Arcadia Care Toulon
Inspection history, citations, penalties and survey trends for this long-term care facility in Toulon, Illinois.
- Location
- 700 E Main St, Toulon, Illinois 61483
- CMS Provider Number
- 145442
- Inspections on file
- 34
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Arcadia Care Toulon during CMS and state inspections, most recent first.
Two residents with dementia-related diagnoses were involved in a physical altercation when one, known for aggressive behaviors, struck another in the eye while assisting with post-meal cleanup. Despite existing care plans and staff presence, the incident occurred in the Memory Care Unit, and both residents were assessed with no injuries noted. The event was reported according to policy, but the facility did not prevent the physical abuse.
A resident who consistently felt cold was deprived of his personal jacket by a CNA, who removed it in response to the resident's exit-seeking behaviors. The jacket was not returned, leaving the resident to use a blanket for warmth and causing ongoing discomfort. Staff and the DON were aware of the situation, but no further investigation was conducted, and the jacket was never recovered.
A resident's family and Power of Attorney observed the resident was cold and missing his jacket, which a CNA admitted to withholding to prevent the resident from leaving. The incident was documented, but the DON delayed notifying the Administrator, and the allegation was not reported to the state agency as required by policy.
A resident's family and Power of Attorney reported that the resident was left without his jacket and was cold after a CNA took it away due to exit-seeking behaviors, stating she would not return it. Despite the facility's policy requiring investigation of all abuse allegations, no investigation was documented, and the administrator confirmed that none was conducted.
Three residents with significant mobility impairments and care plans requiring full mechanical lift transfers were not consistently transferred using the required equipment. Staff manually transferred a resident when no clean slings were available, and others used alternative methods such as sit-to-stand lifts, despite documentation specifying full mechanical lift use. Staff interviews revealed confusion about transfer requirements and inconsistent communication regarding care plan updates.
A resident was transferred twice to the ER for a leg rash later diagnosed as cellulitis, but the facility failed to complete a thorough and accurate assessment before the second transfer. The LPN used outdated vital signs and did not document current observations, evaluations, or notifications to the physician and family, as required by facility policy. The Assistant DON confirmed these documentation gaps.
A resident identified as at risk for falls did not have the required non-slip material in her wheelchair, as specified in her care plan. Observation confirmed the absence of this intervention, and an LPN verified that the non-slip material was not in place, despite the resident's history of being found in a position suggestive of a fall risk.
Four cognitively impaired residents were involved in two separate incidents of resident-to-resident physical abuse. In one case, a resident with a history of aggression placed his hands around another resident's neck and squeezed, while in another, a resident struck a peer in the face. Both aggressors had documented behavioral issues and prior aggressive episodes, but the facility did not prevent these altercations despite known risks.
A resident with a history of paraplegia, ESBL resistance, and urine retention did not have a urine sample collected in a timely manner as ordered by a physician. The DON completed a lab requisition but did not enter the order into the system, resulting in staff not being alerted to collect the specimen. The urine sample was collected several days late, despite the facility's policy requiring prompt entry of physician orders.
A resident with multiple diagnoses, including Dementia and Schizoaffective Disorder, was physically abused by an agency CNA in a LTC facility. The incident occurred when the resident became combative, and the CNA reflexively struck the resident on the head. The facility's administrator was notified, and the CNA was suspended pending investigation. The incident was reported to the police, and the resident was sent to a hospital for evaluation.
The facility failed to resolve resident grievances in a timely manner, with issues such as unchecked smoke detectors and CNAs using phones while feeding residents repeatedly documented in Resident Council Minutes. The Resident Council President noted that grievances are often unresolved, affecting all 64 residents.
The facility did not schedule a Registered Nurse (RN) for at least eight consecutive hours on specific days, as required by their staffing policy. Instead, only Licensed Practical Nurses (LPNs) were on duty, which was confirmed by the Administrator. This deficiency potentially affects the well-being of all 64 residents in the facility.
The facility did not inform residents that signing an arbitration agreement was not a condition of admission and that they could rescind the agreement within 30 days. This was confirmed through a review of agreements for two residents and an interview with a staff member, affecting all 64 residents.
The facility did not ensure the QAA Committee had the required members or met quarterly. The Administrator, employed for seven months, acknowledged no meetings occurred due to a lack of training. The Medical Director did not attend meetings, and there was no Infection Preventionist since January 2024, potentially affecting all 64 residents.
The facility failed to implement an Antibiotic Stewardship Program, affecting all 64 residents. Despite having a policy, the program was not executed, and there was no monitoring of infections. Two residents had antibiotic orders, but the Regional Director confirmed the absence of a stewardship program, infection monitoring, an Infection Preventionist, and necessary logs.
The facility failed to designate a qualified Infection Preventionist, impacting its ability to manage infection control for all 64 residents. Despite ongoing antibiotic treatments for infections in two residents, the facility lacked documentation for infection monitoring and tracking, and has not had an Infection Preventionist since January 2024.
The facility failed to provide influenza vaccines to eligible residents during the flu season, as required by their policy and state guidelines. Despite having physician orders for annual flu vaccines, no vaccines were administered, and none were available in the medication rooms. The Regional Director of Operations confirmed that an outside company contracted to provide the vaccines had not done so, and the facility had not ordered any vaccines.
A facility failed to complete a PASARR screening for a resident admitted with cerebral infarction, anxiety disorder, and major depressive disorder. The resident's medical record lacked the required screening, which the administrator and Business Office Manager acknowledged was not conducted prior to admission, as the hospital also did not perform it.
The facility did not update care plans for two residents as required. One resident's care plan lacked documentation of hospice services, while another's did not reflect a stage 2 pressure wound despite having wound care orders. The Regional Director of Operations confirmed these omissions.
Two residents were inappropriately prescribed Quetiapine, an antipsychotic medication, without proper indications. One resident with unspecified dementia and a BIMS score indicating cognitive intactness was prescribed Quetiapine for dementia, which is not an appropriate diagnosis for the medication. Another resident was prescribed Quetiapine for sleep, which is also inappropriate. The facility failed to adhere to guidelines for the use of psychotropic medications.
The facility failed to follow its Enhanced Barrier Precaution policy, leading to deficiencies in care for two residents. Staff members, including a registered nurse and CNAs, did not wear gowns during high-contact activities, and a LPN did not use appropriate PPE during wound care. The staff lacked training on EBP, and the facility did not provide accessible gowns, as acknowledged by the Director of Operations.
A resident with anxiety and dementia did not receive 15 doses of prescribed Lorazepam due to unavailability. Several LPNs failed to notify the physician or obtain the medication from the emergency supply, and they incorrectly documented that the medication was administered. The facility did not adhere to its policy requiring physician notification of medication errors.
A resident with anxiety and cognitive impairments did not receive 15 doses of prescribed Lorazepam due to unavailability. LPNs failed to request the medication from the Emergency Box or notify the physician, and they inadvertently documented that the medication was administered. This resulted in a significant medication error.
A resident at high risk for pressure ulcers developed a stage three ulcer due to the facility's failure to implement preventive measures and perform required skin checks and treatments. The resident's care plan lacked necessary interventions, and staff did not consistently reposition the resident or use pressure-relieving devices. Communication issues and the absence of key coordinators contributed to these deficiencies.
A resident in a LTC facility fell out of bed and sustained a femur fracture due to the bed being left in a high position and personal items out of reach. Additionally, the resident fell forward out of a wheelchair in a facility van due to improper securing, resulting in neck and shoulder pain. The facility failed to follow its fall prevention and van usage policies, and did not document or investigate the incidents.
A resident's MDS assessments were inaccurately completed, failing to document a fall with major injury and a pressure ulcer. The facility lacked a dedicated MDS Coordinator, leading to discrepancies in the resident's medical records, as confirmed by the DON and Administrator-In-Training.
A cognitively intact resident was disrespected by an RN who made a rude comment while the resident was on the phone with his mother. The resident felt disrespected, and the incident was confirmed by the facility's Administrator-In-Training.
The facility failed to revise a Comprehensive Care Plan for a resident at risk for wandering and elopement. Despite staff interventions and the resident's documented risk, the Care Plan did not include necessary goals or interventions, as confirmed by the Administrator and DON.
The facility failed to provide adequate supervision for a resident with severe cognitive impairment and a history of falls, leading to the resident's unsupervised exit and fall. All CNAs were in the dining room during mealtime, and no one was assigned to monitor the halls, contrary to the facility's policies.
Failure to Prevent Resident-to-Resident Physical Abuse in Memory Care Unit
Penalty
Summary
The facility failed to prevent physical abuse between residents in the Memory Care Unit, specifically involving two residents with dementia-related diagnoses. One resident, who had a documented history of verbal and physical aggression, was assisting with cleaning after a meal and attempted to remove another resident's lunch tray. The second resident reached out as the tray was being removed, and the first resident responded by striking the second resident in the eye. Staff interviews and record reviews confirmed that the incident occurred in the dining area, and that the aggressive resident had a care plan in place addressing behavioral issues, including interventions to minimize disruptive behaviors. At the time of the incident, staff were present in the unit, and an LPN reported hearing a loud noise and observing the aftermath, with the victim covering his eyes and stating he was hurt. Both residents were assessed following the altercation, and no physical injuries were noted. The facility's policies affirm residents' rights to be free from abuse, and the event was reported to the state agency as required. However, the incident demonstrates a failure to effectively implement interventions and supervision to prevent resident-to-resident physical abuse.
Resident Deprived of Personal Jacket Due to Exit-Seeking Behaviors
Penalty
Summary
The facility failed to protect a resident from abuse by depriving him of his personal jacket, which he relied on for warmth due to his constant feeling of being cold. The resident's jacket was taken by a Certified Nursing Assistant (CNA) because the resident was exhibiting exit-seeking behaviors, and the CNA believed that having the jacket increased these behaviors. The jacket was placed in the shower room and not returned to the resident, despite his repeated requests and complaints of being cold. The resident was observed using a blanket to keep warm in the absence of his jacket, and both the resident and his family reported his ongoing discomfort and distress due to the missing jacket. Multiple staff members, including the Director of Nursing (DON) and other CNAs, were aware that the jacket had been taken and that the resident was left without it for several weeks. The facility's policy prohibits the deprivation of goods or services necessary for residents' well-being, yet no further investigation was conducted by the DON after being notified of the incident. The resident's family and Power of Attorney also raised concerns about the deprivation, but the jacket was never recovered, and the resident continued to experience discomfort as a result.
Failure to Immediately Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was immediately reported to the Administrator and the State Agency, as required by facility policy. According to documentation, a family member and a Power of Attorney visiting a resident noticed the resident was without his jacket and was cold. A Certified Nursing Assistant informed them that she had taken the resident's jacket and placed it in the shower room because the resident wanted to leave the facility, and she was not going to return it. The concern was documented on a facility form, but the Director of Nursing did not notify the Administrator until the following day. Additionally, as of the date of the survey, there was no documentation that the allegation of potential abuse had been reported to the state agency, contrary to the facility's policy requiring immediate reporting.
Failure to Investigate Allegation of Potential Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential abuse involving one resident. According to the facility's own Abuse Prevention and Reporting policy, any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property requires an investigation. On 6/15/2025, a resident's family member and Power of Attorney observed that the resident did not have his jacket and was cold, and were informed by a Certified Nursing Assistant that she had taken the jacket because the resident was exhibiting exit-seeking behaviors and intended to keep it from him. This incident was documented on a Concern/Compliment Form, but as of 9/17/2025, there was no documentation of any investigation into the allegation. The facility administrator confirmed that no investigation had been conducted regarding this potential abuse.
Failure to Use Required Mechanical Lifts for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents who required a full mechanical lift for transfers were consistently transferred using the appropriate equipment, as specified in their care plans and facility policy. Observations, interviews, and record reviews revealed that these residents were either manually transferred by staff or transferred using alternative equipment, such as a sit-to-stand lift, instead of the required full mechanical lift. Staff reported that on at least one occasion, a resident was manually transferred by two CNAs because there were no clean slings available for the mechanical lift, and the resident did not have a sling under her, making the lift unusable at the time of transfer. The care plans and Kardex sheets for the three residents clearly documented the need for a full body mechanical lift for all transfers. Despite this, staff interviews indicated a lack of consistent adherence to these documented requirements. Some CNAs stated they relied on verbal instructions from therapy staff or other CNAs rather than the written care plans or Kardex, leading to confusion and inconsistent transfer practices. Additionally, there was a lack of communication among staff regarding changes in transfer status, with some staff unaware of where to find the correct information in the electronic charting system. The residents involved had significant medical conditions affecting their mobility, including dementia, muscle wasting, orthopedic issues, and hereditary spastic paraplegia. All were dependent on staff for transfers and used wheelchairs for mobility. At the time of the deficiency, observations confirmed that these residents did not have full mechanical lift slings under them, and staff acknowledged using manual or alternative transfer methods contrary to the care plan. The facility's own investigation confirmed that the failure to use the mechanical lift as required was due to a lack of proper equipment setup and communication lapses among staff.
Failure to Accurately Assess and Document Resident Condition Prior to Hospital Transfer
Penalty
Summary
The facility failed to thoroughly assess and accurately document the condition of a resident who was transferred to the emergency room for a rash on the leg, later diagnosed as cellulitis. The facility's policy requires comprehensive assessment and documentation during incidents and significant status changes, including reviewing previous notes, documenting findings, and notifying relevant parties. However, the Change in Condition Evaluation form completed by an LPN on the day of the second transfer lacked updated vital signs, relevant observations, and a summary of the nurse's evaluation and recommendations. The vital signs and notification times recorded were from the previous day, and the most recent blood glucose value was several months old. Additionally, the form did not indicate whether the condition had occurred before, incorrectly marking it as "Unknown" despite the same issue prompting a hospital visit the previous day. There was also no documentation of updated notifications to the primary care clinician or the resident's healthcare power of attorney regarding the second transfer. These omissions were confirmed by the Assistant Director of Nursing, who acknowledged the lack of accurate and current assessment and notification documentation for the resident's second emergency room transfer.
Failure to Implement Fall Prevention Intervention for At-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in its Fall Prevention Program for one resident identified as at risk for falls. The program requires individualized assessment and the use of appropriate interventions, including assistive devices, for residents at risk. Documentation showed that a non-slip material was to be added to the resident's wheelchair as a fall prevention measure. However, during observation, the resident was seen propelling herself in the dining room without the required non-slip material in her wheelchair. This was confirmed by a Licensed Practical Nurse present at the time. Additionally, nurse's notes indicated that the resident had previously been found sitting half-upright near her bed, further indicating a risk for falls.
Failure to Prevent Resident-to-Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect four cognitively impaired residents from abuse, specifically failing to prevent resident-to-resident physical abuse. Two separate incidents occurred involving residents with severe cognitive impairment and documented behavioral issues. In the first incident, one resident with a history of aggressive and combative behavior placed both hands around another resident's neck and forcefully squeezed, requiring staff intervention to separate them. The aggressor had a documented pattern of aggression towards staff and peers, including previous episodes of hitting, scratching, and resisting care. Both residents involved were unable to recall the incident due to their cognitive status. In the second incident, another resident with dementia and a history of behavioral problems struck a peer in the face with a closed fist. The aggressor was observed by staff walking quickly toward the victim, calling her by an incorrect name, and then hitting her. The victim complained of pain and had visible redness on her face. Both residents involved in this incident were also severely cognitively impaired and unable to recall the event during subsequent assessments. Staff interviews and record reviews revealed that both aggressors had known histories of aggression and behavioral disturbances, including prior physical altercations and resistance to care. Despite these known risks, the facility did not implement effective interventions to prevent these incidents. The facility's abuse policy affirms residents' rights to be free from abuse and outlines the responsibility to prevent such occurrences, yet the events described demonstrate a failure to uphold these protections for the residents involved.
Failure to Timely Obtain Ordered Urine Sample
Penalty
Summary
The facility failed to follow a physician's order to obtain a urine sample in a timely manner for a resident with a history of paraplegia, depression, ESBL resistance, and urine retention. The resident was on enhanced barrier precautions and required straight catheterization every four hours while awake, with additional catheterization as needed at night. The care plan identified the resident as being at risk for urinary tract infection (UTI) due to their diagnoses and catheterization needs, and noted the presence of a colonized multi-drug resistant organism (ESBL) in the urine. A physician's order for bloodwork and urinalysis (UA) was received after concerns were raised about the resident's behavior and fatigue. Despite the order, the Director of Nursing (DON) completed a laboratory requisition form and provided it to the floor nurse but did not enter a laboratory order into the system, which would have alerted staff to collect the specimen. As a result, staff failed to obtain the urine sample for several days, missing the appropriate collection window. The urine specimen was eventually collected several days after the order was received, and laboratory results showed abnormal findings. The facility's policy required that telephone orders be entered into the resident's chart under the order tab, but this was not done in this instance, leading to the delay.
Failure to Prevent Staff Physical Abuse of Resident
Penalty
Summary
The facility failed to prevent staff physical abuse for a resident, identified as R1, who was at high risk for mistreatment due to a history of previous incidents. R1, who has diagnoses including Dementia, Schizoaffective Disorder, Major Depressive Disorder, Anxiety Disorder, and Generalized Idiopathic Epilepsy, was involved in an incident where a Certified Nursing Assistant (CNA) from an agency allegedly struck R1 on the head. The incident occurred when R1 became combative during assistance, leading to the CNA's reflexive action of hitting R1. This incident was reported by an LPN to the facility administrator, and the CNA was immediately suspended pending investigation. The investigation revealed that the CNA admitted to hitting R1, describing it as a reflexive action after being punched by R1. The facility's social service assistant conducted interviews with staff and residents, confirming the CNA's admission. The incident was reported to the police, and R1 was sent to a local hospital for evaluation. The facility's administrator took immediate action by notifying the staffing agency and ensuring the CNA was placed on a do-not-return list. Despite these actions, the facility's failure to prevent the abuse and protect R1 from harm constitutes a deficiency in their care standards.
Failure to Resolve Resident Grievances Timely
Penalty
Summary
The facility failed to ensure that resident grievances were resolved in a timely manner, as evidenced by repeated unresolved issues documented in the Resident Council Minutes over several months. The facility's policy encourages residents to voice grievances without fear of reprisal and mandates that the Administrator promptly resolve these complaints. However, the Resident Council Minutes from May to October document ongoing issues, such as the need for smoke detectors to be checked and concerns about CNAs using their phones and eating while feeding residents. These grievances were repeatedly brought up in meetings without resolution. The Resident Council President confirmed that grievances are often filed on behalf of the facility but remain unresolved, leading to their recurrence in subsequent meetings. The facility's policy requires the Social Service Director to notify residents and their representatives of the resolution, but this follow-up appears to be lacking. The failure to address these grievances affects all 64 residents residing in the facility, as indicated by the facility's Long Term Care Facility Application for Medicare and Medicaid.
Failure to Schedule Registered Nurse Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours each day, which is a requirement for maintaining the highest practical physical, mental, and psychosocial well-being of each resident. This deficiency was identified through a review of the facility's undated Nurse Staffing Policy and untitled daily assignment sheets for specific dates. The policy mandates that a minimum of 10% of nursing and personal care time should be provided by RNs. However, on the dates of 10/02/24, 10/09/24, and 10/16/24, all nurses working were Licensed Practical Nurses (LPNs), with no RNs scheduled. This was confirmed by the facility's Administrator, who acknowledged the lack of RN coverage on these days. The facility's application for Medicare and Medicaid, dated 10/29/24, indicates that 64 residents currently reside in the facility.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents were informed that signing an arbitration agreement was not a condition of admission and that they had the right to rescind the agreement within 30 days of signing. This deficiency was identified through a review of the arbitration agreements for two residents, dated 05/09/23 and 07/06/23, which lacked language notifying residents of these rights. An interview with a staff member confirmed that the arbitration agreements did not include documentation stating that signing was not a condition of admission or that the agreement could be rescinded within 30 days. This oversight has the potential to affect all 64 residents currently residing in the facility.
Failure in QAA Committee Meetings and Membership
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee had the required number of members and did not meet at least quarterly as mandated. The facility's Quality Assurance Plan, dated August 1, 2017, specifies that the QAA Committee should conduct quarterly meetings at a minimum. However, the Administrator, who has been employed for seven months, admitted that no quarterly QAA meetings had occurred during her tenure. She attributed this to a lack of education and training on conducting the meetings. Additionally, the Medical Director had not attended any meetings, and there was no Infection Preventionist at the facility since January 2024. This oversight has the potential to affect all 64 residents residing in the facility.
Lack of Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an Antibiotic Stewardship Program, which is essential for promoting the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This deficiency potentially affects all 64 residents in the facility. The facility's policy, dated 12/12/18, outlines the purpose of the program, but it was not put into practice. Specific instances include a resident with a physician's order for Doxycycline for skin wounds and another resident with an order for Clindamycin for a left toe infection. Despite these orders, the Regional Director of Operations confirmed that there was no Antibiotic Stewardship Program, no monitoring of infections, no Infection Preventionist, and no Infection/Antibiotic logs or Infection Prevention and Control Program in place.
Lack of Infection Preventionist in Facility
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program, which is crucial for assessing, developing, implementing, monitoring, and managing infection control measures. This deficiency potentially affects all 64 residents in the facility. The facility's policy, dated December 7, 2018, mandates routine surveillance and monitoring to ensure compliance with infection control practices and requires at least a part-time Infection Control Preventionist. However, the facility was unable to provide documentation or logs for infection monitoring and tracking, indicating a lapse in adherence to its own policy. The report highlights specific cases involving two residents receiving antibiotics for infections. One resident was administered Doxycycline for skin wounds, while another received Clindamycin for a left toe infection. Despite these ongoing treatments, the facility lacked an Infection Preventionist since January 2024, as confirmed by the Administrator and the Regional Director of Operations. This absence of a designated IP raises concerns about the facility's ability to effectively manage and control infections, as there is no individual responsible for overseeing these critical functions.
Failure to Administer Influenza Vaccines
Penalty
Summary
The facility failed to provide influenza vaccinations to residents eligible for the vaccine during the flu season, as required by their own policy and state guidelines. The facility's policy, dated 10/10/22, mandates the administration of the influenza vaccine throughout the flu season, from the receipt of the vaccine until March 1. However, the facility did not have any influenza vaccines available in their medication rooms as of 10/31/24, and no vaccines had been administered to residents or staff since the start of the flu season. This failure affected five residents, all of whom had physician orders indicating they could receive the annual flu vaccine with consent unless contraindicated. Each of these residents last received the influenza vaccine on 10/03/23, indicating a lapse in the current flu season's vaccination efforts. The Regional Director of Operations confirmed that the facility had not provided influenza vaccines for residents or staff and that an outside company contracted to administer the vaccines had not done so. The director was unaware of when the vaccines would be administered and stated that the facility had not ordered any influenza vaccines. This lack of action and preparation resulted in the facility's inability to minimize the risk of acquiring, transmitting, and suffering complications from influenza for the residents reviewed.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure a PASARR (Pre-Admission Screening and Resident Review) screening was completed for one of the five residents reviewed for PASARR screenings. The resident, identified as R28, was admitted to the facility with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of the basilar artery, generalized anxiety disorder, and major depressive disorder, recurrent, moderate. Upon review, it was found that R28's medical record did not include a completed PASARR screening. The facility's administrator acknowledged that the screening was not done and stated that all residents should have a screening prior to admission. The Business Office Manager also confirmed that the resident was supposed to be screened before admittance and admitted that the facility failed to conduct the screening after the hospital did not perform it prior to the resident's admission.
Failure to Revise Care Plans for Hospice and Pressure Wound
Penalty
Summary
The facility failed to revise care plans for two residents, which was identified during a review of 16 residents for care plan revisions. According to the facility's policy on Comprehensive Care Planning, care plans should be revised when the needs or problems of a resident change. However, the care plan for one resident, who was placed on hospice services per a physician's order, did not include hospice care. Another resident with a stage 2 pressure wound on the coccyx had wound care orders, but the care plan was not updated to reflect this condition. The Regional Director of Operations confirmed that the care plans for these residents were not revised as required.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to provide an appropriate indication for the use of antipsychotic medications for two residents. The first resident, identified as R6, was diagnosed with unspecified dementia without behavioral, psychotic, or mood disturbances. Despite this, R6 was prescribed Quetiapine, an antipsychotic medication, for dementia, which is not an appropriate diagnosis for this medication. The resident's mental status was assessed as cognitively intact, with a BIMS score of 15, and the care plan noted behaviors of hoarding and paranoia, but these did not justify the use of Quetiapine. The second resident, R14, also diagnosed with unspecified dementia without behavioral disturbance, was prescribed Quetiapine for sleep, which is not an appropriate use of the medication. R14's BIMS score also indicated cognitive intactness, and the care plan documented a history of wandering near exits as the only behavior. The Director of Operations confirmed that the use of Quetiapine for sleep was inappropriate, highlighting the facility's failure to adhere to guidelines for the use of psychotropic medications.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precaution (EBP) policy, which aims to reduce the transmission of multidrug-resistant organisms (MDRO). This deficiency was observed in the care of two residents. The first resident, who had a supra pubic indwelling catheter and a jejunostomy tube, did not receive care in accordance with EBP guidelines. A registered nurse and two certified nursing assistants provided care without wearing gowns, which are required during high-contact activities to prevent MDRO transmission. The staff members involved were not aware of the EBP requirements and had not received training or in-service education on the policy. Additionally, the facility lacked accessible gowns for staff use, and the Director of Operations acknowledged the failure to implement EBP throughout the facility. In another instance, a licensed practical nurse performed wound care for a resident with a coccyx wound without wearing the necessary enhanced barrier personal protective equipment, specifically a gown. The nurse stated that she was not required to wear gowns during wound treatment, indicating a lack of understanding or training regarding the facility's EBP policy. The facility's failure to provide adequate training and resources for staff to follow EBP guidelines contributed to these deficiencies.
Failure to Notify Physician of Medication Omission
Penalty
Summary
The facility failed to notify a physician of a medication error/omission for a resident diagnosed with Anxiety Disorder, Panic Disorder, Dementia, and Alzheimer's Disease. The resident had an order for Lorazepam 0.5 milligrams to be administered three times a day. However, the medication was not available between specific dates, and the doses were not administered as required. Despite the unavailability of the medication, several Licensed Practical Nurses (LPNs) inadvertently signed off that the medication had been administered when it had not. The facility's policy required that the physician be notified of any medication errors or omissions, but this was not done. The incident investigation revealed that the LPNs involved did not notify the physician or request the medication from the emergency supply when it was unavailable. The Director of Nurses confirmed that the resident missed 15 doses of the scheduled medication and that there was no documentation of physician notification during this period. The failure to notify the physician and the incorrect documentation of medication administration were identified as deficiencies in the facility's adherence to its medication administration policy.
Significant Medication Error Due to Unavailability and Misdocumentation
Penalty
Summary
The facility failed to ensure that a resident received prescribed medication for anxiety as per the physician's order, resulting in a significant medication error. The resident, who has diagnoses including Anxiety Disorder, Panic Disorder, Dementia, and Alzheimer's Disease, was prescribed Lorazepam (Ativan) 0.5 milligrams to be taken three times daily. However, the medication was not administered as prescribed between September 15 and September 20, 2024, due to unavailability. Despite the lack of medication, several LPNs inadvertently signed off that the medication had been administered, which was not the case. The incident investigation revealed that the medication was not available in the building, and the LPNs did not request the medication from the Emergency Box or notify the physician about the unavailability. The Director of Nurses confirmed that the resident missed 15 doses of the scheduled medication during this period. The failure to administer the medication as prescribed and the incorrect documentation of its administration constituted a significant medication error, as the facility did not adhere to its policies regarding medication administration and physician notification.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement appropriate pressure ulcer prevention and care interventions for a resident identified as high risk for pressure ulcers. The resident, who was admitted with conditions including paraplegia and wheelchair dependence, was assessed with a high risk for pressure ulcers using the Braden Scale. However, the facility did not conduct further Braden Scale assessments after admission, nor did they include pressure ulcer risks or interventions in the resident's care plan. This oversight contributed to the development of a stage three pressure ulcer on the resident's right medial ankle. The facility also failed to perform daily skin checks and physician-ordered wound treatments as required. Despite a physician's order for skin checks every shift and specific wound care treatments, the facility only conducted weekly skin checks and did not consistently apply the prescribed treatments. The resident's medical records lacked documentation of the pressure ulcer's stage and size when it was first identified, and there was no evidence of a care plan update to address the ulcer and prevent further skin breakdown. Interviews with staff and family members revealed that the resident was not repositioned as needed, and pressure-relieving devices were not used consistently. The facility lacked a Care Plan Coordinator or MDS Coordinator, which contributed to the absence of necessary assessments and care plan updates. The Director of Nursing was unaware of the wound clinic's orders for daily skin checks, indicating a communication breakdown within the facility regarding the resident's care needs.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a resident's bed was kept in the lowest position, which led to the resident falling out of bed while reaching for his cell phone. The resident's bed was left in a high position, and personal items, including the cell phone and bed remote, were not within reach. This resulted in the resident sustaining a left femur fracture. The resident's family member reported that the staff consistently left the bed in a high position despite being informed of the need to keep it low. Additionally, the resident's call light was not within reach, and there was a delay in staff response when the resident called for help after the fall. The facility also failed to ensure the resident was secure while being transported in the facility van. The maintenance assistant, who was not trained in securing residents in wheelchairs, transported the resident to a wound clinic. During the trip, the assistant had to brake suddenly, causing the resident to fall forward out of the wheelchair and hit his head. The resident experienced neck and shoulder pain and was taken to the emergency room for assessment. The incident was not documented in the resident's medical record, and no investigation into the root cause or implementation of new fall interventions was conducted. The facility's policies on fall prevention and van usage were not adequately followed. The fall prevention policy required immediate assessment and documentation of falls, as well as discussion in quality assurance meetings and updates to care plans. However, these steps were not taken following the resident's falls. Similarly, the van usage policy required securing seat belts and ensuring residents were safely secured, which was not adhered to, leading to the resident's fall in the van.
Inaccurate MDS Assessments for Resident with Fall and Pressure Ulcer
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for a resident, identified as R1, who experienced changes in condition. The MDS Coordinator/Care Plan Coordinator was responsible for ensuring the timely and accurate completion of these assessments. However, R1's MDS assessments did not reflect the resident's actual medical conditions. Specifically, R1 had a fall on July 19, 2023, which resulted in a major injury, but this was not documented in the MDS assessment. Additionally, R1 had a pressure ulcer on the right ankle since September 10, 2023, which was not recorded in the MDS assessments dated December 28, 2023, and March 25, 2024. The inaccuracies in the MDS assessments were confirmed through interviews with the Director of Nursing and the Administrator-In-Training. The facility did not have a dedicated MDS Coordinator, and the Corporate MDS Coordinator was responsible for completing the assessments. The failure to accurately document R1's fall and pressure ulcer in the MDS assessments indicates a deficiency in the facility's assessment process, as these conditions were present and should have been recorded. This oversight highlights a lapse in the facility's responsibility to maintain accurate and up-to-date resident assessments.
Failure to Treat Resident with Respect
Penalty
Summary
The facility failed to ensure a staff member treated a resident with respect. The incident involved a cognitively intact resident who was restricted to one cigarette due to tornado warnings. When the resident called his mother to discuss the situation, the RN made a disrespectful comment, asking the resident what he was 'tattling' about. The resident felt disrespected by the RN's harsh and rude tone. The resident's mother also reported hearing the RN's disrespectful comment during the phone call. The facility's Administrator-In-Training confirmed the incident and acknowledged that the RN did not treat the resident with respect.
Failure to Revise Comprehensive Care Plan for Resident at Risk of Wandering
Penalty
Summary
The facility failed to revise a Comprehensive Care Plan for a resident identified as R1, who was at risk for wandering and elopement. Despite R1's Wandering-Elopement Evaluation Scale indicating a score of 10, which classifies the resident as 'At risk to wander/exit seek,' the current Care Plan did not document any goals or interventions addressing these concerns. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), confirmed that R1 exhibited behaviors such as expressing a desire to go home or leave the facility, and staff had to intervene daily to redirect her. However, these behaviors were not reflected in the Care Plan as required by the facility's policy. The facility's Comprehensive Care Plan Policy mandates that Care Plans be revised as necessary to reflect the resident's current needs and conditions. Both the Administrator and the Director of Nursing (DON) acknowledged that R1's Care Plan should have been updated to include her wandering and elopement risks. The failure to update the Care Plan was identified during a review of R1's records and confirmed through staff interviews, highlighting a lapse in adhering to the facility's policy for maintaining accurate and up-to-date Care Plans for residents.
Failure to Provide Adequate Supervision Leading to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident identified as R1, who had a history of falls and was at risk for wandering. On the evening of the incident, R1 was in the dining room for supper but left unassisted and exited through the A-Hall door, falling onto the cement outside. The door alarm was triggered, and staff responded immediately, finding R1 on the ground. Interviews with staff revealed that all CNAs were in the dining room feeding residents, and no one was assigned to monitor the halls during mealtimes. The LPN was also in the dining room passing medications at the time of the incident. The facility's policies on fall prevention and resident monitoring were not effectively implemented, as R1 was not adequately supervised despite being identified as a high risk for falls and wandering. R1's medical records indicated severe cognitive impairment, a history of falls, and a high risk for wandering. The resident's care plan documented the need for supervision due to dementia, impaired decision-making, and other risk factors. Despite these documented needs, the facility did not ensure that staff were monitoring residents who were not in the dining room during mealtimes. The Director of Nursing and the Administrator acknowledged that one CNA should have been monitoring the halls, but this protocol was not followed, leading to R1's unsupervised exit and subsequent fall.
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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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