Arcadia Care Bloomington
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Illinois.
- Location
- 1509 North Calhoun Street, Bloomington, Illinois 61701
- CMS Provider Number
- 145371
- Inspections on file
- 60
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Arcadia Care Bloomington during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently implement care-planned fall precautions for several residents. A resident with cognitive impairment and dementia was observed in bed without a reachable call light, despite a care plan requiring it to be within reach. Another resident with seizures and dementia, and a third resident with dementia and behavioral disturbances, were each found in bed without access to their call lights as specified in their care plans. A resident with a history of cerebral infarction and hemiplegia reported falling while transferring, and surveyors observed that required grip strips were missing from the bathroom and shower areas. CNAs reported that fall precautions are located in the medical record and that call lights should be within reach, and the DON stated she expected all fall interventions to be in place, but the facility’s fall prevention policy was not followed for these residents.
Surveyors found multiple shower rooms in disrepair, with broken tiles, cracked boards, dirty grout, rust, peeling caulk, and black mold-like substances. The Maintenance Director confirmed these issues, and several residents reported ongoing concerns about cleanliness and maintenance, noting that only temporary fixes were being made. These deficiencies affected all residents in the facility.
Multiple residents experienced significant delays in receiving their clean clothing, with laundry carts of clean items left undelivered for days and large amounts of dirty laundry accumulating. Residents and staff reported that it often took several days for clothes to be washed and returned, leading to repeated complaints about missing items that were later found in the laundry. The DON and Administrator confirmed ongoing issues with laundry timeliness and acknowledged multiple complaints from residents.
A resident with severe cognitive impairment and a history of impulsive behaviors experienced multiple falls and repeated removal of a gastrostomy tube, resulting in injuries and hospitalizations. Despite clear documentation of the need for a bed alarm and one-to-one supervision, these interventions were not consistently implemented by facility staff, and care plans lacked adequate updates after each incident.
A resident with COPD and hypertension, who was cognitively intact, was found in a room with dusty cobwebs containing insects along the windowsill and dirt particles on bed linens. The Housekeeping Supervisor confirmed the lack of adequate cleaning, and the Administrator acknowledged ongoing cleanliness issues, despite facility procedures requiring daily cleaning and inspection of resident rooms.
The facility failed to provide an adequate supply of toilet paper, as reported by several residents who had to use alternative items or rely on family for supplies. Certified Nurse's Aides confirmed the shortage. Additionally, the main shower room had missing and broken tiles, creating an unstable surface for dependent residents. These deficiencies affected all residents in the facility.
Multiple residents with chronic conditions experienced unclean living spaces, including dust, dead insects, ant infestations, and persistent urine odors. Residents and staff reported repeated shortages of toilet paper, leading some to use alternative items or rely on family for supplies. These deficiencies resulted in discomfort and feelings of neglect among residents.
Two cognitively intact residents with multiple chronic conditions reported ongoing ant infestations in their rooms, with observations of ants, dead insects, and dust on windowsills. CNAs confirmed the presence of ants in resident rooms and on residents, and the administrator was aware of the issue.
Two residents were involved in separate physical altercations, with one resident—who has severe dementia—being shoved and later slapped on the head by another resident. Staff intervened during both incidents, but not before physical abuse occurred. Documentation and interviews confirm that the aggressor was aware of their actions and had previously expressed frustration about the other resident's wandering and interference with personal belongings.
The facility did not thoroughly investigate or document two separate incidents of resident-to-resident physical abuse. In both cases, the investigation files lacked details on who reported the allegations to administration, whether other residents or witnesses were interviewed, and what immediate or long-term interventions were implemented to protect residents from further abuse. The administrator confirmed that the incomplete files represented the entire investigation.
The facility did not fully document the details of two separate resident-to-resident physical altercations and the subsequent investigations in the affected residents' medical records. Progress notes only briefly referenced the incidents and notifications made, without including specifics about the events, investigative steps, or interventions taken to protect those involved.
A resident with dementia and mobility needs was transported in a facility van without proper wheelchair restraints or seatbelt, resulting in the wheelchair flipping backwards during transit. The resident sustained a head injury and rib fracture, requiring increased pain management. Both the CNA and LPN involved reported they had not been trained on proper van safety procedures, and the DON confirmed the lack of restraint led to the incident.
The facility failed to maintain a clean dining environment for residents on the 300 hall. Observations showed a dirty adult brief in the garbage and staff items on the dining table. CNAs reported that due to a lack of housekeeping staff, the dining room was not cleaned regularly, forcing residents to eat in their rooms. The Maintenance/Housekeeping Director confirmed the staffing shortage and inadequate cleaning.
Two residents with severe cognitive impairments were involved in a physical altercation when one attempted to grab the other's hat, resulting in a punch to the head. The incident was witnessed by a CNA and reported to relevant authorities. The facility's policy emphasizes preventing abuse, but the incident highlights a failure to maintain a secure environment.
A facility failed to report an abuse allegation to the state agency after a CNA witnessed a physical altercation between two residents. The incident, where one resident attempted to grab another's hat and was subsequently punched, was reported to the previous administrator but not to the Illinois Department of Public Health as required. The deficiency was identified when the new administrator was informed and investigated the incident.
The facility failed to maintain a sanitary and comfortable environment, with issues such as missing paint, holes in walls, and unsanitary shower rooms. Residents reported cold temperatures in the dining room, leading them to eat in their rooms. The Maintenance Director was aware of these issues but had not fully addressed them, affecting multiple residents.
A cognitively impaired resident fell while exiting a shower room, and a CNA was observed laughing and not assisting the resident. The incident was captured on camera, and the DON determined it was abuse. The facility failed to report the incident as required by their abuse prevention policy.
A facility failed to report an allegation of mental abuse when a resident fell after attempting to grab a CNA. The Director of Nursing believed the incident needed further investigation, but the Administrator found no evidence of abuse and did not report it to authorities, contrary to facility policy.
Facility staff failed to wait for a nurse assessment after a resident's fall, contrary to the Fall Prevention Program policy. An LPN instructed CNAs to stay with the resident until she could assess him, but the CNAs, with another resident, attempted to stand him up despite his pain complaints. They placed him in a wheelchair and took him to his room. The DON acknowledged the inappropriate handling of the fall investigation.
A resident with severe cognitive impairment and wandering behaviors intruded on the privacy of other residents by entering their rooms uninvited. Despite staff attempts to redirect the resident, the behavior persisted, causing distress and safety concerns among other residents. Staff reported challenges in managing the resident's behavior due to insufficient staffing for constant supervision.
The facility failed to provide an ongoing program of activities for residents, as required by their policy. No activities were scheduled after 3:00 PM or on Sundays, and 19 residents' records lacked documentation of activity participation. Staff confirmed no activities were offered on the memory care unit, citing understaffing and lack of visits from the activity department. The former Activity Director did not track residents' activity attendance or interests, leading to a deficiency in meeting residents' needs.
The facility failed to prevent resident-to-resident abuse involving a severely cognitively impaired resident who exhibited aggressive behaviors. This resident was involved in altercations with two other residents, including throwing a TV remote and physically grabbing another resident's legs. Staff attempts to redirect the resident were unsuccessful, leading to continued aggressive interactions.
A facility failed to update the care plan and implement necessary supervision for a resident with aggressive behaviors, leading to multiple altercations with other residents. Despite the resident's history of severe cognitive impairment and aggression, the care plan did not include interventions for increased supervision, such as one-on-one monitoring or 15-minute checks. Staff interviews revealed that the resident was not adequately monitored, contributing to the deficiency in the facility's abuse prevention policy.
A resident was discharged from the facility without receiving the required 30-day written notice, as per the facility's policy. The discharge was based on a physician's order indicating no further need for nursing home care. The resident was taken to a homeless shelter without prior notification, causing confusion and distress. The facility failed to provide a safe and appropriate discharge, violating their own policies.
The facility failed to provide RN coverage for a 24-hour period on two separate days, potentially affecting all 84 residents. The Director of Nursing confirmed the absence of RN coverage as per the facility's Nursing Daily Schedule.
A resident with Type 1 Diabetes, Generalized Anxiety Disorder, and Morbid Obesity was verbally abused by a dietary aide during dinner. The aide dismissed the resident's request for an alternative meal and later used derogatory language towards the resident in front of others. The incident was reported immediately, and the aide resigned following the report.
A resident with muscle weakness and morbid obesity was improperly transferred without a mechanical lift, contrary to their care plan. A CNA, unfamiliar with the resident, attempted the transfer based on the resident's incorrect claim that a lift was unnecessary, resulting in the resident being lowered to the ground when their knees gave out. The CNA did not verify the transfer requirements, violating the facility's fall prevention policy.
Failure to Maintain Care-Planned Fall Precautions and Call Light Accessibility
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain fall precautions and accident prevention measures as care planned for multiple residents. One resident with moderately impaired cognition, hallucinations, and alcohol-induced persisting dementia was observed lying crosswise in bed without the ability to rise and without a call light within reach, despite a care plan intervention directing staff to ensure the call light was within reach and to encourage its use. Another resident, who was rarely or never understood and had diagnoses of seizures and dementia with behavioral disturbance, was also observed lying in bed without a call light in reach, contrary to a care plan intervention requiring the call light to be kept within reach and used for assistance as needed. A third resident, also rarely or never understood and diagnosed with dementia with behavioral disturbances, was observed lying in bed with the call light located between the wall and the bed, out of reach, despite a care plan intervention to keep the call light within reach and encourage its use. A fourth resident, with intact cognition but with a history of cerebral infarction and hemiplegia/hemiparesis, reported having fallen while trying to transfer independently; surveyors observed that grip strips were not present on the bathroom floor or in the shower room, even though the resident’s care plan included interventions to apply grip strips in both areas with specific initiation dates. CNAs interviewed stated that fall precautions are found in the medical record and that residents should have call lights within reach, and the Director of Nurses stated she expected all fall interventions to be in place. The facility’s Fall Prevention Program policy required safety interventions to be implemented and consistently maintained for residents at risk, but these interventions were not in place for the residents reviewed.
Shower Rooms Found in Disrepair and Unsanitary Condition
Penalty
Summary
The facility failed to maintain the shower rooms in a safe and functional condition, as evidenced by multiple observations of disrepair and unsanitary conditions in the shower rooms on the 100, 300, and 400 halls. Surveyors observed loose and broken tiles, cracked shower boards, dirty grout with black substances, orange rust-like substances along baseboards, peeling caulk, and black or gray fuzzy substances resembling mold on caulking and walls. Additional findings included toilets filled with feces or black water, garbage on the floors, missing tiles, and shower chairs with apparent feces. These conditions were confirmed by the Maintenance Director, who acknowledged the need for deep cleaning and remodeling of all three shower rooms. Interviews with several residents revealed consistent concerns about the cleanliness and state of repair of the shower rooms, with residents describing the areas as dirty, gross, and in need of remodeling. Residents reported that issues such as mold, detached baseboards, and persistent uncleanliness had been ongoing, and that temporary fixes were being applied instead of permanent repairs. Resident Council Meeting Minutes also documented concerns about the adequacy of maintenance staffing to address the volume of needed repairs. At the time of the survey, 94 residents resided in the facility, all of whom had the potential to be affected by these deficiencies.
Delayed Laundry Services Result in Unreturned and Missing Resident Clothing
Penalty
Summary
The facility failed to provide timely laundry services, resulting in residents not receiving their personal clothing in a clean and usable condition. Observations over two consecutive days showed multiple carts of clean, laundered clothing remaining undelivered in the laundry room, while large quantities of dirty laundry accumulated. Interviews with residents and staff confirmed ongoing delays, with residents reporting that it often took two to three days or more to have their clothes washed and returned. Several residents described having to visit the laundry room themselves to retrieve needed clothing, and multiple staff members acknowledged that laundry was consistently backed up due to insufficient staffing and workload. Documentation and interviews revealed a pattern of missing clothing, with numerous Concern/Complaint Forms filed by residents regarding missing items that were later found in the laundry after several days. Resident Council Meeting Minutes over several months also documented repeated complaints about missing and delayed laundry. The Director of Nursing and the Administrator both confirmed the ongoing issue with the timeliness of laundry services and acknowledged receiving several complaints from residents about missing clothing that was eventually located in the laundry.
Failure to Implement Fall and Accident Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate accident and fall prevention interventions for a resident with significant cognitive impairment and multiple medical conditions, including cerebral infarction, encephalopathy, diabetes, chronic embolism, seizures, and substance abuse. Upon admission, the resident was noted to be oriented to person only, unable to follow directions, and had a history of impulsive behaviors such as pulling out medical equipment and attempting to get up unassisted. Hospital discharge documentation indicated the need for a bed alarm and one-to-one sitter, but these interventions were not consistently implemented in the facility. Despite being identified as at risk for falls and removal of medical equipment, the resident's care plan and progress notes lacked adequate and timely interventions to address these risks. The resident experienced multiple incidents, including pulling out a gastrostomy tube on two separate occasions, both requiring hospital visits for reinsertion, and sustaining falls, one of which resulted in a laceration above the left eyebrow that required sutures. After each incident, there was little evidence of new or enhanced interventions being put in place to prevent recurrence, and documentation did not reflect the use of a bed alarm or one-to-one supervision as recommended at discharge. Interviews with facility staff confirmed that the resident was impulsive, had poor safety awareness, and was unable to use the call light due to cognitive impairment. Staff acknowledged that the resident needed one-to-one care and a bed alarm, but these measures were not provided. The lack of appropriate supervision and failure to implement individualized safety interventions directly contributed to the resident's repeated accidents, including falls and the removal of the feeding tube.
Failure to Maintain Cleanliness in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident who was cognitively intact and had diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation and essential hypertension. During observation, dusty cobwebs containing insects were found accumulated along the windowsill next to the resident's bed, and dirt particles were present on top of the resident's bed linens while the resident was in bed watching television. The Housekeeping Supervisor confirmed the presence of cobwebs and insects and acknowledged that the room required better cleaning. The Administrator stated that resident rooms are supposed to be cleaned daily and acknowledged ongoing issues with facility cleanliness. Facility procedures require daily visual inspection and cleaning of resident rooms, including linens and window areas, but these procedures were not followed in this instance.
Inadequate Toilet Paper Supply and Unsafe Shower Conditions
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents by not providing an adequate supply of toilet paper and by failing to keep communal shower floors in a safe and sanitary condition. Multiple residents reported experiencing a shortage of toilet paper, with some having to rely on family members to bring supplies or resorting to using napkins and tissues for several days. Certified Nurse's Aides confirmed the shortage, stating that there were a couple of days when toilet paper was unavailable. The daily census indicated that 92 residents could have been affected by this deficiency. Additionally, the main shower room in one of the facility's halls was observed to have several missing, cracked, and loose ceramic tiles, resulting in an uneven and unstable surface where a shower chair is placed for dependent residents. This condition was confirmed by the facility administrator, who acknowledged awareness of the broken tiles. These deficiencies were identified through observation, resident and staff interviews, and record review.
Failure to Maintain Clean, Homelike Environment and Essential Supplies
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for three residents with chronic medical and mental health conditions. Observations revealed that the rooms of these residents had significant cleanliness issues, including dust, dead insects, and ants on windowsills, as well as baseboards in bathrooms crusted with brown or yellow matter and persistent odors of urine. Paint was observed peeling in multiple areas, and in one room, an empty bed with exposed springs and no linens was present. Residents reported frequent ant infestations, with ants crawling on walls and, in some cases, getting into food. Staff confirmed the presence of ants in resident rooms and noted that some residents, particularly those unable to brush them off, were affected by the insects. Additionally, the facility failed to maintain an adequate supply of toilet paper, resulting in residents being without toilet paper for several days. Residents reported having to rely on family members to bring toilet paper or using alternative items such as napkins and tissues. Staff and the facility administrator confirmed that there was a shortage of toilet paper, and residents were observed keeping extra rolls in their rooms due to previous shortages. These conditions contributed to residents feeling disrespected and ignored.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to provide adequate pest control, as evidenced by the presence of ants and dead insects in resident rooms. One resident, who is cognitively intact and has diagnoses including chronic neuropathy, anxiety, and major depression, was observed in her room where the windowsill was covered in dust, dead spiders, and ants. She reported that ants are present all the time, crawling on the walls and window. Another cognitively intact resident with chronic obstructive pulmonary disease, congestive heart failure, diabetes, anxiety, and depression also had windowsills covered with dust and dead insects, and reported frequent ant infestations, including ants getting into his food. Certified Nursing Assistants confirmed the presence of ants in resident rooms and noted that ants have been seen on residents, which is particularly concerning for those unable to brush them off. The facility administrator acknowledged awareness of the ant problem.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by two separate incidents involving physical altercations between two residents. One resident, who has severe dementia, metabolic encephalopathy, and major depressive disorder, was observed wandering the dementia unit and was involved in altercations with another resident. In the first incident, after the second resident complained to a CNA about the first resident urinating on the floor and being in their shared room, the second resident shoved the first resident on the shoulders, causing the first resident to stumble backward before being intercepted by the CNA. The second incident involved the same two residents, where the second resident was observed yelling at and then slapping the first resident on the head while the first resident was sitting on the edge of another resident's bed. Staff intervened during both incidents, but not before physical contact occurred. Documentation and interviews confirm that the second resident was aware of their actions and expressed frustration about the first resident's wandering and interference with personal belongings. The first resident, due to severe cognitive impairment, was unable to understand or respond appropriately to the situation. Staff statements indicate that the second resident deliberately struck the first resident and had previously threatened further physical harm. These events demonstrate a failure by the facility to prevent physical abuse between residents, despite awareness of the first resident's cognitive limitations and the second resident's escalating behavior.
Failure to Thoroughly Investigate and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of resident-to-resident physical abuse involving two residents. In the first incident, one resident requested a CNA to remove their roommate due to inappropriate behavior, which escalated into a physical altercation where the resident shoved the roommate. The investigation file did not include documentation of who reported the allegation to the administrator, whether other residents were interviewed, if additional witnesses were present, or any specific and immediate interventions implemented to protect residents from further abuse. The administrator confirmed that the investigation file was complete and contained the entire incident investigation. In the second incident, a CNA overheard residents yelling and intervened in a room where one resident was standing over another, yelling. As the CNA intervened and escorted one resident out, that resident struck the other in the head. The investigation included a statement from an LPN who received the report but did not document who reported the allegation to the administrator or any specific and immediate interventions or long-term measures to prevent further abuse. The administrator again confirmed the investigation file was complete. Both incidents lacked thorough documentation and failed to meet the facility's abuse prevention and reporting policy requirements.
Failure to Document Details of Resident-to-Resident Abuse Allegations and Investigations
Penalty
Summary
The facility failed to fully document the details of resident-to-resident physical abuse allegations and subsequent investigations in the medical records of the residents involved. In two separate incidents, altercations occurred between two residents, with one resident physically assaulting another. The facility's abuse investigation files contained some details about the events, such as the sequence of actions and statements made by those involved, but lacked documentation regarding who reported the allegations to the administrator, whether other residents were interviewed, the presence of additional witnesses, and the specific immediate or long-term interventions implemented to protect residents from further abuse. In both incidents, the progress notes for the residents involved only briefly mentioned that a staff member reported an alleged physical altercation and that the residents were separated, with notifications made to the physician, POA, Ombudsman, and police. No further details about the incidents, the residents' conditions, or the investigative process were documented in the electronic medical records. The administrator confirmed that these brief progress notes were the only entries related to the altercations in the residents' records.
Failure to Secure Resident in Van Results in Injury
Penalty
Summary
A deficiency occurred when a resident was transported in the facility van without proper use of vehicle safety restraints, as required by the facility's Motor Vehicle Safety Program. The program specifies that seat belts and shoulder harnesses must be used whenever the vehicle is in operation, and the vehicle should not move until all passengers are properly restrained. On the day of the incident, the resident, who uses a manual wheelchair and requires supervision for transfers, was loaded into the van by a Certified Nurse's Assistant (CNA) and accompanied by a Licensed Practical Nurse (LPN). Neither staff member secured the resident's wheelchair or provided a seatbelt before transport. During the drive, after stopping at a red light, the CNA accelerated the van, causing the resident's wheelchair to flip backwards. The resident fell, striking his head and experiencing immediate pain in the neck, head, and chest. The LPN and CNA assisted the resident back into the wheelchair and completed the transport back to the facility. The resident, who has diagnoses of dementia, major depression, and obesity, reported ongoing pain following the incident, which was not present prior to the fall. Subsequent medical evaluation revealed a closed head injury and a non-displaced acute fracture of the left sixth rib. The resident required increased pain management, including the addition of new medications. Both the CNA and LPN involved in the transport stated they had never received training on how to properly secure residents in wheelchairs in the facility van. The Director of Nursing confirmed that the failure to secure the resident led to the accident and resulting injuries.
Failure to Maintain Clean Dining Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the dining room for residents on the 300 hall. Observations revealed a dirty adult brief in the garbage can and staff items such as a drinking cup and backpack on the dining room table. Interviews with Certified Nursing Assistants (CNAs) indicated that residents typically eat in the small dining room, but due to insufficient housekeeping staff, the area has not been cleaned regularly, forcing residents to eat in their rooms. The Maintenance/Housekeeping Director acknowledged the staffing shortage and the inadequate cleaning of the facility. The Resident Council Minutes also documented a complaint about rooms not being mopped or swept daily, further highlighting the issue of cleanliness in the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents with severe cognitive impairments. Resident R3, diagnosed with Dementia, Major Depressive Disorder, and Alcohol Abuse, and Resident R4, diagnosed with Wernicke's Encephalopathy, Major Depressive Disorder, and Anxiety Disorder, were involved in a physical altercation. Both residents were unable to participate in mental status interviews due to their severe cognitive impairments. On the day of the incident, R4 attempted to grab R3's hat, leading R3 to punch R4 in the head. The incident was witnessed by a Certified Nursing Assistant (CNA) who was working at the time. The facility's administrator was informed and subsequently reported the incident to the Illinois Department of Public Health, as well as notifying the residents' Power of Attorneys, Medical Doctor, Police, and Ombudsman. The facility's Abuse Prevention Policy emphasizes the residents' right to be free from abuse and outlines the facility's commitment to preventing such occurrences. However, the incident indicates a failure in maintaining a resident-sensitive and secure environment as per the policy.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the State Agency for two residents involved in a physical altercation. On February 10, 2025, a Certified Nursing Assistant (CNA) witnessed an incident where one resident attempted to grab another resident's hat, leading to a physical confrontation where the resident in the wheelchair punched the other resident. The CNA reported the incident to the previous administrator, but the administrator did not report the incident to the Illinois Department of Public Health as required by the facility's Abuse Prevention Program policy. The facility's policy mandates that any allegation of abuse or incident resulting in serious bodily injury must be reported to the state agency immediately, but no later than two hours after the allegation. However, the incident was not reported until the new administrator was informed on February 21, 2025, and conducted an investigation. The failure to report the incident promptly constitutes a deficiency in the facility's compliance with state regulations regarding the reporting of abuse allegations.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, homelike, and comfortable environment in several areas, including shower rooms, resident rooms, and a dining room. In one resident's room, there was missing paint and a hole in the wall, which the resident had previously reported to an Ombudsman. The Maintenance Director acknowledged the issues and mentioned that the facility was waiting for corporate direction to address the problems. Additionally, the shower rooms on the 100 and 300 Halls had issues such as continuous water flow, blackened substances, and cracks in the tile grout, which allowed water to penetrate behind the wall. Residents expressed concerns about these conditions, and the Maintenance Director was aware of the issues but had not fully addressed them. The small dining room was notably cold, with food debris on the tables and floor. Residents who usually ate in this room had stopped doing so due to the cold temperature, which was confirmed by temperature measurements taken by the survey team. The Maintenance Director was aware of the draft issue and had attempted to address it with temporary measures, but the problem persisted. Staff and residents reported the cold conditions, and the Maintenance Director found a material obstructing the heating unit, but the temperature did not improve. In another resident's room, a padded floor mat was adhered to the floor by food debris, and the housekeeper had not been trained to clean underneath mats. The Maintenance Director became aware of the issue and had to replace damaged floor tiles after removing the mat. These deficiencies affected multiple residents and were observed by the survey team during their visit.
Failure to Protect Resident from Mental and Emotional Abuse
Penalty
Summary
The facility failed to protect a resident from mental and emotional abuse, as evidenced by an incident involving a cognitively impaired resident who experienced a fall. The resident, who had inattention, disorganized thinking, and memory problems, fell while attempting to reach a grab bar after exiting the shower room. A Certified Nursing Assistant (CNA) was observed laughing hysterically and did not attempt to stop the resident from falling or assist them afterward. This behavior was witnessed by a Licensed Practical Nurse (LPN) and captured on camera footage, which showed the CNA standing in the hallway laughing as the resident stumbled and fell. The Director of Nursing (DON) reviewed the incident and determined that the actions of the CNA constituted abuse. The incident was not reported immediately, and the facility's investigation revealed that the CNA, along with another CNA, failed to provide appropriate care and did not report the fall. The family member of the resident indicated that prior to the resident's cognitive decline, such behavior would have caused the resident to feel hurt and humiliated. The facility's policy on abuse prevention and reporting was not adhered to, as the incident was not reported to the Department of Public Health as required.
Failure to Report Alleged Mental Abuse
Penalty
Summary
The facility failed to report an allegation of mental abuse involving a resident who experienced a fall. The facility's policy requires that any allegations of abuse, including mental abuse, be reported to the Department of Public Health. The incident involved a resident who fell after attempting to grab a Certified Nursing Assistant (CNA) while exiting a shower room. The Director of Nursing reviewed witness statements and felt the incident warranted further investigation, reporting concerns to the Administrator. However, the Administrator determined there was no evidence of abuse and did not report the incident to the authorities.
Failure to Wait for Nurse Assessment After Resident Fall
Penalty
Summary
The facility staff failed to adhere to the Fall Prevention Program policy by not waiting for a licensed nurse to assess a resident after a witnessed fall. The incident involved a resident who fell while coming out of the shower room into the hallway. A Licensed Practical Nurse (LPN) instructed two Certified Nursing Assistants (CNAs) to stay with the resident until she could assess him after attending to another resident. However, the CNAs, along with another resident, attempted to stand the fallen resident up despite his complaints of pain. They eventually placed him in a wheelchair and took him to his room. When the LPN later assessed the resident, he was complaining of pain and was unable to move. The Director of Nursing acknowledged that the fall investigation was inappropriate and that the CNAs should not have moved the resident without a nurse's assessment, as it could have worsened his condition.
Resident Wandering Leads to Privacy Breach
Penalty
Summary
The facility failed to maintain the privacy of residents in their rooms due to the wandering behaviors of a resident (R1) who is severely cognitively impaired. R1's Minimum Data Set (MDS) assessment indicates that R1 exhibits behaviors that intrude on the privacy and activities of others, and R1 wanders daily. Despite staff efforts to redirect R1, the resident continues to enter other residents' rooms, causing distress and potential safety issues. Multiple staff members and residents reported R1's intrusive behavior, with incidents of R1 entering rooms uninvited and, in one case, physically interacting with another resident (R3) in a manner that required staff intervention. The facility's records, including nursing and behavior notes, document several instances where R1's wandering led to altercations and distress among other residents. Staff members have expressed difficulty in managing R1's behavior due to insufficient staffing levels to provide constant supervision. The facility's inability to effectively manage R1's wandering behavior and ensure the privacy and safety of other residents constitutes a deficiency in maintaining resident rights to privacy and safety.
Deficiency in Resident Activity Program Implementation
Penalty
Summary
The facility failed to implement an ongoing program of activities for residents, as required by their Activities Program policy. The policy mandates that activities should be designed to appeal to residents' interests and enhance their well-being, with a minimum of four to seven organized activities scheduled daily. However, the facility's activity calendars showed no scheduled activities after 3:00 PM daily and none on Sundays. Additionally, the medical records of 19 out of 20 residents reviewed did not include documentation of activity attendance or participation levels. Observations revealed that residents were left without activities, with some wandering aimlessly or confined to their rooms. Interviews with staff, including CNAs and an LPN, confirmed that no activities were offered on the memory care unit, and the activity department did not visit the unit. Staff reported being understaffed and unable to conduct activities themselves. The former Activity Director admitted to not tracking residents' activity attendance or interests, and activities on the memory care unit were limited to two per day, with none offered during the second shift. This lack of activities and documentation indicates a significant deficiency in meeting the residents' needs for engagement and stimulation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident verbal and physical abuse involving three residents. Resident 1, who is severely cognitively impaired, exhibited aggressive behaviors, including wandering into other residents' rooms and handling their belongings. On one occasion, Resident 1 threw a TV remote at Resident 2, leading to a physical altercation where Resident 2 punched Resident 1. Despite staff attempts to redirect Resident 1, these efforts were unsuccessful, resulting in continued aggressive interactions. Additionally, Resident 1 was involved in another incident with Resident 3, where Resident 1 was found physically aggressive, grabbing and hitting Resident 3's legs. Staff intervention was required to separate the residents. The facility's failure to effectively manage Resident 1's behaviors and prevent these incidents highlights a deficiency in maintaining a safe environment for all residents, as outlined in their Abuse Prevention and Reporting policy.
Failure to Update Care Plan and Supervise Aggressive Resident
Penalty
Summary
The facility failed to adhere to its Abuse Prevention and Reporting policy by not updating the care plan and implementing necessary supervision for residents with aggressive behaviors. Specifically, the care plan for a resident with a history of aggression was not updated to include interventions for increased supervision, such as one-on-one monitoring or 15-minute checks, after incidents of resident-to-resident altercations. This oversight occurred despite the resident's documented history of severe cognitive impairment and aggressive behaviors, which posed a risk to themselves and others. The report details multiple incidents involving the aggressive resident, who was admitted with diagnoses including Wernicke's Encephalopathy, Major Depressive Disorder, and a history of aggression. The resident was involved in altercations with two other residents, one of which involved physical aggression where the resident threw a TV remote at a roommate, leading to a physical confrontation. Another incident involved the resident being physically aggressive towards another resident, requiring staff intervention to separate them. Interviews with staff revealed that the resident's care plan was not updated to reflect the need for increased supervision, and staff were not always able to monitor the resident closely due to insufficient staffing. The lack of updated care plans and adequate supervision contributed to the failure to prevent further resident-to-resident altercations, highlighting a deficiency in the facility's implementation of its abuse prevention policy.
Failure to Notify Resident of Discharge
Penalty
Summary
The facility failed to notify a resident of their discharge, violating the facility's own Notice of Transfer and Discharge Policy. This policy requires that residents be notified in writing at least 30 days before discharge, along with the reasons for discharge. In this case, a resident was discharged without receiving the required written notice. The resident was admitted to the facility on March 8, 2024, and was discharged on November 27, 2024, without prior notification. The discharge was based on a physician's order stating that the resident no longer needed nursing home care or services. On the day of discharge, the facility's social services and administrator contacted the corporate team for guidance, which led to the decision to discharge the resident. The resident was taken to a homeless shelter with their medications and belongings. The resident's family member was contacted on the day of discharge but was unable to accommodate the resident. The resident expressed confusion and distress over the sudden discharge, indicating they were not prepared for the transition. The facility did not provide a written notice of discharge, and the resident was not adequately prepared for a safe and appropriate discharge, as required by the facility's policies.
Insufficient RN Coverage on Two Days
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on two specific days, which has the potential to affect all 84 residents in the facility. According to the facility's Nursing Daily Schedule, there was no RN coverage for a 24-hour period on two Wednesdays, specifically on 8/21/24 and 8/28/24. This was confirmed by the Director of Nursing, who acknowledged that the hours listed on the schedule were correct and that the facility indeed lacked RN coverage on those days. The Resident Midnight Census documented that 84 residents were residing in the facility at the time of the deficiency.
Verbal Abuse by Dietary Aide
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member, affecting one of the four residents reviewed for abuse. The incident occurred when a dietary aide, identified as V3, verbally abused a resident, R2, during dinner. R2, who has diagnoses including Type 1 Diabetes Mellitus, Generalized Anxiety Disorder, and Morbid Obesity, asked V3 for an alternative meal option. V3 responded dismissively and later, in the presence of other residents and a family member, directed a derogatory and abusive comment towards R2. This incident was witnessed by multiple individuals, including another resident and a family member, who confirmed the abusive language used by V3. The facility's Abuse Prevention and Reporting Policy, dated August 2023, clearly states the residents' right to be free from abuse, including verbal abuse. Despite this policy, the incident was reported to the Dietary Manager, V4, by the receptionist, V6, immediately after it occurred. V4 was not present at the time but was informed of the incident and took steps to address it by contacting V3, who subsequently resigned. The incident was also reported to the facility's administrator at the time, V15, due to its verbally abusive nature.
Failure to Use Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to transfer a resident using a mechanical lift with two-person assistance, as required by the resident's care plan. The resident, who has diagnoses including muscle weakness, gait abnormalities, and morbid obesity, attempted a self-transfer and was lowered to the ground by a CNA when their knees gave out. The CNA, who was not familiar with the resident, believed the resident's claim that they did not need a mechanical lift, despite the care plan specifying its necessity for transfers. The CNA was assisting on a different hall than usual and did not verify the resident's transfer requirements before attempting the transfer. The facility's policies require CNAs to provide care in accordance with established procedures, which include using assistive devices as necessary. The incident highlights a failure to adhere to the facility's fall prevention program, which aims to ensure resident safety through appropriate interventions and supervision.
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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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