Axiom Gardens Of Flora
Inspection history, citations, penalties and survey trends for this long-term care facility in Flora, Illinois.
- Location
- 701 Shadwell Avenue, Flora, Illinois 62839
- CMS Provider Number
- 145624
- Inspections on file
- 31
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Axiom Gardens Of Flora during CMS and state inspections, most recent first.
A resident with cognitive deficits and a history of rash was hospitalized and treated for a diffuse pruritic rash resembling scabies, placed on contact isolation, and discharged back with orders indicating possible scabies and contact precautions. On readmission, an RN documented a generalized rash but did not review the hospital paperwork or obtain verbal report, so no contact isolation, infection tracking, contact tracing, or environmental cleaning was initiated. The infection control nurse did not add the case to the infection control log because the diagnosis and treatment occurred at the hospital, and housekeeping/laundry were not informed of any need for isolation-level cleaning or laundry. The facility’s scabies control policy, which requires resident inspections, DON/infection control assessment, hot washing of linens, environmental disinfection, and simultaneous treatment of affected individuals, was not followed.
A resident with dementia, agitation, and a known history of aggressive behavior repeatedly verbally, physically, and sexually abused several cognitively impaired residents. In one episode, the resident slapped another resident in the face in the dining room while calling her derogatory names and stated he would hit her again. On another occasion, he was found in a resident’s room attempting to tip her out of her wheelchair while yelling and cursing, after having been agitated and disruptive throughout the day. He also grabbed a male resident by the throat and pushed him in his wheelchair out of the dining room, and in a separate incident, came up behind a female resident and grabbed her breast after following her around much of the day. These events occurred despite an existing abuse-prevention policy and a behavior-focused care plan for the aggressive resident.
A resident with dementia and dysphagia was served a whole bratwurst on a bun instead of the ordered mechanical soft diet with thickened liquids. The incorrect meal texture led to a choking incident during lunch, requiring emergency intervention and hospital transfer. Staff interviews and facility records confirmed the diet order was not followed, resulting in the deficiency.
A resident with severe cognitive impairment and behavioral issues physically assaulted two other residents, resulting in one sustaining a fractured coccyx. Staff and administration were aware of the resident's unpredictable aggression but were unable to identify or implement effective interventions to prevent repeated altercations, leading to physical harm and risk of abuse.
A resident with severe cognitive impairment and multiple comorbidities was pushed by another resident, resulting in a fall and subsequent pain complaints. Nursing staff administered pain medication but did not notify the physician of the pain or later x-ray findings indicating a coccyx fracture. The physician and NP were not informed until the family reported the injury, and hospital records documenting the fracture were not promptly reviewed or acted upon by staff.
A resident who was totally dependent on staff for transfers and required two-person assistance was left suspended in a mechanical lift sling by a CNA who exited the room after a disagreement, leaving the resident unable to reach the call light. The transfer was performed without a second staff member, contrary to the care plan, and the incident was not immediately reported or documented, resulting in a failure to protect the resident from neglect.
A resident dependent on staff for transfers was left suspended in a mechanical lift sling by a CNA who became upset and left the room, leaving the resident unattended for about ten minutes until other staff intervened. The incident was not immediately reported to the Administrator, and no incident report was filed, contrary to facility policy requiring prompt internal reporting of suspected neglect.
A resident who was totally dependent on staff for transfers was left suspended in a mechanical lift sling by a CNA who became upset and left the room. The resident, unable to reach the call light, called for help until two staff members arrived to complete the transfer. The incident was not documented or investigated, despite facility policy requiring all allegations of neglect to be investigated.
A resident who was totally dependent on staff for transfers was left suspended in a mechanical lift sling by a single CNA, contrary to the care plan and facility policy requiring two staff for such transfers. The CNA became upset during the transfer, left the resident unattended above a shower chair, and exited the room. The resident remained in the lift for about ten minutes until other staff responded and completed the transfer. The incident was not documented in the nursing notes, and no incident report was filed at the time.
The facility failed to ensure that a physician visited residents as required, affecting 64 residents. The Medical Director only visited for quality assurance meetings, while a nurse practitioner, who recently resigned, was responsible for resident visits. The facility's administrator and DON were unaware of the regulatory requirement for physician visits, leading to non-compliance.
The facility experienced significant staffing shortages, leading to delayed response times to resident call lights, particularly during night shifts. Residents reported waiting over 30 minutes for assistance, and the DON acknowledged the staffing challenges, noting reliance on agency staff to fill gaps. Observations confirmed numerous unfilled shifts, impacting the facility's ability to provide timely care.
The facility failed to maintain a safe and homelike environment, with issues such as a cracked windowpane in the shower room and multiple residents experiencing problems with their wheelchairs, including missing armrests and worn seats. These deficiencies affected residents' ability to safely and comfortably navigate their environment.
A resident, who is cognitively intact, experienced repeated delays in meal service compared to her tablemate, leading to a lack of dignity in dining. The facility's Dietary Manager attributed the issue to an outdated tray card system that had not been updated to include newer admissions, causing the resident to wait for her meal while her tablemate finished eating.
The facility failed to follow dietary orders for two residents, resulting in inadequate nutrition. One resident did not receive the prescribed double protein at meals, while another did not consistently receive fortified pudding. Additionally, the facility did not adhere to its weight policy for a resident with significant weight loss, failing to communicate the change to the dietitian or physician.
A facility failed to maintain accurate narcotic records for a resident with multiple medical conditions. An oxycodone bottle labeled with the resident's information was found in the medication cart without a count sheet, and the resident had no order for the medication. The RN and DON acknowledged the oversight, noting the medication should have been destroyed or returned to the family. Facility policy requires narcotic counts with a partner, which was not followed.
A facility failed to securely store medications for a resident prescribed Lorazepam, as the medication refrigerator was found without a lock on multiple occasions. The Director of Nursing acknowledged the oversight, and a Registered Nurse was unaware of the locking requirement, indicating a lapse in adherence to the facility's medication storage policy.
A resident with severe dementia and Type 2 Diabetes Mellitus was not provided with a therapeutic diet as ordered. The resident's care plan required a mechanically altered diet with bite-sized pieces to prevent choking. However, observations revealed that the resident was served meals with pieces larger than recommended, leading to difficulties in eating. The dietary manager and speech-language pathologist acknowledged the issue, but there was no formal documentation or training to ensure compliance.
The facility failed to maintain aseptic technique during wound care for two residents. A resident's leg was placed on a bed comforter without a barrier during wound care, contrary to infection control expectations. Another resident's wound care involved improper hand hygiene, as the nurse did not change gloves or wash hands after touching potentially contaminated surfaces. These actions were inconsistent with the facility's infection control program.
A resident sustained a leg laceration during transport in a facility van when their motorized scooter was not secured. The Social Service Director, who was driving, missed a turn and abruptly braked, causing the scooter to move forward and injure the resident. The resident required emergency medical attention and treatment for an infected wound. The facility's policy mandates securing all residents and wheelchairs during transport, which was not followed.
Failure to Implement Scabies Infection Control Measures After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including infection tracking, contact tracing, and environmental precautions, for a resident with a presumptive diagnosis of scabies. The resident was admitted with diagnoses including paranoid schizophrenia and unspecified convulsions and had a care plan problem for a rash on multiple body areas related to allergies, eczema, and psoriasis. During a subsequent hospital stay, the resident developed a diffuse pruritic rash resembling scabies and was treated with permethrin cream and placed in contact isolation due to a history of MRSA and the current rash. The hospital transfer orders back to the facility documented contact isolation status and possible scabies. On readmission, nursing notes described a generalized rash, but the RN who readmitted the resident did not review the hospital discharge or transfer paperwork, did not obtain a verbal report from the hospital, and was therefore unaware of the scabies diagnosis and treatment. As a result, the resident’s scabies diagnosis and treatment were not entered into the facility’s March infection control log, and no follow-up skin checks or contact tracing were conducted to determine if other residents were affected. The infection control nurse stated she did not log the case because the diagnosis and treatment occurred at the hospital rather than in the facility. Housekeeping/laundry staff reported they had not been notified of any scabies cases or the need for isolation-level room cleaning or laundry processing, and the APN stated she was not informed of the hospital’s scabies treatment until the survey date. The facility’s own scabies control policy requires inspection of residents who had contact with the affected resident, assessment by the DON and infection control nurse to determine preventive measures, bagging and hot washing of linens and clothing, thorough environmental cleaning and disinfection of furniture and equipment, and simultaneous treatment of affected individuals. None of these specified infection control measures were implemented for this resident upon return to the facility, despite documented possible scabies and contact isolation orders from the hospital.
Failure to Protect Cognitively Impaired Residents From Repeated Abuse by an Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent repeated verbal, physical, and sexual abuse by one resident (R7) toward multiple cognitively impaired residents (R1, R6, R8, and R9), despite R7’s known history of aggressive behaviors. R7 was admitted with dementia with agitation, lack of coordination, anxiety, and depression, and had a care plan focus for behavior problems related to verbal/physical aggression and wandering/elopement risk. The care plan’s only reference to a resident-to-resident altercation was a single entry noting an altercation and referral to behavioral health, without further detail on specific protective interventions for other residents. Facility policy stated that residents who allegedly abused another resident should be immediately evaluated to determine suitable care approaches and placement, and that the facility would take all steps necessary to ensure resident safety, including separation of residents. In one incident, R7 approached R8, who had severe cognitive impairment due to Alzheimer’s disease and other psychiatric and neurologic diagnoses, while she was in the dining room talking out loud to herself. A CNA (V13) observed R7 walk to his usual dining spot where R8 was seated, then step back and slap her across the left side of her face while calling her a “stupid b**ch” and attempting to slap her again. R7 later stated he was annoyed by R8’s yelling and that he slapped her to “shut her up,” adding that he would have slapped her again if staff had not intervened. R8, who also had severe cognitive impairment, was unable to provide a description of the event. This incident was documented in resident-to-resident altercation forms and in a final report to the state agency. In another incident, R7 entered R1’s room, where R1, who had moderate cognitive impairment, major depressive disorder, generalized anxiety, dementia with behavioral disturbance, and unsteadiness on her feet, was in her wheelchair. A CNA (V12) responded to R1’s call light and found R7 holding the wheelchair handles and attempting to tip R1 out of the wheelchair while yelling and cursing at her. Documentation noted that earlier that day R7 had been very agitated, banging doors, attempting to exit the building, and verbally distressing other residents and staff in the dining room. R7 was reported to have walked out of R1’s room cursing and stating, “next time I will hurt her.” A further incident involved R7 and R9, who had severe cognitive impairment with diagnoses including Parkinson’s disease with dyskinesia, Alzheimer’s disease, chronic pain syndrome, and depression. While R9 was eating in the dementia unit dining room, staff reported that R7, who had been agitated and “bickering” and “mouthing” at others most of the day, stood up, went toward R9, grabbed him by the throat, and pushed him in his wheelchair out of the dining room into the hallway. A CNA (V9) stated she removed R7’s hand from R9’s neck and called for assistance. Facility documentation described R7 as visibly agitated and noted that staff had to separate the residents. In a separate event on the same date as the incident with R9, R7 sexually abused R6, a resident with severe cognitive impairment, anxiety disorder, anoxic brain damage, catatonic disorder due to a physiological condition, and depression, who was care planned as being at risk for abuse/neglect. A CNA (V10) reported that R7, who had been agitated and “targeting” R6 by following her around throughout the day, walked up behind R6, reached around from her back, and grabbed her breast. V10 stated she told R7 to let go, he initially said no, and she then removed his hand from R6’s breast and redirected him. R6 was unable to provide a description of the incident. These repeated episodes of physical, verbal, and sexual abuse by R7 toward multiple vulnerable residents occurred despite the facility’s abuse prevention policy and R7’s known behavioral history, demonstrating a failure to protect residents from abuse by another resident.
Failure to Provide Correct Diet Texture Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with dementia and oropharyngeal dysphagia was not provided with the correct textured diet as ordered. The resident's care plan and physician orders specified a mechanical soft texture with thickened liquids, but on the day of the incident, the resident was served a whole bratwurst on a bun, which did not meet the mechanical soft diet requirements. Multiple staff, including the CNA, cook, and dietary aide, confirmed that the resident received the incorrect diet texture, and the facility's dietary records and recipes indicated that the meal should have been ground bratwurst with gravy to ensure proper consistency. During lunch, the resident choked on the improperly prepared food, became unresponsive, and required emergency intervention. Staff performed abdominal thrusts and a finger sweep to remove the food obstruction, after which the resident regained consciousness and normal color. Emergency medical services were called, and the resident was transported to the hospital for further evaluation and care. The incident was documented in progress notes, incident reports, and confirmed by interviews with staff present at the time. The facility's own dietary policy and menu documentation outlined the requirements for mechanical soft diets, including that meats be ground or chopped into small, moist pieces. Despite these guidelines, the resident was served a regular texture meal, which directly led to the choking event. Staff interviews revealed a lack of awareness regarding the resident's current diet order at the time of meal service, contributing to the failure to provide the appropriate diet texture as ordered.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple resident-to-resident altercations involving a resident with severe cognitive impairment and behavioral issues. One resident, with a history of dementia, anxiety disorder, and repeated falls, exhibited aggressive behaviors that were documented in his care plan. Despite these known behaviors, the resident was able to push another resident, who also had severe cognitive impairment and Parkinson's disease, causing the latter to fall and sustain a fractured coccyx. The incident occurred while the second resident was loudly preaching in the hallway, which agitated the aggressive resident, leading to the physical altercation. Initial assessments did not reveal the fracture, and the injury was only discovered after the resident's family took him to an outside physician, who ordered an x-ray confirming the fracture. Further review revealed additional incidents involving the same aggressive resident. In another event, the resident pushed a different peer to the ground and struck him with a walker. Staff interviews indicated that the aggressive resident's behaviors were unpredictable and often triggered without warning, particularly in the late afternoon or early evening. Staff were unable to determine the root cause of the behaviors, and interventions listed in the care plan included medication management, redirection, and attempts to separate the resident from others. However, these interventions were not sufficient to prevent repeated altercations. Documentation and interviews showed that staff and administration were aware of the resident's escalating aggression but were unable to identify effective interventions or consistently implement measures to protect other residents. The care plans referenced behavioral issues and listed general interventions, but there was a lack of specific, individualized strategies to address the aggressive behaviors. The facility's failure to prevent these incidents resulted in physical harm to at least one resident and placed others at risk of abuse.
Failure to Notify Physician of Resident Pain and Injury After Altercation
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of a resident's complaint of pain following a resident-to-resident altercation that resulted in a fall. The resident, an elderly male with severe cognitive impairment, Parkinson's disease, dementia, and other comorbidities, was pushed by another resident, causing him to fall and sustain an abrasion to his right elbow. Initial assessments documented that the resident denied pain and did not report hitting his head, and the incident was reported to the family, administration, and local authorities. However, subsequent documentation showed that the resident later complained of tenderness to the left buttock, for which pain medication was administered by nursing staff, but the physician was not notified at that time. The resident was later taken to a physician appointment by a family member, where he reported pain in the sacral area. The physician ordered an x-ray, which revealed a suspected non-displaced fracture of the coccyx. The facility did not become aware of the x-ray results until the spouse reported them several days later. Additionally, emergency department records faxed to the facility also documented the coccyx fracture, but these records were not reviewed or acted upon by facility staff in a timely manner. Multiple staff members, including the Assistant Director of Nursing and a Registered Nurse, stated they were unaware of the fracture documented in the hospital records. The facility's policy required timely communication of medical care problems to the attending physician and family. Despite this, the physician and nurse practitioner were not informed of the resident's pain complaints or the x-ray findings until after the family reported them. The nurse practitioner indicated that, had she been notified, she could have ordered the x-ray and adjusted pain management sooner. The lack of timely physician notification and review of hospital records led to a delay in appropriate assessment and treatment for the resident's injury.
Resident Left Suspended in Mechanical Lift Due to Staff Neglect
Penalty
Summary
A deficiency occurred when a resident with morbid obesity, diabetes type 2, congestive heart failure, limited lower extremity range of motion, and total dependence on staff for transfers was left suspended in a mechanical lift sling during a transfer. The resident's care plan required two staff members to assist with mechanical lift transfers, but on the evening in question, only one agency CNA performed the transfer. During the process, the resident expressed concerns about back pain and the manner in which the transfer was being conducted. The CNA became upset, left the resident elevated in the sling above the shower chair, and exited the room, shutting the door and leaving the resident unable to reach the call light. The resident reported that he called for help for approximately ten minutes before two other staff members responded and completed the transfer. The incident was not documented in the resident's nursing progress notes, and there was no immediate incident report filed. The CNA involved admitted to performing the transfer alone and leaving the resident in the sling, stating he intended to de-escalate the situation. Other staff confirmed that the resident was found suspended in the sling and that the CNA had left the room, but they did not notify management at the time. The facility's abuse prevention and reporting policy prohibits neglect, defined as the failure to provide necessary goods and services to avoid physical harm, pain, or mental anguish. Despite the resident not reporting injury or emotional trauma, the actions of the CNA and the lack of adherence to the care plan and facility policy resulted in a failure to protect the resident from neglect during the transfer process.
Failure to Immediately Report Staff-to-Resident Neglect During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to immediately report an instance of staff-to-resident neglect to the Administrator. The incident involved a resident with morbid obesity, diabetes type 2, congestive heart failure, and limited range of motion in both lower extremities, who was totally dependent on staff for transfers. During a mechanical lift transfer, a Certified Nursing Assistant (CNA) left the resident suspended in a lift sling above a shower chair after becoming upset with the resident, who was expressing concerns about the transfer. The resident was left alone in this position for approximately ten minutes, unable to reach the call light, until two other staff members responded to his calls for help and completed the transfer. The resident was not injured and did not report emotional trauma from the event. The incident was not documented in the resident's nursing progress notes, and the CNA involved admitted to performing the transfer alone, contrary to the care plan requiring two staff members. The CNA stated he left the room to de-escalate the situation after the resident became verbally aggressive. Other staff members who witnessed the aftermath of the incident did not immediately notify management. The Administrator became aware of the event only after being informed by a nurse the following morning, and no incident report was filed because the resident stated he did not feel neglected or abused. The facility's Abuse Prevention and Reporting Policy requires immediate reporting of any incident, allegation, or suspicion of potential abuse or neglect to the Administrator, and timely external reporting to the state surveying agency. In this case, the required internal reporting procedures were not followed, as the incident was not reported immediately to the Administrator, nor was an incident report completed as required by policy.
Failure to Investigate Alleged Staff-to-Resident Neglect During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to investigate an allegation of staff-to-resident neglect involving a resident with morbid obesity, diabetes type 2, and congestive heart failure, who was totally dependent on staff for transfers. The resident, who was cognitively intact, reported that during a mechanical lift transfer, a Certified Nursing Assistant (CNA) left him suspended in a sling above a shower chair after becoming upset and leaving the room. The resident was unable to reach the call light and had to call out for help for approximately ten minutes before other staff arrived to complete the transfer. The incident was not documented in the resident's nursing progress notes. Interviews with staff confirmed that the CNA performed the transfer alone, contrary to the care plan requiring two staff members and use of a mechanical lift. After the CNA left the room, two other staff members entered and completed the transfer. The CNA later stated that he routinely performed transfers alone and left the room to de-escalate the situation, while other staff corroborated that the resident was left in the sling and required assistance. Despite these accounts, the incident was not reported to management by the staff who responded, and no incident report was completed. The facility's administrator became aware of the event the following day but did not initiate an investigation, citing the resident's statement that he did not feel neglected or abused. The facility's abuse prevention and reporting policy requires that all incidents or allegations involving abuse, neglect, exploitation, or mistreatment be documented and investigated, regardless of the resident's perception. The lack of documentation and investigation in this case constitutes a failure to respond appropriately to an alleged violation.
Failure to Provide Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for transfers due to morbid obesity, diabetes type 2, congestive heart failure, and limited range of motion in both lower extremities, was transferred using a mechanical lift by only one staff member, contrary to the care plan and facility policy requiring two staff for such transfers. During the transfer, the resident expressed concerns about back pain and the manner in which the transfer was being conducted. The staff member performing the transfer became upset, left the resident suspended in the mechanical lift sling above the shower chair, and exited the room, leaving the resident unattended and unable to reach the call light. The resident remained in the lift for approximately ten minutes, calling for help until two other staff members responded and completed the transfer. The resident was not physically injured or emotionally traumatized by the event, as reported in interviews, but the incident was not documented in the nursing progress notes, and no incident report was filed at the time. The staff member involved admitted to routinely performing transfers alone and stated he left the room to de-escalate the situation after the resident became verbally aggressive. Interviews with other staff confirmed that the transfer was performed by a single staff member and that the resident was left suspended in the lift. The facility's policy and the resident's care plan both required two staff members for mechanical lift transfers to ensure safety. The incident was reported to facility management the following morning, but there was a lack of immediate documentation and notification by the staff present at the time of the event.
Failure to Ensure Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that the physician visited and examined residents at least once every 30 days for the first 90 days after admission or at least once every 60 days thereafter. This deficiency affected 64 residents out of a sample of 66. The Medical Director, identified as V17, was listed as the medical doctor for these residents but was reported to only visit the facility once every three months for quality assurance meetings and did not see the residents. Instead, a nurse practitioner was responsible for seeing the residents, but this practitioner had recently resigned, and a new nurse practitioner was conducting telehealth visits until a replacement could be found. Interviews with the facility's administrator and director of nursing revealed a lack of awareness regarding the regulatory requirement for physician visits. The director of nursing stated that the facility used an app to communicate with the nurse practitioner during the day and had an answering service for after-hours, which had not posed any issues. However, the director was unaware that the physician was required to see the residents, indicating a gap in compliance with the regulations. The facility's Medical Director and Management Agreement outlined responsibilities for overseeing medical care and ensuring compliance with regulations, but these were not being met as the physician was not conducting the required visits.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of all 68 residents, as evidenced by multiple resident interviews and staff statements. Residents reported significant delays in response times to call lights, particularly during night shifts when staffing levels were lower. For instance, one resident mentioned having to wait over 30 minutes for assistance, while another reported waiting up to an hour. These delays were attributed to insufficient staffing, with residents noting that the issue was more pronounced during night shifts when fewer staff members were available. The Director of Nursing (DON) acknowledged the staffing challenges, stating that the facility often struggled to maintain adequate staffing levels, especially on night shifts. The DON mentioned that the facility typically aimed to have a certain number of certified nurse assistants (CNAs) and nurses on each shift, but there were instances where these numbers were not met. The facility relied on agency staff to fill gaps, but there were still numerous shifts with unmet staffing needs, as evidenced by the posted schedules showing unfilled shifts and the need for additional staff coverage. Observations during a facility tour further confirmed the staffing deficiencies, with multiple sheets posted near the time clock indicating numerous unfilled shifts for both nurses and CNAs. The facility's personnel policy stated the requirement to provide adequate staffing to meet resident needs, yet the documented schedules and staff interviews highlighted ongoing staffing shortages. These deficiencies in staffing levels directly impacted the facility's ability to provide timely care to residents, as evidenced by the residents' reports of delayed assistance.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. A cracked windowpane in the Northwest Shower Room had been left unrepaired since November 2023, despite being known to the maintenance director, who had not informed the current owners. This affected multiple residents residing in the Northwest Hall, as documented in the facility's daily census sheet. Additionally, two residents, who were roommates, experienced issues with their wheelchairs. One resident's wheelchair was missing a right armrest and had a worn seat, making it difficult for her to propel herself, which was necessary for her rehabilitation. The other resident's wheelchair was also missing an armrest, with a protruding screw posing a potential risk. Another resident's wheelchair was observed to have a large chunk missing from the right armrest, further indicating the facility's failure to ensure equipment was in good repair.
Failure to Serve Meals with Dignity
Penalty
Summary
The facility failed to ensure that residents were served meals in a manner that promoted dignity, as observed with one resident, R35, who was cognitively intact with a BIMS score of 15. On multiple occasions, R35 was observed waiting for her meal to be served while her tablemate, R62, had already received and finished her meal. This pattern was noted over several days, with R35 expressing frustration about the delay and questioning why they could not be served simultaneously. The Dietary Manager, V4, explained that the facility used an assigned seating system to determine the order of meal service, but had not updated the tray cards to include newer admissions, resulting in the delay for R35.
Failure to Follow Dietary Orders and Weight Policy
Penalty
Summary
The facility failed to follow physician dietary orders for two residents, resulting in inadequate nutrition. One resident, diagnosed with hyperlipidemia, bipolar disease, and chronic obstructive pulmonary disease, was on a regular diet with double protein at meals. However, observations revealed that the resident was not consistently receiving the prescribed double protein during meals. The Dietary Manager confirmed that the kitchen missed providing the double protein on multiple occasions. Another resident, with depression, constipation, and congestive heart failure, was supposed to receive fortified pudding with meals due to weight loss. Observations showed that the resident did not consistently receive the fortified pudding, and the Dietary Manager acknowledged the oversight. Additionally, the facility failed to adhere to its weight policy for a resident with Type 2 Diabetes Mellitus, unspecified dementia, and essential hypertension. This resident experienced a significant weight loss of 6.23% in one month, which was not communicated to the dietitian or physician in a timely manner. The Registered Nurse was unsure why the weight loss was not reported, as the weight was entered by a Resident Care Aide instead of the Dietary Manager. The facility's weight policy requires re-weighing and reporting of unanticipated weight changes, which was not followed in this case.
Failure to Maintain Accurate Narcotic Records
Penalty
Summary
The facility failed to maintain accurate records of narcotics for a resident, identified as R15, who was part of a sample of 66 residents reviewed for controlled substance medication. R15, a [AGE] year-old resident with multiple medical conditions including a displaced oblique fracture of the right femur, multiple sclerosis, and dementia, was admitted to the facility on an unspecified date. During a review of the medication cart, an orange pill bottle labeled with R15's information was found in the narcotic box without an accompanying narcotic count sheet. The bottle contained oxycodone, a controlled substance, which was not documented in R15's order summary. The Registered Nurse, V6, acknowledged the absence of a count sheet and stated that the medication should have been destroyed or sent home with R15's family. The Director of Nursing, V2, confirmed that it is the facility's expectation for all narcotics to have a count sheet and for discontinued medications to be discarded. V2 further stated that R15 never had an order for oxycodone and that the medication was brought in by the family upon admission. The facility's policy on narcotic controlled substances requires counting with a partner to verify the accuracy of log sheets, which was not adhered to in this case. The failure to maintain accurate narcotic records and the presence of an undocumented controlled substance in the medication cart led to the deficiency identified by the surveyors.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure the secure storage of medications for a resident, identified as R28, who was prescribed Lorazepam (Ativan) oral concentrate. The medication was observed in a medication refrigerator without a lock, which is a requirement for storing controlled substances. The Director of Nursing (V2) acknowledged the absence of a lock and mentioned that the refrigerator had been changed out recently, but the lock was not installed on the new unit. Despite the expectation that the medication refrigerator should be locked, it was found unsecured on multiple occasions. The facility's policy on medication storage, which requires controlled substances to be stored in a secured, double-locked area, was not adhered to. The Registered Nurse (V6) was unaware of the requirement for a lock on the refrigerator, indicating a lack of communication or training regarding the facility's medication storage policies. R28's medical history includes multiple diagnoses such as type 2 diabetes mellitus, schizoaffective disorder, and chronic kidney disease, among others, highlighting the importance of proper medication management for this resident.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for a resident with severe dementia, depression, hypertension, and Type 2 Diabetes Mellitus. The resident's care plan required a mechanically altered diet with bite-sized pieces to prevent choking, as documented in the Minimum Data Set (MDS). However, during observations on two consecutive days, the resident was served meals that did not comply with these dietary requirements. On the first day, the resident struggled to eat meatballs that were too large, resulting in food spilling onto the table and the resident's lap. On the second day, the resident was served chicken cordon bleu casserole with pieces of ham and chicken that exceeded the recommended bite size. The facility's dietary manager and speech-language pathologist acknowledged the discrepancy between the prescribed diet and the food served. The dietary manager admitted that the recipe did not specify the correct size for bite-sized pieces, and the speech-language pathologist confirmed that the pieces served were larger than appropriate. Despite the speech-language pathologist's efforts to educate staff on the correct portion sizes, there was no formal documentation or in-service training completed to ensure compliance with the resident's dietary needs.
Failure to Maintain Aseptic Technique During Wound Care
Penalty
Summary
The facility failed to maintain aseptic technique during wound care for two residents, R13 and R45. For R13, who was admitted with chronic venous hypertension with ulcer and other related conditions, the Registered Nurse (RN) V10 did not use a barrier under R13's leg while performing wound care. The RN repeatedly laid R13's leg on the bed comforter without a barrier after removing the old dressing, cleaning the wound, and applying silver sulfadiazine cream. This was contrary to the facility's infection control expectations, as confirmed by the Infection Prevention Nurse, V16, who stated that a barrier should be used during such procedures. For R45, who had diagnoses including unspecified dementia and chronic obstructive pulmonary disease, the Infection Prevention Nurse, V12, and a Certified Nurse Assistant, V13, did not follow proper hand hygiene protocols during wound care. V12 moved a bedside table and touched an air mattress pump cord on the floor before cleaning R45's shoulder wound without changing gloves or washing hands. This action was inconsistent with the facility's Infection Prevention and Control Program, which requires routine hand washing and the use of appropriate barrier prevention to prevent infection transmission.
Resident Injury Due to Unsecured Transport
Penalty
Summary
The facility failed to safely secure a resident during transport, resulting in an accident. The resident, identified as R2, was being transported in a facility van to an eye appointment by the Social Service Director, V12. During the transport, R2's motorized scooter was not secured, and V12 did not buckle the scooter because they were not traveling far. On the return trip, V12 missed a turn and abruptly braked, causing R2's scooter to move forward, leading to R2 sustaining a laceration on her left leg. R2, who has a history of morbid obesity, atherosclerosis, lymphedema, and diabetes with neuropathy, was cognitively intact and used a motorized scooter for mobility. The incident occurred when V12 made a quick turn into a parking lot, causing R2 to hit her leg on a metal piece of the seat in front of her. R2's leg was cut, and she required emergency medical attention, including a wound vacuum and antibiotics, due to the injury becoming infected. The facility's investigation revealed that the van used was not the usual one, and R2's power chair did not fit into the lock mechanisms. Additionally, the emergency brake on R2's power chair was not engaged. V12 and other key staff members involved in the incident are no longer employed at the facility. The facility's policy requires all residents and wheelchairs to be safely secured during transport, which was not adhered to in this case.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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