oversights, attributing them to previous staff members.
The facility failed to ensure accurate controlled medication inventory counts, proper double-locking of refrigerated medications, and accurate reconciliation of tracking sheets, affecting residents with controlled medication orders. A missing Hydrocodone dose was not immediately reported, and a leaking Morphine bottle was mishandled, with confusion over its documentation.
A resident's Hydrocodone-Acetaminophen medication was misappropriated when a nurse was found impaired, leading to a missing dose. The DON and another RN discovered discrepancies in the medication count, but the control sheet was lost, and two tablets remained unaccounted for, indicating a failure in the facility's medication management.
The facility failed to verify the nursing license status of an LPN prior to employment, resulting in the LPN working multiple shifts despite having a suspended license. This oversight has the potential to affect all 48 residents in the facility.
The facility failed to have a licensed Administrator and did not thoroughly investigate an incident involving used needles and a suspicious substance. The Administrator in Training had been in training for years without a license and did not investigate reports of suspicious behavior by an LPN. The LPN continued to work until it was discovered she did not have a valid nursing license.
Failure to Prevent Door-Related Fall and Unsafe Post-Fall Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dementia, identified as a wanderer with a history of falls and a prior right hip fracture, was adequately supervised and kept away from the dementia unit doors, despite known risks. The resident’s care plan documented risk factors requiring monitoring and interventions such as disguising exits, covering doorknobs and handles, and distracting the resident from wandering. Staff and the resident’s son reported that the resident had previously been struck by the same unit doors without injury, and staff were aware that the resident tended to stand behind the doors. On the date of the incident, a dietary cook entered the code and pushed open the double doors to bring in a lunch cart, did not see the resident standing in the crack between the door and the wall, and the door hit the resident, causing her to fall. An emergency room radiology report later showed a right femur fracture and right hip dislocation. The facility also failed to ensure a safe transfer of the resident after the fall. After the resident was found sitting on the floor by the doors, the dietary cook and a CNA lifted the resident from the floor without using a gait belt or any assistive device and placed her into a wheelchair, even though the resident could only bear weight on one leg. Both staff later acknowledged that they did not use a gait belt, that moving the resident before a nurse assessed her could worsen any injury, and that it was not safe to transfer her in this manner. The facility’s transfer policy stated that mechanical lifting devices should be used for any resident needing a two-person assist or who could not be transferred comfortably and safely by normal transfer technique, and that manual lifting was not permitted except in emergency or unavoidable circumstances.
Resident Moved After Fall Without Prior Nursing Assessment
Penalty
Summary
The facility failed to ensure a resident was assessed for injury after a fall and prior to being transferred. The resident had been admitted with a primary diagnosis of unspecified dementia without behavioral, psychotic, mood disturbance, or anxiety features. An incident report documented that the resident was ambulating in the hallway behind double doors when the doors were opened, causing a change of plane and resulting in the resident falling, with noted discomfort to the right side. The dietary cook reported that she pushed the lunch cart through the double doors after entering a code and did not see the resident positioned by the crack between the door and the wall. When the door opened, the resident fell. Following the fall, the dietary cook went to get a CNA, and together they picked the resident up from the floor, stood her up, and placed her in a wheelchair, without using a gait belt and before a nurse could assess the resident. The CNA confirmed that she stood the resident up and transferred her to a wheelchair without a gait belt and acknowledged that moving the resident before a nurse assessment could worsen any injury. The LPN stated she returned from break to find the resident already in a wheelchair and that the aides had gotten the resident up before she could perform an assessment, noting they should not have moved the resident in case of a possible broken hip. The DON stated that after a fall, the nurse should perform an assessment first, including range of motion, pain level, and vital signs, and that the resident should not be moved prior to this assessment. The facility’s fall prevention policy indicated that transfer conveyances should be used in accordance with the care plan, and the DON noted there was no specific checklist for post-fall assessments.
Failure to Complete Required Fall Risk Assessments
Penalty
Summary
The facility failed to complete required fall risk assessments for one resident who was admitted with multiple diagnoses, including Major Depressive Disorder, Benign Prostatic Hyperplasia, Hypertension, Diabetes, and Cerebral Ischemia. The resident experienced a fall resulting in a right hip fracture. According to the facility's Fall Prevention Program policy, a fall risk assessment should be performed at least quarterly, upon admission, after any fall, and with any significant change in condition. However, the resident's medical record did not contain documentation of a fall risk assessment from November 2024 through August 2025. This lack of assessment was confirmed by both the DON and a regional RN, who verified that the required quarterly assessments were not completed during this period.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse and Inappropriate Use of Mechanical Lift
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by both other residents and a staff member. Several incidents were documented in which residents with cognitive impairments and behavioral issues engaged in physical altercations. In one case, a resident with severe cognitive impairment and behavioral symptoms pushed another resident, resulting in a fall and injury. Staff interviews confirmed that the residents involved had a history of wandering and aggression, and that staffing levels were low, with only one aide and one nurse on the night shift, making supervision and intervention challenging. Another incident involved a resident being physically assaulted by a peer who accused him of theft. The staff responded quickly to separate the residents, and no physical harm was reported in this case. However, the facility's documentation and staff interviews indicated that the resident who initiated the altercation had escalating behaviors, including a subsequent arrest for staff assault, and required psychiatric care and one-to-one observation upon return to the facility. Additionally, a staff member was observed using a mechanical lift to keep a resident suspended above his bed, allegedly to prevent him from getting out of bed. Witnesses reported the staff member yelling at the resident and expressing frustration, while the staff member claimed he was changing bed linens and waiting for assistance. The facility's investigation confirmed that the use of the lift was inappropriate and did not meet the expected standards of care, as the resident was left in the lift as a means of control rather than for a legitimate care purpose.
Unclean Kitchen Equipment Surfaces
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen area, specifically on the tops of stationary kitchen equipment adjacent to food preparation areas. During an initial kitchen tour, it was observed that the tops of the upright refrigerator and freezer were covered with dirt and debris. These pieces of equipment were located next to food preparation tables, which could potentially affect the sanitary conditions of food preparation. The Dietary Manager confirmed that the tops of the equipment should have been cleaned, acknowledging that ventilation and air movement contributed to the accumulation of dirt and debris. This deficiency has the potential to impact all 38 residents residing in the facility.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the lids of the trash dumpsters located outside were closed and secure, which is necessary to prevent pests and animals from accessing discarded food and trash. This deficiency was observed during an initial kitchen tour conducted with the Dietary Manager. The large, steel trash dumpster was found with its lids open and was not secured by any walls or access doors. The Dietary Manager confirmed that the lids should be kept closed to prohibit access by pests and animals. This oversight has the potential to affect all 38 residents residing in the facility.
Failure to Implement Standardized Infection Diagnosis
Penalty
Summary
The facility failed to implement a standardized method for determining the presence of infections, which is a critical component of their Antibiotic/Antimicrobial Stewardship Program. The policy of the facility, dated 10/24, emphasizes the importance of using standardized diagnosing tools to ensure appropriate antibiotic use, improve patient outcomes, and reduce healthcare costs. However, the facility's infection control logs for December 2024, January, and February 2025 did not reflect any set standards for diagnosing infections. This oversight has the potential to affect all 38 residents currently residing in the facility. During an interview on 3/12/25, the Licensed Practical Nurse/Infection Preventionist acknowledged the absence of standardized diagnosing tools, such as McGeer's or Loeb's criteria, and expressed an intention to implement them immediately. The facility's policy assigns the Medical Director the responsibility of setting antibiotic prescribing standards and reviewing antibiotic use data, while the Director of Nursing and the Infection Control Officer are tasked with setting standards for assessing and monitoring residents' conditions. The lack of adherence to these responsibilities contributed to the deficiency identified by the surveyors.
Failure to Justify Psychotropic Medication Use and Attempt Gradual Dose Reduction
Penalty
Summary
The facility failed to provide appropriate indications for the use of psychotropic medications for four residents, and did not attempt a Gradual Dose Reduction (GDR) for one resident. The facility's policy requires that psychotropic medications be used only when necessary and that GDRs be attempted at least twice yearly unless contraindicated. However, the facility did not document behaviors that necessitated the use of these medications for residents R15 and R29, and failed to attempt a GDR for resident R2, despite the absence of documented harmful behaviors. Resident R15 was receiving Quetiapine for unspecified dementia with agitation, but the care plan did not identify specific behaviors requiring the use of this antipsychotic medication. Observations showed that R15 was easily reassured and redirected, and the behavior monitoring report documented various behaviors such as entering other residents' rooms and expressing frustration, but these were not linked to the use of the medication. Similarly, resident R29 was prescribed Quetiapine for senile degeneration of the brain, but the care plan did not specify behaviors justifying the medication. Observations indicated that R29 was mostly calm and cooperative, with occasional instances of refusing care and expressing frustration. Resident R2, who was on Venlafaxine and Aripiprazole for bipolar disorder, had no documented harmful behaviors in the past year. The facility did not attempt a GDR, citing clinical contraindications, but there was no documentation of any GDR attempts in the past year. The Director of Nursing confirmed the lack of documentation and noted that R2 typically did not exhibit behaviors warranting the use of antipsychotics, aside from occasionally refusing care.
Inadequate Resident Transfer Assessment Leads to Injury
Penalty
Summary
The facility failed to properly assess a new resident's transfer needs, leading to an inappropriate transfer method being used. The resident, identified as R27, was initially documented as requiring a mechanical lift for all transfers. However, the Director of Nursing (DON) instructed staff to use a stand pivot transfer with two-person assistance, without any doctor's order or assessment to support this method. This incorrect transfer method resulted in a near fall incident where the resident's right foot was dragged across the floor, causing pain and bruising. Subsequent nurse's notes and an x-ray confirmed that the resident suffered a broken toe due to the incident. The resident expressed fear of falling during the transfer, and it was noted that five staff members were needed to stabilize and eventually transfer the resident back to bed using a mechanical lift. The lack of a proper assessment and the incorrect transfer method directly contributed to the resident's injury, highlighting a deficiency in the facility's supervision and accident prevention measures.
Failure to Assess PTSD Triggers for Resident
Penalty
Summary
The facility failed to assess and identify triggers for a resident with a primary diagnosis of PTSD, as required by their Behavioral Health Services Program policy. The policy mandates that the facility should identify any previous history of mental illness, trauma, and other related disorders to develop an individualized plan of care. However, the facility did not conduct a comprehensive PTSD assessment for the resident, who was admitted with PTSD as a primary diagnosis. The Social Services Director acknowledged that attempts should have been made to assess the resident for history of trauma and triggers, but no such assessments were completed. The resident, who also has diagnoses of dementia, psychotic disorder, and experiences social isolation, hallucinations, and delusions, was not provided with a care plan that identified specific environmental factors triggering their behaviors. The Behavioral Practitioner noted the resident's chronic PTSD and the need to gain the resident's trust to obtain background stories, but the Trauma Informed Care assessment was refused by the resident. Despite this, the care plan did not reflect any identified triggers or individualized interventions, which is a requirement for residents with PTSD according to the facility's policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents in the Memory Care Unit. On two separate occasions, one resident approached another and made physical contact with closed hands. The first incident occurred when one resident was talking to another, and the aggressor approached and struck the resident on the shoulder. Staff intervened immediately, and no visible injuries or psychosocial needs were noted. Both residents involved had severe cognitive impairments, as indicated by their low BIMS scores. In a subsequent incident, the same two residents were involved in another altercation. The aggressor again approached the other resident and made contact with closed hands. The resident attempted to defend herself by striking back and using a wet floor sign. Staff separated the residents promptly, and no injuries or psychosocial needs were observed. Both residents remained at their baseline condition following the incidents.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to initiate appropriate interventions to prevent resident-to-resident abuse involving two residents, R1 and R2, in the Memory Care Unit. R1, diagnosed with Dementia without Behavioral Disturbance and other mood disorders, and R2, diagnosed with Unspecified Dementia with Agitation, were involved in multiple altercations. On 11/29/24, R1 struck R2 on the shoulder, and on 12/2/24, another altercation occurred where both residents made contact with each other. Despite these incidents, the facility did not implement effective interventions to prevent further interactions between R1 and R2. The facility's response to these incidents was inadequate. Although R2's room was moved to another wing on 12/2/24, this intervention did not prevent further interactions with R1, as R2 continued to wander into other residents' rooms, including R1's. The care plan for R2 did not address the incidents of being struck by R1 or include any interventions to ensure R2's safety from R1. Additionally, R1 was placed on 15-minute checks instead of the recommended 1:1 monitoring, and this was not documented in R2's care plan. Further complicating the situation, R1 was moved to a non-secure unit on 12/19/24, which was unsuccessful due to R1's elopement risk, leading to R1's return to the Memory Care Unit on 12/28/24. No interventions were implemented to keep R1 away from R2 after R1's return, leaving R2 vulnerable to further interactions. The facility's failure to implement and document effective interventions and monitoring contributed to the ongoing risk of resident-to-resident abuse.
Failure to Address Burns and Falls in Residents
Penalty
Summary
The facility failed to notify the physician and obtain wound treatment orders for a resident who sustained second-degree burns. The resident, who has a diagnosis of mild intellectual disability, spilled hot tea on her lap, resulting in burns that were not treated or seen by medical staff. Despite the burns being reported to an agency LPN and the emergency department, there was no documentation of physician orders, measurements, or treatments for the burns until several weeks later. The facility's policy requires immediate notification and treatment for such injuries, which was not adhered to in this case. Additionally, the facility failed to investigate, monitor, and implement new fall interventions for two residents who were at high risk for falls. One resident experienced multiple falls, including incidents where she sustained a laceration to the forehead and was found lethargic, requiring Narcan administration. Despite these incidents, there were no follow-up vital signs documented for 72 hours post-fall, and no new interventions were implemented to prevent further falls. The facility's policy mandates thorough investigation and documentation of falls, which was not followed. Another resident also experienced multiple falls, including an unwitnessed fall and an incident where she was found with a cut on her forehead. Similar to the first resident, there was no investigation or post-fall interventions documented, and follow-up vital signs were not recorded. The facility lacked an accurate system to track and monitor falls, which contributed to the failure to address the residents' fall risks adequately.
Failure to Ensure Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that nurse aides providing direct patient care were not employed full-time for more than four months without successfully completing a state-approved training and competency evaluation program. This deficiency was observed when V4, a nurse aide, was seen working with residents on the secured unit. V4's personnel file indicated that she was eligible to work according to the Illinois Department of Public Health - Health Care Worker Registry, but her certification program information was incomplete, with no record of training or competency evaluation. V4 was initially hired as a housekeeper and later transitioned to a Certified Nurse Aide role. Despite enrolling in a CNA program, V4 did not pass the required skills competency portion. The Director of Nursing/Administrator in Training confirmed that V4 was employed full-time as a CNA and provided direct care, including toileting, transferring, and feeding residents, without completing the necessary state-approved competency training program. This oversight had the potential to affect all 44 residents in the facility.
Failure to Prevent Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement necessary interventions to reduce the risk of falls for two residents, R1 and R2, who were identified as high risk for falls. R1, who had severe dementia with agitation and was legally deaf, experienced multiple falls due to inadequate supervision and lack of proper footwear. Despite being assessed as high risk for falls, R1 was left unattended on several occasions, resulting in injuries including a laceration to the head and a hematoma. The staff failed to ensure R1 was under direct supervision and wearing non-skid footwear, as required by the care plan. R2, admitted with a history of weakness and recent fractures, also experienced falls due to insufficient supervision. R2's fall in the dining room, where no staff were present, resulted in serious injuries including a fractured right hip, pelvis, and T12 compression fracture. The facility's failure to provide adequate supervision, as documented in R2's care plan, contributed to these incidents. Staff interviews revealed that there were not enough personnel present to monitor residents effectively, leading to R2 being left alone and unsupervised. The facility's policy on fall prevention, which mandates staff to observe residents for safety and implement appropriate interventions for those at high risk, was not adhered to. The lack of adequate staffing and supervision, as well as the failure to follow care plans and ensure the use of non-skid footwear, directly contributed to the falls and subsequent injuries sustained by R1 and R2.
Failure to Assess and Treat Pressure Wound
Penalty
Summary
The facility failed to properly assess, notify the physician, and obtain a treatment order for a newly identified pressure wound on a resident's left buttock. The facility's policy requires that upon notification of skin breakdown, the pressure area should be assessed, documented, and the physician notified for treatment orders. However, this protocol was not followed for the resident, who was readmitted to the facility with a history of fractures and was noted to have an open area on the left buttock during the initial skin assessment. Despite the presence of the wound, there was no documentation of the pressure wound in the resident's Treatment Administration Record, nor was there a physician's order for its treatment. The wound was only discovered later by an LPN who found a heavily soiled bandage on the resident's left buttock, revealing a Stage 2 pressure wound. The LPN confirmed that she was unaware of the wound and that no previous assessment, physician notification, or treatment orders had been completed.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to obtain and administer physician-ordered medication for a resident diagnosed with severe dementia, agitation, and anxiety. The resident was prescribed Alprazolam, an anti-anxiety medication, to be taken three times daily. However, the medication was not administered on multiple occasions, specifically on June 29, June 30, July 1, and July 2, 2024, at the scheduled times of 8:00 A.M., 12:00 P.M., and 4:00 P.M. The facility's Medication Administration policy requires documentation of any omitted doses, but no such documentation was present for these dates. The Director of Nurses confirmed the omission of doses due to the unavailability of the medication, stating that the hospice nurse was supposed to order the medication, but it was not delivered. The facility had options to obtain the medication from an emergency box or local pharmacies like Walmart or CVS, but these were not utilized. An LPN also confirmed the medication was unavailable during their shifts, leading to increased agitation and anxiety in the resident. The facility's failure to ensure the availability and administration of the prescribed medication resulted in a deficiency in pharmaceutical services provided to the resident.
Failure to Administer Timely Antibiotic Medication
Penalty
Summary
The facility failed to administer a physician-prescribed antibiotic medication to a resident diagnosed with lower extremity cellulitis. The resident, who had Methicillin Resistant Staphylococcus Aureus (MRSA) in her leg wound, was discharged from the hospital with an order to take Linezolid 600 mg by mouth every twelve hours for seven days. The resident returned to the facility on June 15, 2024, at 1:45 PM, but the medication was not administered until 8:00 PM on June 16, 2024, resulting in a 35-hour gap between doses. The facility's Medication Administration Policy requires medications to be prepared and administered within one hour of the designated time or as ordered, using the six rights of administration. The Director of Nursing confirmed that the medication should have been delivered and administered as scheduled. The delay occurred because the medication was not delivered to the facility until 7:32 PM on June 15, 2024, and the first dose was not given until the following evening, leading to a significant medication error.
Failure to Timely Collect Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were collected as scheduled for a resident who was being monitored for infections. The resident had a physician order for a complete blood count (CBC), basic metabolic panel (BMP), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) test to be collected on a specific date and sent to an infectious disease physician. However, the laboratory tests were not collected until three days after the scheduled date, resulting in the rescheduling of the resident's appointment with the infectious disease physician. The Director of Nursing confirmed that the laboratory tests were supposed to be drawn on the scheduled date to coincide with the resident's appointment. The delay in collecting the laboratory tests was attributed to a lack of awareness of the orders by the nursing staff and repeated failures by the laboratory to process the orders despite multiple follow-up calls by a registered nurse. The nurse confirmed that she had ordered the tests as STAT and had contacted the laboratory multiple times, but the tests were still not drawn in a timely manner.
Undignified Labeling of Residents' Clothing
Penalty
Summary
The facility failed to ensure residents' clothing was labeled in a dignified manner. During a tour of the Laundry Department, the Housekeeping Supervisor stated that the facility no longer provides labels for residents' clothing and instead uses a black marker to write names on the inside of the clothing. This method is problematic as it is difficult to read on dark clothing and can ruin nicer articles of clothing. Observations showed multiple pieces of clothing with residents' names or initials written on the collars. During a Resident Council Meeting, two residents demonstrated how the marker had bled through and smeared on their white tops. Another resident was observed with black marks that had bled through the collar of their gray t-shirt.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure grievances or recommendations from residents were considered, addressed, and acted upon. The Resident Grievances/Complaints policy outlines that complaints and grievances should be directed to the appropriate Department Head and resolved within 15 days, with the Administrator receiving copies of the minutes for follow-up. However, multiple grievances documented in the Resident Council Meeting Minutes, such as missing clothes, call light issues, maintenance requests, and transportation issues, were not properly investigated or resolved. The reports lacked documentation of an investigation, resolution, and notification to the residents about the outcomes. The Resident Council President stated that residents do not receive verbal or written reports about the initiation or resolution of their complaints/grievances. The President expressed frustration that the same issues are repeatedly brought up without resolution. Specific grievances included missing laundry, no heat in the dining room, and ants in the building, among others. Despite these complaints being documented, there was no evidence that the facility took appropriate actions to investigate and resolve them, leading to ongoing dissatisfaction among the residents.
Failure to Post Daily Direct Care Staff Hours and Resident Census
Penalty
Summary
The facility failed to post the daily direct care staff hours and resident census, potentially affecting all 44 residents. During a tour on 6/2/24 at 9:15 AM, no daily nursing hour data and census sheet were observed throughout the building. The Director of Nursing (DON) stated at 12:00 PM that she was unaware of the requirement to post this information and confirmed that she had not done so since starting in March 2024. Subsequent checks on 6/3/24, 6/4/24, and 6/5/24 also found no posted data. The facility did not provide a policy on staff posting by the time of the Exit Conference on 6/5/24. The CMS Long Term Care Facility Application for Medicare and Medicaid Form 671, dated 6/5/24 and signed by the Administrator, documented 44 residents in the facility.
Deficiencies in Kitchen Sanitation and Food Safety Procedures
Penalty
Summary
The facility failed to ensure that the kitchen equipment was clean and free of debris, and did not properly date cooked food items to ensure they were used before expiration. Additionally, the facility did not monitor and record the required refrigerator and freezer temperatures, food temperatures of served foods, and the required dishwasher sanitation levels. These deficiencies were observed during a survey, where undated food items and missing thermometers were found in the kitchen and food storage areas. The facility's policies on refrigerator and freezer storage, dish machine sanitation, and food storage were not followed, leading to these lapses in compliance. During the survey, it was noted that the facility's logs for refrigerator and freezer temperatures, sanitizing solution checks, and dishwasher temperature/sanitizer levels were incomplete or missing for several dates. The kitchen staff verified these missing logs and checks. The facility's room roster confirmed that 44 residents were currently residing in the facility, all of whom could potentially be affected by these deficiencies. The observations and interviews with the kitchen staff highlighted significant gaps in the facility's adherence to its own policies and procedures regarding food safety and sanitation.
Deficiencies in Infection Control and Legionella Management
Penalty
Summary
The facility failed to place appropriate signage in a conspicuous location to clearly identify the category of transmission-based precautions, instructions for PPE, and/or instructions to see the nurse prior to entering a resident's room. This deficiency was observed for one resident who required transmission-based precautions due to a diagnosis of MRSA in leg wounds. Despite the resident's readmission with this diagnosis, the room lacked the necessary signage between specific dates, which could lead to improper handling and increased risk of infection transmission. Additionally, the facility failed to have interventions in place to mitigate the growth and spread of Legionella and did not maintain logs of these interventions. The Director of Nursing/Infection Preventionist indicated that the Maintenance Supervisor was responsible for Legionella management, but the only documentation provided was a log of water flushes. The facility's Infection Control Plan and Quality Assurance Performance Improvement (QAPI) Agenda lacked inclusion of a Legionella prevention policy, monitoring measures, and a flow diagram of the building's water system. This oversight has the potential to affect all residents in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that included assessing and monitoring residents for signs and symptoms of infections, ensuring antibiotic usage was appropriate, and using a nationally recognized surveillance criteria to define infections. This deficiency was identified for three residents reviewed for the Antibiotic Stewardship Program out of a sample of 43 residents. The facility's Infection Control Surveillance and Monitoring policy, dated 4/11/22, outlines the procedures for routine surveillance and monitoring to ensure compliance with infection control practices. However, the Director of Nursing/Infection Control Preventionist (DON/ICP) admitted to not formally tracking or documenting observations of infection control practices and not conducting any reports since starting in March. Additionally, residents treated for infections were not tracked or trended according to caregivers, locations, or other sources that could be controlled, and antibiotic usage was not reviewed. The findings indicate that the facility's failure to adhere to its own infection control policy has the potential to affect all 44 residents residing at the facility. The DON/ICP's lack of formal audit processes and failure to track and trend infections and antibiotic usage contributed to the deficiency. The facility's policy requires the DON/ICP and/or Administrator to maintain records of surveillance and monitoring, but this was not being done, leading to a lack of proper infection control and antibiotic stewardship within the facility.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the Infection Prevention and Control Plan. The facility's policy required at least a part-time Infection Control Preventionist, which could be the Director of Nursing (DON) with an approved Infection Control Certification. However, the designated Infection Preventionist, who was also the DON, had not completed the required specialty training in Infection Prevention and Control. This was confirmed through interviews with the DON and the Administrator, who stated that the DON had not had time to complete the training due to other responsibilities. This deficiency has the potential to affect all 44 residents in the facility.
Failure to Document and Offer Required Immunizations
Penalty
Summary
The facility failed to offer and document immunizations and vaccinations for five residents as per their policy. The policy, dated 5/19/23, requires verification of the last vaccination date, assessment of vaccination status upon admission, and documentation of immunizations on the resident's Immunization Record and Medication Administration Record. However, the records for five residents lacked documentation that the influenza and/or pneumococcal vaccinations were offered, given, or refused. Specifically, the records for residents R12, R14, R39, R40, and R96 were missing this critical information. Additionally, the facility's Infection Preventionist/Director of Nursing confirmed that the immunizations should be documented but acknowledged that refusals were not properly recorded, either through signed declinations or verbal documentation. Resident R12's Immunization Record did not show any documentation regarding the influenza vaccination. Similarly, R14's record lacked documentation for the influenza vaccination. For residents R39 and R40, there was no documentation for either the influenza or pneumococcal vaccinations. R96's record was missing documentation for the pneumococcal vaccination. The Infection Preventionist/Director of Nursing admitted that while R39 and R40 had refused the influenza vaccination, this refusal was not documented properly, raising questions about the facility's adherence to its own immunization policy.
Failure to Maintain Safe and Clean Environment in Memory Care Unit
Penalty
Summary
The facility failed to ensure the memory care unit had warm water and was clean and free of odors for 19 of 42 residents. During a tour, it was observed that the hallway and several rooms had pungent urine odors, sticky floors, and debris. Specific rooms had additional issues such as a bucket with brownish/black liquid and feces smeared on various surfaces. The joint bathroom between two rooms had the hot water knob turned off, resulting in only cold water being available. Maintenance staff confirmed that the hot water had been turned off for a while and that the pipes needed to be re-routed, a task that had not been scheduled for repair due to high costs. Interviews with staff revealed that the lack of hot water had been an ongoing issue for approximately a year. CNAs reported that they had to use cold water for handwashing and resident care, as the dietary staff did not consistently fill the orange jug with hot water. The Director of Nursing and the Housekeeping Supervisor both acknowledged the problem, with the latter stating that CNAs were supposed to clean the bucket in one of the rooms every two hours, but often did not. Maintenance staff also confirmed that the hot water issue had not been addressed due to the need for extensive and costly repairs. The Administrator confirmed that the Dementia Unit had been without hot water for about a year and that the necessary repairs would cost over $60,000. The lack of hot water and the unsanitary conditions in the memory care unit were not addressed promptly, leading to a failure in providing a safe, clean, and comfortable environment for the residents. The facility's policies on water temperature monitoring and housekeeping were not followed, contributing to the deficiencies observed during the survey.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were stored in their original packaging with proper labels until administered for four residents. An Agency Licensed Practical Nurse (LPN) was observed pre-popping medications and storing them in medication cups labeled only with the residents' first names. The LPN admitted to pre-popping the medications and storing them in the cart, despite knowing it was against policy. The Director of Nursing (DON) confirmed that nurses should not pre-pour medications and should administer them immediately after verifying the medication, label, and date.
Failure to Notify Resident and Ombudsman of Transfer
Penalty
Summary
The facility failed to notify the facility Ombudsman monthly of a resident transfer to the hospital and did not provide the resident and resident representative with a written notice of transfer. Specifically, a resident was transferred to a local hospital, and there was no evidence of a facility notification to the resident of the transfer/discharge in the resident's chart. The Social Services Director confirmed that the facility did not provide the resident or their representative with a written notice of transfer and also did not send notification to the local Ombudsman of monthly facility transfers/discharges.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative upon the resident's transfer to a hospital. Specifically, the medical record of a resident who was hospitalized on an unspecified date did not contain documentation of written notice of the facility's bed hold policy. This deficiency was confirmed by the Social Services Director, who verified that neither the resident nor the resident's representative received the required bed hold policy or written notice of transfer.
Failure to Monitor Self-Catheterization and Update Care Plan
Penalty
Summary
The facility failed to monitor a physician's order for self-catheterization and did not update a resident's care plan to reflect self-catheterization needs. The facility's policy requires comprehensive assessment and periodic reassessment of each resident to develop a person-centered comprehensive plan of care. However, for one resident diagnosed with Hereditary Spastic Paraplegia and Neurogenic Bladder, the physician's order for self-catheterization was not included in the current Physician Order Sheet. Additionally, the resident's care plan did not document any problem/need areas, goals, or interventions related to self-catheterization. The resident, who is cognitively intact with a BIMS score of 15:15, had a physician's order dated several months prior, allowing self-catheterization as needed for retention, with staff required to educate and monitor for retention and UTIs weekly. Despite this, the current care plan lacked any documentation addressing these needs. Furthermore, a laboratory test result showed the resident had a urinary tract infection with Escherichia Coli. The Director of Nurses confirmed the missing documentation for monitoring and care planning related to the resident's self-catheterization.
Failure to Obtain Physician's Order and Monitor Dialysis Fistula
Penalty
Summary
The facility failed to obtain a physician's order for dialysis treatments and did not update the care plan for a resident receiving dialysis services. Additionally, the facility did not assess the resident's dialysis fistula for hemorrhage post-dialysis. The resident, who is cognitively intact and has been receiving thrice-weekly dialysis for many years, reported that the nurse never monitors the fistula after dialysis for signs of hemorrhage. The resident's current Physician Order Sheet did not include a physician's order for dialysis treatments, and the care plan did not address the resident's dialysis needs. The Director of Nurses confirmed the missing physician's order and the lack of a care plan addressing the resident's dialysis needs. The facility's policy on comprehensive care planning and dialysis care was not followed, leading to these deficiencies. The resident's Minimum Data Set Assessment indicated a diagnosis of End Stage Renal Disease, but the necessary documentation and monitoring procedures were not in place, as verified by the Director of Nurses.
Failure to Administer IV Medication as Ordered
Penalty
Summary
The facility failed to administer an IV medication, Vancomycin, as ordered by the physician for a resident identified as R32. The resident, who was cognitively intact with a BIMS score of 15, had been readmitted to the facility with a PICC line and new orders for Vancomycin to treat a wound infected with MRSA. The medication administration record indicated that the Vancomycin doses were missed on several occasions, specifically on 5/24, 5/27, 5/28, and 5/29. The facility's policy required notifying the physician when a scheduled dose was not administered, but this was not done. Interviews with the nursing staff revealed a lack of communication and accountability regarding the missed doses. The primary nurse, V21/RN, acknowledged that the resident informed her about the missed doses, and upon reviewing the records, she confirmed that at least 3 to 4 doses were missed. Other staff members, including V23/RN and V22/RN, noticed discrepancies in the medication administration but did not take action to address them. The Director of Nurses, V2/DON, was unaware of the missed doses and stated that no requests were made to administer the medication. The oversight resulted in the resident expressing concern about the potential worsening of their condition due to the missed antibiotic doses.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving two residents. The incident occurred in the dining room where one resident, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was inappropriately touched by another resident. The inappropriate behavior was first observed by an Activities Aide, who noticed the resident's hand on the other resident's leg. The Aide immediately reported the incident to the Director of Nursing, who then separated the residents and took the offending resident to speak with Social Services. The Director of Nursing confirmed that the resident's hand was inside the other resident's pants on the hip/groin area but did not reach further. The offending resident was then moved to a different hallway away from the victim's room. The facility's Abuse Prevention Program policy, dated 11/28/16, explicitly prohibits any form of abuse, including sexual abuse, and aims to create a secure environment for residents. Despite this policy, the facility failed to prevent the incident, which was observed by staff and reported immediately. The incident report and staff interviews confirm that the offending resident is capable of moving around the facility independently, which may have contributed to the occurrence of the abuse. The facility's immediate response involved separating the residents and addressing the situation with Social Services, but the initial failure to prevent the abuse constitutes a significant deficiency in resident protection.
Failure to Update Care Plans After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to revise the care plans of two residents following an incident of resident-to-resident sexual abuse. According to the facility's Comprehensive Care Plan (CCP) policy, care plans should be reviewed and revised as necessary to reflect the resident's current medical, nursing, and psychosocial needs. However, after an incident where one resident was observed placing his hand inappropriately on another resident, the care plans for both residents were not updated to include the incident or interventions to prevent further abuse. This failure was confirmed by the Director of Nursing, who acknowledged that the care plans should have been updated to reflect the risk for abuse and the need for supervision. The incident report documented that the inappropriate behavior was observed by an activities employee and reported immediately to the Director of Nursing. The residents were separated, and the offending resident was taken to speak with social services. Despite these immediate actions, the care plans remained unchanged, leaving staff without updated guidance on how to manage the residents' needs and prevent future incidents. This oversight highlights a significant lapse in the facility's adherence to its own policies regarding care plan updates and resident safety.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the family of a resident about a change in condition following a fall, as required by their policy. The resident, who was admitted to the Alzheimer's Unit with a diagnosis of dementia and other mental health conditions, was found on the floor with a hematoma and laceration on her forehead. The nurse's notes indicated that a message was left for the family on the day of the incident, but there was no documentation of which family member was contacted or any further attempts to reach them. This lack of communication led to the family being unaware of the fall and head injury until informed by a hospice nurse. The resident's Health Care Power of Attorney and second emergency contact expressed their frustration and disbelief at not being informed by the facility. They stated that they had made it clear to the facility that if the primary contact was unreachable, the second contact should be notified. Despite this, the facility staff, particularly a registered nurse, failed to follow through with these instructions, leading to the family being upset and unaware of the resident's condition. The registered nurse involved did not respond to calls for a statement regarding the notification process.
Inadequate Monitoring and Intervention Post-Fall
Penalty
Summary
The facility failed to adequately monitor and implement new interventions for two residents following falls, resulting in deficient practices. One resident was found on the floor with a head laceration, and the required neurological assessments were not completed as per the facility's policy. The resident's care plan did not document the fall or the resulting injury, and no new interventions were put in place to prevent future falls. The Director of Nursing confirmed the lack of documentation and interventions, which led to the resident's condition worsening, requiring hospital evaluation. Another resident experienced a fall and expressed a desire to die, indicating potential self-harm risk. However, the facility did not conduct further assessments or implement increased monitoring as required by their Suicide Precautions policy. The resident's medical record lacked documentation of psychological assessments or any follow-up on the suicidal statement. The Director of Nursing acknowledged the oversight and attributed it to previous staff members who failed to investigate the resident's statements. The facility's policies on fall prevention and suicide precautions were not followed, leading to inadequate supervision and care for the residents involved. The lack of documentation and failure to initiate necessary interventions and assessments contributed to the deficiencies identified in the report.
Deficiencies in Controlled Medication Management
Penalty
Summary
The facility failed to ensure accurate shift-to-shift controlled medication inventory counts, proper double-locking of refrigerated controlled medications, and accurate reconciliation of controlled medication tracking sheets. This deficiency potentially affects all 16 residents who have physician orders for controlled medications. The facility's policy mandates that all controlled drugs be counted by the oncoming and outgoing nurse at each shift change, with both nurses signing the inventory sheet to confirm accuracy. However, the report indicates incomplete signature documentation for the shift change accountability record sheet from March to May, suggesting a lack of compliance with the policy. An incident involving a missing dose of Hydrocodone-Acetaminophen for a resident was reported. The Director of Nursing (DON) stated that a nurse was found impaired and subsequently replaced, but the controlled medication count was off by one tablet. The missing tablet was not immediately reported, and the control sheet for the medication could not be located. Additionally, there was confusion regarding the count of Hydrocodone tablets, with two tablets unaccounted for, and the control sheet was still missing at the time of the report. Further issues were observed with the storage and handling of controlled substances. A bottle of Lorazepam was found in an unlocked refrigerator, contrary to the policy requiring double locks. A leaking bottle of Morphine was also discovered, with the label soaked and unreadable, making it impossible to accurately account for the medication. The facility failed to report the leaking bottle to the pharmacy or document the leakage, and there was confusion regarding the association of the Morphine with the correct proof of use form. The facility's responsibility to track control sheets and ensure proper handling of medications was not met.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication for a resident, identified as R1, when a dose of Hydrocodone-Acetaminophen was found missing. The incident began when a registered nurse, V3, was found impaired and subsequently taken to the hospital. During this time, the Director of Nursing (DON), V9, was informed that the controlled medication count was off by one tablet. The police were notified, and upon their arrival, it was confirmed that one tablet of R1's medication was missing. Despite efforts to locate the missing control sheet, it remained unaccounted for, and the discrepancy in the medication count persisted. Further investigation revealed that V4, another registered nurse, conducted a self-count of the controlled medications and discovered the inaccuracy. However, V4 did not immediately report the missing Hydrocodone to the DON. It was only after the police arrived that V4 informed them of the missing tablet and subsequently notified V9. When V9 and V4 later recounted the medications, they found that two tablets were unaccounted for, with only one documented as administered. This lack of proper documentation and communication led to the misappropriation of R1's medication, highlighting a significant deficiency in the facility's handling of controlled substances.
Failure to Verify Nursing License Status
Penalty
Summary
The facility failed to check the nursing license status of a Licensed Practical Nurse (LPN) prior to employment, which has the potential to affect all 48 residents in the facility. The facility's Nurse Staffing Policy mandates that no person may provide direct resident care without a certification and records check. Despite this, the LPN worked multiple shifts in February and March 2024. It was later discovered that the LPN's license had been suspended effective February 5, 2024, for posing an imminent danger to the public. This was identified on March 12, 2024, by another LPN who then alerted the Administrator in Training and the Corporate Registered Nurse. The Administrator in Training admitted to not checking the LPN's license prior to employment, which was a requirement according to the facility's policy and job description for the Administrator.
Failure to Have Licensed Administrator and Investigate Incident
Penalty
Summary
The facility failed to have a licensed Administrator and did not thoroughly investigate an incident involving used needles and syringes. The Administrator in Training (V1) had been in training for about three to four years and had failed the licensing test twice. Despite this, V1 was acting as the Administrator on a daily basis with oversight from a Corporate Administrator (V6). The facility's Administrator job description requires a current unencumbered Nursing Home Administrator's License, which V1 did not possess. Additionally, V1 did not conduct a thorough investigation when used needles and a white powdery substance, suspected to be crystal methamphetamine, were found in the clean utility room. Staff members had reported suspicious behavior by V5, a Licensed Practical Nurse, but V1 did not interview or investigate V5 or other staff members regarding the incident. A police report documented that a police officer responded to the facility after the discovery of the suspicious items. The officer noted that V18, a Certified Nurse Aide, had found the items and suspected V5 due to her strange behavior. Other staff members, including another LPN (V3) and a housekeeper (V19), also reported V5's odd behavior to V1. Despite these reports, V1 did not take further action to investigate V5 or the incident. V5 continued to work at the facility until she was asked to leave for not having a valid nursing license. The facility currently has 48 residents who could potentially be affected by these deficiencies.
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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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