Arcadia Care Kewanee
Inspection history, citations, penalties and survey trends for this long-term care facility in Kewanee, Illinois.
- Location
- 144 Junior Avenue, Kewanee, Illinois 61443
- CMS Provider Number
- 145968
- Inspections on file
- 36
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Arcadia Care Kewanee during CMS and state inspections, most recent first.
Surveyors identified that staff failed to accurately document and account for controlled substances, including missing signatures on shift-change narcotic counts, pre-signing controlled medications before administration, and unresolved discrepancies in liquid morphine volumes and records. An LPN did not sign the narcotic count at shift change as required, another LPN pre-signed hydrocodone/APAP and pregabalin doses before actually giving them, and a resident’s liquid morphine record showed inconsistent volumes, missing MAR entries, and a count correction without documented administration. Leadership acknowledged that controlled substance records and MARs are required to match and that staff are not permitted to pre-sign medications.
A resident with morbid obesity and depression, who required a WC for mobility and staff assistance for transfers and showers, was not provided with an appropriately sized WC or safe shower equipment. Despite care plan goals for the resident to get out of bed and socialize, records showed only one shower over several weeks and no documented WC assessment by therapy or nursing. The administrator and ADON confirmed that two bariatric WCs obtained did not fit, no additional WC was secured, and no suitable shower chair was available. CNAs reported the resident could not access the shower room, was bathed in bed, and had to sit on the side of the bed to eat, and observation showed the resident could not sit safely or comfortably in the available bariatric WC.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage each day and did not employ a full-time DON. The Administrator confirmed multiple days with no RN coverage and reported ongoing difficulty securing RNs, noting that the company prohibited use of agency RNs. A Regional Nurse functioned as an interim DON but was only physically present one to two times per week, as shown on a work log, while reviewing 24-hour nursing reports remotely. At the time of the survey, 53 residents lived in the facility.
Surveyors found that dietary staff failed to follow facility policies for labeling, dating, and discarding food, as well as for cleaning and maintaining kitchen cabinets and equipment. Open and undated food items were observed in the refrigerator, freezer, and dry storage, including sliced meats, cheese, scrambled egg mix, bread, stuffing mix, and various condiments and sauces, along with several items that were past their expiration dates. Clean dishes were stored in a cabinet without a door that contained debris and loose wood pieces, and other cabinets were in disrepair with visible dirt and food debris. The dietary aide and dietary manager confirmed these conditions and acknowledged that foods should be labeled, dated, and discarded when expired, and that cabinets should be kept clean and in good repair, affecting all 53 residents receiving meals from this kitchen.
Surveyors found that the facility failed to follow its own COVID-19 vaccination guidelines for staff by not maintaining required documentation of employee vaccine education, vaccination status, and refusals. The Infection Preventionist reported there was no log of which employees had received or refused the COVID-19 vaccine, and the Administrator confirmed that the facility did not use refusal forms or track education provided to new employees who declined vaccination, despite policies requiring this documentation for all staff while 53 residents were in care.
The facility failed to ensure that multiple residents’ POLST orders for scope of treatment were accurately reflected in their EMR face sheets, physician order sheets, and care plans. For several residents, documentation listed only DNR status, while their signed POLST forms included additional directives such as selective or limited additional interventions, use of CPAP/BiPAP, IV fluids, antibiotics, vasopressors, antiarrhythmics, cardiac monitoring, hospital transfer parameters, and a time-limited trial of tube feeding. These detailed treatment preferences were not incorporated into the care plans or EMR, even though an LPN reported relying on the EMR status board to determine code status in emergencies, and facility leadership acknowledged that POLST instructions should match and be reflected in the medical record and care plans.
The facility did not ensure that bedtime snacks were consistently offered and documented for multiple residents, despite a policy requiring provision of bedtime snacks and/or fluids before sleep. Residents reported that staff did not routinely come around to offer snacks, with some stating they had to request snacks and that staff sometimes forgot to bring them, while others were unaware they could request snacks but wanted them offered. The Dietary Manager indicated that dietary staff only delivered a sealed snack box to the nurses’ station each evening, and the Interim DON stated CNAs were responsible for offering snacks to appropriate residents but acknowledged there was no documentation that these residents received bedtime snacks.
A resident who was cognitively intact and at moderate risk for pressure ulcers used a CPAP device and developed a painful, bright red, dime-sized area on the bridge of the nose that the resident reported had been present for over a week and had been reported to staff. The only action taken, per the resident, was application of a bandage, and the area was attributed by the resident to CPAP mask pressure without a cushion. Facility policy required regular skin assessments, daily observation for skin breakdown, and prompt documentation and assessment of any pressure injuries, but the admission and subsequent skin assessments did not note this area, the EMR contained no documentation of the nasal wound or bandage, and the ADON, though having seen a bandage previously, was unaware an ulcer had developed.
A resident with Type 2 DM and long-term insulin use was admitted with physician orders and a hospital discharge list specifying 30 units of Insulin Aspart after meals, including an evening dose that had been missed in the hospital, as well as bedtime blood glucose monitoring. Facility policy required medications to be administered per physician orders and documented on the eMAR. The resident reported that her medications and scheduled insulin were not available on admission and that it took two days before she received them. Review of the eMAR showed no documentation that the ordered evening insulin dose or bedtime blood sugar check were provided on the admission date, and the ADON confirmed that these evening and bedtime medications, including the 30 units of Insulin Aspart, were not administered.
Surveyors found that a resident was receiving risperidone without a documented psychosis diagnosis, identified target behaviors, or a care plan addressing antipsychotic use, despite facility policy requiring these elements for psychotropic medications. The physician’s order linked risperidone to vascular dementia with behavioral disturbance, but staff, including CNAs and an LPN, described the resident as generally pleasant, non-aggressive, and mainly impatient with frequent call light use and occasional yelling for help. The interim DON acknowledged that the record lacked a psychosis diagnosis, behavior tracking, and a care plan related to the antipsychotic, and could not provide evidence to justify the medication.
A resident with documented diagnoses of Bipolar Disorder, MDD, and ADHD was admitted with these conditions present, but the Level I PASRR screening incorrectly indicated that no mental health diagnosis was known or suspected and that no Level II PASRR was required. The staff member responsible for PASRR review at the time of admission did not ensure the resident’s mental illness diagnoses were reflected on the Level I screen, and an LPN/MDS coordinator later confirmed that no Level II PASRR had ever been completed for this resident.
A resident receiving PRN O2 via nasal cannula at 2–4 L had in-use O2 tubing and a humidifier bottle that were not changed and dated weekly as required by facility policy and physician orders. On multiple observations, the nasal cannula tubing remained dated from a prior week and the humidifier bottle in use had no date, while humidified O2 was being administered. The interim DON acknowledged that O2 tubing and humidifiers are supposed to be changed weekly, typically on Sunday nights, and could not explain why this resident’s equipment had not been changed.
The facility did not ensure that multiple-occupancy rooms met the minimum 80 square feet per resident requirement, despite housing two residents in several rooms identified as undersized. A CMS census form documented the total number of residents, and a state health department letter granted a waiver for specific rooms, subject to annual review. The administrator acknowledged that certain rooms were below the required size, provided a floor plan listing these rooms, and stated that the waiver is submitted annually while confirming that two residents are placed in these waived rooms and that any resident may be assigned there with a roommate.
A resident with multiple neurological and metabolic diagnoses was not provided with the prescribed carbohydrate-controlled, low concentrated sweet (LCS) diet, as he was served apple juice instead of a sugar-free beverage. Staff interviews revealed confusion about dietary orders, and the dietary manager confirmed the error, noting that the resident's care plan and physician orders required strict adherence to a carb-controlled, no added sweets diet.
A facility failed to label and date a multidose insulin pen and a tuberculin vial, as observed by an LPN during a survey. The insulin pen, used for a resident's daily insulin administration, and the tuberculin vial, used for any resident, were both found without open date labels. The Director of Nursing confirmed that these items should have been labeled according to the facility's policy and manufacturer guidelines.
A facility failed to conduct a PASARR Level II evaluation for a resident who developed new severe mental illness diagnoses after admission. Initially admitted with depression, the resident later received diagnoses including bipolar disorder and vascular dementia with severe psychotic disturbance. Despite these changes, the facility did not perform the necessary PASARR re-screening or Level II evaluation, as confirmed by an LPN who was unaware of the requirement.
A facility failed to follow hand hygiene protocols during catheter care for a resident with an indwelling urinary catheter. Two CNAs assisted the resident to bed and removed clothing with gloved hands. One CNA changed gloves without washing or sanitizing hands and performed catheter care. The lapse was confirmed by the CNAs and the Assistant Director of Nursing/Infection Preventionist.
The facility failed to obtain physician orders and develop care plans for oxygen use for two residents. One resident was receiving oxygen at 4.5L without a physician order or care plan, while another was receiving oxygen at 4L despite an order for 2L. These actions did not comply with the facility's policies on medication administration and care planning.
The facility did not ensure rooms for multiple residents met the 80 square feet per resident requirement, affecting 31 rooms. A waiver was granted for specific rooms, allowing them to be smaller, subject to annual review. The administrator confirmed the deficiency and provided a floor plan highlighting the affected rooms.
The facility failed to provide timely access to personal funds for 18 residents, as required by its policy. Residents reported being unable to access their money due to the facility waiting on a corporate check, with no cash available since early December. The LPN managing the business office confirmed the issue, despite the administrator's denial of any hold on the resident trust.
The facility failed to notify the health care power of attorney for two residents of significant changes in their conditions. One resident with CHF was transferred to the ER and evaluated for hospice without notifying their power of attorney due to unreachable contact information. Another resident was transferred to the hospital for pneumonia and CHF exacerbation, but their power of attorney was not informed because the facility overlooked the contact information in the medical record.
A resident experienced a fall resulting in a wrist injury, but the facility failed to notify the physician and the resident's representative promptly. The incident was not reported by the CNA who found the resident on the floor, and the LPN did not communicate the injury to the necessary parties. The DON confirmed the lapse in notification, which is against the facility's policy.
The facility failed to complete physician-ordered treatments and monitoring for three residents with wounds. A resident with a left stump and buttock wounds had multiple missed treatments and infection monitoring. Another resident with Peripheral Vascular Disease had missed skin checks and wound care for a right ankle wound. A third resident with a history of pressure ulcers had missed daily skin checks. The DON confirmed the missing treatments, citing the use of agency nurses as a potential cause.
The facility failed to provide a varied activity program for its 43 residents due to the absence of an Activity Director since October 2023. The interim director, a CNA without formal training, only assisted occasionally, leading to repetitive activities and no weekend staff. Residents reported a lack of engagement, with some unable to participate in the limited activities offered.
The facility failed to employ a qualified Activity Director, impacting the activities program for 43 residents. The interim director, a CNA/Activity Aide, lacked formal training and certification, serving in the role for four months without meeting the facility's policy requirements. The facility has been without a certified Activity Director since late 2023.
The facility failed to verify the Nurse Aide Registry for five CNAs before hiring, potentially affecting all 43 residents. Due to staffing issues, the Administrator in Training had no documentation of registry checks prior to January 2024 and had to perform these checks retrospectively. Specific instances include CNAs hired between October 2023 and May 2024, with registry checks delayed by days to months.
The facility lacks sufficient qualified dietary staff, affecting all 43 residents. The Food Service Manager is not certified and lacks a nationally recognized certification in food service management. The facility does not employ a full-time dietician, relying on a dietician who visits twice a month.
The facility did not provide a posted alternatives or always available menu for residents during mealtimes, affecting all 43 residents. Only the main meal and one alternative, usually leftovers, were displayed. The Dietary Manager confirmed the absence of additional posted options, leaving residents unaware of available choices like cottage cheese, cold sandwiches, and soups.
The facility failed to serve palatable food at lunchtime, affecting all 43 residents. The meal included a pork fritter that was described by residents as overcooked, rubbery, tasteless, and difficult to chew. Observations confirmed these issues, and the Dietary Manager acknowledged receiving complaints, suggesting the cook may have overcooked the meat.
The facility failed to maintain a clean kitchen environment, lacking a cleaning schedule and dishwasher detergent. Observations revealed unclean ovens and an empty detergent container, confirmed by the Dietary Manager and Aide. This deficiency potentially affects all 43 residents, as meals are prepared in this kitchen.
The facility failed to monitor infections, identify necessary precautions, and provide PPE for staff. The DON and Infection Preventionist did not track infections, and multiple residents lacked PPE and disposal bins for infection control. Additionally, the supply room was inadequately stocked, with restricted access to necessary PPE, affecting all 43 residents.
The facility failed to implement its Antibiotic Stewardship Program, as neither the DON nor the Infection Preventionist tracked resident infections or used standards to define infections. The logs from January to May 2024 lacked documentation of infection signs, symptoms, and culture results, affecting all 43 residents.
A resident experienced a malfunctioning bathroom light that had been an issue for a couple of months. The light was dim and flickering, requiring multiple attempts to turn on. The maintenance staff was aware of the problem but had not yet repaired it, causing inconvenience to the resident.
A facility failed to report an injury of unknown origin for a resident to the state agency, as required by their Abuse Prevention Program. The Administrator in Training did not investigate the resident's injuries, which included purpura and a scratch, believing them to be non-concerning due to the resident's history of easy bruising. The resident's spouse expressed concerns about improper handling by aides and reported communication issues with the administrator.
A resident's injury of unknown origin was not investigated by the facility, violating their Abuse Prevention Program. The Administrator in Training dismissed the need for an investigation into the resident's arm injuries, despite previous similar incidents being investigated. The resident's spouse raised concerns about improper handling by aides, which were not addressed by the facility.
A facility failed to implement a restorative walking program for a resident recommended to participate in a walk-to-dine program to prevent functional decline. The resident was not observed walking with his walker, and he reported not walking due to insufficient assistance. The DON was unaware of the walking program, and a CNA noted the resident usually propels himself in a wheelchair and can walk with a walker in his room.
A resident with a history of urinary retention and sepsis was found with their catheter bag and tubing on the floor, contrary to facility policy and CDC guidelines. Despite being relatively independent, the resident's preference for a low bed may have contributed to this improper placement. Staff confirmed the catheter bag should not touch the floor, but the issue persisted.
A resident with COPD and acute respiratory failure was found to have oxygen therapy administered incorrectly, with undated tubing and equipment resting on the floor. The facility's policy requires weekly changes and proper documentation of oxygen equipment, which was not adhered to. Staff noted the resident often adjusted his oxygen flow independently.
The facility failed to use non-pharmacological interventions before administering psychotropic medications and did not identify target behaviors for two residents. One resident was given Seroquel without prior behavior tracking or documentation of non-pharmacological attempts. Another resident was on Quetiapine for psychotic disorder and dementia, but behavior monitoring showed no observed behaviors, and the consent form lacked a diagnosis or target behaviors. The DON admitted to not knowing the resident's behaviors, and a pharmacy report highlighted the need for updated records.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An LPN administered incorrect dosages of Carbidopa-Levodopa and Gabapentin to two residents, affecting their treatment for Parkinson's Disease and polyneuropathy. The errors were due to a misunderstanding of the correct dosages, as confirmed by the Director of Nursing.
The facility failed to ensure rooms met the required 80 square feet per resident in multiple resident rooms, affecting 16 residents. The Minimum Data Set Coordinator confirmed the deficiency, and the facility submitted a waiver to the State Agency, but the Administrator in Training could not provide the date of the last submission.
Inaccurate Controlled Substance Documentation and Narcotic Count Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and timely documentation and accountability for controlled substances, including failure to follow its own narcotic counting and documentation policies. During review of the B/C hall Narcotic Book, the Shift Change Controlled Substance Inventory Sheet for a morning shift change was found to be signed only by the oncoming day nurse; the off‑going night LPN did not sign the form as required. The Assistant DON confirmed that both nurses are required to participate in the narcotic count and sign the sheet at shift change to verify the counts are correct. Further review of controlled substance documentation showed that an LPN pre‑signed controlled medications as if administered before actually giving them. For one resident’s hydrocodone/APAP (Norco), the Controlled Substance Proof of Use form was not in the narcotic book but on the nurse’s desk and showed the 11:00 a.m. dose of two tablets signed out, bringing the count to zero, even though the medication had not yet been given. For another resident’s pregabalin (Lyrica), the card contained 16 pills, but the Proof of Use form showed the 12:00 p.m. dose already signed out, reducing the documented count to 15. The LPN confirmed she had signed out these controlled medications ahead of time and acknowledged she knew this was not permitted. For a third resident receiving liquid morphine 100 mg/5 ml, there were multiple discrepancies between the amount documented on the Controlled Drug Receipt/Record/Disposition Form, the actual volume in the bottle, and the MAR and progress notes. At the time of reconciliation, the bottle contained 24 ml, while prior entries showed inconsistent volumes and missing or incorrect subtractions, including an instance where the documented remaining volume did not mathematically match the dose given and no explanation was recorded. Several doses were signed out on the controlled drug record on specific dates but were not documented as administered on the MAR, and in some cases there were no corresponding progress notes. A later “count correction” entry changed the documented volume from 25 ml to 24 ml without any recorded administration between those dates, and staff acknowledged they had attempted to clarify the amount in the bottle due to apparent subtraction errors. The Administrator and Assistant DON confirmed that the MAR and narcotic sheet should match for controlled medication administration and that these discrepancies should have been identified.
Failure to Provide Proper Wheelchair and Shower Equipment for Obese Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not providing an appropriately sized wheelchair and suitable shower equipment. The resident, who has morbid obesity and depression, was documented as cognitively intact, requiring a wheelchair for mobility, two staff for transfers, and one to two staff for showers. The resident’s care plan included a goal that she would not refuse to come out of her room, get out of bed, and socialize with others, and indicated she required staff assistance for showers. However, shower records showed she received only one shower over several weeks, and there was no documentation of a wheelchair assessment in the medical record or therapy notes. An OT treatment note did not include a wheelchair assessment, and the Interim DON confirmed there was no evidence of any such assessment to recommend a proper wheelchair or positioning. The resident reported that the facility did not have a wheelchair that fit her, leaving her confined to her room and mostly in bed, and that she had only been showered once since admission. She stated she brought a shower chair from home because the facility had no way to give her a shower, but staff told her it was not safe to use, and a scheduled shower was canceled because staff were too busy. The Administrator confirmed that two bariatric wheelchairs had been ordered and delivered but neither fit the resident comfortably, and no further wheelchairs had been obtained. The ADON stated the available wheelchair was too tall and uncomfortable, that the facility was limited in wheelchair sizes, and that they were unable to find a safe shower chair for the resident. CNAs confirmed the resident did not have a fitting wheelchair, could not go to the shower room, was bathed in bed, and sat on the side of the bed to eat. During observation, the resident was unable to sit safely and comfortably in the bariatric wheelchair, and the ADON verified it was not safe for her to sit in it alone. The ADON also confirmed that only one shower was documented for the resident and stated that if showers were not documented, they did not occur.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide RN services for at least eight consecutive hours daily, seven days a week, and failed to employ a full-time DON to oversee the nursing department. The facility’s Director of Nursing job description dated 7/2023 states that the DON is responsible for planning, organizing, developing, and directing the overall operation of the nursing department in accordance with applicable regulations to ensure quality care. The facility assessment dated 1/4/2026 documents that a DON is required to meet residents’ needs. A list titled “Days without RN coverage as of 1/5/26,” provided by the Administrator, showed there was no RN coverage on 12/10/25, 12/14/25, 12/25/25, 12/27/25, 12/28/25, and 1/2/26. The Administrator confirmed there was no RN coverage on those dates and acknowledged the requirement for a minimum of eight consecutive hours of RN coverage seven days a week, further stating that the facility was having difficulty obtaining RN coverage and that the company did not allow the use of agency RNs. The facility also did not have a full-time DON. The Administrator identified a Regional Nurse as the current interim DON and stated that this individual was in the building only about twice a week, a practice that had been in place for approximately one to one and a half months while the facility searched for a permanent DON. The interim DON provided a list of days worked in December 2025, documenting presence in the facility on only six specific dates and confirming that they were at the facility only one to two times per week, although they reviewed the 24-hour nursing report daily. CMS Form 671 dated 1/4/26 and signed by the Administrator documented that 53 residents resided in the facility at the time these deficiencies occurred.
Failure to Properly Label, Date, Store, and Sanitize Food and Kitchen Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow policies for labeling, dating, storage, and sanitation of food and equipment. The facility’s policies required all refrigerated and frozen foods, as well as dry goods, to be labeled and dated upon receipt and when opened, and to be discarded according to safe food storage guidelines or manufacturer expiration dates. Policies also required drawers and cabinets in the dietary department to be cleaned weekly or more often as needed. During an initial kitchen visit, surveyors observed a cabinet without a door that contained accumulated debris and loose wood pieces at its base, while clean dishes were stored in this compromised area. Other kitchen cabinets were also in disrepair and had food and debris on their exterior surfaces. The dietary aide confirmed the presence of dirt and debris on cabinets where clean dishes were stored and stated that the manager was aware the cabinets were an issue. Further observations in the refrigerator, freezer, and dry storage revealed multiple opened food items that were not labeled or dated, as well as items that were past their expiration dates. In the refrigerator, surveyors found an open bottle of food and liquid thickener mix, sliced cheese, sliced ham, sliced turkey, and a carton of scrambled egg mix, all opened and undated. They also found an open container of French dressing labeled with an expiration date that had passed, opened bags of carrots with expired dates, several condiment containers with unknown sauces that were unlabeled and undated, and leftover cake labeled with an expiration date that had passed. In the freezer, opened bags of bread sticks, cinnamon rolls, and mixed vegetables were not labeled or dated. In the dry storage room, opened bags of bread and stuffing mix lacked opened dates, and three large containers of cereal were stored without labels or dates. The dietary manager verified each of these observations, acknowledging that the foods were opened and undated, some were expired and should have been discarded, and that all foods should be labeled and dated and cabinets cleaned and in good repair. The CMS Form 671 documented that 53 residents resided in the facility at the time of the survey.
Failure to Document and Track Staff COVID-19 Vaccination, Education, and Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of COVID-19 vaccination processes for employees. The facility’s own Interim COVID-19 Vaccination Guidelines for Residents and Employees, dated 12/2025, require that staff be provided education on the risks, benefits, and potential side effects of the COVID-19 vaccine, be offered the vaccine or information on obtaining it, and that the facility maintain documentation of staff education, vaccination status, and refusals, including information needed for NHSN reporting. The CMS Form 671 dated 1/5/26 and signed by the Administrator documents that 53 residents reside in the facility. During interviews, the Infection Preventionist stated there was no log of employees who had received the COVID-19 vaccine and no record of employees who refused it. The Administrator confirmed that the facility did not keep COVID-19 vaccination logs for employees, did not have employees sign a refusal form, and did not track education provided to new employees who refused the COVID-19 vaccination. As a result, the facility failed to document and track employee COVID-19 education, vaccine administrations, and vaccine refusals as required by its policy.
Mismatch Between POLST Orders and Documented Advanced Directives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ electronic medical records (EMR), care plans, and physician order sheets accurately reflected and matched their completed Physician’s Orders for Life-Sustaining Treatment (POLST) forms for scope of treatment. The facility’s Advance Directives policy requires that when a resident has an advance directive regarding CPR or scope of treatment (POLST), appropriate forms are completed, a specific physician order is obtained for each directive, and the directives are included in the resident’s plan of care. For four residents reviewed for advance directives, the EMR face sheets and physician order sheets documented only a Do Not Resuscitate (DNR) status and did not incorporate the additional treatment preferences specified on their POLST forms. For one resident, the EMR face sheet and physician order sheet listed “Advanced Directives: DNR,” and the care plan documented that the resident had signed a valid DNR and instructed staff not to resuscitate if there was no breathing or pulse. However, the resident’s POLST, signed by the resident, also directed that if not in cardiac arrest and with a pulse, staff should follow “Selective Treatment,” including limited medical measures such as non-invasive positive airway pressure (CPAP/BiPAP), IV fluids, antibiotics, vasopressors, antiarrhythmics, and hospital transfer if indicated. These additional scope-of-treatment instructions were not reflected in the care plan, EMR face sheet, or physician order sheet. Similarly, three other residents had EMR face sheets and physician order sheets that documented only DNR status, and their care plans addressed only the DNR directive. Their signed POLST forms, however, contained more detailed instructions for care when not in cardiac arrest, including “Selective Treatment” or “Limited Additional Interventions,” specifying use of medical treatments such as antibiotics, IV fluids, cardiac monitoring, non-invasive airway support, hospital transfer with general avoidance of ICU, and, for one resident, a defined six-month trial of artificial nutrition by tube. These POLST directives were not incorporated into the residents’ care plans or reflected on the EMR face sheets and physician order sheets. In interviews, an LPN stated that nurses rely on the EMR status board/face sheet to determine advanced directives in an emergent situation, and the Administrator and Interim DON confirmed that POLST instructions should be reflected in the EMR and care plans and that these documents should match the residents’ wishes.
Failure to Offer and Document Bedtime Snacks for Residents
Penalty
Summary
The facility failed to ensure that bedtime snacks were offered and provided in accordance with residents’ needs, preferences, and the facility’s own policy, which required staff to provide a bedtime snack and/or fluids as appropriate to promote comfort and relaxation before sleep. Review of the electronic health records for six residents showed no documentation that they were offered or received bedtime snacks. During a resident council meeting, all six residents reported that staff did not come around to offer bedtime snacks; several stated they had to specifically request a snack and that staff sometimes forgot to bring it, while others reported they were not aware they could request a bedtime snack but would like to have them offered. The Dietary Manager stated that dietary staff place a sealed box of bedtime snacks on the nurses’ desk each evening and do not offer snacks directly to residents, and the Interim DON stated that CNAs were expected to offer snacks to all appropriate residents but confirmed there was no documentation that these residents received any bedtime snacks. No additional medical history or clinical conditions for the involved residents were documented in the report.
Failure to Assess and Document CPAP-Related Nasal Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its own pressure injury and skin assessment policies for a cognitively intact resident who used a CPAP device and was assessed as being at moderate risk for pressure ulcers on multiple Braden Scale assessments. Facility policy required that pressure ulcers and other ulcers be assessed and measured at least every seven days by a licensed nurse, that each resident be observed daily for skin breakdown by CNAs with changes promptly reported to the charge nurse, and that the earliest sign of a pressure injury be documented in the clinical record and nursing progress notes with notification to the physician and resident or representative. The resident’s admission skin assessment and subsequent Braden Scale assessments did not document any pressure ulcer or skin alteration on the bridge of the nose, despite the resident’s use of a CPAP mask. Surveyor observation found the resident lying in bed with a CPAP device in place and, shortly thereafter, sitting on the edge of the bed with a bright red, dime-sized area on the bridge of the nose. The resident reported that this area had been present for over a week, was painful, and had been reported to staff about a week earlier, with the only response being application of a bandage. The resident stated the breakdown was caused by the CPAP mask due to the absence of a cushion and that the area hurt when touched or when the mask contacted it. The electronic medical record contained no documentation of the nasal area or the application of a bandage. The Assistant DON acknowledged seeing a bandage on the bridge of the resident’s nose previously but stated she was not aware that the resident had developed an ulcer there, confirming that the area had not been identified, assessed, or documented as a pressure injury in accordance with facility policy.
Failure to Administer Ordered Insulin and Perform Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to administer physician-ordered insulin and perform ordered blood glucose monitoring for a resident with Type 2 Diabetes Mellitus and long-term insulin use. Facility policy dated 1/2015 requires medications to be administered in accordance with physician orders and documented on the Medication Administration Record. The resident was admitted with diagnoses including Type 2 Diabetes Mellitus and long-term insulin use, and the physician orders dated 12/11/25 specified Insulin Aspart 100 UNIT/ML, 30 units subcutaneously after meals for Type 2 Diabetes. The hospital discharge medication list for the same date documented that the resident was prescribed 30 units of Insulin Aspart that evening because an evening dose had not been given in the hospital. On interview, the resident reported that upon admission the facility did not have her medications or scheduled insulin and that it took two days before she received her medications. Review of the electronic Medication Administration Record (eMAR) for 12/11/25 showed no documentation that the resident received the scheduled 30 units of Insulin Aspart or that a bedtime blood sugar check was performed. The Assistant DON confirmed that if medications are not marked off on the eMAR, they were not given, and verified that the resident did not receive her evening or bedtime medications on 12/11/25, including the ordered 30 units of Insulin Aspart from the hospital discharge medication list. The resident’s admission time was confirmed as 6:49 PM on that date.
Lack of Diagnosis, Behavior Monitoring, and Care Plan for Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its Behavioral Health Services Program policy for the use of psychotropic medications, specifically antipsychotics, for a resident receiving risperidone. The policy dated 1/2023 requires that psychotropic medication care plans include the indication or rationale for use, specific target behaviors, and monitoring for efficacy and adverse consequences. For this resident, the care plan dated 1/6/2026 did not document a psychosis medical diagnosis, did not identify specific target behaviors, and did not include any care plan interventions related to antipsychotic use. The physician’s order sheet listed risperidone 1 mg as related to vascular dementia, mild, with other behavioral disturbance, but there was no corresponding behavioral documentation or behavior tracking in the record to support the need for an antipsychotic. Surveyor observations and staff interviews further showed an absence of behaviors that would typically warrant antipsychotic use. The resident was observed resting in bed watching a cell phone and later eating lunch peacefully in the dining room, and reported no concerns with the facility. Multiple CNAs and an LPN consistently described the resident as not violent or aggressive toward others, characterizing him instead as impatient, frequently using the call light, and sometimes yelling for help if not assisted quickly. The interim DON confirmed that if there was no psychosis diagnosis, no targeted behaviors, and no care plan addressing antipsychotic use in the record, then the facility did not have the required documentation, and was unable to provide evidence of a mental diagnosis or behavior monitoring to warrant the use of risperidone.
Failure to Complete Required Level II PASRR for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with documented serious mental illness diagnoses received a required Level II PASRR evaluation upon admission. The resident’s Level I PASRR, dated 7/23/25, indicated that no mental health diagnosis was known or suspected and concluded that no Level II PASRR was required, stating there was no evidence of a PASRR condition such as intellectual/developmental disability or serious behavioral health condition. However, the resident’s care plan, dated 1/6/26, shows that at the time of the most recent admission the resident had diagnoses of Bipolar Disorder, Major Depressive Disorder (MDD), and Attention-Deficit Hyperactivity Disorder (ADHD), and the LPN/MDS coordinator confirmed these diagnoses were present on the original admission. The LPN/MDS coordinator also confirmed that no Level II PASRR had been completed for this resident and that the former Social Services Director had been responsible for reviewing records and PASRR results at the time of the original admission, during which the resident’s mental illness diagnoses were not listed on the Level I screening. This discrepancy between the resident’s known mental health diagnoses at admission and the information recorded on the Level I PASRR screening led to the failure to initiate the required Level II PASRR review for a resident with Bipolar Disorder, MDD, and ADHD.
Failure to Change and Date Oxygen Tubing and Humidifier Weekly
Penalty
Summary
The facility failed to follow its own policy for changing oxygen and respiratory equipment for a resident receiving oxygen therapy. The facility’s policy dated 12/2025 required nasal cannulas and oxygen humidifiers to be changed weekly or as needed and to be dated when changed, in order to ensure safety and minimize infection transmission. A physician order dated 1/5/26 directed that the resident receive oxygen at 2–4 L via nasal cannula as needed, with oxygen tubing to be changed weekly and as needed. On 1/5/26 at 11:05 AM, the resident was observed in bed with oxygen running at 2.5 L with humidity; the nasal cannula tubing in use was dated 12/28 and the humidifier bottle in use had no date. On 1/6/26 at 11:25 AM, the same resident was again observed receiving humidified oxygen via nasal cannula, with the tubing still dated 12/28 and the humidifier bottle still lacking a date. The Interim DON confirmed that residents on oxygen should have their tubing and humidity changed weekly and stated they are usually changed on Sunday nights, but could not explain why this resident’s equipment had been missed. These observations, combined with the documented policy and physician orders, show that the facility did not ensure weekly changing and proper dating of oxygen tubing and the humidification bottle for this resident receiving oxygen therapy.
Noncompliance With Minimum Square Footage Requirements in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure that multiple-resident rooms provided at least 80 square feet per resident, as required, affecting rooms that could house 31 residents. The CMS Form 671 dated 1/4/26, signed by the Administrator (V1), documented that 53 residents resided in the facility. An Illinois Department of Public Health letter dated 4/1/2025 granted a waiver for specific rooms (107-112, 115-119, 201-209, 301-306, 307-311), with the waiver subject to annual review or review at any time the facility did not meet the conditions under which it was granted. During an interview on 1/4/26, the Administrator acknowledged that the facility had rooms that did not meet the 80 square feet per resident requirement and provided a floor plan highlighting rooms 107, 108, 109, 110, 111, 112, 115, 116, 117, 118, 119, 201, 202, 203, 204, 205, 206, 207, 208, 209, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, and 311 as being under the required size. On 1/5/26, the Administrator further stated that the waiver is sent every year to the State Agency and confirmed that the facility places two residents in the rooms covered by the waiver and that any resident could be moved into those rooms with a roommate. No additional resident-specific medical histories or clinical conditions were documented in relation to this deficiency, and the report focused on the room size measurements, the existence of the waiver, and the Administrator’s statements about room occupancy and use of the waived rooms.
Failure to Provide Prescribed Carbohydrate-Controlled Diet
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral infarction, sleep apnea, multifocal motor neuropathy, and polyneuropathies, was not provided with the prescribed carbohydrate-controlled, low concentrated sweet (LCS) diet. During a lunch observation, the resident was served apple juice, which was not compliant with his dietary order for sugar-free beverages. The resident confirmed he consumed whatever was provided, and the meal ticket indicated he should have received a diet beverage and sugar-free hot chocolate. The certified nursing assistant stated she only checks the name on the meal ticket, while the cook is responsible for assembling the tray based on the ticket. The dietary manager confirmed that the resident should not have received apple juice and that the dietary flowsheet specified diet beverages for those on LCS diets. The cook provided apple juice, mistakenly believing it was high in fiber, despite the resident's physician and spouse preferring sugar-free options. The resident's care plan and physician orders both specified a no added salt/carb-controlled diet with no additional sweets, and the facility's policy required adherence to documented diet orders. The failure to follow the prescribed diet was identified through observation, interview, and record review.
Failure to Label and Date Multidose Medications
Penalty
Summary
The facility failed to ensure proper labeling and dating of a multidose insulin pen injector and a multidose tuberculin vial, which were not labeled with an open date. This oversight was observed during a survey when a Licensed Practical Nurse (LPN) accessed the medication cart and refrigerator in the B and C Wing medication storage room. The insulin pen injector, used for a resident with a physician order for daily insulin administration, was found to be 1/3 full and lacked an open date label. Similarly, the tuberculin vial, which was used for any resident in the facility, was also found to be half full and without an open date label. The facility's Medication Storage Policy requires that once any medication or biological package is opened, the facility should follow manufacturer guidelines regarding expiration dates and record the date opened on the medication container. The Director of Nursing confirmed that the multidose insulin pens and tuberculin vials should have been labeled and dated with an open date, as per the facility's policy and manufacturer guidelines. The failure to adhere to these guidelines has the potential to affect all 56 residents residing in the facility.
Failure to Conduct PASARR Level II Evaluation for Resident with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with new diagnoses of mental illness after admission was referred to the state agency for a Level II PASARR evaluation. The facility's policy requires screening all potential admissions on an individualized basis and completing a PASARR Level I for all new and readmissions. This process is meant to determine if the individual meets the criteria for a mental disorder, intellectual disability, or related condition. However, the facility did not conduct a PASARR re-screen or a Level II screening for the resident after new diagnoses of severe mental illness were identified. The resident, identified as R25, was admitted with a diagnosis of depression, which did not initially require a Level II PASARR evaluation. However, subsequent diagnoses included bipolar disorder, psychophysiologic insomnia, vascular dementia with severe psychotic disturbance, unspecified affective mood disorder, delirium due to a known physiological condition, and unspecified psychosis not due to substance or known physiological condition. Despite these significant changes in the resident's mental health status, the facility did not perform the necessary PASARR re-screening or Level II evaluation. A Licensed Practical Nurse confirmed the oversight, stating that they did not realize the need to redo the PASARR after new diagnoses were made.
Failure in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during the provision of urinary catheter care for a resident with an indwelling urinary catheter. The facility's policy mandates that hand hygiene should be performed before and after touching any part of the urinary catheter drainage system. However, during an observation, two Certified Nursing Assistants (CNAs) were seen preparing to perform catheter care for a resident diagnosed with Retention of Urine, Benign Prostatic Hyperplasia, and Obstructive and Reflux Uropathy. The CNAs assisted the resident to bed and removed the resident's clothing with gloved hands. One CNA, after removing her gloves, reapplied new gloves without washing or sanitizing her hands and proceeded to perform the catheter care. Throughout the procedure, the CNA failed to wash or sanitize her hands, even when changing gloves and moving from dirty to clean areas. This was confirmed by the CNAs themselves, who acknowledged the lapse in hand hygiene. The Assistant Director of Nursing/Infection Preventionist also verified that the CNA should have washed her hands before and during the catheter care procedure. The CNA admitted to not using hand sanitizer due to the inconvenience of bringing a large bottle into the resident's room.
Failure to Obtain Physician Orders and Develop Care Plans for Oxygen Use
Penalty
Summary
The facility failed to obtain a physician's order and develop a care plan for oxygen use for two residents, R16 and R21. R21 was observed lying in bed with oxygen flowing at 4.5 liters per nasal cannula, but there was no physician order for this oxygen use, nor was there a care plan addressing it. This was confirmed by both an LPN and the Director of Nursing, who acknowledged the absence of a physician order and care plan for R21's oxygen use. Similarly, R16 was observed with oxygen flowing at 4 liters per nasal cannula, despite having a physician order for oxygen at 2 liters via nasal cannula as needed. An LPN confirmed that R16's oxygen was set higher than the ordered amount. These observations indicate a failure to adhere to the facility's policies regarding medication administration and comprehensive care planning, which require following physician orders and developing care plans that address residents' medical needs.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that rooms housing multiple residents met the required minimum of 80 square feet per resident. This deficiency was identified through observation, interview, and record review, affecting 31 rooms that could potentially house 31 residents. The facility's application for Medicare and Medicaid documented 56 residents residing within the facility. An Illinois Department of Public Health letter granted a waiver for specific rooms, allowing them to be less than 80 square feet per resident, subject to annual review. The administrator confirmed that the facility has rooms not meeting the 80 square foot requirement and provided a floor plan highlighting these rooms. The administrator also stated that the waiver is submitted annually to the State Agency, and rooms with waivers accommodate two residents, with any resident potentially being moved to these rooms with a roommate.
Failure to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to provide access to personal funds for 18 residents whose money was managed by the facility. According to the facility's Resident Funds policy, requests for access to funds should be honored promptly, with same-day access for amounts less than $100 and within three banking days for larger amounts. However, residents reported being unable to access their funds due to the facility waiting on a check from corporate. This issue was confirmed by the Licensed Practical Nurse (LPN) who was temporarily managing the business office, indicating that there had been no cash available since December 3rd. Residents expressed their frustration, with one resident stating they had been unable to withdraw $150 for Christmas shopping. The facility's Resident Council meeting minutes also reflected ongoing issues with the management of resident funds, noting the absence of a permanent Business Office Manager and limitations on cash availability. Despite the administrator's denial of any hold on the resident trust, the evidence from interviews and records indicated that residents' requests for funds were not being fulfilled in a timely manner, as required by the facility's policy.
Failure to Notify Health Care Power of Attorney of Change in Condition
Penalty
Summary
The facility failed to notify the health care power of attorney of a change in condition for two residents, R5 and R19, as required by their policy. R5, who was admitted with a diagnosis of congestive heart failure, experienced shortness of breath, altered mental status, and tachycardia, leading to a transfer to the emergency room and a subsequent hospice evaluation. Despite these significant changes, there was no documentation of notification to R5's health care power of attorney, V12. The Social Service Director, V7, admitted to being unable to contact V12 and confirmed the absence of any documented attempts to reach him, as the phone number listed was not in use. Similarly, R19, admitted after a fall with a hip fracture and other health issues, was found unresponsive and transferred to the hospital for pneumonia and exacerbation of congestive heart failure. The facility failed to notify R19's health care power of attorney, V11, due to the belief that her phone number was unavailable, despite it being documented in R19's medical record. The Director of Nursing, V2, confirmed the oversight and acknowledged that V11's phone number was not listed on the face sheet as it should have been.
Failure to Notify Physician and Representative After Resident Fall
Penalty
Summary
The facility failed to promptly notify the physician and the resident's representative after a fall with an injury occurred. The incident involved a resident who sustained an unwitnessed injury of unknown origin, first noted at midnight. Despite the resident's vocal complaints of pain and visible signs of discomfort, the practitioner, resident's responsible party, and interested party were not notified at the time of the event. The facility's policy requires immediate notification of changes in a resident's condition, but this protocol was not followed. The deficiency was further highlighted when the resident's representative discovered the injury during a visit and was informed by staff that the resident had fallen the previous day. The LPN acknowledged that the fall and subsequent swelling of the resident's wrist were not communicated to the primary physician or the representative. Additionally, a CNA who found the resident on the floor did not report the incident, mistakenly believing it did not constitute a fall. The Director of Nursing confirmed the failure to notify the appropriate parties immediately after the fall and the injury.
Failure to Complete Physician-Ordered Treatments and Monitoring
Penalty
Summary
The facility failed to ensure that physician-ordered treatments, skin checks, and infection monitoring were completed for three residents with wounds. For the first resident, several treatments for wounds on the left and right inner buttocks, as well as the left stump, were not completed on multiple occasions in June and July 2024. The resident had a history of hospitalizations for infections and other health issues, and the Treatment Administration Record (TAR) showed numerous missed treatments and monitoring for signs of infection. The second resident, who had Peripheral Vascular Disease and was at risk for skin tears, also experienced missed treatments. The TAR indicated that daily skin checks and wound care for a right ankle wound were not completed on several occasions in June 2024. Additionally, monitoring for signs of infection and the application of protective barrier cream were not consistently administered. The third resident, with a history of pressure ulcers and other health conditions, had missed daily skin checks in July 2024. The Director of Nursing confirmed the missing treatments for the second and third residents, acknowledging that the lack of documentation meant there was no proof the treatments were completed. The facility's reliance on agency nurses was suggested as a reason for the missed treatments.
Lack of Activity Program Variety and Staffing
Penalty
Summary
The facility failed to provide an ongoing program of a variety of activities for all residents, affecting the physical, mental, and psychosocial well-being of the 43 residents. The facility's activity policy mandates a diverse program under the direction of an Activity Director, but the position has been vacant since October 2023. The interim Activity Director, a Certified Nurse Assistant without formal training, only assisted with activities three days per month. The activity calendars for April, May, and June 2024 showed little variety, with repetitive card games and Bingo, and lacked activities for residents unable to participate in these games. There were no activity staff on weekends, and residents reported a lack of activities during these times. Specific residents expressed dissatisfaction with the activity program. One resident stated there were no activities on weekends and desired more engagement. Another resident, who primarily stays in bed, reported that no activity staff visited her room, and she relied on television and puzzle books for entertainment. A third resident mentioned that card games in the dining room were not organized by the facility but were resident-directed. The Director of Nursing confirmed the limited activity schedule, with only one activity per day, including weekdays.
Lack of Qualified Activity Director
Penalty
Summary
The facility failed to have a qualified Activities professional to direct the provision of activities for all residents, affecting the 43 residents in the facility. The facility's job summary for the Activity Director outlines responsibilities such as planning, scheduling, and implementing an ongoing program of activities to meet the physical, mental, and psychosocial needs of each resident. However, the facility did not have a licensed or certified Activity Director since October 27, 2023, as confirmed by the Administrator in Training. A Certified Nurse Assistant/Activity Aide, who served as the interim Activity Director for four months, admitted to having no formal training, certification, or degree, and only received one day of formal training at another facility. This individual now assists with activities only three days per month. The facility's policy requires the Activity Director to have completed a State-approved Basic Orientation Course, which was not met, leading to the deficiency identified by the surveyors.
Failure to Verify CNA Registry Prior to Hiring
Penalty
Summary
The facility failed to perform registry verification for five Certified Nursing Assistants (CNAs) prior to their hiring, which has the potential to affect all 43 residents residing in the facility. The Administrator in Training (V1) admitted that there was no documentation available to confirm that the Nurse Aide Registry was checked for CNAs V10, V24, V25, V27, and V28 before they were employed. This lapse was attributed to staffing problems, which left V1 without anyone to conduct the verifications, and a lack of documentation prior to January 2024. Consequently, V1 had to retrospectively perform these checks herself. Specific instances include V10 CNA, who was hired on March 22, 2024, but whose registry was not checked until June 4, 2024. Similarly, V24 CNA was hired on May 15, 2024, with the registry checked a day later on May 16, 2024. V25 CNA was hired on January 5, 2024, but the registry was not checked until June 4, 2024. V27 CNA was hired on October 25, 2023, with the registry checked on November 10, 2023. Lastly, V28 CNA was hired on December 15, 2023, and the registry was not checked until June 4, 2024. The facility's CMS Form 671, signed by the Director of Nursing (V2), documented 44 residents currently residing in the facility.
Deficiency in Qualified Dietary Staff
Penalty
Summary
The facility failed to employ sufficient qualified dietary staff, which has the potential to affect all 43 residents. The Food Service Manager, responsible for managing all aspects of the Food Service Department and the nutritional care of all residents, is not certified as a dietary or food service manager, does not have a nationally recognized certification in food service management, and is not currently enrolled in a relevant course. The manager, who started the position in 2024, was previously a dietary aide. Additionally, the facility does not have a full-time dietician employed, relying instead on a qualified dietician who visits twice a month.
Lack of Posted Alternative Menu Options
Penalty
Summary
The facility failed to provide an alternatives or always available menu for residents during mealtimes, potentially affecting all 43 residents. Over several days, the dining room only displayed the main meal and one alternative food choice, which was typically leftovers. The facility did not have a posted menu or list of always available food options for residents who did not prefer the main or alternative meal. The Dietary Manager confirmed the absence of additional posted food options and acknowledged that residents would not know their food choices without them being displayed. Although the facility had items like cottage cheese, cold sandwiches, peanut butter and jelly, soups, and cereal available, these options were not communicated to residents through any posted menu or distributed food menu.
Facility Fails to Serve Palatable Food at Lunchtime
Penalty
Summary
The facility failed to serve palatable food at lunchtime on June 3, 2024, affecting all 43 residents. The menu for that day included a pork fritter with gravy, scalloped potatoes, green beans, and peaches. Multiple residents expressed dissatisfaction with the meal, describing the pork fritter as overcooked, rubbery, tasteless, and difficult to chew. Residents reported that the quality of food was inconsistent and often unappetizing, with some resorting to eating snacks in their rooms instead of the provided meal. Observations confirmed that the pork fritter was hard on the edges, difficult to cut, and lacked flavor. The Dietary Manager acknowledged receiving complaints about the food and suggested that the cook may have overcooked the meat in the convection oven. The manager confirmed that several residents had complained about the meal served at lunchtime on June 3, 2024.
Deficiency in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by the lack of a cleaning schedule and the absence of dishwasher detergent in the dishwashing machine. During a kitchen tour, it was observed that the dishwashing machine did not have detergent, which was confirmed by both the Dietary Manager and a Dietary Aide, who were responsible for monitoring and refilling the detergent. Additionally, the facility's ovens were found to have a buildup of a black sticky substance with tin foil stuck in it, indicating that they had not been cleaned as required. The Dietary Manager acknowledged that the ovens needed cleaning and admitted that there was no established cleaning schedule for the dietary employees, necessitating daily written task assignments. The facility's policies, including the Ware-Washing and Kitchen Sanitation policies, require that utensils and dishes be clean and sanitized and that the Food Service Manager develop a cleaning schedule for the dietary department. However, the facility was unable to provide any documentation of a cleaning schedule or completed cleaning tasks. This deficiency has the potential to affect all 43 residents in the facility, as all residents have diet orders and consume meals prepared in the kitchen.
Inadequate Infection Control and PPE Management
Penalty
Summary
The facility failed to effectively monitor and manage active infections, identify the need for transmission-based precautions, and ensure the availability of Personal Protective Equipment (PPE) for staff. The Director of Nursing (DON) and the Infection Preventionist did not track resident infections, as evidenced by the absence of documented signs and symptoms of infection, whether infections were facility-acquired, or if they were cultured. This lack of monitoring was confirmed by the DON and the Infection Preventionist, who admitted to not maintaining an infection tracking log. Multiple residents were affected by the facility's failure to provide necessary PPE and disposal bins for infection control. For instance, a resident with an indwelling catheter had Enhanced Barrier Precautions documented on their door, but no PPE was available outside the room, nor were there disposal bins inside. Similarly, another resident on Contact Precautions for a wound infection had no PPE available, and the Infection Preventionist was unsure if the resident should remain on Contact Precautions or switch to Enhanced Barrier Precautions due to a lack of follow-up culture results. The facility's supply management also contributed to the deficiency, as the clean supply room was inadequately stocked with gloves and gowns, and additional supplies were locked away, accessible only by managers. This restricted access to necessary PPE further hindered staff's ability to adhere to infection control protocols, as they would need to call an on-call manager to access these supplies. The combination of inadequate infection monitoring, unclear precautionary measures, and restricted access to PPE posed a risk to all 43 residents in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program, which is crucial for monitoring and assessing antimicrobial use trends. The program's policy, dated November 1, 2017, emphasizes the importance of regularly assessing antimicrobial use to identify gaps in communication, inconsistencies in documentation, and compliance with facility policies and evidence-based recommendations. However, the facility did not adhere to these guidelines, as confirmed by the Director of Nursing and the Infection Preventionist, who admitted to not tracking resident infections or using a set of standards to define infections. Additionally, they did not encourage physicians to wait for culture results before starting antibiotics. The Resident Infection Control and Antimicrobial logs from January 2024 through May 2024 lacked documentation of signs and symptoms of infection, whether infections were acquired within the facility, or if infections were cultured. This oversight has the potential to affect all 43 residents residing in the facility, as documented in the facility's Long Term Care Facility Application for Medicare and Medicaid. The absence of a structured approach to monitoring antibiotic use and infections indicates a significant deficiency in the facility's infection control practices.
Failure to Maintain Working Bathroom Light
Penalty
Summary
The facility failed to maintain a working overhead light in the bathroom for one resident, identified as R20, among a sample of 43 residents. The deficiency was observed when the bathroom light switch was flipped on, and the light did not work properly. The light was dim and flickering, and it required multiple attempts to turn on. R20 reported that the bathroom light had not been functioning correctly for a couple of months and that the maintenance staff was aware of the issue, attributing it to a bad ballast. Despite this knowledge, the light had not been repaired, causing inconvenience to R20, who had to flip the switch multiple times to use the bathroom light for daily activities like brushing teeth. The maintenance staff, identified as V16, confirmed the issue and acknowledged that the light did not come on immediately and flickered when it did. V16 had been employed at the facility since March 2024 and stated an intention to replace the faulty light. However, at the time of the survey, the light remained unrepaired, indicating a lapse in maintaining a safe and comfortable environment for the resident.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the local state agency, as required by their Abuse Prevention Program. The program mandates that any injury of unknown origin should be investigated as potential physical abuse and reported to the state agency within five working days. However, the Administrator in Training (V1) did not conduct an investigation into the resident's (R11) injuries, which included four scattered areas of open purpura and a superficial scratch on the left upper arm. V1 was notified of the injury on 3/19/24 but did not report it, believing it was not a cause for concern due to the resident's history of bruising easily. The resident's spouse and legal guardian expressed concerns about the bruises, suspecting that the aides were improperly handling the resident by the arms instead of using a gait belt. Despite these concerns and previous investigations into similar bruising incidents, V1 did not investigate the March occurrence or notify the state agency. The spouse also reported difficulties in communicating with V1, who allegedly avoided addressing these concerns. This lack of action and communication contributed to the facility's failure to adhere to its abuse prevention policy and state reporting requirements.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, identified as R11, which is a violation of their Abuse Prevention Program. The program mandates that all injuries of unknown origin should be investigated as potential physical abuse. Despite this, the Administrator in Training, V1, did not conduct an investigation into the injuries sustained by R11 on the left upper arm, which included four scattered areas of open purpura and a superficial scratch. V1 was notified of the injury on 3/19/24 but dismissed the need for an investigation, citing that R11 frequently gets marks on his arm and did not consider it a concern. R11's spouse and legal guardian expressed concerns about the bruises, suspecting that the aides were improperly handling R11 by the arms instead of using a gait belt for transfers. The spouse reported these concerns to V1, who allegedly avoided addressing them. The facility's records show that V1 had conducted two previous investigations into similar bruising incidents on R11's arms, but she could not articulate why the incident on 3/19/24 was treated differently. This lack of investigation into the injury of unknown origin constitutes a failure to adhere to the facility's abuse prevention policy.
Failure to Implement Restorative Walking Program
Penalty
Summary
The facility failed to implement a restorative walking program for a resident, identified as R43, who was recommended to participate in a walk-to-dine program to prevent decline in function and mobility. Despite the recommendation documented in the resident's physical therapy discharge summary dated 5/30/2024, R43 was not observed walking with his walker during the survey period. On 6/2/24, R43 expressed that he no longer walks because there is not enough help to assist him. On 6/4/24, the Director of Nursing (V2) was unaware of R43's walking program and confirmed that to her knowledge, R43 does not walk to or from meals. Additionally, on 6/5/24, a Certified Nurse Assistant (V11) stated that R43 usually propels himself in his wheelchair and can walk with his walker in his room to the toilet.
Improper Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to a deficiency in infection prevention. The resident, who has a history of urinary retention, urinary device use, and sepsis, was observed on two occasions with their catheter collection bag and tubing resting on the floor. This placement is contrary to the facility's Catheter Care policy and the CDC guidelines, which state that the collection bag should be kept below the bladder level and not rest on the floor. The resident's care plan included interventions to prevent catheter-related trauma and infection, such as positioning the catheter bag and tubing below the bladder level and monitoring for signs of infection. Despite these guidelines and care plan interventions, the resident's catheter bag was found on the floor, and staff members, including a CNA, the MDS Assessment and Care Plan Coordinator, and the Director of Nursing, confirmed that the catheter bag should not touch the floor. The resident was described as being relatively independent and often moved the catheter bag themselves. The Director of Nursing noted that the resident preferred their bed to be lowered to the floor, which may have contributed to the improper placement of the catheter bag. Staff were aware of the issue but had not effectively ensured compliance with the catheter care policy.
Deficiency in Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as R40, by not ensuring that oxygen was infused correctly, that oxygen tubing was dated, and that the tubing was not resting on the floor. The facility's Oxygen Therapy policy requires a physician's written order for oxygen therapy, specifying the liter flow per minute, the type of delivery method, and the time frame. Additionally, the policy mandates that oxygen tubing, masks, and cannulas be changed weekly, with the changes documented on the treatment sheet. However, observations revealed that R40's oxygen concentrator was infusing at 3 liters per minute, contrary to the physician's order of 2 liters per minute via nasal cannula as needed. Furthermore, the oxygen tubing was not dated, and it was observed resting on the floor. R40, who has a medical history of acute respiratory failure with hypoxia, COPD with acute exacerbation, and centrilobular emphysema, was noted to be oxygen-dependent. The resident was observed multiple times with undated oxygen tubing while using both an oxygen concentrator and a cylinder tank. Interviews with staff indicated that R40 often adjusted his oxygen flow and switched between the concentrator and the tank independently. Despite being educated on the proper handling of oxygen equipment, the resident's tubing and nasal cannula were found on the floor, and the Director of Nursing confirmed that the tubing should be changed weekly, dated, and not placed on the floor.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to implement non-pharmacological interventions before administering psychotropic medications and did not identify target behaviors for the use of antipsychotic medications for two residents. For one resident, identified as R19, the facility's records showed an order for Seroquel due to a diagnosis of psychosis. However, there was no behavior charting or documentation of non-pharmacological interventions attempted prior to starting the medication. The Director of Nursing confirmed the absence of behavior tracking before the medication was administered. Observations of R19 showed the resident interacting appropriately with others, yet the medical record lacked documentation of targeted behaviors for the antipsychotic medication. Another resident, identified as R39, was on Quetiapine for stimulant-induced psychotic disorder with hallucinations and dementia with behavioral disturbance. The care plan indicated the use of psychotropic medication for behavior management, but behavior monitoring records showed no observed behaviors. The consent form for the medication was incomplete, lacking a diagnosis or target behaviors. The Director of Nursing admitted to not knowing the resident's psychosis or behaviors and acknowledged the need for a new consent form. A pharmacy consultation report highlighted the need for updated medical records to include specific diagnoses, target behaviors, and documentation of non-pharmacological interventions, which were not adequately addressed.
Medication Error Rate Exceeds 5% Due to Incorrect Dosages
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during a medication pass review. This deficiency affected two residents out of ten reviewed. The first incident involved a Licensed Practical Nurse (LPN) administering an incorrect dosage of Carbidopa-Levodopa to a resident with Parkinson's Disease. The medication card indicated a dosage of 2.5 tablets, but the LPN administered only 1.5 tablets, mistakenly believing it to be the correct dosage. The Director of Nursing confirmed that the correct dosage was indeed 2.5 tablets. The second incident involved the same LPN administering an incorrect dosage of Gabapentin to another resident with polyneuropathy. The physician's order required two capsules of Gabapentin, but the LPN administered only one capsule, along with two Tylenol tablets. The LPN later stated that she thought she had given the correct dosage of Gabapentin. These errors highlight a failure to adhere to the facility's medication administration policies, which emphasize the importance of following the six rights of medication administration.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide rooms that meet the required minimum of 80 square feet per resident in multiple resident rooms. This deficiency affected 16 residents out of a sample of 44, as observed during a survey. The Minimum Data Set Coordinator confirmed that some rooms do not meet the square footage requirement. The facility's floor plan indicated that the rooms occupied by these residents were indeed less than 80 square feet per resident. An undated letter from the Administrator in Training revealed that the facility has submitted a waiver to the State Agency regarding this issue, as the rooms are slightly under the required square footage. However, the Administrator in Training was unable to provide information on when the waiver was last sent.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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