Bria Of Belleville
Inspection history, citations, penalties and survey trends for this long-term care facility in Belleville, Illinois.
- Location
- 150 North 27th Street, Belleville, Illinois 62226
- CMS Provider Number
- 145668
- Inspections on file
- 54
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Bria Of Belleville during CMS and state inspections, most recent first.
A resident with multiple comorbidities and a neurogenic bladder managed by an indwelling urinary catheter had a urologist’s order for the catheter to be changed immediately and then monthly, with PRN changes if not draining. Facility documentation showed the order was transcribed to the TAR, but the monthly catheter changes were not completed or documented on at least two scheduled months, and the DON later confirmed the catheter was not changed as ordered and could not produce any revised order changing the frequency. Progress notes described delayed catheter change after bleeding from the penis, subsequent UTI treatment with oral and IM antibiotics, and later acute illness with fever, tachycardia, and emesis leading to hospital transfer, where the resident was found to meet sepsis criteria with significant pyuria and leukocytosis. The resident and a hospital case manager reported that the facility had not been changing the catheter monthly as ordered, the resident stated catheter site care was rarely done and described the situation as neglect, and facility leadership acknowledged that undocumented catheter changes were assumed not done and that specialist orders were not maintained indefinitely or systematically reconciled after hospitalizations.
The facility failed to maintain a safe, clean, and comfortable dining room environment for multiple residents when housekeeping services were not consistently provided. Staff interviews showed that no one was regularly assigned to clean the dining room floor between meals, and several housekeepers reported they either had never been assigned to that area or could not manage both resident rooms and the dining room. Dietary staff cleaned only tables and stated that floors were the responsibility of housekeeping, but that there were not enough housekeepers and the floor machine had been broken for several weeks. The housekeeping supervisor confirmed significant staffing shortages following a change in housekeeping companies and a floor buffer machine that had been inoperable for over eight weeks, preventing proper floor cleaning. Observation revealed the dining room floor littered with trash, liquid spills, and sticky residue.
Two residents with complex medical histories and intact cognition experienced misappropriation of funds after their debit cards were accessed without authorization, resulting in significant financial losses. Facility investigations identified staff involvement and led to police reports, but the incidents occurred despite existing abuse prevention policies and care plan interventions for financial monitoring.
A resident with multiple serious medical conditions experienced an acute change in condition, including shortness of breath and low oxygen saturation. Staff delayed calling EMS for about an hour after the change was first noticed, and there was no documentation of when the change began, when EMS was called, or physician notification. Upon EMS arrival, the resident was unresponsive and later died at the hospital. The facility failed to follow its policy for timely notification and documentation during a significant change in condition.
Two residents, both cognitively intact and with significant medical histories, engaged in a physical altercation following a verbal dispute over room privacy. Although staff intervened promptly and no injuries occurred, the facility failed to update care plans and document the incident as required, resulting in a deficiency related to the prevention and management of resident-to-resident abuse.
A resident who was dependent for mobility and transfers developed multiple new and re-opened pressure ulcers after staff failed to consistently turn and reposition the resident as required by the care plan. Despite documented interventions and facility policy, the resident was observed in the same position for hours, reported poor care, and was found to have slow-healing, in-house acquired pressure wounds.
A resident with severe cognitive impairment and high fall risk experienced multiple falls, including one resulting in a hip fracture, due to the facility's failure to implement and follow progressive interventions and provide adequate supervision. Despite care plan interventions and staff awareness of the resident's needs, the resident was able to attempt self-transfers without assistance, leading to injury.
Surveyors observed that food containers were not labeled or dated, scoops were stored inside bulk food, and food items were placed directly on the floor. Eggs were stored above items requiring freezing, dishware had visible debris, and the dishwashing machine lacked sanitizer. Staff interviews confirmed improper food storage and cleaning practices, affecting all residents.
A resident with severe cognitive impairment and a history of wandering was pushed to the floor by another resident with a history of agitation and aggression. The incident occurred after the cognitively impaired resident entered the other resident's room while looking for the bathroom, and was witnessed by staff. Despite both residents having care plans identifying their risks, the facility failed to prevent the abusive interaction.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained bruising and shoulder pain. Staff attributed the injuries to the resident's positioning in bed and degenerative changes, but did not conduct an investigation or report the injury as required by facility policy for injuries of unknown origin.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained bruising and shoulder pain. Although an x-ray showed degenerative changes and possible subluxation, the facility did not conduct an investigation into the injury of unknown origin as required by its abuse policy.
A resident with a history of repeated falls, hemiplegia, and mobility deficits experienced multiple falls, but the care plan was not consistently updated with new interventions after each incident. Despite facility policy requiring care plan revisions based on root cause analysis after every fall, documentation showed that interventions were either missing or minimally addressed, resulting in a deficiency in fall prevention and management.
A resident with end stage renal disease did not have required monitoring of their dialysis access site documented on several days, and the facility failed to ensure communication with the outpatient dialysis center as per policy. Physician orders and facility protocols for checking the dialysis site and completing communication forms were not followed, as confirmed by facility leadership.
A resident with a documented cinnamon allergy and asthma was served raisin toast containing cinnamon, despite clear documentation of the allergy on multiple records. Staff failed to communicate and verify the allergy, resulting in the resident being repeatedly offered foods containing the allergen.
The facility did not display daily nurse staffing information in a visible and accessible location for residents, staff, or visitors, as required by policy. Instead, the staffing schedule was kept at the nurse's station and not posted publicly.
A resident with epilepsy did not receive her prescribed seizure medication, Vimpat, for several days, resulting in multiple seizures and hospitalization. The facility's staff acknowledged issues with prescription management and pharmacy communication, which contributed to the medication not being administered as ordered. The resident's care plan required medication administration to manage her condition, but the facility failed to ensure the medication was available and administered.
Staff at the facility were observed using cell phones in resident areas, leading to an un-homelike environment. Multiple staff members, including LPNs and CNAs, were seen on their phones at nurse's stations and other areas, despite facility policies prohibiting such use. Residents reported feeling neglected, as staff were often on their phones instead of attending to their needs.
The facility failed to provide food at acceptable temperatures, with several residents reporting cold and unappetizing meals. Food temperatures were recorded below the required threshold, and the Dietary Manager admitted to infrequent temperature checks. The Administrator was unaware of a plate warmer issue, which contributed to the problem. Resident Council Minutes also documented complaints about cold food.
The facility failed to provide nourishing snacks between meals or at bedtime for several residents, including those with diabetes and renal dialysis needs. Snacks were left at the nurse's station, and residents who could access them took all the available snacks, leaving none for others. The dietary manager noted that snacks were not consistently offered by staff, and the kitchen was locked after hours, limiting access to additional snacks. This failure contributed to inadequate nutrition for some residents.
The facility failed to provide adequate showers and incontinent care to three residents who were dependent on staff for assistance with activities of daily living. One resident with a chest port reported not receiving showers due to staff concerns about getting the port wet, and was left in a soiled brief overnight. Another resident reported infrequent showers, and a third resident's family raised concerns about nursing care. Facility policy required scheduled showers and assistance, but documentation and resident council minutes indicated these were not consistently provided.
A resident with ALS and COPD experienced a change in condition, reporting shortness of breath. The facility failed to consistently monitor and document her vital signs, leading to her hospitalization and intubation. Despite staff being aware of her distress, there was confusion in documentation and communication, contributing to the deficiency.
A resident with a complex medical history was sent to the hospital due to respiratory issues, but the facility failed to notify her family about the change in condition. The family only discovered her hospitalization upon visiting the facility. The facility's policy mandates notifying the resident's family and documenting the communication, which was not adhered to in this case.
A resident with chronic respiratory issues was not transferred to the hospital in a timely manner after showing signs of distress, resulting in a diagnosis of sepsis and acute respiratory failure. Additionally, several residents did not receive prescribed wound care treatments, indicating systemic issues in the facility's wound care practices. Interviews revealed lapses in communication and documentation among staff.
A resident with chronic respiratory issues experienced a significant change in condition, including shortness of breath and low oxygen saturation. Despite the facility's policy, the physician and family were not notified, and the resident was eventually hospitalized for sepsis and hypoxia. Staff interviews revealed miscommunication and documentation issues, contributing to the deficiency.
The facility failed to protect residents' clothing from loss, affecting four cognitively intact residents who reported missing items such as jeans, shirts, and shoes. Despite reporting the issues to staff, the residents did not receive assistance in locating or replacing their belongings. The facility's policies on missing items and grievances were not followed, and ongoing issues with clothing management were documented in Resident Council Minutes.
The facility failed to maintain proper food temperatures before and during meal service, affecting all 121 residents. Multiple residents and CNAs reported that the food was consistently cold. An inspection revealed that the food warmer was malfunctioning, and food was often left uncovered and exposed to contamination. The facility's policies on food preparation and meal distribution were not followed.
The facility failed to assess, monitor, and treat pressure ulcers for two residents. One resident did not receive wound care due to a lack of orders and communication failures, while another had an uncovered wound despite prescribed treatments. Staff did not follow the facility's wound management and admission policies, leading to inadequate care.
The facility failed to provide timely and complete incontinent care for two residents, leading to significant discomfort and potential health risks. One resident was left in a soiled brief for an extended period, and the CNA did not follow proper hygiene protocols. Another resident often remained in a wet state for long periods, especially at night, despite using the call light for assistance. Interviews revealed inconsistencies in care routines, and the facility's Incontinence Care Policy was not consistently followed.
The facility failed to protect two residents from abuse and neglect. One resident reported feeling sexually assaulted by a CNA, while another resident experienced mistreatment from two different CNAs. The incidents were documented, and the involved CNAs were either suspended or sent home.
The facility failed to follow its Abuse Policy and Prevention Program, resulting in two residents experiencing abuse and neglect. One resident felt sexually assaulted by a CNA, while another resident reported neglect and verbal abuse. Both incidents were corroborated by witnesses, and the facility's response included suspending the involved CNAs and involving law enforcement.
A resident with severe cognitive impairment and multiple pressure ulcers was not properly repositioned or provided with necessary wound care, leading to the worsening of their condition. The resident was observed sitting for extended periods without being turned, and their wound-vac was not re-applied after returning from the hospital. Facility staff admitted to not following the care plan and policies for pressure injury prevention.
The facility failed to serve meals at regular times, affecting all 117 residents. Observations showed breakfast and lunch trays being passed late, and residents and staff reported consistent delays. The issue was attributed to kitchen staffing problems and the recent departure of the Dietary Manager.
The facility failed to ensure safe mechanical lift transfers and follow care plan interventions for four residents. Observations showed that staff did not provide hands-on guidance during transfers and did not ensure call lights were within reach or proper footwear was used, leading to multiple falls and safety risks.
The facility failed to remove expired stock medications from the front hall medication room and two medication carts, potentially affecting 54 residents. Inspections revealed several expired medications, and interviews indicated a lack of clarity regarding responsibility for checking and disposing of expired medications.
The facility failed to ensure that residents were offered and received pneumococcal vaccinations as per CDC recommendations. Five residents with various diagnoses had no documentation of pneumonia vaccination in their electronic medical records. The Infection Preventionist nurse confirmed that no pneumonia vaccines had been administered or offered during her tenure, contrary to the facility's policy.
The Facility failed to assist two residents with their ADLs. One resident, who is severely cognitively impaired, was left in a soiled adult brief overnight, while another resident, who had a stroke, was told to change herself after an episode of incontinence. The latter also reported verbal abuse from a CNA.
A resident with Type Two Diabetes and chronic ulcers did not receive prescribed daily wound treatments for four consecutive days. The wound nurse and the resident confirmed the missed treatments, and the administrator was unaware of the issue. The facility's policy did not ensure that physician's orders were completed as prescribed.
The facility failed to provide timely and complete incontinent care for three residents, leading to deficiencies in their care. One resident was not attended to promptly despite requesting a change, and the CNAs did not perform proper hand hygiene or cleaning. Another resident was left unchanged since the previous night, and a third resident received inadequate care with improper hygiene practices.
A facility failed to administer medications according to physician orders, resulting in incorrect doses being given to a resident. An LPN administered a 1000 mg dose of Fish Oil instead of the prescribed 1200 mg and almost gave an incorrect dose of Folic Acid. The LPN also failed to provide proper instructions for using a Symbicort Inhaler, and the medication cart was left unlocked and unattended.
The facility failed to provide appetizing and palatable meals for two residents with Moderate Protein-Calorie Malnutrition, leading to significant weight loss and dissatisfaction. Complaints included poor food quality, inconsistency, and issues documented in Resident Council Meeting Minutes.
The facility failed to perform proper hand hygiene and cleanse multi-use resident equipment, leading to potential infection risks for four residents. CNAs and an LPN were observed not following hand hygiene protocols during resident care and medication pass, as well as not cleaning equipment between uses.
Staff failed to administer several significant medications to a resident during a scheduled medication pass. The resident, with multiple diagnoses including Bipolar Disorder and Hypertension, did not receive their scheduled doses due to medication shortages and discarding of doses. Despite the facility's policy on medication administration, the issue was not addressed by the DON, leading to missed doses.
The facility failed to monitor the administration of medications as ordered by the physician for five residents, resulting in significant medication errors. One resident received another resident's medication due to a nurse's inattention, while another resident was handed a cup of pills that were not hers. A third resident took medication from another resident, and a fourth resident received another resident's medication due to a bed number mix-up. The fifth resident was administered a higher dose of medication than prescribed due to a mix-up with home supply medication.
Failure to Follow Urology Orders for Indwelling Catheter Care Leading to UTI and Sepsis
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide appropriate care for a resident with an indwelling urinary catheter, resulting in a urinary tract infection with sepsis requiring hospitalization and IV antibiotics. The resident had multiple significant diagnoses, including cerebral infarction, osteomyelitis, diabetes mellitus, peripheral vascular disease, chronic kidney disease, congestive heart failure, diabetic polyneuropathy, a stage 4 pressure ulcer, and a neurogenic bladder managed with an indwelling urinary catheter. The resident was cognitively intact and dependent on staff for mobility. A urology consult on 7/8/25 documented that the resident’s catheter had not been changed at the facility and that the resident reported the facility could change it with an order. The urologist assessed the resident and ordered an indwelling urinary catheter change that day and monthly thereafter, indefinitely, with PRN changes if the catheter was not draining. Following the urology visit, a facility progress note on 7/8/25 documented that the resident returned from the appointment with a new order to change the indwelling urinary catheter that day and monthly thereafter. The Treatment Administration Records (TARs) for October and November 2025 showed a standing order to change the catheter monthly on night shift starting on the 8th of each month, but there was no documentation that the catheter was changed on 10/8/25 or 11/8/25 as ordered. A progress note on 10/9/25 recorded that the resident had bleeding from the penis and that the monthly catheter change, due the previous day, was then performed. Subsequent notes documented a urinalysis collected on 10/20/25 and initiation of nitrofurantoin for a UTI on 10/23/25, as well as continuation of IM antibiotics related to UTI on 11/4/25. The DON later acknowledged that the catheter was not changed as ordered in October or November 2025 and could not produce any order or physician notification changing the monthly order to PRN only. On 12/3/25, a progress note described the resident as shaky with elevated temperature and tachycardia, with a blood sugar of 319, followed by emesis and transfer to the hospital. The hospital history and physical documented that the resident reported noticing sediment in his urine, stated his catheter had been changed three days prior but that it had been over 40 days since the previous change, and that he had been telling facility staff about it. The hospital documented that the resident met sepsis criteria with a markedly elevated white blood cell count, fever, tachycardia, increased respiratory rate, and significant pyuria and hematuria on urinalysis. The resident later stated that prior to moving to the facility his catheter tubing and bag had been changed monthly and he did not get UTIs, and that at the facility his catheter bag and tubing were not changed monthly despite his belief that there was a physician’s order to do so. He reported being hospitalized twice in recent months for severe UTIs requiring IV antibiotics and expressed frustration that staff were not following physician orders, describing the situation as neglect. The facility’s catheterization policy addressed changing catheters PRN when not draining but did not address following physician orders for catheter changes, and the DON stated the facility does not do indefinite orders and that specialist orders were considered no longer in effect once a resident goes to the hospital, despite no documentation of revised orders for this resident. The resident also reported that staff did not clean around his catheter site daily and that this care was rarely performed. A wound care nurse stated that the catheter was ordered to be changed on night shift and that if it was not signed off, it was not done, and further stated that when the resident was readmitted from the hospital, the nurse should have restarted the previous orders for consistency unless otherwise specified. A hospital case manager confirmed that urology had ordered monthly catheter changes during a July 2025 hospitalization and that during the December 2025 hospitalization the resident again reported that the facility had not been changing his catheter monthly as ordered, leading physicians to again order monthly catheter changes. The administrator acknowledged that if a catheter change was not documented on the TAR, she assumed it was not completed. Overall, the documented failures included not completing monthly catheter changes as ordered, not following the urologist’s written orders, not verifying or reinstating specialist and hospital discharge orders, and not consistently performing catheter site care, culminating in the resident developing a UTI with sepsis requiring hospitalization and IV antibiotics.
Failure to Maintain Clean and Safe Dining Room Environment Due to Inadequate Housekeeping
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate housekeeping services to maintain a safe, clean, and comfortable environment for four residents reviewed for physical environment. Multiple staff interviews revealed that no staff, including housekeepers, were consistently cleaning the dining room floor between meals. A CNA stated that no one cleans the dining room floor between meals. One housekeeper reported that the floor machine had been broken for over six weeks and that she was not assigned to clean the dining room floor and had never done so. Another housekeeper stated she tried to clean the dining room floor between meals but could not manage both resident rooms and the dining room at the same time, and that the floor technician could not use the floor machine because it had been broken for over eight weeks. Dietary staff reported they were responsible only for cleaning tables and that housekeepers were supposed to clean the floors, but that no one was cleaning the dining room floor between meals due to insufficient housekeeping staff and the broken floor machine. Another housekeeper, working full time, stated he did not know who cleaned the dining room floor and that it was not on his assignment and he had never been assigned to clean it. A different housekeeper stated she cleans the dining room between meals but was late doing so on the day of observation because she was cleaning resident rooms. The housekeeping supervisor stated that after a change in housekeeping companies, multiple housekeepers quit or went on leave, leaving him as the only housekeeper for the month of December despite working over 40 hours per week, and that the floor buffer machine had been broken for over eight weeks, preventing proper floor cleaning, including deep cleaning. On observation, the dining room floor had trash such as milk cartons, napkins, and straws, along with multiple liquid spills and sticky residue.
Failure to Prevent Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent misappropriation of funds for two residents who were cognitively intact and at risk for abuse. One resident, admitted with multiple diagnoses including end stage renal disease, diabetes, and major depressive disorder, discovered several unauthorized ATM withdrawals totaling thousands of dollars after his debit card was given to a staff member who claimed payment was needed for his account. The resident noticed the missing funds when his card was declined and subsequently contacted his bank and the police. The facility's internal investigation revealed that the staff member misused the resident's credit card and misappropriated cash payments for personal use. Another resident, also cognitively intact and with a history of cerebral infarction, diabetes, and other serious conditions, reported that his debit card was taken from his room and approximately $2,000 in unauthorized transactions occurred. The resident discovered the missing funds after reviewing his bank account and reported the incident. The bank provisionally credited the resident's account while the police investigation was ongoing. The facility's investigation included interviews and review of surveillance footage, leading to the suspension of two employees suspected of involvement. Both incidents were documented in the residents' care plans as abuse risks, with interventions for additional financial monitoring. The facility's abuse prevention policy affirms residents' rights to be free from misappropriation of property and outlines the facility's responsibility to prevent such occurrences. Despite these policies, the facility did not prevent the misappropriation of funds in these cases.
Delay in Emergency Response and Incomplete Documentation Following Resident's Acute Change in Condition
Penalty
Summary
The facility failed to provide timely emergency medical intervention for a resident who experienced an acute change in condition. The resident, who had multiple significant diagnoses including rib fractures, vertebral fractures, dysphagia, severe malnutrition, and acute thrombosis, was noted to be cognitively impaired and at risk for altered nutrition and hydration. On the day of the incident, the resident was observed to be eating normally during breakfast and lunch, but was later found by a CNA to be wheezing and with glazed eyes. The CNA alerted the LPN and ADON, who responded to the change in condition. Despite the resident exhibiting shortness of breath, audible crackles, and a dangerously low oxygen saturation of 65%, there was a delay in calling Emergency Medical Services (EMS). Documentation revealed uncertainty and lack of clarity regarding the exact times of the change in condition, when EMS was called, and when the physician was notified. There was no documentation of when the change began, no SBAR form completed, and no evidence that the physician or on-call provider was notified prior to EMS being called. The facility's own policy requires notification of the physician or nurse practitioner in the event of a significant change in condition, except in a medical emergency. EMS records and staff interviews indicated that EMS was called approximately one hour after the initial change in condition was noticed. Upon EMS arrival, the resident was unresponsive, tachypneic, and had evidence of aspiration. The resident was transferred to the hospital, where she later expired. The lack of timely EMS notification and incomplete documentation contributed to the delay in treatment for the resident.
Failure to Prevent and Address Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, as evidenced by an altercation involving two residents with cognitive capacity for decision-making. One resident, with diagnoses including nontraumatic subarachnoid hemorrhage, malnutrition, chronic bronchitis, depression, heart failure, pleurisy, anxiety, and spinal stenosis, was noted to be independent in most activities of daily living and cognitively intact. The other resident involved had diagnoses of type 2 diabetes, morbid obesity, chronic respiratory failure, depression, anemia, hyperparathyroidism, and chronic kidney disease, and required minimal assistance for most activities. Both residents engaged in a physical altercation after a verbal dispute regarding room privacy, resulting in each striking the other, though no injuries were reported. The incident was witnessed by staff, who intervened immediately to separate the residents. However, the facility failed to update the care plans for both residents to address the altercation that occurred. The care plan for one resident referenced a previous altercation but did not include the most recent event, and the progress notes also lacked documentation of the incident. Similarly, the other resident's care plan did not reflect the altercation, despite her being identified as at risk for abuse and neglect due to her medical conditions. Interviews with staff and the residents confirmed the sequence of events, with both residents acknowledging their involvement in the altercation and the reasons behind it. The facility's policy affirms the right of residents to be free from abuse and outlines the definition of abuse, including willful infliction of injury or pain. Despite this policy, the lack of timely and appropriate care plan updates and documentation following the incident demonstrates a failure to ensure residents are protected from all forms of abuse, as required.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident who was dependent for mobility and transfers and had no cognitive deficits. Despite a care plan that required turning and repositioning every one to two hours, the resident was not consistently turned or repositioned, as evidenced by the resident's own statements and observations by surveyors. The resident reported not being turned or pulled up for extended periods and expressed concerns about poor care and fear of being left in pain. Multiple progress notes and wound evaluations documented the development of new, in-house acquired pressure ulcers, including stage III and unstageable wounds, as well as a re-opened pressure ulcer. The resident was also observed to be incontinent and in the same position for several hours during the survey. The medical record review showed that the resident was admitted with intact skin and no wounds, but subsequently developed several pressure ulcers over time, with slow healing noted. Staff interviews indicated that the resident sometimes refused a pressure-reducing mattress and could turn himself slightly, but the care plan interventions for regular turning and repositioning were not consistently implemented. Facility policy required standards of practice to prevent or reduce pressure injuries, but these were not followed, resulting in the resident developing multiple pressure ulcers while under facility care.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement and follow progressive interventions and provide appropriate supervision to prevent falls for a resident with severe cognitive impairment and a high risk for falls. The resident, who had diagnoses including metabolic encephalopathy and required partial to moderate assistance with mobility and transfers, experienced multiple falls. Despite being identified as high risk and having a care plan that included interventions such as prompting or assisting with position changes, toileting, and encouraging the use of the call light, the resident attempted to self-transfer to the bathroom and fell, sustaining a head injury. The care plan also included education for the resident to use the call light and wait for staff assistance, but the resident's severe cognitive impairment limited the effectiveness of this intervention. Following the initial fall, the resident was found on the floor again after attempting to get up independently, which resulted in a fracture of the left inferior pubic ramus. Documentation shows that the resident was not always toileted prior to being put to bed, and staff interviews indicated that the resident could stand but required significant assistance. The facility's policy emphasized the need to identify residents at risk for falls and to implement preventative strategies, but the failure to provide adequate supervision and timely assistance contributed to the resident's repeated falls and subsequent injury.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards to prevent foodborne illness. Observations revealed that bulk food containers in the kitchen were not labeled or dated, and scoops were stored directly inside the food, contrary to facility policy. In the walk-in refrigerator, cartons of milk and applesauce were found lying directly on the floor, and pasteurized shell eggs were stored above boxes of nutritional shakes that required freezing. Additionally, saucers stored near the walk-in freezer had visible crumbs and debris, and the dish room floor was covered in food debris. The dishwashing machine was found to be operating without sanitizer, as evidenced by a test strip that did not change color and an empty sanitizer bucket. Interviews with dietary staff confirmed a lack of adherence to proper food storage protocols, including the improper placement of eggs and the failure to keep food off the floor. The dietary manager acknowledged the issues with labeling, storage, and cleaning, and the registered dietitian explained the importance of proper food storage to prevent contamination. The facility's policies require all food containers to be labeled and dated, scoops to be stored outside of food containers, and all foods to be stored off the floor and at appropriate temperatures. These deficiencies had the potential to affect all 108 residents in the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with severe cognitive impairment and a history of encephalopathy, altered mental status, and cognitive communication deficit was involved in an incident where he was pushed to the floor by another resident. The resident who was pushed was known to wander into other residents' rooms due to his cognitive deficits and occasional incontinence, sometimes forgetting where the bathroom was. On the day of the incident, he entered another resident's room while looking for the bathroom. The resident who pushed him had diagnoses including Alzheimer's disease, traumatic brain injury, adjustment disorder, and intellectual disabilities, and was documented as being at risk for abuse and displaying behaviors such as agitation and aggression. On the day of the incident, a witness observed the cognitively intact resident push the cognitively impaired resident, causing him to fall to the floor. The incident was reported by a staff member who witnessed the event, and the resident who was pushed was assessed with no injuries noted at the time. Prior to the incident, the resident who pushed had exhibited agitation and verbal aggression, and the resident who was pushed had a care plan identifying his risk for abuse and neglect. Despite these known risks and behavioral histories, the facility failed to prevent the abusive interaction between the two residents, resulting in one resident being pushed to the floor by another.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and investigate an injury of unknown origin for one resident who was observed with multiple large and small reddish/purple bruises and purpura on her bilateral forearms and right hand. The resident, who has severe cognitive impairment, dementia, stage 4 chronic kidney disease, hypertension, and dysphagia, was noted to be dependent on staff for bed mobility and had limitations in range of motion. Progress notes indicated that a nurse discovered a bruise on the resident's lower left arm and that the resident complained of shoulder pain, prompting an x-ray. The x-ray revealed degenerative changes and possible anterior subluxation of the shoulder, but no recent fracture. Despite these findings, there was no facility investigation into the cause of the injury to the resident's right shoulder. Interviews with facility staff confirmed that no investigation was conducted regarding the bruising or shoulder injury. The administrator and DON stated that the bruising was attributed to the resident lying in bed with her arms pressed against the bed rail, and that the shoulder pain and subsequent x-ray findings were considered to be related to degenerative changes. The facility's abuse policy requires an internal investigation and reporting to authorities for injuries of unknown source, but this process was not followed in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who was observed with multiple large and small reddish/purple bruises and purpura on her bilateral forearms and right hand. The resident, who has severe cognitive impairment, dementia, stage 4 chronic kidney disease, hypertension, and dysphagia, was noted to be dependent on staff for bed mobility and had limitations in range of motion. Progress notes indicated that a nurse discovered a bruise on the resident's lower left arm and that the resident complained of shoulder pain, prompting an x-ray. The x-ray revealed mild degenerative arthritic changes and possible anterior subluxation of the humeral head, but no recent fracture. Despite these findings and the facility's abuse policy requiring an internal investigation for injuries of unknown source, no investigation was conducted into the resident's right shoulder injury. The administrator and DON stated that the bruising was attributed to the resident lying with her arms against the bedrail and that the shoulder pain and subsequent x-ray occurred afterward. However, there was no documentation of an investigation to determine the source of the injury, as required by facility policy.
Failure to Update Care Plan with Progressive Interventions After Multiple Falls
Penalty
Summary
The facility failed to revise and update the care plan with progressive interventions following multiple falls for one resident with a history of repeated falls, hemiplegia, and difficulty walking. The resident required varying levels of assistance for mobility and transfers, as documented in the Minimum Data Set. Despite being identified as high risk for falls due to cognitive and functional deficits, the care plan was not consistently updated with new interventions after each fall event. Multiple nursing notes documented a series of falls experienced by the resident, including incidents where the resident was found on the floor after attempting to use the urinal, transferring to the toilet, or moving from bed to wheelchair. In several instances, no new interventions were added to the care plan following the falls, and in other cases, only minimal interventions such as education or equipment checks were documented. The care plan did not reflect a systematic approach to updating interventions based on the root cause of each fall, as required by facility policy. Facility policy mandates that the care plan be evaluated and modified as needed after each fall, with new interventions based on root cause analysis. However, the record review and staff interview confirmed that this process was not consistently followed for the resident in question. The lack of timely and progressive updates to the care plan after each fall event constituted a deficiency in the facility's fall prevention and management practices.
Failure to Monitor and Communicate Dialysis Care for a Resident
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the outpatient dialysis center and did not consistently monitor the dialysis access site for a resident with end stage renal disease who required hemodialysis. The resident was admitted with a diagnosis of end stage renal disease and was documented as cognitively intact and dependent with mobility. Physician orders required that the resident's dialysis access site be checked for thrill and bruit, as well as for signs and symptoms of infection, every day and night shift. However, the Treatment Administration Record (TAR) for the specified month showed that these checks were not documented as completed on multiple days. Additionally, the facility's policy required that the dialysis site be checked every shift and that a Dialysis Communication form be completed and sent with the resident for each treatment, with documentation reviewed upon the resident's return. Interviews with the Assistant Director of Nursing and the Administrator confirmed that there was no additional documentation to show that the required monitoring and communication had occurred. The lack of documentation and communication represents a failure to follow physician orders and facility policy for dialysis care.
Failure to Accommodate Food Allergy in Meal Service
Penalty
Summary
A deficiency occurred when a resident with a documented cinnamon allergy was served raisin toast containing cinnamon for breakfast. The resident's allergy was clearly indicated on the face sheet, allergy report, and diet card, and the facility's product details confirmed that the raisin bread contained ground cinnamon. Despite these records, dietary and nursing staff failed to communicate and verify the allergy, resulting in the resident being served the allergen. The dietary aide relied on CNAs to communicate dietary restrictions, but the CNA did not relay the allergy information and assumed the raisin bread did not contain cinnamon before delivering it to the resident. The resident, who is cognitively intact and has a history of asthma affected by cinnamon, reported that this issue has occurred repeatedly during their stay. The dietary manager and registered dietitian acknowledged that staff should have checked for allergies and communicated them to ensure safe food service. The facility's policy requires providing safe foods and appropriate substitutions for individuals with food allergies, but this was not followed in this instance.
Failure to Publicly Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to display the daily nurse staffing information in a clearly visible and accessible location for residents, staff, and visitors. During a facility tour, surveyors observed that the required staffing information was not posted anywhere in public view. An interview with the receptionist confirmed that the daily nursing staff schedule was kept at the nurse's station and was not accessible to the public. Facility policy requires that the number of licensed nurses and unlicensed nursing personnel responsible for direct resident care be posted in a prominent and readable location within two hours of each shift's start. At the time of the survey, the facility census was 108 residents. No specific residents or staff members were directly affected or mentioned in relation to the deficiency, and no medical history or resident conditions were described in the report.
Failure to Administer Seizure Medication Leads to Hospitalization
Penalty
Summary
The facility failed to administer a seizure medication, Vimpat, to a resident diagnosed with epilepsy, resulting in multiple seizures and hospitalization. The resident, who is cognitively intact, reported not receiving her medication for two days, which led to four seizures and subsequent hospital admission. The resident's care plan indicated the necessity of medication administration to manage her seizure disorder, yet the medication was not given as ordered on several occasions. The facility's records show that the resident's Vimpat was not administered on specific dates due to issues with prescription management and pharmacy communication. The resident experienced several seizures during this period, with documentation indicating that the facility was aware of the medication shortage but failed to resolve it promptly. The facility's staff, including a Family Nurse Practitioner and an LPN, acknowledged the medication administration issues and the impact on the resident's health. The facility's Medication Administration Policy requires timely notification and documentation when medications are not administered as ordered. However, the report highlights a lack of initiative from the nursing staff to ensure prescriptions are filled and available, leading to the resident's seizures and hospitalization. The facility's administrator noted that insurance issues delayed the medication's availability, but the facility eventually paid for and obtained the medication from a local pharmacy.
Staff Cell Phone Use Creates Un-Homelike Environment
Penalty
Summary
The facility was found to have allowed its staff to use cell phones in resident areas, creating an un-homelike environment for residents. Observations were made of several staff members, including LPNs and CNAs, using their cell phones at various locations within the facility, such as nurse's stations, hallways, and near the dining room. These observations were made over several days and included instances where staff were seen playing games or otherwise engaged with their phones during work hours. Residents expressed dissatisfaction with the staff's cell phone usage, stating that it interfered with their care. Multiple residents reported feeling neglected and noted that staff were often on their phones instead of attending to their needs, such as responding to call lights or assisting with feeding. The facility's policies, including the Cellular Phone and Electronic Tablet Policy and the Resident Rights Policy, explicitly prohibit personal cell phone use during work time, yet these policies were not adhered to, as evidenced by the staff's actions and the residents' complaints.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide palatable food at an acceptable temperature for several residents, as observed and reported by both residents and staff. On multiple occasions, food temperatures were recorded below the acceptable threshold, with potatoes and eggs served at temperatures as low as 92.6 degrees Fahrenheit. Residents expressed dissatisfaction with the food, describing it as cold, unidentifiable, and unappetizing. One resident's grievance highlighted dietary concerns, which were communicated to the facility by the resident's family. The Dietary Manager acknowledged that food temperatures on hall trays were only checked occasionally and noted complaints about cold eggs. The facility had a plate warmer that was initially thought to be broken, but it was later found to be functional. The Administrator was unaware of the plate warmer issue until recently and was informed that using the pellet warming system could break cold plates. The Resident Council Minutes also documented complaints about cold food and the need for breakfast improvement. The facility's Food Preparation Policy requires hot foods to be held at temperatures greater than 135 degrees Fahrenheit.
Failure to Provide Nourishing Snacks to Residents
Penalty
Summary
The facility failed to provide nourishing snacks between meals or at bedtime for four out of five residents reviewed for snacks. Observations and interviews revealed that snacks were typically left at the nurse's station, and residents who were able to access them would take all the available snacks, leaving none for others. This issue was particularly problematic for residents with specific dietary needs, such as those with diabetes or those dependent on renal dialysis. For instance, one resident with diabetes and end-stage renal disease reported not receiving snacks unless her roommate retrieved them for her. Another resident, also diabetic, stated she never received snacks. The dietary manager acknowledged that snacks were not consistently offered by staff, and the kitchen was locked after dietary staff left, limiting access to additional snacks. The administrator confirmed that a snack cart was brought to the nurse's station, but it was up to the CNAs to deliver them to resident rooms. The facility's policy required that the time between the evening meal and breakfast not exceed 14 hours unless a nourishing snack was provided at bedtime. However, the facility did not adhere to this policy, as evidenced by residents' complaints and the lack of available snacks, which contributed to one resident's significant weight loss due to inadequate nutrition.
Inadequate Shower and Incontinent Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate showers and incontinent care to three residents who were dependent on staff for assistance with activities of daily living. One resident, who had a port in her chest, reported not receiving showers because staff did not want to get the port wet and would not cover it. She also mentioned infrequent bed baths and rarely having her hair washed. Observations confirmed that this resident was left in a soiled brief overnight without being changed until the morning, despite being unable to feel when she needed changing. Her care plan indicated she required assistance with daily care needs, and records showed significant gaps between documented showers. Another resident reported receiving only two showers in three weeks, with documentation supporting infrequent showers. A third resident also expressed that showers were infrequent, and a grievance from the resident's family highlighted concerns about nursing care. The facility's policy stated that showers should be scheduled and assistance provided as needed, yet the administrator acknowledged that residents should receive showers twice a week. Resident Council Minutes further documented complaints about inadequate changing and showering by CNAs.
Failure to Monitor and Document Resident's Change in Condition
Penalty
Summary
The facility failed to adequately assess, monitor, and document the vital signs of a resident (R2) who experienced a change in condition. R2, who had a history of amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), and other health issues, reported feeling unwell and experiencing shortness of breath. Despite these complaints, there was a lack of documented vital signs, including oxygen saturation levels, from 9/19/2024 until the resident was sent to the hospital on 9/25/2024. The only recorded oxygen saturation on 9/25/2024 was at 6:56 PM, which showed a low level of 79% before being increased to 91% with supplemental oxygen. The report highlights discrepancies in the documentation and communication among the facility staff. A physical therapist and a certified nursing assistant (CNA) noted the resident's distress and informed the nursing staff, but there was confusion about who documented the resident's condition in the progress notes. The Licensed Practical Nurse (LPN) involved was new to the facility and did not recall writing the note or testing the resident for COVID-19, despite the resident later testing positive at the hospital. The facility's electronic charting system showed no vital signs recorded for the resident on the day of the incident, except for the oxygen saturation level noted during the medical doctor's consultation. The facility's policy requires that any change in a resident's condition be documented and communicated to the resident's physician and responsible party. However, the lack of consistent monitoring and documentation of the resident's vital signs, as well as the failure to notify the nurse practitioner of the resident's respiratory distress, contributed to the resident's hospitalization and subsequent intubation. The facility's failure to adhere to its policy and ensure proper documentation and communication led to a deficiency in the care provided to the resident.
Failure to Notify Family of Resident's Hospitalization
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for one resident, identified as R2, who was reviewed for change of condition. R2 had a complex medical history, including amyotrophic lateral sclerosis, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease, among other conditions. On a specific date, R2 was sent to the emergency department due to shortness of breath and low oxygen saturation levels. Despite the severity of the situation, no family member was documented as being contacted about R2's change in condition before she was sent to the hospital. Interviews revealed that R2's family was unaware of her hospitalization until they visited the facility and found her belongings being packed. The facility's administrator acknowledged the lack of family notification and stated that such communication should have been documented in the nurse's notes. The facility's policy requires notifying the resident, their physician, and responsible party of any change in condition, and documenting this communication. However, this protocol was not followed in R2's case, leading to the deficiency noted in the report.
Delayed Medical Response and Inadequate Wound Care in LTC Facility
Penalty
Summary
The facility failed to assess, monitor, and transfer a resident, identified as R2, to the hospital in a timely manner after a change in condition was observed. R2, who had a history of chronic respiratory failure with hypoxia and chronic pulmonary embolism, developed a venous wound on her right leg. Despite physician orders for regular wound care and monitoring, there were multiple instances where R2 did not receive her prescribed treatments. On the morning of July 27, 2024, R2 exhibited symptoms of distress, including shaking and low oxygen saturation, but was not transferred to the hospital until the afternoon, resulting in a diagnosis of sepsis and acute respiratory failure. The report also highlights deficiencies in wound care management for several other residents, including R1, R3, R4, and R5. These residents, who had various chronic conditions and wounds, did not receive their prescribed wound treatments on numerous occasions. The lack of documentation and adherence to treatment orders for these residents indicates a systemic issue in the facility's wound care practices. Interviews with facility staff, including LPNs and CNAs, revealed communication and procedural lapses. Staff members failed to consistently monitor vital signs and document changes in residents' conditions. The facility's administration acknowledged that the response time for medical emergencies was inadequate, and there was a lack of proper documentation and follow-up on residents' health status. These deficiencies contributed to the delayed medical intervention and inadequate wound care for the residents involved.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician and resident representative of a change in condition for a resident with chronic respiratory failure, chronic pulmonary embolism, and a non-pressure chronic ulcer. The resident was found shaking, warm to touch, and short of breath with an oxygen saturation of 85%. Oxygen was administered, and the resident's condition slightly improved, but the resident continued to experience shortness of breath. Emergency Medical Services (EMS) were called, and the resident was eventually transported to the hospital, where they were admitted for sepsis and hypoxia. The report highlights that there was no documentation of the physician or family representative being notified of the resident's change in condition. The resident's daughter stated she was not contacted by the facility and was informed by the hospital instead. The nurse practitioner was also not notified of the incident. The facility's policy requires notifying the resident's physician and responsible party of a change in condition, which was not followed in this case. Interviews with staff revealed that there was confusion and miscommunication regarding the notification process. The night nurse did not contact the resident's daughter, and the oncoming nurse was informed of the ambulance's arrival but did not follow up with the family. Additionally, there were issues with the transfer paperwork, which delayed communication with the hospital. The facility's policy on change in resident condition was not adhered to, leading to a deficiency in communication and documentation.
Failure to Protect Residents' Clothing from Loss
Penalty
Summary
The facility failed to protect residents' clothing from loss, affecting four residents who were reviewed for a homelike environment. These residents, who are cognitively intact, reported missing clothing items, including jeans, shirts, and shoes. Despite reporting the missing items to various staff members, including CNAs and laundry staff, the residents did not receive assistance in locating or replacing their belongings. The facility's staff appeared to be unclear about their responsibilities regarding labeling and tracking residents' clothing, leading to confusion and inaction. The facility's policies on missing items and grievances indicate that all reports of missing items should be taken seriously, with a search conducted and options discussed with the resident if the items are not found. However, the staff did not follow these procedures, as evidenced by the lack of communication and resolution for the residents' complaints. The facility's Resident Council Minutes also documented ongoing issues with clothing not being returned and incorrect items being sent to residents' rooms, highlighting a systemic problem with managing residents' personal belongings.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain proper food temperatures before and during meal service, affecting all 121 residents. Multiple residents reported that their food was consistently cold, whether they ate in their rooms or in the dining room. Specific examples include one resident who stated that the food is always cold, another who mentioned that the cold food could be colder, and another who noted that the food is sometimes hot and sometimes cold. These complaints were corroborated by Certified Nursing Assistants (CNAs) who confirmed that residents frequently complained about the temperature of their food. During an inspection, the Dietary Manager and District Manager were observed checking food temperatures. The Chicken Parmesan patty was initially found to be at 112 degrees Fahrenheit, well below the required temperature. The food was reheated to 162.6 degrees Fahrenheit, but the process revealed that the warmer section had not been functioning correctly for a while. Additionally, the process of plating and delivering food was inefficient, with food often left uncovered and exposed to contamination. For instance, noodles were pushed off a tray and back into the warmer, and food carts were left in hallways for extended periods, leading to further cooling of the food. The facility's policies on food preparation and meal distribution were not followed. The Food Prep Policy requires that hot foods be held at temperatures greater than 135 degrees Fahrenheit and that any food dropping below this temperature be reheated to 165 degrees Fahrenheit. The Meal Distribution Policy mandates that all food items be covered during transport and delivered promptly to maintain appropriate temperatures. These policies were not adhered to, as evidenced by the multiple instances of food being served at unsafe temperatures and the inefficient delivery process. The facility's Resident Council Meeting minutes also documented ongoing issues with food quality and temperature, further highlighting the systemic nature of the problem.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to assess, monitor, and treat pressure ulcers for two residents, R3 and R6. R3 was admitted with multiple wounds but did not receive appropriate wound care due to a lack of orders and communication failures among staff. Despite having a follow-up appointment at a wound clinic, the appointment was canceled, and no alternative wound care plan was implemented. The staff did not perform wound care on R3 as expected, and the facility's medical doctor was not contacted for necessary orders, resulting in untreated wounds for several days. R6, who was admitted with severe cognitive impairment and multiple diagnoses, also did not receive proper wound care. During a wound treatment session, it was discovered that R6's wound was not covered with the prescribed dressing, and pieces of calcium alginate were found in the wound bed and brief. The staff failed to ensure that R6's wound was properly dressed and monitored, despite the resident's high risk for infection and other complications. The facility's policies on wound management and admission procedures were not followed, leading to inadequate care for both residents. The staff did not assess wounds upon admission, did not obtain necessary orders, and did not perform wound care as required. These failures were confirmed through interviews with various staff members, including the LPNs, the Director of Nursing, and the Administrator, who all acknowledged the lapses in care and communication.
Failure to Provide Timely and Complete Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for two residents, leading to significant discomfort and potential health risks. Resident 1, who has multiple medical conditions including Multiple Sclerosis and paraplegia, reported being left in a soiled incontinence brief for an extended period. The Certified Nursing Assistant (CNA) responsible for her care admitted to not checking on her regularly and only cleaning her when she requested it. During the observed care, the CNA did not follow proper hygiene protocols, such as washing hands or changing gloves appropriately, and did not thoroughly clean or dry the resident, leaving her in a soiled state for a prolonged period. Resident 7, who has a moderate cognitive impairment and is always incontinent of both bowel and bladder, also experienced neglect in incontinent care. The resident and her daughter reported that she often remained in a wet state for long periods, especially at night. On one occasion, the resident used the call light for assistance but was left unattended for over 30 minutes. When staff finally attended to her, they found her in a wet incontinence brief and wheelchair pad. Although the care provided at that moment was appropriate, the delay and previous neglect were evident. Interviews with other CNAs revealed inconsistencies in the care routines, with some staff checking residents regularly and others not adhering to the expected protocols. The facility's Incontinence Care Policy mandates regular checks and proper hygiene practices, but these were not consistently followed. The Administrator confirmed that staff are expected to check on residents every two hours and provide timely and complete care, which was not done in these cases.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to ensure residents were free from abuse and neglect, resulting in two residents experiencing distressing incidents. One resident reported feeling sexually assaulted by a CNA who responded to her call light request for pain medication. The CNA allegedly got too close to the resident's face, began rubbing her chest, and made inappropriate comments, causing the resident to feel uncomfortable and violated. The incident was witnessed by the resident's roommate, who corroborated the account. The resident expressed fear of future similar incidents and a desire to leave the facility if such behavior continued. Another resident reported being mistreated by two different CNAs on separate occasions. The first incident involved a CNA who threw a diaper at the resident and told her to clean herself up after an episode of incontinence. The resident, who had difficulty moving due to a stroke, was left distressed and in tears. A second incident involved another CNA who yelled at the resident to move herself up in bed and later threw a diaper on the table, instructing the resident to change herself. The resident struggled to clean herself and was left with residual feces until another CNA assisted her the following morning. The facility's abuse policy affirms the right of residents to be free from abuse, neglect, and mistreatment. However, the incidents involving the two residents indicate a failure to uphold this policy. The facility's reported incident forms document the allegations and witness statements, and the involved CNAs were either suspended or sent home. The police were involved in investigating the incidents, and the facility's administrator acknowledged the severity of the complaints and the need for corrective action.
Failure to Prevent Abuse and Neglect
Penalty
Summary
The facility failed to follow its Abuse Policy and Prevention Program, resulting in two residents experiencing abuse and neglect. One resident reported feeling sexually assaulted by a CNA who, instead of providing the requested pain medication, began rubbing the resident's chest and making inappropriate comments. This incident left the resident feeling violated and fearful of future occurrences. The resident's roommate corroborated the account, and the police were involved in the investigation. The facility's administrator acknowledged the incident and indicated that the CNA would be terminated. Another resident reported neglect and verbal abuse by a different CNA. The resident, who had a stroke and was unable to move independently, was told to change herself after an episode of incontinence. The CNA threw a diaper at the resident and left her to clean herself, resulting in incomplete hygiene care. This resident also reported a previous incident where a CNA yelled at her to get up and do things for herself, causing significant distress. A witness confirmed the CNA's inappropriate behavior, and the facility's administrator indicated that the CNA would be fired. Both incidents highlight the facility's failure to ensure a safe and dignified environment for its residents, as mandated by its Abuse Policy and Prevention Program. The residents involved were left feeling unsafe and neglected, with their needs unmet in a respectful manner. The facility's response included suspending the involved CNAs and involving law enforcement, but the initial failure to prevent these incidents indicates a significant lapse in adherence to established policies and procedures.
Failure to Provide Proper Wound Care and Repositioning
Penalty
Summary
The facility failed to provide proper wound care and to turn and reposition a resident, leading to the development and worsening of pressure ulcers. The resident, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was observed sitting in a recliner for extended periods without being repositioned. Despite having multiple severe pressure ulcers, including stage-4 ulcers and unstageable wounds, the resident was not turned or repositioned every one to two hours as required by their care plan. Additionally, the resident's wound-vac was not re-applied after returning from the hospital, and there were no orders to continue its use. The wound care nurse admitted to not calling the physician to inquire about the wound-vac and acknowledged that the resident's wounds were worsening due to prolonged sitting. The nurse also discovered three new blistered areas on the resident that had not been previously documented. The facility's transporter and dialysis staff confirmed that the resident was not repositioned during dialysis sessions, further contributing to the deterioration of the resident's skin condition. The nurse practitioner and other staff members emphasized the importance of repositioning the resident to promote wound healing, but this was not consistently done. The facility's policies on pressure injury prevention and skin care were not followed, as evidenced by the lack of regular skin assessments and failure to reposition the resident as needed. The resident's care plan included specific interventions to prevent skin breakdown, such as turning and repositioning every one to two hours, but these were not implemented. The facility administrator acknowledged the issue and indicated that the resident should not be sitting for long periods, but no immediate corrective actions were taken to address the deficiency at the time of the survey.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to serve meals at regular times in a manner that meets the residents' needs and per posted scheduled mealtimes. The posted mealtimes are breakfast at 7:30 AM, lunch at 12:00 PM, and dinner at 5:30 PM. However, observations on multiple dates showed that breakfast trays were being passed as late as 10:15 AM and lunch trays as late as 1:20 PM. Residents and staff reported that breakfast has been consistently late for the past couple of weeks, with some meals being served as late as 7:00 PM. The Resident Council minutes also documented complaints about late meals and inconsistent mealtimes, particularly on weekends. The facility's Infection Prevention Nurse and Administrator acknowledged the issue, citing kitchen staffing problems and the recent departure of the Dietary Manager as contributing factors. The facility's Meal Distribution Policy, dated 9/2017, outlines that meals should be transported and delivered in a timely and accurate manner, ensuring proper temperature maintenance and protection against contamination. Despite this policy, the facility has not adhered to the scheduled mealtimes, affecting all 117 residents. The Administrator confirmed that the current meal service times are unacceptable and not in line with the facility's standards. The CMS 671 form dated 5/13/24 documented that there are 117 residents in the facility, all of whom are potentially affected by this deficiency.
Failure to Ensure Safe Transfers and Follow Care Plans
Penalty
Summary
The facility failed to ensure mechanical lift transfers were conducted safely and care plan interventions were followed to prevent falls for four residents. For Resident R78, who has diagnoses including amyotrophic lateral sclerosis and is dependent on staff for transfers, the care plan required the use of a Hoyer lift with two assists. However, during an observed transfer, neither of the two CNAs provided hands-on guidance while R78 was in the lift, only guiding the resident into the wheelchair at the last moment. Resident R90, who has multiple diagnoses including metabolic encephalopathy and is moderately cognitively impaired, had a care plan that included ensuring the call light was within reach and providing proper footwear. Despite this, observations showed the call light was often out of reach, and the resident was frequently found without shoes, only wearing socks. This resident had multiple documented falls, indicating a failure to follow the care plan interventions. Resident R91, who is cognitively intact but dependent on staff for transfers, also required a Hoyer lift with two assists. Similar to R78, during observed transfers, the CNAs did not provide hands-on guidance while the resident was in the lift, only guiding the resident into the bed at the last moment. Additionally, Resident R65, who has severe cognitive impairment and a high risk for falls, had multiple falls documented. Observations showed that the fall mat was not in place as required by the care plan, and the resident was often found without proper supervision or footwear, further indicating a failure to follow care plan interventions.
Expired Medications Found in Medication Carts and Room
Penalty
Summary
The facility failed to remove expired stock medications from the front hall medication room and from two medication carts, potentially affecting 54 residents. During an inspection of the 200 hall medication cart, several expired bottles of medications were found, including Bisacodyl stool softener tablets, Geri Dryl allergy relief tablets, Acidophilus probiotic capsules, lutein capsules, sodium bicarbonate tablets, sodium chloride tablets, Coenzyme Q-10 tablets, Optimum iron tablets, and multivitamins. Similarly, the 100-hall medication cart contained expired bottles of vitamin E capsules, sodium chloride tablets, Acidophilus probiotic capsules, and Optimum iron tablets. Additionally, the front hall medication room had expired sodium chloride pre-filled flush syringes in the stock medication supply area. Interviews with staff revealed a lack of clarity regarding responsibility for checking and disposing of expired medications. An LPN stated that she did not know who was responsible for ensuring the expired medications were disposed of. The Administrator and the Director of Nursing both indicated that they expected floor nurses to check the expiration dates on stock medications daily and that the nurse management team should also be checking the medication carts and rooms for expired medications. The facility's policy on medication storage, dated April 2018, requires that outdated, contaminated, or deteriorated drugs be immediately withdrawn from stock and disposed of according to drug disposal procedures.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and received pneumococcal vaccinations in accordance with CDC recommendations. Specifically, five residents (R6, R9, R48, R82, and R91) were identified as not having any documentation of pneumonia vaccination administration or history in their electronic medical records. These residents had various diagnoses, including amyotrophic lateral sclerosis, chronic obstructive pulmonary disease, metabolic encephalopathy, type two diabetes, chronic kidney disease, peripheral vascular disease, atherosclerotic heart disease, cerebral infarction, hemiplegia, Alzheimer's disease, and cognitive communication deficit. The Infection Preventionist (IP) nurse, who has been with the facility for over a year, confirmed that she had not arranged for the contracted vaccine clinic to administer pneumonia vaccines nor had she offered any residents the pneumonia vaccine during her tenure. The facility's Pneumococcal Vaccinations Policy, last reviewed in September 2022, mandates that all residents be screened and offered the pneumonia vaccine within the first week of admission and annually if eligible. The policy also requires documentation of vaccination or refusal in the Electronic Health Record (EHR). However, this procedure was not followed, leading to the identified deficiency.
Failure to Assist Residents with ADLs
Penalty
Summary
The Facility failed to ensure that two residents, R58 and R99, were assisted with their Activities of Daily Living (ADLs). R58, who is severely cognitively impaired and always incontinent of bowel and bladder, was found in a saturated adult brief with a large amount of urine and feces. The brief had not been changed since the previous night, and the bed linen pad was heavily soiled. V15, a Certified Nursing Assistant (CNA), confirmed that R58 had been left wet all night and expressed concern about potential skin breakdown due to prolonged exposure to moisture and waste. R99, who had a stroke and requires assistance with daily care needs, reported that a CNA had refused to help her move up in bed and had told her to change herself after an episode of incontinence. R99 attempted to clean herself but was not able to do so completely, and V15 had to assist her the following morning. Additionally, R99 reported an incident where a CNA threw a diaper on the table and told her to clean herself up, leaving her with streaks of feces. The Facility-Reported Incident Form documented that R99 had also experienced verbal abuse from a CNA, who yelled and demanded that she get up and get herself ready. Another CNA, V15, witnessed this behavior and confirmed that the yelling was intense and that the aide walked out of the room cussing. The Administrator acknowledged R99's complaint and noted that R99 did not feel abused but was concerned about the treatment of other residents who might not be able to speak for themselves.
Failure to Administer Prescribed Wound Treatments
Penalty
Summary
The Facility failed to ensure that treatments prescribed daily by a physician were completed for four consecutive days for a resident with Type Two Diabetes, Peripheral Vascular Disease, and chronic ulcers. The resident's care plan required daily application of betadine and a dry dressing to the right great toe and left medial ankle. However, these treatments were not administered on four consecutive days, as confirmed by both the resident and the wound nurse. The resident reported that the dressings had not been changed since the previous Thursday or Friday, and the wound nurse confirmed that the treatments were not done over the weekend and the following Monday and Tuesday. The wound nurse stated that the floor nurses were responsible for applying the dressings over the weekend, but this was not done. The administrator was unaware of the missed treatments and mentioned the need for an additional wound nurse to manage the 60 wounds in the facility. The facility's policy on Physician's Orders did not address ensuring that orders are completed as prescribed, contributing to the oversight. The failure to administer the prescribed treatments was evident from the undated dressings and the resident's report.
Failure to Provide Timely and Complete Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for three residents, leading to deficiencies in their care. One resident, diagnosed with amyotrophic lateral sclerosis, COPD, and hypertension, was observed to have requested a change due to incontinence. Despite the request, the resident was not attended to promptly, and when care was finally provided, the CNAs did not perform hand hygiene, used wet washcloths without soap, and failed to clean all necessary areas properly. The CNAs also did not change gloves or perform hand hygiene during the process, and the resident's skin was not dried after cleaning, which is against the facility's policy for incontinence care. Another resident, who is severely cognitively impaired and always incontinent, was found to have been left unchanged since the previous night. The CNA providing care noted that the resident's brief was saturated with urine and feces, and the bed linen was heavily soiled. The resident's roommate confirmed that no one had checked on the resident since 11 PM the previous night. The CNA expressed concern about the resident's skin condition, noting that prolonged exposure to moisture could lead to skin breakdown. A third resident, with multiple diagnoses including diabetes, severe obesity, and chronic kidney disease, was also found to have received inadequate incontinent care. The CNAs did not perform hand hygiene before donning gloves, used wet washcloths without soap, and failed to clean all necessary areas. The resident had open areas on the buttocks, and the same gloves were used throughout the care process without changing. The facility's policy requires that incontinent care be performed every two hours and as needed, using soap and water, which was not adhered to in these cases.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to administer medications according to the physician's order for one resident. On multiple occasions, an LPN administered incorrect doses of medications to a resident. Specifically, the LPN gave a 1000 mg dose of Fish Oil instead of the prescribed 1200 mg and almost administered an incorrect dose of Folic Acid before correcting the error. Additionally, the LPN did not provide proper instructions for the use of a Symbicort Inhaler, resulting in the resident not using the inhaler correctly. The medication cart was also left unlocked and unattended in the hallway, which is against the facility's policy. The Director of Nursing (DON) acknowledged that nurses are expected to follow physician orders for medication administration, perform hand hygiene, and wipe down medical equipment as needed. The facility's Medication Administration Policy outlines specific steps for safe medication administration, including verifying the correct medication, dose, route, and time, and ensuring the medication cart is never left open and unattended. The observed deficiencies indicate a failure to adhere to these policies, leading to medication administration errors and potential risks to resident safety.
Failure to Provide Appetizing and Palatable Meals
Penalty
Summary
The facility failed to provide appetizing and palatable meals for two residents diagnosed with Moderate Protein-Calorie Malnutrition. Resident R99 expressed dissatisfaction with the facility's food, describing it as 'disgusting' and 'nasty,' leading to the resident's daughter bringing in outside food. Resident R57 also reported the food quality as poor, mentioning that the burgers had a smell, the fries were half-cooked, and the hashbrowns were not properly browned. This resident's refusal to eat the facility's food resulted in missed doses of medication and significant weight loss from 137 pounds in January 2024 to 128 pounds in February 2024. Additionally, there were no recorded weights for March or April 2024 for R57, indicating a lack of monitoring of the resident's nutritional status. The Facility's Resident Council Meeting Minutes from February, March, and April 2024 documented multiple complaints about the food, including finding hair in the meatloaf, not receiving requested items, food arriving late, inconsistency in food quality, insufficient portions, incorrect menus, stale bread, and spoiled milk. These consistent complaints from residents highlight ongoing issues with the dietary services provided by the facility, contributing to the residents' dissatisfaction and potential health risks due to inadequate nutrition.
Failure to Perform Proper Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to perform proper hand hygiene and cleanse multi-use resident equipment, leading to potential infection risks for four residents. For instance, two CNAs provided incontinent care to a resident without performing hand hygiene before donning gloves, using wet washcloths without soap, and failing to change gloves or perform hand hygiene after the care. The same dirty gloves were used to apply ointment and handle personal items, violating infection control protocols. Another incident involved two CNAs performing incontinent care on a different resident without hand hygiene before donning gloves and using wet washcloths without soap. They also failed to perform hand hygiene after completing the care, using the same gloves throughout the process. This lack of proper hand hygiene and glove use was observed during multiple instances of resident care. Additionally, an LPN was observed assisting a resident and passing medications without performing hand hygiene before or after these tasks. The LPN also took vital signs without cleaning the blood pressure cuff between uses. The Director of Nursing and another LPN confirmed that hand hygiene should be performed before and after resident care, during medication pass, and before glove application, as per the facility's hand hygiene policy.
Failure to Administer Scheduled Medications
Penalty
Summary
Staff failed to administer several significant medications to a resident (R4) during a scheduled medication pass. R4, who has diagnoses including Metabolic Encephalopathy, Bipolar Disorder, and Hypertension, did not receive their scheduled doses of Amlodipine, Quetiapine, and Venlafaxine on 4/14/24. The eMAR documented the missed doses, and the Nurse Progress Notes indicated that the medication roll had run out. Interviews with staff revealed that R4 often requests medications and then changes their mind, leading to discarded doses and subsequent shortages. The pharmacy confirmed that medications are filled on a 7-day basis and can be retrieved from the med room if discarded or dropped. The facility's policy on medication administration requires checking for misplaced medications and contacting the pharmacy if necessary. However, the issue was not addressed by the DON despite being reported by the nurse. The resident expressed frustration with the medication administration process, and the Nurse Practitioner acknowledged the problem and discussed ways to reduce medication waste with R4. The pharmacist and administrator confirmed the procedures for medication refills and access to the med room, but the deficiency in medication administration persisted, leading to missed doses for R4.
Medication Administration Errors
Penalty
Summary
The facility failed to monitor the administration of medications as ordered by the physician for five residents, resulting in significant medication errors. One resident with moderate cognitive impairment received another resident's medication because the nurse turned her back, allowing the resident to give the medication to another. Another resident, who is cognitively intact, reported being handed a cup of pills that were not hers, and the nurse mistook her for another resident. The resident did not take the incorrect medication but expressed concerns about the potential for such errors to cause harm. A third resident with a history of cerebral infarction and Parkinson's disease received medication from another resident due to the nurse's inattention. The resident took the medication, believing it was hers. Another resident with moderate cognitive impairment received another resident's medication because the nurse mixed up bed numbers. The resident was monitored for side effects, and the medical director confirmed that no harm was caused. The fifth resident, who is cognitively intact, was administered a higher dose of medication than prescribed due to a mix-up with home supply medication. The medical director noted that the additional dosages were what the resident was taking at home, and there was no harm caused. The facility's policy on medication administration emphasizes the importance of identifying residents using two identifiers and remaining with the resident to ensure they swallow the medication. However, these procedures were not followed, leading to the medication errors.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
