Bloomington Rehabilitation & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Illinois.
- Location
- 1925 South Main Street, Bloomington, Illinois 61701
- CMS Provider Number
- 145610
- Inspections on file
- 43
- Latest survey
- January 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bloomington Rehabilitation & Hcc during CMS and state inspections, most recent first.
A facility failed to conduct proper pressure ulcer risk assessments and aseptic wound care for a resident. The resident's TAR showed inconsistent documentation of skin checks and wound care, with missing records and assessments. An LPN did not maintain aseptic technique during wound care, failing to perform hand hygiene and improperly handling wounds. The Assistant Director of Nursing confirmed these protocol lapses, contributing to the deficiency.
A facility failed to follow Enhanced Barrier Precautions during wound care for a resident with wounds. The policy required the use of gowns and gloves for high-contact care activities. An LPN performed wound care without a gown or mask, despite the presence of PPE and signage indicating the need for full PPE. The LPN acknowledged the oversight, and the Infection Preventionist confirmed the requirement for full PPE.
A resident in an LTC facility reported $305 missing from his coat pocket after receiving the money from his sister. The resident, who is cognitively intact and dependent on staff for transfers, expressed distrust in the facility's ability to safeguard his belongings. Despite an investigation, the money was not recovered, leading to the resident feeling distraught and angry.
A resident, who is wheelchair-bound and dependent on staff for transfers, fell forward out of their wheelchair and sustained a subarachnoid hemorrhage after a staff member pushed the wheelchair too fast through a doorway. The wheelchair wheel hit the door frame due to a gap in the ramp, causing the fall. The resident was taken to the emergency room for treatment.
A resident's cell phone, wallet, and checks went missing, but the facility failed to report the potential misappropriation to the state surveying agency or police. The resident, with a history of heart disease and other conditions, required modified independence. The facility's policy mandates reporting such incidents, but no documentation or investigation was found.
A resident with cognitive issues and multiple medical conditions reported missing a cell phone, wallet, and checks. The facility failed to investigate the potential misappropriation of these items, as required by its abuse policy. The administrator could not find any documentation of an investigation, highlighting a deficiency in the facility's response to the incident.
A resident reported missing money from their wallet multiple times, but the facility failed to report the allegations to the State Agency and local law enforcement in a timely manner. Despite the Administrator's awareness of the situation, the required reporting was not completed as per the facility's abuse prevention policy.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 37 residents. The Dietary Manager, V10, lacked necessary qualifications and experience, and the facility Dietician worked only one day per month. The survey revealed failures in preventing cross-contamination, labeling TCS food, and maintaining sanitary food storage. The facility's assessment highlighted the need for a full-time qualified nutrition professional.
The facility failed to maintain sanitary conditions in the kitchen, with biological growth on the ice machine, unlabeled food items, and soiled equipment. The ice machine had pink-colored growth in contact with ice, and the ice scoop had mildew. Opened deli meats were not labeled with use-by dates, and the can opener was dirty. Nutritional shakes were stored on a sticky cooler floor. These issues could affect all 37 residents.
The facility did not develop a comprehensive water management plan to prevent Legionella and other pathogens, affecting 37 residents. The plan lacked a risk assessment, testing protocols, and adherence to ASHRAE and CDC guidelines. The administrator and maintenance director confirmed the absence of necessary policies and assessments.
The facility failed to document resident infections and antibiotic treatments, affecting all 37 residents. The Antibiotic Stewardship Policy lacked CDC's Core Elements, and the stewardship binder from January to September 2024 did not document clinical responses, cultures, or infection trends. The DON confirmed documentation should be in the binder, but no standardized tool was used to assess antibiotic need.
The facility failed to maintain the dignity of two residents by allowing their catheter bags to be visible to others. One resident, with severe cognitive impairment, was seen with their catheter bag unsecured in a dignity bag while moving through the hallway. Another resident, who was cognitively intact, expressed dissatisfaction with their catheter bag being visible and stated that staff often forget to place it in a privacy bag. An LPN and the facility administrator confirmed the oversight, acknowledging it as a resident rights issue.
A facility failed to accurately complete a comprehensive assessment for a resident, as the assessment incorrectly documented insulin administration despite no physician orders for insulin. The resident's insulin was discontinued upon starting hospice services, a fact confirmed by a registered nurse. The facility administrator noted adherence to the Resident Assessment Instrument (RAI) for assessments, highlighting a documentation lapse.
The facility failed to provide scheduled showers and timely toileting assistance for two residents. One resident, dependent on staff due to multiple medical conditions, received only one documented shower despite being scheduled for two per week. Another resident with Spastic Quadriplegic Cerebral Palsy experienced toileting accidents due to delays in staff assistance during meal service, as staff cited insufficient staffing to promptly meet the resident's needs.
A resident with multiple medical conditions did not consistently receive prescribed treatments, including antifungal and hydrocortisone applications, as per physician orders. The LPN and facility administrator confirmed the treatments were not administered on numerous days, violating the facility's documentation policy.
The facility failed to provide catheter care and obtain physician orders for three residents with indwelling catheters. Despite having orders for catheter care every shift, documentation showed multiple instances where care was not provided. Staff confirmed the absence of physician orders and inconsistent documentation, contrary to the facility's catheter care policy.
A facility failed to provide nutritional supplementation as ordered for a resident at nutritional risk with protein-calorie malnutrition. Despite the care plan indicating the need for supplements three times a day, the resident reported receiving them only occasionally. An observation confirmed the absence of the supplement during a meal.
The facility failed to change the oxygen tubing and humidifier bottles for two residents as required. Both residents, who were receiving oxygen therapy, had their equipment undated and uninitialed, with no documentation of changes in the Treatment Administration Record. An LPN confirmed the lack of adherence to the facility's policy, which mandates weekly changes and dating of oxygen tubing.
A facility failed to conduct psychotropic medication assessments and implement non-pharmacological interventions for a resident with Schizoaffective Disorder and Borderline Personality Disorder. The resident was prescribed multiple psychotropic medications without documented assessments, behavior tracking, or side effect monitoring. Staff interviews confirmed the absence of necessary documentation and interventions, contrary to the facility's protocol.
The facility failed to educate and offer pneumococcal and influenza vaccines to three residents, despite CDC recommendations and facility policies. A resident with multiple health conditions was not offered a pneumococcal vaccine since 2021, another since 2022, and a third resident lacked documentation for the 2023 influenza vaccine. The DON confirmed the absence of necessary documentation.
A resident with Spastic Quadriplegic Cerebral Palsy was found using a wheelchair missing a right-side armrest, exposing the steel frame. The resident reported the issue to staff, but it remained unresolved for several days.
The facility failed to follow its infection control policy by not testing all residents within 24 hours of COVID-19 exposure and not ensuring staff wore appropriate PPE when caring for COVID-19 positive residents. This led to a delay in testing and potential exposure to all 36 residents.
The facility failed to have a qualified infection preventionist on staff, which is essential for managing the infection prevention and control program. Despite being in outbreak status, the facility, housing 36 residents, lacked both a Director of Nursing and an Infection Preventionist. This deficiency was confirmed through interviews and record reviews, highlighting the absence of designated personnel to oversee critical infection control functions.
A facility failed to notify a resident's emergency contact of significant changes in the resident's medical condition and treatment plan. The resident, who was severely cognitively impaired, had new physician orders for a swallow evaluation and a chest X-ray due to possible aspiration. Despite these changes and a hospital visit for a malfunctioning G-Tube, the resident's responsible party was not informed, contrary to facility protocol.
A facility failed to supervise a resident with a physician order for NPO status, resulting in multiple incidents of the resident consuming food and liquids. The resident, with severe cognitive impairment and a history of swallowing problems, was not adequately monitored, leading to several documented instances of eating and drinking against medical orders. Staff interviews confirmed the need for close supervision to prevent potential health risks.
A facility failed to follow G-Tube medication and feeding guidelines for a resident with severe cognitive impairment, not checking tube placement or elevating the head of bed as required. The RN used a syringe instead of gravity for administration. Additionally, the facility did not consistently weigh the resident, missing weekly weight checks, which hindered nutritional assessments.
A resident with a G-Tube was not placed on Enhanced Barrier Precautions (EBP) upon admission, and a nurse administered medication and feeding without wearing appropriate PPE. The facility lacked EBP signage and supplies, contrary to its policy requiring gown and gloves for high-contact activities involving medical devices.
The facility failed to provide wound dressing changes and skin checks according to physician orders, affecting two residents. One resident experienced maggot infestations in their foot wounds due to missed dressing changes and skin checks, while another resident had incomplete treatments for a heel wound. Nursing staff interviews indicated that undocumented treatments were likely not completed, contributing to the deficiencies.
A facility failed to provide necessary supervision and safety measures for two residents, leading to serious injuries. One resident, on anticoagulant therapy, was left unsupervised in the bathroom and suffered a subdural hematoma after a fall. Another resident, with a history of substance use, was allowed unsupervised outings with a broken walker, resulting in a fracture. The facility did not update care plans or conduct proper safety assessments, contributing to these incidents.
A facility failed to clarify and accurately transcribe medication orders for a resident, leading to discrepancies in insulin administration and blood glucose monitoring. The resident's hospital discharge orders were not fully implemented, and conflicting instructions from a family member were followed without physician clarification. The DON acknowledged that agency and staff nurses did not seek necessary clarifications, resulting in a breakdown of the medication administration process.
A resident admitted with complex medical needs did not receive any prescribed medications during their stay due to procedural failures. Despite prior notice of the admission, the facility did not ensure medication delivery, citing timing and staffing issues. The DON and LPN acknowledged the lack of follow-through in obtaining necessary medications.
Failure in Pressure Ulcer Care and Aseptic Technique
Penalty
Summary
The facility failed to implement proper pressure ulcer risk assessments and aseptic techniques during wound care for a resident identified as R4. The facility's guidelines required a full body skin check, Braden assessment, and nutritional assessment upon admission, with pressure ulcer risk assessments to be completed within the first four weeks. However, R4's Treatment Administration Record (TAR) showed inconsistent documentation of daily skin checks and wound care, with several dates missing signatures indicating that assessments and treatments were not completed as ordered. Additionally, R4's wound care TAR for December 2024 could not be located, and the Assistant Director of Nursing confirmed the absence of skin assessments and pressure ulcer risk assessments in R4's medical record. During an observation of wound care, a Licensed Practical Nurse (LPN) identified as V6 failed to maintain aseptic technique. V6 did not perform hand hygiene between tasks, set clean wounds on the bed, and applied medicated honey with her gloved fingers, which had touched other wounds. V6 also did not have R4's treatment orders present during the procedure, leading to uncertainty about whether the care was provided according to orders. The Assistant Director of Nursing confirmed these lapses in protocol, including the lack of hand hygiene and the improper handling of wounds, which contributed to the deficiency in providing appropriate pressure ulcer care.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during wound care for a resident, identified as R4, who was part of a sample of five residents reviewed for EBP compliance. The facility's policy, revised in April 2024, mandates the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices, regardless of MDRO colonization. On January 24, 2025, a Licensed Practical Nurse (LPN), identified as V6, performed wound care on R4 without donning a gown or mask, despite the presence of an isolation cart with PPE and an enhanced barrier sign indicating the need for full PPE. V6 acknowledged the oversight, confirming that only gloves were worn during the procedure. The Infection Preventionist, identified as V3, verified that full PPE should have been used during the wound care.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of funds, resulting in the resident feeling distraught, fearful, and angry. The incident involved a resident who was cognitively intact and dependent on staff for transfers, with medical diagnoses including Type 2 Diabetes, Anxiety, Congestive Heart Failure, Major Depression, and a Neuromuscular Disorder. The resident reported that $305 cash was missing from his coat pocket after being given the money by his sister during a visit. The resident expressed distrust in the facility's ability to keep his money safe, opting to keep it in his coat pocket instead. The resident's sister confirmed giving him $325, including three $100 bills, and expressed concerns about theft within the facility. A staff member, V7, acknowledged seeing the resident with the money and noted that the resident did not trust the facility to safeguard his belongings. The Social Service Director, V6, confirmed that the money was reported missing and an investigation was initiated, but the money was never found. The facility's failure to prevent the misappropriation of the resident's funds led to the resident's distress and loss of trust in the care environment.
Resident Falls from Wheelchair Due to Unsafe Transport
Penalty
Summary
The facility failed to safely transport a resident in a wheelchair, resulting in the resident falling forward and sustaining a subarachnoid hemorrhage. The incident involved a resident who is cognitively intact, uses a manual wheelchair, and is dependent on staff for transfers. The resident has a medical history that includes Type 2 Diabetes, Anxiety, Congestive Heart Failure, Major Depression, and a Neuromuscular Disorder. On the day of the incident, the Social Service Director was pushing the resident in a wheelchair through a doorway when the wheelchair wheel hit the door frame, causing the resident to fall forward onto the ground. The resident reported that the staff member was pushing the wheelchair too fast, and the wheel slipped off the ramp ledge into the door frame. The doorway ramp was in need of repair, which contributed to the accident. The resident was transported to the emergency room, where a head CT scan confirmed an acute subarachnoid hemorrhage. The facility's Fall Prevention Program/Protocol was in place to guide staff in preventing falls, but the incident indicates a failure to adhere to safe transport practices, resulting in the resident's injury.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of potential misappropriation of property to the state surveying agency, affecting one resident. The facility's abuse policy mandates that all allegations of abuse, including misappropriation of property, be reported immediately to the Administrator and timely to the proper authorities. However, in this case, the facility did not report the missing items of a resident, which included a cell phone, wallet, and checks, to the state surveying agency or the police. The resident involved had a medical history of heart disease, shortness of breath, spinal stenosis, orthostatic hypotension, repeated falls, and major depression, and required modified independence due to cognition. The resident's secretary and a registered nurse confirmed the missing items, and the current Administrator acknowledged the lack of documentation and investigation regarding the missing items. The Administrator confirmed that such allegations should have been reported and investigated as potential theft or misappropriation.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to investigate a potential misappropriation of property involving a resident, identified as R3, who was missing a cell phone, wallet, and checks from his checkbook. The facility's abuse policy mandates that all allegations of abuse, including misappropriation of property, be immediately and thoroughly investigated. However, despite the policy, there was no documentation or evidence of an investigation into the missing items, except for the wallet, which was found in the laundry. The facility's administrator at the time of the survey could not confirm whether an investigation had been conducted, as he was not in the position when the incident occurred. R3, who has a medical history including heart disease, shortness of breath, spinal stenosis, orthostatic hypotension, repeated falls, and major depression, requires modified independence due to cognitive issues. Interviews with R3's secretary and a registered nurse confirmed the missing items and the lack of investigation. The failure to investigate and document the incident as potential theft or misappropriation represents a deficiency in the facility's adherence to its abuse policy and state reporting requirements.
Failure to Report Allegation of Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's property to the State Agency and local law enforcement in a timely manner. This deficiency involved a resident, referred to as R2, who reported having money missing from his wallet on multiple occasions. R2, who has been residing in the facility for about three years, mentioned that he had experienced missing money three times, with two incidents occurring in the last month. Despite informing various staff members, including the Social Services Director and a Registered Nurse, the resident's allegations were not consistently documented or reported to the appropriate authorities. The Administrator, identified as V1, acknowledged awareness of the allegations but did not report them to the Illinois Department of Public Health (IDPH) or the police as required by the facility's abuse prevention policy. The policy mandates immediate reporting of any alleged violations involving mistreatment, exploitation, neglect, or abuse, including misappropriation of resident property, to the administrator and other officials in accordance with state law. The failure to report the allegations within the stipulated timeframe of 24 hours after forming suspicion constitutes a breach of the facility's policy and regulatory requirements.
Facility Lacks Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 37 residents. The Dietary Manager, identified as V10, was observed supervising dietary operations but admitted to not being a clinically qualified Certified Dietary Manager or having equivalent training. V10 did not meet the State of Illinois standards to be a Food Service Manager or Dietary Manager and reported that the facility Dietician only works one day per month. V10 also confirmed not having the necessary qualifications or experience required for the position, such as being a Dietician, a Certified Dietary Manager, or having an associate's or higher degree in food service management or hospitality. During the survey conducted from 9/15/2024 to 9/17/2024, the facility was found to have failed in several areas related to food safety and sanitation. These included failing to prevent direct cross-contamination of ice, failing to date and label time/temperature control for safety (TCS) food, failing to prevent potential physical cross-contamination of food, and failing to maintain sanitary food storage equipment. The facility's assessment from 4/26/2024 documented the need for a full-time Dietician or other clinically qualified nutrition professional to serve as the Director of Food and Nutrition Services to provide competent support and care for the resident population every day and during emergencies.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitary conditions in the kitchen, leading to potential cross-contamination and food safety issues. Observations revealed that the kitchen ice machine had a shiny, pink-colored biological growth along the condenser cover, which was in direct contact with the ice. This condition persisted over several days, despite the Dietary Manager's acknowledgment that maintenance staff were responsible for cleaning the machine every three months. Additionally, a plastic ice scoop stored in a caddy on top of the ice machine was found with mildew growth, which the Dietary Manager confirmed should have been cleaned by the dietary staff. Further inspection of the kitchen revealed that opened packages of bologna and cubed ham in the reach-in cooler were not labeled with the date or time opened, nor a use-by date, which is necessary for ensuring food safety. The Dietary Manager admitted that the ham should have been labeled and needed to be discarded. The kitchen's table-mounted can opener was also found to be excessively soiled with metal shavings and sticky food debris. Moreover, individual servings of nutritional shakes were stored in a metal bin on the floor of the cooler, surrounded by sticky orange and red deposits, indicating a lack of cleanliness. These deficiencies have the potential to affect all 37 residents residing in the facility.
Failure to Develop Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to develop a comprehensive water management plan to mitigate the risk of Legionella and other pathogens in its water system, potentially affecting all 37 residents. During an interview and record review, it was found that the facility's water management plan was undated and lacked documentation of a required risk assessment for the water system. The plan did not consider the ASHRAE standard or the CDC Water Management Program toolkit, nor did it identify specific testing protocols, acceptable control measure ranges, or corrective actions for maintaining control limits. The facility's administrator confirmed the absence of additional policies or records related to Legionella or waterborne infection prevention. Furthermore, the maintenance director reported that no water system survey or risk assessment had been completed, and no written policies for waterborne infection prevention had been developed.
Deficiency in Antibiotic Stewardship Documentation
Penalty
Summary
The facility failed to document resident infections and antibiotic treatments as required, which has the potential to affect all 37 residents in the facility. The facility's Antibiotic Stewardship Policy/Procedure, revised in December 2023, outlines the mission of promoting appropriate antibiotic use to treat infections and reduce adverse events. However, the policy did not list the Core Elements of Antibiotic Stewardship in Long Term Care as defined by the CDC. The facility's antibiotic stewardship binder, containing monthly Resident Infection Control and Antimicrobial Logs from January 2024 through September 2024, lacked documentation of residents' clinical responses or resolutions of infections after beginning antibiotic therapy. Additionally, there was no documentation of whether cultures were obtained, testing was done to confirm infections, or any trends in infections were identified. The Director of Nursing confirmed that all documentation related to antibiotic use, tracking, and cultures should be in the antibiotic stewardship binder. Despite this, the records failed to document any attempts to use a standardized tool to determine the need for antibiotic use. The facility's failure to ensure antibiotic prescriptions were limited to residents meeting nationally recognized surveillance criteria and to document residents' responses to antibiotic therapy indicates a significant deficiency in their antibiotic stewardship program.
Failure to Maintain Resident Dignity with Visible Catheter Bags
Penalty
Summary
The facility failed to maintain the dignity of residents by allowing catheter bags to be visible to other residents, visitors, and staff. This deficiency was observed in two residents, one with severe cognitive impairment and another who was cognitively intact. The first resident, who has a history of cognitive communication deficit, dementia, Alzheimer's disease, and urinary retention, was seen propelling down the hallway with their catheter bag unsecured in a dignity bag, making it visible to others. The second resident, with chronic kidney failure and urological trauma, expressed dissatisfaction with their catheter bag being visible and stated that staff often forget to place it in a privacy bag. The observations were confirmed by a Licensed Practical Nurse (LPN) who acknowledged that both residents' catheter bags were not placed in dignity bags, thus visible to everyone. The facility administrator also confirmed that catheter bags should be placed in dignity bags at all times to ensure privacy and acknowledged this as a resident rights issue. The report highlights the failure of the facility to uphold the residents' rights to privacy and dignity as outlined by the Illinois Long-Term Care Ombudsman Program.
Inaccurate Comprehensive Assessment for a Resident
Penalty
Summary
The facility failed to accurately complete a comprehensive assessment for a resident, identified as R24. The deficiency was identified through interviews and record reviews, revealing discrepancies in R24's medical documentation. Specifically, R24's comprehensive assessment, dated on a certain date, inaccurately documented that the resident had received insulin for the past seven days. However, the August 2024 Physician Order Sheet for R24 did not include any orders for insulin. Further investigation showed that R24's insulin was discontinued when the resident began receiving hospice services on May 17, 2024. This was confirmed by a registered nurse, V8, during an interview. The facility administrator, V1, stated that the facility follows the Resident Assessment Instrument (RAI) to complete comprehensive assessments, indicating a lapse in the accurate documentation process for R24's assessment.
Failure to Provide Scheduled Showers and Timely Toileting Assistance
Penalty
Summary
The facility failed to provide scheduled showers and timely toileting assistance for two residents, R7 and R2, respectively. R7, who is totally dependent on staff due to multiple medical conditions including bilateral leg amputations, reported receiving only one shower and a few bed baths since admission. Despite being scheduled for two showers per week, documentation showed only one shower was recorded, with no records of bed baths or refusals. The facility's policy requires documentation of showers, bed baths, and refusals, which was not adhered to in R7's case. R2, diagnosed with Spastic Quadriplegic Cerebral Palsy, requires substantial assistance for toileting. R2 reported experiencing toileting accidents due to delays in staff assistance while in the dining room. Staff reportedly declined R2's requests for toileting assistance during meal service, citing insufficient staffing to accommodate R2's needs promptly. This lack of timely assistance led to R2's discomfort and dissatisfaction with the care provided.
Failure to Administer Prescribed Treatments
Penalty
Summary
The facility failed to follow physician orders and administer prescribed treatments for a resident, identified as R7, who was admitted with multiple medical diagnoses including sepsis, dysphagia, muscle weakness, and morbid obesity. R7 was cognitively intact but totally dependent on staff for activities of daily living. The physician's orders required the application of antifungal powder and hydrocortisone cream to specific areas twice a day. However, observations and interviews revealed that these treatments were not consistently administered, as confirmed by the resident and the facility's Treatment Administration Record (TAR). The Licensed Practical Nurse (LPN) acknowledged that the treatments were not completed on numerous days in September, which was corroborated by the Medication Administration Record (MAR). The facility's administrator confirmed the deficiency, stating that all residents should receive their prescribed treatments, and these should be documented in the TAR. The facility's charting and documentation policy mandates that all services provided to residents be documented to facilitate communication among the interdisciplinary team, but this was not adhered to in R7's case.
Failure to Provide Catheter Care and Obtain Physician Orders
Penalty
Summary
The facility failed to provide appropriate catheter care and obtain necessary physician orders for indwelling urinary catheters for three residents. Resident 17, who has severe cognitive impairment and requires assistance with personal care, was observed with an indwelling catheter but lacked a physician's order for its use. The Treatment Administration Record (TAR) indicated that Resident 17 did not receive catheter care on multiple occasions throughout September 2024. Similarly, Resident 20, who is cognitively intact and also requires assistance, had an indwelling catheter without a physician's order, and the TAR showed missed catheter care on several dates. Resident 24, who is cognitively intact and dependent on staff for toileting, also had an indwelling catheter without a documented physician's order. The TAR and ADL Flow Record confirmed that Resident 24 did not receive catheter care on numerous dates, and there was no documentation of a catheter bag change during September 2024. Interviews with facility staff, including a CNA, RN, and LPN, confirmed the lack of physician orders and the failure to document catheter care consistently. The facility's policy on indwelling catheter care emphasizes the importance of following orders and maintaining infection control standards, which were not adhered to in these cases.
Failure to Provide Nutritional Supplementation
Penalty
Summary
The facility failed to provide nutritional supplementation as ordered for a resident identified as being at nutritional risk. The resident, who is cognitively intact, has a diagnosis of protein-calorie malnutrition. According to the resident's comprehensive assessment and care plan, they are supposed to receive a nutritional supplement three times a day with meals. However, the resident reported that the facility staff only provide the supplement occasionally. During an observation, the resident was seen eating lunch without the prescribed nutritional supplement present.
Failure to Change Oxygen Tubing and Humidifier Bottles
Penalty
Summary
The facility failed to provide appropriate respiratory care by not changing the oxygen tubing and humidifier bottles for two residents, R8 and R10, as required. Both residents were observed receiving oxygen therapy via nasal cannula and humidification bottle, but their equipment was not dated or initialed, indicating a lack of adherence to the facility's policy. R8, who has medical diagnoses including congestive heart failure and asthma, was receiving oxygen continuously, yet there was no documentation in the Treatment Administration Record (TAR) of the tubing or humidifier bottle being changed. Similarly, R10, with conditions such as diabetes and chronic obstructive pulmonary disease, was also receiving oxygen therapy without evidence of equipment changes documented in the TAR. The Licensed Practical Nurse (LPN) confirmed that the oxygen tubing and humidifier bottles for both residents were not dated or initialed, and acknowledged the absence of documentation in the TAR for the month of September. The facility's policy requires that oxygen tubing be changed and dated weekly, and humidifiers be labeled with the date opened. Despite this policy, the LPN stated that all residents' oxygen tubing is supposed to be changed on Saturday evenings, but this was not reflected in the records for R8 and R10. This oversight indicates a failure to comply with the facility's established procedures for respiratory care.
Failure to Conduct Psychotropic Medication Assessments and Implement Interventions
Penalty
Summary
The facility failed to complete necessary assessments and implement appropriate interventions for a resident receiving psychotropic medications. Specifically, the facility did not conduct psychotropic medication assessments, track targeted behaviors, or implement non-pharmacological interventions for behavior management for a resident diagnosed with Schizoaffective Disorder Depressive Type and Borderline Personality Disorder. The resident was prescribed Buspirone, Amitriptyline, and Olanzapine, but there was no documentation of psychotropic medication assessments, behavior tracking, or monitoring of medication side effects in the resident's medical record. The care plan for the resident did not include specific behaviors or non-pharmacological interventions to manage behaviors, despite the resident being on multiple psychotropic medications. Interviews with facility staff revealed that behavioral tracking sheets were previously used but were no longer available, and the Director of Nursing confirmed the absence of a psychotropic medication assessment. The facility's Psychotropic Medication Protocol requires initial assessments, behavior tracking, and side effect monitoring, none of which were documented for this resident.
Failure to Provide Vaccination Education and Offers
Penalty
Summary
The facility failed to provide education and offer immunizations for three residents, leading to a deficiency in their vaccination protocol. Resident 8, with medical conditions including congestive heart failure, hypertension, asthma, and morbid obesity, had not been offered a pneumococcal vaccine since receiving PPSV23 in 2021, despite CDC recommendations for a subsequent dose. The resident expressed willingness to receive the vaccine if offered, but there was no documentation of education or an offer being made. Similarly, Resident 13, diagnosed with cerebral infarction, aphasia, and thrombocytopenia, had not been offered a pneumococcal vaccine following their last PPSV23 dose in 2022, contrary to CDC guidelines. Additionally, Resident 24, with type 2 diabetes, congestive heart failure, neuromuscular dysfunction bladder, and morbid obesity, lacked documentation of education or an offer for the influenza vaccine for the 2023 season. The Director of Nursing confirmed the absence of documentation for these residents, highlighting a lapse in adherence to the facility's vaccination policies.
Deficiency in Wheelchair Maintenance
Penalty
Summary
The facility failed to maintain a functional wheelchair armrest for a resident, identified as R2, who is cognitively intact and uses a wheelchair for mobility. R2 has a diagnosis of Spastic Quadriplegic Cerebral Palsy, which affects movement, balance, and posture, and is at risk for pain and impaired skin integrity. On 9/16/2024, it was observed that R2's wheelchair was missing the entire right-side armrest, leaving the narrow tubular steel frame exposed. R2 reported that a retaining screw broke, causing the padded armrest to be missing for quite a while, and stated that facility staff were aware of the issue. The deficiency persisted as of 9/19/2024, with no changes made to the wheelchair armrest.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility staff failed to adhere to their infection control policy, which mandates testing all residents within 24 hours of exposure to COVID-19 and wearing appropriate personal protective equipment (PPE) when caring for COVID-19 positive residents. The facility's policy requires that residents suspected or confirmed to have COVID-19 be placed in a private room, and staff must wear a respirator, eye protection, gown, and gloves when entering these rooms. However, observations revealed that staff members were not consistently following these guidelines. For instance, a Certified Nursing Assistant (CNA) was seen entering a COVID-19 isolation room wearing only a surgical mask, contrary to the facility's policy. Additionally, there was a delay in testing all residents after the initial exposure to COVID-19, which occurred when a CNA tested positive. The facility administrator confirmed that not all residents were tested within the required 24-hour period, and some residents were not tested until several days later, resulting in additional positive cases. This delay in testing and failure to use appropriate PPE had the potential to affect all 36 residents in the facility, as evidenced by the number of positive cases among both residents and staff during the outbreak.
Lack of Infection Preventionist in Facility
Penalty
Summary
The facility failed to have a qualified infection preventionist on staff, which is a requirement for managing the infection prevention and control program. This deficiency was identified during an interview and record review, where it was revealed that the facility, housing 36 residents, did not have a Director of Nursing or an Infection Preventionist at the time of the survey. The facility's own documentation, including a midnight census report and a facility assessment, highlighted the necessity of having an infection preventionist to manage resident admissions, readmissions, infections, and exposures. Despite being in outbreak status, the facility lacked the designated personnel to oversee these critical functions, as confirmed by the Regional Director of Nursing and the Administrator.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's emergency contact of a change in condition and new physician orders. The resident, identified as R1, was severely cognitively impaired and had a history of feeding tube problems. On July 24, 2024, a physician ordered a Modified Barium Swallow for the diagnosis of dysphagia, and on August 20, 2024, further orders were made for a swallow evaluation and a STAT chest X-ray due to possible aspiration. Despite these significant changes in R1's medical condition and treatment plan, the facility did not inform R1's responsible party, V14, of these developments or of R1's hospital visit due to a malfunctioning G-Tube. Interviews with facility staff, including the Assistant Director of Nurses (ADON) and the Regional Director of Operations, confirmed that the facility's protocol requires notifying the physician, resident, and resident's representative of any change in condition. However, the facility was unable to provide documentation that R1's representative was informed of any part of his care. V14, R1's responsible party, expressed that neither they nor R1's family were notified of any changes or included in decision-making processes, despite R1's inability to make decisions independently.
Failure to Supervise Resident on NPO Status
Penalty
Summary
The facility failed to adequately supervise a resident who had a physician order for nothing by mouth (NPO) except for ice chips, leading to multiple incidents where the resident consumed food and liquids. The resident, who was admitted with medical diagnoses including moderate protein-calorie malnutrition, alcohol dependence with alcohol-induced persisting dementia, and pneumonitis with inhalation of food and vomit, was documented as severely cognitively impaired and able to self-propel in a wheelchair. Despite having a care plan that included nutrition through a feeding tube due to swallowing problems, the care plan did not address the resident's behavior of eating and drinking while on NPO status. The resident's nurse progress notes documented several incidents where the resident attempted to eat solid food, consumed food from a roommate's tray, mistakenly received water from staff, and reported eating food. Interviews with staff and the resident's responsible party confirmed that the resident was unable to make safe decisions and required close supervision to prevent eating and drinking, which could lead to choking or other health issues. The assistant director of nurses acknowledged the need for staff to closely supervise the resident, as the resident had access to other residents' food and drink when not monitored.
Failure to Follow G-Tube Administration and Weight Monitoring Protocols
Penalty
Summary
The facility failed to adhere to Gastrostomy Tube (G-Tube) medication and feeding administration guidelines for a resident with severe cognitive impairment and multiple medical diagnoses, including Moderate Protein-Calorie Malnutrition and Gastrostomy Status. The resident was admitted with orders for nothing by mouth (NPO) and was to receive enteral nutrition through a G-Tube. However, the Registered Nurse (RN) did not check the placement of the G-Tube before administering water flushes, enteral feeding, or medication. Additionally, the RN did not elevate the resident's head of bed to the required 30-45 degrees during the administration process and used a syringe to push the medication and feeding instead of allowing them to flow by gravity, contrary to facility policy. Furthermore, the facility failed to consistently weigh the resident as required. The resident's medical record showed weights recorded only on two occasions, with no weights documented prior to these dates, despite orders for weekly weights upon admission. The Registered Dietician noted the absence of height and weight in the resident's chart, which hindered the calculation of the resident's weight status and nutritional needs. The Assistant Director of Nursing (ADON) acknowledged the oversight in obtaining the resident's weights, indicating a significant lapse in following the facility's weight assessment and intervention policy.
Failure to Implement Enhanced Barrier Precautions for Resident with G-Tube
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) while administering medications and feeding through a Gastrostomy Tube (G-Tube) for a resident. The resident, who was admitted with several medical diagnoses including Gastrostomy Status and was severely cognitively impaired, did not have an 'Enhanced Barrier Precaution' sign posted in their room. Additionally, there were no Personal Protective Equipment (PPE) supplies available outside the room, nor were there designated linen and/or trash disposal bins. On two separate occasions, the resident was observed in their room without the necessary EBP signage and supplies. A Registered Nurse (RN) was observed administering medication and feeding through the resident's G-Tube without wearing a mask or gown, which is contrary to the facility's policy on EBP. The Assistant Director of Nursing (ADON) confirmed that the resident should have been placed on EBP due to the presence of a G-Tube, and the RN should have worn appropriate PPE. The Director of Nurses (DON) acknowledged that the resident should have been placed on EBP upon admission, as residents with indwelling medical devices are at higher risk of infection. The facility's policy indicates that gown and gloves are required for high-contact resident care activities involving devices like feeding tubes, regardless of MDRO colonization.
Failure to Provide Wound Care and Skin Checks
Penalty
Summary
The facility failed to provide wound dressing changes and skin checks according to physician orders, affecting two residents. One resident, admitted with multiple medical diagnoses including diabetes and a right above-knee amputation, experienced multiple occasions of parasitic maggot infestations in their foot wounds. The Treatment Administration Records (TAR) for June and July 2024 showed numerous instances where dressing changes and weekly skin checks were not completed as ordered. The resident's nursing notes did not document any completion of the ordered treatments, and the wound care physician confirmed that the presence of maggots was preventable with proper treatment. Another resident, with medical diagnoses including diabetes and peripheral vascular disease, had an open wound on the heel that was initially visible with muscle and tendon but later healed. However, the TAR for June, July, and August 2024 documented missed weekly skin checks and incomplete treatments for the heel wound. The wound care nurse confirmed the presence of an open wound and the subsequent healing process, but the documentation indicated lapses in the prescribed care. Interviews with nursing staff revealed that if treatments were not documented, they were likely not completed. The wound care physician noted that the situation of having maggots in a wound is uncommon and preventable with the right treatments. The lack of documentation and adherence to treatment orders contributed to the deficiencies observed in the care provided to the residents.
Failure to Implement Safety Measures and Supervision
Penalty
Summary
The facility failed to implement necessary safety measures for a resident (R3) who was on anticoagulant therapy and had a history of falls. Despite recommendations for supervision, R3 was left unsupervised in the bathroom, resulting in a fall and an acute subdural hematoma. The incident occurred when R3 attempted to self-transfer from the toilet, leading to a serious head injury. The care plan did not reflect the required intervention of assistance with toileting, and staff were not adequately informed or trained to prevent such incidents. Additionally, the facility did not conduct a proper safety assessment for another resident (R1) who was allowed unsupervised outings. R1, who had a history of substance use and functional limitations, was found intoxicated and fell while using a broken walker outside the facility. The walker was not maintained in a safe condition, and there was no documentation of a safety assessment or IDT meeting to evaluate R1's ability to safely leave the facility unsupervised. This oversight led to R1 sustaining a fracture of the first metatarsal bone. The facility's policies and procedures for accident prevention and resident safety were not effectively implemented or communicated to staff. The lack of updated care plans and inadequate staff training contributed to the unsafe conditions that resulted in serious injuries to the residents. The facility's failure to ensure proper supervision and equipment maintenance highlights significant deficiencies in their care practices.
Removal Plan
- All residents were evaluated for fall risk with resident centered interventions implemented for those at risk.
- Staff were educated to ensure knowledge and utilization of fall interventions. Staff including new staff and agency staff were inserviced by V6, Registered Nurse Consultant, on the Fall Program/Prevention and Anticoagulation policies, on knowledge of and implementation of interventions for residents high-risk for falls and/or bleeding, and on which residents are at risk for falls/bleeding with a roster posted out of public view until an electronic system is fully implemented. All direct care staff will be in-serviced before they take the floor to work.
- The Medical Director was notified of the Immediate Jeopardy.
- All resident fall assessments were reviewed and updated by V2.
- All Care plans for fall risk related to supervision and monitoring were reviewed and updated by V4, Care Plan Coordinator, and V2.
- All residents on anticoagulation/antiplatelet therapy were identified by V4 and V2.
- All residents on anticoagulation/antiplatelet therapy with high fall risk were identified to ensure implementation of fall interventions and post fall responsibilities for residents who are at risk for bleeding by V4 and V2.
- Fall policies were reviewed/updated by the QAPI (Quality Assurance Performance Improvement) team.
- An audit tool was developed to ensure sustained compliance with objectives. V2 or designee will perform audits three times weekly for four weeks.
- The QAPI (Quality Assurance Performance Improvement) team will meet/discuss Fall Program/Prevention Plan on an ongoing basis.
Failure to Clarify and Transcribe Medication Orders
Penalty
Summary
The facility failed to clarify conflicting medication orders, accurately transcribe physician orders, and obtain physician orders for a resident's medication regimen. This deficiency affected one resident, who was admitted with specific medication orders from the hospital, including Atorvastatin, Carvedilol, Darbepoetin, Duloxetine, Vitamin D, Ferrous Sulfate, Folic Acid, Glargine insulin, lispro insulin, Midodrine, Probiotic, Psyllium Husk Powder, Trulicity, and Sevelamer. The hospital discharge orders also included instructions to check the resident's blood glucose levels four times daily. However, the facility's Medication Administration Record (MAR) and Physician Order Sheets (POS) did not include the Glargine insulin injections or the order for blood glucose checks four times daily. Instead, there was an incorrect order for a 6:00 AM blood glucose check daily, which was not part of the hospital's discharge orders. Additionally, the order for Midodrine was transcribed as twice daily in the facility, despite the hospital record indicating three times daily. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) acknowledged that the facility's nurses should have clarified the insulin orders and blood glucose checks with the physician, rather than taking instructions from the resident's family member. The DON noted that agency nurses and staff nurses failed to ask questions or clarify the orders, leading to a breakdown in the process.
Failure to Administer Medications to Admitted Resident
Penalty
Summary
The facility failed to obtain and administer physician-ordered medications for a resident (R2) who was admitted with complex medical conditions, including end-stage renal disease, multi-drug resistant infections, diabetes, and anemia. Upon admission, R2 had a comprehensive list of medications prescribed, including Atorvastatin, Carvedilol, Darbepoetin, and others critical for managing his conditions. Despite the facility being informed of R2's impending admission, no medications were administered during his stay, which lasted until he left for a dialysis appointment two days later. The deficiency arose from a series of communication and procedural failures. The spouse of R2 confirmed that the facility was aware of the admission in advance, yet the medications were not delivered due to the timing of the admission on a Saturday evening and the pharmacy's delivery schedule. The Licensed Practical Nurse (V3) acknowledged that medications could have been sourced from a convenience box or through a 'STAT' order from a backup pharmacy, but these actions were not taken. The Director of Nursing (V2) noted that the admitting nurse and subsequent staff failed to ensure the medications were obtained, highlighting a breakdown in the facility's processes for managing weekend admissions and medication procurement.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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