Arcadia Care Havana
Inspection history, citations, penalties and survey trends for this long-term care facility in Havana, Illinois.
- Location
- 609 North Harpham Street, Havana, Illinois 62644
- CMS Provider Number
- 145774
- Inspections on file
- 44
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 18 (3 serious)
Citation history
Health deficiencies cited at Arcadia Care Havana during CMS and state inspections, most recent first.
The facility failed to implement its infection prevention and control policies for scabies, including surveillance and contact precautions. Multiple residents had physician orders for antiparasitic topical medication for scabies, yet the infection surveillance report did not document parasitic or skin infections for these individuals. One resident with a widespread, itchy rash and numerous sores was diagnosed with scabies and treated, but there were no contact precaution orders, no isolation signage, and no PPE at the room entrance. A CNA and an LPN reported using only gloves or no PPE when entering rooms of residents treated for scabies and were unsure who was affected. The DON acknowledged that no skin scrapings were performed, surveillance records were not maintained for residents treated as scabies cases, and no isolation precautions were posted on doors, while the administrator stated they were unaware residents were being treated for scabies until informed by surveyors.
The facility failed to provide and document scheduled showers and hygiene assistance for several dependent residents, despite a policy and shower schedule requiring at least twice-weekly bathing. A resident with hemiplegia and dementia had multiple missed shower days and incomplete, unsigned shower sheets. Another resident with DM, stage 4 CKD, mobility issues, and an excoriation disorder had several undocumented shower days, was observed with blood-stained clothing, and reported not consistently receiving help with showers. A third resident with hemiplegia and chronic back pain lacked shower documentation on scheduled days, and the DON could not produce shower sheets. A fourth resident with dementia, morbid obesity, incontinence, and a history of UTIs had no bathing documentation over an extended period, was associated with a persistent urine odor in the room and hallway, and reported not receiving regular showers or in-bed washing when showers were missed; the DON confirmed the absence of required documentation for these residents.
The facility failed to reasonably accommodate two cognitively intact residents’ requests to electronically monitor their own rooms. One resident with hemiplegia, anxiety, and restless leg syndrome signed the required consent form but was subjected to additional corporate-imposed conditions, including paying a professional to install the camera, obtaining a private internet service, being prohibited from using the facility’s free Wi‑Fi (which is otherwise available to residents), and hiring a security company to monitor the feed. Another resident with MS, chronic pain, and PTSD, who is technologically savvy, was told he could not use a Bluetooth-based setup to view his room and was similarly informed he must use his own internet provider and a security company, even though his proposed system did not use the internet. These actions prevented both residents from exercising their right to use electronic monitoring devices in their rooms.
Staff engaged in a loud, profane, and physically violent altercation in a resident care area, during which a CNA yelled obscenities at an RN and then grabbed another CNA by the throat, slammed her into a doorway, and threw her to the floor while residents were present and within hearing distance. Several residents later reported being scared, upset, or angry after witnessing or learning of the incident, and nursing notes documented crying, fear, and a sad, worried affect in multiple residents. In a separate situation, a resident reported loaning a CNA money after she complained about her finances, and another resident reported being asked for money by the same CNA, raising concerns about potential exploitation despite the facility’s abuse and exploitation policy.
The facility failed to substantiate clear allegations of abuse and exploitation despite its own policy definitions and resident accounts. In one event, a CNA loudly cursed, threatened others, and physically pushed another CNA in front of multiple alert and oriented residents, leading to fear, crying, and ongoing distress documented in nursing notes. The Administrator acknowledged residents witnessed the incident but deemed it unsubstantiated because no resident was physically involved or directly threatened. In a separate event, a resident who manages his own finances reported loaning a CNA $50 that was not repaid, while another resident reported the same CNA had asked him for money; the CNA refused to participate in the investigation. The Administrator, despite describing both residents as reliable historians, concluded the allegation was unsubstantiated due to lack of proof of the loan and asserted it was not misappropriation because the money was offered voluntarily.
The facility did not ensure that all CNAs, including those from a temporary agency who made up about half of the CNA staff, received the required 12 hours of in-service training in areas such as dementia care and abuse prevention. The Administrator acknowledged having no documentation of any trainings completed by agency staff and confirmed that the temporary agency was treated as not responsible for the performance or training of its personnel. Several residents reported that agency staff did not know what was going on, did not seem to care, did not know the residents, and did only the bare minimum, reflecting concerns about the skills and preparedness of these CNAs.
The facility failed to maintain safe, comfortable temperatures in the dining room after the main heating unit malfunctioned, despite policies requiring operable heat and appropriate cold-weather measures. Staff, including RNs, CNAs, and dietary personnel, reported that the dining room had been extremely cold for weeks, with residents’ teeth chattering and residents needing coats, gloves, hats, and blankets while still complaining of being cold. A small wall-mounted heater was installed but was widely described as ineffective, and a long-standing unsealed, rusted door allowed a strong draft into the room. Multiple residents reported the dining room was "freezing," that they had to wear multiple layers and blankets, that it was hard to eat or they left meals early due to the cold, and one resident reported a sore throat. Surveyors observed an immediate temperature drop entering the dining room, residents bundled in outerwear during meals, and documented temperatures as low as 57°F via the maintenance director’s monitoring application, with no specific or documented temperature checks performed after the heating failure and prior grievances about heat issues lacking documented resolution.
A resident receiving short-term rehab, with cognitive deficits and a right femur fracture, was verbally abused by an agency CNA who swore at the resident and disregarded reported hip pain during a transfer, in the presence of the resident’s spouse. The CNA was described by staff and the spouse as rude, impatient, and berating toward the resident. The facility’s abuse prevention policy prohibits such conduct, and the CNA job description requires safeguarding resident welfare and interacting tactfully, yet the CNA’s file lacked documentation of abuse training.
The facility failed to maintain a safe transportation van, resulting in a resident and the resident’s family member being transported over a long distance in the dark and rain with non-functioning headlights and broken windshield wipers. The transportation driver reported that the van’s headlights had been dim or non-functional since he started work, that he had previously driven at night with the Maintenance Director in the same unsafe condition, and that the van had high mileage and persistent dashboard warning lights. During the trip with the resident, the driver had to travel slowly on the interstate due to poor visibility, and a CNA later observed that the resident and family member returned very upset and tearful. The Maintenance Director confirmed the headlights were burnt out, acknowledged difficulty replacing them, and was unable to produce maintenance records, while grievance logs noted headlight issues without documented resolution or follow-up.
The facility failed to maintain sufficient housekeeping, laundry, and maintenance staffing, resulting in chronically dirty resident rooms, overflowing trash, stained and feces‑smelling linens, and unclean linen storage areas. Staff reported that only one housekeeper or one laundry aide often covered the entire building, with no laundry staff on later shifts, leading to routine shortages of clean washcloths, bed pads, towels, and mechanical lift slings. A resident stated their sheets always smelled like feces, that they bought their own washcloths, and that their room had not been cleaned for weeks, while others described toilets overflowing into rooms with feces on the floor for extended periods. Surveyors observed damaged walls, missing or makeshift window coverings, and a flickering over‑bed light that had not been repaired. A mechanical lift was found extremely dirty and missing its emergency button, and staff reported residents being stuck in the air when batteries died and that one of two lifts had been broken for about a month, contributing to missed showers and transfers.
Surveyors found that the facility did not maintain adequate direct care staffing to meet residents’ ADL, hygiene, and hydration needs, and did not have a complete facility assessment specifying required direct care staffing levels. On multiple reviewed days, CNA staffing on day and night shifts was below the minimum numbers identified by the DON. Several residents who were dependent on staff for showers and personal hygiene did not receive scheduled showers, and some were observed with long, untrimmed fingernails. Despite a policy requiring fresh ice water at least three times daily, residents across all hallways were observed without bedside water and reported not receiving fresh ice water regularly, sometimes having to save water from meals. Numerous CNAs, LPNs, and RNs reported chronic understaffing, inability to complete showers and water passes, and prolonged call light response times, including nights with only one CNA or two CNAs for the entire building.
A resident's belongings or money were wrongfully used due to the facility's failure to provide adequate protection, resulting in unauthorized or inappropriate use.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not provide quarterly financial statements to residents or their representatives, as confirmed by interviews with a resident, a resident's Power of Attorney, and both current and former Business Office Managers. The administrator acknowledged the lapse, which affected all residents in the facility.
Following a change in facility ownership, all residents and their representatives did not receive or sign updated admission agreements within the required timeframe. The Business Office Manager did not ensure timely distribution and completion of these contracts, as confirmed by both record review and interviews.
A resident's unused trust fund balance was not refunded to their representative within the required 30-day period following the resident's death. Despite multiple requests from the resident's Power of Attorney, the facility had not returned the funds, and the Regional Director of Operations confirmed the delay and lack of a specific facility policy for timely distribution.
Multiple residents were left without access to disposable or cloth hand towels in their restrooms, and some bathrooms were found to be unclean, with issues such as black debris in toilet bowls and urine on floors. Residents reported going several days without towels, leading them to dry their hands on their clothes or not at all. Housekeeping staff and supervisors confirmed a facility-wide shortage of paper towels, and supply records indicated only one recent order. The administrator was unaware of the shortage until notified by staff.
A resident with multiple chronic conditions did not receive physician-ordered bilateral lower extremity compression stockings for edema, as staff failed to apply them as directed. The same resident also did not receive required nail care, resulting in long fingernails with visible debris, despite care plan instructions for hygiene assistance on bath days.
The facility failed to have an RN on duty for eight hours a day, seven days a week, affecting all 46 residents. The staffing data showed no RN coverage on multiple dates, including weekends and a holiday. The facility employs two RNs, including the DON, and relies on LPNs for weekend coverage. The DON confirmed staffing vacancies and the lack of agency RNs.
The facility failed to employ a Certified Dietary Manager and certified dietary staff, as observed during a survey. The Dietary Manager lacked a valid CDM certificate and had an expired food handler certificate, while other dietary staff also lacked necessary certifications. This deficiency affects the quality and safety of nutritional services for all 46 residents.
The facility failed to provide adequate staff during meal service, leading to delays in serving meals to residents in the dining room. Staff prioritized delivering room trays, leaving the dining room unattended. Residents expressed concerns about the delays and insufficient staffing during a council meeting.
The facility failed to label and date a bag of frozen zucchini and multiple loaves of bread as required by its food storage policy. During a kitchen tour, it was found that these items lacked a delivery, use-by, or expiration date. The Dietary Manager acknowledged the oversight, which has the potential to affect all 46 residents in the facility.
A facility failed to complete a PASARR Level I screening and Level II referral for a resident with unspecified psychosis and other conditions. The facility's policy mandates these screenings before admission, but documentation was missing. The MDS/Care Plan Coordinator noted the absence of records, possibly due to a change in facility ownership, and planned to verify the screenings with the relevant agency.
A facility failed to provide scheduled showers for a resident who requires assistance due to hemiplegia following a stroke. The resident only received bed baths, with no showers documented, despite expressing a desire for a proper shower. The facility's records showed showers were scheduled at midnight, leading to refusals and the resident not receiving any showers, contrary to the facility's policy.
The facility failed to maintain proper orders and labeling for respiratory equipment for three residents. One resident had outdated oxygen tubing and undated nebulizer tubing, another used a BiPAP machine without documented orders, and a third had undated nebulizer and oxygen tubing. These issues indicate non-compliance with the facility's policies on respiratory care.
A resident admitted with Polymyalgia Rheumatica and CHF did not receive timely specialized rehabilitative services as prescribed. Despite orders for therapy evaluations and treatments, the resident's physical therapy did not start until ten days post-admission, leading to frustration and disappointment. The delay in initiating therapy services resulted in a deficiency identified by surveyors.
The facility failed to make the state survey binder accessible to residents and inaccurately posted its location. During a resident council meeting, several residents were unaware of the binder's location. It was found outside the Administrator's office, obscured by other binders, with a note incorrectly stating it was at the nurses' desk. This affects all 46 residents.
The facility did not post daily staffing information, including total hours worked by nursing staff, as required. Observations on two occasions revealed outdated staffing information dated 3/15/25, despite being checked on later dates. The DON confirmed the oversight, noting the night nurse's responsibility for updating the information. This affects all 46 residents in the facility.
A resident with a history of traumatic brain injury and cognitive impairment experienced multiple falls due to inadequate fall interventions at the facility. Despite the facility's policy requiring individualized fall prevention strategies, the interventions remained ineffective, leading to injuries and hospital visits. Staff acknowledged the inadequacy of the interventions and the resident's impulsive behavior.
The facility failed to provide ongoing resident-centered activities, affecting all 40 residents, due to the sudden departure of the Activity Director. Observations and resident interviews confirmed the absence of scheduled activities, with residents expressing a desire to participate in activities like Bingo and music. The Social Service Director, newly assigned to the Activity Director role, confirmed the lack of activities and the vacancy left by the former Activity Director.
A Business Office Manager at an LTC facility misappropriated $11,815 from residents' pooled trust accounts over eight months by forging signatures and depositing funds into a personal account. The facility failed to monitor the trust account monthly, and several residents' signatures were forged on withdrawal logs. The lack of oversight and adherence to policies led to an Immediate Jeopardy situation.
The facility failed to report allegations of misappropriation of resident funds, affecting all residents reviewed. A Business Office Manager was suspected of making fraudulent charges and unauthorized withdrawals from residents' accounts, but the facility did not notify the police or state agency promptly. An audit revealed a significant deficit in the residents' pooled trust fund, and many residents were unaware of the misappropriation. This led to an Immediate Jeopardy situation.
The facility failed to investigate allegations of misappropriation of funds by the Business Office Manager, who was not removed from contact with residents during the investigation. This affected all residents reviewed, as the BOM allegedly made unauthorized withdrawals from residents' accounts. Despite reports from residents and the bank, the facility did not act promptly, resulting in a significant deficit in the residents' trust fund.
A resident developed a facility-acquired unstageable pressure ulcer on the right heel and a stage three ulcer on the right buttock due to the facility's failure to implement adequate pressure ulcer prevention and care interventions. Despite being at high risk, the resident did not receive necessary interventions such as daily skin checks, heel protectors, or proper repositioning, leading to the development and worsening of pressure ulcers.
The facility failed to hold Resident Council Meetings for five months, affecting all 36 residents. The absence of an Activity Director led to the cessation of meetings, leaving residents without a platform to voice concerns. Residents reported issues such as long wait times for call lights, cold meals, and inadequate staffing. The Administrator in Training was unaware of these complaints, and documentation showed repeated grievances without resolution.
The facility failed to maintain an adequate supply of washcloths and towels, forcing staff to use inappropriate substitutes for resident hygiene. Additionally, the main shower room's curtain was moldy, a condition known to staff for an extended period. Residents expressed dissatisfaction with the lack of basic hygiene supplies.
The facility failed to inform residents about the grievance process and did not address complaints raised in resident council meetings. Residents were unaware of how to submit grievances or who the grievance official was. Complaints about church services and outings were repeatedly voiced without resolution, affecting all 36 residents.
The facility failed to provide a consistent program of activities for residents, with no activities observed on several days and no activity staff employed for over two months. Residents expressed dissatisfaction, citing boredom and lack of engagement, while staff confirmed the absence of scheduled activities. The deficiency was compounded by the lack of updated activity assessments and care plans for residents.
The facility failed to employ a full-time Activity Director, resulting in a lack of scheduled activities, activity calendars, and resident council meetings for all 36 residents. Observations and interviews confirmed the absence of activities, with only a brief bingo session offered. The Social Service Director and Administrator-In-Training acknowledged the deficiency, citing the vacancy in the Activity Director position since March 2024.
The facility failed to provide sufficient nursing staff, resulting in delayed medication administration and incomplete treatments. An LPN reported being unable to complete all tasks due to being the only nurse on duty during certain shifts. Residents expressed concerns about the lack of morning staff, leading to late medications.
The facility failed to provide RN services for eight hours daily and lacked a DON to oversee the Nursing Department, affecting all 36 residents. The Nurse Master Schedule showed multiple days without RN coverage, and interviews confirmed the absence of a DON since February. The Facility Assessment Tool highlighted the need for a DON to support resident care.
The facility has not employed a Certified Dietary Manager since August 2023, leading to dietary aides managing kitchen operations without sufficient staff. This deficiency affects all 36 residents, as the aides struggle to handle additional responsibilities. The Administrator in Training confirmed the difficulty in filling the position.
The facility failed to maintain proper food storage and sanitation practices, leaving shredded ham unrefrigerated overnight and failing to label or date food items. The kitchen environment was not clean, with grime on equipment, dust on vents, and missing floor tiles. Improper storage of salt and paper goods was also noted, potentially affecting all 36 residents.
The facility failed to address resident complaints, maintain adequate staffing, and implement infection control practices. Residents reported a lack of church services and activities, while the facility lacked a full-time DON, Activity Director, and Dietary Manager. Infection control measures were inadequate, with staff not using protective gear for residents needing enhanced precautions. The facility also faced staffing shortages, insufficient linens, and broken dietary equipment, impacting resident care and services.
The facility failed to employ a licensed administrator to manage operations, with V1, the designated administrator, visiting infrequently. V2, an Administrator-In-Training without a license, has been managing the facility since November 2023. Staff confirmed V2 is the only administrator present, indicating a lack of proper oversight.
The facility failed to implement QAPI plans, leading to unresolved resident complaints, insufficient nursing staff, and inadequate training on QAPI, dementia care, and infection control. The absence of key department heads contributed to the lack of activities and unresolved grievances. Observations revealed improper infection control practices, equipment disrepair, and linen shortages. Interviews highlighted residents' dissatisfaction with services and staffing issues, while the administrator confirmed the lack of corrective plans.
The facility failed to have a DON or the required number of members at quarterly Quality Assurance Meetings, potentially affecting all 36 residents. The review of sign-in sheets over the past year showed the absence of a DON, with meetings having fewer members than required. The Administrator in Training confirmed this absence, and the facility's daily census documented 36 residents.
The facility failed to repair essential kitchen equipment, including ovens, a steam table, and a freezer door, affecting meal preparation for 36 residents. Staff reported these issues to the Administrator months ago, but no repairs were made, and there was no formal work order process. The Administrator in Training was unaware of the equipment failures, indicating a lack of communication and oversight.
The facility did not provide annual in-service training on Abuse Prevention to its direct care staff, as required by its policy. A review of training logs revealed that several CNAs did not receive this training over the past year. The Administrator-In-Training confirmed the lapse, which could impact all 36 residents in the facility.
The facility did not provide required annual QAPI in-service training to its direct care staff, as evidenced by missing documentation in the training logs for several CNAs. The Administrator-In-Training confirmed that the staff had never received this training, which is required by the facility's QAPI Plan policy. This deficiency could potentially affect all 36 residents in the facility.
Failure to Implement Scabies Surveillance and Contact Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the management of scabies. The facility’s policies required surveillance, documentation of suspected and confirmed infections, and implementation of contact precautions for transmissible conditions such as scabies and rash of unknown origin. Despite this, the Infection Surveillance Report from January 1, 2026, through March 24, 2026, documented no parasitic or skin infections, even though multiple residents had physician orders for antiparasitic topical medication (Permethrin) for Sarcoptes scabiei. The report only partially noted three residents as having been treated with antiparasitic medication without marking the parasite option, and it omitted several other residents who were treated for scabies during February and March. For one resident with extensive symptoms, documentation showed an itchy rash over most of the body, a request for dermatology referral, and a weekly skin observation noting a new rash over the body with physician notification. The medical director’s nurse stated that the medical director diagnosed this resident with scabies and ordered antiparasitic cream. The treatment administration record showed the antiparasitic medication was applied, and the resident was observed with numerous red, itchy sores on the chest, back, and arms, actively scratching. However, there were no physician orders for contact precautions in the electronic health record, and the resident’s room did not have contact precautions signage or PPE available at the door on the days of surveyor observation. Staff interviews further demonstrated a lack of implementation of required isolation precautions and surveillance. A CNA reported applying scabies cream to the resident while only wearing gloves and stated they usually did not wear PPE when entering rooms of residents treated for scabies and were unsure who had scabies. An LPN stated that no one had informed staff that the resident actually had scabies, acknowledged not using PPE when entering the room, and confirmed that the resident’s roommate had not been moved and that no contact isolation sign was posted. The DON stated that no skin scrapings had been done on any residents with scabies, that surveillance records were not being kept despite residents being treated as scabies cases, and confirmed that no isolation precautions were implemented on residents’ doors. The administrator stated they were unaware that any residents were being treated for scabies until informed by surveyors.
Failure to Provide and Document Scheduled Showers and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers or alternative bathing and to document these services for multiple dependent residents, contrary to its Bathing - Shower and Tub Bath Policy and posted shower schedule. The policy requires that residents be offered a shower, tub bath, or bed/sponge bath according to preference at least twice weekly and as needed, and the shower schedule lists specific days for each resident. For one resident with hemiplegia, chronic pain, dementia, and dependence on staff for bathing and grooming, the Section GG ADL report showed multiple missed scheduled shower days, and the available shower sheets were incomplete and lacked required nurse or DON signatures, including one sheet noting three refusals and pain without complete documentation. Another resident with Type II DM, stage 4 CKD, asthma, gait and mobility abnormalities, weakness, and an excoriation (skin-picking) disorder had a care plan indicating a need for supervision and assistance with bathing and showering. The GG ADL Lookback report did not show showers on several scheduled days, and only one shower sheet was found for the review period, which was incomplete and unsigned. During observation, this resident was found in bed with a shirt and protective sleeves stained with blood from scabs and reported having received only one shower more than a week prior, stating they did not always get help with showers on scheduled days and felt dirty when showers were missed. A third resident with hemiplegia, chronic back pain, disability-related activity limitations, and muscle disorder, requiring one to two staff for bathing and grooming, had no documented showers on two scheduled dates, and the DON confirmed that shower sheets for those dates were unavailable. A fourth resident with anemia, schizoaffective disorder bipolar type, morbid obesity, chronic pulmonary embolism, osteoarthritis, overactive bladder, bipolar disorder, major depressive disorder, heart disease, cervical spondylosis, and a history of UTIs had a care plan indicating dependence on staff for bathing and hygiene due to dementia, morbid obesity, and large skin folds. For this resident, there was no documentation of bathing or showers over a 10-day period, and surveyors repeatedly noted a strong, persistent malodorous urine smell in the resident’s room and hallway. This resident reported urinary incontinence, needing help to be changed and cleaned after episodes, not consistently receiving two showers weekly, and not being washed in bed when scheduled showers were missed. The DON confirmed that all residents are scheduled for twice-weekly showers and acknowledged the lack of documentation for the identified dates for all four residents.
Failure to Reasonably Accommodate Residents’ Requests for Electronic Room Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ requests to electronically monitor their own rooms, despite state guidance that residents have the right to purchase and use an electronic monitoring device after providing notice via the Electronic Monitoring Notification Consent Form. One resident (R1), who is cognitively intact with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, anxiety, and restless leg syndrome, reported that she requested electronic monitoring of her room and signed the required consent. She stated she was repeatedly told the facility was waiting for a response from corporate and that she was given a long list of requirements, which she felt were intentionally burdensome. The Social Services Director (V16) confirmed that R1 had requested electronic monitoring and had signed the consent, and further relayed corporate’s requirements that the resident pay a professional to install the camera, not use facility Wi‑Fi, obtain her own internet service, and contract with a security company to monitor the feed. At the same time, V16 confirmed that residents are allowed to use the facility’s Wi‑Fi at no charge for phones and laptops, and that the Maintenance Director typically hangs residents’ wall decorations and pictures. A second cognitively intact resident (R3), with diagnoses including multiple sclerosis, chronic pain, and post‑traumatic stress disorder, described using Bluetooth on his phone to connect to his TV for gaming and noted that, based on his prior work experience with Google, he was technologically savvy and could potentially view his room through his TV and phone. R3 stated that after he mentioned this capability to a CNA, the Social Services Director informed him he was not allowed to monitor his room without a consent form, which he agreed to sign, but she then told him he would have to use his own internet provider even though his proposed system did not use the internet. R3 expressed that he did not believe the facility should be able to require him to incur costs to monitor his own room. V16 confirmed she told R3 he could not monitor his room via Bluetooth and that any monitoring must be done through the resident’s own internet provider with a security company monitoring it for him. These actions and requirements resulted in the facility not allowing or reasonably accommodating the residents’ requests to electronically monitor their rooms.
Failure to Protect Residents From Abuse, Mental Distress, and Possible Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including mental abuse and exploitation, as required by its Abuse Prevention and Reporting policy. The policy defines abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and mental abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, or agitation. Despite this policy, a certified nurse aide (V5) engaged in a loud, profane, and aggressive altercation with staff in a resident care area, with residents present in the hallway and within hearing distance in their rooms. On the date of the incident, a registered nurse (V8) directed V5 to report to the dining room, which escalated into V5 yelling, cursing, and using profane, degrading language toward V8 in an area where residents were present and could hear. Another CNA (V7) intervened by telling V5 to stop yelling because she was scaring the residents. V7 reported that V5 then grabbed her by the throat, lifted her off the ground, slammed her into a door, and threw her to the floor. V8 similarly reported that V5 grabbed V7 by the throat, slammed her into a doorway, and flung her to the ground. The facility’s Final Abuse Investigation Report acknowledged that V5 raised her voice, used profanity, and pushed V7 with residents present, but concluded the allegation was not substantiated because no residents were physically involved in the altercation. Multiple residents later described fear, distress, and ongoing emotional impact from witnessing or being aware of the altercation. One resident recalled V5 beating up V7 and stated that the yelling and cursing were very scary. Another resident, who described himself as generally able to take care of himself, reported seeing V7 on the ground holding her neck and crying and expressed concern for residents who could not protect themselves. Nursing notes documented a resident with a sad and worried look, another resident crying and verbalizing fear after witnessing the altercation, and a resident stating he was struggling with having been a witness and was very angry about it. The administrator acknowledged that the whole building was in an uproar over the incident. In a separate matter, a resident reported loaning a CNA (V3) $50 after she complained about her money situation, and another resident reported that V3 had asked him for money but he refused; the administrator deemed this allegation unsubstantiated because the resident could not prove he had given the money, despite the facility’s policy defining exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion.
Failure to Substantiate Resident Abuse and Exploitation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to recognize and substantiate clear instances of abuse under its own Abuse Prevention and Reporting policy. The policy defines abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and mental abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation. It also defines exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. Despite these definitions, the Administrator, who serves as the Abuse Coordinator, determined that two separate abuse allegations were not substantiated. In the first incident, the facility’s Final Abuse Investigation dated 1/23/26 documented that a CNA (V5) raised her voice, used profanity, and pushed another CNA (V7) in the presence of residents, with residents witnessing the altercation and staff member screaming, cursing, and threatening anyone who tried to calm her down. Multiple residents (R1–R7) later described being present or affected: one resident recalled the CNA “beating up” the other CNA and described it as very scary; another resident, who described himself as able to care for himself, expressed concern for residents who could not protect themselves; another resident reported the building was tense afterward. Nursing notes documented residents as alert and oriented, with one having a sad and worried look, another having episodes of crying and verbalizing fear related to witnessing the altercation, and another stating he was struggling with having been a witness and was very angry about it. The Administrator acknowledged that five residents were in the hallway and witnessed the attack but concluded the allegation was not substantiated because no residents were physically involved, none were within arm’s reach of the aggressor CNA, and the CNA did not specifically threaten to harm a resident. In the second incident, the facility’s Final Abuse Investigation dated 3/6/26 documented that a resident (R2) reported loaning a CNA (V3) $50, which she did not repay. R2, who manages his own finances and is described by the Administrator as alert, oriented, usually laid back, and not known to fabricate stories, stated he gave the CNA a $50 bill after she complained about her money situation. Another resident (R3), also described as alert, oriented, and not known to fabricate stories, reported that the same CNA had asked him for money, which he refused. The CNA in question refused to participate in interviews and made herself unavailable despite multiple attempts to contact her. Nonetheless, the Administrator determined the allegation was unsubstantiated, stating that R2 could not prove he had given the money or even possessed $50, and further asserted that it should not be considered abuse because the resident had offered the money on his own accord and, therefore, it was not misappropriation of funds.
Failure to Ensure Required In-Service Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including those provided by a temporary staffing agency, received the required 12 hours of in-service training, including dementia care and abuse prevention. Review of the Client Service Agreement between the facility and the temporary agency showed that the facility acknowledged agency CNAs as independent contractors and agreed that the agency was not their employer and was not responsible for their performance or non-performance. The agreement also documented that the agency had no responsibility for, control over, or involvement in the scope, nature, quality, character, timing, or location of the work performed by these CNAs. During the survey, the Administrator stated she did not have any documentation of trainings completed by the agency staff and confirmed she would not be able to provide any such documentation, noting that approximately 50% of the CNA staff were from the temporary agency. Interviews with residents further described concerns related to the care provided by agency CNAs. One resident stated that agency staff were "horrible" and did not seem to know what was going on. Another resident reported that agency staff did not care and had no idea what they were doing. A third resident stated that agency staff did not know anything about the residents and always did the bare minimum. These resident statements, combined with the lack of training documentation and the facility’s reliance on agency CNAs for about half of its CNA staffing, formed the basis of the deficiency related to failure to ensure required in-service training for all CNAs.
Failure to Maintain Safe and Comfortable Temperatures in Dining Room After Heating System Failure
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, comfortable temperature in the dining room during very cold winter weather and after a primary heating unit malfunctioned. The facility’s own Code White-Extreme Weather Policy requires notification of the Maintenance Director and Administrator for heating failures, movement of residents to adequately heated areas if a unit fails or temperatures become uncomfortable, and ensuring the heating system is operable with extra blankets available. Resident rights documents state that residents must be kept safe, comfortable, and in a homelike environment that promotes quality of life. Despite these policies, the main dining room heating unit stopped working correctly, and the Maintenance Director acknowledged there were no maintenance records for the unit and that only random temperature checks were done, with no specific or documented monitoring of dining room temperatures after the unit failed. Staff interviews and observations showed that the dining room remained uncomfortably cold for weeks while residents continued to be served meals there. Multiple CNAs and nursing staff reported that the dining room was “freezing,” that residents’ teeth were chattering, and that residents had to wear coats, gloves, stocking hats, and use extra blankets, which still did not alleviate the cold. Staff stated that management required them to bring residents to the dining room for meals despite the cold and that they would “get into trouble” if they did not. Dietary staff confirmed that all or many residents complained daily about the cold, that a small wall-mounted space heater had recently been installed but “did not help at all,” and that they were keeping the kitchen door open and placing blankets in window sills to try to reduce drafts. A door near the serving window, which had not been used for years, was observed and acknowledged by the Maintenance Director to be rusted, not sealed correctly, and allowing a noticeable draft into the dining room. Residents consistently reported that the dining room was extremely cold, that they had to wear multiple layers and blankets, and that it was uncomfortable to eat under these conditions. Several residents stated they had stopped going to the dining room or left meals early because of the cold, with one resident reporting developing a sore throat and another stating they did not finish breakfast due to the temperature. On-site observation on the survey date confirmed an immediate temperature drop when entering the dining room from the hallway and a cold draft from the unsealed door. The Maintenance Director’s phone application showed a low temperature of 57°F in the dining room over a recent 24-hour period, and spot checks during the survey showed temperatures in the high 60s°F while approximately 25 residents sat in the dining room wearing coats and blankets before lunch. The Administrator initially stated being unaware of the cold conditions and later stated not being involved with the heating issue because the Maintenance Director was handling it with corporate, despite multiple prior grievances about heat issues documented in the facility’s grievance logs without recorded resolution or follow-up notification.
Failure to Protect Resident From Verbal Abuse by Agency CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a staff member. According to the facility’s abuse prevention and reporting policy, the facility affirms residents’ rights to be free from abuse and prohibits abusive behavior, including verbal abuse. Despite this, an agency CNA (V8) engaged in a verbal altercation with a resident (R1), who was a short-term rehabilitation patient with altered cognitive deficits (BIMS score 12/15) and diagnoses including a right femur fracture and COPD. During a transfer, V8 swore at the resident and disregarded the resident’s reported hip pain, demonstrating a poor attitude and impatience. The incident was witnessed by the resident’s spouse (V14), who observed that the CNA was very rude and impatient with the resident. Staff, including a registered nurse (V4) and the administrator (V1), reported that the CNA was cussing at and berating the resident in the presence of the spouse. The CNA’s employee file documented termination for verbally abusing a resident but did not contain documentation of abuse training, despite the facility’s CNA job description requiring safeguarding residents’ health, safety, and welfare, demonstrating tact with residents and families, and knowledge of public health regulations. These circumstances show that the resident was subjected to verbal abuse by a staff member, contrary to facility policy and job expectations.
Failure to Maintain Safe Transportation Van for Resident Travel
Penalty
Summary
The facility failed to ensure its transportation van was properly maintained and safe for resident transport, resulting in use of a vehicle with non-functioning headlights and broken windshield wipers during resident trips after dark and in the rain. The transportation driver reported that when he started employment in early November 2025, the van’s headlights were already not working properly and that he had been instructed to drive with the bright lights on because the regular headlights were very dim. He described a late appointment in November and a subsequent nighttime hospital transport around Christmas, both over an hour away, during which he and the Maintenance Director drove in the dark with improperly functioning headlights and nearly struck three deer. The driver stated the van had almost 300,000 miles and dashboard warning lights that remained illuminated, and that he continued to drive the van but did not want to drive it after dark. For a later appointment involving one resident (R3), the driver transported the resident and the resident’s daughter more than an hour away and returned in the dark while it was raining, using the same van with non-functioning headlights and broken windshield wipers. The driver reported having to drive approximately 40 miles per hour on the interstate due to these conditions and described the trip as very scary for both himself and the resident’s daughter. A CNA confirmed that upon return from this van ride, the resident and the daughter were very upset, and the daughter was crying. The Maintenance Director acknowledged that the transport van’s headlights were burnt out, stated he had been notified after the daughter complained, and indicated he had attempted but was unable to replace the headlights himself. He also could not provide maintenance records for the van. The facility’s grievance tracking logs documented issues with the headlights but did not include a resolution date or follow-up notification.
Failure to Maintain Adequate Housekeeping, Laundry, and Maintenance Resulting in Unsanitary Environment and Equipment Issues
Penalty
Summary
The deficiency involves the facility’s failure to employ and schedule sufficient maintenance, custodial, laundry, and housekeeping staff to maintain a safe, clean, comfortable, and homelike environment for all 58 residents. The facility assessment referenced support staff such as plant operations, custodians, housekeeping, and maintenance, but did not include an addendum specifying the staffing plan or number of staff needed for maintenance, housekeeping, and laundry services. Housekeeping/laundry schedules showed that only one laundry aide worked eight hours on 12 of 15 days reviewed, and only one housekeeper worked eight hours on 7 of 15 days, leaving large portions of time and shifts without coverage. Staff interviews consistently reported that there were not enough housekeepers or laundry staff, especially on second and third shifts, and that CNAs did not have time to perform laundry duties. As a result of this inadequate staffing and scheduling, the facility was not kept clean and free of odors, and there were persistent shortages of clean linens and mechanical lift slings. Multiple clean linen storage rooms were observed to be dirty, with floors covered in brown staining, trash, and debris, sinks with rust or white buildup, missing floor tiles, and overflowing trash cans. Linens stored in these rooms, including towels and sheets, were stained a light brown color and smelled of feces, and there were no clean washcloths or bed pads available in some areas. Staff and residents reported that linens frequently arrived stained, dirty, or smelling of feces, and that clean washcloths, bed pads, towels, and slings were routinely unavailable in the mornings. CNAs and nurses stated they often had to use towels instead of washcloths to clean residents, dig through dirty laundry to find the “least dirty” sling, or encountered “clean” washcloths with feces still on them. The lack of adequate housekeeping and maintenance also led to resident rooms and bathrooms not being cleaned daily and to physical plant disrepair. Observations showed resident rooms with scattered debris, overflowing trash cans, stained cubicle curtains, missing chunks of drywall, exposed unpainted drywall patches, cracked and bulging drywall above heating/cooling units, and a flickering over‑bed light that had been ongoing for weeks. Residents reported that their rooms and floors were always dirty, that their trash was always full, and that housekeepers were not able to clean their rooms every day. Several residents described toilets that overflowed into their rooms for weeks before being fixed, resulting in water and feces (“turds”) on their floors. One resident stated their sheets always smelled like feces, that they had purchased their own washcloths because they refused to use the facility’s, and that they had not had a housekeeper clean their room since early in the month. In addition, the facility failed to ensure that mechanical lifts and related equipment were adequately maintained and available. The manufacturer’s manual specified that the emergency red button is used when the control unit is not functioning and that a person can be lowered by pulling the red quick release lever in a power failure. During demonstration, the mechanical lift’s emergency button was found to be missing, and the lift’s legs were covered in debris and brown stains. The maintenance supervisor acknowledged not realizing the emergency button was missing and was unsure who was responsible for cleaning the lift, while a CNA reported that residents had been stuck in the air when batteries died and that there were not enough batteries to keep the lift functioning. Staff also reported that one of two full mechanical lifts had been broken for about a month, leaving only one working lift for multiple residents who required mechanical lift transfers, and that showers and transfers were missed when slings and clean linens were unavailable. Environmental observations further showed that the facility did not provide a homelike environment. On the memory care unit, two dining room windows lacked blinds or curtains and instead had see‑through bed sheets tacked up unevenly, covering only part of the windows. A concern form from a visitor described sheets hanging on dining room windows as “very tacky” and noted the absence of pictures on the walls. Another resident reported never having curtains and therefore hanging a bedspread over the window to block the sun. These conditions, combined with the dirty linen rooms, stained and foul‑smelling linens, unclean resident rooms, and unrepaired fixtures, demonstrate that the facility did not honor residents’ rights to a safe, clean, comfortable, and homelike environment and did not provide treatment and supports for daily living in a safe and sanitary manner.
Failure to Ensure Adequate Direct Care Staffing, Hydration, Hygiene, and Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate direct care staffing and to operationalize a facility assessment that specified the number of direct care staff needed daily to meet resident needs. The facility’s assessment tool referenced an addendum for direct care staffing needs, but no such addendum existed, leaving the facility without a defined staffing plan for direct care staff. The Director of Nursing later stated that specific numbers of CNAs were needed on each shift to meet resident needs, and confirmed that the facility was unable to staff those minimum numbers on multiple days. Review of CNA schedules and time sheets for selected dates showed that the number of CNAs actually working on day and night shifts was below the stated minimums. The facility also failed to provide scheduled showers and basic hygiene as outlined in residents’ care plans and facility policies. Multiple residents had care plans and MDS assessments indicating dependence on staff for showers and personal hygiene, as well as preferences or schedules for showers on specific days. Documentation showed missed showers on scheduled days, including one resident whose shower report explicitly cited lack of staff as the reason a scheduled shower was not given. Another resident submitted a written concern stating they were not getting showers and that it had been another whole week without one. During observations, residents were noted with long, jagged fingernails and reported not receiving showers or nail care as expected. The facility further failed to follow its hydration policy requiring fresh cold ice water to be provided to each resident at least three times daily. During tours of all four hallways, no residents were observed with fresh ice water at the bedside, and several residents reported they did not receive fresh ice water every shift or at all, and that they had to save water from meals to have water in their rooms. Residents also reported that call lights often remained on for long periods, sometimes over an hour, before being answered. Multiple CNAs, LPNs, and RNs consistently reported that there were not enough CNAs on various shifts, that showers and ice water passes were frequently not completed, and that call lights could not be answered promptly due to low staffing, including reports of nights with only one or two CNAs for the entire building. These observations, interviews, and record reviews collectively show that the facility did not ensure adequate numbers of direct care staff to complete daily ADLs such as showers, nail care, hydration, and timely response to call lights for the 58 residents in the building. The failures occurred despite facility policies requiring at least weekly bathing and a minimum of three daily fresh ice water passes, and despite care plans directing staff to encourage oral fluids and maintain fresh ice water at the bedside for residents with urinary alterations and risk for dehydration.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific actions or omissions by facility staff led to this breach, directly impacting the resident's rights and property. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Quarterly Financial Statements to Residents and Representatives
Penalty
Summary
The facility failed to provide quarterly financial statements to residents and their representatives as required by its own policies and procedures. Record review and interviews revealed that neither residents nor their representatives received these statements, with one resident's Power of Attorney and another resident both confirming they had never received such documentation. The prior Business Office Manager admitted to not sending out quarterly statements during her tenure, citing workload issues, and the current Business Office Manager, who had recently started, also had not sent out any statements. The facility's administrator acknowledged that the previous Business Office Manager was terminated in part for not fulfilling this responsibility. At the time of the survey, 44 residents resided in the facility, all potentially affected by this deficiency.
Failure to Provide Updated Admission Agreements After Change of Ownership
Penalty
Summary
The facility failed to promptly provide updated admission agreements or contracts to all residents and/or their representatives following a change in facility ownership. Record review showed that, as of the date of ownership change, 34 residents were residing in the facility, but none received the updated admission agreement within 30 days. The Business Office Manager's job description and policy required ensuring that resident admission contracts are signed and appropriately filed, but this was not carried out in a timely manner. Interviews confirmed that residents and their representatives did not receive or sign the updated admission contracts immediately or within the required timeframe after the change of ownership. For example, a resident's guardian stated that the admission contract was not signed until months after the new ownership took effect. The Administrator also verified that none of the residents' admission contracts were provided or signed within the expected period following the ownership transition.
Failure to Timely Refund Resident Trust Funds After Death
Penalty
Summary
The facility failed to refund unused resident funds to a resident's representative within 30 days of the resident's death, as required by guidelines. Record review showed that a resident was transferred to the hospital and subsequently passed away. The resident had $420 remaining in the facility's trust fund account, which had not been spent or used for several months prior to death. Despite repeated requests from the resident's Power of Attorney, the facility had not refunded the remaining funds as of the time of the survey. The Regional Director of Operations confirmed that there was no facility policy specifying when trust funds should be distributed, but acknowledged that the funds should have been returned within 30 days according to CMS guidelines.
Failure to Maintain Sanitary and Homelike Resident Restrooms
Penalty
Summary
The facility failed to maintain a sanitary and orderly environment for residents by not providing disposable or cloth hand towels in resident restrooms and by not ensuring the cleanliness of certain resident bathrooms. Observations revealed that nine residents did not have access to disposable or cloth hand towels or washcloths in their restrooms. Multiple residents reported that they had been without paper towels for several days, leading some to dry their hands on their clothes or simply shake their hands dry. Additionally, two residents' bathrooms were found to be unclean, with one commode bowl described as black-tinged with debris and another with a raised seat riser and surrounding area covered in black and brown debris, which a resident believed to be mold. Interviews with residents confirmed the ongoing lack of hand towels, with several stating that the dispensers had not been refilled for days and that they sometimes had to request towels without success. One resident, who serves as the Resident Council President, noted the absence of towels and the presence of urine and debris on the bathroom floor. Housekeeping staff confirmed the lack of paper towels on their supply carts, and the main supply closet was found to be out of stock. The Housekeeping/Maintenance/Laundry Supervisor acknowledged the shortage, attributing it to a delayed shipment and the recent holiday weekend, and verified that some rooms had not been restocked. Facility documentation, including the Resident Rights policy, Housekeeper job description, and Facility Assessment, all require the maintenance of a clean, safe, and homelike environment, as well as the provision of body cleansing products and hand hygiene supplies. Despite these requirements, supply purchase records showed only one recent order for paper towels, and the administrator was unaware of the extent of the shortage until it was brought to their attention. The deficiency was further compounded by the inexperience of the staff member responsible for ordering supplies, who was new and managing multiple departments.
Failure to Follow Physician Orders and Provide Basic Nail Care
Penalty
Summary
The facility failed to follow physician orders and provide basic care for a resident with multiple medical conditions, including chronic kidney disease, osteoarthritis, repeated falls, muscle disorder, abnormal gait, anemia, zoster, major depressive disorder, and dementia. The physician order sheet specified that compression stockings were to be applied to both lower extremities in the morning and removed at night to address edema. However, during multiple observations, the resident was found with swollen legs exhibiting moderate pitting edema and was not wearing the prescribed compression stockings. The resident confirmed that staff were not applying the stockings as ordered. Additionally, the resident's care plan required staff assistance with personal hygiene, including checking, trimming, and cleaning fingernails on bath days and as necessary. Despite this, shower records did not indicate that nail care was provided, and the resident was observed with long fingernails containing a moderate amount of black dry debris. The resident stated that their nails had not been cleaned, and the administrator verified the presence of debris, acknowledging that nail care should have been performed during the most recent shower.
Failure to Maintain Required RN Staffing Levels
Penalty
Summary
The facility failed to maintain the required staffing levels by not having a Registered Nurse (RN) on duty for eight hours a day, seven days a week, which is a regulatory requirement. This deficiency potentially affects all 46 residents in the facility. The facility's assessment, updated on March 1, 2025, indicated an average daily census of 40 residents and documented the need for RN coverage on the day shift. However, the State Payroll Based Journal Staffing Data Report for the quarter from October 1 to December 31, 2024, showed no RN hours on multiple dates, including weekends and a holiday. Additionally, daily staffing sheets for January through March 2025 confirmed the absence of RN coverage on several dates. The facility employs ten nurses, of which only two are RNs, including the Director of Nursing (DON) and another RN. The DON confirmed that there are three nursing vacancies and that no RNs are available through agencies. The facility relies on Licensed Practical Nurses (LPNs) to cover weekend shifts when the sole RN does not work. The DON also verified that she does not cover the RN shifts on weekends. The facility's administrator stated that the current management took over the nursing home on November 1, 2024, which coincides with the start of the documented staffing deficiencies.
Lack of Certified Dietary Staff in Facility
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills in the food and nutrition service department, as evidenced by the absence of a Certified Dietary Manager (CDM) and certified staff. During the survey, it was observed that the facility's Dietary Manager (DM) did not possess a valid CDM certificate and had an expired food handler certificate. Additionally, the facility was unable to provide food handler certificates for any of the dietary staff, including dietary aides and cooks, indicating a lack of compliance with required certifications. The deficiency was further highlighted during a meal delivery service where dietary staff, including the DM and dietary aides, were observed preparing and serving food without the necessary certifications. The facility's job descriptions for dietary roles emphasize the need for compliance with federal, state, and local standards, yet the lack of certified staff suggests a failure to adhere to these standards. This deficiency has the potential to affect all 46 residents residing in the facility, as it compromises the quality and safety of nutritional services provided.
Insufficient Staffing During Meal Service
Penalty
Summary
The facility failed to provide sufficient staff during meal service, affecting the timely delivery of meals to residents. On March 18, 2025, during the 11:00 AM meal service, staff were observed filling meal carts for residents who eat in their rooms and subsequently left the dining room unattended to serve these meals down the hallways. This left no staff available to serve the residents who were seated in the dining room, resulting in delays. The Dietary Manager confirmed that room trays are prioritized, and due to insufficient staffing, residents in the dining room have to wait for their meals. During a resident council meeting on March 19, 2025, five residents expressed concerns about the delays in receiving their meals in the dining room. They reported that the staff is occupied with serving room trays first, which leads to insufficient staff available for dining room service. The residents noted that attempts to serve the dining room first were unsuccessful, and they emphasized the need for a solution to the staffing issue during meal times.
Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to comply with its food storage policy, which requires all foods to be covered, labeled, and dated. During a kitchen tour, it was observed that a bag of frozen zucchini and multiple loaves of bread lacked a delivery, use-by, or expiration date. The Dietary Manager acknowledged the oversight, noting that the bread was expected to have a date and that the zucchini had been removed from its box that day. This deficiency has the potential to affect all 46 residents residing in the facility, as proper food labeling is crucial for ensuring food safety and quality.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure that a PASARR Level I screening and/or Level II referral were completed for a resident reviewed for PASARR screenings. The facility's policy requires that all potential admissions undergo a PASARR Level I screening to determine if the individual meets the criteria for a mental disorder or intellectual disability. If the Level I screening indicates such conditions, a Level II screening must be requested before admission. However, the facility did not have documentation of a PASARR screening for the resident, who was admitted with diagnoses including unspecified psychosis, COPD, alcohol dependence, and other conditions. The Minimum Data Set/Care Plan Coordinator acknowledged the absence of the required PASARR documentation and noted that the facility had undergone a change in ownership, which may have contributed to the missing records. The coordinator was unable to locate the Level I screening that should have been completed prior to the resident's admission and recognized that a Level II screening referral should have been made due to the resident's psychosis diagnosis. The coordinator expressed intent to follow up with the relevant agency to verify if the screenings were conducted and to obtain copies.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate assistance for activities of daily living (ADL) related to hygiene and scheduled baths for a dependent resident, identified as R4. The facility's policy mandates that residents should be offered a shower, tub bath, or bed/sponge bath at least once a week or according to their preference. However, R4, who requires assistance due to hemiplegia/hemiparesis following a stroke, did not have a scheduled shower day or time documented. The facility's records showed that R4 only received bed baths and no showers were documented during the period reviewed. Observations and interviews revealed that R4 had not received a proper shower since before Christmas, despite expressing a desire to get out of bed and into the shower. The Corporate Regional Nurse Consultant admitted that R4's showers were scheduled for midnight, leading to documentation of refusals and resulting in R4 not receiving any showers. This lack of proper hygiene assistance was evident as R4 was observed with unkempt and oily hair, indicating a failure to maintain the resident's cleanliness and dignity as per the facility's policy.
Failure to Maintain Proper Orders and Labeling for Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper orders and labeling for respiratory equipment for three residents. One resident had an order for oxygen at 3 liters via nasal cannula, with instructions to change the oxygen tubing weekly. However, the oxygen tubing was dated from February, and the nebulizer tubing was not dated, indicating a failure to adhere to the facility's policy of changing and labeling respiratory equipment. Another resident had a BiPAP machine in use every night, but there were no medical orders documented for its use, which is a critical oversight in ensuring proper respiratory care. Additionally, a third resident had a CPAP machine, nebulizer, and oxygen at 4 liters via nasal cannula, with orders to change the oxygen tubing and humidifier weekly. However, the nebulizer and oxygen tubing were not dated, and the nebulizer was not stored in a bag as required. These deficiencies highlight a lack of compliance with the facility's own policies regarding the maintenance and documentation of respiratory equipment, potentially compromising the quality of care provided to the residents.
Failure to Provide Timely Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services to a resident, identified as R191, who was admitted with a medical diagnosis of Polymyalgia Rheumatica and Congestive Heart Failure. Upon discharge from the hospital, R191 was recommended to receive physical therapy 1-2 times per day, Monday through Friday, for two weeks. The treatment plan included gait training, mobility, transfers, strength, range of motion exercises, education, family training, and balance activities. However, despite the physician's orders for occupational, physical, and speech therapy evaluations and treatments as indicated, R191's physical therapy evaluation and plan of treatment did not commence until 3/14/25, which was ten days after the resident's admission. During an interview on 3/21/25, R191 expressed disappointment and frustration over the delay in starting therapy, stating that they did not receive therapy for two weeks and were considering leaving the facility. The resident began receiving therapy on 3/17/25, with sessions documented on 3/17, 3/18, 3/20, and 3/21/25. The delay in initiating the prescribed therapy services resulted in a failure to meet the resident's rehabilitative needs as outlined in the hospital discharge plan, which was a contributing factor to the deficiency identified by the surveyors.
Inaccessible State Survey Binder
Penalty
Summary
The facility failed to make the state survey book or binder readily accessible to residents, family members, and legal representatives, and did not accurately post the location of the survey book. This deficiency was identified during a resident council meeting where five residents expressed that they were unaware of the survey binder's location. Upon investigation, the survey binder was found outside the Administrator's office, obscured by other binders, with its label not visible. Additionally, a note on a communication board incorrectly indicated that the survey book was located at the nurses' desk. The Administrator later confirmed the binder's location outside their office at the front entrance. This oversight has the potential to affect all 46 residents residing in the facility.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily staffing information, including the total number of actual hours worked by both licensed and unlicensed nursing staff. This deficiency was observed on two separate occasions, where the staffing information posted at the front entrance was outdated, showing a date of 3/15/25, despite the observations being made on 3/19/25 and 3/21/25. Additionally, the posted staffing sheet lacked the total hours worked for the date of 3/15/25. The Director of Nursing (DON) confirmed the oversight and acknowledged that the staffing information should have been updated daily, with the night nurse being responsible for posting the next day's staffing information. This failure potentially affects all 46 residents residing in the facility, as documented in the Department of Health and Human Services Centers for Medicaid and Medicare Services Form 671.
Failure to Implement Effective Fall Interventions for Resident
Penalty
Summary
The facility failed to implement resident-specific fall interventions for a resident with a history of falls, resulting in multiple injuries requiring hospital treatment. The facility's Fall Prevention Program Policy mandates assessing individual resident needs and implementing appropriate interventions, but this was not adequately followed for the resident in question. The resident, who has a history of traumatic brain injury, cognitive impairment, and mobility issues, experienced several falls, some resulting in lacerations and hospital visits. The resident's care plan acknowledged the risk factors, including decreased mobility and impaired cognitive function, but did not document specific interventions for each fall. Despite multiple incidents, the interventions remained largely unchanged and ineffective, such as encouraging the resident to use a call light, which was not within reach during observations. The resident's roommate and staff acknowledged the frequent falls and the inadequacy of the interventions. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed an awareness of the resident's impulsive behavior and the ineffectiveness of the current interventions. The staff admitted that the interventions were not appropriate for the resident's needs, indicating a lack of proper assessment and adjustment of fall prevention strategies as required by the facility's policy.
Lack of Resident-Centered Activities Due to Vacant Activity Director Position
Penalty
Summary
The facility failed to ensure that ongoing resident-centered activity programs were being offered, affecting all 40 residents. The facility's Resident Rights Policy emphasizes the importance of providing services that promote residents' quality of life, including participation in social and community activities. However, observations on multiple occasions revealed that no scheduled activities were being conducted. Interviews with residents confirmed the absence of activities, with several expressing their desire to participate in activities such as Bingo and music, which were not available. The lack of activities has been ongoing for over a week, as noted by the Resident Council President and other residents. The deficiency was further compounded by the absence of an Activity Director. The Social Service Director, who recently started working at the facility, confirmed that the previous Activity Director had quit over a week ago, leaving the position vacant. The Administrator in Training verified the lack of an Activity Director or a full-time Activity Assistant, acknowledging the sudden departure of the former Activity Director. As a result, the Social Service Director was assigned to take on the responsibilities of the Activity Director, despite the lack of activities being conducted for the residents.
Misappropriation of Resident Funds by Business Office Manager
Penalty
Summary
The facility failed to protect the rights of 74 out of 75 residents from the misappropriation of their property by the Business Office Manager (BOM), identified as V4. Over a period of eight months, V4 stole $11,815 from the residents' pooled trust account without their knowledge. This misappropriation involved forging signatures on checks, cashing them, and then depositing the funds into V4's personal bank account. The facility did not monitor the residents' pooled trust account monthly, which allowed V4 to continue these fraudulent activities. The facility's policies required dual signatures on all banking transactions and monthly oversight by the Administrator, but these measures were not enforced. V3, the Administrator in Training, admitted to not monitoring the monthly trust fund account or ensuring that residents received their quarterly statements. Additionally, V4 kept a resident's pre-paid social security card and made unauthorized charges, further violating the residents' rights. Interviews with residents and staff revealed that several residents did not receive receipts for purchases made on their behalf, and some residents' signatures were forged on withdrawal logs. The facility's audit confirmed a deficit of $11,815 in the residents' trust funds, and the trust fund withdrawal logs for several months were missing. The facility's lack of oversight and failure to adhere to its own policies allowed the misappropriation to occur, resulting in an Immediate Jeopardy situation.
Removal Plan
- The facility staff have interviewed all cognitive residents to identify those residents who allowed the facility to manage their monies and who had given V4/Business Office Manager monies for items and never got items, receipts, or monies back.
- V1 notified all resident's/responsible parties of discharged residents of misappropriation of funds.
- V2 was in serviced by V1/Regional director on the facility's Abuse Policy and Procedures.
- V2 was educated by V1 on how the resident trust fund is supposed to work and procedures on handling the resident's cash.
- V20 was thoroughly trained by V1 on the resident trust.
- A deposit was made in the amount of 11,815.00 to the resident's new trust fund account. This amount was the amount audited and determined by V7 to be missing from the resident's pooled trust fund account.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to adhere to its Abuse Policy by not immediately reporting allegations of misappropriation of residents' funds to the local police department, the state agency, and the residents or their representatives. This failure affected all 75 residents reviewed in the sample. The issue began when a resident reported to the Prior Administrator-In-Training that the Business Office Manager was making fraudulent charges from her debit card. This allegation was not reported to the state agency. Subsequently, the Prior Administrator was informed by a bank manager of suspected fraudulent withdrawals from the residents' trust fund, but the police and state agency were not notified until eight days later, leaving the residents' accounts vulnerable. An audit revealed a deficit of $11,815 missing from the residents' pooled trust fund account. Further investigation showed that the Business Office Manager had been forging signatures and writing checks to cash, then depositing the funds into her personal account. Residents reported unauthorized withdrawals and fraudulent charges on their accounts, and many were not informed by the facility about the misappropriation of their funds. The facility's failure to report these allegations promptly and to notify the residents or their representatives resulted in an Immediate Jeopardy situation. The facility's Abuse Prevention Program policy requires immediate reporting of any potential mistreatment, exploitation, neglect, or abuse to a supervisor and the administrator, and further reporting to the state agency and law enforcement as per state law. However, the facility did not follow these procedures, leading to significant financial losses for the residents and a breach of trust. The facility's inaction and lack of communication with the affected residents and their representatives contributed to the severity of the deficiency.
Removal Plan
- V4/Business Office Manager was suspended and has not worked at the facility since.
- V2 (AIT) was educated by V1 (Regional Director) on the Abuse Policy and Procedures with an emphasis on two-hour reporting window to (State Agency), notifying the responsible party, doctor, and local police.
- V2 (AIT) and V20 (Business Office Manager/Social Service Director) were both in-serviced by V1 (Regional Director) on how the resident trust fund is supposed to work and procedures on handling the resident's cash.
- The facility completed all measures on the abatement plan, including providing in-servicing to all the staff on abuse policy and procedures and notifying all responsible parties of the residents in the facility of the misappropriation of funds.
Failure to Investigate Misappropriation of Funds
Penalty
Summary
The facility failed to adhere to its Abuse Policy by not thoroughly investigating allegations of misappropriation of funds and not removing the alleged perpetrator, the Business Office Manager (BOM), from contact with residents and their funds during the investigation. This failure affected all 75 residents reviewed for protection against abuse. The issue began when a resident reported to the Administrator-In-Training (AIT) that they suspected the BOM of making fraudulent charges on their debit card. Despite this report, no investigation was initiated, and the BOM was not suspended, leaving residents' funds unprotected. Further allegations arose when the Bank Manager informed the Prior Administrator of suspicious activities involving the BOM, who was allegedly making unauthorized withdrawals from the residents' trust fund for personal use. Despite being notified, the Prior Administrator did not suspend the BOM or initiate an investigation immediately. The BOM continued to have access to the residents' pooled trust fund account, resulting in a significant deficit of over $11,000 due to unauthorized withdrawals. Another resident reported that the BOM had taken their pre-paid social security card and made fraudulent charges. This allegation was not immediately investigated, and the state agency was not notified promptly, allowing further fraudulent charges to occur. The facility's failure to act on these allegations and protect residents' funds resulted in an Immediate Jeopardy situation, highlighting significant lapses in following established abuse prevention protocols.
Removal Plan
- V4 (Business Office Manager) was suspended and has not worked at the facility since.
- V2 (AIT) was educated by V1 (Regional Director) on the Abuse Policy and Procedures with an emphasis on two-hour reporting window to (State Agency), notifying the responsible party, doctor, and local police.
- V2 (AIT) and V20 (Business Office Manager/Social Service Director) were both in-serviced by V1 (Regional Director) on how the resident trust fund is supposed to work and procedures on handling the resident's cash.
- The facility completed all measures on the abatement plan, including providing in-servicing to all the staff on abuse policy and procedures and notifying all responsible parties of the residents in the facility of the misappropriation of funds.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement adequate pressure ulcer prevention and care interventions for a resident, leading to the development of a facility-acquired unstageable pressure ulcer on the right heel and a stage three pressure ulcer on the right buttock. The resident was admitted with a femur fracture and no existing pressure ulcers. Initial assessments indicated the resident was at risk for pressure ulcers, but the care plan did not include specific interventions to address this risk. Despite being identified as high risk for pressure ulcers, the facility did not perform daily skin checks or implement necessary interventions such as heel protectors or proper turning and repositioning. The resident reported not having pressure-relieving boots or sufficient staff assistance to reposition, which contributed to the development of the pressure ulcers. The facility's policy required these interventions for high-risk residents, but they were not documented or executed. The resident's care plan lacked individualized goals and interventions to treat and prevent the worsening of the pressure ulcers. Observations and staff interviews confirmed that the necessary preventive measures were not in place, and the resident's pressure ulcers developed and worsened while in the facility's care. The facility's failure to adhere to its pressure sore prevention guidelines resulted in significant harm to the resident.
Failure to Conduct Resident Council Meetings
Penalty
Summary
The facility failed to conduct Resident Council Meetings for five out of twelve months in the past year, affecting all 36 residents. The absence of these meetings was attributed to the lack of an Activity Director, who was responsible for organizing and facilitating the meetings. Residents expressed concerns about not being invited to Care Plan Meetings, a shortage of essential supplies like towels and linens, and a lack of knowledge about formal grievance procedures. They also reported feeling unheard when raising issues and were unaware of the existence or importance of a Survey Book. Residents expressed dissatisfaction with the lack of activities and the cessation of meetings since February. They felt that the meetings provided a platform to voice concerns and discuss improvements, which was no longer available. Specific grievances included long wait times for call lights, cold meals, and inadequate staffing, among others. The Administrator in Training acknowledged the absence of meetings and was unaware of the complaints raised during previous meetings. The facility's documentation showed repeated grievances without evidence of resolution, indicating a systemic issue in addressing resident concerns.
Inadequate Linen Supply and Moldy Shower Curtain
Penalty
Summary
The facility failed to provide an adequate supply of washcloths and towels, as well as maintain a clean shower curtain, affecting the quality of care for all 36 residents. Observations and interviews revealed that staff members, including CNAs, were forced to use alternative items such as pillowcases, bath blankets, and paper towels for resident hygiene due to the lack of washcloths and towels. Multiple residents expressed dissatisfaction with the situation, noting the absence of basic hygiene supplies and the use of inappropriate substitutes for personal care. Additionally, the main shower room's curtain was found to be in poor condition, with a thick black, musty-smelling substance covering a significant portion of it. Staff and residents reported that the moldy condition of the shower curtain had persisted for an extended period, with one CNA stating it had been an issue for two years. The Administrator-In-Training acknowledged awareness of the moldy shower curtain and the shortage of linens but had not yet taken action to resolve these issues.
Failure to Address Resident Grievances and Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process, including how to submit grievances and who the grievance official is. This deficiency was identified through observations, interviews, and record reviews, revealing that residents were not informed about the grievance procedures and that complaints raised during resident council meetings were not being addressed. Specifically, residents expressed that they were unaware of what a grievance was, where to find grievance forms, or who the grievance official was. Additionally, residents reported that their complaints, such as the desire for church services and outings, had been repeatedly voiced in resident council meetings over several months without resolution. The facility's grievance policy outlines that grievances should be reported to the Social Service Director, who serves as the grievance official, and that these should be addressed in daily Quality Assurance meetings. However, the facility did not have an activity director to submit resident council concerns, and the Administrator-In-Training admitted to being unaware that residents could submit grievances themselves. This lack of awareness and action resulted in unresolved complaints, such as the absence of church services and outings, affecting all 36 residents in the facility.
Lack of Resident Activities and Engagement
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the physical, mental, and psychosocial well-being of its residents. Observations and interviews revealed that no activities were offered to residents on several days, and there was a lack of activity calendars or postings throughout the facility. The facility had not employed any staff in the activity department for over two months, resulting in no scheduled activities on the second shift or weekends. This lack of activities was confirmed by multiple staff members, including CNAs and the Social Service Director, who stated that the facility had not provided activities consistently for several months. Residents expressed dissatisfaction with the lack of activities, stating that they were bored and had nothing to do outside of their rooms. Several residents, including those with cognitive impairments and mental health diagnoses, reported that they had not been offered activities such as bingo, church services, or outings, which they had previously enjoyed. The Resident Council Meeting Minutes documented repeated requests for church services and outings, which had not been addressed by the facility. Interviews with residents and their family members highlighted the negative impact of the inactivity on their well-being, with some residents expressing feelings of depression and boredom. The facility's failure to assess and update residents' activity preferences and care plans further contributed to the deficiency. Several residents' medical records lacked Activity Preferences Assessments or Quarterly Reviews of Activity Participation, and their care plans did not address their activity goals or interests. This oversight affected residents' participation in activities, as evidenced by the low attendance recorded in their Activity Tracking Logs. The absence of an activity director and the lack of staff to facilitate activities were cited as reasons for the deficiency, leaving residents without meaningful engagement or opportunities for social interaction.
Lack of Activity Director Leads to Deficiency in Resident Activities
Penalty
Summary
The facility failed to employ a full-time Activity Director to plan, schedule, and implement an ongoing program of activities, affecting all 36 residents. The facility's policy requires the Activity Director to plan and coordinate activities to meet the physical, mental, and psychosocial needs of each resident, including completing assessments and participating in care plan development. However, observations and interviews revealed that the facility has not had an Activity Director since March 12, 2024, after the previous director resigned. As a result, no scheduled activities, activity calendars, or resident council meetings have been provided for several months. During the survey, it was observed that no activities were offered to residents on multiple days, except for a brief bingo session. Residents expressed concerns about the lack of activities, and the Social Service Director confirmed the absence of scheduled activities and staff to conduct them. The Administrator-In-Training acknowledged the vacancy in the Activity Director position since March 2024, contributing to the deficiency in providing an adequate activities program for the residents.
Inadequate Nursing Staff Leads to Delayed Care
Penalty
Summary
The facility failed to ensure adequate nursing staff was available to meet the needs of all 36 residents, as evidenced by observations, interviews, and record reviews. The facility's Daily Census confirmed the presence of 36 residents, and the Facility Assessment Tool emphasized the necessity for sufficient nursing staff with appropriate competencies to ensure resident safety and well-being. However, the Nurse Master Schedule revealed multiple dates where staffing was insufficient, specifically on 5-11-24, 5-12-24, 5-25-24, 5-26-24, 5-31-24, 6-1-24, and 6-2-24, during the 6am to 6pm shifts. On 6-2-24, an LPN was observed administering medications from 7:10 AM to 10:45 AM, despite the scheduled medication pass time being 8:00 AM. The LPN reported that the facility required two full-time nurses on both day and evening shifts to complete all tasks, including wound treatments and timely medication administration. During a resident council meeting, several residents expressed concerns about the lack of morning nursing staff, resulting in delayed medication administration. The Resident Care Coordinator confirmed the staffing requirements and acknowledged the staffing shortages on the specified dates.
Deficiency in RN Coverage and Lack of DON
Penalty
Summary
The facility failed to provide Registered Nurse (RN) services for eight hours daily and did not employ a Director of Nursing (DON) to oversee the Nursing Department, affecting the quality of care for all 36 residents. The facility's policy mandates RN services to be available every day, but the Nurse Master Schedule revealed multiple days without RN coverage. Specifically, there was no RN coverage on several dates in May and June, and no DON was present on multiple days in early June. The absence of a DON has persisted since February, following the departure of the previous DONs. Interviews with facility staff confirmed the lack of RN coverage on the specified dates. The Administrator-In-Training acknowledged the absence of a DON since February, and the Resident Care Coordinator confirmed the lack of RN coverage on the listed dates. The facility's Facility Assessment Tool also highlighted the need for a DON to support and care for the resident population, indicating a systemic issue in maintaining adequate nursing leadership and coverage.
Absence of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager, which is a requirement for managing the food and nutrition services effectively. The job description for the Food Service Manager outlines responsibilities such as managing food service personnel, ensuring residents receive physician-ordered diets, and maintaining sanitation and safety standards. However, since August 2023, the facility has not had a Dietary Manager, and the tasks have been divided among the existing dietary staff, who are already understaffed. This situation has the potential to affect all 36 residents living in the facility. During an observation on June 2, 2024, it was noted that the dietary aides were managing the kitchen operations without a designated manager. They expressed challenges in handling additional responsibilities due to the lack of sufficient staff. The Administrator in Training confirmed the absence of a Dietary Manager, citing difficulty in filling the position. The facility's daily census documented 36 residents, indicating that the deficiency could impact the entire resident population.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, which were observed during a kitchen tour. Two pans containing shredded ham were left unrefrigerated overnight, and several food items were found without proper labeling or dating. Additionally, the refrigerator was leaking fluid onto food containers, potentially contaminating the food. The facility also failed to discard outdated food, as evidenced by luncheon meat that had been pulled from the freezer on a previous date. The storage room door was left open, and the outside door was also open, compromising the safety and sanitation of the food storage area. The kitchen environment was not maintained in a clean and safe condition. There was a buildup of grime on the base of the can opener, dust on the hood and baffles over the range, and gaps in ceiling tiles and around pipes. The ceiling vents and returns were covered in dust and grime, and floor tiles were missing under the sink area. Additionally, bags of water softener salt and boxes of paper goods were improperly stored on the floor. The lighting in the food preparation room was inadequate, with several lights out and one light cover cracked. These deficiencies have the potential to affect all 36 residents living in the facility.
Deficiencies in Staffing, Infection Control, and Resident Care
Penalty
Summary
The administration of the facility failed to address ongoing resident complaints and ensure adequate resources and staffing were available. Residents reported not receiving church services and desired more activities like bingo. The facility lacked a full-time Director of Nursing, Activity Director, and Dietary Manager, which contributed to the absence of daily activities and unresolved resident grievances. Additionally, the facility did not conduct monthly resident council meetings, and residents were unaware of the grievance process. The facility was also deficient in maintaining adequate infection control practices. Several residents with indwelling urinary catheters and wounds were not placed in enhanced barrier precautions, and staff were observed not wearing appropriate protective gear while providing care. The facility's infection preventionist was unaware of the enhanced barrier precautions policy, indicating a lack of training and implementation of up-to-date infection control measures. Furthermore, the facility struggled with staffing and resource management. There were insufficient nursing staff on multiple occasions, and the facility lacked adequate linens, with reports of only one or two washcloths available for all residents. The dietary department faced challenges with broken equipment, such as a non-functional convection oven and a rusted freezer door, which hindered meal preparation. The facility also failed to provide required annual in-service training for CNAs, including abuse prevention, Alzheimer's dementia management, and QAPI training.
Failure to Employ Licensed Administrator
Penalty
Summary
The governing body of the facility failed to employ a licensed administrator to oversee and manage the everyday operations, which has the potential to affect all 36 residents residing within the facility. Observations and interviews revealed that the designated administrator, V1, has not been present at the facility regularly, with staff reporting that V1 visits only about once a week. The facility's job description for the administrator position requires the individual to hold a current, unencumbered Nursing Home Administrator's license or meet the state's licensure requirements, which V1 possesses but is not fulfilling the role's responsibilities. Instead, V2, an Administrator-In-Training, has been managing the facility since November 2023 without holding an administrator's license or the necessary education to obtain a temporary license. Staff members, including LPNs and CNAs, confirmed that V2 is the only administrator they have seen managing the facility, and they have not seen V1 in months. This situation indicates a lack of proper oversight and management as required by the facility's governing body, potentially impacting the quality of care provided to the residents.
Facility Fails to Implement QAPI Plans and Address Multiple Deficiencies
Penalty
Summary
The facility failed to develop and implement Quality Assurance and Performance Improvement (QAPI) plans to address several deficiencies, including the lack of follow-up to resident complaints, insufficient nursing staff, and inadequate training on QAPI, dementia care, infection control, and abuse prevention. The facility also did not have department heads such as the Director of Nursing, Activity Director, and Dietary Manager, which contributed to the lack of an ongoing program of activities and unresolved resident complaints. Additionally, the facility did not conduct resident council meetings consistently, and there was a lack of required employees attending QAPI meetings. Observations revealed that residents were not placed in enhanced barrier precautions despite having conditions that warranted such measures, and staff were not wearing appropriate protective gear while providing care. The facility's equipment was in disrepair, with a broken convection oven and a rusted freezer door, affecting dietary operations. The facility also faced a shortage of linens, with reports of insufficient washcloths and towels for resident care. Furthermore, there was no activity calendar for several months, and activities were not offered consistently, leaving residents without meaningful engagement. Interviews with staff and residents highlighted the lack of awareness and resolution of grievances, with residents expressing dissatisfaction with the absence of church services and delayed medication administration due to staffing shortages. The facility's administrator confirmed the absence of a Director of Nursing since February and acknowledged the lack of required training for staff. The facility also restricted access to QAPI meeting minutes and had not developed or implemented corrective plans to address these issues.
Deficiency in Quality Assurance Meetings Attendance
Penalty
Summary
The facility failed to have a Director of Nursing (DON) or the required number of members present at the quarterly Quality Assurance Meetings, which is a deficiency that could potentially affect all 36 residents living in the facility. The document titled 'Members of Quality Assessment and Assurance' lists the required members, including the Administrator, Administrator in Training, Resident Care Coordinator, Social Services Director/Business Office Manager, Medical Director, Therapy, and Pharmacy. However, the review of the Quality Assurance quarterly sign-in sheets for the past twelve months revealed that a DON was not present at any of the meetings. Specifically, the meeting on January 19, 2024, had five members, while the meetings on October 19, 2023, and July 21, 2023, each had four members. During an interview on June 6, 2024, the Administrator in Training confirmed the absence of a DON at these meetings, stating that the number of members able to attend signed the attendance sheets. The facility's daily census as of June 2, 2024, documented 36 residents currently residing within the facility.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, impacting the ability to prepare and serve meals safely and efficiently to all 36 residents. Observations and interviews revealed that several large appliances, including the convection oven, range oven, steam table, and large hood with baffles, were not functioning properly. The convection oven had been broken for months, and one of the range ovens could only be used as a warmer, failing to reach the correct temperature for cooking. Additionally, a broken pipe in the steam table and a non-functional large hood with baffles were reported. Staff members stated that they had informed the Administrator about these issues six or seven months ago, but no repairs had been made, and there was no formal work order process in place. Further inspection showed that the door to the outside freezer was severely rusted, with the inner door material and insulation exposed. Staff indicated that attempts to repair the door had been unsuccessful, and there was no plan to replace it. The Administrator in Training was unaware of these equipment failures, highlighting a lack of communication and oversight in addressing maintenance issues. The facility's Maintenance and Environmental Policy emphasizes the importance of a well-maintained environment for safe and effective care, yet the failure to repair critical kitchen equipment contradicts this policy.
Failure to Provide Annual Abuse Prevention Training
Penalty
Summary
The facility failed to ensure that direct care staff received the required annual in-service training on Abuse Prevention. This deficiency was identified through a review of the facility's records and interviews. The facility's policy, dated September 2017, mandates that staff should receive annual training on abuse prevention. However, the In-Service Training Logs for several Certified Nursing Assistants (CNAs) from June 1, 2023, to June 2, 2024, did not show evidence of them receiving this training. During an interview on June 6, 2024, the Administrator-In-Training confirmed that the staff had not received abuse training within the last 12 months. This oversight has the potential to affect all 36 residents currently residing in the facility, as documented in the facility's Daily Census dated June 2, 2024.
Failure to Provide Annual QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that direct care staff received the required annual in-service training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through a review of the facility's records and interviews. The facility's QAPI Plan policy mandates annual training for all staff, using the annual QAPI report to summarize goals, progress, and Performance Improvement Projects (PIPs). However, the In-Service Training Logs for several Certified Nursing Assistants (CNAs) did not show evidence of receiving this training over the past year. During an interview, the Administrator-In-Training confirmed that the staff had never received QAPI in-service training. This oversight has the potential to impact all 36 residents currently residing in the facility.
Latest citations in Illinois
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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