Axiom Healthcare Of Mount Vernon
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Illinois.
- Location
- 1700 White Street, Mount Vernon, Illinois 62864
- CMS Provider Number
- 145517
- Inspections on file
- 26
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Axiom Healthcare Of Mount Vernon during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to meet resident needs, resulting in long call light response times and delays in care, especially during night shifts. Residents with significant mobility and care requirements reported waiting extended periods for assistance, sometimes having to call out for help or seek staff themselves. Staff interviews and records confirmed frequent understaffing, with only one or two CNAs present for 47 residents during some shifts, making it difficult to provide timely care and complete necessary tasks.
Staff did not consistently use or change required PPE when caring for COVID-19 positive residents, and COVID-positive individuals were not always isolated from those who were negative. Some residents with COVID-19 were observed in shared rooms with uninfected roommates and in common areas without masks. Additionally, vital signs for COVID-positive residents were not monitored or documented every shift as required by facility policy.
The facility did not have a qualified, certified Infection Preventionist overseeing the infection prevention and control program. The staff member performing most infection control duties had not completed required certification or received training, and the Administrator, though certified, was not involved in the program. Facility records indicated a certified IP should be in place, but this was not the case for the 44 residents present.
A resident with severe cognitive impairment and multiple comorbidities died from positional asphyxiation after being found with their head and neck trapped between a loose bed rail and mattress. The facility failed to attempt alternatives before bed rail use, did not complete required assessments or obtain physician orders, and used old equipment without following manufacturer guidelines. Staff lacked training and documentation was incomplete, with no incident report made after the fatal event.
A resident with a history of Type 2 Diabetes Mellitus and multiple comorbidities experienced persistently high blood sugar readings that exceeded the facility's glucometer range. Despite observable changes in condition and repeated 'HI' readings, staff did not seek emergency care, instead administering insulin and waiting for physician response. Communication breakdowns, lack of staff training, and incomplete documentation contributed to the resident's deterioration and subsequent death from probable diabetic ketoacidosis.
A resident with a history of sepsis, peritonitis, and dialysis dependence experienced severe respiratory distress after untrained staff administered an excessive volume of dialysate during a manual peritoneal dialysis procedure. Miscommunication, lack of training, and failure to follow physician orders resulted in the resident being hospitalized and intubated for respiratory failure.
A resident with severe cognitive impairment, legal blindness, and total dependence on staff experienced an unwitnessed fall from bed after the removal of a side rail, with no new fall prevention interventions implemented. Staff confirmed that no alternative measures such as alarms or fall mats were put in place, and the resident was later hospitalized with head injuries. The facility's failure to update fall interventions after the incident did not meet its own fall prevention policy requirements.
The facility did not ensure that a physician reviewed residents' care plans or signed and dated orders, as all such documentation was completed by a nurse practitioner. The Medical Director did not make patient rounds or sign progress notes, despite contractual obligations, affecting all residents.
The facility did not ensure that residents were seen by a physician at the required intervals, with the Medical Director only attending quarterly meetings and not making rounds. Instead, a Nurse Practitioner conducted rounds intermittently, and several residents reported never seeing a physician or only rarely seeing the Nurse Practitioner. Medical record reviews confirmed the absence of physician progress notes for multiple residents.
A resident with a critically high blood sugar was reported to an LPN, who attempted to contact the on-call physician but only reached voicemail and was advised by the DON to wait for a callback. The LPN was unfamiliar with the facility's electronic communication system and had not been trained on its use. A nurse later received physician orders after repeated attempts. The medical director confirmed he was unreachable due to a silenced phone, resulting in a lack of 24-hour physician coverage as required.
The facility did not provide enough nursing staff to meet residents' daily needs, leading to missed scheduled showers and delays in assistance with activities of daily living (ADLs). Multiple cognitively intact residents reported going extended periods without bathing, and staff confirmed that frequent short-staffing made it impossible to complete all required care tasks.
The facility did not serve meals according to the planned menus, frequently substituting items due to missing ingredients without proper documentation or approval from the RD. Staff reported confusion with food ordering and recipe management, and residents expressed dissatisfaction with the quality, variety, and temperature of meals. Several residents with significant medical needs, including malnutrition and diabetes, were affected by the lack of adherence to menu planning and substitution policies.
The facility did not provide food at appropriate temperatures due to a broken steam table, resulting in multiple residents consistently receiving cold and unappetizing meals. Staff and residents confirmed the ongoing issue, and the administrator acknowledged the equipment had not been repaired due to lack of funds. The deficiency affected all residents, with food temperatures falling below the facility's own standards for palatability.
The facility failed to investigate and report a resident death, did not seek emergency services for a resident with a critical change in condition, and did not implement new fall interventions after a fall. Staff lacked training on emergency procedures, peritoneal dialysis, and change of condition protocols. The administrator was unfamiliar with regulatory requirements and her own licensure status, and the medical director was not regularly present or available for communication. These failures affected the care and safety of all residents.
The facility did not conduct ongoing effective communication training for direct care staff, as required by its own assessment and training protocols. Review of in-service records and staff interviews confirmed the absence of this training, potentially affecting all 50 residents in the facility.
The facility did not conduct ongoing QAPI training for all staff, as confirmed by record review and staff interview. In-service documentation lacked evidence of QAPI training, and the Regional Director of Operations acknowledged that the training was not completed. Fifty residents were present in the facility at the time.
The facility did not conduct ongoing Compliance and Ethics training for all staff, as confirmed by both record review and staff interview. Documentation of such training was absent, and the Regional Director of Operations acknowledged that the training was not completed. This affected all 50 residents in the facility.
The facility did not complete the required annual in-service training and competency assessments for CNAs, as confirmed by record review and staff interview. This deficiency potentially affected all 50 residents in the facility.
The facility did not conduct ongoing behavioral health training for all staff, as required by regulations and the facility assessment. Review of in-service records showed no documentation of such training, and the Regional Director of Operations confirmed that it had not been completed. At the time of the survey, 50 residents were present in the facility.
Several residents who required staff assistance for ADLs, including showering and toileting, experienced significant delays or missed care due to frequent short staffing and equipment issues, such as a single mechanical lift battery. Staff and resident interviews, along with documentation, confirmed that scheduled showers were often not completed and residents sometimes waited extended periods for help, with staff acknowledging they could not meet all care needs during understaffed shifts.
Two residents did not have their physician notified as required: one missed multiple doses of IV antibiotics due to pharmacy and communication issues, and another experienced a significant change in condition with extremely high blood glucose that was not effectively communicated to the physician. Staff interviews revealed a lack of training on notification protocols and use of the facility's communication system.
A resident admitted with multiple serious diagnoses, including abdominal abscess and sepsis, did not receive several ordered doses of IV Vancomycin and Unasyn due to the facility's failure to promptly communicate medication orders to the pharmacy during a transition to electronic records. The DON confirmed the missed doses were caused by not sending required phone or fax orders, resulting in delayed delivery and administration of critical antibiotics.
Two residents did not receive prescribed IV antibiotics and sliding scale insulin as ordered due to medication unavailability and incomplete order entry. One resident missed multiple doses of IV antibiotics after admission because the pharmacy did not receive the orders, and the other did not receive sliding scale insulin for diabetes management until the day of discharge, despite high blood glucose readings and communication from the resident and physician. Facility policy requiring timely administration and physician notification for missed doses was not followed.
Two residents in the facility experienced significant deficiencies in pressure ulcer care. One resident developed a Stage 3 pressure ulcer due to the lack of prescribed pressure-relieving devices, while another resident's unstageable pressure ulcer worsened due to the absence of a necessary protein supplement. The facility failed to implement care plans and communicate supply issues, leading to these deficiencies.
The facility failed to ensure RN coverage for 8 consecutive hours daily, affecting all 48 residents. Nursing schedules showed multiple days without the required RN presence from April to November. Interviews with the DON, an RN, and the Administrator confirmed the ongoing issue. The facility's policy mandates compliance with professional standards, which was not met.
The facility failed to prepare food according to the planned menu and recipe, affecting all 48 residents. A family member raised concerns about poor food quality, and a cook admitted to using incorrect ingredients for the Chicken Cordon Bleu Casserole. Another cook had to substitute the planned sweet and sour pork due to unavailable ingredients. This led to uncertainty about the nutritional content of meals served.
The facility's kitchen was found to be unsanitary, with issues such as a propped open door, a damaged window screen, and improper food storage. Observations included expired and unlabeled food, incomplete temperature logs, and a cooler with cloudy water and food items. The administrator acknowledged the refrigerator had been out of service and emphasized the need for cleanliness and pest prevention.
The facility did not hold required quarterly QAPI meetings, as the administrator could not provide documentation for meetings in early 2024. No evidence of meeting minutes or attendance was found, despite the facility's QAPI Plan requiring quarterly meetings with records maintained. This deficiency potentially affects all 48 residents.
A facility failed to notify a resident's representative in writing about hospital transfers. The resident, initially admitted in 2021, was sent to the emergency department for choking and later admitted to the hospital with preseptal cellulitis. The administrator acknowledged the absence of bed hold or discharge notices and was unsure why notifications were not sent, despite the facility's usual practice.
A facility failed to notify a resident's representative in writing of the bed hold policy during hospital transfers. The resident, initially admitted in 2021, was transferred to a hospital twice in 2024 for choking and preseptal cellulitis. The administrator admitted the absence of notifications and was unsure why the representative was not informed, despite the facility's policy requiring such notification at the time of transfer.
A facility failed to accurately code the MDS assessment for a resident with schizophrenia due to a miscommunication regarding the resident's Level II PASRR status. The LPN responsible for the MDS was unaware of the resident's PASRR status, leading to incorrect documentation. The DON expected accurate coding, but the oversight resulted in a deficiency in the assessment process.
A resident with Parkinsonism, Diabetes Mellitus Type 2, and Dementia did not receive timely toileting assistance, remaining in a wheelchair for extended periods without peri care. The resident's adult brief was found saturated with urine, and CNAs admitted to not checking or changing the resident due to being reassigned or starting shifts later. Facility policy requires checks every two hours, which was not followed.
A resident with Parkinsonism, Diabetes Mellitus Type 2, and Dementia was not provided with necessary restorative care to maintain or improve mobility. Despite a care plan to prevent immobility complications, the facility lacked an active restorative program, resulting in the resident not receiving daily range of motion exercises. Observations showed the resident in soiled clothing and not repositioned for long periods, with staff confirming the absence of a restorative program for two years.
A resident with ESRD requiring dialysis experienced a lack of communication between the facility and the dialysis center, resulting in a delay in receiving prescribed medication. The resident also did not receive the prescribed double protein portions with meals, despite it being listed on her meal card. The DON acknowledged poor communication with the dialysis center, and the dialysis nurse confirmed multiple attempts to communicate the new medication order to the facility.
A facility failed to implement a gradual dose reduction (GDR) for a resident on lorazepam, despite a consultant's recommendation and acceptance by a nurse practitioner. The resident's POA opposed the reduction, and the RN documented this without notifying the physician. The facility's policy requires GDRs unless clinically contraindicated, but the reduction was not pursued due to the POA's wishes, leading to a deficiency.
A resident with multiple health conditions was mistakenly given Eliquis, an anticoagulant, despite a discontinuation order due to anemia and a positive occult blood test. The error was discovered by an RN, and the Assistant Director of Nursing admitted to missing the discontinuation order during record checks.
The facility failed to follow infection control protocols for two residents. A resident with pressure ulcers and a catheter was not placed under enhanced barrier precautions, and staff performed wound care without PPE. Another resident required suctioning, but the nurse used a contaminated yankeur due to a lack of proper equipment and policy. These actions led to deficiencies in infection control practices.
The facility failed to provide enough dietary staff, resulting in delayed meal services for all 29 residents. Observations showed breakfast and lunch were served late, with insufficient staff in the kitchen. Residents and staff confirmed the delays, citing inadequate staffing as the cause. The Dietary Manager struggled to retain staff, and the DON acknowledged previous citations for this issue.
The facility failed to serve meals on time, affecting all 29 residents. Breakfast and lunch services were consistently delayed, with some residents receiving meals on Styrofoam due to insufficient kitchen staff. Both residents and staff confirmed frequent meal delays, and the DON acknowledged the issue as a recurring problem.
The facility failed to serve meals on time as per their designated schedule, affecting all 27 residents. Observations and interviews revealed that meals are consistently late due to a shortage of kitchen staff, with lunch service starting 25 minutes past the scheduled time. Residents and family members reported difficulties in planning around meal times, and the Dietary Manager confirmed the need for additional staff.
The facility failed to investigate abuse allegations involving three residents. One resident reported being shoved by another, but the administrator dismissed the incident. Another resident reported verbal abuse by a CNA, but the investigation was incomplete. Anonymous reports of neglect were also not investigated. The facility's policy requires thorough investigations, which were not conducted, leading to a deficiency.
A resident with multiple medical conditions and Stage 2 pressure injuries did not receive wound care as per physician's orders. The treatments were supposed to be administered every 12 hours, but were only done once daily due to a transcription error by the DON, leading to inadequate care.
A facility failed to monitor a resident's food intake, leading to significant weight loss. The resident, with multiple health conditions, had incomplete meal intake documentation for several days. The Dietary Manager delayed placing meal intake sheets due to staffing issues, and CNAs were not specifically assigned to document meal intakes, resulting in gaps in records.
The facility failed to provide 8 hours of daily RN coverage, affecting all 27 residents. The Administrator and DON acknowledged the shortage and ongoing recruitment efforts. A review of nursing staff schedules for March, April, and May 2024 revealed specific dates without the required RN coverage.
The facility failed to ensure that the physician visited and examined residents at the required intervals, affecting three residents with various medical conditions. Staff confirmed that the physician had not been visiting regularly, and the Medical Director cited non-payment as the reason for his absence.
Failure to Maintain Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents, as evidenced by interviews, record reviews, and direct observations. Three residents with significant care needs reported long wait times for call light responses, particularly during the night shift when staffing was lowest. One resident, with diagnoses including Multiple Sclerosis and a history of falls, described having to yell for help after falling out of bed when her call light was not answered. Another resident with mobility limitations stated that night shifts often lacked enough staff to provide timely assistance with medications and personal care. A third resident, who required assistance with activities of daily living, reported delays in call light responses and sometimes had to seek out staff herself. Staff interviews corroborated these resident accounts, with multiple CNAs stating that the facility was frequently understaffed, especially at night. CNAs reported that with only one or two staff members on duty for 47 residents, it was impossible to provide timely care, complete necessary documentation, or perform all required tasks such as repositioning, changing, and showering residents. Staff also noted that mechanical lifts could not be used safely without adequate personnel, and that some residents were left wet or not transferred as needed due to insufficient staffing. The administrator acknowledged the staffing challenges, citing a recent COVID outbreak and reliance on agency nurses, but confirmed that the facility often operated below its own assessed staffing needs. Review of staffing schedules and payroll records confirmed that on multiple occasions, only one CNA was present in the facility during overnight hours, despite the facility's own assessment indicating a need for at least 10 CNAs over a 24-hour period. The administrator admitted that she was not always notified of these staffing shortages and that the facility's budget allowed for only two CNAs on the night shift, which was not sufficient to meet resident needs. The deficiency was further substantiated by the facility assessment tool, which documented the high level of assistance required by the majority of residents for activities of daily living.
Failure to Implement Infection Control and COVID-19 Isolation Protocols
Penalty
Summary
Staff failed to consistently don the required Personal Protective Equipment (PPE) when caring for residents with confirmed COVID-19, and contaminated PPE was not always discarded as required after use. Observations included staff exiting rooms of COVID-positive residents wearing only surgical masks or not changing N95 masks and other PPE between resident encounters, despite signage and facility policy requiring full PPE including N95 respirators, gowns, gloves, and eye protection. Some staff members reported not receiving recent or any infection control or COVID-specific training, and there was confusion among staff regarding the COVID status of residents and the need to follow posted isolation precautions. COVID-positive residents were not consistently separated from COVID-negative residents. Instances were observed where COVID-positive residents shared rooms with COVID-negative roommates, and COVID-positive residents were allowed to eat in the dining room and move about the facility without masks, in direct contact with other residents. Staff interviews revealed uncertainty about cohorting practices, with some staff and leadership stating they were told not to move residents to avoid spreading the virus, despite facility policy and infection control guidelines recommending isolation and cohorting of positive cases. Additionally, the facility failed to monitor and document vital signs for COVID-positive residents every shift as required by policy. Electronic health records for several COVID-positive residents did not include evidence of vital sign checks each shift following diagnosis. Staff interviews confirmed that vital sign monitoring lists were not consistently created or followed, and there was a lack of clarity and adherence to the policy regarding the frequency and documentation of vital sign assessments for symptomatic and COVID-positive residents.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist (IP) responsible for the infection prevention and control program. During interviews, the DON stated that the Resident Care Coordinator was handling infection control duties but had not completed the required certification. The Administrator, who holds an Infection Control Preventionist Certification, indicated that they were not involved in the infection control program due to their current administrative role. The Resident Care Coordinator confirmed she had not received infection control or COVID-19 training at the facility, had not passed the certification test, and was unfamiliar with the facility's infection control and COVID-19 policies. Facility documentation, including the Facility Assessment Tool and the Infection Prevention and Control Program policy, indicated that a certified and trained Infection Control Preventionist should be in place to oversee infection tracking, decision-making, and staff education. However, the individual performing most infection control tasks lacked the necessary certification and training, and there was no evidence of staff education being provided. At the time of the survey, 44 residents were living in the facility.
Failure to Assess, Document, and Safely Install Bed Rails Resulting in Resident Death
Penalty
Summary
The facility failed to implement appropriate alternatives and conduct adequate assessments prior to the installation of bed rails for multiple residents, resulting in a fatal incident for one resident. Specifically, the facility did not attempt different approaches before using bed rails, did not adequately assess or monitor residents for risk of injury or entrapment, and did not ensure that bed rails were installed and maintained according to manufacturer’s recommendations. Additionally, the facility failed to obtain physician orders for the use of bed rails for six residents reviewed, and did not document informed consent or proper care planning related to bed rail use. One resident, who had diagnoses including Parkinson’s Disease, dementia, morbid obesity, and hydrocephalus, was admitted with severe cognitive impairment and required significant assistance with activities of daily living. The resident’s care plans did not address the use of side rails, and documentation regarding alternatives attempted prior to bed rail use was incomplete or inconsistent. The bed rail assessments were not fully completed, and there was no evidence of interdisciplinary team review or staff signatures. The resident was found deceased in a sitting position on the floor with the head and neck trapped between the mattress and bed rail, with the coroner determining the cause of death as positional asphyxiation. Observations revealed that the bed rail was loose and the gap between the mattress and rail exceeded safe limits, expanding further when weight was applied. Interviews with facility staff revealed a lack of knowledge and training regarding bed rail assessments, installation, and maintenance. Maintenance staff installed bed rails without reference to manufacturer specifications or gap measurements, and there was no routine checking of bed rails after installation. Staff were unclear about who was responsible for assessments, consents, and documentation, and there was no incident report completed following the resident’s death. The facility used old beds and side rails from other facilities without proper documentation or manuals, and there was no system in place to track when bed rails were installed or to ensure that care plans and physician orders were updated accordingly.
Failure to Seek Emergency Care for Resident with Critically High Blood Sugar
Penalty
Summary
A deficiency occurred when the facility failed to seek emergency care for a resident with Type 2 Diabetes Mellitus who was experiencing blood sugar levels too high to be measured by the facility's glucose monitoring device. The resident, who had a complex medical history including cerebral palsy, quadriplegia, chronic kidney disease, and a history of diabetic ketoacidosis (DKA), exhibited a significant change in condition with persistently elevated blood glucose readings that exceeded the glucometer's measurable range. Despite repeated 'HI' readings on the glucometer, which indicated blood glucose levels above 600 mg/dL, and observable changes in the resident's behavior and responsiveness, emergency medical intervention was not initiated in a timely manner. Throughout the day, certified nurse assistants (CNAs) reported to the agency LPN that the resident was not acting normally and recommended hospital transfer, but the LPN chose to administer insulin and wait for a physician's response instead. The LPN was unfamiliar with the facility's policies, the glucometer's limits, and had not received training on change in condition or emergency protocols. The DON was consulted and advised the LPN to use her judgment or wait for physician orders, but did not direct immediate transfer. Communication with the on-call physician was attempted, but there was no documented response or follow-up, and the facility's communication system was not effectively utilized. The resident's condition continued to deteriorate, with ongoing 'HI' blood sugar readings and increasing unresponsiveness. Later, the oncoming agency RN also observed the resident's critical state, continued to attempt to reach the physician, and administered additional insulin per verbal orders, but did not document the physician's name or the new orders properly. The resident's blood sugar eventually decreased to 488 mg/dL, but his condition worsened, culminating in respiratory distress, unresponsiveness, and ultimately death. Documentation and communication lapses were evident, including incomplete MAR entries and lack of proper notification or escalation. The cause of death was listed as probable diabetic ketoacidosis.
Removal Plan
- Facility administrator was in-serviced by Regional Reimbursement Consultant on ensuring that glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner.
- Facility administrator was in-serviced by Regional Reimbursement Consultant on ensuring that licensed nursing personnel will inform the physician or authorized designee with any change in condition of the resident in an effective, timely and efficient manner.
- Facility administrator was in-serviced by Regional Reimbursement Consultant on medications being administered in accordance with the good nursing principles and practices and only by persons legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system.
- Facility's administrator in-serviced by Regional Reimbursement Consultant on using nursing judgement to seek emergency treatment when appropriate.
- Facility Administrator initiated in-servicing for nursing staff on using nursing judgement to seek emergency treatment when appropriate.
- Facility Administrator initiated in-servicing for all nursing staff on ensuring glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner to be completed before the start of their next shift.
- Facility Administrator initiated in-servicing for all nursing staff on medications being administered in accordance with the good nursing principles and practices and only by legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system, to be completed before the start of their next shift.
- Facility policy for physician notification has been reviewed by Regional Director of Operations and has been found to be in compliance.
- Facility completed an audit of all diabetic residents to ensure that their blood sugars are within therapeutic range and a weekly audit will be performed by the DON or designee weekly for four weeks.
- Quality Assurance and Performance Improvement (QAPI) plan has been revised to include that the facility will ensure residents experiencing an acute critical situation receive timely emergency care and lacks a process for physician notification and receiving orders in an acute situation. QAPI revisions will be discussed at the next QAPI meeting.
- Monitoring will be ongoing in the morning Quality Assurance (QA) meeting by the QA team (Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS)), the QA team will review the 24-hour report and follow up on any changes in condition to ensure that proper care was received and proper procedures were followed.
Failure to Provide Safe Peritoneal Dialysis Care by Qualified Staff
Penalty
Summary
The facility failed to provide safe and appropriate peritoneal dialysis care for a resident who required such services, resulting in a serious adverse event. The resident, who had a history of sepsis, peritonitis, and dependence on dialysis, was admitted with moderate cognitive impairment and had recently been discharged from the hospital. On the day of the incident, the resident's peritoneal dialysis (PD) cycler was malfunctioning, and staff were unable to resolve the issue. Communication between the facility staff and the dialysis company led to instructions for a manual fill of dialysate fluid, with a specific order for 1.5 liters to be administered manually. Despite the order, the nursing staff involved were not properly trained in manual peritoneal dialysis procedures. The Director of Nursing (DON) was unfamiliar with manual fills and relied on a Registered Nurse (RN) and an LPN, neither of whom had received adequate training for the procedure. Miscommunication and lack of clarity regarding the correct volume to be infused resulted in the entire 2.5-liter bag of dialysate being administered, rather than the ordered 1.5 liters. The staff did not verify the order or ensure proper documentation in the resident's medical record, and there was confusion about who was responsible for the procedure and the amount to be infused. As a result of the over-infusion, the resident developed severe shortness of breath, hypotension, and hypoxemia, requiring emergency transfer to the hospital. Upon arrival, the resident was found to be in acute respiratory distress with significant abdominal distention and was subsequently intubated and placed on mechanical ventilation. Hospital records confirmed that over 3.9 liters of fluid were drained from the resident's abdomen, and the event was attributed to excessive dialysate instillation at the facility. The lack of proper training, failure to follow physician orders, and inadequate communication and documentation directly led to this Immediate Jeopardy event.
Removal Plan
- The contract for dialysis was terminated with the facility.
- Facility Administrator and Director of Nursing reviewed all the residents at the time of the event and no other residents were receiving PD services at the time of the event and no other residents have received PD services since this event.
- Facility Administrator and Director of Nursing were in-serviced by dialysis company on manual fill PD.
- Both nurses involved in the event were suspended pending investigation and terminated.
- Facility policy for dialysis was reviewed by Regional Director of Operations and found to be in compliance.
- QA meeting was held with dialysis company and policies and procedures were reviewed.
- Administrator or designee will review PD patients weekly times 4 weeks.
Failure to Implement New Fall Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement new fall interventions for a resident identified as high risk for falls. The resident had multiple diagnoses, including dementia, legal blindness, history of falls, and was dependent on staff for all care, including transfers and mobility. The resident's care plan noted a risk for falls due to cognitive impairment and unawareness of safety needs, but after an unwitnessed fall from bed, there was no evidence that new or additional fall prevention interventions were put in place. The resident previously had a side rail and the bed positioned against the wall, but the side rail was removed at the request of the family, and no alternative interventions such as alarms, lowering the bed, or fall mats were implemented. Staff interviews confirmed that the resident was totally dependent, rarely moved independently, and required two staff for transfers. Both CNAs involved in the resident's care on the day of the fall stated that after the side rail was removed, no other interventions were added, and they were unaware of any new fall prevention measures. The resident was found on the floor by a roommate, with significant bruising and swelling to the head and face. The incident was unwitnessed, and the resident was unable to describe how the fall occurred. Documentation indicated that the resident was placed on a scoop mattress after the fall, but this was the only intervention noted. Following the fall, the resident exhibited a decline in condition, including decreased responsiveness and abnormal vital signs, which led to eventual transfer to the hospital. Imaging revealed new hyper density in the posterior right globe and soft tissue swelling/hematoma. The facility's fall prevention policy required individualized assessment and implementation of appropriate interventions, but the record review and staff interviews indicated that this was not done after the resident's fall, resulting in a failure to provide adequate supervision and prevent further accidents.
Physician Review and Signature Deficiency on Resident Care Orders
Penalty
Summary
The facility failed to ensure that the physician reviewed residents' plans of care and signed and dated orders as required. Interviews with staff, including the Registered Nurse/Resident Care Coordinator and the Administrator, confirmed that the Medical Director did not review or sign physician orders or progress notes; instead, these tasks were performed solely by the Nurse Practitioner. Review of both electronic and paper medical records for multiple residents over several months showed that all physician orders were signed by the Nurse Practitioner, with no signatures or progress notes from the Medical Director or other physicians. Further, the Medical Director stated that he did not see patients and only attended quarterly meetings, attributing the lack of direct involvement to poor reimbursement. The facility's Medical Director Agreement specified that the physician was responsible for reviewing residents' overall condition and care, documenting progress notes, and signing all orders, but these requirements were not being met. The deficiency had the potential to affect all 50 residents in the facility.
Failure to Ensure Required Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter, as required. Interviews with the Administrator and Registered Nurse/Resident Care Coordinator revealed that the Medical Director only visited the facility for quarterly Quality Assurance meetings and did not make regular rounds to see residents. Instead, a Nurse Practitioner was reported to make rounds every other Thursday, with telehealth visits occurring on alternate weeks for residents needing to be seen. Multiple residents confirmed that they had never seen a physician during their stay, with some stating they had only seen the Nurse Practitioner infrequently or not at all. Review of medical records for several residents over a three-month period showed no progress notes signed by the Medical Director. The Medical Director confirmed that he did not see patients in the facility and relied on Nurse Practitioners to conduct resident visits, citing poor reimbursement as a reason for this practice. The Medical Director Agreement indicated that physician services, including the required frequency of visits, were part of his responsibilities. At the time of the survey, the facility census documented 50 residents, all of whom were potentially affected by the lack of required physician visits.
Failure to Ensure 24-Hour Physician Availability for Emergencies
Penalty
Summary
The facility failed to ensure that the medical director or an on-call physician was available 24 hours a day for emergencies, as required by their agreement. On a specific date, a resident was reported by CNAs to be acting abnormally and appeared unwell. The LPN checked the resident's blood sugar, which registered as 'HIGH' on the glucometer. The LPN attempted to contact the on-call physician but was only able to leave a message. While waiting for a return call, the LPN consulted the DON, who advised waiting for the physician's response before taking further action. The LPN stated she was unfamiliar with the facility's electronic communication system and had not received training on it, relying instead on a phone number written at the nurse's station. A registered nurse who worked the same shift confirmed that the resident continued to have high blood sugar readings and that multiple messages were left for the on-call physician before eventually receiving a callback with orders for insulin. The medical director later stated that his phone had been accidentally silenced, preventing him from being reached for several days, and confirmed he did not receive any calls during the incident in question. The facility's medical director agreement specifically requires 24-hour physician availability for emergencies, but this was not met during the event, potentially affecting all residents in the facility.
Insufficient Nursing Staff Resulting in Missed Showers and Delayed ADL Assistance
Penalty
Summary
The facility failed to provide a sufficient level of nursing staff to meet the daily needs of all residents, specifically in providing timely assistance with activities of daily living (ADLs) such as scheduled showers. Interviews with CNAs and the facility administrator revealed that the facility often operated with only 2 CNAs and 2 nurses on day shift several times a week, despite a staffing plan that called for 4 CNAs and 2 nurses. Staff reported that with only 2 CNAs, they were unable to complete scheduled showers and other necessary ADL tasks, and even with 3 CNAs, all tasks could not be completed. The administrator confirmed that the facility was frequently short-staffed and unable to cover all positions, even when using agency staff. The day shift CNA schedule for February documented multiple days with only 2 CNAs scheduled, and the facility assessment tool indicated a 1:11 staff-to-resident ratio for direct care staff on days and evenings, with a census of 50 residents. Multiple residents, all cognitively intact per their BIMS scores, reported going extended periods without showers due to insufficient staffing. One resident stated she had to go 7 to 9 days without a shower during a particularly short-staffed period. Review of ADL documentation for several residents showed infrequent bathing, with some residents receiving only a few showers over a month-long period. Residents also reported that staff were unable to assist them with showers and that there were not enough staff to meet their needs. These findings demonstrate that the facility did not provide adequate nursing staff to ensure timely assistance with ADLs for all residents.
Failure to Provide Meals According to Planned Menus and Inadequate Menu Substitution Documentation
Penalty
Summary
The facility failed to provide meals in accordance with the planned menus, as observed during multiple meal services. On several occasions, the food served did not match the posted menus due to missing ingredients, such as chicken cordon bleu casserole being replaced with plain chicken breast, and orange sherbet being substituted with mandarin oranges. Staff interviews revealed that substitutions were made frequently, at least once a week, because of inadequate ingredient availability. The recipe binder was disorganized, making it difficult for staff to locate recipes, and there was confusion regarding food orders, with the Dietary Manager admitting to ordering ingredients for the wrong week. Additionally, rolls that were supposed to be served were omitted despite being available in the freezer. Further review showed that menu substitutions were not properly documented or approved by the Registered Dietitian, as required by facility policy. The Menu Substitution Log was largely blank, and when substitutions were made, they were not consistently recorded or justified. For example, planned meals such as Italian sausage with potato salad and peppers were replaced with mashed potatoes and California vegetable blend due to missing ingredients, and snickerdoodle blondie bars were omitted because of a lack of eggs. Another meal of chicken tenders and potato wedges was replaced with biscuits and gravy because there were not enough chicken tenders available. Resident interviews indicated dissatisfaction with the quality, variety, and temperature of the food. Several residents, all cognitively intact, reported that meals were repetitive, lacked variety, and sometimes consisted of leftovers. One resident with severe protein calorie malnutrition stated that the food was bad and sometimes cold, while another with muscle wasting and diabetes noted the lack of options and poor quality of the always available menu. A resident on a mechanical soft diet reported being served mashed potatoes daily. The facility's policy required menus to be followed as written, with substitutions documented and approved, but these procedures were not followed, affecting all 50 residents.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food at palatable temperatures, affecting all 50 residents. During a kitchen tour, it was observed that the steam table was not functioning properly: the center compartment was missing a pan, and the right compartment had an ill-fitting pan. Staff interviews revealed that the steam table had been broken for several months, with makeshift repairs attempted but not resolving the issue. Dietary staff reported that food was kept on the stove as long as possible, but once it cooled, there was no way to reheat it effectively due to the broken equipment. The administrator was aware of the issue but stated that the facility lacked funds to repair the steam table. A test tray delivered to a resident's room was found to have food at 110.6°F, below the facility's policy preference of 120°F or greater for palatability, and the food was described as cold and mushy. Multiple residents, both cognitively intact and moderately impaired, reported that their food was consistently cold upon delivery to their rooms. Staff confirmed the poor quality and temperature of the food, and the ombudsman had previously discussed resident complaints with the administrator. The facility's own policy required periodic temperature checks to ensure hot foods on room trays were served at palatable temperatures, which was not being met.
Multiple Failures in Reporting, Emergency Response, Staff Training, and Oversight
Penalty
Summary
The facility failed to investigate and report a resident death to the Department, did not seek emergency services for a resident experiencing a significant change in condition, failed to implement new fall interventions after a resident fall, did not obtain or document orders for a resident receiving peritoneal dialysis, and did not provide adequate staff training or maintain effective communication with the medical director. In one instance, a resident with multiple comorbidities was found unresponsive and in a compromised position between the bed and bed rail, with no interventions in place for his known behavior of throwing his legs out of bed. The administrator did not report the death, believing it was not related to a fall or injury, and demonstrated a lack of knowledge regarding regulatory requirements and the use of side rails. Another resident with a history of diabetes and DKA experienced a critical change in condition when his blood sugar was too high to read on the glucometer. The LPN administered insulin and attempted to contact the on-call physician but received no immediate response. The DON advised waiting for the physician's return call rather than sending the resident to the ER. The resident's condition deteriorated, and CPR was initiated only after he became unresponsive. Staff reported a lack of training on change of condition protocols, blood glucose monitoring, and emergency procedures, and there was confusion about who was authorized to call 911. Additional deficiencies included the lack of new fall interventions after the removal of side rails for a resident with a history of falls, the absence of written orders for peritoneal dialysis, and insufficient training for staff on PD procedures. The facility also failed to provide routine and required training to staff, including effective communication, QAPI, compliance and ethics, and behavioral health care. The administrator lacked training on her duties and was unclear about her licensure status. The medical director was not regularly present, did not review care plans, and was sometimes unreachable, further compromising oversight and communication.
Failure to Provide Ongoing Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide ongoing training in effective communication for direct care staff, as required by its own facility assessment. Review of in-service training records conducted by the Administrator showed no documentation that effective communication training had been completed. Additionally, the Regional Director of Operations confirmed that such training had not been conducted with facility staff. At the time of the survey, the facility census documented 50 residents who could potentially be affected by this lack of training. No specific residents or their medical histories were mentioned in the report, and the deficiency was identified through interviews and record reviews.
Lack of Ongoing QAPI Training for All Staff
Penalty
Summary
The facility failed to provide ongoing training in Quality Assurance and Performance Improvement (QAPI) for all staff. Review of in-service records conducted by the Administrator showed no documentation that QAPI training had been completed. During an interview, the Regional Director of Operations confirmed that QAPI training was not conducted with facility staff. At the time of the deficiency, there were 50 residents residing in the facility according to the census report. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Lack of Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to provide ongoing training in Compliance and Ethics for all staff. Review of in-service records conducted by the Administrator showed no documentation that such training had taken place. During an interview, the Regional Director of Operations confirmed that Compliance and Ethics training was not completed with facility staff. At the time of the survey, there were 50 residents residing in the facility, as documented in the census report.
Failure to Complete Annual CNA In-Service Training and Competencies
Penalty
Summary
The facility failed to conduct the required annual in-service training and competency assessments for Certified Nursing Assistants (CNAs), as documented in the facility's own assessment, which specifies the need for annual education and competency checks. Review of in-service records provided by the Administrator showed no documentation that these trainings or competencies were completed. This was confirmed by the Regional Director of Operations, who stated that the annual CNA in-services and competencies, due in September 2024, were not completed. At the time of the survey, the facility census indicated 50 residents who could be affected by this deficiency.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide ongoing behavioral health training for all staff as required by regulatory standards and as determined by the facility assessment. Review of in-service records conducted by the Administrator showed no documentation of training related to meeting residents' behavioral health care needs. During an interview, the Regional Director of Operations confirmed that behavioral health care training had not been completed with facility staff. At the time of the survey, the facility census documented 50 residents residing in the facility.
Failure to Provide Timely ADL Assistance Due to Staffing and Equipment Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically showering and toileting, for four residents who were dependent on staff for these needs. Documentation and interviews revealed that residents with diagnoses such as congestive heart failure, diabetes, muscle wasting, and severe malnutrition, who were cognitively intact and required varying levels of assistance, experienced significant delays or missed care. For example, one resident reported waiting up to two hours for toileting assistance and going 7 to 9 days without a shower due to staff shortages and issues with equipment, such as a dead mechanical lift battery. Multiple residents confirmed that there were frequent and prolonged periods without showers, and ADL documentation supported these claims, showing infrequent bathing over a one-month period. Staff interviews corroborated these findings, with CNAs and the facility administrator acknowledging that staffing levels were often insufficient to meet residents' scheduled care needs. Staff reported that with only two CNAs and two nurses on shift, it was not possible to provide timely ADL care or complete scheduled showers, and even with three CNAs, all necessary tasks could not be completed. The facility was also limited by having only one mechanical lift battery, which, when depleted, caused further delays in resident care. Meeting minutes from the resident council and additional staff interviews further confirmed ongoing issues with staffing and equipment, leading to delays and missed care for residents dependent on staff for ADLs. The administrator admitted that the facility was unable to consistently cover all required positions, even when using agency staff, and was not always certain that missed showers were made up by subsequent shifts.
Failure to Notify Physician of Missed Medications and Change in Condition
Penalty
Summary
The facility failed to notify the physician regarding the unavailability and non-administration of intravenous (IV) antibiotics for a resident admitted with multiple serious diagnoses, including peritoneal abscess, sepsis, and severe malnutrition. Documentation showed that the resident missed several doses of Vancomycin and Unasyn due to pharmacy issues and a transition to electronic records, but there was no evidence that the physician or nurse practitioner was informed of these missed doses. The Director of Nursing acknowledged uncertainty about whether the physician was notified and attributed the missed doses to a lack of communication with the pharmacy during the electronic records transition. Another deficiency involved the facility's failure to notify the physician of a significant change in condition for a resident with complex medical needs, including diabetes with ketoacidosis, quadriplegia, and chronic kidney disease. The resident experienced extremely high blood glucose levels, with the glucometer reading "HI," and received insulin as per orders. The LPN on duty attempted to contact the on-call physician but only left a message and did not receive a return call. The LPN also reported a lack of training on change of condition protocols and the facility's electronic communication system. The resident's condition deteriorated throughout the shift, and subsequent staff also failed to effectively communicate the ongoing critical condition to the physician. Facility policies required physician notification when vital medications are not administered or when there is a significant change in a resident's condition. However, documentation and interviews confirmed that these notifications did not occur as required. Staff also reported insufficient training on relevant protocols and communication systems, contributing to the failure to notify the physician in a timely and effective manner.
Failure to Timely Obtain and Administer IV Antibiotics
Penalty
Summary
The facility failed to obtain and administer intravenous (IV) medications as ordered by the physician for one resident. The resident, who was admitted with diagnoses including peritoneal abscess, anal abscess, sepsis, colostomy, hypertension, severe protein-calorie malnutrition, and anemia, had physician orders for IV Vancomycin and Unasyn to treat an abdominal abscess. Upon admission, the resident missed several doses of these IV antibiotics because the pharmacy did not receive the orders electronically, and the medications were not available in the facility. Documentation shows that a total of five doses of Vancomycin and seven doses of Unasyn were missed over several days. Progress notes indicate that the facility was transitioning to electronic records and failed to send a required phone or fax order to the pharmacy, resulting in the delay of medication delivery. The resident confirmed missing multiple doses of IV medication during the initial days after admission and reported that the pharmacy did not send the medications on time. The DON acknowledged the missed doses and attributed the issue to the facility's switch to electronic records and lack of awareness about the need for a phone or fax order for IV medications. The facility's policy requires immediate notification to the pharmacy for interim or emergency medication orders, but this procedure was not followed, leading to the resident not receiving prescribed IV antibiotics as ordered.
Failure to Administer Prescribed IV Antibiotics and Insulin Orders
Penalty
Summary
The facility failed to ensure that physician's orders for intravenous (IV) medications and insulin were followed for two residents. One resident, admitted with diagnoses including peritoneal abscess, sepsis, and severe malnutrition, had orders for IV Vancomycin and Unasyn to treat an abdominal abscess. Upon review, it was found that several doses of both antibiotics were missed in the initial days after admission due to the pharmacy not receiving the orders and the medications not being available in the facility. The Director of Nursing confirmed that the transition to electronic records contributed to the delay, as the necessary phone order was not faxed to the pharmacy. Documentation showed a total of five missed doses of Vancomycin and seven missed doses of Unasyn, with progress notes indicating medication unavailability as the reason for omission. There was no documentation that the physician was notified about the missed doses, as required by facility policy. Another resident with multiple chronic conditions, including diabetes mellitus, was admitted without a sliding scale insulin order due to missing discharge instructions from the hospital. Although the resident and his endocrinologist communicated the need for sliding scale insulin to the nursing staff, the order was not entered until the day of discharge. During the resident's stay, blood glucose readings were consistently high, and there was no documentation of sliding scale insulin administration prior to the order being entered. Nursing staff acknowledged that the sliding scale order was not completed as intended, and the Director of Nursing was unaware of the need for the order until it was finally entered. Facility policy requires that medications be administered as prescribed and that any withheld or unavailable doses, especially of vital medications, be documented and reported to the physician. In both cases, the facility did not follow these protocols, resulting in significant medication errors for the residents involved.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess, treat, and implement interventions to prevent pressure ulcers for two residents, R33 and R18, leading to significant health issues. R33, who was at high risk for skin breakdown due to conditions such as Parkinsonism, diabetes, and dementia, developed a Stage 3 pressure ulcer on his right ischium. Despite having a care plan that included the use of an air mattress and pressure reduction cushion, observations revealed that R33 was not provided with these essential items. He was frequently seen in a wheelchair without a pressure reduction cushion and on a mattress that was not an air mattress, contrary to the treatment orders. This lack of adherence to the care plan and physician orders contributed to the development and persistence of R33's pressure ulcer. R18, another resident with severe cognitive impairment and multiple health issues including diabetes and end-stage renal disease, experienced a worsening of an unstageable pressure ulcer on the left heel. The care plan for R18 included a high-protein supplement to aid in wound healing, but the facility failed to provide this supplement for an extended period due to supply issues. The dietary department had been out of the protein supplement, and the physician was not notified of this lapse, nor was an alternative supplement requested. This failure to provide necessary nutritional support likely contributed to the deterioration of R18's pressure ulcer. The facility's policies on skin condition assessment and pressure ulcer prevention were not effectively implemented, as evidenced by the lack of appropriate interventions for both residents. The facility's failure to follow through with prescribed treatments and nutritional support, as well as the lack of communication regarding the unavailability of essential supplies, directly led to the deficiencies observed in the care of R33 and R18.
Failure to Provide RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day, seven days a week, which has the potential to affect all 48 residents living in the facility. The Long-Term Care Facility Application for Medicare and Medicaid documented 48 residents residing in the facility. A review of the nursing schedules revealed that there were multiple days from April 6, 2024, to November 17, 2024, where no RN was on shift for the required 8 hours. Interviews with the Director of Nursing (DON), a Registered Nurse (RN), and the Administrator confirmed the facility's ongoing struggle to maintain daily RN coverage. The facility's Personnel Policy and Procedure, dated September 2024, states that the facility operates in compliance with applicable laws and professional standards, which was not adhered to in this case.
Failure to Follow Planned Menu and Recipe
Penalty
Summary
The facility failed to prepare food according to the planned menu and recipe, which has the potential to affect all 48 residents living in the facility. On December 12, 2024, a family member expressed concerns about the poor quality of food, stating that it was difficult for residents to eat. The cook admitted to not having the required chicken or ham for the Chicken Cordon Bleu Casserole and used frozen luncheon-style ham and chunk chicken instead. The cook was unsure of the amount of protein added, as the packaging labels with nutritional information were discarded. The recipe called for specific amounts of ingredients, but the cook used what was available without measuring, leading to uncertainty about the nutritional content of the meal. On December 13, 2024, another cook had to substitute the planned sweet and sour pork with a pork fritter and brown gravy due to the unavailability of the correct ingredients. This cook mentioned that substitutions were often necessary because the correct ingredients were not available. The facility's failure to follow the planned menu and recipe, as well as the lack of proper ingredient management, resulted in a deficiency in meeting the nutritional needs of the residents.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which could potentially affect all 48 residents. During an initial tour, several issues were observed, including a propped open back door without a screen and a kitchen window with a damaged screen, both of which could allow pests to enter. The refrigerator in the store room contained a dried brown spill under a bottle of Worcestershire sauce with an inadequate lid, expired milk, and undated, unlabeled cups with a milky liquid. Additionally, there were dried pink puddles and yellow splatters inside the refrigerator, and the temperature logs were incomplete for November 2024. A bulk sugar bag was improperly stored, not secured in an airtight container. Further inspection revealed a cooler with cloudy water and food items floating in it, which had not been used since a cook started working on November 26, 2024. The administrator acknowledged that the stationary refrigerator had been out of service since November 28, 2024, and a portable cooler was used during this time. The administrator also noted the importance of keeping the kitchen door closed to prevent pest entry and expressed expectations for the refrigerators to be clean and sanitary. The facility's food storage policy from 2020 outlines guidelines for proper food labeling, storage, and disposal, which were not adhered to in this instance.
Failure to Hold Quarterly QAPI Meetings
Penalty
Summary
The facility failed to hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings, which is a requirement to ensure quality care for all residents. The administrator, who began her role in July 2024, was unable to provide documentation of QAPI meetings for January 2024 and April 2024. During the survey, no meeting minutes or attendance sheets were found, and the facility could not provide evidence that these meetings were scheduled or occurred. The facility's QAPI Plan, revised in October 2022, mandates that the committee meet at least quarterly, with minutes and attendance records maintained in the administrator's office. This deficiency has the potential to affect all 48 residents residing in the facility.
Failure to Notify Resident's Representative of Hospital Transfers
Penalty
Summary
The facility failed to notify the resident's representative in writing about hospital transfers for a resident who was reviewed for hospitalizations. The resident, who is [AGE] years old, was initially admitted to the facility on 08/27/2021. According to the nurse's notes, the resident was sent to the local emergency department on 09/11/2024 due to an episode of choking and was later admitted to the local hospital on 11/11/2024 with a diagnosis of preseptal cellulitis. On 12/13/2024, the facility administrator acknowledged the absence of bed hold or discharge notices for the resident's hospital transfers on the specified dates and was unsure why the resident's representative was not notified, despite the facility's typical practice of sending such notifications.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident's representative in writing of the bed hold policy during transfers to a hospital. This deficiency was identified for a resident who was initially admitted to the facility on August 27, 2021. The resident, aged [AGE], was transferred to a local emergency department on September 11, 2024, due to an episode of choking and was later admitted to a hospital on November 11, 2024, with a diagnosis of preseptal cellulitis. During an interview on December 13, 2024, the facility's administrator acknowledged the absence of bed hold notifications for the specified dates and expressed uncertainty about why the resident's representative was not informed. The facility's policy, revised on September 16, 2017, mandates that the bed hold policy be provided to the resident or their representative at the time of transfer, which was not adhered to in this case.
Inaccurate MDS Coding Due to PASRR Miscommunication
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident, identified as R21, who was part of a sample of 24 residents reviewed for assessment accuracy. R21's admission record indicated multiple diagnoses, including schizophrenia, depression, unspecified dementia, essential hypertension, anxiety disorder, and hyperlipidemia. The Preadmission Screening and Resident Review (PASRR) Level I and Level II outcomes documented that R21 was referred for a Level II onsite review and was determined to be excluded from PASRR due to a primary neurocognitive disorder with no loss of consciousness. However, the MDS assessment dated 11/15/2024 incorrectly marked the PASRR question as 'No,' indicating that R21 was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite having an active diagnosis of schizophrenia. The Licensed Practical Nurse (LPN) responsible for completing the MDS for R21 stated that she was unaware of R21's Level II PASRR status at the time of the assessment. The LPN had only been in the role for a few weeks and was not informed that R21 had a Level II PASRR. The Director of Nursing (DON) expressed that it is her expectation for MDS assessments to be coded accurately. This oversight in communication and documentation led to the inaccurate coding of the MDS assessment for R21, highlighting a deficiency in the facility's assessment process.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide necessary toileting assistance to a resident, identified as R33, who was dependent on staff for activities of daily living, including toileting. R33, who has diagnoses of Parkinsonism, Diabetes Mellitus Type 2, and Dementia, was observed in a wheelchair for extended periods on two consecutive days without receiving appropriate peri care or repositioning. On the second day, R33 reported that he had not been to the bathroom since 5 AM, and it was noted that he remained in his wheelchair without being checked or changed until the afternoon. During the afternoon of the second day, R33 was finally transferred to bed, and peri care was provided. It was observed that R33's adult brief was saturated with foul-smelling urine, indicating a lack of timely incontinence care. The CNAs involved, V5 and V6, admitted to not checking or changing R33 due to being pulled to work in other areas or starting their shifts later in the day. The facility's policy, as stated by the Administrator, requires residents to be checked every two hours for toileting or peri care, which was not adhered to in this case.
Failure to Implement Restorative Program for Resident with Limited Mobility
Penalty
Summary
The facility failed to implement appropriate treatment and services for a resident with limited range of motion (ROM) to maintain or improve their mobility. The resident, identified as R33, has a medical history that includes Parkinsonism, Diabetes Mellitus Type 2, and Dementia, and is dependent on staff for various activities of daily living. The resident's care plan, revised on 7/11/24, aimed to prevent complications related to immobility, such as contractures and skin breakdown. However, observations and staff interviews revealed that the facility did not have an active restorative program, and residents, including R33, were not receiving daily ROM exercises as required. On multiple occasions, R33 was observed in a state that indicated neglect of care. The resident was seen sitting in a wheelchair with soiled clothing and a cluttered room, and reported not being repositioned or toileted for extended periods. Staff members acknowledged the absence of a restorative program for two years, which contributed to the resident's stiffness and lack of mobility exercises. The facility's Restorative Nursing Program policy, last revised in 2019, outlines the need for individualized programs to maintain or regain residents' independence, but this was not being implemented for R33, leading to the deficiency noted in the report.
Failure in Communication and Dietary Provision for Dialysis Resident
Penalty
Summary
The facility failed to maintain effective communication and collaboration with an offsite dialysis center for a resident with end-stage renal disease (ESRD) who requires dialysis. The resident, who is cognitively intact, reported that she no longer has a permanent dialysis access site in her arm and only has a catheter in her chest, which is managed by the dialysis center to prevent infection. The resident also mentioned that she was prescribed a medication by her nephrologist at the dialysis center about a month ago, but had not received it. The Director of Nursing (DON) was unaware of the current order for the phosphorous binder, which had been discontinued previously, and acknowledged the poor communication between the facility and the dialysis center. The dialysis center's registered nurse confirmed multiple attempts to communicate the new order for the phosphorous binder to the facility, including phone calls and a fax, but no follow-up was conducted by the facility to ensure the order was received and implemented. Additionally, the resident's dietary needs were not met, as she did not receive the prescribed double protein portions with her meals, despite it being listed on her meal card. Observations confirmed that the resident received only single portions of protein at meals, and the only snacks she received were those she kept in her room.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to implement a gradual dose reduction (GDR) for a resident who was receiving lorazepam 0.5 mg twice daily. The resident, who was admitted to the facility with multiple diagnoses including major depressive disorder and generalized anxiety disorder, had been on lorazepam since October 2023. A company consultant recommended a GDR to reduce the dosage to 0.5 mg at bedtime, which was accepted by the nurse practitioner. However, the resident's power of attorney (POA) opposed the reduction, and the registered nurse (RN) documented this opposition without notifying the physician that the medication was not reduced. The facility's policy requires that residents on psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated, with attempts encouraged at least twice yearly. Despite this policy, the RN stated that the facility does not reduce medication if the family opposes it. The resident's behavior tracking record showed no behaviors that would contraindicate a GDR, yet the reduction was not pursued due to the POA's wishes. This inaction led to the deficiency as the facility did not adhere to its policy or notify the physician of the POA's decision.
Medication Error: Eliquis Administered Despite Discontinuation Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Eliquis, an anticoagulant medication. The resident, who was admitted to the facility with multiple diagnoses including chronic obstructive pulmonary disease, major depressive disorder, unspecified dementia, and chronic diastolic heart failure, returned from the hospital with orders to discontinue Eliquis due to a positive occult blood test and anemia. Despite this, the medication was administered from the beginning of November until the error was discovered on November 8th. The error was identified by a registered nurse who was preparing the resident's medication and noticed the discontinuation order. The Assistant Director of Nursing, responsible for verifying medication administration records, admitted to missing the discontinuation order. The Director of Nursing was informed of the error but did not complete a medication error report. The facility's policy requires medications to be administered according to prescriber's written orders, which was not adhered to in this case.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control protocols for two residents, R197 and R33, as observed during a survey. R197, a resident with multiple medical conditions including pressure ulcers and a suprapubic catheter, was not placed under enhanced barrier precautions despite having open wounds and an indwelling catheter. During a wound care session, a registered nurse and a certified nurse aide entered R197's room without donning personal protective equipment (PPE) and proceeded to perform wound care without following the enhanced barrier precautions. The facility's policy required the use of PPE during high-contact activities for residents with chronic wounds or indwelling devices, but this was not followed, leading to a deficiency in infection control practices. For R33, a resident with parkinsonism, diabetes, dementia, and hypertension, the facility failed to maintain proper infection control during a suctioning procedure. When R33 began coughing and required suctioning, the registered nurse found the suction machine without necessary components and had to leave the room to retrieve them. Upon returning, the nurse inadvertently contaminated the yankeur by hitting it against the wall but continued to use it for oral suctioning. The Director of Nursing later stated that the expectation was to discard and replace contaminated equipment, but the facility lacked a specific policy on suctioning procedures, contributing to the deficiency.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide a sufficient number of dietary staff to ensure meals were served at the designated meal times, affecting all 29 residents. Observations revealed that breakfast service began late at 7:25 am, with only two dietary workers, including the Dietary Manager, present in the kitchen. Several residents were still without trays at 7:35 am, and some were served on Styrofoam plates and bowls. Lunch service also started late at 11:50 am, with only two dietary workers, and trays were still being served at 12:30 pm. On another occasion, lunch trays were served at 11:42 am with three dietary workers present. Interviews with residents and staff confirmed the issue of meals being served late. Residents reported that breakfast and other meals were often delayed. The Dietary Manager stated difficulties in retaining staff, as many do not pass background checks, and mentioned using Styrofoam bowls due to limited staff. CNAs also reported frequent delays in meal service due to inadequate kitchen staffing. The Director of Nursing acknowledged the issue, noting that the facility had been cited for it before, and part of their plan of correction involved her assisting with breakfast service, although the kitchen was often not ready. The dietary schedule for July showed only four employees, including the manager, working in the kitchen.
Meal Service Delays Due to Staffing Issues
Penalty
Summary
The facility failed to serve meals at designated meal times, affecting all 29 residents. Observations revealed that breakfast service began late at 7:25 am, with some residents still without trays at 7:35 am. Lunch service also started late, with trays being served inconsistently, causing some residents to finish their meals while others were still waiting. The use of Styrofoam plates and bowls was noted, attributed to insufficient kitchen staff. Interviews with residents and staff confirmed that meals were frequently late, with breakfast being consistently delayed. The Dietary Manager acknowledged the use of Styrofoam due to limited staff, and the Director of Nursing admitted that meals were not served on time, a recurring issue for which the facility had been previously cited. Staff members, including CNAs, reported that meal delays were often due to inadequate kitchen staffing. Residents expressed dissatisfaction with the timeliness of meal service, with some stating that meals were never timely, especially when served in their rooms.
Facility Fails to Serve Meals on Time Due to Staffing Shortages
Penalty
Summary
The facility failed to serve meals according to their designated schedule, which has the potential to affect all 27 residents living there. The Meal Time Policy, dated June 2006, specifies that breakfast should begin at 7:00 am, lunch at 11:30 am, and supper at 5:00 pm. However, observations on 5/28/24 revealed that lunch service did not start until 11:55 am, 25 minutes past the scheduled time. Interviews with the Dietary Manager confirmed that meals are usually late, and the kitchen is understaffed, needing three additional cross-trained staff members. Family members and residents reported that meals are consistently served late. A family member of a resident stated that lunch is typically served between 12:15 pm and 12:30 pm, making it difficult to plan visits. Residents also confirmed that meals are late due to insufficient kitchen staff. On 5/29/24, breakfast was reported to be 30 minutes late because only one staff member was working in the kitchen. The Director of Nurses confirmed that all 27 residents rely on meals from the facility kitchen.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving three residents, R4, R6, and R9. R4 reported an incident where R9 allegedly shoved his chair into her, causing a small discoloration on her forearm. Despite R4's report, the administrator, V1, did not initiate an investigation, dismissing the incident as unwarranted and attributing R4's behavior to being problematic. R6 reported an incident involving a CNA, V9, who allegedly screamed and cursed at her over a snack request. Although an investigation was initiated, it was incomplete as it did not include interviews with all involved staff, particularly V8, who was also accused of being mean to R6. V1 admitted to not suspending or investigating any staff other than V9. Additionally, the facility's abuse investigation included anonymous staff interviews that reported staff denying residents showers and leaving them in bed for meals. However, V1 did not investigate these anonymous reports further, believing they did not warrant an investigation. The facility's Abuse Prevention Program policy mandates thorough investigations of all reports, including anonymous ones, to prevent mistreatment, neglect, or abuse. The failure to investigate these allegations thoroughly and in accordance with the facility's policy constitutes a deficiency in handling abuse allegations.
Failure to Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment according to physician's orders for a resident with multiple medical conditions, including Diabetes Type 2, Anxiety Disorder, Depression, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Hypertension. The resident had two Stage 2 pressure injuries upon admission. The physician's orders required specific wound care treatments to be administered every 12 hours and as needed. However, the Treatment Administration Record (TAR) indicated that these treatments were only performed once daily over a period of several days. This discrepancy was due to an error made by the Director of Nurses when transcribing the orders from the Physician's Order Sheet (POS) to the TAR, resulting in inadequate care for the resident's pressure ulcers.
Failure to Monitor Resident's Food Intake
Penalty
Summary
The facility failed to adequately monitor the food intake of a resident with a history of weight loss. The resident, who had been diagnosed with several conditions including Diabetes Type 2, Anxiety Disorder, Depression, Hypertension, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease, experienced significant weight loss from February to May 2024. The resident's care plan identified a risk of weight loss due to a preference for not eating at times and occasionally ordering food independently. However, the facility's documentation of the resident's meal intake was incomplete for several days in May 2024. The deficiency was attributed to a lack of proper documentation procedures and staff assignment. The Dietary Manager, responsible for placing meal intake sheets in the binder, delayed this task due to staffing issues, resulting in missing documentation for the first two days of May. Additionally, CNAs were not specifically assigned to document meal intakes, leading to further gaps in records. The Director of Nurses confirmed that all meal intakes should be documented, as per the facility's policy, but this was not consistently done, contributing to the oversight in monitoring the resident's nutritional intake.
Failure to Provide 8 Hours of Daily RN Coverage
Penalty
Summary
The facility failed to provide 8 hours of daily Registered Nurse (RN) coverage, which has the potential to affect all 27 residents residing in the facility. On 5/15/24 at 11:00am, the Administrator acknowledged the shortage of RNs and admitted there were times when the facility did not meet the required 8 hours of RN coverage. The Director of Nurses also confirmed the ongoing efforts to recruit more RNs. A review of the nursing staff schedules for March, April, and May 2024 revealed specific dates (3/2/24, 3/30/24, 4/6/24, 5/4/24, and 5/12/24) when the facility did not have the required RN coverage. The Midnight Census Report Form dated 5/14/24 documented that 27 residents were residing in the facility, with one resident in the hospital.
Failure to Ensure Regular Physician Visits
Penalty
Summary
The facility failed to ensure that the physician visited and examined residents at least once every 30 days for the first 90 days after admission or at least once every 60 days thereafter. This deficiency was observed in three residents (R1, R2, and R3) out of a sample of seven. R1, who has multiple diagnoses including congestive heart failure and diabetes, was only seen by the physician on two occasions, with the last visit documented almost a year ago. R1 reported seeing the Nurse Practitioner (NP) regularly but not the physician. Similarly, R2, who has conditions such as cellulitis and chronic kidney disease, had no documentation of being seen by the physician since the previous Medical Director left. R2 also confirmed seeing the NP but not the physician. R3, with diagnoses including Parkinson's disease and bipolar disorder, also had no documentation of recent physician visits and reported seeing the NP regularly instead of the physician. Interviews with the facility staff, including the Administrator, Director of Nurses (DON), and the Licensed Practical Nurse (LPN), confirmed that the physician had not been visiting the facility regularly. The Medical Director admitted to not visiting the facility for a long time due to non-payment issues. The NP, who visits the facility about every other week, confirmed that she works under a different physician and has limited interaction with the Medical Director. The facility's Medical Director Agreement explicitly requires the physician to visit residents and review their medical conditions as needed, which was not being adhered to.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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