Arcadia Care Watseka
Inspection history, citations, penalties and survey trends for this long-term care facility in Watseka, Illinois.
- Location
- 715 East Raymond Road, Watseka, Illinois 60970
- CMS Provider Number
- 145389
- Inspections on file
- 62
- Latest survey
- March 15, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Arcadia Care Watseka during CMS and state inspections, most recent first.
Two cognitively impaired residents with known physical and verbal behaviors became involved in an altercation when one resident attempted to take the other’s walker while the latter was seated at a table drinking. When the resident using the walker refused to let go, the other resident slapped the resident on the back with an open hand, constituting physical abuse. Staff witnesses, including an LPN, an activity aide, and a CNA, reported that as they intervened, the resident with the walker attempted to retaliate and instead struck the LPN in the mouth, while the aggressor resident lost balance and fell, hitting their head on a table leg. Both residents had existing care plans addressing behavioral issues, and the facility’s abuse prevention policy states that residents have the right to be free from abuse and that the facility prohibits such mistreatment.
A resident with severe cognitive impairment entered another resident's room multiple times, made inappropriate sexual comments, and engaged in unwanted physical contact. The cognitively intact resident, who had limited mobility and was at moderate risk for abuse, screamed for help, leading a CNA to intervene and remove the offending resident. Staff interviews and records confirmed the incident and the facility's failure to prevent the abuse.
The facility did not provide the required RN coverage for nine days, as confirmed by the DON and Regional Director of Operations, with zero RN hours scheduled for entire 24-hour periods. This affected all 61 residents present in the facility during the reviewed period.
The facility assigned a Dietary Manager to supervise and manage food service operations for all residents without ensuring the individual held the required certification or credentials, as specified by regulations and the facility's own assessment tool.
The facility did not complete required PASARR Level II screenings for three residents after they received new diagnoses of serious mental illness, despite policy and initial screening instructions to do so when such changes occur. This lapse was confirmed by the Social Service Director.
A resident did not receive several prescribed medications during a medication pass, and an LPN administered a medication with duplicate and conflicting orders, resulting in a 20% medication error rate. There was no documentation of the missed doses or notification to the provider or pharmacy, and a physician's note identifying an excessive dosing regimen was not followed up in the medical record.
Two residents at nutritional risk did not receive proper monitoring and intervention for significant weight changes. One resident with protein-calorie malnutrition was not weighed weekly as ordered, did not consistently receive or consume prescribed nutritional supplements, and poor meal intake was not reported to the dietitian. Another resident with a history of weight loss was not reweighed after a significant weight gain, and weekly weights were not documented, despite staff awareness of facility policy.
A resident with a history of aggressive behavior physically and verbally abused two other residents in the facility. Despite being aware of the resident's behavior issues, the facility failed to implement effective interventions to prevent these incidents, resulting in physical and verbal abuse. Staff witnessed the altercations and intervened, but the facility's administrator acknowledged the need for further measures to ensure resident safety.
The facility failed to provide RN coverage for at least eight consecutive hours a day, seven days a week, as required. On specific dates in March 2025, there was no RN coverage, affecting all 62 residents. The facility's assessment tool required one RN per shift, but the nursing schedule and daily assignments showed a lack of RN coverage. The Regional RN and DON confirmed the deficiency and are working on a solution.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 62 residents. The Dietary Manager, who was supervising operations, admitted to not being certified and not meeting state standards. The facility's assessment indicated the need for a qualified nutrition professional to support resident care.
The facility failed to have an Infection Prevention Nurse physically onsite at least part-time, affecting 62 residents. Observations showed no certified Infection Preventionist nurse present, and the Regional Infection Preventionist, responsible for infection tracking, works offsite and visits only once a week. The DON does not have access to infection logs, and the March 2025 schedule showed no onsite Infection Prevention nurse.
The facility failed to provide showers to three residents according to their care plans and preferences. One resident, dependent on staff for bathing, received showers sporadically, while another, requiring partial assistance, reported not receiving scheduled showers. A third resident, needing a mechanical lift, also reported inconsistent showering. Staff interviews revealed discrepancies in documentation and adherence to the facility's bathing policy.
The facility failed to engage residents in the memory care unit in structured activities, leaving them idle or asleep. Despite care plans outlining specific activity needs, residents were not participating in any activities due to short staffing and lack of engagement by CNAs. The Activity Director acknowledged the issue, citing staffing challenges.
A resident reported to the DON that an agency LPN was rough and used a harsh tone. The DON did not report this to the Administrator, assuming the resident had done so. The Administrator was unaware of the allegation, violating the facility's policy requiring immediate reporting of potential abuse.
The facility failed to coordinate PASARR Level II evaluations for two residents with serious mental health diagnoses. Despite having conditions such as Schizoaffective Disorder and Major Depressive Disorder, their PASARR Level I screenings inaccurately indicated no need for further evaluation. The Business Office Manager confirmed these discrepancies, highlighting the necessity for accurate and routine review of PASARR screenings.
A facility failed to provide a resident with an appropriate indwelling urinary catheter collection bag and secure it in a dignified manner. The resident, with multiple urinary-related diagnoses, was observed with a catheter bag visibly attached to his pants, contrary to the facility's policy. An LPN confirmed the absence of leg bags, and the administrator acknowledged the need to order more.
The facility failed to provide sufficient RN hours on six out of fifteen days reviewed, potentially affecting all 66 residents. The Nursing Daily Schedule documented zero hours of RN coverage for 24-hour periods on specific dates, confirmed by the Regional Director. At the time, 66 residents resided in the facility.
A resident with cognitive impairments was physically abused by another resident in the dining room following an argument. Despite the facility's abuse prevention policy, staff intervention occurred only after the altercation escalated, resulting in one resident being struck on the shoulder. The incident was reported, and an investigation was initiated.
A facility failed to implement a comprehensive care plan for a resident with dementia and schizophrenia who frequently undressed and walked around naked. Despite documented behaviors and staff observations, no care plan was developed to address these issues, contrary to facility policy requiring person-centered care plans with measurable objectives.
The facility failed to provide adequate personal hygiene care to four residents who were dependent on staff assistance. Despite policies requiring weekly showers and daily dental care, residents reported not receiving showers due to staffing issues, with records confirming infrequent showers over two months. One resident also reported not having her teeth brushed for several days. A CNA acknowledged the lack of showers due to insufficient staffing, highlighting a failure to adhere to the facility's hygiene care policies.
A resident with moderate cognitive impairment entered another resident's room and physically assaulted a fellow resident by kicking them in the shin and attempting to steal property. The incident was witnessed by an LPN who intervened and removed the aggressor. The facility's policy on abuse prevention was not effectively implemented to prevent this occurrence.
A resident with Multiple Sclerosis was injured when their foot caught on a rug while being transported in a shower chair lacking foot support. The facility failed to report the injury to the state survey agency and did not conduct a thorough investigation. The resident's care plan was not updated, and the use of the shower chair for transportation was deemed inappropriate by the resident's physician.
The facility did not staff an RN for eight consecutive hours per day, as required, affecting the care of 68 residents. On several dates, only LPNs were on duty, and the Director of Nursing worked limited hours without additional RN coverage. The facility relies on agency nurses, with corporate restrictions allowing only LPNs, and has limited RN staff.
The facility failed to administer insulin and diabetic medications timely and as ordered for four residents. The MARs were incomplete, and there was a lack of documentation and physician notification for missed doses. Residents reported delays in receiving medications, and agency nurses were unaware of the protocol to notify physicians when medications were unavailable, leading to significant medication errors.
A resident with a history of multiple health conditions suffered a leg fracture in a LTC facility, leading to severe pain. Despite the facility's Pain Management Program requirements, the resident's pain was not routinely assessed, and their care plan was not updated to address the injury and pain management. Discrepancies in pain medication documentation were noted, and staff interviews confirmed the lack of routine pain assessments following the injury.
The facility failed to protect residents from abuse, including sexual and physical incidents involving cognitively impaired residents. One resident was inappropriately touched by another, while separate physical altercations occurred due to misunderstandings and territorial behavior. Staff witnessed these events and intervened, but the incidents highlight a lack of effective prevention measures.
A facility failed to implement adequate fall prevention measures and supervision, resulting in falls for three residents with severe cognitive impairments. One resident fell twice due to environmental hazards and improper clothing, while another fell after leaving the bathroom without a walker. Investigations were inadequate, with insufficient staffing and lack of thorough assessments. A third resident experienced multiple falls without appropriate interventions, and a non-functional call light further compromised safety.
The facility failed to implement specific interventions for residents with dementia-related behaviors, leading to repeated incidents of aggression and safety concerns. One resident exhibited severe cognitive impairment and aggression, while another displayed aggressive behaviors and required psychiatric evaluations. A third resident's care plan lacked documentation of specific behaviors during meal times, resulting in altercations with others.
A resident experienced psychosocial harm due to the misappropriation of funds by a Business Office Manager and an Activity Aide, who allegedly took $600 from the resident's Trust Fund for personal use. The facility failed to adhere to its Abuse Prevention Program and Resident Funds Policy, as transactions lacked proper authorization and documentation. The resident, with moderate cognitive impairment, was unaware of these unauthorized transactions due to not receiving receipts or statements.
The facility failed to provide quarterly statements for Resident Trust Funds for several residents, as required by policy. Transaction logs were not signed, and no quarterly statements were available. Residents confirmed not receiving statements, and the Business Office Manager admitted to not being trained on this requirement, leading to their termination.
The facility failed to maintain adequate Surety Bond coverage for resident trust funds, with the bond amount of $73,500 falling short of the actual fund balances, which exceeded $136,000 over three months. This affected five residents with trust funds managed by the facility, as confirmed through interviews and a review of financial records.
A facility failed to report a sexual abuse allegation involving a resident and two staff members to the Illinois Department of Public Health as required. An anonymous call alleged inappropriate touching in exchange for money and misappropriation of $600 from the resident's Trust Fund. The facility reported only the financial misappropriation, omitting the sexual abuse claim, and did not document it in their abuse log.
A resident with kidney failure requiring thrice-weekly dialysis was hospitalized for hypervolemia after the facility failed to provide necessary dialysis services for nearly two and a half months. The Social Services Director did not coordinate dialysis appointments, and the facility initially failed to provide transportation for dialysis, leading to a critical delay in care.
A facility failed to manage pain for a hospice resident, leading to uncontrolled pain. The resident, with severe cognitive impairment and multiple medical conditions, was observed in distress. Pain assessments were not routinely conducted, and medication orders were delayed. Discrepancies in medication administration and documentation were noted, with several doses of Morphine being ineffective. Staff interviews revealed communication and documentation lapses in pain management protocols.
The facility failed to monitor potential Legionella exposure sites and did not adhere to contact precautions for a resident with ESBL. The Legionella policy lacked documentation of plumbing inspections and preventive measures. Staff entered a resident's contact isolation room without PPE, despite signs indicating isolation, exposing themselves to infection risks.
The facility failed to employ a certified Infection Preventionist, affecting all 44 residents. The DON and Assistant DON, who handle infection prevention tasks, are not certified. This gap undermines the facility's infection control program, despite having a policy for surveillance and monitoring.
The facility failed to maintain a safe and functional environment due to unresolved roof leaks, resulting in sagging and stained ceiling tiles near the nurse's station and resident areas. A resident reported worsening ceiling discoloration since their admission, and the DON confirmed the issue has persisted for over a year. Despite obtaining repair quotes, the roof remains unrepaired, potentially affecting all 44 residents.
The facility failed to provide timely laboratory services and document results for three residents. A resident with diabetes did not receive A1C tests as ordered, another resident's Hepatic Function Panel was not completed, and a third resident's blood glucose levels were not documented. The Assistant DON confirmed these deficiencies, citing a possible computer issue for the documentation lapse.
The facility failed to accurately account for controlled substances and ensure medications were provided as ordered. A resident's Fentanyl patches were unaccounted for, and discrepancies were found in medication administration records for multiple residents. Additionally, a resident did not receive prescribed Omeprazole due to insurance issues, with no physician notification documented. Facility policies on controlled substances and medication administration were not consistently followed.
The facility failed to obtain consent for psychotropic medications and justify their use for several residents. There was no documentation of resident-specific behaviors or tracking of behaviors to support the use of antipsychotics. Additionally, consents for medications were not signed until the survey date. The Director of Nursing acknowledged these issues, indicating a lack of adherence to the facility's policy on psychotropic medications.
A facility failed to administer medications as ordered for three residents, leading to significant medication errors. One resident missed a Fentanyl patch, another did not receive Lacosamide for seizures due to insurance issues, and a third lacked nebulizer treatments due to a missing machine and medication. Staff were unsure of reasons for omissions, and documentation was inadequate.
The facility failed to provide the correct consistency for pureed diets for several residents. A staff member prepared pureed pork fritters without a recipe, using unmeasured water and thickener, resulting in lumpy food. The Dietary Manager confirmed that cooks should follow recipes and ensure smooth consistency to prevent choking.
The facility failed to maintain the dignity of two residents who reported disrespectful behavior by a CNA. One resident, dependent on assistance for personal hygiene, felt disrespected when unable to move her legs during care. Another resident, requiring moderate assistance, described the CNA as having a 'smart mouth.' The DON confirmed receiving complaints about the CNA.
A facility failed to schedule a follow-up cardiology appointment for a resident with multiple diagnoses, including Type 2 Diabetes Mellitus and Hypertension, as per hospital discharge instructions. The Social Services Director, responsible for scheduling, did not find any record of the appointment, and the ADON mentioned the process might have been underway when the resident passed away. The facility lacked a policy for scheduling appointments, relying on physician's orders to be followed.
The facility failed to provide appropriate pressure ulcer care and prevention for three residents, leading to untreated wounds and lack of pressure-relieving interventions. A resident did not receive prescribed barrier cream, resulting in untreated stage two wounds. Another resident lacked a pressure-relieving cushion, worsening her skin condition. A third resident did not receive necessary protective boots, leading to a necrotic sore. Staff were unaware of these issues, indicating a lack of communication and adherence to care protocols.
A resident experienced a significant weight loss of over 10% within a month, but the facility failed to notify the physician, POA, and dietician as required by policy. Despite the resident's medical history of cognitive decline, depression, and anxiety, and a care plan addressing nutritional issues, the necessary parties were not informed of the weight change. The DON and Social Services Director confirmed the lack of communication.
A resident with a history of aggression threw water on another resident, who has PTSD, in the dining room. The facility failed to prevent this incident by seating them together despite knowing the potential for conflict. The affected resident's care plan lacked specific interventions for PTSD, highlighting a deficiency in protecting residents from abuse.
The facility did not follow its abuse policy in two cases: a resident's missing phone was not reported to the Administrator, delaying investigation, and another resident's family was not informed about missing Fentanyl patches, despite the Administrator being aware. The Administrator cited being busy with audits as a reason for the oversight.
A resident's urinary catheter care was deficient, with the collection bag found on the floor and not covered as per policy, risking cross-contamination. The facility also failed to change the catheter monthly as ordered, with no documentation of changes, and the resident developed a urinary tract infection.
The facility failed to maintain respiratory equipment in a sanitary manner and did not follow prescribed orders for two residents. One resident's nebulizer equipment was not changed as required, and another received incorrect oxygen levels with undated tubing. These actions indicate non-compliance with the facility's oxygen therapy policy.
Resident-to-resident physical abuse during altercation over walker
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse when one resident struck another. According to the facility’s preliminary and final abuse investigation reports, a cognitively severely impaired resident with Alzheimer’s disease, anxiety disorder, restlessness, and agitation approached another cognitively severely impaired resident who requires a walker for ambulation while the second resident was seated at a table sipping a drink. The first resident attempted to take the second resident’s personal walker, and when the second resident refused to relinquish it, the first resident slapped the second resident on the back with an open hand. Witness statements from an LPN, an activity aide, and a CNA consistently described the first resident trying to take the walker, the second resident holding onto it, and the first resident then smacking the second resident on the back. The records show that both residents had prior care plans addressing physical and verbal behaviors toward staff and peers, and both had BIMS scores of three, indicating they were cognitively severely impaired. The MDS for the first resident documented independence in walking and the presence of physical and verbal behaviors, while the MDS for the second resident documented the need for a walker to assist with walking. During the incident, when staff intervened to separate the residents, the second resident attempted to retaliate and instead struck the LPN in the mouth, and the first resident became unsteady, lost balance, and fell, hitting their head on a table leg. The facility’s abuse prevention policy affirms residents’ rights to be free from abuse and states that the facility prohibits abuse and is responsible for preventing occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services, and mistreatment of residents.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment entered another resident's room multiple times in the early morning hours. The resident who was cognitively intact and at moderate risk for abuse/neglect reported that the other resident made inappropriate sexual comments and engaged in unwanted physical contact by placing a hand under the blanket and touching the resident's leg. The incident escalated to the point where the resident screamed for help, prompting a Certified Nursing Assistant (CNA) to intervene and remove the offending resident from the room. Interviews and record reviews confirmed that the resident who was subjected to the inappropriate behavior felt helpless due to limited mobility and inability to protect herself. Staff accounts corroborated the sequence of events, including the CNA's observation of the resident's hand under the blanket and immediate removal of the resident from the room. The facility's abuse prevention policy prohibits such conduct, yet the incident demonstrated a failure to protect the resident from inappropriate touching and sexual comments by another resident.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide sufficient Registered Nurse (RN) coverage, as required, on nine out of forty-four days reviewed. According to the Facility Nursing Daily Schedule, there were zero RN hours scheduled for entire 24-hour periods on specific dates, which was confirmed by both the Director of Nursing (DON) and the Regional Director of Operations. The facility's records indicated that 61 residents were present during this time, and the lack of RN coverage had the potential to affect all residents. The deficiency was identified through interview and record review, with the facility's own documentation confirming the absence of required RN staffing on the noted days.
Unqualified Dietary Manager Supervising Food Services
Penalty
Summary
The facility failed to ensure that the director of food services met the required regulatory qualifications. Observations and interviews over several days confirmed that the individual serving as the Dietary Manager was actively supervising dietary operations and managing food service for all 61 residents, but did not possess certification as a Certified Dietary Manager, certified food service manager, or equivalent credentials as required. The facility's own assessment tool specified the need for a clinically qualified nutrition professional to serve as the director of food and nutrition services, yet the current manager did not meet these qualifications. This deficiency affected all residents in the facility at the time of the survey.
Failure to Initiate PASARR Level II After New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate Pre-admission Screening and Resident Review (PASARR) Level II assessments for three residents who had new or updated diagnoses of serious mental illness during their stay. Specifically, the records for these residents showed diagnoses such as Schizoaffective Disorder, Bipolar Disorder, and Major Depressive Disorder, which were documented after their initial PASARR Level I screenings. The initial Level I screenings had determined that Level II was not indicated, but the screenings also stated that a new screen must be submitted if changes or new information arose. Despite the emergence of new diagnoses indicating serious mental illness, the facility did not initiate or complete PASARR Level II screenings for these residents. This was confirmed by the Social Service Director, who acknowledged that the required Level II assessments were not performed following the updated diagnoses. The facility's own PASARR policy requires referral for Level II review upon significant changes in status or new evidence of serious mental disorder, but this procedure was not followed in these cases.
Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to administer medications according to physician's orders for one resident, resulting in a medication error rate of 20%, which exceeds the acceptable threshold. During a medication pass, an LPN administered several medications to the resident but omitted Carvedilol 25mg, Fluticasone 50mcg nasal spray, and Duloxetine 60mg, all of which were ordered to be given at that time. Additionally, the resident's medication administration record (MAR) showed duplicate and conflicting entries for Fluticasone-Salmeterol (Advair) Inhaler, leading to the potential for over-administration. A physician's note had previously identified that the dosing regimen for this inhaler exceeded the recommended frequency, but there was no documentation of follow-up or correction in the electronic medical record. There was also no documentation in the electronic medical record regarding the missed doses or any notification to the prescribing physician or pharmacy about the omissions. The facility's policy requires that medications be administered as ordered and that any errors or omissions be documented, with appropriate notifications made. The Director of Nursing confirmed that staff should use backup pharmacy stock if available and notify the provider and pharmacy if medications are not in stock, as well as document any missed doses, but these steps were not followed in this instance.
Failure to Monitor and Manage Nutritional Status and Weight Changes
Penalty
Summary
The facility failed to ensure adequate nutritional management for two residents identified as nutritionally high-risk. One resident with a diagnosis of protein-calorie malnutrition experienced significant weight loss over a six-week period, with documentation showing a 5.8% decrease in body weight. Despite physician orders for weekly weights, fortified ice cream, and nutritional shakes three times daily, the resident's records lacked documentation of weekly weights on two occasions, and meal intake records showed poor consumption on 22 occasions. Observations revealed that nutritional supplements were not consistently provided with meals, and when they were, staff did not encourage consumption or inform the resident about the supplement. Additionally, there was no documentation that the dietitian was alerted to the resident's poor intake, as required by the care plan. Another resident, who was on hospice care and had a history of significant weight loss, was not reweighed after a documented significant weight gain, as required by facility policy. The resident's weight increased dramatically between two recorded dates, but there was no evidence of weekly weights or follow-up actions in the medical record. Staff interviews confirmed awareness of the policy to reweigh residents in case of discrepancies, but this was not carried out or documented. The facility's policies on significant weight changes and obtaining accurate weights were not followed for these residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by incidents involving three residents. Resident R26, diagnosed with Bipolar Disorder, Borderline Personality Disorder, and Dementia with Agitation, exhibited aggressive behavior towards other residents. R26's care plan noted a history of verbal and physical aggression, yet incidents continued to occur. R61, who is cognitively intact and at high risk for abuse, reported being yelled at and slapped by R26 during a dining room altercation. A CNA witnessed the incident and intervened to prevent further harm. R61 expressed fear of R26, who frequently engaged in aggressive behavior towards others. Another resident, R24, also cognitively intact, reported being punched in the arm by R26 in the dining area. R24 described R26 as often verbally and physically abusive, using foul language towards other residents. An LPN confirmed R24's distress following the incident. The facility's administrator acknowledged R26's behavior issues and the need for interventions to ensure resident safety. Despite the facility's abuse prevention policy, these incidents highlight a failure to protect residents from abuse, as required by regulations.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that there was no RN coverage on specific dates in March 2025, including 3/8, 3/9, 3/13, 3/14, 3/17, and 3/18. The facility's assessment tool indicated that staffing should include one RN during both the day and night shifts. However, the nursing schedule and daily assignments documented the absence of RN coverage over a 24-hour period on the aforementioned dates. This lack of RN coverage has the potential to affect all 62 residents currently residing in the facility. The Regional Registered Nurse and the Director of Nursing confirmed the deficiency and acknowledged that they are working on correcting the issue.
Facility Lacks Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 62 residents. The deficiency was identified through observation, interview, and record review. On multiple occasions, the Dietary Manager, who was actively supervising dietary operations, admitted to not being a Certified Dietary Manager and failing to meet the State of Illinois standards for a food service manager/dietary manager. The facility's assessment indicated the need for a full-time dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services to provide competent support and care for the resident population.
Infection Preventionist Not Onsite
Penalty
Summary
The facility failed to employ an Infection Prevention Nurse who physically works onsite at least part-time, potentially affecting all 62 residents. Observations made over several days revealed that no certified Infection Preventionist nurse was present in the facility. The Regional Registered Nurse confirmed that the facility's Infection Preventionist works offsite and is responsible for infection tracking and logs, which are not maintained in the facility. The Director of Nursing acknowledged that she does not have access to the infection tracking log and relies on the Regional Infection Preventionist, who visits the facility only once a week. The clinical nurse schedule for March 2025 showed no onsite Infection Prevention nurse, and the resident census documented 62 residents residing in the facility.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers to residents according to their care plans, physician orders, and preferences, affecting three residents. One resident, who is dependent on staff for bathing due to dementia and other medical conditions, was scheduled for showers twice a week but only received them sporadically over a two-month period. Another resident, requiring partial assistance, reported not receiving the scheduled showers, with records showing refusals but no alternative bed baths documented. A third resident, dependent on staff and requiring a mechanical lift, also reported not consistently receiving showers, with records indicating only five instances of bathing over nearly two months. Staff interviews revealed that showers are documented on shower sheets, which are supposed to reflect whether a shower, bed bath, or refusal occurred. However, discrepancies in documentation and resident reports indicate a failure to adhere to the facility's bathing policy, which mandates at least one shower per week or according to resident preference. The lack of consistent documentation and adherence to scheduled bathing routines contributed to the deficiency in providing adequate hygiene care for the residents.
Failure to Provide Activities for Memory Care Residents
Penalty
Summary
The facility failed to provide and implement activities to meet the interests and needs of residents in the locked memory care unit, affecting four residents. Observations on multiple occasions revealed that these residents were either asleep or sitting unengaged in their rooms, with no structured activities provided. The care plans for these residents outlined specific activity preferences and needs, such as horticulture-based activities, crafts, exercise, and structured activities to promote engagement and prevent boredom. However, these plans were not being followed, as the residents were not participating in any activities. The Activity Director, V14, acknowledged the lack of activities, citing short staffing as a reason for the deficiency. V14 mentioned that a new assistant had been hired to address this issue, but until the assistant is trained, the facility's corporate office instructed that memory care CNAs should conduct activities on weekends. Despite this directive, V14 confirmed that staff had not been engaging residents in activities, resulting in residents sitting idle or sleeping due to boredom. The facility's Dementia Unit Program emphasizes providing a safe environment with attributes that support the best quality of life, which was not being met in this instance.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident. The Director of Nursing (DON) was informed by the resident that an agency LPN was rough in her approach, used a harsh tone, and discussed other residents with him. Despite this, the DON did not report the incident to the Administrator, mistakenly believing the resident had done so himself. The Administrator confirmed that no report of abuse was made by the resident or staff. The facility's policy requires immediate reporting of any potential abuse to the Administrator, which was not followed in this instance.
Failure to Coordinate PASARR Level II Evaluations
Penalty
Summary
The facility failed to coordinate a Pre-Admission Screening and Resident Review (PASARR) Level II evaluation for two residents, R21 and R62, who were reviewed for PASARR II completion. R21 was admitted with diagnoses of Schizoaffective Disorder: Bipolar Type and Anxiety Disorder. Despite these diagnoses, R21's PASARR Level I screening indicated that a Level II screening was not required due to the absence of a serious behavioral health condition. However, the Business Office Manager confirmed that the PASARR Level I screening was inaccurate, as it did not reflect R21's actual mental health diagnoses. Similarly, R62 was admitted with diagnoses of Major Depressive Disorder, Brief Psychotic Disorder, and Generalized Anxiety. R62's PASARR Level I screening also incorrectly indicated that a Level II screening was not necessary, citing no evidence of a serious behavioral health condition. The Business Office Manager acknowledged the discrepancy, confirming that the PASARR Level I screening did not accurately represent R62's mental health conditions. The staff was reminded of the need to routinely review PASARR screenings for accuracy.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide an appropriate indwelling urinary catheter collection bag and secure it in a safe and dignified manner for a resident reviewed for indwelling urinary catheters. The resident, who has diagnoses including Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Chronic Kidney Disease Stage IV, Calculus of Ureter, and presence of Urogenital Implants, was observed with a catheter bag attached to his pants, visible to all. The catheter tubing was looped through his pant leg and secured on the outside, which was not in accordance with the facility's Urinary Catheter Care Policy. A Licensed Practical Nurse confirmed the absence of leg bags and acknowledged that the resident should have had one for safety and dignity. The facility administrator was aware of the need for more leg bags and acknowledged it was his responsibility to place the order.
Insufficient RN Coverage in Facility
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on six out of fifteen days reviewed, which has the potential to affect all 66 residents in the facility. Specifically, the facility's Nursing Daily Schedule from February 20, 2025, through March 6, 2025, documented zero hours of RN coverage for a 24-hour period on February 22, 23, 27, and March 3, 4, and 5, 2025. This deficiency was confirmed by the Regional Director on March 6, 2025, who verified that the hours listed on the facility's nursing daily schedule were correct, indicating a lack of RN coverage on the specified dates. At the time of the deficiency, the facility's Resident Midnight Census documented that 66 residents resided in the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. The incident involved two residents, both with moderate cognitive impairments, who were involved in a physical altercation in the dining room. One resident, who has a history of cerebrovascular disease, hemiplegia, schizoaffective disorder, and other medical conditions, was struck on the right shoulder by another resident with dementia and bipolar disorder. The altercation occurred after an argument between the two residents, and staff members attempted to intervene by separating them. The facility's abuse prevention policy emphasizes the right of residents to be free from abuse and the establishment of a secure environment. However, the incident indicates a failure to prevent the physical altercation, as staff intervention occurred only after the argument escalated to physical contact. The facility's documentation shows that the administrator and other relevant parties were notified, and an investigation was initiated following the incident.
Failure to Implement Comprehensive Care Plan for Resident Behaviors
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident with behaviors related to undressing and walking around naked. The resident, who has been diagnosed with dementia and schizophrenia, was observed on multiple occasions to be restless during the night, refusing personal care, and removing clothing. Despite these behaviors being documented in nursing notes and witness statements, there was no comprehensive care plan addressing these specific behaviors. Interviews with staff, including CNAs and an LPN, confirmed that the resident frequently undresses and walks around the facility without clothes, requiring continuous redirection. The facility's policy mandates the development of a comprehensive care plan that includes measurable objectives and timeframes to meet residents' needs, but this was not done for the resident in question. The administrator confirmed the absence of a care plan for the resident's behavior, highlighting a deficiency in the facility's compliance with its own policies.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care, specifically showers and dental care, to four residents who were dependent on staff assistance. The facility's policy required that showers or baths be offered at least once a week according to resident preference, and dental care be provided both morning and night. However, observations and interviews revealed that residents R6, R7, R8, and R9 did not receive showers as per the policy. R6 had not received a shower for over a week, as evidenced by his disheveled appearance and long, untrimmed nails. R7, who required a mechanical lift and preferred evening showers, reported not receiving showers due to staffing issues. R8 could not recall the last time he had a shower, and R9, who was supposed to receive whirlpool baths twice a week, reported not having had a bath or dental care for several days. The facility's records corroborated these deficiencies, showing infrequent showers for the residents over the past two months. R6 received showers only three times, R7 once, R8 once, and R9 had no recorded showers. Additionally, R9 reported not having her teeth brushed for four days, which was confirmed by her stale smell and her statement to the administrator. A Certified Nursing Assistant acknowledged the lack of showers due to insufficient staffing, and the Regional Nurse confirmed that residents should receive at least one shower per week. These findings indicate a failure to adhere to the facility's policies for personal hygiene care, impacting the residents' comfort and dignity.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse by another resident. An incident occurred where a resident with moderate cognitive impairment, who was able to propel themselves in a wheelchair, entered another resident's room unprovoked and physically assaulted a fellow resident. The aggressor resident kicked the victim in the shin and attempted to steal property from another resident in the room. The incident was reported to the facility administrator, and the residents were separated immediately. The victim, who also had moderate cognitive impairment and was dependent on staff for transfers, reported pain in the shin after being kicked and hit with a cane. The incident was witnessed by a Licensed Practical Nurse who intervened by removing the aggressor from the room. The facility's policy on abuse prevention and reporting was not effectively implemented to prevent this occurrence of resident-to-resident abuse.
Improper Use of Equipment Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, resulting in a significant injury. A resident with Multiple Sclerosis, who is wheelchair-bound and has impaired range of motion in both legs, was being transported in a shower chair by a CNA. The shower chair, which lacked foot pedals or leg support, was used to move the resident down a hallway. During this process, the resident's foot caught on a rug, causing a fracture to the tibia and fibula. The incident was witnessed by another CNA, who confirmed that the resident's foot was low to the ground and struck the edge of the carpet. The facility did not adhere to its incident/accident policy following the injury. The injury was not reported to the state survey agency, and a thorough investigation to determine the root cause was not conducted. The resident's care plan was not updated to reflect the injury, and there was no documentation of interventions developed to prevent future occurrences. The facility's administrator acknowledged the failure to report the injury and confirmed that the incident should have been investigated. The use of the shower chair for transportation was deemed inappropriate by the resident's physician, who noted that a wheelchair would have been safer due to its foot support. The facility's policy requires reporting serious injuries within 24 hours and conducting a comprehensive investigation, which was not followed in this case. The shower chair's owner's manual explicitly states that it is not intended for use as a transfer device, highlighting the facility's failure to use proper equipment for resident transportation.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day, which is a requirement for the care of the 68 residents residing in the facility. On multiple dates, the facility's Daily Assignment Sheets did not document the presence of an RN for the required duration. Specifically, on dates such as 11/21/24-11/24/24, 11/27/24, 11/28/24, 11/30/24, and 12/1/24, only Licensed Practical Nurses (LPNs) were on duty, and no RN was present for eight consecutive hours. Additionally, on 11/20/24, 11/25/24, and 11/26/24, the Director of Nursing (V2) worked only three to four hours on the second shift, with no other RNs listed to cover the remaining hours. V2 confirmed the lack of RN coverage and mentioned the facility's reliance on agency nurses, with corporate restrictions allowing only LPNs. The facility has one full-time RN and a part-time RN who works only on Mondays and Tuesdays.
Failure to Administer Insulin and Diabetic Medications Timely
Penalty
Summary
The facility failed to administer insulin and diabetic medications timely and as ordered for four residents. The Medication Administration Policy requires that medications be administered according to physician's orders, including the right time, and that any medication errors be reported to the physician. However, the facility did not adhere to these guidelines, as evidenced by the incomplete documentation on the Medication Administration Records (MARs) and the lack of notification to physicians about missed doses. For one resident, there were multiple instances where Humulin R was not administered as ordered, and there was no documentation explaining the missed doses or any notification to the physician. Another resident's MAR was incomplete for several scheduled insulin administrations, and although the physician was notified once, there was no documentation for other missed doses. Additionally, a resident reported waiting up to four hours for medications, and their MAR showed several instances of late or missed doses of Lantus, Trulicity, and Humalog, with no follow-up documentation or physician notification. The facility's issues were compounded by agency nurses not being aware of the protocol to notify physicians when medications were unavailable. This led to further missed doses and lack of documentation for another resident, whose MAR showed missed doses of Ozempic, Tresiba, and Lispro. The Director of Nursing confirmed that medications with specified times should be administered within an hour window and documented accordingly, but this was not consistently done, leading to significant medication errors.
Failure to Assess and Manage Pain for Resident with Fracture
Penalty
Summary
The facility failed to routinely assess and manage pain for a resident who suffered a left leg tibia/fibula fracture. The resident, who has a history of Multiple Sclerosis, Type Two Diabetes Mellitus, a Sacral Stage Four Pressure Ulcer, and Osteoarthritis of the hip, reported severe pain following the incident where their foot caught on a rug while being pushed in a shower chair by a CNA. Despite the resident's complaints of pain and the administration of Ultram as needed, the facility did not have a care plan in place to address the resident's pain or injury. The facility's Pain Management Program requires pain assessments to be conducted under specific conditions, including changes in condition or when pain medication is administered. However, the resident's care plan was not updated to include interventions for the fracture and pain management. The resident's pain was not assessed every shift, and there were discrepancies in the documentation of pain medication administration, with some doses not recorded on the Medication Administration Record (MAR). Interviews with staff, including CNAs and the Director of Nursing, confirmed that the resident's pain was not routinely assessed following the injury. The Director of Nursing acknowledged that there should have been an order to assess the resident's pain every shift and that the care plan should have been updated to address the fracture and pain. The resident's physician also confirmed that pain assessments should have been conducted routinely after the injury.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. An incident occurred where a resident with severe cognitive impairment was inappropriately touched by another resident, also with severe cognitive impairment, in the leisure room. The inappropriate touching was witnessed by staff, who immediately separated the residents. The resident who was touched did not appear to be aware of the actions due to her cognitive impairment, and her family confirmed that she would not have consented to such contact if she were cognitively intact. The facility also failed to protect residents from physical abuse by other residents. One incident involved a resident with severe cognitive impairment who pushed another resident, causing a fall. Another altercation occurred when a resident with a history of physical aggression grabbed another resident's arm during a dispute over shared bathroom space. The aggressive resident had a history of territorial behavior, which was exacerbated by a recent room change. Additionally, the facility failed to prevent a physical altercation between two residents during a meal. One resident, who was eating, believed another resident was trying to take his food and responded by hitting the other resident's hand. The resident who was hit had a history of behaviors that could provoke others, including going into other residents' rooms and touching their belongings. Staff were aware of these behaviors and attempted to intervene when necessary.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement adequate safety measures and supervision to prevent falls among residents, as evidenced by incidents involving three residents. One resident, with severe cognitive impairment, fell twice due to environmental hazards and improper clothing. The first fall occurred when the resident tripped over a mole mound on the patio, resulting in facial lacerations requiring medical glue closure. The second fall happened when the resident slipped on pants that were too long, causing a cut above the eye. The facility's fall prevention policy was not effectively implemented, as staff failed to monitor and address the environmental hazard of mole mounds and did not ensure the resident wore properly fitting clothing. Another resident, also with severe cognitive impairment, fell after leaving the bathroom without a walker, sustaining a laceration above the eye and a bump on the forehead. The investigation into this fall was inadequate, with only one staff statement documented and no thorough assessment of the resident's toileting needs or last observed activity. The facility's staffing levels were insufficient, with only one CNA on duty at the time of the fall, which was identified as a contributing factor but not documented in the investigation. A third resident, with a history of falls and severe cognitive impairment, experienced multiple falls without appropriate interventions being documented or implemented. The resident's care plan was not updated to reflect recent falls, and necessary checks were not completed. During one incident, the resident fell from bed while being changed by a CNA who was unaware that two staff members were required for the task. The resident's call light was found to be non-functional, further compromising safety. The facility's failure to conduct thorough investigations and implement effective fall prevention strategies contributed to these incidents.
Failure to Address Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement specific interventions to address behavioral disturbances associated with dementia for three residents. One resident, identified as R3, exhibited severe cognitive impairment, hallucinations, and daily aggressive behaviors. Despite a history of violent aggression and psychiatric hospitalizations, R3's care plan lacked personalized interventions to manage these behaviors. Incidents included physical aggression towards other residents, such as grabbing a peer by the arm and pushing another resident, which were not adequately addressed in the care plan. Another resident, R4, also displayed severe cognitive impairment and aggressive behaviors, including hitting another resident's hand and attempting to hit a staff member. R4's care plan did not document these behaviors or provide personalized interventions to prevent them. The facility's behavior monitoring reports for R4 were generic and did not reflect the specific needs and behaviors of the resident, leading to repeated incidents of aggression and the need for psychiatric evaluations. The third resident, R6, had Alzheimer's Disease and Dementia with Behavioral Disturbances, exhibiting behaviors such as reaching for other residents' food and items during meal times. R6's care plan did not document these specific behaviors or interventions to address them, resulting in altercations with other residents. The facility's failure to provide personalized care plans and interventions for these residents with dementia-related behaviors contributed to ongoing conflicts and safety concerns within the facility.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds by an employee, resulting in psychosocial harm. The incident involved a Business Office Manager (BOM) who, along with an Activity Aide, was alleged to have taken $600 from the resident's Trust Fund for personal use, specifically for car repairs for a family member. The facility's Abuse Prevention Program and Resident Funds Policy were not adhered to, as evidenced by the lack of signed vouchers and resident authorization for transactions. The resident, who has moderate cognitive impairment, was unaware of unauthorized transactions due to not receiving receipts or quarterly statements. The investigation revealed that a check for $200 was made out to cash without the resident's signature authorizing the transaction. The BOM admitted to providing cash to the resident without proper documentation, and the facility's Administrator confirmed the absence of required resident signatures on the Trust Fund logs. The BOM's employment was terminated for failing to follow facility policy, which included not providing necessary receipts and statements to residents, further contributing to the misappropriation of funds.
Failure to Provide Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for Resident Trust Funds for five residents, as required by their policy. The policy mandates security measures to safeguard resident funds, including signed vouchers, computerized tracking, monthly oversight, and signed quarterly statements. However, upon review, it was found that the facility's Resident Trust Fund binder contained transaction logs for the months of July to September 2024, which were not signed by the residents, and there were no signed quarterly statements available. This deficiency was highlighted during an investigation following an allegation of misappropriation of a resident's property involving the Business Office Manager and an Activity Aide. Interviews with residents and staff revealed that residents did not receive receipts or quarterly statements for their trust fund accounts. One resident, with moderate cognitive impairment, confirmed not receiving any receipts or statements, which prevented them from noticing unauthorized transactions. Another resident, who was cognitively intact, also stated they never received quarterly statements. The Business Office Manager admitted to not being trained on providing these statements, resulting in their absence. The Administrator in Training confirmed the lack of documentation for quarterly statements and stated that the Business Office Manager's employment was terminated for not adhering to facility policy.
Inadequate Surety Bond Coverage for Resident Trust Funds
Penalty
Summary
The facility failed to ensure that its Surety Bond provided adequate coverage for the Resident Trust Funds. The Surety Bond, dated May 8, 2023, was for the sum of $73,500, which was insufficient to cover the total amount of resident funds held by the facility. The facility's bank statements for July, August, and September 2024 showed ending balances of $136,483.09, $146,255.16, and $168,628.65, respectively, indicating that the Surety Bond did not cover the total amount of resident funds, which consistently exceeded $136,000 over the past three months. The deficiency affected five residents who had trust funds managed by the facility. Interviews with these residents confirmed that they had Resident Trust Funds managed by the facility. The facility's Administrator in Training acknowledged that the Surety Bond amount was insufficient and needed to be increased to match the total resident trust fund balance. The deficiency was identified during a review of the facility's Resident Trust Fund binder and bank statements, which documented transactions, withdrawals, and balances for each resident.
Failure to Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident and two staff members to the Illinois Department of Public Health (IDPH) as required by their Abuse Prevention Program. The program mandates that any suspicion of sexual abuse must be reported within two hours, or within 24 hours for other types of abuse. An anonymous call was received by the facility, alleging that two staff members allowed a resident to touch them inappropriately in exchange for money. Additionally, it was alleged that these staff members misappropriated $600 from the resident's Trust Fund Account. However, the facility's report to IDPH only included the misappropriation allegation and omitted the sexual abuse claim. The facility's cumulative abuse log did not document the sexual abuse allegation, and the administrator in training, who was notified of the incident, admitted to not reporting the sexual abuse allegation to IDPH. The administrator stated that the thought of reporting the sexual abuse allegation did not occur until after the fact. This oversight indicates a failure to adhere to the facility's own abuse reporting protocols, which are designed to ensure timely and appropriate responses to allegations of abuse, thereby safeguarding residents' well-being.
Failure to Provide Dialysis Services
Penalty
Summary
The facility failed to provide necessary dialysis services to a resident, identified as R15, who required such services due to kidney failure. R15 was admitted to the facility with a renal shunt for dialysis and a diagnosis of kidney failure, necessitating dialysis three times a week. However, due to a lack of understanding and coordination by the Social Services Director, V11, R15 missed nearly two and a half months of dialysis treatments. This oversight led to R15 being hospitalized for hypervolemia, a condition resulting from fluid overload, on January 30, 2024. The deficiency was further highlighted by the facility's inability to provide transportation for R15's dialysis on the day of admission, which was supposed to be managed by the Social Services Director. The Director of Nursing, V2, acknowledged that nursing issues such as dialysis should be managed by the nursing department, indicating a lapse in the facility's internal processes. The Dialysis Registered Nurse, V32, confirmed that R15's first dialysis treatment at the facility occurred only after hospitalization, underscoring the critical delay in providing essential medical care.
Failure to Manage Pain for Hospice Resident
Penalty
Summary
The facility failed to effectively manage pain for a resident on hospice care, resulting in the resident experiencing uncontrolled pain. The facility's Pain Prevention & Treatment policy requires routine pain assessments and timely implementation of pain medication orders, but these were not consistently followed. The resident, who had severe cognitive impairment and multiple medical conditions, was observed moaning, grimacing, and yelling out in pain. Despite the resident's care plan indicating a need for immediate response to pain complaints, there were no new interventions implemented after a certain date to address the resident's ongoing pain. The resident's medication records revealed inconsistencies in the administration of prescribed pain medications. A Fentanyl patch order was not implemented for 11 days, and there were discrepancies in the documentation of Morphine administrations. The resident's pain was frequently rated as severe, and several doses of Morphine were documented as ineffective in providing relief. Additionally, there was no documentation of the resident refusing pain medication, suggesting a lack of proper pain management and assessment. Interviews with facility staff indicated a lack of communication and documentation regarding the resident's pain management. The Director of Nursing and other staff members acknowledged the need for hourly pain assessments for hospice residents and the importance of consulting hospice for uncontrolled pain. However, there were lapses in following these protocols, as evidenced by the delayed implementation of medication orders and insufficient documentation of pain assessments and medication effectiveness.
Inadequate Infection Control and Legionella Monitoring
Penalty
Summary
The facility failed to monitor potential exposure sites for Legionella, which could affect all 44 residents. The facility's Legionella Policy and Procedures lacked documentation of plumbing inspections, assessments for redundant piping, and regular flushing of potential stagnation sites. The administrator confirmed the absence of an assessment or plan to address these issues, indicating a lack of surveillance and preventive measures against Legionella bacteria. Additionally, the facility did not adhere to its Contact Precautions policy. A resident on contact isolation due to ESBL in the urine was not properly protected, as staff entered the room without donning PPE. Despite a sign indicating contact isolation, there were no specific instructions on required PPE. Observations showed that a nurse and a housekeeping supervisor entered the resident's room without PPE, exposing themselves and potentially others to infection. The resident's laboratory reports confirmed the presence of bacteria, necessitating strict adherence to contact precautions.
Facility Lacks Certified Infection Preventionist
Penalty
Summary
The facility failed to employ a certified Infection Preventionist, which is a requirement for maintaining an effective infection prevention and control program. This deficiency potentially affects all 44 residents residing in the facility. The facility's policy on Infection Control Surveillance and Monitoring, last reviewed in December 2018, outlines the responsibilities of the Administrator, Infection Control Preventionist (ICP), and the Director of Nursing (DON) in monitoring and ensuring compliance with infection control practices. However, during an interview, the DON admitted that neither she nor the Assistant Director of Nursing, who assists with infection prevention tasks, are certified Infection Preventionists. The facility's policy includes procedures for routine surveillance, monitoring work practices, investigating exposure incidents, and maintaining communication with physicians and the Illinois Department of Public Health regarding infectious cases. Despite these outlined procedures, the lack of a certified Infection Preventionist indicates a gap in the facility's ability to effectively implement and oversee these critical infection control measures. The Assistant Director of Nursing, who is involved in tracking infections, cultures, and antibiotics, also confirmed that they have not completed the necessary infection preventionist training.
Facility Fails to Address Roof Leaks, Affecting Resident Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and functional environment by not addressing roof leaks, which resulted in sagging and stained ceiling tiles. Observations on multiple occasions revealed sagging ceiling tiles with large brown stains near the nurse's station and at the beginning of the C Hall. In one instance, a ceiling tile had been removed, exposing cords hanging down. A wet floor sign and a bath towel with a basin were placed below the leaking area to collect water droplets. This issue was noted to have persisted for a significant period, as confirmed by the Director of Nursing, who mentioned that the problem existed even when they worked as a hospice nurse at the facility a year and a half ago. A resident, who was admitted to the facility in October 2023, reported that the brown discoloration on the ceiling tile in their room had increased in size since their admission, indicating ongoing roof leaks when it rains. The facility's administrator confirmed the presence of the brown, sagging ceiling tiles and acknowledged that the roof still leaks despite having been patched. The administrator stated that roof repair quotes had been obtained, but the repairs had not been completed as they were awaiting corporate approval. This deficiency potentially affects all 44 residents residing in the facility.
Deficiencies in Laboratory Services and Documentation
Penalty
Summary
The facility failed to provide timely and accurate laboratory services for three residents, leading to deficiencies in monitoring and documenting essential health information. Resident R4, diagnosed with Type 2 Diabetes Mellitus, had an order for an A1C test every three months. However, the last A1C test was conducted nine months prior, with results indicating high levels. The Assistant Director of Nursing confirmed the absence of A1C results for the required period, highlighting a lapse in following the physician's orders. Resident R25 had a physician's order for a Hepatic Function Panel, which was not documented in the medical record. The Director of Nursing confirmed the missing test results, and the facility's contracted laboratory phlebotomist clarified that the Hepatic Function Panel includes tests not covered by a Comprehensive Metabolic Panel. Additionally, Resident R46's care plan required regular blood glucose monitoring, but the Medication Administration Records for several months lacked documentation of these results. The Assistant Director of Nursing acknowledged the omission, attributing it to a potential computer issue.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to accurately account for controlled substance medications and ensure medications were provided as ordered for several residents. For Resident R45, there was a discrepancy in the delivery and receipt of Fentanyl patches. The facility's investigation revealed that the package containing both Lorazepam and Fentanyl patches was delivered, but only Lorazepam was accounted for. The Administrator and Assistant Director of Nursing were involved in the handling of the package, but the Fentanyl patches were never located. Additionally, there was no requirement for a second signature to verify the receipt of controlled medications, which contributed to the oversight. Further discrepancies were noted in the medication administration records (MAR) for R45, where the documented administration of Lorazepam and Morphine did not match the controlled substances proof of use records. This inconsistency was acknowledged by the Administrator, who conducted a facility-wide audit and found similar issues. The lack of proper documentation and verification of medication administration was a recurring problem, as evidenced by the mismatched records for other residents as well. Other residents, such as R32 and R22, also experienced issues with controlled medication documentation. R32's Lorazepam count did not match the proof of use sheet, and R22's Lorazepam was administered without proper orders or documentation on the MAR. Additionally, R14 did not receive their prescribed Omeprazole due to insurance issues, and there was no documentation of physician notification regarding the missed doses. The facility's policies on controlled substances and medication administration were not consistently followed, leading to these deficiencies.
Failure to Obtain Consent and Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain consent for psychotropic medications, identify resident-specific targeted behaviors, and justify the use of duplicative antipsychotic medications for five residents. The facility's policy on psychotropic medications, which requires obtaining consent and ensuring medications are not unnecessary, was not followed. For Resident 38, there was no documentation of behaviors justifying the use of antipsychotics, no tracking of behaviors, and no physician's documentation to justify concurrent duplicative orders for antipsychotic medications. Additionally, there was no consent documented for the use of Haldol. Similar issues were observed for Residents 19, 33, and 39, where there was no documentation of resident-specific behaviors justifying the use of antipsychotics and no tracking of behaviors. Resident 5's behavior tracking could not be located, and consents for medications were not signed until the day of the survey. The Director of Nursing acknowledged the lack of specific behaviors identified or tracked for the residents and the absence of physician documentation to justify the use of multiple antipsychotics. The facility's failure to adhere to its policy on psychotropic medications and the lack of proper documentation and consent contributed to the deficiency identified during the survey.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered for three residents, leading to significant medication errors. For one resident, a Fentanyl patch was not administered as ordered, with no documentation explaining the omission or any indication of refusal by the resident. The Licensed Practical Nurse was unsure of the reason for the missed administration, and the Hospice Registered Nurse confirmed that missing the Fentanyl could contribute to increased pain for the resident. Another resident did not receive their prescribed Lacosamide for seizures due to a pharmacy and insurance issue, resulting in the medication being unavailable for an extended period. There was no documentation that the physician was notified of the unavailability or the missed doses. The Assistant Director of Nursing confirmed the issue, and the Regional Nurse and Administrator stated that the facility should have provided cost coverage or sought an alternative medication. The physician was unaware of the insurance issue and the missed doses, which placed the resident at risk for seizures. A third resident did not receive their prescribed nebulizer treatments due to a lack of a nebulizer machine and medication. The resident's notes documented multiple instances where the treatment was not administered, with reasons ranging from the resident sleeping to the unavailability of a nebulizer machine due to insurance issues. The resident confirmed not receiving the treatments and experiencing chest pain. The Assistant Director of Nursing acknowledged the incorrect initial order and the insurance-related lack of a nebulizer machine.
Failure to Provide Correct Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct consistency for a pureed diet for seven residents who were on pureed diets. The facility's policy from October 2012 specifies that pureed food should be blended to a smooth, pudding-like consistency and should not be pureed with water. However, during an observation on August 26, 2024, a staff member, V17, prepared pureed pork fritters without using a recipe and added unmeasured amounts of water and thickener multiple times. The resulting pureed meat contained lumps, which were confirmed during a taste test. V17 admitted to not testing the consistency and relying on visual assessment, stating that there were no complaints. The Dietary Manager, V15, indicated that cooks are supposed to follow recipes, use broth for blending, and ensure the product is smooth to prevent choking hazards.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of two residents, R5 and R15, as part of their commitment to a dignified existence and self-determination for residents. R5, who is cognitively intact and dependent on assistance for personal hygiene, reported that a Certified Nursing Assistant (CNA), identified as V12, was disrespectful and made her feel bad during care, particularly when R5 was unable to move her legs. Similarly, R15, also cognitively intact and requiring partial to moderate assistance with lower body care, expressed dissatisfaction with V12 CNA, describing her as having a 'smart mouth' and being disrespectful. The Director of Nursing (DON) confirmed receiving complaints about V12 CNA and acknowledged addressing the issue.
Failure to Schedule Follow-Up Cardiology Appointment
Penalty
Summary
The facility failed to schedule a follow-up cardiology appointment for a resident who was reviewed for dialysis. The resident had multiple diagnoses, including Type 2 Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease, Seizures, Stenosis of Carotid Artery, and Nonrheumatic Mitral Valve Prolapse. The hospital discharge instructions indicated that the resident had acute respiratory failure and hypertension and required dialysis three times weekly, with a follow-up appointment with a cardiologist. However, there was no documentation in the resident's medical record that the facility contacted the cardiologist's office to schedule this appointment. The Social Services Director, responsible for scheduling appointments, did not find any record of the appointment being scheduled. The Assistant Director of Nursing mentioned that the facility might have been in the process of scheduling the appointment, but the resident passed away before it was completed. The facility administrator stated that there was no policy for scheduling resident appointments, and they expected physician's orders to be followed.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for three residents, leading to deficiencies in their care. Resident R5, who was at high risk for skin breakdown, did not receive the prescribed barrier cream on multiple occasions, and staff were unaware of her existing wounds. Despite R5's cognitive awareness and reporting of her wounds, the Director of Nursing and LPN were not informed, resulting in untreated stage two wounds on her buttocks and thigh. Resident R14, also at high risk for skin breakdown, did not have a pressure-relieving cushion in her wheelchair, despite having open areas and irritation on her thighs and buttocks. The Director of Nursing was unaware of R14's wounds, and the LPN confirmed that the posterior thigh wound was only recently identified. The lack of pressure-relieving interventions contributed to the worsening of R14's skin condition. Resident R4, with multiple diagnoses including dementia and diabetes, was not provided with the necessary protective boots and pressure-relieving devices as per her care plan. Despite being at high risk for skin impairment, R4's left heel developed a large necrotic sore, and her right ankle showed signs of pressure damage. The facility failed to implement the prescribed interventions, and there were no treatment orders for R4's wounds, indicating a lack of communication and adherence to care protocols.
Failure to Notify of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician, Power of Attorney (POA), and dietician of a significant weight loss in a resident, identified as R43, who experienced a weight loss of over 10% within a month. The facility's policy requires notification of such changes within 24 hours, but this was not adhered to. R43's weight dropped from 134.2 pounds to 119.4 pounds between July 25 and August 14, 2024, marking an 11.03% weight loss. Despite this significant change, there was no documentation indicating that the necessary parties were informed. R43's medical history includes age-related cognitive decline, depression, and anxiety, with a care plan addressing potential nutritional problems related to depression. The dietary manager noted the weight loss and possible edema on August 16, 2024, but no further action was taken to notify the physician, POA, or dietician. The Director of Nursing and Social Services Director confirmed the lack of communication regarding the weight loss, indicating a lapse in following the facility's notification policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R28, from physical abuse by another resident, R38. The incident occurred when R38, who was known to be physically aggressive at times, became agitated and threw a glass of water at R28 while in the dining room. Although R28 did not sustain any injuries or report pain, the event highlights a lapse in the facility's responsibility to ensure residents are free from abuse. The facility's administrator acknowledged that placing R28 and R38 at the same table for meals was not the best choice, given R28's tendency to yell out, which may have contributed to R38's agitation. R28's medical records indicate diagnoses of Dementia, Psychotic Disturbance, Anxiety, Bipolar Disease, and Post-traumatic Stress Disorder. However, there were no specific resident-centered interventions documented in R28's care plan related to the PTSD diagnosis. The facility's Abuse Prevention Program outlines the residents' rights to be free from abuse and defines abuse as willful actions causing physical harm, pain, or mental anguish. Despite this, the facility did not adequately prevent the incident, as evidenced by the lack of appropriate interventions and the decision to seat the two residents together, which may have exacerbated the situation.
Failure to Report and Notify in Cases of Misappropriation and Missing Narcotics
Penalty
Summary
The facility failed to adhere to its abuse policy in two instances involving residents. In the first case, a resident reported a missing cellular phone to the Social Services Director over a week prior, but the allegation of potential misappropriation of personal property was not reported to the Administrator, who is the abuse coordinator, until the State Agency brought it to her attention. This delay in reporting prevented the immediate initiation of an investigation into the misappropriation of personal property, as required by the facility's policy. In the second instance, the facility did not notify a resident's family about missing Fentanyl patches, despite being aware of the issue. The Administrator was informed of the missing narcotics and initiated an investigation, but failed to communicate the situation to the resident's family. The facility's documentation confirmed the delivery of Lorazepam but not the Fentanyl patches, and the Administrator acknowledged the oversight in family notification, attributing it to being occupied with narcotic audits at the time.
Deficiency in Urinary Catheter Care and Infection Control
Penalty
Summary
The facility failed to maintain proper care for a resident with a urinary catheter, leading to a deficiency in infection control practices. Observations revealed that the resident's urinary collection bag was repeatedly found lying on the floor, containing dark urine, which poses a risk of cross-contamination. Certified Nursing Assistants admitted to using a pillowcase to cover the bag due to a shortage of privacy bags, which are intended to prevent the bag from contacting the floor. The facility's policy requires urinary drainage bags to be covered with a dignity bag, but this was not adhered to, as confirmed by the Director of Nursing. Additionally, the facility did not follow the physician's order to change the resident's urinary catheter monthly. The resident's medical records for July and August did not document any catheter changes, and the hospice nurse confirmed that hospice had not changed the catheter. The resident's urine culture indicated a urinary tract infection with significant bacterial growth. Despite requests for documentation of catheter changes, the facility failed to provide evidence that the catheter was changed as ordered.
Non-compliance with Respiratory Care Protocols
Penalty
Summary
The facility failed to maintain respiratory equipment in a clean and sanitary manner and did not adhere to the prescribed orders for changing and administering respiratory care equipment. For one resident, the nebulizer machine and mask were observed to be uncovered and exposed to the air, with the mask and medication cup dated over two weeks prior, indicating a failure to change the equipment as required. Additionally, there was no documented order to change the nebulizer mask or tubing, which is a deviation from the facility's policy that mandates weekly changes and proper documentation. Another resident was prescribed oxygen at two liters per nasal cannula while in bed, but was observed receiving four liters instead, with no date of change documented on the tubing or water bottle. The resident reported that staff consistently administered four liters of oxygen at night, contrary to the physician's order. The oxygen tubing was also found undated and improperly stored on top of the concentrator, further indicating non-compliance with the facility's oxygen therapy policy.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
