Axiom Gardens Of Nashville
Inspection history, citations, penalties and survey trends for this long-term care facility in Nashville, Illinois.
- Location
- 485 South Friendship Drive, Nashville, Illinois 62263
- CMS Provider Number
- 146043
- Inspections on file
- 35
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 13 (4 serious)
Citation history
Health deficiencies cited at Axiom Gardens Of Nashville during CMS and state inspections, most recent first.
A facility failed to prevent accidents by not completing or implementing fall risk assessments, not ensuring required alarms and safety devices were in use, and not performing safe transfers. A resident with severe dementia and high ADL needs was admitted without a documented fall risk assessment and later sustained an unwitnessed fall with a hip fracture while attempting to toilet herself. Another resident with vascular dementia and a history of falls had multiple unwitnessed wheelchair falls with head lacerations and LOC, despite being care planned for chair and bed alarms and close visual supervision; surveyors observed her repeatedly without alarms connected and out of staff view. Two residents requiring full-body mechanical lift transfers were lifted while their wheelchairs were left unlocked, and one high fall risk resident had no fall mat in place. A cognitively intact bilateral amputee who smoked was documented on assessments as not smoking and safe to smoke unsupervised, yet staff provided her cigarettes and a lighter and she reported smoking at will, with burn marks noted on her clothing. Exit door alarms were found turned off or malfunctioning, with staff stating alarms were disabled so residents could go outside and the administrator acknowledging ongoing alarm issues despite policies requiring functional elopement systems.
Multiple residents with bowel and bladder incontinence, including one with an indwelling Foley cath and history of UTIs, did not receive complete perineal care or proper infection control during toileting and incontinence care. CNAs were observed wiping only limited areas (such as the anal area or buttocks) without cleansing the full peri, groin, inner thigh, or labial/genital regions, and in one case not cleansing the anal area at all. Staff used wet cloths without soap or peri-cleaner, reused soiled gloves from contaminated tasks to clean residents and handle clothing, linens, and equipment, and failed to perform hand hygiene before donning gloves, between glove changes, and after glove removal. These actions did not follow the residents’ care plans or the facility’s policies on incontinence care, glove use, and hand hygiene.
The facility failed to prevent two separate abuse incidents despite having an abuse prevention policy. In one case, a severely cognitively impaired resident with multiple comorbidities was sexually abused when a staff member kissed the resident on the lips in the resident’s room, an act later admitted by the staff member and substantiated by the facility’s investigation. In another case, a cognitively intact resident with serious medical conditions was verbally harassed outside by another resident, who later threw coffee on the resident as he walked past the aggressor’s room, prompting the victim to push the aggressor in the chest; the incident was witnessed and no injuries were found.
A resident with multiple complex wounds did not receive timely and appropriate wound care as ordered by the NP, including delays and omissions in dressing changes and skin assessments. The low air loss mattress intended to provide pressure relief was not maintained in working order, resulting in the resident experiencing significant pain and worsening wounds. These failures led to multiple infections, hospitalizations, and surgical interventions.
A resident with significant risk factors for skin breakdown developed new and worsening pressure ulcers after staff failed to complete regular skin assessments, ensure wound care supplies were available, and perform wound treatments as ordered. The resident was left in a wheelchair for extended periods without adequate repositioning, and new wounds were only identified by a nurse practitioner during rounds, not by facility staff. Documentation showed repeated lapses in wound care and missed assessments, despite no evidence of the resident refusing care.
Two residents with cognitive impairment and identified elopement risks were able to repeatedly exit the facility unsupervised due to staff failing to monitor or respond to door alarms, doors being left unalarmed or cracked open, and inadequate supervision. One resident was found outside in unsafe conditions, including in the middle of the road and in a visitor's van, while another was found outside in cold weather without proper clothing. Staff interviews confirmed awareness of the risks and repeated incidents, but monitoring and timely responses were inconsistent.
A resident with multiple pressure ulcers and complex medical needs experienced extreme pain due to a malfunctioning low air loss mattress that repeatedly lost inflation, leaving her on a hard bed frame. Staff and family reported the issue, and photographic evidence confirmed the mattress was not maintained in safe working order, despite care plan requirements and facility policy.
A facility-wide assessment was not updated to include required elements such as identification of current Administrator and DON, resources for care during routine and emergency operations, evaluation of staffing needs, resident population details, physical environment, assistive technology, staff training programs, and risk assessments. The Administrator confirmed no additional information or policy was available for the facility assessment, affecting all 60 residents.
The facility did not ensure CNAs received the required 12 hours of annual education, including dementia care and abuse prevention training. Review of records showed that several CNAs received significantly fewer hours than required, and there was no documentation of dementia training or timely training after hire, as mandated by facility policy. This deficiency has the potential to impact all residents in the facility.
A resident with severe cognitive impairment and multiple medical conditions was found outside the facility on several occasions. Although staff documented the incidents and returned the resident safely, there was no evidence that the resident's legal representative was notified as required by facility policy. The representative confirmed she was not informed by the facility about these events.
A resident with a coccyx wound and diagnoses of HIV and Hepatitis B was placed on enhanced barrier precautions, but an LPN failed to follow infection control protocols during wound and incontinence care. The LPN did not change gloves or perform hand hygiene after handling soiled materials and touched multiple surfaces, including the medication cart, before eventually using hand sanitizer. Contaminated dressings and PPE were not disposed of in biohazard bags as required by facility policy.
A resident with multiple comorbidities and high risk for pressure ulcers developed a stage 3 ulcer on the left heel after abnormal findings were repeatedly documented without timely assessment, treatment orders, or completion of physician-ordered care. Facility staff confirmed gaps in documentation and treatment, and the facility's policy for skin breakdown assessment and intervention was not followed.
A facility failed to prevent verbal and mental abuse for four residents, resulting in psychosocial harm. A CNA, identified as V3, refused to assist a resident with dressing in her room, forcing her to dress in the bathroom, leaving her exposed and cold. Another resident was dismissed by V3 when requesting help to get out of bed. Additionally, V3 yelled at two residents with Alzheimer's for not dressing properly and for having an accident. The facility's investigation confirmed V3's actions constituted abuse or neglect.
The facility failed to implement proper infection control measures for COVID-19 positive residents. Staff lacked access to necessary PPE, such as N95 masks and eye protection, and isolation signage was missing. Additionally, a resident exposed to a COVID-positive roommate was not documented as tested, and staff were unaware of proper rooming arrangements. These deficiencies highlight lapses in adhering to the facility's infection control policies.
The facility did not have a qualified Infection Control Preventionist (ICP) working full-time, affecting all 59 residents. The Administrator admitted the absence of an ICP and ongoing hiring efforts. Residents with COVID-19 were present, and the DON, off with a COVID infection, was unaware of the current situation, highlighting a lack of infection control oversight.
The facility failed to maintain a safe environment for three cognitively impaired residents on the dementia unit. A broken window and an unlocked door were observed, posing potential hazards. One resident was seen sitting in the dining room near the broken window, while another walked past the room with broken glass. A third resident, requiring supervision, became confused and agitated near the Alzheimer's unit door. Maintenance staff were unaware of the need for repairs, and the administrator believed the room was locked.
The facility failed to implement progressive fall interventions for two residents, resulting in injuries. One resident, with conditions like cognitive decline, experienced multiple falls with injuries requiring ER visits, yet no new interventions were documented. Another resident sustained a bruise from a mechanical lift incident, with staff unaware of the event. Facility policies on safe lifting and fall prevention were not effectively followed.
A resident with Alzheimer's and other conditions experienced severe weight loss due to the facility's failure to implement nutritional interventions. Despite documented interventions to provide supplements, the resident lost 15.7% of body weight over six months. The RD did not document or communicate dietary recommendations effectively, and the facility's documentation of meal and supplement intake was minimal. Observations showed the resident appeared very thin, and there was poor communication between staff regarding the resident's nutritional needs.
The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, 7 days a week, as required. Staffing schedules showed no RN coverage on nine specific days, and the facility's administrator acknowledged the shortage. The deficiency potentially affects all 56 residents, with the facility's PBJ Report indicating a one-star staffing rating.
The facility did not post nurse staffing information in a clear and accessible manner, affecting all 56 residents. During a facility tour, it was found that no nursing information was available for review. The PBJ report showed insufficient RN coverage, leading to a 1-star staffing rating. Interviews revealed a lack of awareness about the posting requirement, with the Business Office Manager unsure if staffing information was posted under new management. The facility's assessment and staffing policy highlighted the need for adequate staffing, but no updated assessment was provided.
The facility failed to store and prepare food in a manner preventing contamination, affecting all 56 residents. Observations included a greasy fryer basket, unlabeled and undated food items in the refrigerator, and significant ice buildup in the freezer affecting various food products. The Dietary Manager acknowledged the labeling requirements, and the Maintenance Man was aware of the freezer issues but had not resolved them.
The facility did not ensure its Facility Assessment was current and reviewed annually, potentially affecting all 56 residents. The Administrator confirmed the most recent assessment was from July 2023, and no updated version was provided. The DON stated there was no policy on Facility Assessment.
The facility failed to document the organisms causing UTIs in several residents, despite prescribing antibiotics. Additionally, an LPN did not follow proper hand hygiene during a dressing change for a resident with pressure ulcers, indicating lapses in infection control practices.
The facility did not have a qualified Infection Control Preventionist (ICP) working full-time, potentially affecting all 56 residents. The DON, acting as the ICP, had not completed the required training and lacked oversight. The facility's policy outlines the ICP's responsibilities, including monitoring antibiotic use and providing staff education, but these may not be adequately fulfilled due to the lack of a qualified ICP.
A resident with an indwelling urinary catheter experienced embarrassment due to the facility's failure to cover the catheter bag, compromising their dignity. The resident expressed frustration about the situation, and CNAs acknowledged the need for a dignity bag. The facility's policy emphasizes treating residents with dignity, which was not upheld in this case.
A resident with a sore on her lower left leg did not have a physician's order for treatment documented in her EHR. Despite the resident's cognitive intactness and medical history, the sore was dressed without an order, and the facility's policy for notifying physicians was not followed. The DON confirmed the lack of an order, and an LPN noted the sore's condition and planned to contact the doctor.
A resident with Alzheimer's Dementia fell from their wheelchair, leading to an incident where an LPN became angry, yelled, and physically handled the resident inappropriately. Multiple staff witnessed the mistreatment, and the facility's investigation substantiated the abuse allegations, resulting in the LPN's termination.
A facility failed to monitor a resident requiring dialysis and paracentesis. The resident's care plan noted risks related to end-stage renal disease, but there was no documentation of monitoring for fluid overload. Post-paracentesis instructions from a hospital were not recorded in the resident's records. LPNs checked the dialysis access site but did not document these checks unless issues arose. No dialysis and paracentesis policy was provided.
A resident with dysphagia was fed by a unit aid who lacked state-approved training and supervision by an RN or LPN. The facility did not have a policy on feeding assistance, and the unit aid's job description did not include feeding duties. The Director of Nursing confirmed that unit aids should not feed residents, especially those at high risk for choking.
A resident with Alzheimer's and dementia eloped from a memory care unit due to inadequate supervision and monitoring. Despite being identified as an elopement risk, the resident was not equipped with an electronic monitoring bracelet and was able to leave the facility undetected. Staffing was insufficient, with only one CNA present when the LPN was administering medications on other halls, leaving residents unsupervised. The resident was found by a passerby in a field near a hospital.
The facility failed to provide adequate staffing for a memory care locked unit, affecting 11 residents with dementia and Alzheimer's disease. Staff interviews revealed that only one CNA was often left to supervise the unit while the assigned nurse attended to other halls, leaving residents unsupervised during 1:1 care. The facility's staffing policy was not met, leading to the deficiency.
The facility failed to secure and control medications for several residents, leading to deficiencies in medication management. A cognitively intact resident had unauthorized medications at bedside, while a severely cognitively impaired resident had medications left unattended on a dining table. Another resident had medications left out of reach, and a confused resident had topical gel on her bedside table without a self-administration assessment. The facility's policy on self-administration of medications was not followed.
Failure to Prevent Falls, Ensure Safe Transfers, Smoking Safety, and Maintain Exit Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents, particularly related to falls, transfers, smoking safety, and exit door alarms. One resident with severe dementia, osteoarthritis, and high assistance needs for ADLs was admitted without a documented admission fall risk assessment, despite transfer paperwork indicating she was high risk for falls and required 1:1 observation. Her care plan later identified her as at risk for falls and wandering, but the fall risk evaluation and precautions were not initiated on admission. She experienced an unwitnessed fall in her room while attempting to toilet herself after removing her non-skid socks, complained of right hip pain, and was subsequently found to have a right hip fracture requiring hospital transfer and surgical repair. Later observation showed her call light attached to the bed sheet and out of her reach. Another resident with vascular dementia, a history of falls, fractures, restlessness, and incontinence was care planned for multiple fall interventions, including bed pad and chair alarms, placement near the nurse’s station, and keeping her within staff’s visual field when up in a wheelchair. She had an unwitnessed fall from her wheelchair in a common bathroom, sustaining a laceration above her right eye that required repair in the ER. She later had another unwitnessed fall from her wheelchair in a dining area, with reported loss of consciousness and multiple forehead lacerations requiring ER treatment. Despite these events and her care-planned interventions, surveyors repeatedly observed her in her wheelchair without the chair alarm connected, with the alarm monitor left on the bed and the pull cord on the back of the wheelchair, and at times placed in her room out of staff view. Staff interviews confirmed that the alarm was not consistently used when family was present. The facility also failed to provide safe mechanical lift transfers for multiple residents. One cognitively intact resident with a history of falls, fractures, weakness, and high fall risk was care planned to require two staff and a full-body mechanical lift for transfers, with a fall mat and other fall-prevention measures. During observation, CNAs transferred her from wheelchair to bed using a full-body lift while the wheelchair was left unlocked, and no fall mat was present or placed afterward. Another resident with severe cognitive impairment, dementia, and high fall risk was similarly transferred from a geriatric chair to bed with a full-body lift while the wheelchair remained unlocked. Smoking safety practices and exit door alarm management were also deficient. A cognitively intact bilateral above-knee amputee with a documented history of smoking and burn concerns was care planned as a smoker, but her smoking safety risk assessments twice documented that she did not currently smoke, and one assessment concluded she was safe to smoke unsupervised. Observations showed CNAs assisting her into a wheelchair, providing her with a burn-marked smoking gown, handing her cigarettes and a lighter from her bedside, and the resident reporting that she could smoke whenever she wanted, usually without staff outside. At the same time, the facility’s smoking policy required a smoking safety assessment to determine supervision needs and noted that burning clothing or being generally careless while smoking jeopardizes independent privileges. In addition, exit door alarms were not consistently activated or effectively audible. A surveyor opened the 200 hall exit door and found that the alarm did not sound until a CNA used a key to activate it; the CNA stated the alarm was often left off so residents could go out for fresh air and that keeping it on was considered a restraint. On another unit, an exit alarm sounded continuously for over ten minutes, and the administrator was unsure which door was alarming and acknowledged existing issues with door alarms, including a memory care unit exit alarm not functioning properly. The facility’s elopement device policy required regular inspection and documentation of exit door security systems and staff placement at malfunctioning doors, but survey findings showed alarms not being kept on and alarms that were difficult for staff in other areas to hear.
Failure to Provide Complete Perineal Care and Proper Hand Hygiene During Incontinence and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide complete incontinence and catheter-related care, including appropriate perineal cleansing and hand hygiene, for multiple residents with bowel and bladder incontinence and/or indwelling catheters. One resident with a history of UTIs, an indwelling Foley catheter placed for pressure ulcers, cognitive impairment, and total dependence for toileting was observed after a bowel incontinence episode. Two CNAs assisted the resident to her side and used wet washcloths to wipe only the anal area, then repositioned and covered her without cleansing the entire buttocks or performing full incontinent care as outlined in her care plan and facility policy. Another resident, cognitively intact but frequently incontinent of urine and always incontinent of bowel, and dependent on staff for toileting, was assisted from a wheelchair to a bedside commode. Staff exposed a heavily urine-soaked brief, seated the resident on the commode, and later applied a clean brief. During cleansing, a CNA used a wet washcloth to clean only the buttocks before the brief and pants were pulled up. The staff did not cleanse the entire buttocks, perineal area, groin, inner thighs, or labia, despite the resident’s care plan directing assistance with toileting every two hours and as needed. A third resident with multiple chronic conditions, moderate cognitive impairment, frequent bowel and bladder incontinence, and dependence for ADLs was provided incontinent care while in a wheelchair using a sit-to-stand device. CNAs donned gloves without performing hand hygiene, removed a wet brief, and one CNA changed gloves without hand hygiene, then used only wet washcloths from the sink without soap or peri-cleaner to briefly wipe the front genital area and buttocks; the anal area was not cleaned. The same soiled gloves were then used to handle the resident’s clothing, equipment, and positioning. A fourth resident with severe cognitive impairment, total dependence for ADLs, and constant bowel and bladder incontinence was observed with a saturated, strong-smelling urine brief. A CNA, wearing the same soiled gloves used to remove the saturated brief, used wet cloths from a basin to wipe the vagina, buttocks, and anal area, then a dry cloth, and subsequently touched the resident’s pillows, sheets, and blanket without any glove change or hand hygiene. These practices were inconsistent with the facility’s written policies for incontinence care, glove use, and hand hygiene, which require thorough perineal cleansing, use of soap or peri-cleaner, changing gloves between contaminated and clean tasks, and performing hand hygiene after glove removal.
Failure to Prevent Sexual Abuse by Staff and Physical Abuse Between Residents
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident from sexual abuse by an employee. The resident, who had vascular dementia with behavioral disturbance and multiple other medical conditions, required substantial to maximal assistance with transfers. According to the facility’s abuse investigation reports, an activity director reported to the administrator that a unit aide kissed this resident on the mouth/lips in her room. The aide admitted in his statement that he kissed the resident once on the lips. The facility’s investigation, including interviews with staff and residents, concluded that the incident did occur and substantiated that the resident was subjected to sexual abuse. The facility also failed to prevent physical abuse between residents when one resident threw a cup of coffee on another resident. One resident, who was cognitively intact, independent with ADLs, and had diagnoses including end stage renal disease, COPD, major depressive disorder, diabetes, and anxiety disorder, reported that another resident had previously harassed him. On the day of the incident, the aggressor resident went outside, yelled at the cognitively intact resident, then returned to his room. When the cognitively intact resident came back inside and passed the aggressor’s room, the aggressor opened his door and threw coffee on him, after which the cognitively intact resident pushed the aggressor in the chest with open hands. The incident was witnessed, residents were separated and assessed, and no injuries were noted. These events occurred despite the facility’s written policy affirming residents’ rights to be free from abuse and describing measures intended to prevent abuse and mistreatment.
Failure to Implement Wound Care Orders and Maintain Pressure Relief Equipment
Penalty
Summary
The facility failed to follow and implement wound care orders from the Wound Nurse Practitioner (NP) in a timely manner for a resident with multiple complex wounds, including stage 3 pressure ulcers and chronic skin conditions. Orders for wound dressings, specialty equipment such as a low air loss mattress, and heel float boots were not promptly initiated or maintained as directed. Documentation shows that wound care treatments were delayed, incorrect treatments were applied, and there were multiple instances where dressing changes and skin assessments were either not performed or not documented as completed according to the NP's orders. The resident's low air loss mattress, which was ordered to provide pressure relief and prevent further skin breakdown, was not maintained in proper working order. Staff, family members, and the resident reported that the mattress frequently lost air, leaving the resident lying on a hard surface, which caused significant pain and discomfort. The mattress was described as being held together with duct tape, with hoses repeatedly disconnecting and the air pump malfunctioning. Despite repeated notifications to facility leadership and maintenance, the issues with the mattress persisted for an extended period before a replacement was provided. As a result of these failures, the resident experienced worsening of wounds, which became infected with multiple organisms including MRSA, Pseudomonas, Enterococcus faecalis, and ESBL E. coli. The infections led to several hospitalizations, surgical debridement, and the need for intravenous antibiotics. The facility's lack of timely and appropriate wound care, failure to maintain essential equipment, and inadequate documentation directly contributed to the deterioration of the resident's condition and the escalation of her wounds.
Removal Plan
- Facility wound care policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
- Director of Nursing or designee initiated in-servicing for all nursing staff on the wound care policy and procedures.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on wound care policy and procedures.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all wound orders are carried out and all interventions are in place.
- Director of Nursing or designee will conduct audits of all wound care orders and interventions weekly.
- The Director of Nursing or designee will interview 3 staff members, 3 times weekly to ensure that staff understand wound care policies and procedures.
- Maintenance Director checked all Low Air Loss (LAL) mattresses to ensure proper functioning.
- Maintenance will perform checks of LAL mattresses weekly to ensure proper functioning.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents with wounds to ensure all orders have been processed and treatments are being done correctly.
- R2's mattress was replaced with a new mattress.
Failure to Prevent and Manage Pressure Ulcers Due to Missed Assessments and Treatments
Penalty
Summary
The facility failed to implement and document new care plan interventions to prevent new or worsening pressure ulcers for a resident with multiple risk factors, including diabetes, peripheral vascular disease, and immobility. The staff did not consistently complete skin assessments, ensure the availability of wound care supplies, or perform wound treatments as ordered. As a result, the resident developed a stage II pressure ulcer on the right buttock, a stage III pressure ulcer on the left buttock, and experienced worsening of an existing right heel wound, which required antibiotic treatment. These wounds were discovered by a nurse practitioner during rounds, not by facility staff, indicating a lack of timely identification and intervention. Observations and record reviews revealed that the resident was left in a wheelchair for extended periods without adequate repositioning, and incontinent care was delayed, as evidenced by a full brief with bowel movement upon being returned to bed. Documentation showed repeated lapses in wound care, with multiple entries indicating that treatments were not completed due to unavailable supplies or lack of documentation. There were also missed or delayed skin assessments, including after hospital readmission, and no evidence that new wounds were promptly identified or addressed by staff. Behavioral tracking did not indicate that the resident refused care or treatments during the relevant period. Interviews with facility leadership and clinical staff confirmed expectations that nurses should follow up on treatment changes, document assessments, and notify supervisors if supplies are lacking. However, the nurse practitioner and administrator acknowledged that these processes were not followed, and new wounds were only discovered during external wound care rounds. The facility's own policy required regular skin inspections, timely repositioning, and the use of appropriate pressure-relieving equipment, but these measures were not consistently implemented for the resident in question.
Removal Plan
- Facility pressure ulcer prevention policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
- R1 was seen by Wound Care Provider and received new treatment orders, LAL (low air loss) mattress ordered, and wheelchair cushion replaced.
- Director of Nursing or designee initiated in-servicing for all facility and Agency nursing staff to include RNs, LPNs and CNA's, on the pressure ulcer prevention policy and procedures.
- In-servicing will be completed by the start of each staff member's next shift.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on pressure ulcer prevention.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all newly acquired pressure wounds are identified timely and addressed immediately by reviewing shower sheets daily and ensuring all skin assessments are completed timely and thoroughly.
- Director of Nursing or designee will in-service all facility and Agency nursing staff to include RNs, LPNs and CNA's on identifying all newly acquired pressure areas timely by completing assessments timely and accurately.
- All nursing staff will be educated by the beginning of their next shift.
- Director of Nursing or designee will conduct audits of skin assessments weekly to ensure all new skin conditions are identified timely and addressed accurately as part of the QA process.
- The Director of Nursing or designee will interview 3 staff members weekly x4 weeks to ensure that staff are completing assessments and addressing any new pressure areas.
- Director of Nursing and or designees will conduct skin assessments on all to ensure that any pressure areas are being identified and addressed.
- The staff members responsible for not completing assessments or wound treatments as ordered have been disciplined.
- The DON or designee will review all new admissions to ensure that all assessments are completed.
- The DON or designee educated all facility and agency nurses of how and when to complete skin assessments.
- All facility and agency nurses will be educated by the beginning of their next shift.
- R1 has had a full skin assessment performed by the ADON to ensure all areas of concern have been identified and addressed appropriately.
- All facility and Agency nursing staff to include RNs, LPNs and CNA's, educated by DON or designee that all residents need to be turned and repositioned at least every two hours and as needed.
- All in-servicing will be completed by the beginning of the staff member's next scheduled shift.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents to determine if they are at risk for potential for impaired skin integrity.
- IDT team ensured all skin assessments have been done timely, all new skin areas have been identified and addressed accordingly including care plan review.
Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Door Alarms
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to elopement risks. Multiple observations revealed that door alarms were either not functioning, turned off, or not responded to in a timely manner. On several occasions, doors leading to the outside were found cracked open or could be opened without triggering an alarm, and staff were observed not checking on residents who were at risk of elopement. These lapses allowed a severely cognitively impaired resident, who was identified as an elopement risk, to repeatedly leave the facility unsupervised, including incidents where the resident was found outside in unsafe conditions such as in the middle of the road or inside a visitor's van. The resident in question had a history of alcohol-induced dementia, Wernicke's encephalopathy, and chronic kidney disease, and was documented as being ambulatory and prone to wandering. Despite being placed on frequent checks and having a wander guard, the resident was able to exit the facility multiple times. Staff interviews confirmed that the resident was able to find ways to leave the building, sometimes with the assistance of visitors or by exploiting malfunctioning or inaudible alarms. Documentation also indicated that staff were aware of the resident's repeated elopements, but there was a lack of consistent monitoring and timely response to alarms, and the resident's legal guardian was not notified of these incidents. Another resident, also identified as an elopement risk with cognitive impairment and mobility limitations, was able to exit the facility on multiple occasions. This resident was found outside in inclement weather, inadequately dressed, and required staff intervention to be brought back inside. Staff interviews and progress notes indicated that alarms did not always sound when doors were opened, and there was uncertainty about how long the resident had been outside. The facility's own logs did not consistently document these incidents, and staff acknowledged that some doors were routinely left unalarmed for convenience, further contributing to the risk.
Removal Plan
- Facility Elopement Policy was reviewed by Regional Director of Operations and was found to be in compliance with state and federal regulations.
- Facility Administrator or designee initiated in-servicing for all staff on the elopement policy and procedures. In-servicing will be completed by the start of each staff members next shift.
- Facility Administrator or designee initiated in-servicing for all staff on ensuring all staff are monitoring door alarms and responding immediately. In-servicing will be completed by the start of each staff members next shift.
- Maintenance Director or designee will conduct an audit of all facility door alarms and to be completed weekly to ensure they are adequately functioning and audible to staff areas.
- Administrator or designee to conduct Elopement Drill weekly x4 weeks to ensure monitoring and compliance.
- The Administrator or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand elopement policies and procedures.
- IDT team (Admin, DON, SSD, MDS, DM) has assessed R4 and care plan updated to reflect new interventions for R4 being placed on the locked unit.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents for the potential to elope and care plans updated to reflect interventions to protect residents from elopement.
- R4 was placed on the locked unit.
- All facility exit door keys were removed and placed in secured location.
- Facility Administrator or designee initiated in-servicing for all staff to not turn off door alarms. In-servicing will be completed by the start of each staff members next shift.
- Maintenance Director replaced the door lock to 300 Hall door to courtyard and is functioning properly.
Failure to Maintain Low Air Loss Mattress in Safe Working Condition
Penalty
Summary
The facility failed to ensure that a low air loss mattress was maintained in proper working order for a resident with multiple pressure ulcers and complex medical conditions. The resident, who was cognitively intact and required substantial assistance for mobility, had a care plan that included the use of a low air loss bariatric mattress for pressure reduction due to her high risk for skin breakdown and existing stage 3 pressure ulcers. Despite this, the mattress provided to her was not functioning correctly, as the hose that kept the mattress inflated repeatedly disconnected, causing the mattress to deflate and leaving the resident lying on a hard metal bed frame. Multiple staff members, including a CNA and an LPN, confirmed that the mattress was not staying inflated and that the hose would frequently come off, sometimes requiring makeshift repairs such as duct tape to keep it in place. Family members also reported the issue to facility leadership, providing photographic evidence and written communication about the malfunctioning equipment. The resident herself described experiencing extreme pain, rating it as a 10 out of 10, particularly when the mattress lost air and she was left without adequate pressure relief for her wounds. Interviews with the wound care nurse practitioner and review of the resident's care plan confirmed that the use of a properly functioning low air loss mattress was a necessary intervention for her condition. The facility's own preventive maintenance policy required systematic inspection and timely repair or replacement of essential equipment, but the failure to maintain the mattress in working order resulted in the resident enduring significant pain and inadequate pressure relief for an extended period.
Facility Assessment Lacks Required Components and Updates
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was updated to include all necessary components as required by current standards of practice. The assessment provided did not identify the current Administrator or Director of Nursing (DON), nor did it specify resources required to provide necessary care and services to residents during both routine operations and emergencies, including nights and weekends. Additionally, the assessment lacked an evaluation of the overall number of staff needed to ensure sufficient qualified personnel are available to meet each resident's needs as identified through assessments and care plans. The assessment also omitted pertinent information about the resident population, such as race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, health literacy, or other factors affecting access to care and health outcomes related to health equity. Further deficiencies included the absence of information regarding the physical environment, assistive technology, individual communication devices, or other material resources needed to provide required care and services. The facility assessment did not evaluate the training program to ensure training needs are met for all staff, including managers, nursing and direct care staff, contracted service providers, and volunteers. There was also no evaluation of applicable policies and procedures, nor a facility-based and community-based risk assessment using an all-hazards approach to maintain continuity of operations and secure required supplies and resources during emergencies or natural disasters. When asked, the Administrator confirmed that the provided assessment was all the information available and stated there was no policy for the facility assessment. At the time of the survey, there were 60 residents residing in the facility.
Failure to Provide Required Annual CNA Education and Dementia Training
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) completed the required 12 hours of annual education, including mandatory training in dementia care and abuse prevention. Record review showed that six CNAs had received between 0 and 2.5 hours of education in the past year, far below the required amount. The Administrator confirmed that the in-service records provided were limited to short sessions, with most lasting only 30 minutes and only one session lasting an hour. Additionally, there was no documentation of dementia training for the year, and the Administrator admitted that dementia training within 60 days of hire, as required by facility policy, was not being conducted. The facility's Employee Education policy mandates a coordinated staff education plan, including both pre-service and annual requirements in key areas such as infection control, abuse prevention, and dementia care. Despite this, both the Administrator and the Director of Nursing acknowledged that the required education hours had not been met for the CNAs reviewed. The deficiency has the potential to affect all 60 residents currently residing in the facility, as documented in the daily census report.
Failure to Notify Resident Representative After Elopement
Penalty
Summary
The facility failed to notify a resident's representative after the resident, who was severely cognitively impaired and diagnosed with alcohol dependence with alcohol-induced persisting dementia, Wernicke's encephalopathy, and chronic kidney disease, was found outside of the facility on multiple occasions. Documentation showed that the resident was found by staff outside by the dumpster, sitting in a visitor van, and exiting through a back door with a broken lock. In each instance, staff responded by returning the resident to the facility and documenting the events in the progress notes, but there was no documentation that the resident's representative was notified of these incidents. Interview with the resident's family member, who is also the legal guardian, confirmed that she was not informed by the facility about the resident leaving the premises. The family member stated she only learned of one incident through her sister, not directly from the facility. Facility policy requires that the responsible party be notified in the event of a resident attempting to leave or leaving the premises, but this was not followed in the case of this resident. The administrator confirmed that staff are expected to notify the representative immediately and document the notification, which did not occur.
Failure to Follow Infection Control Standards During Wound and Incontinence Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for hand hygiene, wound dressing disposal, and contaminated linen disposal for one resident who was under enhanced barrier precautions due to a coccyx wound and diagnoses of asymptomatic HIV and chronic Hepatitis B. The resident was observed in a single occupancy room with clear signage indicating the need for enhanced barrier precautions, including hand hygiene before entering and upon leaving the room, and the use of gloves and gowns for high-contact care activities such as wound care. During an observation, an LPN donned appropriate personal protective equipment (PPE) before entering the resident's room. While assisting the resident, who had a bowel movement, the LPN used a disposable brief to clean the resident and disposed of it in a trash bag placed on the floor by the room door. Without changing gloves or performing hand hygiene, the LPN touched the trash bag, room door, door handle, door frame, and requested clean bedding from a CNA. The LPN continued to touch various surfaces, including the bathroom door and sink faucet, while still wearing the same soiled gloves. The LPN then removed the resident's soiled wound dressing, cleaned the wound area, and allowed the wound to come into contact with the bed linens. The soiled dressing and PPE were disposed of in the same trash bag, and the LPN exited the room, again without performing hand hygiene, and touched additional surfaces including the medication cart before eventually using hand sanitizer in the hallway. Interviews with facility staff, including the LPN, ADON/Infection Control Nurse, and DON, confirmed that the resident was on enhanced barrier precautions and that facility policy required proper disposal of items contaminated with blood or body fluids in red biohazard bags in the dirty utility room. The facility's policy and referenced infection control guidelines emphasized the importance of hand hygiene, appropriate glove use, and proper disposal of contaminated materials to prevent the transmission of infectious agents. However, these protocols were not followed during the observed care of the resident.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to obtain timely treatment orders and complete physician-ordered treatments for a resident with pressure ulcers. The resident, who had diagnoses including congestive heart failure, pneumonia, urinary tract infection, and type 2 diabetes, was identified as high risk for pressure ulcer development and had a care plan in place for skin breakdown prevention. Despite documentation of abnormal findings on the left heel on multiple shower sheets, there were no corresponding progress notes, treatments, or orders on those dates. The weekly wound evaluation did not document the left heel until it was identified as a stage 3 ulcer, and the treatment order for the left heel was not obtained until several days after abnormalities were first noted. Additionally, the treatment administration records showed that the ordered treatments for the left heel were not completed on the first two days after the order was written. Interviews with facility staff confirmed that documentation and treatment for the left heel were lacking, and that the wound was not addressed in a timely manner. The wound nurse stated that the left heel was not open prior to the treatment order, but there was no documentation of assessment or intervention when the area was first identified as abnormal. The facility's policy requires assessment and documentation of risk factors and skin breakdown, but this was not followed for the resident's left heel, resulting in a delay in treatment and incomplete documentation.
Failure to Prevent Verbal and Mental Abuse
Penalty
Summary
The facility failed to prevent verbal and mental abuse for four out of six residents, resulting in psychosocial harm. Resident 3, who was cognitively intact, required assistance with activities of daily living due to conditions such as atherosclerosis, unsteadiness, and a fractured humerus. On one occasion, a Certified Nursing Assistant (CNA), identified as V3, refused to help Resident 3 get dressed in her room, insisting she dress in the bathroom despite her objections. V3 was forceful and rushed, leaving Resident 3 feeling exposed and cold without a button-up shirt. Resident 4, also cognitively intact, required assistance with transfers due to conditions like heart failure and hemiplegia. V3 displayed a dismissive attitude towards Resident 4, refusing to help her out of bed and making her feel terrible. Resident 4 reported V3's behavior to the facility administrator, who acknowledged the inappropriate actions. Additionally, Resident 5 witnessed V3 yelling at Residents 6 and 7, who had Alzheimer's disease and required assistance with dressing and toileting. V3's behavior included yelling at Resident 6 for not dressing in the clothes laid out and at Resident 7 for having an accident. The facility's investigation confirmed that V3 engaged in behaviors constituting abuse or neglect. The facility's abuse policy emphasizes providing an environment free from abuse, neglect, and exploitation, defining abuse as actions causing physical harm, pain, or mental anguish. Despite the policy, V3's actions led to residents experiencing feelings of shame, embarrassment, and humiliation, highlighting a significant deficiency in the facility's ability to protect residents from abuse.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place for residents who tested positive for COVID-19. Specifically, staff did not have ready access to or use appropriate personal protective equipment (PPE) such as N95 masks and eye protection when entering the rooms of COVID-positive residents. Isolation signage was also missing from the doors of these residents, which is crucial for indicating the type of isolation required. For instance, one resident was found in bed with the door open and no isolation signage, and the isolation cart outside the room lacked necessary PPE. Another resident was assisted by a CNA who wore inadequate PPE, and the CNA acknowledged the absence of N95 masks and face shields. The facility's medical records and supplies staff confirmed the availability of PPE, but it was stored in locked areas, making it inaccessible to staff when needed. Additionally, the facility did not document COVID testing for a resident who was exposed to a COVID-positive roommate. The facility's policy requires that only residents with the same respiratory pathogens be housed together, yet this was not adhered to. The Director of Nursing and other staff members were unaware of the reasons for the lack of isolation signage and the rooming arrangements. The facility's policy mandates that healthcare providers entering the room of a COVID-positive patient should wear a respirator with an N95 filter, gown, gloves, and eye protection, but this was not consistently followed, leading to a deficiency in infection control practices.
Absence of Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to ensure the presence of a qualified Infection Control Preventionist (ICP) working full-time, which has the potential to affect all 59 residents. On the specified date, the Administrator acknowledged the absence of an ICP and mentioned efforts to hire one. During the same period, residents who tested positive for COVID-19 were residing in the facility. The Director of Nursing, who was off due to a COVID infection, expressed uncertainty about the current situation, indicating a lack of oversight and management in infection control practices.
Failure to Maintain a Safe Environment for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide a safe and hazard-free environment for three residents on the dementia unit, all of whom were severely cognitively impaired. Resident 4, who can walk independently, was observed sitting in the dining room, and it was noted that the window in the area was broken and the door was not locked. The activities staff member was unaware of the broken window and unlocked door. Resident 5, also able to walk independently, was seen walking up and down the hall, passing the room with broken glass. Resident 6, who requires supervision or assistance for walking, was observed returning from therapy and became confused and agitated near the Alzheimer's unit door. She was later seen at the nurses' station, unable to make sentences or answer questions. The room with the broken window was supposed to be locked, as confirmed by the maintenance staff, who stated they were not asked to repair it. The administrator was under the impression that the room was locked. The facility's policy on safety and supervision emphasizes maintaining an environment free from accident hazards, but this was not adhered to in this instance.
Failure to Implement Progressive Fall Interventions
Penalty
Summary
The facility failed to implement progressive fall interventions for two residents, resulting in injuries. One resident, admitted with conditions such as weakness, polyneuropathy, and cognitive decline, experienced multiple falls. On one occasion, the resident was found on the floor with lacerations requiring emergency room transfer and sutures. Despite being at high risk for falls, the resident's care plan and progress notes did not document any new interventions following these incidents. Interviews with staff confirmed the absence of documented progressive interventions for the falls. Another resident, diagnosed with vascular dementia and other conditions, sustained a bruise on the forehead after being bumped by a mechanical lift bar. The incident report noted the injury, but the social worker and registered nurse were unaware of the incident or the staff involved. The facility's policies on safe lifting and fall prevention were not effectively implemented, as evidenced by the lack of appropriate interventions and staff awareness.
Failure to Implement Nutritional Interventions Leads to Severe Weight Loss
Penalty
Summary
The facility failed to implement nutritional interventions to prevent significant weight loss in a resident diagnosed with Alzheimer's disease, anemia, and other conditions. The resident was admitted with a nutritional deficit, and interventions were documented to provide supplements as ordered. However, the resident experienced a severe weight loss of 15.7% over six months, indicating a failure to maintain adequate nutrition. The Registered Dietitian (RD) was responsible for recommending dietary changes, but there was a lack of documentation and communication regarding these recommendations. The RD did not document recommendations in the resident's progress notes for September and November, and the facility's Nutritional Care Form did not reflect the necessary dietary changes. The RD admitted to not seeing the resident in person and was unaware of the continued weight loss and refusal of supplements. The facility's documentation of meal and supplement intake was minimal, and the Director of Nursing acknowledged poor communication with the RD. Observations revealed that the resident appeared very thin with muscle and orbital wasting, and there was no meal tray or nutritional supplement provided at times. The Dietary Aid confirmed that the resident often refused supplements, and the Dietary Manager acknowledged the resident's poor intake of supplements. The facility's policy required monitoring and documentation of weight and dietary intake, but this was not effectively implemented, leading to the resident's significant weight loss.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through a review of staffing schedules and interviews with facility staff. The staffing schedules for the past 14 days revealed that there were no RNs working on nine specific days, including 12/1/2024, 12/2/2024, 12/3/2024, 12/5/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/10/2024, and 12/15/2024. The facility's administrator acknowledged the shortage of RN coverage, and the Director of Nursing confirmed that the facility currently employed only two RNs, including herself, and efforts were being made to hire more RNs. The deficiency potentially affects all 56 residents living in the facility. The facility's PBJ Report for the 4th quarter indicated a one-star staffing rating, and the Facility Assessment dated 7/1/2023 outlined a staffing plan based on the current census, which was not met. The facility's staffing policy, revised in 2017, stated that sufficient numbers of staff with the necessary skills and competency should be available to provide care and services for all residents. However, the lack of RN coverage on the specified days indicates a failure to adhere to this policy, potentially impacting the quality of care provided to the residents.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information in a clear and readable format in a prominent place, which is required to be readily accessible to residents and visitors. During a tour of the facility, it was observed that no nursing information, including the facility name, current date, total number of actual hours worked by RNs, LPNs, CNAs, and resident census, was posted or available for review. The facility's PBJ report for the 4th quarter documented insufficient RN coverage for 8 consecutive hours per day, resulting in a 1-star staffing rating. Interviews with the Director of Nursing and the Business Office Manager revealed a lack of awareness regarding the requirement to post staffing information, with the Business Office Manager noting that staffing was previously posted by the door but was unsure if it had been posted under new management. The facility's assessment and staffing policy indicated the need for adequate staffing to meet resident care needs, but no updated assessment was provided.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a manner that prevents potential contamination, affecting all 56 residents. During an inspection, surveyors observed several deficiencies in the kitchen and storage areas. The fryer station next to the oven was found with a basket covered in old grease and crisp pieces floating in it, indicating a need for cleaning. In the walk-in refrigerator, there was a large container of unidentified meat with noodles in red sauce, and a tray with eight bowls of unidentified food, both without labels or dates. Additionally, there was an 18-quart container of white liquid and another of red liquid, both lacking labels and dates. The freezer also presented issues, with large chunks of ice on the floor and ice crystals dripping from the ceiling onto various food items, including ice cream cups, waffles, chocolate pies, meat, and bread. A large block of ice was covering a box of hamburger. The Dietary Manager acknowledged the requirement for all items to be dated and labeled, and the Maintenance Man, who was new to the facility, was aware of the ice buildup issue but had not yet resolved it. The facility's Food Receiving and Storage Policy, revised in July 2014, mandates that food be stored in compliance with safe handling practices, including proper labeling and dating, which was not adhered to in this instance.
Facility Assessment Not Current or Reviewed Annually
Penalty
Summary
The facility failed to ensure that its Facility Assessment was current and reviewed annually, which has the potential to affect all 56 residents living in the facility. On December 17, 2024, the Facility Assessment was requested and later provided by the Administrator, V1, with a revision date of July 1, 2023. When asked if this was the most up-to-date version, V1 confirmed it was. No other Facility Assessment was provided by the facility by December 18, 2024. Additionally, the Director of Nursing, V2, stated there was no policy on Facility Assessment. The facility's daily census sheets documented a total of 56 residents living in the facility.
Inadequate Infection Control Documentation and Practices
Penalty
Summary
The facility failed to maintain a comprehensive infection surveillance program, as evidenced by the incomplete documentation in the Monthly Infection Control Log for November. Several residents were diagnosed with urinary tract infections (UTIs) and prescribed antibiotics, but the logs did not document the organisms causing these infections. Specifically, residents were prescribed Cipro and Cephalexin for their UTIs, yet the causative organisms were not recorded, indicating a lapse in the facility's infection control documentation practices. Additionally, there was an observed breach in infection control practices by a Licensed Practical Nurse (LPN) during a dressing change for a resident with pressure ulcers. The LPN did not wash or sanitize hands after leaving and returning to the resident's room, nor did they sanitize hands between glove changes. This failure to adhere to proper hand hygiene protocols further highlights deficiencies in the facility's infection prevention and control measures.
Lack of Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to ensure they had a qualified Infection Control Preventionist (ICP) working full-time, which has the potential to affect all 56 residents. The Administrator identified the Director of Nursing (DON) as the current ICP. However, the DON admitted to not having completed the required training for the role and stated there was no oversight in place. The facility's Antibiotic Stewardship Policy outlines responsibilities for the ICP, including monitoring antibiotic use and resistance, collaborating with the pharmacist, and providing education to nursing staff. Despite these outlined duties, the lack of a qualified ICP suggests these responsibilities may not be adequately fulfilled.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain a dignified existence for a resident, identified as R11, who was cognitively intact and dependent on a wheelchair with an indwelling urinary catheter due to neurogenic bladder. The resident's catheter bag was observed uncovered on multiple occasions, which was a source of embarrassment for the resident. R11 expressed frustration about the lack of a cover for the catheter bag, stating it was embarrassing when people walked by the room. Certified Nursing Assistants (CNAs) acknowledged the need for a dignity bag to cover the catheter bag, especially when the resident was moving around the unit. The facility's Administrator and Director of Nursing also stated that they expected catheter bags to be covered. The facility's Resident Rights Policy emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance, as the resident's dignity was compromised by the visible catheter bag.
Failure to Notify Physician and Obtain Treatment Order for Resident's Sore
Penalty
Summary
The facility failed to notify the physician and obtain an order for treating a non-pressure sore on a resident's lower left leg. The resident, who is cognitively intact and has a medical history including an acquired absence of the right leg above the knee and peripheral vascular disease, reported a sore on her leg that was leaking. Despite this, there was no documented order in the Electronic Health Record for the dressing applied to the sore. The nurse's note from the previous day indicated that the sore was dressed and covered with triple antibiotic ointment and a bandage, with no signs of warmth or redness, and the plan was to continue monitoring. The Director of Nursing confirmed the absence of a treatment order, and a Licensed Practical Nurse (LPN) noted the sore was scabbed over but had an open tip. The LPN cleansed the area, applied ointment and a bandage, and noted a new area on the leg that was not measured. The LPN stated she would call the doctor, and the physician confirmed being contacted but had not yet seen the resident. The facility's policy requires the charge nurse or supervisor to contact the attending physician for immediate discussion and management if a clinical situation necessitates it, which was not adhered to in this case.
Failure to Protect Resident from Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a cognitively severely impaired resident with Alzheimer's Dementia and other medical conditions. The incident occurred when the resident fell out of their wheelchair, and a CNA reported the fall to an LPN. The LPN became visibly angry, yelled at the resident, and was reported to have physically handled the resident inappropriately. Multiple staff members witnessed the LPN mistreating the resident, including aggressive talking and forcibly moving the resident's wheelchair. The facility's investigation substantiated the allegations of abuse, leading to the termination of the LPN's employment. The facility's policy on Abuse Prevention, revised in 2017, states that residents should be provided with an environment free from abuse, neglect, or misappropriation of property. Despite attempts to contact the involved staff for interviews, they were unavailable, and their written statements were included in the investigation.
Failure to Monitor Post-Dialysis and Paracentesis Care
Penalty
Summary
The facility failed to adequately monitor a resident, identified as R34, who required dialysis and paracentesis. R34's electronic health record documented diagnoses of end-stage renal disease, alcoholic cirrhosis of the liver with ascites, and dependence on dialysis. Despite these conditions, the facility did not document post-dialysis and post-paracentesis monitoring in the resident's records. The care plan for R34 indicated a risk for complications related to end-stage renal disease and dialysis, but there were no documented orders or evidence of monitoring for signs and symptoms of fluid overload in the electronic health record. Additionally, the facility did not document the post-paracentesis instructions provided by the local hospital, which included specific care instructions such as removing the bandage in 3 to 5 days and monitoring for redness or drainage. The Medication Administration Record and Treatment Administration Record lacked documentation of these instructions. Licensed Practical Nurses (LPNs) at the facility acknowledged checking the dialysis access site for thrill and bruit but did not document these checks unless issues were noted. Furthermore, there was no dialysis and paracentesis policy provided upon request, indicating a lack of formalized procedures for these critical care activities.
Improper Feeding Assistance by Untrained Staff
Penalty
Summary
The facility failed to ensure that residents who required assistance with feeding were attended to by properly trained staff under the supervision of a registered nurse (RN) or licensed practical nurse (LPN). This deficiency was identified during an observation where a unit aid, who had not completed a state-approved training class for assisting residents with feeding, was feeding a resident diagnosed with dysphagia and other digestive issues. The resident was on a pureed diet, and the feeding occurred without the presence of a nurse in the dining room. The unit aid's job description did not include feeding residents, and the Director of Nursing (DON) confirmed that unit aids were not supposed to feed residents, especially those at high risk for choking. The facility did not have any paid feeding assistants, nor did it have a policy on feeding assistance or residents needing assistance with feeding. The facility's existing policy required that paid feeding assistants complete a state-approved training course and be supervised by a registered dietitian and an RN, but this was not adhered to in practice.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident identified as R2, who was at risk due to her cognitive impairments. R2, who had been admitted to the facility with a diagnosis of Alzheimer's disease and dementia, was known to be confused, agitated, and frequently expressed a desire to leave the facility. Despite these known risks, R2 was able to elope from the facility undetected on the afternoon of 10/15/2024. On the day of the incident, R2 was last seen by staff at approximately 3:00 PM. She was later found by a passerby at around 4:30 PM, walking in a field near the local hospital. The facility's investigation revealed that a window in an unoccupied room on the memory care unit was found ajar, suggesting that R2 may have exited through it. Alternatively, it was suspected that she might have followed a visitor out of the secured door. The facility's staffing on the memory care unit was insufficient, with only one CNA present when the LPN was administering medications on other halls, leaving the residents unsupervised. R2's care plan and elopement risk assessments were not adequately updated or implemented. Although R2 was identified as an elopement risk upon admission, she was not equipped with an electronic monitoring bracelet, which could have alerted staff to her exit. The facility's failure to ensure that R2 was continuously monitored and that preventive measures were in place directly contributed to her elopement.
Removal Plan
- The issue has the potential to affect all memory care residents and any other residents within the facility that have been identified as an elopement risk.
- R2 was evaluated at local hospital following the elopement and again upon returning to the facility. No injuries were observed. R2's responsible party, attending physician, and State Survey Agency were all notified.
- All residents on the memory care unit were placed on 15-minute checks for a period. At the expiration of the period, residents were placed on a 2-hour check, with the exception of R2 who remained on 15-minute checks, and QA team will review to see if any changes need to be made.
- R2 care plan was reviewed and updated to assess exit seeking triggers and none were identified. The care plan was updated to include the use of an electronic monitoring device.
- The electronic monitoring device, which is present on all exterior doors of the facility, was tested and determined to be in working order. The electronic monitoring alert system was tested and determined to be functioning properly and the electronic monitoring bracelet was placed on the resident.
- The facility has conducted updated risk assessments on all current residents. This risk assessments included identifying exit seeking triggers, if any. No new elopement risks were identified.
- The facility's administrative and clinical teams, led by the administrator, met to review all elopement policies and procedures. Current policies and procedures were determined to be satisfactory, and no changes were proposed.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate staffing for the memory care locked unit, affecting all 11 residents residing on the unit. These residents, who have dementia and Alzheimer's disease, require assistance with activities of daily living (ADLs) and are at risk of wandering and setting off door alarms. The staffing issue was observed during various shifts, where only one CNA was left to supervise the unit while the assigned nurse attended to residents on other halls. This left the CNA alone to manage high-acuity residents, which was deemed unsafe by multiple staff members. Interviews with staff, including LPNs, RNs, and CNAs, revealed that the current staffing pattern left the memory care unit inadequately supervised. Staff members reported that they were often required to leave the unit to care for residents on other halls, leaving only one CNA to manage the 11 residents. This situation was described as unsafe, particularly when the CNA had to provide 1:1 care, such as toileting, which left other residents unsupervised for extended periods. The Director of Nursing (DON) and the facility administrator acknowledged the staffing issues but did not have a clear understanding of the acuity of the memory care unit or the specific staffing assignments. The facility's staffing policy requires a minimum of 3.8 hours of nursing and personal care each day for residents needing skilled care, but the current staffing did not meet these requirements, leading to the deficiency noted in the report.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to secure and control the disposition of administered medications for several residents, leading to deficiencies in medication management. Resident 1, who was cognitively intact but required assistance with activities of daily living, was found with hydrocortisone cream in her wheelchair and diclofenac gel at her bedside without a documented order for medications at bedside. The registered nurse and licensed practical nurse were unaware of any assessments for residents to have medications at bedside, and the care plan nurse admitted there was no comprehensive assessment policy in place. Resident 7, who was severely cognitively impaired, had medications left unattended on a dining table for over half an hour. The licensed practical nurse left the medication cup on the table without continuous nursing observation. The care plan nurse acknowledged the lack of a comprehensive self-administration assessment for Resident 7, despite the expectation of nursing supervision and oversight of medications left for residents to administer. Resident 8, who was cognitively intact, also had medications left unattended on a dining table for nearly an hour. The licensed practical nurse left the medication cup on the table without continuous nursing observation. Additionally, Resident 2 had seven pills left out of reach on a bedside table, and Resident 3, who was confused, had diclofenac gel on her bedside table without a self-administration assessment. The facility's policy on self-administration of medications was not followed, as there was no documentation of comprehensive assessments or secure storage of medications.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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